Authored by: Scott Mohr, MBA, CNIM
Shortly before 0700, Adam, a CNIM-certified intraoperative neuromonitoring technologist, approaches the pre-operative patient holding bay. Stopping at the door to confirm patient identity, he knocks, asking permission to enter. Welcomed inside, he taps a wall-mounted pump, applying hand sanitizer. Briskly rubbing hands together, he smiles in greeting.
“Good morning,” he greets the patient by name. “My name is Adam, and I am the neuromonitoring technologist working with your surgeon today. I wanted to introduce myself and give you an overview of my role in your procedure. I can also answer any questions you have about neuromonitoring.”
So begins a typical day for Adam and many of his colleagues in the field of intraoperative neuromonitoring (IONM). Today, IONM technologists such as Adam are increasingly becoming a valued part of the surgical workflow as the value of neuromonitoring proves to be an asset in preserving surgical patient quality of life. Over the years, our profession – lead by professional societies such as ASET – has waged a campaign for awareness and acceptance of IONM both among medical professionals and the public.
Like any good campaign, our efforts toward increased awareness of IONM and providing optimal patient care support is augmented by sound tactics. A key strategy in any undertaking is to identify the key intersections on the map and invest in them. Continuing to think in this tactical theme, there are few intersections in the field of IONM more relevant than the patient interview process, where IONM awareness, surgical planning, and above all – the patient – form a brief nexus shortly before the onset of a very significant moment in that patient’s life.
As the technologist, you are representing our profession as you gather information relevant to the surgical procedure. You are also the eyes and ears of your oversight physician (OP), who relies on you to provide the data they need to make informed interpretations in a timely manner. You and your OP can in turn make informed suggestions to the surgeon for an optimal monitoring strategy. The patient interview process is a valuable opportunity to fulfill this obligation.
Of course, these goals are not without their own significant challenges. We live and work in the COVID era, and no observations of healthcare practices can steer around this issue. Practices and protocols in hospitals around the world continue to evolve to meet the challenge of keeping both patients and practitioners safe. COVID precautions may affect our access to the patient prior to the procedure. As medical professionals, IONM technologists should always adhere to federal, state, local and healthcare system policies in relation to COVID exposure risk.
When addressing the patient interview process, we need also consider the diversity of IONM operations in our field. During my career, I have worked in university hospitals where an OP could walk into the operating room to consult my data, and I have also worked remotely with OPs in different time zones. As we address the patient interview process in this article, we will assume remote physician oversight, as is the case in most scenarios.
What follows are some practical considerations when conducting a patient interview prior to a procedure. This article is designed to be an overview of key strategies to maximize the patient interview experience and is not meant to be an exhaustive clinical reference or detailed protocol for clinical evaluation. As always, follow your neuromonitoring organization and hospital regulations regarding patient contact, patient interview and documentation practices.
First Contact – Being an Advocate for IONM
When you as the technologist first walk into the pre-op holding area, your patient is bringing some intense experiences to the meeting. They are likely hungry, cold, nervous and probably experiencing discomfort and pain. They are wearing a thin gown and possibly feeling vulnerable. They are also facing an imminent surgical procedure, which is a significant event in anyone’s life.
Your role is to provide a service to the surgeon which will make the procedure safer and enhance the likelihood of a good outcome for that patient. You are their ally. Making this apparent is an integral part of the patient interview.
Start with an introduction. Give the patient your name and title. If you work for an independent neuromonitoring group that contracts with the hospital, be sure to let them know your company. Your name tag identification should clearly be visible. Ask how the patient would like to be addressed. This information can be useful for asking the patient to follow commands during wakeup tests and post-op assessments when they are still groggy from the effects of anesthesia.
For example, “Good morning, my name is Scott, and I will be providing neuromonitoring services for your procedure today. How may I address you?” Take a moment to connect with your patient and show them respect by initiating the dialog on their terms. As the neuromonitoring team, we are trying to do more than simply talk at the patient; the patient interview process should be two-way communication.
Explain why you are there. Let them know you stopped in to introduce yourself and make clear you will be involved with the procedure, assisting the surgeon.
Describe your role. Start in a general sense and try not to rush. Surgical patients have a great deal of information pressed on them on the day of their operation, and we are yet another entry in a complicated and confusing process during a stressful time for the patient. General overview phrases are good starting points, such as: “I will collect information on the state of your nervous system and provide real-time feedback to your surgeon.”
Tell them how you are going to accomplish this. This is the time to dive down into more specifics depending on the procedure type. Try to be frank while reassuring the patient. Are you using cup electrodes, corkscrew or straight subdermal needles? Don’t give in to the urge to avoid discussing the use of needles – it is not a good practice to let the patient wake up with multiple pin pricks and have no idea what they are from. If you are monitoring in a general anesthesia procedure, be quick to assure them you won’t be placing any of your electrodes until after the patient is fully asleep (if that is the case). Often, I reassure a patient “You will never know I was there, except for us having this discussion now”.
Let them know why the surgeon is using neuromonitoring. Your patient interview experience should key on the fact that the use of neuromonitoring provides useful information to the surgeon, so that he or she can make informed decisions for the best outcome possible. This need not be an academic lecture; frame the discussion in perspective of the patient’s experience. In concise format, focus on what the patient’s procedure is, what anatomy is at risk, and how neuromonitoring helps to provide protection. For example, if the patient is undergoing a thyroidectomy, you can explain that the recurrent laryngeal nerve (RLN) will be in the surgeon’s field, and monitoring of the vocalis muscles via a neural integrity monitor endotracheal (NIM ET) tube provides feedback on the state of the RLN during surgical manipulation, helping the surgeon avoid the structure. This in turn protects the patient’s speech and swallowing function. A good example of this delivery is as follows: “I see you are scheduled for a thyroidectomy today. After you go to sleep, the anesthesia team will place a breathing tube that has built-in sensors. These sensors can detect activity in your vocal muscles, which allows us to monitor what is called the Recurrent Laryngeal Nerve. That nerve contributes to your speech and ability to swallow, and it will be in the surgeon’s field. We can provide your surgeon feedback on its status during the surgery to help them keep that nerve safe.”
Make them aware of the risks. As with anything surgical, there are inherent risks to what we do. Although the percentage of such an occurrence is very low, debrief the patient on any complications that may arise with the use of neuromonitoring. This can range from slight bleeding and needle stick marks from subdermal electrodes, to tongue lacerations from the use of transcranial stimulation.
Temper all risk advisories with the reassurance that every precaution will be taken to keep the patient safe. For example, you may want to discuss the use of bite blocks during transcranial stimulation. Again, the purpose of the patient interview is to gather useful data while keeping the patient informed and encouraged.
Do they have questions? Finally, make time to answer any questions the patient may have. Often, you will find the patient responds positively to the knowledge such a service as IONM is in play during their procedure. However, many won’t have any immediate questions as they process the information. Some neuromonitoring organizations leave printed material with the patient, such as a brochure or other handout describing the service or company, but this practice can be complicated by the fact the patient may not have the time to read the info and may not have a good place to keep the document during their stay.
When providing a description of the neuromonitoring process, you will want to keep things brisk and succinct, especially if this is the first procedure of the day. However, you also want the patient to have at least a general sense of neuromonitoring’s role in their procedure, to the best of the patient’s ability to comprehend the service.
Be Part of the Team – Keep Everyone on the Same Page
The patient interview experience is a two-way conversation. In addition to providing the patient with information, you want to gather as many facts from the patient’s perspective as possible. As always, communication is the life blood of healthcare.
Neuromonitoring functions best when it is well-integrated into the surgical workflow. The technologist should be on the same page with the surgeon and anesthesia team regarding the patient’s initial condition, the surgical goals, and the best neuromonitoring approach for the surgical plan. Therefore, the neuromonitoring team should be included in discussions and planning to the degree that is practical.
A very important player in this surgical planning is your partner in the monitoring process, your OP. In cases where the OP is remotely monitoring, you effectively serve as their eyes and ears. OPs take on responsibility for providing interpretations that can positively affect the patient outcome, but they only know what data they seen on the screen and what information you provide them.
Providing a comprehensive history and overview of the patient’s pre-operative status, along with the surgical consent’s stated goals can help your OP establish an effective monitoring plan. This crucial information can also help him or her respond more effectively to changes in patient status during the procedure. Also, knowing the starting condition of the patient helps to make insightful baseline data interpretations.
As a technologist, develop a good working relationship with your OP. You will get to know their preferences for information and how best to communicate with them, allowing you to extract information more effectively during the patient interview process. Give your OP the information they need to do their job, and they will have your back during the procedure.
Know Before You Go
It happens to just about every technologist. You set up for what appears to be a routine case; leads placed accurately, program settings are true, and you have perfect accord with the anesthesia team, who agree to maintain parameters optimal for your monitoring. You confidently initiate the software, start your first average and… something is wrong.
Where are the robust cortical signals? The nice, sharp peaks that an auto cursor can easily latch onto? Can your posterior tibial nerve sensory responses possibly be that delayed?
While your data is collecting, certainly your training kicks in as you check down through your troubleshooting options. Undoubtedly you work to manipulate data collection parameters, titrating your stimulation, increasing your sweeps, working to augment poor signals into something that can be reliably tracked. Meanwhile, you are stuck between a rock and a hard place; the surgeon wants a report on the initial baseline status and your OP – who only has their initial impression of the data on screen and the information you provided to them – is waiting.
Information and communication are powerful tools in intense scenarios such as this. It is far better to tackle poor signals with as much pertinent knowledge as we can gather prior to starting our first average. These scenarios serve to underscore the value of being on the same page with the patient, surgeon, and OP prior to the patient wheeling into the room. Therefore, a technologist should have access to three key elements: Access to the patient for interview purposes in pre-op holding, the patient’s electronic medical record (EMR) and the surgeon.
I should take a moment and acknowledge the practical considerations that may stand in the way of technologist access to these resources. Time is a major constraint. There is a limited amount of time first thing in the morning for a technologist to prepare for a surgery and be in position when the wheels-in time is clocked for the procedure. The same applies to procedures that follow each other, especially for facilities with fast turnovers between cases.
Also, not every facility affords the same access to patient information for the neuromonitoring service. In-house departments at university hospitals usually have full access to the EMR. Contracted neuromonitoring services often experience a spectrum of access, from receiving a hard copy printout of the patient’s history at one facility to virtually no information at the next. EMR access for neuromonitoring services is beyond the scope of this article, but the potential for limited information on patient status prior to a procedure serves to underscore the value of the patient interview experience. The more we know about the patient’s initial condition, the better we can report useful information to our surgeons during the procedure.
The same obstacles to EMR access can also apply to patient access in pre-op holding. Depending on the hospital’s policies, and the contracted arrangement between neuromonitoring provider and the hospital, a technologist may not be permitted to conduct a patient interview. This is especially possible considering COVID contact precautions. It is vital that we as technologists always adhere to hospital policies on these matters. These policies exist to safeguard patient privacy and maintain a secure environment in which to provide healthcare. We need to respect this as medical professionals. The time to contest such policies is never in the operating room or pre-op holding. However, the neuromonitoring community should continue to lobby for access to patient information that is crucial for us to effectively provide a valuable service.
What We Need to Know
When conducting the interview, focus on the cause and effect of the patient’s condition and impact on data collection. If you were to execute a perfect setup, what patient condition could preclude you from obtaining data within normal limits? What follows are some key discussion points to focus on during the patient discussion. This list is by no means exhaustive, nor is this overview intended to be a comprehensive, step-by-step protocol for the patient interview process. Also, remember that the patient interview should supplement – not replace – the official clinical history and physical (H&P) in the patient’s record.
As with all patient interview questioning, it is a good idea to start general and focus down on specific details. Start with a general inquiry:
- “What brings you in today?”
- “Why are you seeing Dr. [surgeon’s name] this morning?”
- “What are we operating on today?”
Commonly, patient responses will refer to the source of pain or pathology:
- “I have been having difficulty walking…”
- “I am having neck and arm pain…”
- “Dr. [surgeon’s name] is operating on my back…”
The conversation can then follow symptoms to intervention, from a broad focus narrowing down to specifics of symptoms and causation. A good patient interview allows you to understand the patient’s story leading up to the date of the procedure. Your patient interview process should establish a narrative of the patient’s experience leading to the time of surgery. Your interview questions will be generally organized in the following categories:
- Onset of symptoms
- Impact of symptoms
- Pre-existing conditions
- Previous interventions
- Surgical plan
Onset of Symptoms: Ask the patient when their symptoms first began. This is especially important for pain, numbness, and weakness. “When did your symptoms first start?” is a simple lead-in question. In certain cases, the symptoms can be traced to an event or activity, such as a fall, or motor vehicle accident. Are the symptoms acute or chronic in nature?
Impact on Quality of Life: As noted previously, a good strategy is to start with general questioning and narrowing down to specifics that can impact neuromonitoring data. Queries such as, “Are you having any pain? Any weakness” are good staring points. The interview should follow up with more specific descriptions and localization in relation to pain, weakness, and numbness:
- What (if any) activities that make the condition worse?
- What is the localization of the symptom? Unilateral versus bilateral?
- Is the condition specific to a certain dermatome or dermatomes?
- How does the patient describe the symptoms, especially for pain?
- Burning sensation
- Electrical sensation
- Tingling and numbness
- Can the patient describe the current pain symptoms on a 1–10 scale, 10 being most extreme?
Previous Neuromonitoring: Determining a history of surgeries, such as a previous spinal fusion, are a priority. If the procedure was monitored, access to the neuromonitoring report is very useful. It is always a good practice to see if there are records of your neuromonitoring organization having provided neuromonitoring services for the patient during a previous procedure. This data can answer such important questions as:
- Did the patient have good baseline data at that time?
- Were there significant events that affected the neuromonitoring data?
- What were the optimal monitoring parameters for achieving optimal data, such as TcMEP settings?
Diabetes, Neuropathy and Demyelinating Conditions
According to some sources, approximately 50% of patients with diabetes also experience some form of neuropathy (Anderson & Yamaski 2016). Because neuropathy can have a detrimental effect on SSEP waveforms, be sure to inquire if the patient has diabetes and whether it is controlled. As with all information collected during a patient interview, you can correlate the patient’s response with the medical history in the chart, provided you have access to it.
Demyelinating conditions can also affect sensory and motor monitoring. Conditions such as multiple sclerosis deconstruct the myelin sheath of nerves and reduce their saltatory conduction. The result for neuromonitoring is often increased latencies and poor amplitudes. If the patient’s record indicates a demyelinating condition, try to ascertain the degree to which the condition impacts the patient’s quality of life. Do they have numbness, tingling and decreased sensation? Is there a region of the body (such as fingertips) where the symptoms are worse? Follow up questions of this nature can alert you and your OP to the possibility of poor baseline signals independent of anesthesia considerations or technical factors.
Surgical history is another major factor in determining the likelihood of patient neuropathy. A published report from the Mayo Clinic noted the low occurrence of new peripheral nerve injury in surgical patients. Welch et al. (2009) reported that over a 10-year time span among 380,680 patients, there was only a 0.03% occurrence of new peripheral nerve injuries among a variety of procedure types. However, despite the resilience of peripheral nerves, such injuries do occur and can affect neuromonitoring data in future procedures. Crushing of the myelin sheath, localized demyelination (neuropraxia) and stretching of the nerve can cause temporary and even permanent impairment to peripheral nerve conduction. Additionally, depending on the time elapsed between surgical procedures, inflammation can affect nerve conduction and impinge on nerve roots. The findings of another study highlight the importance of post-operative follow up and documentation by the neuromonitoring team (Laughlin et al. 2020).
Hypertension can have an impact on neuromonitoring. Patients with a history of chronic hypertension present an additional challenge to the anesthesia team as they work to maintain a balanced steady state in heart rate and perfusion during the surgery. As the anesthesia team works to manage a hypertensive patient during surgery, rises and falls in mean arterial pressure (MAP) can affect neuromonitoring waveforms, particularly in SSEPs. Overcorrection of hypertension can result in a hypotensive state, which can result in poor perfusion to neural structures (Laughlin 2020). The neuromonitoring technologist will need to work closely with the anesthesia team during surgeries with patients who are hypertensive. It is important to report and document when lower pressures affect the neuromonitoring data, an early indication that the nervous system is not being adequately perfused. The technologist can empower the anesthesia provider to find an adequate balance in MAP that allows for effective nervous system perfusion while keeping the pressure low enough to mitigate blood loss.
Patient Post-Op Assessment
A general assessment of patient cooperation is valuable. Can the patient follow commands? Are there any communication barriers? This can be important in the event of a wakeup test, or to see if the patient can follow commands post-op for functional assessment.
Can the patient move all extremities? Do they have symmetric grip strength? Especially after vascular and spinal procedures, the patient will be asked to move their extremities, wiggle their toes, squeeze someone’s hand, and perform other displays of motor function. Knowing the overall baseline compliance of the patient to such commands serves as a comparison for post-operative assessment.
Consider accompanying the anesthesia team during their final patient interview in pre-op holding if this can be coordinated. The anesthesia team will ask many of these questions and likely even perform grip strength tests, which you can observe and take note of.
Finally, when conducting the patient interview, be certain to show the patient some grace. Likely, they have described their condition and answered similar questions many times over by the time you make your introduction.
The patient interview experience is an excellent opportunity for the neuromonitoring community. We can integrate into the surgical planning workflow, serve as an ambassador for our field and encourage the patient with the knowledge we are working with the surgeon to make the procedure as safe as possible. Finally, the knowledge intel we gather on patient status and history will serve to equip us for communication planning conversations with the surgeon and oversight physician.
- Anderson J & Yamasaki D. (2016). Intraoperative nerve monitoring during nerve decompression surgery in the lower extremity. Clin Podiatr Med Surg. Apr;33(2):255–66.
- Kudo D, Miyakoshi N, Hongo M, Kasukawa Y, Ishikawa Y, Misawa A, Shimada Y. (2013). Surgical treatment and intraoperative spinal cord monitoring in scoliosis associated with chronic inflammatory demyelinating polyneuropathy: a case report. Ups J Med Sci. May;118(2):134–7.
- Welch MB, Brummett CM, Welch TD, Tremper KK, Shanks AM, Guglani P, Mashour GA. (2009). Perioperative peripheral nerve injuries: a retrospective study of 380,680 cases during a 10-year period at a single institution. Anesthesiology. 111(3):490–7.
- Laughlin RS, Johnson RL, Burkle CM, Staff NP. (2020). Postsurgical neuropathy: a descriptive review. Mayo Clin Proc. February;95(2):355–69.