Meeting the Standard of Care

Last week on the UNPA website, someone posted a link to a Prezi entitled “Do I Meet Standard of Care? A Critical Look at a Charles Yingling Presentation.” [NOTE: this Prezi has been removed from the web by its author.]

Basically, the prezi reviews a malpractice lawsuit in which judgement was made for the plaintiff and the defendants were ordered to pay $20 million in damages.

The post first appeared to me on LinkedIn, but it was a little confusing. I reviewed the prezi several times, and I came away with three questions. My first question was, who made the presentation? The title mentions Charles Yingling, but I knew he didn’t actually develop the presentation. My second question was, where is the original Charles Yingling presentation, to which the prezi refers? My third question was, where is the “critical look at [the] Charles Yingling presentation” that was promised in the title? I found the whole thing to be very confusing. So, I started doing some digging.

My first question was easily answered once I finally made my way to I found that the prezi was developed by Ryan Rosenhahn at Intranerve. Problem solved… but, I was still terribly confused by the whole “critical look” and “Charles Yingling Presentation” think.  I’m still confused, actually, but I’m going to venture a guess.  My guess is that Dr. Yingling served as an expert witness in this trial, and that he gave a presentation to Intranerve on the subject. Furthermore, I’m guessing that the prezi was meant to be a critical look at the Charles Yingling presentation, a presentation to which we don’t have access. These are all just guesses. Someone please correct me.

Anyway, I started digging around a little more on the internet, when I found something very interesting… another lawsuit in which Dr. Yingling served as an expert witness. This verdict was published online and entitled, Failure to notify surgeon of signal loss resulted in paralysis. Since it is published online and free for anyone to access, I don’t have a problem sharing the link.

What I find interesting is the many similarities that exist between the two cases. The surgical procedures are different (ACDF vs PSF), but other details are remarkably similar. Both lawsuits serve as an exposé of the incompetence that is rampant in the field of intraoperative neurophysiology. I encourage my readers to take a close look at both cases, because I’d love to hear your thoughts

Some interesting questions arise:

  1. It is interesting to note that, in both cases, the reading neurologist was not sued, not deposed, and not otherwise involved in the lawsuit. Contrary to popular belief, this is frequently the case. So, what is the point of having a neurologist online and “making decisions”, if the technologist is ultimately the one who usually gets sued? Who is protecting whom?
  2. No mention is made of whether or not the neurologist was knowledgeable about intraoperative neurophysiology. Was he/she board certified in intraoperative neurophysiology? Does it matter, or is it sufficient to be a neurologist?
  3. The online neurologist had seen 17 other patients and billed 21 hours of professional IONM time before 12:00 noon on the day of surgery? Is this common? Ethical? What do you think?
  4. The technologist had 7 years of experience in IONM. Do you think that “number of years experience ” is an important metric?
  5. The tech’s CNIM had recently expired, and there are tons of techs out there working in IONM without a CNIM. Does CNIM certification even matter?
  6. It was mentioned at trial that the tech failed the CNIM on first attempt. Is this even important? What if the person had failed 5 times?
  7. When signals were lost, the technologist thought the problem was technical. He called his boss who helped him troubleshoot over the phone. Is this acceptable? How should troubleshooting be provided…phone, internet, in-person?
  8. The IONM company’s clinical Policy and Procedure manual was subpoenaed and found to contain behavioral guidelines (how to act in the OR) and references to literature that were out-of-date.  What do you think about that?
  9. In the second link that I provided, the IONM company was dismissed from the lawsuit. The defendants were IONM technologists. They were ordered to pay $22 million in damages. Most IONM companies carry $4 million in liability insurance for each technologist. What are the financial implications for the individual when (s)he loses a lawsuit of this magnitude?
  10. My final question is this: Do we have a standard of care in the field of intraoperative neurophysiology? By definition, standard of care is how similarly qualified practitioners would have managed the patient’s care under the same or similar circumstances. That’s the legal definition, anyway. So, who defines our standard of care…?

I could go on and on, but I think these are good questions to start with. I’m really interested in hearing your comments.

Dr. Rich Vogel is board-certified intraoperative neurophysiologist working for Safe Passage Neuromonitoring. He started the Neurologiclabs website and blog to connect with others in the field of neuromonitoring.


14 thoughts on “Meeting the Standard of Care

  • Reply Vince Petaccio October 6, 2014 at 18:00

    “The online neurologist had seen 17 other patients and billed 21 hours of professional IONM time before 12:00 noon”

    Given a 7am start time, this means the neurologist was warching no less than four cases simultaneously at any given time, with five for at least an hour.

    Who are we kidding? The remote neurologists are 100% a way to squeeze more money out of payors. My question is, is *this* ethical? To exploit insurance and medicare payments that, in the end, we *all* pay for?

    • Reply Richard Vogel October 7, 2014 at 19:44

      CMS has certainly caught on to this. Other insurance companies will follow. As prices bottom out, people will suddenly start to talk about quality again, but quality will be much more difficult to find.

  • Reply Lindsay Henderson October 6, 2014 at 18:41

    Thanks for clearing up, Richard. I was also slightly confused by original post.

  • Reply Derek Connor October 7, 2014 at 09:36


    If you trace back in Prezi, it says Ryan Rosenhahn posted the original Intranerve presentation. Any input from him could clear up your initial questions.


    • Reply Richard Vogel October 7, 2014 at 19:47

      Yeah…I’ve been meaning to drop him a line. Probably time.

  • Reply Richard Vogel October 7, 2014 at 19:42

    This is a message posted by Derek Connor on LinkedIn:

    “Thanks for shedding some more light on this recent post. Off the main topic, one thing that stood out to me in the 2nd case docket you posted was that Richard Spain (trainer) was found 50% at fault, while the primary IONM clinician (Johnson) was found 30% at fault. A real eye opener for all of us who are charged with training.”

  • Reply Ryan Rosenhahn October 8, 2014 at 20:24


    I received a message today from Richard about this post and would like to clear up some questions. To start this presentation was never intended to be public. The original presentation was by Dr. Yingling at one of the society meetings. My version of this was designed and only intended as for internal use that I presented at our annual directors meeting with our company. This was meant to be a round table discussion for internal purposes only. I was not informed this would be posted on either blog or website and is a bit of a surprise. Nonetheless, I think we can all agree that when preparing any sort of literature or document for public use there is a significant different in they way it is prepared and present so please keep that in mind. I have a great deal of respect for Dr. Charles Yingling and others alike in our field. Agree or disagree I do believe this is an important topic to discuss but please keep in mind the intent this was created.

    Richard, to maybe clarify your other question of “where is the critique?” it was not necessarily a critique on Dr. Yingling’s presentation but a critical review for internal purposes using a case example. Again this was not intended to be a public document and was intended for a group with nearly 200 combined years of IOM experience discussing.

    Thank you

  • Reply Dean October 19, 2014 at 09:30

    Was there any documentation of the technologists conversations with the surgeon,informing him of the changes and his responses.

    • Reply Richard Vogel October 19, 2014 at 10:40

      These are 2 independent lawsuits. Since I wasn’t involved, I don’t have any information beyond what is presented on those websites. As far as I can tell, the answer to your question is yes in the first case and no in the second case. Also, there were no recommendations made by the technologist or the technician for intervention.

  • Reply B. Alemany November 9, 2014 at 09:53

    In quantic physics if you dont observe something it doesnt exists. So, let me aske averyone for something. Lets make observance of creative things, not competitive but creative. And make things better each day. Not perfection, but progression. And WHY? Because it is our responsability to work hard and consioussness, each day better for those who are our energy: our patients.

    My Peace and my Love with all of U,

    Beatriz Alemany

  • Reply 2015 at NeuroLogicLabs@NeuroLogicLabs January 28, 2015 at 22:13

    […] at stake in keeping that a secret. I represent a threat to that secret. The fact is that the “standard of care” out there is so horrifyingly low that people don’t want it to draw attention to it. […]

  • Reply Kyle Hargrove October 31, 2015 at 11:32

    I will be the least intelligent person in this forum. I had spinal surgery 17 days ago – a relatively routine procedure as spines go. Waking up in recovery, I found that I had no sensory or muscle activity anywhere below my waist. I spent more than a week in a rehab hospital following the general hospital stay, and am currently busting my tail in outpatient PT. In reading the medical chart, which I procured from the hospital, I did note that the technologist informed my surgeon that the IONM had “lost its signal.” This was about 75 minutes before the procedure was completed.

    I was not “told” about this by anyone, but overheard the surgeon’s assistant mentioning to someone that he had never seen that happen before. A regular signal one second, and nothing the next. The signal did not return for the remainder of the surgery.

    My two questions are:

    1. Is there a way to determine the “chicken or egg” dilemma here? In other words, did the equipment malfunction? Or was there simply no longer a signal to monitor from that area?

    2. How would I go about determining the level of certification needed and/or if this technologist was indeed certified/qualified in the state of Texas?

    Although some sensation and slight movement has returned to my legs in the two-plus weeks following surgery, the progress is very, very slow, and I am trying to organize any documentation I can in the event that my recovery is partial, or does not happen at all.

    I look forward to any information you all might share with me.

    Very Best Regards,

    Kyle Hargrove

    • Reply Richard Vogel November 1, 2015 at 08:26

      Hi Kyle, I responded to your comment via e-mail using the address that you provided. Please let me know if you don’t get the response.

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