Special Interests Section – Spring 2020

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Welcome Spring & Welcome Colleagues

SpringAs we leave the winter behind us and dash into spring for warmth and greenery, we are reminded to be green in all we do. In this edition of ASET News, we asked our Special Interest Section Leaders to share ways in which they were bringing about a greener environment for our future generations. We can never do too much to help our fellow journey travelers.  

Personally, I am trying to save everything to a cloud and lessen the mountain of paper in my file cabinet. I also try to scrutinize what I need to save because I know that all that digital storage takes up precious land space. Did you know that the music video for one hit song on the internet can burn as much energy as 40,000 US homes use in one year (from Fortune.com)? So just because you are using digital storage, does not mean that you are not using vital non-renewable resources. How are you being wise and reducing your carbon AND digital footprints?  

On another note, it has been brought to my attention the dedication, service and loyal support of several of our Special Interest Section Leaders. I would like to thank Jennifer Carlile, Dorothy Gaiter and Kathy Johnson for all of the generosity of their time and support of the ASET Special Interest Sections as they have been serving as Leaders for over 20 years! Please join me in thanking Jennifer, Dorothy and Kathy – We are so very grateful for you and your service to the ASET membership.  

And thank you, ASET members, for your diligence to our communities and our profession. Thank you for being a faithful reader. I feel safe to speak on behalf of our group to share that we love participating in and contributing to our field through sharing knowledge, resources and wisdom. It is an amazing hobby to write for you all.  

Happy Spring,  

Petra 


Acute/Critical Care Neurodiagnostics

Ambulatory Monitoring 

Clinical EEG

Epilepsy Monitoring 1

Epilepsy Monitoring 2

IONM

Nerve Conduction

Neurodiagnostic Education

Technologist Entrepreneurs  


Acute/Critical Care Neurodiagnostics

Author: Todd Ham, BS, R. EEG T., CLTM 

Please let me first apologize in advance for the following ramblings which jump around like an electrode pop artifact.  Historically, to me, the most obvious move away from paper which has impacted our profession was the transition from analog (paper) to digital EEG.  This change was before my professional time began but it must be the case that significantly fewer trees have been used since digital’s implementation.  But during my professional time, I have seen a transition at my institution from paper medical record charting to a digital medical records interface; this has also significantly reduced tree trauma.  I do wonder if there has been a net increase in electrical demands across the grid since computers and related electronic equipment have exponentially increased in usage; those demands do burden power plants which include those which are coal-fired.  I found it interesting when Petra Davidson commented that digital storage actually occupies physical space; I never thought about that.  We prune/clip/edit our long-term EEGs which significantly saves storage space; video files, of course, demand a disproportionate amount of gigabytes so those are only saved if associated with remarkable clinical events, such as, but not limited to, seizures.  For both EMU and ICU LTMs (cEEGs), we clip out five minutes of every hour of data (again, without video).  If there are remarkable electrographic interictal and/or ictal findings, then we also clip those out (with video, when applicable).  Tap tests are also saved with the video files.   

In Charleston, SC, we are rapidly eliminating the use of plastic straws (and bags), which is certainly progressive.  But our food service contractor Sodexo now keeps their plastic-free straws in the cashiers’ drawers under their registers.  So that is not ideal – you have to ask for a straw and they will pull out the drawer and hand you one of perhaps five that are in there.  Subway, which is adjacent to the main cafeteria, is not immune to straw withdrawal as when I asked for a straw recently they said I needed to go to the main cafeteria area and request one from the cashier (yes, the straws kept in the drawer); for me, this was the final straw.  But I digest…or is it digress?   

Instead of sending paper faxes, we have the option of using an electronic fax system, which saves both time and trees (certainly less work for the saw tooth).  And I’m still getting used to it but I received a boogie board writing tablet a few years ago and dusted it off recently.  I can write down quick notes at my desk and click a button to erase whenever the message isn’t needed anymore.  So that saves on paper.  Might I suggest that to prove the presence of lambda waves we don’t perform the classic recommendation of holding a blank piece of paper over the patient’s field of vision?  Instead, hold a computer (laptop preferable as they’re lighter) over the patient’s eyes to prove that the activity is lambda waves – a further way to utilize digital instead of paper.    


Ambulatory Monitoring 

Author: Jennifer Carlile, R. EEG T. 

Our topic suggestion was “ways we can use more digital and less paper” …. I believe in our office we do as much as we can do to diminish the use of paper but there are times when it is necessary. For those times, we recycle and have a Shred-It company come in every two weeks. They let us know how many trees we saved by recycling these documents. On the home front, we have different recycling containers for paper, plastic, aluminum and trash. Utilizing these different containers really makes a difference. Over the years I have collected many articles, journals and books that I have been separating into bins to eventually offer to NDT programs both here in the USA and abroad. I hate to think that all this information that I have acquired over my 30 years in this field would end up in a landfill.  

Now for an interesting case file that I would like to share with you. It is about the importance of using EKG. I understand that some places do not use the standard 2 lead EKG protocol in their offices/labs. In my opinion, it is not only helpful to determine some artifacts in the EEG, but it is especially necessary with our elderly population. The following EEG samples are from a patient who is 80 years old. PMH: patient presented with two episodes of blurred vision, was verbally unresponsive to wife, acting strange and afterwards complained of feeling odd and dizzy. No previous cardiac problems were noted.  The EKG sensitivity was not changed. 

Fig. 1
Fig. 2
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Fig. 8

Note screen display is at 30mm/sec to better showcase the EKG.

Fig. 9

As displayed, the EKG changes were significant. Bringing this to the doctor’s attention was important in the care for this patient. If the patient was treated symptomatically, his doctor would never had known of his EKG issues. Even if your doctors do not require EKG, go the extra mile, place the leads on the patient, acquire the data and if the doctor does not want to read the EKG, then delete the channel. But you might come across a patient like this where if EKG was not used then the patient could end up going into cardiac arrest.  


Clinical EEG 

Author: Emily Scanlan, BA, R. EEG T. 

In our lab area, we have made several shifts into greener pastures. When we started our new adventure into the EPIC world we had a HUGE decrease in paper consumption in our lab. Our tech sheet used to be on an 8 x 14 (ish) sheet of paper. We then used a folder and a sticky label to identify the folders. We would then print off the report and store it in the patient folder along with their referral sheet. This would then have to be stored for up to five years depending on the diagnosis. In order to store these, we had to have people sort and file them into the cabinet and at the end of the year, we had to ship them to a storage room. This caused a lot of pollution with transportation and storage space. Every time we had a patient who returned for an annual EEG we had to call out to the warehouse and have the records shipped back. 

After thinking about this whole process, although the EPIC conversion was difficult, it has improved, streamlined and made our practice greener. We have gone from all of that paper to one half-sheet per person. 


Epilepsy Monitoring 

Author: Magdalena Warzecha, R. EEG/EP T, CLTM 

My 17-year-old son recently did research on climate change. He was very concerned that businesses and governments don’t do enough about clean energy, reducing pollution, reducing emission of CO2 and reducing waste. He worries if we don’t take radical steps now, the earth’s climate will soon reach the point of no return. According to NASA, emission of greenhouse gases causes global temperatures to raise faster than expected. Landfills filled with human waste products contribute to raising levels of methane. The healthcare industry produces thousands of tons of medical waste, not only polluting the environment, but also the combined toxic and infectious properties of this waste represents a public health threat. As healthcare workers and as citizens of our global village, we have the responsibility to care about our patients and about our planet.  

There are many steps we can take in our neurodiagnostic labs to help the environment. We can recycle, re-use and reduce waste. In our organization, we recycle; there are labeled baskets for recyclables and for waste products in every one of our offices. We make efforts to reduce plastic waste in our workplace: instead of plastic water bottles and water cups we use reusable water bottles and glasses, reusable food containers, no plasticware nor plastic bags. We also try to eliminate printing and reduce the use of paper; documents are saved in electronic version with electronic signatures, protocols and policies accessible to all employees online. Video conference calls and video meetings with employees in satellite locations help us reduce travel.  

In the EEG department, technologists are trained to use the right amount of EEG supplies and products per patient. Frequently checking expiration dates of supplies is a good practice. Items with the closest expiration dates are marked and used first. It prevents us from wasting supplies and saves money. Unless there are infection control precautions, technologists use reusable electrodes for EEGs. Disposable electrodes are very appealing, but they are not bio-degradable, and their cost is higher. Disinfectants and bleach are used and disposed of as prescribed, without overuse. This year we will research Earth-friendly products to potentially switch from hazardous chemicals to safer alternativesWith the increase in public awareness about environmental issues, in healthcare, a growing number of resources are available to managers and hospital administrators for guidance and ideas, examples include: greenhospitals.net or noharmuscanada.org. Lets hope we can use them while there is still time! 

https://climate.nasa.gov/causes/ 

https://www.greenhospitals.net/waste/ 

https://noharm-uscanada.org/ 

https://www.epa.gov/environmental-topics/greener-living 


Epilepsy Monitoring 

Author: Susan Hollar, MBA, R. EEG T. 

Many years ago, the switch from analog EEG to digital EEG occurred. For those of us who lived during that era, we remember stacks of EEG studies that would fill a room waiting to be clipped” and scanned. There was an enormous amount of paper waste in that process. Even with that change, there was still a lot of paper with patient charts, schedules and reports. Currently, my organization is getting ready to join the EPIC generation. I know this will allow an additional reduction in paper usage in our department. We are currently getting our orders via a printer, put our daily schedule on paper and print a patient history on paper for each study. The new EHR will allow us to eliminate all of this paper. A huge win for the planet! 

Some of the other items to consider are the acetone and batteries that are used in most labs. Do you have a way to dispose of your acetone without putting it in the drain? We have a policy to use the collodion remover instead of acetone unless the patient is going to be re-hooked. This minimizes how much acetone we use.  It is important to dispose of the products correctly so they don’t get into the water or soil. Batteries should also be collected and disposed of properly so they don’t end up in the trash. Some organizations have strong processes that allow for this, others do not. 

We also requested a recycle bin for our department for plastic and paper (nonHIPAA related paper). We had an ice and water machine placed in the lab so bottled water is not required. This has reduced the amount of used plastic, which is important since the recycling of plastic is in jeopardy. 

About two years ago, we made the switch to disposable electrodes. This was a big win for saving time and reducing the risk of infection spread. What I am wondering about is the contribution to the landfill with all the disposable electrodes being used across the nation. I had not considered this until I started writing this article. Can they be recycled for anything? Should they go in regular trash that goes to the landfill? Will they ever disintegrate?  

I look forward to your feedback and ideas on this opportunity. 


IONM 

Author: Josh Mergos, MS, CNIM 

Online Education in IONM 

As of mid-March, both health care and education have been impacted on a national as well as global level, as the concern over the Coronavirus intensifies.  In just a week’s time, Ohio State University, Michigan State University and the University of Michigan, among others all made the decision to suspend face-to-face instruction for the remainder of the semester (along with the Big Ten Conference Tournament). 

So now what? 

Instructors who have had the luxury of in-person teaching, who have benefited from the constant feedback from a live classroom, are now forced to embrace what has been utilized by other organizations for over a decade, and figure out how to deliver the same level of instruction via the internet.  IT departments have come in full force to help tenured professors face the challenge of using web-streaming software, explaining how to mute noisy audience members and coaching them on how to present to an empty room as though delivering the same lecture to an auditorium full of students. 

That’s not to mention the issue of assessments.  How are we to deliver and proctor in-class exams?  Can these be done online?  Are there testing centers we can use?  How can we prevent students from working together on individual assignments?  Do we use the honor system?  Do we scrap things altogether and wait until things settle? 

The answer is simple, but not easy.  We have to entirely rethink our concept of education and remind ourselves that the goal is for students to learn by engaging the material and coming away with a solid mastery of the objectives taught.  Assessments can take many forms and may include timed activities distributed synchronously to students across the country or world.  I’ve had the advantage of experimenting with several different assessment strategies over the years.  Despite hoping and pleading for a “take-home” quiz or exam, students have found that these may be significantly more challenging, as the understanding is that students will have access to any resource imaginable, thus the requirement for the assigned task must be more profound.  This works for my upper-level courses, where the mainstay of exam content remains essays and the like.  These can be reformatted as written papers or reflections on a current journal article.  These are a few of the concepts I’ll be incorporating over the next six weeks to redesign assessment strategies. 

But I’ve neglected to mention one of the most pressing issues – how do we approach the clinical education of students that is held in facilities that are actively treating COVID-19 positive patients?  The answer here is a bit involved, but one could argue that of all public venues, a hospital is best-equipped to implement strategies and protocols to mitigate the spread of an infectious disease.  Universal precautions as well as droplet precautions are taught to all clinical students.  These are practiced in the hospital environment, where staff have a heightened sense of awareness, and preparedness to prevent the spread of contagions.  We teach our students proper technique, and as a field we later send them to hospitals that are filled with sick patients, because they will need to practice proper safety and precautionary measures throughout their entire careers.  This a great learning opportunity and not something to panic about.  Along these lines, the University of Michigan has chosen to continue clinical rotation programs across all of its health professional schools, including Nursing, Dentistry, Medicine, Pharmacy, Public Health, Social Work, Physical Therapy and Kinesiology and continue to assess the situation. 

I look forward to the challenge of remote classroom instruction and believe that it will result in the implementation of several new strategies that I will continue to use once the dust (and germs) settles. 


Nerve Conduction Studies (NCS) 

Author: Dorothy J Gaiter, R. EEG T., CNCT, R.NCS.T., FASET, MHA 

If you really think the economy is more important than the environment, try holding your breath whilst you count your money.” ~Dr. Guy McPherson~ 

 The green initiative” has been a concept that healthcare and people around the world have been working to find the best solution to save the planet in every aspect of daily living.  

Since becoming a traveler in the neurodiagnostic field, I do not stay at one facility long enough to know what methodology is used to go green. Although, I still see lots of paper… clearly less than what it was several years ago though.   

What I do during my travels when planning an out of town trip 

  • Always try to book a hotel close to where I will be working to save on gas 
  • When staying at a hotel, I comply with their “go green” initiatives, such as: 
    • Limiting the number of towels used each day and  
    • Having the linens change after three days of my stay instead of every day 
  • Comply with airports and other facilities that have separate trash bins, one for recyclables and the other for trash.  

Some neighborhoods are required to have a separate trash bin for recyclable materials. This past year while visiting family over the holidays in another state, I learned some states have  also passed laws regarding the use of plastic bags. Some grocery stores no longer have plastic bags, only the reusables, which you have to purchase and other stores charge a very small fee to put your items in a plastic bag. 

On a personal note, I removed the paper clutter from my office and it’s sad to say, but there were eight garbage bags of paper to be shredded 

The wheels of change are slowly turning, because many are not onboard, nonetheless, they do have to comply with the laws of their state(s).  

“The greatest threat to our planet is the belief that someone else will save it.” ~Robert Swan~ 


Neurodiagnostic Education 

Author: Mark Ryland, AuD, R. EP T., R.NCS.T., CNCT, RPSGT 

 Going Green 

Having grown up in a household where my father (although somewhat of a curmudgeon at times) was ahead of his time in many areas. He investigated and tracked our ancestry back to England, Wales and Scotland long before Ansestry.com AND he recycled in the late 1960’s. We had a small steel mill in our town who asked people to save cans and bring them to the mill. Dad did this religiously. Later, when our town began recycling cardboard, paper, etc., Dad enthusiastically did so. 

Fast forward to my Navy days. I generated an enormous number of cans and bottles (hmmmm…wonder what they contained when full!!) and discovered that Charleston, SC recycled, so I too began my recycling. This carried through into my actual adulthood. 

Our college, being the type of institution it is, does generate a fair amount of paper, but there are recycling bins pretty much EVERYWHERE on campus for paper, cardboard, cans and plastic. I have been using a supplemental Blackboard site for all my classes, and post all the lectures, weekly schedules and syllabi, rather than printing for the students (which, back in my neophyte days, I did!). 

At home, my wife and I could literally have garbage picked up once a month because we recycle so much. I have also started composting degradable food items with my usual grass clippings and leaves (another thing my father did, seriously, I think I owe him!) 

I would really like the planet to remain habitable for Lena & Talia, so I sincerely hope our politicians get on board with recycling & reusing “stuff” as well.  


Technologist Entrepreneurs 

Author: Janna Cheek, R. EEG T., CNIM 

Welcome SPRING and welcome GREEN!  Of course we are all ready for green trees, green grass, rainbow colors of flowers peeping up from their bulbs which have survived the winter bite of cold, snow and ice.  With this said, our office just went through another JACHO inspection, with a few minimal hiccoughs that of course were immediately corrected.  As I reviewed the recommended updates of policies and forms, I was reminded that since the last JACHO review (inspection) we converted all of our policy, procedures and protocol manuals into digital form.  With this conversion, there were several items missed or not updated, and not only was the inspection an eye opener to the missed items but as we cleaned out closets, went through boxes and wiped down now empty shelves with all the binders and notebooks gone, my heart leaped for joy when an entire box of 10 channel analog EEG tracings were opened up.  My young staff thought I had totally lost it, but I had an adrenalin rush of excitement like never before, and of course so many memories of “days of old” surged through my brain!   

Now I sew, paint and am a crafter and with all this EEG paper with squiggly EEG lines on it. Oh BOY!  A crafter delight for making scratch pads, notebooks, wall art, decoupage items, decorative paper flowers, Neuro EEGlacquered up shiny and sealed Christmas tree ornaments and, of course, since I love to teach, saved a few EEGs on paper for that!  I am making books and journals with these mounds of accordionfolded pages to utilize in an entirely different way than ever intended.  So, I feel content by not only transforming our entire office of manuals and threering binders into digital files which are now stored in the cloud but also by repurposing this storage box of analog EEG tracings into another useful product. 

We also save all correspondence, contracts and agreements to our computers instead of printing and filing in file cabinets.  This not only saves on paper but also saves on all that ink.  Over the past 18 months we have downsized our automobiles from large SUVs to smaller economical, less emissions and more fuel-efficient automobiles.   

There is so much that we each can do however I feel we at NeuroLinks have made great strides to step up to the plate and will be constantly pushing forward to help where we can.   

… I also live outside the city and plant lots of trees… 

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