IN THIS ISSUE

BRIEFINGS FROM THE BOARD 3

TECHNICAL TIPS 5

INTEREST SECTIONS 7

GOVERNMENTAL AFFAIRS AND ADVOCACY 29

CONNECTIONS CORNER 31

NEW MEMBERS 34

ASETnews Spring 2013 SPRING 2013 VOLUME 37, NUMBER 1

ASET OFFICERS BOARD OF TRUSTEES

PRESIDENT Susan Agostini, R. EEG/EP T., CLTM Judy Ahn-Ewing, R. EEG/EP T., CNIM, CLTM, FASET, BA Banner Good Samaritan Medical Center St. John Providence Health System Phoenix, AZ Detroit, MI [email protected] TJ Amdurs, R. EEG T., MS University of Pittsburgh Medical Center PRESIDENT ELECT Pittsburgh, PA Brian Markley, R. EEG/EP T., R.NCS.T., BS The Neurology Center, PA Sara Batson, R. EEG/EP T., RPSGT, CNIM, CLTM Silver Spring, MD Neurology Mobile System Associates, Inc. [email protected] Miami, FL

SECRETARY/TREASURER Scott Blodgett, R. EEG T., RPSGT, RST, BBA Pat Smith, R. EEG T., AA ResMed Corporation Child Neurology Center of Orlando, PA Rochester, NY Orlando, FL [email protected] Marcia Davidson, R. EEG/EP T., RPSGT, CNIM, RET, RN St. Mary’s Hospital Madison, WI

Ryan Lau, R. EEG/EP T., CNIM, CLTM, MS Indiana University Health Indianapolis, IN

Cheryl Plummer, R. EEG T., CLTM, BS University of Pittsburgh Medical Center Pittsburgh, PA

Christine Scott, R. EEG/EP T., CLTM, BA Massachusetts General Hospital Boston, MA

Cherie Young, R. EEG T., CNIM Children’s Hospital New Orleans, LA

2 BRIEFINGS FROM THE BOARD

Editor’s Note: This new column replaces the “President’s Message” and “From the Executive Director’s Desk” newsletter columns.

ASET BOARD APPROVES FIRST CHAPTER CHARTER NEW MEMBER-GET-A-MEMBER REWARD PROGRAM t its March 1-2, 2013 midyear meeting, the ASET Board of Trustees voted unanimously to approve the Hawaii Pacific ffective January 1, 2013, any Active, petition to be charted as the Hawaii Pacific (HIP) Chapter Associate or Student member in good Aof ASET – The Neurodiagnostic Society. The new chapter covers the standing of the Society who sponsors territory of Hawaii and the Pacific Islands. HIP annual chapter dues Ea new Active member for the 2013 member are only $20 for individual memberships and $30 for organizations, year will have the choice of receiving a $10 gift corporations, and institutions. The chapter plans on holding monthly certificate for use in purchasing any item in meetings with guest lectures that qualify for ACE credit hours, the ASET store, including webinar and online starting a lending library for distributing educational resources, course registrations, or a $10 credit toward developing a job resource guide for contract and coverage work in its their 2014 member dues. Any Institutional territory, producing annual meetings, and organizing chapter trips employee member who sponsors a new Active to the ASET annual conferences. For more information and to join member for the 2013 member year will receive the chapter, contact Michelle Russo, HIPASET Chapter President, at a $10 gift certificate for use in purchasing any [email protected]. item in the ASET store. The Hawaii Pacific Chapter becomes the first organization to be To be credited with sponsoring a new Active chartered as an ASET chapter since the program was officially adopted member, all you need do is have him or her by the ASET board at its August 2012 meeting. To learn more about the enter your name where it asks for the “Sponsor’s new chapter program and for helpful tools to start a chapter in your area, Name/Who Introduced You to ASET” on either or to learn how your current local, state or regional neurodiagnostic the hardcopy or online member application society can be recognized as an ASET chapter, click here, or visit the form. When ASET receives the new Active “Chapters” page under the membership tab of the ASET website. member application, you will be notified by email and asked to let us know whether you would like to receive the gift certificate or dues credit. (Institutional employee members will automatically be mailed the gift certificate.) There is no limit on the amount of credit that you can earn. The more new Active members Welcome that you sponsor, the more gift certificates or dues credits you can accumulate. In addition, HIPASET it does not matter what time of year the new Active member application is received. Even though the first-year dues are pro-rated, you will still receive the gift certificate or dues credit for the full $10. Click here or click on the Membership tab of the ASET website for some tips for recruiting your co-workers and colleagues.

3 BRIEFINGS FROM THE BOARD continued

ASET BOARD ANNOUNCES NEW RECOGNITION AWARD BALLOTING FOR THE 2013 ELECTION IS ABOUT TO OPEN he ASET board is pleased to announce the “ASET Trustees Award.” The purpose of this new award is to honor an individual, institution, he ASET Nominating Committee is neurodiagnostic program, or industry supplier who, through putting the finishing touches on its Ta body of work, has made a profound impact on the neurodiagnostic report and slate of candidates for the profession or advancement in the improvement of quality patient care. T2013 election. This year, you will be asked The nomination criteria for the new award is that the body of work for to cast your vote for the offices of President- which the individual, institution, neurodiagnostic program, or industry Elect and Secretary/Treasurer, and for two supplier is being nominated must encompass at least two of the following trustees to the board. When the Nominating six criteria: Committee Report is published, please 1. Has made a profound impact on the neurodiagnostic carefully review each candidate’s information profession to determine the skills, background and 2. Contributed to the improvement of quality patient experience, and strategic foresight that you care think will best guide ASET into the future, 3. Advanced the practice, art, and science of and then cast your vote. neurodiagnostics 4. Reflects the values, ideals and ethics of the All Active, Associate, Student, Lifetime neurodiagnostic profession and Emeritus members – and Institutional 5. Presents an extraordinary and heightened favorability members’ voting representatives/primary view of the values and contributions of the billing contacts – in good standing of the neurodiagnostic profession to the general public and Society are eligible to vote. Your vote is community at large, or within the neurodiagnostic critically important and may very well profession influence the outcomes of the election. As 6. Represents an extraordinary commitment to the with prior year elections, voting will be neurodiagnostic profession and/or to ASET – The electronic. Announcement of when voting Neurodiagnostic Society is open will be posted under the “Breaking News” section of the ASET website and sent in a broadcast email to the membership. For information on how to nominate an individual, organization, or supplier for the ASET Trustees Award, and to access the nomination form, click here, or visit the “Awards” page under the “About” tab of the ASET website. The deadline for submitting nominations is May 31, 2013. The recipient of the annual award will receive recognition and presentation of the award at the business meeting & awards luncheon held in conjunction with the ASET Annual Conference, a suitably engraved plaque, and recognition in The Neurodiagnostic Journal.

4 TECHNICAL TIPS

MEDICARE UPDATES 2013 Kathryn Hansen, R. EEG T., BS, CPC Healthcare Consultant Integration Consultants Lexington, Kentucky

egulatory challenges have tested our practice profitability with the need to implement documentation and billing changes. This year there are additional factors which will impact clinical and financial practices: CPT® coding guidelines updates, place of service (POS) Rcode updates, ordering and referral edits in Provider Enrollment, Chain and Ownership System (PECOS), and implementation of ICD-10-CM code changes.

A very important change in wording for 2013, as documented in the CPT® Coding Guidelines and subsequent CPT® Codes, is the definition of a qualified healthcare professional. This is the description noted in the 2013 CPT® Manual published by the American Medical Association (AMA):

“When advanced practice nurses and physician assistant are working with physicians, they are considered as working in the exact same specialty and exact same subspecialties as the physician. A ‘physician or other qualified health care professional’ is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional service. These professionals are distinct from ‘clinical staff.’ A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional…..who does not individually report that professional service.”

For practices who bill evaluation and management codes and professional services associated with interpretation of procedures, these changes may impact subsequent credentialing for contracting with third party payers. Take time now to ensure all providers who are submitting claims for your patients are enrolled with a current profile documenting current credentials for practice. This may be impacted by the information posted in PECOS as well.

Related to this is another important update on PECOS and the need for validating ordering/ referring edits.

All providers who submit claims to Centers for Medicare & Medicaid Services (CMS) for services, that were ordered or referred by a provider, who has not been approved through the PECOS system, will have the claim denied. This is being introduced in two phases. At the end of the second phase, specifically: if the ordering/referring provider is not on the claim, it will be rejected; if the ordering/ referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and is eligible to order/refer; and if the ordering/referring provider is not in PECOS or is in PECOS, but is not of the type/specialty allowed to order or refer, the claim will be rejected starting TIPS TECHNICAL May 1.

5 TECHNICAL TIPS continued

Physicians with a valid opt-out affidavit on file are excused. As well, clinicians will need to identify what additional Others must have a valid enrollment on file, either on clinical documentation and descriptive language needs to paper via 855-O or electronically via PECOS, or claims will be added to digital templates in billing and coding systems be rejected. (CMS mentioned in the Open Door call that to ensure selection of the correct code for ICD – 10. Take practitioners with a current 885-I would also be covered.) time to identify how your practice enters key words, medical notes, and content in the medical records so the protocols Another factor, which will impact our practice in sleep are clearly communicated to the coder. If your practice medicine, is the documentation for and providers use a billing service or Place of Service – POS. Effective clearinghouse, take time to work with them after April 1, 2013, POS is defined as It is time to prepare to collaborate on the content in templates, the setting in which the beneficiary our electronic on encounter forms, and in documentation receives the face-to-face service. If medical records templates to ensure they have the same the face-to-face is not completed by with comprehensive information you have in updated electronic the physician, such as those when a clinical templates to records and reports. physician provides the professional ensure more detailed interpretation of a diagnostic test documentation for the Additional education on anatomy and from a distant site, the POS is the physiology may be required to clearly new code set. setting in which the beneficiary communicate with coding and billing received the technical component staff the required clinical condition(s) of the service. For example: a and associated co-morbidities which are patient receives a sleep study or EEG at an outpatient medically indicated to define the comprehensive clinical hospital near his home. The hospital submits a claim for documentation required for medical necessity supporting the technical component. The Physician submits a claim the procedure. This documentation is critical to reduce for the interpretation in her office. Submit POS 22 for the denials, reduce delays obtaining reimbursement for services, professional component to indicate the patient received and reducing the time to rework a claim. All of these delays the face-to-face portion of the procedure at the outpatient cost money. hospital facility. Today, efficiency and streamlined services reduce costs and And yes, the integration of ICD-10 CM will occur October subsequently increases revenue. 1, 2014. There may be other opportunities to consider in the face of According to all communication this author has received all these changes. With the changing landscape for clinical from CMS and published national coding initiatives, the providers, there are opportunities to consider as we respond to implementation will occur on this date. Therefore, it is time to all these changes. Integrating monitoring of testing outcomes prepare our electronic medical records with comprehensive is needed to ensure effective therapies and patient adherence clinical templates to ensure more detailed documentation with therapy. Collaboration with third party payers, the for the new code set. Critical to this implementation is a patient, your referral network, and the community will boost strong knowledge of anatomy and physiology for each coder recognition of your services. working in your program to effectively translate the clinical documentation into the appropriate code selection.

6 INTEREST SECTION BRIEFINGS INTEREST SECTION COORDINATOR Margaret Hawkins, R. EEG/EP T., CNIM, CLTM Wausau, WI WELCOME FROM THE INTEREST SECTION COORDINATOR [email protected] By Margaret Hawkins, R. EEG/EP T., CNIM, CLTM INTEREST SECTION LEADERS our times each year I ask the members of the Special Interest ACUTE/CRITICAL CARE Group to compose articles for this ASET Newsletter feature. NEURODIAGNOSTICS I give them a “theme”, pose some questions, try to tweak Sara Batson, R. EEG/EP T., RPSGT, CNIM, CLTM Ftheir imaginations, and they then do the hard part of reaching Miami, FL into their individual experiences, knowledge bases, current and [email protected] past employment situations, etc. to come up with a pertinent Erika Diaz, R. EEG T., CLTM and interesting written item. Because I believe that we are each a Chicago, IL product of our past and present, I thought it would be fun to explore [email protected] and share “something old and/or something new” as related to neurodiagnostics. As usual, these special people did not fail in their response to this challenge. I hope you enjoy (and learn from!) their AMBULATORY MONITORING Jennifer Carlile, R. EEG T. submissions. Cleveland, OH Lucy has informed me that this is the Spring Issue of [email protected] ASETnews—Perhaps by the time it reaches your inbox, our Midwest piles of snow and sub-freezing temperatures will have given way to greening grass and sunshiny days! CLINICAL EEG Keith Davidson, R. EP T., BA Mankato, MN Acute/Critical Care Neurodiagnostics [email protected] By Sara Batson, R. EEG/EP T., CNIM, CLTM, RPSGT Petra Davidson, R. EEG/EP T., BS. Mankato, MN The theme for this newsletter is “Something Old, Something New.” [email protected] As we all know in the EEG world, continuous EEG monitoring at bedside in the ICUs has been growing over the recent years. Let’s discuss some old and new methods of applying the leads in these cases. COMPUTERS IN THE WORKPLACE In Neurodiagnostic school, we had to obtain one glue competency TJ Amdurs, R. EEG T., MS per semester, either in lab class or at the clinical site. Most of the class Pittsburgh, PA utilized the classroom lab. I was taught then, to pre-fill my EEG cup lead [email protected] with conductive paste, and then to use a little glass dish filled with collodion to dip the gauze square in. After that, I would cover the lead on the head CPT® CODES with the saturated gauze square, and dry with an air hose pump. One of my Lynn Bragg, R. EEG/EP T. classmates tried gluing the lead with hair crossed over the top of the lead Canton, OH per a suggestion. She would then proceed using a bottle with an applicator [email protected] tip filled with collodion to squeeze the glue out, saturating the area, and drying it with the air hose pump. (I happened to be the lucky recipient on Kristina Port, R. EEG/EP T., RPSGT, MPH the other end of that glue bottle. I picked dried glue out of my long hair for Novelty, OH over a week after that.) [email protected] At the clinical site I attended, gluing was not very common. Generally, if there was a need to use collodion it was for a long-term DEPARTMENT MANAGERS monitoring patient. In that case, I was taught by a little older lady, (who Stephanie Jordan, R. EEG/EP T., CNIM, CLTM had been a tech longer than I had been alive,) to fill the EEG cup lead with Seattle, WA conductive paste and place it in the spot I had scrubbed with the skin prep [email protected] product on the patient’s scalp. Following, I would put the gauze square in the palm of my hand while wearing gloves. Once I had done that I would begin Pat Lordeon, R. EEG T. using the bottle with an applicator tip like at school or just thecollodion Pittsburgh, PA bottle itself, and saturate the gauze in my hand. What a mess that was! [email protected] 7 EPILEPSY MONITORING Acute/Critical Care Neurodiagnostics...Continued Susan Agostini, R. EEG/EP T., CLTM Phoenix, AZ The sweet little older tech had mastered the art of it, but I had it spread from [email protected] me to the patient and everything in between, including the head of the bed. After graduation, I began working at a Level 1 Trauma Facility. This Cheryl Plummer, R. EEG T., CLTM, BS is where I learned to master gluing. We would glue several patients a day Pittsburgh, PA [email protected] whether it was for a routine order or a continuous order. These patients ranged in all ages. Whether the tech decided to glue or not always depended on the patient, the situation, and the order. It was here I was taught by a tech INTRAOPERATIVE NEUROMONITORING to put the conductive paste on the back of my hand and fill the EEG cup lead Jeff Balzer, PhD, FASNM, DABNM one at a time. This was much more efficient for me. After filling and placing Pittsburgh, PA the EEG cup lead on the prepped area of the patients scalp I could then pull [email protected] a collodion saturated gauze square from a frozen meal dish, such as what is used for microwavable dinners. It was wonderful! Yes, she showed me that Ryan Lau, R. EEG/EP T., CNIM, CLTM, BA frozen meal dinner containers could come in handy. They could be used Indianapolis, IN for more than warming up your dinner. They could be used in the world of [email protected] Neurodiagnostic Technology. Who would have ever thought? Justin Silverstein, CNIM, R.NCS.T., CNCT, MS Utilizing these wide and shallow dishes, I could neatly lay out the Deer Park, NY amount of gauze squares I needed all at once, individually count them out, [email protected] and then pour the collodion glue over the top so they were completely covered. As each square is picked up out of the dish the excess glue can be wiped off on the edge of the container and applied to the EEG cup lead MAGNETOENCEPHALOGRAPHY on the scalp. Then it is dried with an air hose plugged into the air outlet Hisako Fujiwara, R. EEG/EP T., CLTM, RPSGT in the wall behind the bed using a chemtron and christmas tree. (If the Cincinnati, OH air supply is being utilized by the vent we have a T-bar, which is like a [email protected] splitter enabling us to share the air supply with the vent. I always call the JP Lowe, R. EEG/EP T., CNIM, CLTM Respiratory tech to plug this in for me in this type of situation.) I was very Summit, NJ pleased to have a good air supply and less mess; becoming more proficient [email protected] with time soon followed. Afterwards, the excess glue dries nicely and neatly in the container which can then be pulled out and thrown in the trash or the whole container can be thrown away. There’s typically always someone NERVE CONDUCTION STUDIES eating a frozen dinner, so as long as the container is cleaned out well, it can Dorothy J. Gaiter, R. EEG T., R.NCS.T., CNCT, be ready to go glue the next patient. FASET, MHA For instances when all I need to do is repair a lead or two, then I Birmingham, AL use a medicine cup with a gauze square in it and a little bit of collodion. A [email protected] couple techs I know use collodion in a tube. It can be purchased that way Jerry Morris, R.NCS.T., CNCT, MS and it is great for repairing just a few leads when needed. Shreveport, LA Whether utilizing an air pump or the wall outlet, I have always [email protected] used a steel tip applicator to put in the EEG cup hole and twist the top to make the hole open for refilling. I refill it with conductive cream via a blunt tip needle and syringe when needed to keep impedances down. It will also NEURODIAGNOSTIC EDUCATION allow for the recording to look good and be as artifact free as possible. Some Mary Feltman, R. EEG T., MEd techs have told me they use an air hose with just the open end of the hose Hewitt, TX and no applicator tip for drying. [email protected] Some techs use gauze squares of various sizes and made out of Mark Ryland, R. EP T., RPSGT, R.NCS.T., CNCT, various types of woven mesh. Some techs prefer to pre-fill the EEG cup AuD leads prior to gluing them on. Some techs apply all the EEG cup leads empty Parma, OH and then fill the leads with conductive cream after all the leads have been [email protected] applied. I prefer the paste on the back of the gloved hand method! I have tried utilizing EC2® Genuine Grass Electrode Cream for those patients in ICU that are comatose, but I personally have not found it to work very well. The patient may not be moving, but everyone else around the patient is constantly moving the patient. Rotating the patient side to side intermittently, pulling the patient up in bed, and moving the 8 NEUROFEEDBACK Acute/Critical Care Neurodiagnostics...Continued Bill Coslett, CNIM, PhD, BCIA, EEG-C Lake Worth, FL patients head pillow or pillows, etc. causes EEG leads to be tugged and [email protected] pulled on which in turn can cause the leads to fall off. I have also tried the new collodion (Collodion A10) due to Riki Rager, R. EEG T., FASET, BS Nashville, TN complaints from hospital staff, patients, and family members in our facility [email protected] who do not like the smell of the collodion glue. Collodion A10 does not have the pungent odor (which I feel is better smelling than some other things in the hospital,) but I have not found it to dry very well or keep the NEW TECHNOLOGIES & RESEARCH leads adhered to the patient’s head. Andrew Ehrenberg, R. EEG T., CNIM, BS There have been questions raised by new techs in the lab that do not Atlanta, GA find this method of gluing to be very sanitary. In that case some techs utilize [email protected] the emesis basins for the method I described above in place of the frozen dinner containers. We utilize emesis basins for removing glued leads by Marco Moreno, R. EEG T., MS lining the bottom with cotton balls and then pouring acetone or collodion Fenton, MO [email protected] remover over the cotton balls until they are saturated. Then we dispose of the container properly afterwards. I recommend you check with your safety officer at your facility and PEDIATRICS & NEONATOLOGY see what works best for you in your situation. Collodion has to be stored in Shelly Gregory, R. EEG T. a fire safe. Collodion cannot be left sitting out anywhere in its container or Snohomish, WA in any other type of container, such as the bottle with the applicator tip. This [email protected] is according to our Safety Champion in our area of the facility. I hope I have given you “Something Old and Something New” to Melanie Sewkarran, R. EEG T., CLTM ponder for the next time you need to glue a continuous EEG at bedside on St. Louis, MO a patient in your facility. Thanks for reading the interest section. [email protected] Ambulatory Monitoring POLYSOMNOGRAPHY/SLEEP By Jennifer Carlile, R. EEG T. TECHNOLOGY Scott Blodgett, R. EEG T., RPSGT, BBA Rochester, NY The theme for this newsletter is “something old and something [email protected] new.” I thought it would be a good time to revisit the question to glue or not to glue…? Kathryn Johnson, R. EEG/EP T., RPSGT, FASET For many years I have been asked the same question, is there a way to Huntington, WV attach electrodes without using collodion? [email protected] So many people complain of the strong odor and the residue it leaves in the hair. Well, I am very excited to share with you another way to attach electrodes… without collodion! For the past 6 years, I personally have been using this type of adhesive tape to apply electrodes for ambulatory EEG monitoring. Okay, I know what you are thinking, I thought the same thing…what, tape on patient’s hair…no, way! Well, I am here to tell you it works and works well. The name of the product is Cover-roll® stretch adhesive gauze (Figure 1). It comes in 2 inches x 10 yards and other various sizes. As listed on the box, it is hypoallergenic, air permeable, cross elastic, non- woven adhesive bandage. This is the only brand I have tried and I swear by it. As with anything, the more you use it, the more comfortable you become and the more efficient you will work. Your patients will be happy because there is no collodion residue left in the hair after electrode removal. And not only your patients but your 9 Ambulatory Monitoring...Continued co-workers will be most happy because no more collodion The most important challenge is making sure the odor. It is always best to use on clean-product free hair. hairs are laying as flat as possible or at least make sure once However, I have used this method successfully on a little the tape is in place. If the patient has longer hair, take a African-American girl whose mother the night before put strand of their hair and lay it over the piece of tape, kind of special oil all over her hair. There were a few electrodes that holding it down until the head wrap is in place. Because some I thought might not hold up (posterior region) but I was people are active sleepers, tossing and turning all night, if the unable to use collodion at this lab, and so I really did not head wrap comes off, instruct the patient not to remove the have any other choice but to try. Well, I cannot begin to tell entire wrap, give them extra gauze and tape to add to what is you how excited I was to see how well this method worked already on their head. The electrodes really should not come even with the oily hair product. off without using a remover, unless the patient actually pulls How to use: the adhesive tape comes on a 10 yard them off, and they can do that even with collodion. roll. Cut the tape into 2 to 2½ inches in length. Just like As far as removing the electrodes, once the test is applying electrodes with collodion, after measuring the head complete I use collodion remover (acetone not necessary), as normal, use a small amount of skin prepping cleanser, with starting on one side, saturate a piece of tape, move to the the electrode, scoop a nice amount of electrode paste into the next electrode, until you get all the way around the head. electrode, depending on how long the electrodes need to stay By that time, where you first started saturating the tape, that in place, (use a bit more if monitoring for more than two piece of tape should pull off easily without pulling any hair days), then place the electrode onto head. Making sure the with it. Remove each piece of tape then peel off the actual paste is laying directly on the scalp and that the surrounding electrodes. I then like to take a towel and really give a good hairs are lying flat, take a 2 to 2½ inch piece of tape, peel head massage, absorbing the excess oil from the remover as off the backing paper cover, exposing the sticky side, lay the well as any leftover paste. You should be able to easily comb sticky side over top of the electrode. Making sure to center the through the hair. Then I instruct the patient to go home and tape over the electrode helps eliminate any potential lifting, wash as normal. There should be no residue like there is with which could cause popping artifacts. Holding that portion of collodion. If you have any questions and wish to discuss this the electrode and tape down, use your other hand to peel off application process, please feel free to either email me or the remaining paper covering of the tape, then press firmly call me. I am so excited to share this method with everyone over top the entire electrode (covering above tip of electrode, who has had hurdles to jump with collodion. In my opinion, past the hub), again insure the entire electrode is covered. If collodion is still the very best way to attach electrodes; it is not, add another piece of tape going diagonal, making however, this tape method is a close second. sure to cover the biggest part of the electrode. As with most I am including a few samples of the tape method tapes, a little bit of heat makes the adhesive stickier, so that was used on a patient for 7 days (Figures 2 through once all electrodes are in place, I wrap the head with cotton 4)…can you tell the difference between collodion vs. tape? gauze rolls. Between the head wrap and the patient’s body temperature, the tape really sticks well.

10 Ambulatory Monitoring...Continued

11 Clinical EEG We ordered televisions, DVD players, movies, and By Petra Davidson, R. EEG/EP T., BS and books for our patients. We banned chloral hydrate from our Keith Davidson, R. EP T., BS lab. We banned the papoose boards. Yes, we know there are labs who love them. We allow a parent to hold the child, gen- Greetings readers, tly swaddling the child in the parents’ arms with a blanket, Yeah, Spring!! We are looking forward to some green and we turn on a movie. As the child watches the movie, we grass, buds on trees, and hearing birds again. Looking for- explain about the “camel snot” we will use to clean their head, ward to the things which seem new after the long winter, we the “toothpaste” that holds the little wires, and how their are reminded of the new things that greet us at the ASET brain draws us pictures. We also explain to the parents that conferences, in the ASET journal, and from the colleagues the smaller children will cry a bit and that is okay, it is the we meet. same as the breathing exercise we would ask an older child Keith and I have each been performing EEGs for or adult to perform. We then turn down the lights, allow the over 13 years. In that time we have developed a great deal of movie to play while the parents and technologist talk quietly. confidence in our preparation and application of electrodes. Soon the child sleeps naturally. The children play bubbles or We also felt very secure with how we performed EEGs on pinwheels with us to perform hyperventilation. When they children. wake up, we play with the strobe light and the child is shown While our lab has very specific policies and guide- how to make their fingers move in slow motion. When all is lines on how to perform an EEG in a variety of circumstanc- done, we wash their hair with a little warm water and give es, our written policy on how to attach the electrodes is in- them a sticker and they are a new friend. tentionally vague. The reason for this is to allow freedom to A technologist that trained both of us once said perform this action in the manner most efficient for each these very wise words “the moment you think you know ev- of our techs with some general guidelines on supplies used erything there is to know about EEG, a patient will walk in but nothing too specific. The great thing about keeping this the lab and turn everything on its side.” He was so right and policy vague is that we have the freedom to try new things this has served as a reminder to always be open to what’s new out without having to rewrite a policy every time a change is and changing, whether that is in how we prep our patients, made. or in how we work to calm them during the test, remember For example, for years we used collodion on all pa- there is always something new about to walk in the door. tients that had a high risk of removing the electrodes. It suc- cessfully served its purpose and still does. However, we have Computers in the Workplace had patients and staff complain about the odor, had near By TJ Amdurs, R. EEG T., MS misses with the collodion coming into contact with patient’s faces, and experienced the unpredictability of the formula of I never envisioned that I would have a career in Neu- collodion. At the last ASET conference, a presentation was rodiagnostics. It surely never was the plan when I first began done on securing electrodes. EC2® Genuine Grass Electrode college. Life takes many different twists and turns. My life Cream was mentioned and methods used to secure the elec- was no different. I started college as a music performance trodes utilizing EC2® were explained. We brought our new- major. I continued with this path until I was injured during a ly acquired information back home and after a trial period summer job that changed my life forever. Due to the injury, I of using EC2® we found we love this stuff (after getting past could no longer endure the amount of time it took for prac- the learning curve). No smell, no special remover, easier to ticing, rehearsals, and performances. I did not know what I control where it goes, formulation remains consistent, and was going to do at that point until a conversation that I had it doesn’t require special storage. We have now been using with a neurologist. I was explaining that I wanted to contin- EC2® in place of collodion for many months. ue on with school yet did not know what I may want to do. In the realm of pediatric EEG it was not until after Music had been such a big part of my life. He told me of a our youngest son had his first seizure that we really evalu- program they had at one of the local colleges. It was called ated how we performed EEGs on kids. He was 2 years old EEG Technology. at the time (yes, we were both already EEG techs and that I enrolled into the EEG Technology Certificate was strange having work show up at home in your arms that program at Carlow University in Pittsburgh, Pennsylva- way). We had a bad experience with his first EEG at another nia. I figured it would at least provide me with education facility. At the time we (patients parents) were the only EEG and training to be able to work. When the day came to techs in our facility so we had to take him elsewhere for his start, I tried to keep an open mind and see what this EEG test. It ended with sedation with chloral hydrate, scabs on his Technology was all about. I sat there talking to a few peo- head that lasted over a month, and no results for six months. ple not knowing what to expect. As the class started and We promised ourselves we would make it better for those the instructor began with the frequency ranges: alpha, who came to our facility. theta, delta, and beta, I thought I made a huge mistake. 12 Computers in the Workplace...Continued

It was as if he was speaking a foreign language or in tongues. I am not a physicist! Everyone started asking questions right away with a lost and confused look. At the very least, I am not alone. I slowed myself down and remembered to keep an open mind. I went home and started reading and talking to others in the class. I ended up doing very well in the program and came to love EEG. I tried to learn as much as possible and still continue to learn today. As the program progressed into the final semester, I enrolled into a Health Science bachelor’s degree program at Carlow University. Around the same time, I began my first job in EEG. I began working at Children’s Hospital of Pittsburgh in the Epilepsy Monitoring Unit. There were many special people who worked there and I was very proud of my first job in my Neurodiagnostic career. After I moved to a smaller community working nights for a few years, I moved to a smaller community hospital where I hospital where I was the only was the only technologist. I gained valuable experience and built some great bonds technologist. I gained valuable with people there. One of them was a neurologist who asked me to come and work experience and built some great at my next job at a large city hospital. It was the Chief Technologist position where bonds with people there. I held management responsibility as well. As I worked here, I went back to school and completed my Master’s Degree in Health Services/Professional Leadership. I soon after wanted more responsibility in management. I moved to Boise, Idaho and worked at a great health system there. I was responsible for Neurodiagnostics, an epilepsy monitoring unit and intraoperative monitoring. While I was here, I was on the Board of Directors for the Epilepsy Foundation of Idaho. It was a great experience. Following this, we ultimately moved back home to Pittsburgh to work at the University of Pittsburgh Medical Center where I am currently the Coordinator for MEG Services. I remain active in ASET and am on the Membership Committee and I am on the Board of Trustees for ASET. The work for ASET has been some of the most rewarding work I have done. It has been an awesome career and I have met many incredible people along the way. I can’t wait to see where the road takes me next!

CPT® Coding office. For the technologist it is a bit more work, filling out By Lynn Bragg, R. EEG/EP T. the demographic information and patient history. For me personally, it is double the work since I complete a patient Ahh!! The good old days. Remember when you history for the EEG recording in the EEG acquisition process could have a kidney stone and the doctors would order an as well. EEG because you happen to mention you had a headache a The changes in reimbursement and requirements week ago? for billing purposes have made changes in our field a global So much has changed through the years and I have change. It most likely will be a continuing force for us as well my suspicions that billing and coding will be high on the list as many other fields of medicine. Unfortunately, with these of most changes for some time. Just in the past year or so, changes, if it doesn’t work well for your lab you can’t change look at how coding and billing for EMGs has changed. it like you could if you had changed your brand of paste or In past years for EEG, billing for portable studies was gauze. permitted. Now it is based on awake, drowsy, sleep, or length of recording, regardless of how much “tech” time is needed for a study. Accepted diagnoses are now a major part of SAVE THE DATE reimbursement. As mentioned at the beginning of my article, SATURDAY, AUGUST 3, 2013 years ago kidney stones would not have been questioned, today probably not so much. Most of the studies done today regardless of the ASET ANNUAL CONFERENCE modality should be billed from the interpreted report. RENO, NV Electronic Medical Records (EMR) is the future of medical records. Interpretations are being done by completing templates that have been specifically formatted for the CPT CODING modality tested. WORKSHOP My office has been using EMR for several years and we have been using templates for all the testing done in the 13 Department Managers changes are the most likely to meet pushback, or to not be By Pat Lordeon, R. EEG T. implemented successfully. Change for the sake of change is never a good idea. The successful manager keeps one foot in When I look back and compare how our labs the past, and one in the future. operate now compared to how they operated years ago, some changes seem very dramatic, and others more subtle. Some By Stephanie Jordan, R. EEG/EP T., CNIM, CLTM changes were implemented with a firm start date: today we do this, but tomorrow and every day afterwards we will Here is something very old taken from: The do that. Other changes evolved over time, gradually and American Board of Registration of Electroencephalographic unobtrusively becoming part of our everyday routine until and Evoked Potential Technologists (ABRET) Code of Ethics we can’t remember a time we didn’t do it this way! and Standards of Practice: Principle Number Seven: If asked to detail the most substantial change we have experienced over time, I would have to say that the change in “7. Refuse primary responsibility for our workflow due to the increase in our volume is the most interpretation of testing or monitoring obvious. When I started working in the EMU years ago, we of Electroencephalograms, Evoked were a four bed unit; our hours were Monday to Friday 7am Potentials, or Neurophysiologic to 4 pm; we had a staff of four techs and two RNs; and only Intraoperative Monitoring for performed an occasional depth electrode monitoring. Now purposes of clinical diagnosis and we are a Level IV eight bed EMU; open 24/7; responsible for treatment. Individuals who are all emergent/on call EEGs (thus eliminating the need to have licensed or otherwise authorized a tech on call for the hospital); we implant and monitor grid by practice standards to provide electrodes; provide cEEG for ICU patients; and have a staff of interpretation are excluded.” 16 techs, 16 RNs, and 1 Physician Assistant. Our work flow is more regulated and systematic, with the techs adopting and The ABRET code of ethics and standards of practice following many nursing policies. The “tech I was” would be have been around as long as I have, yet seem to remain new. dazzled with the way things work in the unit today! This is something that Managers and Supervisors should go The other dramatic change is in the way we train over with students and new hires during their orientation; our techs. I was trained in an “on the job” training manner. the students and new hires are so eager to share what they We were fortunate to have a physician in our department have learned or know. It can also be refreshed with staff at who was quite invested in tech education. He taught classes department meetings under the umbrella of patient safety; in Instrumentation, Neuroanatomy, Seizure Disorders, what if a medicine was withheld or given due to technologist Metabolic Disorders, and many more topics to both our lab interpretation? There have been many times I have been techs as well as to techs from neighboring hospitals, one to pressured by an attending physician to give EEG results at two hours per week. During the other 38 to 39 hours of the the bedside that could possibly influence diagnosis and week you worked in the lab. The only pre-requisite for the job treatment. I have always relied on the code of ethics that was a high school diploma. comes with your ABRET registration certificate. There is Currently, we operate a formal tech education always a distressed family member that asks for the results program for our tech trainees, with a dedicated staff of tech or an anxiety ridden patient who pleads and begs. Use and physician educators; a diverse curriculum consisting of Principle Number 7. When evoked potentials moved into the several half days of didactic classroom experience (plus a operating room and surgeons came to rely on intraoperative brain cutting); graded tests; Neurodiagnostic area rotations; monitoring to guide their surgery, the pressure to give and established pre-requisites for entry into the program interpretation became palpably higher. But you can stand (including possessing at least an associate degree). Very your ground on Principle Number 7. Do not enter the different from the days of old! operating room without a licensed or authorized interpreter. However, the “something new” in both of these examples As registered technologists we are responsible to has its roots in the “something old.” The workflow changes have an impression of the recording that we can share with evolved from the addition of new tasks to our basic job the interpreting physician. We must analyze what we are structure. We still do EEGs…we just do more of them, in recording to best document the clinical neurophysiologic more diverse situations and in a more complex manner. We events occurring for the patient at the time of our recordings still train techs….we just increased the amount of classroom but our responsibility stops there. Don’t forget Principle time and varied the types of experience. Number 7; it is like the Rock of Gibraltar. Lest we begin to think that everything new is good, keep in mind that the best and most acceptable changes are usually those with a familiar base or starting point. Radical 14 Epilepsy Monitoring accommodate the care of our new guests! We communicated By Susan Agostini, R. EEG/EP T., CLTM the change to the staff that would be affected and reassured them that all processes would be in place before initiating this “Something old, something new” made me think new workflow. EMU core staff gave many ideas, suggestions, about our Epilepsy Monitoring Unit (EMU) and how easily and recommendations that were taken in consideration we tend to become comfortable with the way we do things during the planning phase. every day. The staff is familiarized with the equipment. The The day came when we had to put into practice our procedures, and the overall daily workflows and operations new workflows. There were two patients transferred to our are clear and smooth. I am going to share our own experience unit as a pilot. These two patients were “hand-picked” by the when we had to deal with changes to our nursing director. Needleless to say, it was an EMU environment that shook the floor anxious and stressful situation, but it did beneath us! not take too long for the staff to continue Change is inevitable, and providing the same excellent patient care specifically in the healthcare arena we have that we have always provided. Management been hit pretty hard in the recent years as a debriefed the experience and it has been result of the economy downturn. Medical decided that the option of transferring non- insurances coverage, optimization projects, EMU patients to the EMU will be entertained re-engineering projects, patient volumes when the need to facilitate patient flow is changes, and staffing changes are only a few absolutely imminent, and of course if there of the many challenges that we are currently facing. are EMU beds available. The patients that will be selected for When we opened our EMU doors in 2011, I chose this will be pending discharge, or neurological conditions to create a culture that embraces and fosters change, turning such as stable post-stroke patients. So, our epilepsy patients them into opportunities to tap into our “creative juices” continue to be our priority and our passion! coming up with possible ideas and solutions! Change is not Every day that goes by is one more day that we prove easy, and it certainly creates a sense of instability in the staff to ourselves that we can manage changes, and that we can that has to be addressed in order to successfully transition be team players! So, during times when I am faced with a from “the something old to the something new.” I think that challenging situation such as the one that I shared with you one of the most important details when faced with what today, I remind myself of the unofficial Marine Corps motto could seem as a drastic change is to maintain “patient safety” shared by my husband and other retired military personnel, as our #1 priority in every action we take and every decision a long time ago… “Improvise, Adapt, and Overcome.” So we make. true! Our most recent change in the Epilepsy Monitoring Unit was the possibility of utilizing available EMU beds in By Cheryl Plummer, R. EEG T., CLTM, BS situations when the hospital is faced with patient overflow. The first time I heard of this idea I became very anxious as Well speaking of new, there are two new we had created a culture of ownership and accountability anticonvulsants that I wanted to be sure that all of you are within the core staff that now would be tested by opening aware of. One of the new medications is called Oxtellar XR™ our doors to a different type of patient population and to (oxcarbazepine extended release). This medication is used as staff that have not been in the unit before. For most, this idea adjunct therapy for partial seizures in adults and in children seemed most logical and feasible; however, the reason why it 6 years to 17 years of age. It comes in three size tables: 150 also raised some concern was because our unit is not located mg, 300 mg, and 600 mg tablets. To read more about this in the main inpatient tower. We are located in an adjacent medication and its side effects visithttp://www.drugs.com/ tower connected by a “spine” with the main tower. Some of pro/oxtellar-xr.html. the questions and concerns were… “What kind of medical The other drug is called Fycompa® (perampanel) problems will these non-EMU patients have, and are we fully which is used for adjunct treatment of partial onset seizures equipped for this?”, “Will float staff take care of our unit the with and without secondary generalization. This is used way we do?”, “Will things disappear from the unit?”, “We have in patients who are 12 and older. Fycompa® is a once a been a self-contained unit since we opened, and now we have day dose medication and the “first FDA approved non- to share our unit (the protective in us)?”... “Will our EMU competitive AMPA (alpha-amino-3-hydroxy-5-methyl-4- patients continue to be safe when we have other patients to isoxazolepropionic acid) glutamate receptor antagonist.” take care of?” This medication has interactions with other anticonvulsants The first step was to meet with all parties involved in that it can reduce their benefits. To read more about (patient placement, nursing managers, pharmacy) in order this drug and its side effects, visithttp://www.drugs.com/ to identify the type of patients that we could manage in our fycompa.html. unit, and the areas that we would have to modify in order to Wishing you all a happy Spring. 15 Intraoperative Neuromonitoring of injury to these innervations if we stimulate distal to them. By Justin Silverstein, R. EP T., CNIM, R.NCS.T., CNCT, MS By stimulating the deep peroneal distally at the ankle, we are able to better monitor for foot drop, which could be missed if Adding Specificity to the Neurophysiological Monitoring stimulated at the fibular neck, especially if the issue is caused Paradigm by Adding More SSEPs by leg positioning and not nerve root injury. It is really nice to have a more global view of the About a year and a half ago I decided after starting my nervous system and with more specificity I am able to trouble own practice that I wanted to offer better monitoring to my shoot better. For example, not too long ago I was monitoring patients by being more specific with the neurophysiological an ACDF where the right upper extremity ulnar cortical monitoring. I implemented median nerve and deep peroneal SSEP became attenuated. To rule out technical issues I ran nerve SSEPs in addition to ulnar nerve and posterior tibial the median SSEP to learn that the right median cortical SSEP nerve (PTN) SSEPs during every surgery. When I first was also attenuated. This allowed me to deduce that it was began in IONM I was taught to run ulnar nerve SSEPs most likely a carotid artery occlusion caused by the surgeon’s almost exclusively for monitoring of upper extremities and retractors. When I informed the surgeons and they removed PTN SSEPs for monitoring of lower extremities. There was the retractors, the responses from both nerves came back always the option to run other nerves such as the median or (Figures 1A, 1B, 1C, 1D). It gives you a nice feeling when peroneal; however, this was presented as use for very specific you do not have to second-guess yourself because you are procedures for example, median nerve SSEPs during carotid double checking yourself electrophysiologically. In another endarterectomy. example, I was unable to obtain the right ulnar SSEP I want to stress that we stimulate the deep peroneal response at baseline for a posterior cervical decompression nerve superior to the medial malleolus, as opposed to the and fusion likely due to a technical issue. I could have fixed deep peroneal at the fibular neck or the common peroneal the technical issue, but the surgeon would have had to undo at the lateral popliteal fossa. The reason for this is that the the entire patient positioning and taping. The surgeon felt deep peroneal innervates the muscles for dorsiflexion of the comfortable enough to move forward just monitoring the foot (tibialis anterior muscle and extensor digitorum brevis right upper extremity with the median nerve because it muscle). Which in turn are the muscles that are affected when allowed us to monitor spinal cord function without being a patient has a foot drop. We feel we can be more predictive inhibited by not having the ulnar SSEPs (Figures 2A and 2B).

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I have my entire group monitoring all these nerves and we have seen isolated deep peroneal SSEP losses that were attributed to retraction of the L5 nerve root during a laminectomy (Figures 3A, 3B, and 3C) and distraction of the L4-L5 disc space (Figures 4A, 4B, and 4C) during an ALIF. We feel our intervention in both cases prevented post-operative foot drop and upon initial follow up learned that the patients were neurologically intact.

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20 Intraoperative Neuromonitoring...Continued The method of monitoring multiple nerves also has great benefit when troubleshooting a change in the evoked potential caused by patient positioning. We are able to differentiate distal injuries vs. proximal or ischemic injuries in the upper extremities by using median and ulnar SSEPs. If the ulnar nerve attenuates or has a prolonged latency from initial baseline and the median nerve does not change, we know the event is occurring distal to the brachial plexus, most likely at or about the elbow and the cubital tunnel (Figures 5A and 5B). If both the median and ulnar attenuate, we know the injury is most likely occurring at the brachial plexus or the limb has become ischemic (Figure 6). By monitoring multiple nerves with SSEPs, we have made our monitoring paradigm more specific and less sensitive. We are more specific because we have become more focal in determining the source of a potential injury or technical issue. For example, if I were monitoring only ulnar SSEPs for a positional injury during a lumbar surgery and had a positive event occur where a change in the ulnar nerve is detected, I know that there is an issue affecting the limb in question; however, I cannot pinpoint where the injury is occurring (i.e. brachial plexus, cubital tunnel or ischemic event) therefore, the modality is highly sensitive but not specific. Whereas, if I am also running median SSEPs and they are also changed, we have now taken a sensitive modality and made it specific, because I know this is either a brachial plexus injury or an ischemic event, and definitely not an event occurring due to pressure or entrapment of the cubital tunnel. Another example would be a loss of the peroneal nerve SSEP due to the belt that straps the patient to the Jackson table impinging the peroneal nerve at the fibular neck. This again, is a specific injury, which would not have been seen if I were only running PTN SSEPs. Therefore, by adding multiple nerves to our SSEPs we are able to predict and prevent injuries from occurring that may have gone unnoticed. Surgeons and anesthesiologists like the fact that we are able to monitor “more” of the nervous system and we are able to give them better feedback regarding the neurological status of their patient during surgery.

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Magnetoencephalography By Hisako Fujiwara, R. EEG/EP T., CLTM, RPSGT

Brain network

On February 18th 2013, it was revealed that the U.S. government is planning a large-scale project that seeks to create the most comprehensive map of the human brain assembled so far. It is called “The Brain Activity Map.” Scientists likened the Brain Activity Map effort to the Human Genome Project, the government-led initiative that helped decipher the human genetic code and provided a huge boost for the genetics industry. According to Dr. John Donoghue, a neuroscientist at Brown University, the idea of this project is to organize a national effort to crack the problem of how the brain functions at its deepest levels, and how various neurological ailments might be better treated. Advocates for the project hope that exhaustive research into the brain’s neurons would produce insights that could be used to understand mental illness (i.e., schizophrenia) help treat diseases such as Parkinson’s and Alzheimer’s and even enable advances in artificial intelligence. A comprehensive map of brain activity has similar scope to the Human Genome Project, which recorded all the genes in human DNA and was completed in 2003 at a cost of $3.8 billion. This would be a great opportunity for the MEG world to be part of this project. In recent years, the interest has grown in the study of connectivity between spatially separate, functionally specific brain regions. The ‘default network’ is a network of brain regions that are active when the individual is not focused on the outside of the world and the brain is at wakeful rest. It is also called ‘resting state networks’ or ‘task-negative network’. The ways in which separate areas synchronize to form networks is integral to information processing. Abnormal communication between regions is thought to be the basis for a number of neurological pathologies (i.e., Alzheimer’s, autism, schizophrenia). If we are to generate a complete understanding of brain function, then elucidation of the role of brain networks will be critical. All the same requirements apply to brain dysfunction. (Well, it is a basic principle of neuroscience. If you do not know what the normal function is and what it looks like, than you cannot tell what the abnormal looks like, right?)

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The majority of research on this default, or resting time frame to do the test is still the same. With other aspects state, network has been conducted using functional magnetic of their neurology or rehab practice requiring as much if not resonance imaging (fMRI). During the resting state, blood- more time, it is difficult to add a patient or two or three to oxygenation level dependent (BOLD) signals originating compensate for the loss of revenue. From what I understand, in spatially separate brain regions are correlated in time. the specifics of this part of the study is never compromised More recently, there have also been studies investigating by these physicians, so what do you do, work longer hours to resting state networks using noninvasive measurements of squeeze in a few more patients?? electrophysiology, including MEG. MEG has an advantage In our hospital setting, we do a lot fewer EMGs in that it offers a useful way to measure connectivity between than NCVs. With the new NCV codes put in for 2013 it brain regions and does not rely on a delayed hemodynamic is hard to tell yet how it will affect our reimbursement. response, such as BOLD signals in fMRI, which is an I would guess we would have decreased revenues from indirect measure of brain activity. By comparison MEG our NCV studies but time and the end of the fiscal year measures directly the electrophysiological basis of brain will tell. The same would hold true for the physician NCV activity by measuring the magnetic fields associated with the studies as well. In my lab we still have the same protocols synchronized current flow in neuronal assemblies. for CTS, neuropathies, radiculopathies. You get the idea…. Unlike EEG, magnetic fields are not distorted by the only time there is deviation from these protocols, is inhomogeneous conductivity in the head. With higher sensor when I see something during the exam that shows me that density and complex source reconstruction algorithms, some other study or studies need to be done. Fortunately MEG provides improved spatial resolution compared to I have the leeway to do that. I still do the same nerves the standard 10–20 EEG topography. With its excellent temporal same way using the necessary time and then bill them resolution MEG has become the most attractive noninvasive by a different name than I did in 2012. To me the quality technique for measurement of electrodynamic connectivity and thoroughness of my NCS exam is absolutely essential in the human brain. However, there are still challenges in order to help the physician with the patient’s diagnosis. and unanswered questions in the MEG field, especially the Other coding changes in all aspects of electrodiagnosis projection of sensor space data to its source level. “MEGers” may be just around the corner. From what I understand, a lot have been working hard on this task worldwide. So we of the changes were to prevent billing abuse from individuals, already see progress on solving this task each and every day. offices, or companies that were simply doing lots and lots of Would you like to be a part of this national project unnecessary studies. They do bad – we all suffer! Who would “The Brain Activity Map”? have thought 3 to 5 or even 10 years ago we would be where we are now. As healthcare changes these next few years we Nerve Conduction Studies may see more changes, some good; some bad. By Jerry Morris, R.NCS.T., CNCT, MS Have a wonderful summer. Reno will be here before you know it – a great program, great friends, terrific Hey all you nerve stimulators out there! I’m baaaack!! networking, and a fun city with Lake Tahoe only an hour Dorothy was so gracious and kind to write the last couple away. See you there! of newsletter articles while I recouped from a knee injury and surgery. Weren’t her articles terrific? Here in Louisiana Spring is here, not just around the corner… the jonquils and tulip trees and redbuds and plum trees are already budding and blooming…..and the crawfish are cookin’… maybe the old groundhog got it right, at least for this part of the south. Margaret, the only white stuff I’ve seen is the white blossoms on the Bradford pear trees that are so abundant around here. Here in our area the EMG/NCS coding changes have been very noticeable. The EMG coding changes that took place for 2013 took away a good bit of revenue from the needle exam portion of the study. Several of the physicians affiliated with our hospital have been affected by these coding changes. There is less reimbursement coming in from the insurance company pay outs; on top of that the price of needles has either increased or remained the same with no decrease in price. Pay more to make less, so to speak plus the 23 Neurodiagnostic Education When I first entered the IONM field, I was very By Mark Ryland, R. EP T., RPSGT, R.NCS.T., CNCT, AuD obsessive compulsive. I would have individual packs of supplies for each patient including tape measure and When it comes to the latest and greatest technology marking pen to mark for precise measurement for cortical I must definitely put myself in the category of “Pterodactyl.” electrodes. It seems like after the first 1,000 patients I was My cell phone has an IQ of about -3; I can actually call people more comfortable in localizing placement for cortical leads with it, and have proudly acquired the ability to text (not easy and stopped marking each patient’s head. I have talked to on a device developed in the late Jurassic Period). Last year many of my co-workers who experienced the same process. my wife and I purchased our first flat screen TV, and there is Cortical electrodes were placed through anatomical markers. nothing automatic in the 2006 Mazda 3 I drive. My notion of I have been thinking that maybe I will go back to marking new may be skewed a bit. So my “new” topic is not really all individual heads! Early in my career, I was encouraged that new, but it is “new to me.” to used cup style electrodes rather than subdermal needle In 2010, I completed my AuD degree through a electrodes. Today I almost exclusively use subdermal needle distance learning Audiology Program. That was an absolute electrodes. leap for me. I had some basic computer skills from teaching My father used to tell me that the more things for four years, but the notion of not being in classroom was change, the more things stay the same. I find that this holds new. I now find myself on the other end of the computer, particular truth in the field of IONM. Many of the modalities teaching several courses for the UNC BA Distance END that I used early in my career have changed. I started out using Program as well as my brick and mortar END/Poly Program very basic modalities such as SSEP and EMG monitoring. at Tri-C. The adaptations for online learning have been Today, we have added TCMEP to ensure motor function as interesting. I think one of the most compelling differences well as specific nerve root function. EEG has been added to boils down to human nature. I tend to make many off-the- ACDF as well as laryngeal monitoring to ensure patient safety wall references/comments during lectures at Tri-C, which during cervical procedure. Additional channels of EMG have occasionally sends students into a tail spin or just makes been created to more complete monitoring abilities. Even their heads explode. When you make off-the-wall comments though technology has created fast computers for real time to an online student, the miscommunication is compounded monitoring, the basic assumption that we are truly patient and can be amusing at times. I recently made a comment to a advocates during their procedure hold true as the day I first UNC student that her lab assignment was so well done, that entered this field. she could present with it. Her interpretation was that this was Early in my career, it seemed as if there was no real going to be requirement! After assuring her it was merely a consensus as to what montages should be used. Asking ten compliment, I assume she had a reduction in blood pressure different technologists what montages they used would which averted a significant CVA. produce as many as ten different responses. I distinctly My assumption is that online learning is not going remember how amazed I was to realize when talking with away, and indeed more programs will be developed as our other professionals that there were different montages that field moves forward. If a dinosaur like me can adapt to online were being used. I know the company that I work for has learning from both a student and instructor standpoint, then spent a lot of time and effort to standardize montages to be there is nothing we can’t do. used in our data collection. I remember my first introduction to intraoperative Neurofeedback neuromonitoring. I wondered if I was qualified to be in the field. I remembered how amazed I was to find out that the By Bill Coslett, CNIM, BCIA, EEG-C, PhD only requirement was a high school degree. Why, anyone could sit in front of a computer and do monitoring. As The theme of this article is the changes that you have the profession changed so did the expectation for those witnessed in your field. Perhaps things that we used to do monitoring. The field strove to increase their professional and no longer do or things that we are now doing that we image. Soon entrance requirements increased. Professional did not do early in our careers. I am working in the field of schools opened teaching the needed skills to enter the field intraoperative neuromonitoring (IONM). I first came into of IONM. Although still a shortage of skilled professionals, the field in 2003, and have witnessed many changes in the employers are no longer looking for any warm body to way that IONM is done. I must be the first to admit that I fill a seat behind the computer!! Companies are looking am not always one to welcome change. It seems like once for professionals who possess the needed skills to do their I develop a comfort zone, I have a tendency to stay within monitoring. that zone. I am sure that I am not the only one with this tendency!! 24 Neurofeedback...Continued

One of the most enjoyable changes for me generated artifact. Respiration belts that has been the addition of a neurologist online to help watch use strain gauges are often employed. and answer questions that may arise. The neurologist is also Trying to get the belts on an ICU patient available to speak directly to the surgeon if need be. When I can be challenging. Some techs place first started monitoring, I was one of three techs in a mom electrodes on the abdomen or on the and pop monitoring company. There was a reading physician, ventilator itself. These often introduce although he was not online with me. I was instructed to another type of artifact and often do not use my cell phone camera to take a picture of the screen if show the true respiratory pattern. I needed his help or opinion and then text it to him! Talk The following method works about feeling out on a limb. Today, we have much better and extremely well but requires seeking assistance from faster technology that allows neurologist to be online and respiratory therapists initially. With training from the monitoring the case with you. It is reassuring to me to have respiratory therapists, the EEG techs become competent and them online and available to input into the case. can do this on their own. Well I have rambled on long enough about how A bronchoscopy adaptor (Figure 1) is placed in-line things were then and how they are now. Times have between the patient’s mouthpiece and the ventilator tubing. changed. Technology has improved. Our understanding of The adaptor has a neurophysiology has improved. But the most important thing plastic tab that can has not changed and that is the protection of the patient. We be opened to insert need to continue to be proactive for our patients. Be safe out a bronchoscopy. there!! Using that opening, place a single airflow By Riki Rager, R. EEG T., FASET, BS thermocouple (Figure 2) into the This article is the Neurofeedback Section because I tubing and close the used to do neurofeedback. However, this time I am writing tab. The thermocouple is then plugged into any available about “something old” from EEG that could be “something channel. new” for today’s EEG technologists. The resulting recording is a very smooth, artifact free Since becoming an educational program director, I oscillating waveform Figure 3, bottom channel). With each have learned that electrocerebral inactivity (ECI) recordings inspiration and expiration, the waves rise and fall. This is are ordered very infrequently now. The physicians tell me due to the change in the temperature of the cooler air being it is because interpretable EEGs are hard to obtain and inhaled and the warmer air being exhaled. are full of artifacts. In addition, the use of other testing is I used this technique for many years in the hospital becoming more widely accepted. New technologies always environment and never encountered any problems with present a challenge for EEG. However, we shouldn’t let new insertion of the adaptor or with introducing unwanted technologies replace what we do due to poor techniques. artifacts. There are still times when ECI is needed and interpretable Here is an old paper recording obtained before recordings are indeed possible. reformatting was possible (Figure 3). We often used During the past week, we spent a lot of time in the combinations of montages to localize abnormalities. In this classroom talking about artifacts and how to eliminate or example, the referential portion clearly shows a generalized monitor them. Because we are starting a new long-term spike and wave while the bipolar circumferential portion monitoring program in the ICU and artifacts are so prevalent shows equipotential at Fp1 and Fp2. On the referential in that setting, we felt a real need to make sure everyone is portion, highest amplitude appears to be at F3 and F4. educated on artifact recognition and control. The next montage used might have been a combination of For my part, I would like to resurrect a technique referential and transverse bipolar going through F3 and F4. for monitoring ventilator artifact on the EEG. This technique Having the freedom to play around with montages was published in the Delta Recorder many years ago. often produced some unexpected findings. Creativity was Unfortunately, I cannot remember the author’s name or date encouraged as long as the combined montages followed of publication. the American Clinical Neurophysiology Society (ACNS) There are many techniques for monitoring ventilator recommendations of anterior to posterior, left over right, etc.

See Figure 3 on next page...

25 Neurofeedback...Continued

New Technologies and Research -Realize the opportunities to grow you are afforded; By Andrew Ehrenberg, R. EEG T, CNIM, BS oh never mind, you probably won’t even realize the opportunities until after they have passed, and you either The following is in a form inspired by the 1993 commencement took it and grew or just nodded your head and let it pass you address at Harvard University, commonly known as ‘Wear by. Trust me, you will look back in years to come and laugh Sunscreen’. The content, opinions and advice contained here at how much you thought you knew now. though, no one else bears responsibility for except my own self. -There is no perfect anything in neurophysiology. Ladies and Gentlemen of the field of neurophysiology; No perfect montage, or technique, paper versus digital, one If I could offer you only one piece of advice, head measuring vendor or another... would be it. The proper placement of electrodes ensures The only way to use anything is to know both its strengths recording from specific and comparable neuroanatomical and its weaknesses. locations. The correlation of the International 10–20 System to these locations has been verified by neuro-imaging and -Know your own strengths and weaknesses. literature and is the key to a technically accurate EEG; ...Whereas the rest of my advice has no basis more reliable -Ask questions… than my own opinions and experience. I will dispense this advice now… -Don’t be stingy with your knowledge; don’t put up with people who are.

26 New Technologies and Research...Continued -Don’t waste your time on regret; Sometimes you do a perfect test, sometimes you don’t. -Network with your peers. You never know when it will come Sometimes you do a perfect test on the wrong patient. in handy… Own it and make it right. And really, fellow neuro-nerds are the only people who will People will respect you for it. understand half of what you are talking about when you are excited by your first craniotomy. -Praise in public, criticize in private. -Learn the 10–10 system. -Feel good about the patients you help; Don’t feel bad about the ones you can’t. -Where you work employs you but does not own your If you succeed in doing this please tell me how. professional name. Always maintain your integrity as a professional, for your -Never stop learning. patients, with coworkers and peers, and especially for yourself. -Actually, this is brain science. -Be deserving of the sacred trust that is the responsibility of -Remember Ars Longa, Vita Brevis, Our search for knowledge patient care. is an endless, ever branching road with an ever expanding Remember anywhere else, a seizure would result in 911 or horizon, but never forget Carpe Diem, Seize each day and a code blue being called; we see them all the time and try to what it has to offer. make them happen.

-Pay attention to detail; -Care...even if it’s not your patient, or not a patient at all but but know that at some point you will step away from your a visitor who looks lost. patient for one second Treat them how you would want your loved ones treated, and that’s when they will seize. because they are someone’s loved one… And one day you too will be a patient or a visitor somewhere and be scared or lost. -Don’t feel embarrassed about the things you don’t know. Some of the smartest people I know will be the first to tell -Don’t limit yourself. You can achieve greatness. you all about how much they don’t know. In fact, I’d be wary Know that the only person who can keep you from learning of those who say they have nothing left to learn. or achieving everything you want is yourself.

-Work in the OR at some point, it teaches you to be confident. -Remember that you stand upon the shoulders of giants. Work with pediatrics at some point, it teaches you to be Those great clinicians who pioneered this field and know tender. that, one day, someone will be standing on the shoulders of giants of which you might be one. -Be confident with what you know, be honest about what you don’t. -Accept certain inalienable truths; healthcare will change, new procedures and technology will -Maybe you’ll get registered, maybe you won’t. come, Maybe you’ll get published, maybe you won’t. some of your knowledge and experience will become Maybe one day you will be speaking at a conference on outdated, something you are struggling to learn now, because you have and people will have their own opinions and experiences. become THE expert in it. Always take other people’s -Be intentional. In your work, relationships, learning, opinions and experience with a managing... grain of salt.

-Get involved in research. But trust me on the head Don’t ask to get paid and you will be surprised how many measuring... people will want the free labor. Seeing your name in print, being published, realize how much more valuable that is than money.

27 Pediatrics and Neonatology By Shelley Gregory, R. EEG T.

“Something old, Something new,” that’s the theme for this edition. As I am sure most hospitals around the country have done or are doing is to standardize whatever lab processes they can. Seattle Children’s Neurodiagnostics was recently asked to be part of a group of similar Seattle Children’s Diagnostic Departments (Echo, Radiology, MRI/CT, etc.) and have a “production dashboard.” This is the term that administration gives for a board that reflects our daily inpatient/outpatient EEG schedule as well as EEG reader of the day and staff vacations that allows us to track patient and interpreter no shows or late arrivals. For the patient and interpreter no shows or late arrivals, we can see if there are any commonalities or trends to improve on in those areas. As an example, we have interpreters that show up late for an EEG and we have already applied the electrodes. We really don’t need to have them start the introduction period as we already have used the telephone interpreter to communicate with the parent. We have different buttons that reflect if a patient is in isolation, if there is an alert on a parent, or an interpreter is ordered for the study. If cancellations occur during the day and the Neurology clinic has an add-on patient, it gives a great quick visual of where to put them in. We also have the Reader of the Day, Emergency Reader, and Telemetry Attending on it as well. This is helpful when you are going to do a portable in the NICU so you know whom to page for an emergent read. We have been using this for two weeks now and really haven’t had any issues arise. For us it was a culmination of various lists and schedules all put into one place making it very visual for anyone that needs to know. It is definitely a step up from the former EEG schedule that was one single paper hidden under a coversheet so we were HIPPA compliant. It also gives us a chance to work with other departments in the hospital and exchange ideas.

Polysomnography/Sleep Technologies By Kathy Johnson, R. EEG/EP T., RPSGT, FASET

The theme of “something old, something new” really hit home with me right now. My sleep center recently got capital funds approved to replace our sleep study equipment and I found myself giving the purchase even more than usual thought and debate. In the distant past (I am giving away my age here), I considered things like how easy it was to switch out tubes in the EEG machine or fill the ink wells or load the paper. When we moved into the “future” with computer recordings, we had to think about different criteria, like sampling rates and monitor resolution. More recently, commercially available computerized systems have become pretty standardized with respect to the capabilities of the PC but we have had to think about how recordings can be accessed over the internet from a remote location and stored on a server or the “cloud.” So I finally gained a basic understanding of computers and felt comfortable that we had it all covered……..and then here comes home sleep testing! Of course, home sleep testing (HST) did not appear overnight but many of us tried to ignore it for a long time. We knew it was out there but CMS previously did not recognize it as an appropriate diagnostic tool. Many labs did not think HST would have any effect on them—some sleep specialists had no interest in home testing, declared that they would not use it, and would not read those studies so many of us believed that ended it for our labs. Well, we were wrong. As most of us now know, the insurance payers have become the primary decision maker in determination of the type of testing they will cover for their subscribers. This is where it becomes challenging. Many insurance companies are now using HST as a way to reduce the cost of sleep evaluations and they frequently utilize sleep management companies and/or require pre-authorization for sleep studies, which can be an arduous process. Some payers will only approve home sleep testing instead of in-lab tests. So, most sleep labs have incorporated HST into their procedures. If you have not, you probably will in the near future. Keep in mind, however, that many insurance companies use outside contractors to provide the home sleep testing rather than their local sleep centers/labs. So, what did I do with my recent equipment purchase? For my six bed sleep lab, we kept our old (but still functional) equipment for two beds. We will replace parts with the extra equipment from the other rooms as these devices die off. We replaced four beds with new equipment which is capable of performing not only PSG but also clinical EEG, including continuous EEG in ICUs. We also purchased two HST devices in hopes that we can capture some of this market for payers who do not have a contracted service. We also plan to use the HST equipment for inpatient studies when needed and hope to be able to use it for pre-operative screening studies in the near future. We believe this will give us flexibility to meet the foreseeable changes in the world of sleep medicine (until the next new thing comes along).

28 GOVERNMENTAL AFFAIRS AND ADVOCACY By Bradley A. Hix, Governmental & Grassroots Advocacy Manager

Legislative Update:

urrently the majority of State legislative bodies are in session, only Louisiana has yet to convene this year. A few State legislative bodies have adjourned for the year. The Governmental Advocacy Committee has been busy reviewing Chundreds of bills and regulations and has identified a few that directly impact the neurodiagnostic profession. The bills we are tracking have been posted in ourNeurodiagnostic Legislative & Regulatory Action Center website, accessible under the “Advocacy” tab of the ASET website. Details on the legislation and the actions we have taken to address our concerns are below:

Indiana: House Bill 1383 would license polysomnographic technologists. The legislation would establish licensing requirements to practice polysomnography. The bill seeks to establish the polysomnography standards committee under the medical licensing board. It provides that, beginning July 1, 2015, a person must have a license to practice polysomnography or use certain titles. The bill has been referred to be considered for study by an Interim Study Committee and will not see further action this year. The Indiana Legislative Council will determine after the session has adjourned whether or not the topics related to the practice of polysomnography will be officially assigned to a study committee. We will monitor the study committee to make sure that Neurodiagnostic Technologists performing EEG studies are not inadvertently prohibited from practice if any legislation is proposed by the committee.

Iowa: House Study Bill 59 and Senate Study Bill 1091 are identical study bills which would license polysomnographic technologists. The legislation would establish licensing requirements to practice polysomnography. The bills are proposing to add the practice of polysomnography to the respiratory therapy board and add members to that board who practice polysomnography. The bills provide that, beginning January 1, 2014, a person must have a license to practice polysomnography or use certain titles. The bills have been introduced at the request of the Iowa Sleep Society. We held a conference call with the President of the Iowa Sleep Society to discuss our concern that Neurodiagnostic Technologists performing EEG studies may be inadvertently prohibited from practice. In addition, we sent a letter requesting exemption language be included in the bill to clarify that regulations which might result from this legislation do not adversely affect the Neurodiagnostic Technologists’ ability to practice their profession. Both bills have been assigned to a subcommittee of their respective State Government Committee. At this time neither bill has been scheduled for a hearing.

Nevada: Assembly Bill 73 is a bill which revises provisions governing chiropractic practice. Specifically, it would allow a chiropractor to use a needle for diagnostic purposes. If enacted, the bill would change the scope of chiropractic practice and allow them to perform diagnostic procedures, including presumably Needle Electromyography (EMG). We sent a letter to the committee requesting that language be added to the bill which would make sure that needle electromyography is only performed by practitioners who are specifically educated, trained, skilled, and licensed to perform the procedure. The bill has been referred to the Assembly Commerce and Labor Committee but has not been scheduled for a hearing. We worked with the American Association of Neuromuscular & Electrodiagnostic Medicine, the Physical Medicine and Rehabilitation Society of Nevada and the American Academy of Neurology to coordinate our opposition to the bill. The lobbying effort was successful as it has been reported that the bill will not see further action this year.

New Hampshire: House Bill 326 is a bill which would require persons practicing polysomnography to be licensed by the board of respiratory care practitioners. Included in the legislation’s definition of practice of polysomnography are (1) sleep staging, including surface electroencephalography, surface electrooculography, and surface submental electromyography, and (2) surface electromyography. We sent a letter requesting exemption language be included in the bill to clarify that regulations which might result from this legislation do not adversely affect the Neurodiagnostic Technologists’ ability to practice their profession. The bill has been referred to a summer study committee by the House Executive Departments and Administration Committee. We will monitor the study committee and make sure they are aware of our concerns with the bill.

29 GOVERNMENTAL AFFAIRS AND ADVOCACY continued

Pennsylvania: SB 137 is the Speech-Language Pathologists and Audiologists Licensure Act. Areas of audiology practice proposed in the legislation include administration of electrophysiologic measures of neural function, including, but not limited to, sensory and motor-evoked potentials, tests of nerve conduction velocity and electromyography, plus preoperative and postoperative evaluation of neural function, neurophysiologic intraoperative monitoring of the central nervous system, spinal cord and cranial nerve function. SB 137 is the reintroduction of SB 1352 from last session. SB 1352 passed the Senate and was referred to the House Professional Licensure Committee but was not heard before the Pennsylvania General Assembly adjourned for the year. SB 137 has been referred to the Senate Consumer Protection and Professional Licensure Committee but has not been scheduled for a hearing at this time.

ASET has requested that the language which would allow Audiologists to expand their scope of practice into Intraoperative Neuromonitoring be stricken from the bill. We are working with a coalition of interest groups to tighten up the language if Audiologists are ultimately allowed to perform IONM.

Point of Contact Handbook: The ASET Point of Contact program is ASET’s coordinated legislative grassroots effort. Its aim is to promote the best possible patient care while protecting the neurodiagnostic profession. To achieve this aim the program seeks to utilize and strengthen existing relationships between neurodiagnostic technologists and state legislators to make certain our message and point of view are heard and considered in the public policy arena. A handbook has been created to provide details on how to best develop personal relationships with elected officials.

Development of these personal relationships is critical to making sure the voice of neurodiagnostic technology is heard by elected officials. When an issue that impacts neurodiagnostic technology is being debated in committee or on the floor of the House or the Senate, members of the Point of Contact Team are activated to communicate ASET’s position to their legislators and ask them to support our position. Click here, or visit the “Advocacy” tab of the ASET website to download a copy of the handbook.

30 CONNECTIONS CORNER Interviews Connecting Members

“Technologist, Teacher, Advocate, Volunteer, ASET Member” By Sarah Dolezilek, Marketing & Communications Manager

Susan Denise Agostini, R. EEG/EP T., CLTM Incoming Manager for Epilepsy Monitoring Unit and Neurodiagnostic Manager Banner Good Samaritan Medical Center Phoenix, AZ

echnologist, teacher, advocate, volunteer, passionate, mentee, mentor; all these things describe one, Susan Denise Agostini, ASET member. I first met Susan in Atlanta, GA at ASET’s Annual Conference in 2011, where she was installed as a Board of Trustee. I remember reading her biography for the board nomination packet and hoping that Tshe would get elected. You could tell just by reading it that she had a special interest in the neurodiagnostic field and would make a terrific board member. Since joining the ASET board in 2011 she has been on numerous committees and taskforces, never shying away from leading a committee or discussion on topics close to her heart. Currently, she serves as the Chair of the Standards and Practices Committee, Special Interest Section Leader for the Epilepsy Monitoring Interest Section, and on the Marketing Committee.

My interview with Susan was done on March 27, 2013 via a phone conversation. My intention with this interview and the ones to follow in this new section of the newsletter is for you to learn more about the amazing individuals who make up the neurodiagnostic profession, who live and breathe it every day. The profession would not be where it is today without these remarkable, hard-working, intelligent believers.

ASET: How did you first learn of the field of neurodiagnostics and what drew you to it? Susan: My mother passed away from brain cancer in 1984, from then I began developing a very strong interest in the brain. In 1988 I moved to Tampa, Florida, found a job at the University of South Florida Medical Clinic, which is where I met an EEG technologist, Lydia, who became my mentor, and role model. She was very passionate about EEG and the brain, and I wanted to be just like her. Lydia was willing to share her knowledge with me and she provided me with the information to pursue a career in Neurodiagnostics. Now I am a passionate technologist, just like her. I would be so happy to see Lydia again. I recently met the physician who worked with her at a meeting. She had the same fondness for Lydia. I think Lydia saw something in me that she thought would be good for the field. She would leave little notes of encouragement on my desk saying I was right for this field, and she was totally right, this is my field.

ASET: Tell me how you first got involved with ASET Susan: Lydia was an ASET member and she always said “ASET takes care of us”. She showed me that it was important to be involved. I joined as a student member in 1989, then after school, transitioned into an Active member and eventually became an Institutional member. When I ran for the Board of Trustees I upgraded to the Active class of membership again. I encourage my students to join ASET. When I was a tech on my own, just starting out, ASET became my home, held my hand and was my virtual educator.

Susan Agostini (left) with her mentor Lydia (1990) 31 CONNECTIONS CORNER continued

ASET: What was your first impression of the Society? Susan: Very good experience with ASET. I graduated from the EEG program in Tampa and went to my home island of Puerto Rico to share my knowledge. I was very scared; I needed the emotional and educational support of ASET, and their continuing education. ASET held my hand through all that. I believe in ASET, I believe in the mission, I believe that they hold true to their mission. It has been a great learning experience.

ASET: Looking back at where you were when you started this journey, where did you think it was going to lead you? Susan: I never thought I would be in the position to influence others in the field of neurodiagnostics. My mother’s favorite quote is “you find a job that you love and you will never work a day in your life”. That imprinted in my brain, I have been so lucky and blessed to find a job that I love. I share this now with my own daughter and my students. I never regret the choice I made back in 1989 when I decided to become a neurodiagnostic technologist. I believe things happen for a reason and losing my mother to brain cancer was tough, but it pushed me to where I am today. It made me be a better person and a better care provider for my patients. Susan Agostini (circa 1989-1991)

ASET: What accomplishments are you most proud of in your professional life? Susan: The opportunity that this whole profession has given me to give back, share my knowledge and most importantly, change people’s lives. Our patients depend on us to help give them a better quality of life. That fact that we, as technologists, can change people’s lives in the ways that we do, makes me most proud.

ASET: What do you find most challenging about the Neurodiagnostic field? Susan: A couple of things. My definition of challenge is the opportunity to prove what seems impossible, possible. One of the challenges I see is the misconceptions of epilepsy and increasing awareness for epilepsy. [Susan is an advocate for Epilepsy in her community and with the Epilepsy Foundation]. Also, there are not enough schools in the country to train technologists. As we go forward, we need more “We are not just EEG formally trained technologists out there. ASET is an amazing resource for this.

Technologists anymore, ASET: What do you think will change in neurodiagnostics over the next five we are Neurodiagnostic years? Susan: Changes in healthcare and changes overall. I think that all the new Technologists.” Neurodiagnostic Technologists and seasoned techs need to buckle up, continue our education, broaden our knowledge, learn all the modalities, etc… I think the degree requirements will change, and I would like to see licensure. There are lots of changes to come. We have come a long way, a long way. We are not just EEG Technologists anymore, we are Neurodiagnostic Technologists.

ASET: What is it like to be a volunteer for ASET? Susan: Giving back to the Neurodiagnostic Community. ASET gave me so much when I was a student and still gives me so much and see and feel like I am giving back. Volunteering is also my way of being heard. If you want to make a difference, there is only one way to do that and there is a place for you, there is a place for everyone. Volunteering is an amazing opportunity to contribute to the future of the field, our field.

32 CONNECTIONS CORNER continued

ASET: Do you volunteer for other organizations? Susan: Yes. Currently I facilitate an Epilepsy Empowerment Group for central Phoenix. They meet once a month; it is such a humbling experience. They need someone who is there for them, knowing that someone is listening to their concerns, and provide emotional support. Sometimes I am tired, or feel overworked and stressed, and then comes that night; and it gives me a boost of energy, it is just a really good feeling. I am also on the Board of Directors for the Epilepsy Foundation of Arizona. We help organize the Walk for Epilepsy in Arizona, and are currently working on a seizure education program for bus drivers. There are many ways to help out and you can make the time if it is something that is important to you. Volunteering gives me a sense that I have done something for the community. I’ve even been able to get my co-workers and family involved in volunteering. Overall, volunteering is such a great thing, and can make such a huge impact.

ASET: What would you tell someone who is thinking about volunteering with ASET? Susan: “Go for it! Go for it whole-heartedly; we would love to have them”. We would embrace anyone in any way that they want to help. Not only until you participate do you realize how much day-to-day volunteer work is done. You see all the professionals working together for the membership, the neurodiagnostic profession, trying to keep up with all the demands, changes in healthcare, etc. There are so many different committees and groups; you can find your niche. I would tell them to go ahead and approach us, approach ASET. Don’t wait for ASET to approach you, just go for it. Your help is very much needed.

ASET: What is the best piece of advice that you have ever received? “You don’t learn that Susan: You know where this advice came from; my mother! I wanted to become her. She said, always be honest, be true to others, and be transparent. stuff in textbooks; Always act in good faith, feel good in giving; it will make you a better person. If we do what we are supposed to do as humans, then the numbers will fall compassion, dedication, into place, believe it. You don’t learn that stuff in textbooks; compassion, honesty, that needs to dedication, honesty, that needs to come from within. Contribute to changing people minds. I put myself in my patient’s shoes every day; I don’t know any come from within. “ other way.

ASET: Is there anyone (living or deceased) in the neurodiagnostic field that you would like to talk to? Susan: There are many people. Ernst Niedermeyer, I saw him at ASET’s 50th Annual Conference in Phoenix but couldn’t get close enough to talk to him. Lewis Kull; I have read so many of his articles; I knew he was really involved with ASET, and I truly admired him. Lastly is Hans Berger; The Father of EEG. I would have so many questions for him, “What sparked his interest in the brain and recording brain waves?” I know there was work on animals before him, but what made him stay with it. I know he did many EEGs on his son. I would just want to know how it came around. I would also ask him why he committed suicide. What happened? I have a lot of respect for them, their work and their contributions to the field.

ASET: Last questions; if you had $30,000 to donate to our organization, what would you wish it be used for? Susan: I would want it to be used for someone else’s success in education, grants, something to make them successful in the neurodiagnostic field. I would want it to be used to provide programs for students and help them develop into amazing techs; definitely education.

Thank you Susan for you dedication to advancing the profession and making this world a better place. I hope we can all take a lesson from your book and become the best technologist we can be, share our knowledge and teach those around us, advocate for what we believe in, help others by volunteering because it makes us feel good, be passionate about our careers, find amentor to guide us on our way and be a mentor to a friend searching for theirs. The future of the neurodiagnostic profession is in our hands, we must continue to grow and develop the field for those who follow us.

33 CONGRATULATIONS TO OUR NEW MEMBERS [since 01.01.13] Institutional Members Jefferson Regional Medical Center Lawrence & Memorial Hospital Abington Memorial Hospital Long Beach Memorial Medical Center - Miller Children’s Akron Children’s Hospital NeurIOM Banner Good Samaritan Medical Center Neuro-Med Healthcare Professionals, Inc. Baptist Medical Center NLR New York Presbyterian Hospital Brain & Spine Center, LLC Oregon Health & Sciences University Community College of Denver Pacific Neurophysiological Systems Concorde Career College Pamlico Community College Crystal Run Healthcare South Georgia Medical Center Florida Hospital Neuroscience Institute St Francis Hospital Geisinger Medical Center Texas Health Harris Fort Worth Grady Memorial Hospital University of Kentucky Hospital Hamilton Health Sciences General Hospital UPMC Center for Clinical Neurophysiology Hartford Hospital UPMC Epilepsy Monitoring Unit

Individual Members Michael Bosler Windey Boyd Francisco Aguirre Theresa Boyd, RN, AS Suzanna Allen, R. EEG/EP T. Charles Brandau, RPSGT Jonica Allison, CNIM, AS Kristina Brooks Nasser Alzahrani, MD Tiffany Brown, BS Christiana Amoafo, R. EEG T. Glenda Buell, R. EEG/EP T., CNIM, BA Charlotte Anderson, BS Edward Buggie, R. EEG T., CNIM, MBA Nathan Anderson, CNIM, BA Brittany Bulick, AS Elena Antonetty, AS Rhonda Butler, AS Louis Archila, CNIM, BS Amy Caccamo Dustine Arnold, AS Vivialyn Cadell Melissa Avery, RPSGT Carey Camu, BS Michelle Awalt, AS Denise Cannon, R. EP T., CNIM, CRET David Bailey, RPSGT James Captain, CNIM, BA Samantha Baker, AA Darlene Carson, RET Andrea Ball, BA Timothy Carter Micah Bates Michael Cavallaro, R. EEG/EP T., CNIM, RPSGT, BS Tammy Batzel, R. EEG T., AS Ashley Chapman, AS Deborah Beblaw Igor Chereshnev, CNIM, MD Aster Bekele, AS Nimesha Cheruku, CNIM, MS Melissa Belknap, R. EP T., CNIM Jane Chung, R. EEG T., CNIM Erik Bennett, BS Lygia Church, R. EEG T., BS Elizabeth Bennigsdorf, R. EP T., MA Jane Churchill, R. EEG T., AS Tina Berisford Dana Ciano, BA Gercina Bhuiyan Sonay Cileci, BS Pamela Bitner, RPSGT Cynthia Cone Deena Bizzle Adrienne Coombs Alison Blankenship Mitchell Cordle, CNIM, BS Rachel Blaylock Mindy Corridoni, CNIM, BS Michele Blocker, RPSGT Kayla Costello

34 Florica Crisan, BS Angel Guzman, RPSGT Josmery Cruz Leslie Hack, CNIM, BS Marisol Cuevas Benjamin Hall Moises Cuevas, R. NCS T., MD Jessica Hall Jennifer Cule, R. EEG T., AS Shaunda Hamm, R. EEG T. Joanna Dadajewska, R. EEG T., AS Laura Hammer, AA Pepi Dakov, R. EEG T., MD Ryan Hannah Jessica Damiano, BS Leah Hanson, R. EEG/EP T., AAS Elias Debella James Hardenstine, RPSGT, BS Maria Del Rio Sheila Harris, RPSGT Lorraine Delorme, RT, RET Dana Hayes, AAS Susan Dempsey Fei He Kirsten DePrimo, BA Ashley Hein, R. EEG T., AS Alain Despeignes Bonnie Henry, R. EEG T. Paul Dureus, MD Nelson Hernandez Jayme-Lynne Dykes Logan Hight Anna Dynowska, CNIM, MD Hung Hoang Charlene Earls, R. EEG T. Dayne Hollmuller JoAnne Edvardsen, R. EEG T., RPSGT Lisa Holmes, RPSGT, AA Hoda Elzawahry, PhD, MD Jesse Hoose, BA Kamel Elzawahry, PhD, MD Lowell Horner, R. EEG T. Michael Enos, RPSGT, RRT, AS Timothy Hoselton, RPSGT, BA Brian Errigo, CNIM, MBA Jeremy Hourtienne Cheri Fanciullo Kimberly Howard Bryan Ferguson, R. EP T., CNIM Vesselina Hristodorova Paul Ficht Lin Huang Jennie Figueroa, AA Amy Hubbard, MA Alissa Finley, R. EEG T., BS Hannah Hutmacher, BA Bonnie Flatten, AS Debi Huyler-Parsons Mark Frangullie, CNIM Laura Ilnicki, AS Sarah Fredman, RPSGT, MA Darrell Irvine Xu Fu Ashley Jackson, R. EEG/EP T. Jennifer Furgala, CNIM, BS Anthwan Jackson, CNIM, BS Briana Gamret, BS Eric Jackson Vicki Gardner Jolene Jackson Blair Gardner, R. EEG/EP T., BS Gloria Janz, BA Melissa Garner, R. EEG T. Erinn Jefferson, BS Thomas Gaylor Jerra John, CNIM, BS Lynne Gelfuso Rebecca Johns, R. EEG T. Timothy George, AS Leslie Jones, AAS Debra Gibbons Mark Jones, LPC Anthony Giordano, MD Newin Jose, BS Daniel Giorgianni, R. EEG T. Emily Kale, BS Terry Gomez Sarah Kapusta, CNIM, BS William Goodrich Bekre Kassegn, RPSGT Jessica Goodwin Prabhjot Kaur Autumn Gregory, R. EP T. Lyubov Kernyakevych, MA Angela Grgat Sargoon Keso, BS Stephanie Gross Kristin Kincade, BS Tena Groves, BA Claudia King, R. EEG T., LPN Charity Guiddy, CNIM, BS Andrew Klein, CNIM, BS Andrea Gutierrez Bradley Kline, CNIM, BA

35 Barbara Kocol, RPSGT, AAS Grace Mutonyi-Lamantia Michael Kormanik, R. EEG/EP T., CNIM, RPSGT, CLTM, Trista Myers, AS BS Yashuo Narkalayeva, RVT Rebecca Kraenbring Teresa Nelson, R. EEG/EP T., CNIM, RPSGT, AAS John Kramer, CNIM, BS Patty Newton, CNIM, MS Renee Krebs David Ninaci, CNIM, BS Theresa Krupski, RPSGT, RRT, BS Kayla Nolan, R. NCS T., BS Emily Lahue John Norbert, BS Kennan Langjahr, CNIM Jennifer Norman, BS Jennifer Large, R. EEG T., BS Lacey Norwood, AS Christie Lattner, AS Amanda Ledford, BA Timothy Osterman, AS Shalee LeFever Jayoung Pak Steven Leon Nicole Pakos, BS Kjerstin Lere Ronny Pasley, BS Jordan LeRoy Tom Pavlovick, R. EEG/EP T., R.NCS.T., MPA Renauda Lewis Sofia Peguero Natalie Lipinski, BS Jamie Pelster Michael Litten Amy Perez Christopher Long Deidre Perry Christina Luksich Shannon Pigneri, R.NCS.T. John Lundin Amanda Pike Anne Maas, R. EEG T., AS Anthony Pohlman, R.NCS.T., BS Achraf Makki, PhD, MD Lawrence Porter, R. EEG T. Wendy Manasco, AS Katherine Poulson, R. EEG T., BA Markell Marshall Candice Prof Eric Marshall, R. EEG T., RPSGT, AS Ryan Quallich, CNIM, BS Bethany Martin Michael Rahenkamp, BS Peter Matos Karen Rama, R. EEG T. Alicia Matthews Jennifer Ramirez, RPSGT Adam Matthews, CNIM, BS Brian Ramnath, R. EEG/EP T., CNIM, CLTM Melissa Mayberry Tiffalynh Ramos Michael McCaffrey, CCC-A, MA Elisabeth Ransom, CNIM, MS Benjamin McPherson, BS Donna Renfroe, R.NCS.T. Kristen Means, R. EEG T., AA Sarah Reppe Luis Mena, MS Hayle Ritchey, CNIM, BS Jessica Mesing, CNIM, BS Dee Ritter, BS Rachel Mihal, BS Jose Rivera Jane Mitchell, AS Kalyan Robinson Nicole Mitter Sergio Rodriguez Oleg Modik, CNIM, PhD Kristi Rogers Heather Mogridge, R.NCS.T., RT Mariam Ronaghy, R. EEG T., AS Scott Mohr, CNIM, BS Leslie Rosa, AS Debra Monahan Carla Rose Brittany Montgomery Melissa Rotter, BA Keith Moon, R. EEG T., BA Dominic Rowe, MD Sabrina Moore, CNIM, BS Sherri Rudolph, R. EEG T. Don Morrison, R. EEG T., AS Anne Marie Salser, CRTT Andrew Moyer, CNIM, BS Mark Sanders, CNIM, BS Aubrey Murano, BS Melissa Sandezer Carlene Murphy, R.NCS.T., AS Isabelle Sarazin Judith Murphy, BS Kerry Schmittgens, R. EEG T., R.NCS.T. Tina Murphy, AS Liudmila Schumacher, R. EEG T., RPSGT, AS

36 Kate Semmig Kim Vaughn Bradford Sheldon, AS Sonia Veleva Joann Sherrill Kristi Verbalaitis Matilda Shkembi Donata Viazzo-Trussell Clifford Short, RPSGT, BS Phyllis Videtich, R. EEG T., BA Emilia Silianova Ashley Volf, CMA, AS De Anne Simon, R. EEG T. Anthony Wallace, RPSGT, AS Rachel Skeie, R. EEG T. Rhianna Walorski, BA Tammie Smallwood, RRT Twila Walter, RPSGT, CRTT, CPFT Tara Smolick, CNIM, BS Renee Washburn-Sunmola, RPSGT, AS Larissa Souzer, CNIM, BS Ashley Webster, BA Heather Sparks, R. EEG T. Rebecca Webster Janet Stephens, R. EEG T. Jared White, R. EEG T. Michelle L. Suhayda, CNIM, BS Ashley Whitlock, BS Kelly Suitor, BA Nicole Whitman, AS Robert Sunderlin, CNIM, BS Hoshin Wi, R. EEG T., BS George Swinston, CNIM, BS Thamarai Wilkinson, R. EEG T., BS Gian Tanwar Raeanne Williams Anne Marie Tardi, DC Stephanie Williams Elena Tewari, RPSGT, MA Angela Williams Hirasha Then Dawn Wilson, AS Alaina Thomas, BA Kerri Wright Peter Thomas Patricia Wrynn, RN, BS Jacob Tillman, BA Melissa Yee, BA Victoria Torres, BS Courtney Youngblood Julie Toups Trott, CNIM, MS Ivanka Zaprianov Jessi Trainer, AS Nabil Zareif, MD Laura Trent, MS Junqing Zhou, R. EP T., CNIM, PhD Steven Turner, R. EEG T., BS Elena Zotova, PhD Tanya Vassar

37 ASET STAFF:

Executive Director Director of Education Arlen Reimnitz; Faye Mc Nall, R. EEG T., MEd [email protected] PO Box 36 East Boothbay ME, 04544 Marketing & Communcations 207.350.4087 (p) Manager [email protected] Sarah Dolezilek [email protected] Director of Publications Lucy Sullivan, R. EEG T., CLTM Membership Coordinator 3350 S. 198th Rd. Kathy Wolff Goodson, MO 65663 [email protected] 417.253.5838 (p) [email protected] Governmental & Grassroots Advocacy Manager Online Education Coordinator Bradley Hix Maggie Marsh-Nation, R. EEG/EP T., [email protected] CNIM, MSIDT 2013 Lime Creek Rd. Registration & Fullfillment Manager Kerrville, TX 78028 Mandy Gist 830.895.7460 (p) [email protected] [email protected]

402 E Bannister Rd, Ste A, Kansas City, MO 64131 816.931.1120 (p)  816.931.1145 (f) [email protected]  www.aset.org