Neuromonitoring for Monsters

Contrary to what your parents may have told you in an effort to calm your midnight fears in the sweaty aftermath of a childhood nightmare, I regret to inform you that monsters are real and they’re everywhere! In so many hospitals across the country, and perhaps around the world, monsters dwell in operating rooms, waiting to prey on vulnerable victims….just…like…you!

Monsters are the surgeons, anesthesiologists, nurses and hospital administrators that treat you like trash. These nasty people make your day hell and their actions often result in a skyrocketing risk of you getting sued. Whether they do it because they’re jerks, or because they’re just plain ignorant about what you do, these monsters are very real and you need to know how to defend yourself against them.

In honor of the month of October and the approach of Halloween, I present to you: Neuromonitoring for Monsters

Full disclosure: I don’t work with monsters. In fact, I have the privilege of working with people who (mostly) treat me like an equal; like the colleague that I am. I know that monsters exist, though, because I’ve met a few during the course of my career, and people often write to me requesting advice on how to deal with monsters.

Here are some paraphrased quotes taken directly from stories that people sent to me:

The surgeon won’t let me talk. I can’t verify what tests he wants me to run before surgery, I can’t ask to update MEPs, I can’t even alert him to changes. He just screams at me. He said if I speak to him at all, he’ll make sure to have me fired.

“The surgeon only wants EMG in complex spine cases (no MEPs or SSEPs!), then he keeps the patient paralyzed throughout the entire procedure; even through screw testing. He gets mad at me if I miss a screw breach. He just doesn’t get it. If I complain, he’ll kick me out of the room and I’ll lose my job.”

“The surgeon won’t let me run any tests during surgery. I get baseline data and that’s it.”

“Anesthesia always runs gas. I can never get motors, and the surgeon always blames me!”

“I told the surgeon that I had no signals at baseline, probably due to anesthesia running N2O. The surgeon screamed at me for talking and told me to sit in the corner and shut up. He wouldn’t let me run any tests during surgery. The patient woke with a new deficit, and the surgeon called my boss to complain. He claimed that I’m at fault for the patient being paralyzed. He lied and said I never told him about absent baselines.”

The surgeon threw a bloody screwdriver at the wall and almost hit me. He was frustrated with the metal rep because the old screws were difficult to remove.

“I asked anesthesia for TIVA in a very kind and polite way. I was kicked out of the room and then told to leave the hospital and not return. They said “sales reps” have no place asking for TIVA.”

“The surgeon had me in the OR for 14 hours. I got no food or bathroom breaks. After surgery, he had pizza delivered for the entire OR, but I wasn’t invited.”

“I’m not allowed to see patients in holding. They won’t even let me get consent for neuromonitoring.”

“I’m not allowed in the OR while the patient is awake.”

I wasn’t allowed to enter the OR. They wanted me to monitor the patient from the hallway, but my cables weren’t long enough to reach the bed. It’s the only reason they let me in the OR at all.

“They won’t give me scrubs without making me trade in my car keys. I’m in the OR for 12+ hours, and then my keys are locked in someone’s office for the night and I have no way to get them back. Then, I have to track down security and it’s another hour before I can finally get my keys to go home.”

“I’m not allowed to place needles in the patient.”

“They make me wear bright orange scrubs because they think I’m a sales rep. It’s embarrassing to see patients when I’m dressed like a prisoner.”

“The remote neurologist didn’t like that I spoke to the surgeon about the monitoring plan without his permission. He accused me of practicing medicine without a license. Then, he started telling me how famous he is, how many cases he’s monitored, and how much he’s published. He was just trying to belittle and bully me. It’s easy to monitor a lot of cases when you’re doing them all simultaneously from your living room. Funny thing is, the guy only had 1 publication and it wasn’t even peer reviewed!”

Who created the monster?

Aside from the fact that some people are jerks, and others are just plain ignorant, it isn’t uncommon for people to use any excuse to exercise their power in abusive ways. When it comes to neuromonitoring, there are a few factors working against us.

  1. Neuromonitoring is largely used for the surgeon’s medicolegal protection. He/she might not believe in it’s utility, but feels obligated by the medicolegal climate to use IONM. So, surgeons will use IONM, but they don’t want to have any interaction with us. They will outright ignore us and do whatever they want.
  2. Telemedicine has created an environment in which the person who is usually in the best position to have a high-level conversation with the surgical team is unknown to the patient, unknown to the surgical team, and usually physically located hundreds or thousands of miles away. Since the person performing IONM in the room is often not a doctor of any kind, the absence of any professional figurehead leads the surgical team to believe they have carte blanche to walk all over the IONM tech.
  3. IONM is frequently provided by outsourced corporations who tend to focus on surgeon satisfaction above patient care. They tell the surgeon jokes, tie up their gown, do whatever they say just to make them happy. The tech gets grouped in with sales reps, then surgeons & anesthesiologists have no intentions of listening to them when it comes to clinical matters.

So, basically, our profession created the monster by 1) under-demonstrating efficacy, 2) removing the oversight from the OR, and 3) failing to differentiate ourselves from the sales reps. That doesn’t mean we can’t do something about it. We can always make change, but we need the tools to do so.

How do we defeat the monsters?

Change the Surgeon

When people in the clinical setting see that surgeons don’t care about IONM, then they feel empowered to talk down to the IONM tech. So, change the surgeon, change the world. It’s easier said than done. Perhaps the fastest way to change a surgeon’s tune is to save his or her ass one day in the OR by catching something very important. Those events are rare, though, so you’ll have to use different methods. Changing a surgeon is a marathon; not a sprint. It can take months or years to get a surgeon to trust your expertise. In order to do that, you have to become an expert and stop acting like a sales rep.

Be the Expert

You have to master your craft and show the people on the OR team that you are better and smarter than most people out there. This isn’t easy. You’ll have to study extensively and then be able and willing to have high-level discussions about the literature. You’ll need to study surgery, anesthesiology, pharmacology, pathology, neuroscience, neurophysiology and more to have these discussions.

Then, you have to pick the right time and place to talk to the surgeon. My approach has always been to make an appointment with a surgeon through their assistant, to sit down in his/her office, and present my problem/perspective in that environment. The surgeon’s office is a bit more of a laid back, academic setting than the clinic. The surgeon has to be in that frame of mind in order to have these discussions. It is certainly better than talking to them with a patient in the room, or by the scrub sink. You need a low stress environment. You’ll need to present a strong, evidence-based argument, to provide literature and find a path for working together moving forward.

Aside from meeting with a surgeon or anesthesiologist, you can also do things like give in-service presentations, give grand rounds, or just email them relevant papers/articles.

Stop Acting Like a Sales Rep

You are not in the OR to talk sports, make jokes, answer the surgeon’s phone, tie up their gowns or please them in any other way. You are there to monitor the patient’s nervous system. If you want to be treated like a professional, then act like one.

Document, Document, Document

I can’t stress this enough. The very most important thing that one can do to protect him/herself is to document, document, document.

If you tell anesthesia that TIVA is optimal and they tell you to go “F yourself” put that in the medical record. Put it in the event log. Put it in the chat log. Write down exactly what was said by each party. By the same token, you tell that surgeon that MEPs are recommended for a surgery, and the surgeon declines, document it. If you request MEPs after the surgeon places a graft, and the surgeons says, “No, not now”, then document it. Documentation will save your ass!

Here is an example of some things that you might have to put in your event log, or comment log, in order to document conversations:

Anesthesia Plan: The attending anesthesiologist was informed that TIVA is optimal for neuromonitoring, including the fact that N2O and volatile anesthetics are suboptimal and increase the likelihood that baselines will be unobtainable. The attending anesthesiologist acknowledged this information and elected to proceed with administration of N2O.

Surgeon Consult: Regarding Anesthesia: Attending surgeon informed that MEPs may not be obtainable at baseline due to anesthesia administering N2O. Surgeon stated he “doesn’t care”.

Baseline Note: Motor evoked potentials are absent from the lower extremities at baseline. Surgeon informed and acknowledged absent MEPs and that this precludes our ability to monitor lower extremity motor function during this procedure. With the understanding that we are unable to monitor lower extremity motor function during this procedure, the surgeon elected to proceed.

All of this might sound excessive, but it will definitely save your ass in court, because I can guarantee you 100% that the anesthesiologist will throw you under the bus and state that you never recommended TIVA, and the surgeon will throw you under the bus (again) and state that you never informed him that MEPs couldn’t be monitored. You event log will be subpoenaed and your time-stamped documentation will prove that they are both liars.  These are just some examples of what one could write. My perspective is, when it comes to protecting yourself, the more information, the better.

By the way, if the surgeon or anesthesiologist absolutely refuses to use a certain method, you could ask them to sign a “standing declination order” so you don’t need to have the same conversation every single day. You can tell the anesthesiologist: “I know you don’t want to keep having this conversation, neither do I, but I do it because I’m required to. You can sign a paper that says from now on I will always decline to use the recommended TIVA protocol“. You might want to have a lawyer draw up the document. I don’t really recommend this, but I know of at least one surgeon who actually wanted this done.

Give Up!

There are some people in the world that are just going to treat you like trash and not listen to you no matter what. Sometimes documentation isn’t enough. I once worked with the most awful surgeon. He cursed at me, he called me awful names, he threw instruments, he wouldn’t let me run tests and he wouldn’t listen. He was a monster of the worst kind. He was the only surgeon that used monitoring in the hospital, and working with this guy was a serious liability. The next day, our company cancelled the account. No one should have to be treated like that at work. So, if all else fails, cut the monster loose. Let him terrorize someone else. It could just save you and your company from ruin.

11 thoughts on “Neuromonitoring for Monsters

  • Reply Bernie Cohen October 11, 2016 at 04:50

    Great summary of the world we live in. More or less, every one of us who has made any effort to be a part of patient care, has experienced some or all of this at one time or another.

    Keep on writing

  • Reply Shannon October 11, 2016 at 06:08

    This is brilliant! Having faced many Monsters before i can totally identify with this article! Well done for writing in support of the Rep, we really do get thenraw end of the deal at times.

  • Reply Tyson Hale October 11, 2016 at 10:42

    Very well thought out, and wonderful advice. I have also experienced many of these situations. Thanks for writing!

  • Reply Lawrence October 11, 2016 at 12:19

    Thanks for bringing the monsters into the light. Great topic Rich!

  • Reply Richard Vogel October 11, 2016 at 12:36

    Thanks, everyone! Appreciate all the positive feedback!!

  • Reply John October 12, 2016 at 13:17

    I tip toe around the hospital OR and I swallow my pride to be a team player wherever I’m sent to cover IOM cases. I get sent to a different hospital nearly every single day of the week.

    Basically, to be an accommodating “guest” in the OR, I allow myself to get stepped on a lot, and just try shrug off all the “monsters” coming at me everyday, because that’s what it takes to do the job right?
    Sometimes I’m wonder to myself when I’m going to snap and lose my “Zen” state of mind after constantly be the “new guy” everywhere I go.

    There are perks to being sent to a new hospital everyday, but incredibly frustrating too.

    We need IOM advocates to stand up for our right to work without harassment. Maybe it’s time to Unionize the profession.

  • Reply Lori Avery October 14, 2016 at 15:03

    This is fantastic! I am so lucky to have a wonderful employer.

  • Reply Art Buehrer, Jr. October 14, 2016 at 20:04

    I have been from the “Ditch Nurse” to the ER, Cardiac and Pulmonary, and 25 years in Neuro research and can verify everything Dr. Vogel has said. I might also say that the entertainment series “Fringe” is foretelling some of that!

    Beware!

  • Reply Art Buehrer, Jr. October 14, 2016 at 20:07

    I have been from the “Ditch Nurse” to the ER, Cardiac and Pulmonary, and 25 years in Neuro research and can verify everything Dr. Vogel has said. I might also say that the entertainment series “Fringe” is foretelling some of that!

    Beware!

  • Reply Rudy A Leemhuis October 17, 2016 at 16:02

    Great info! In my 30+ years of monitoring I have dealt with my share of these monsters. We must remember we have a responsibility to the patient. It is better to be thrown out of the room than to be thrown under the bus. But also remember that monsters can change when they realize that everyone’s goal is the same. Thank you, Dr Vogel!

  • Reply Ryan Conant October 20, 2016 at 16:07

    Really great examples and points made here. I have some repeat experience with “monster” anesthetists whom I inform of a positioning change and they refuse to help reposition or check that limb.

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