EPISODE 20

[INTRODUCTION]

[00:00:00] ANNOUNCER: Do you enjoy listening to On The Ear, but wish you could earn ASHA CEUs for it? Start today. Speechtherapypd.com has over 175 hours of audio courses on-demand, with an average of 19 new audio courses released each month. Here's the best part, each episode earns you ASHA Continuing Ed Credits. Oh, no wait. This is the best part. As a listener of On The Ear, you can receive $20 off in annual subscription when you use code Ear21. Just head to speechtherapypd.com to sign up and use code Ear21, E-A-R-2-1 for $20 off your annual subscription.

[00:00:48] DS: You're listening to On The Ear, an audiology podcast sponsored by speechtherapypd.com. I'm your host, Dr. Dakota Sharp, Au.D, CCC-A, audiologist, clinical professor and lifelong learner.

Well, I primarily work with pediatric cochlear implants and hearing aids. I am absolutely intrigued by the many areas of audiology and communication in general. This podcast aims to explore the science of hearing, balance and communication with a variety of experts in hopes of equipping you to better serve your patients, colleagues and students. Let's go. We are live and On the Ear, brought to you by speechtherapypd.com.

[INTERVIEW]

[00:01:36] DS: One of my favorite things about audiology is how diverse different specializations can be within the profession. Audiologists have a scope of practice that is far wider than most outsiders even realize. In a new series we're calling the Full Scope of Audiology, we'll be talking with audiologists who work in exciting contexts, not typically considered by students and seasoned clinicians.

Today's guest is going to help explain an audiologist role in a very unique environment. Neuro monitoring in the operating room. Did anybody else's hair just stand up on edge? Is that a little intense for anyone else? It’s definitely intense for me. I'm so excited I'm going to be talking with Dr. Cheryl Wiggins, and she's got a lot of letters after her name. I know some of us have some letters after our name, but Cheryl Wiggins has some letters. She's Dr. Cheryl Wiggins, Au.D, D.ABNM, CNIM, CPC. She earned her Bachelor's Degree in Communication Sciences and Disorders from Towson University and went on to earn her Doctorate in Audiology from the University of Louisville.

But very quickly after graduation transition to a career in interoperative neuro monitoring, or IONM, as we'll call it tonight. She's worked in that industry ever since. Cheryl is the Vice President of Intraoperative Neuro Monitoring Education and clinical Performance at SpecialtyCare. In this position, she assists in advancing the company's commitment to IONM and clinical education and clinical quality, as well as helping to optimize the process that supports clinical delivery of care.

Other work-related interest or revenue cycle management and other non-work-related interests are hiking in gardening. Cheryl and her husband live in Nashville and I'm so excited to talk about IONM, something I've always been very intrigued by and heard a little bit about in my Au.D. program, but didn't really know anybody who did that. So, Dr. Cheryl Wiggins, thank you so much for joining me.

[00:03:08] CW: Oh, wonderful. I'm really excited to be able to share more about IONM. So, I'm glad to be here.

[00:03:14] DS: Is that a reaction you get often if you go to like an audiology convention, and people are like, “Oh, where do you work?” And you're like, “Oh, I'm an IONM.” Are people just amazed? Or what's the general reaction?

[00:03:23] CW: Typically, the first thing they ask is, “What's that?” Most audiologists at least have heard about it these days to know that it's kind of around evoked potentials and things of that nature. But I typically spend a lot of time explaining what it is that we do and how much in the OR are you really and that's typically where it starts. But in my opinion, most audiologists that I've talked to at traditional audiology conventions, just are amazed as to how broad the IONM scope goes. They typically tend to think it's only associated with ENT surgeries, and that is usually what requires most of the explanation.

[00:04:00] DS: Got it. Okay, so wait, let's start there then, how would you explain what IONM is to like a total newbie? Audiologist or non-audiologist.

[00:04:08] CW: Yeah, absolutely. So, the way that I typically phrase it is, we're there to assist any surgeon and to be able to help either guide the surgery or give an update to the surgeon on the status of any part of the patient's nervous system. So, whether that's a nerve that's going to be near where maybe a tumor is getting resected, or whether that's the status of the spinal cord, during a scoliosis correction, or something of that nature.

So basically, anywhere where the surgeon may want additional feedback about how their patient is doing, then that's typically where we kind of come into play and help out.

[00:04:44] DS: That's so interesting. Are there typical audiologic, electrophysiological test that you're doing? Or these tests that we would have never heard of before?

[00:04:53] CW: There are some very typical audiologic tests that we would do for procedures where those structures are at risk.

[00:05:00] DS: Okay.

[00:05:00] CW: So, we definitely use the auditory brainstem response when the eighth cranial nerve is at risk. I always find it funny. People in the world of interoperative neuro monitoring tend to call it a BAER or a brainstem auditory evoked response.

[00:05:14] DS: Oh, I've seen that terminology before in like an old textbook or in a paper or something.

[00:05:17] CW: Yeah, so it is always funny. When I talk to my audiology friends, I say ABR and when I talked to my IONM friends, I say BAER, but that's probably what most of us as traditional audiologist would be familiar with. But keeping in mind, the majority of the testing that we do is still an evoked potential or an evoked response. So, many of those same basic neuroscience principles still apply. It's just providing different stimulus and recording from different nerves, if that makes sense.

[00:05:45] DS: Yeah, it does.

[00:05:47] CW: Yeah. So, some of the other tests you might not recognize off the bat, when you break them down into the fundamentals of how those tests, or those we typically call them modalities in IONM, how those modalities work is really not that far off from the basics that we learn in EP class when we're in school.

[00:06:04] DS: Wow. Okay, that's really interesting. Are there any other typical audiology modalities or tests that you guys – are you guys using ECOGs or the myogenic potentials or anything like that?

[00:06:14] CW: Yeah, they're not as common. Probably the most common would be the ABR but yes, we definitely use ECOG interoperatively and I like to kind of make the distinction for those of us in the audiology world, we say ECOG. It also, the acronym ECOG also means electrocorticography for folks on the IONM side. So, to answer your question, we absolutely use electrocochleography intraoperatively. We just don't come across those procedures as often. 

Vestibular myogenic evoked potentials, we absolutely use on occasion, and then different forms of electromyography. So, while we might not do a full ENOG, or looking at facial nerve function quite like that, we do record EMG activity from the facial nerve on quite a regular basis for different ENT procedures.

[00:07:06] DS: Wow. That's so interesting. Okay, I'm about to have like a million different questions. This is going to be a good discussion. Okay. Before I kind of go down that rabbit hole, because first of all, I want some tips from you on preparation to get my impedances better, because I bet you are an expert at that, because that's something I'm like, still struggling with, with the little babies who are three months old and screaming at me. But before we go down that rabbit hole and more about the test, and kind of the day to day, what brought you into this field, because it does feel so small? I'll be honest, when we kind of bumped into each other online. I was like, “Wow, this is somebody who's in this world. I just have never met another professional who's doing this.” So, what brought you into that field? How did you get there? And I've got more questions related to that. But yeah, how'd you get into IONM?

[00:07:49] CW: Oh, absolutely. So, when I was finishing up my doctoral work, and I don't want to sound down on audiology, but in my head, I did all this work and I just wasn't as intrigued by hearing aids. I don't know if it's as I thought I was going to be, but I wanted to be able to really look down multiple avenues to say like, “What else can I do with my doctoral degree?” Because at the time, I'd gotten very used to my work with the VA system. I loved my patients. I love the patient care aspects of audiology, but I had some trepidation about selling, just say it honestly. 

So, in investigating copious options that I potentially could do, I came across an advertisement that specifically was focused towards audiologists to work to get trained in the field of IONM. The practice, it just was like the right place at the right time. The practice that put out the ad, specifically looked for audiologist and people with advanced degrees to cross train to do interoperative neuro monitoring.

In looking at that, it helps me kind of, one move from where I was in graduate school to get closer to home. In my head, when you're immediately out of graduate school, I was thinking, “I can do anything for a little while. If I don't like it, then back to the drawing board. I'll figure out what comes next.” So, I investigated continued to go through the recruiting process with that particular company and probably within 10 minutes of being in the OR for my first kind of visit, I was hooked on just the whole energy that happens in the operating room. As soon as I started training, it was probably within a week or two, there was no looking back for me at that point in time.

[00:09:35] DS: That's awesome. I want to ask you more about the training process, but I'm curious, do you feel like there were any signs in your Au.D. program that you were going to want to do something more in the electrophysiological world?

[00:09:43] CW: Yeah. I did have the opportunity while I was in the Au.D. program to go into the OR once to actually do some interoperative ABR recordings for one of our ENTs that we worked with. So, that was probably the first kind of taste of it that really said, “Hey, I could get used to this.” And always the parts of my studies that I enjoyed the most were around evoked potentials. So, looking back, it probably is not that surprising that this is a pathway that really, I found as interesting as I do.

[00:10:15] DS: Gotcha. So, now that you're in this world, do you feel like – sure it gets bigger, now that you're in it, and you met other professionals. But about how big would you say that this kind of specific specialty is in audiology? Do you have a guess of like about how many in the country are doing this kind of work?

[00:10:31] CW: Well, I know that we have around 25 audiologists that work for the company that I work for, and like you said, it’s a small world. This a small professional circle of audiologists who also do IONM. But when you look at the bigger picture of audiologists, we're probably still only about, I want to say somewhere between like 3% and 5% of the total audiologists that we have out there. We're really kind of hyper focused, so to speak.

[00:10:57] DS: And when you think that there's a limited number of audiologists, and then 3% to 5% of that, yeah, it's a small subcategory.

[00:11:03] CW: So, it's not uncommon to come across audiologists in the world of IONM, but it's just when you put it in that context of all the audiologists that are out there.

[00:11:11] DS: Sure. So, are there other professionals that do this kind of work?

[00:11:15] CW: Yeah. So, there are some of the obvious ones, neurologists that we work with, other physicians that have subspecialty training, specifically to EMG testing, or other neurologic testing. But the kind of cross trained other professionals that we see, there's chiropractors that have left the world of chiropractic and kind of stayed focused on the IONM side. They do get various aspects of neurology training through their DC education. We've also seen physical therapists who have left the PT world. Let's see, there's a handful more. I mean, people come from all walks of life really. And then basic neuroscience folks, some people that have gone on to get PhDs or Master's in Neuroscience, and numerous people that come straight out of their undergrad programs to join us. Other kinesiology majors, things that have like little snippets of the different evoked potential testing, or research that comes from there.

[00:12:12] DS: Gotcha. So, what was that cross training like? What did it entail? Was it its own separate program or how did that work?

[00:12:18] CW: Yes, so we're kind of the – I don't want to say were the Wild West, but we are a relatively new field as a whole. When you think about how long brick and mortar educational institutions have been building audiology programs, and things like that, IONM is very young in that regard. So, most people who've trained in IONM trained on the job or as part of a formal program that's been run by the practice, or the company that they work for. Only very recently, has there been a few educational institutions that offer IONM specific curriculum.

So, there's only I think, three or four that are in the country right now that have IONM specific curriculum, and it's in various forms. There are some that are tagged on to undergrad programs, along with other academic spheres like kinesiology and IONM. There is a master's program that obviously would be after somebody's got a conferred bachelor's degree, and there's other post Bach certificates that you can get in IONM. And then there's a smattering of other certificate kind of based programs that are, “formal”.

So, the company that I work for at Specialty Care, we have built our own training program, including educational curriculum, as well as the clinical training aspects as well, because we needed to be able to build a pipeline of great folks who can do what we do. That's why we look at various different backgrounds, because if we can meet and speak to them and see what will make them successful, we feel like we have a good idea of the attributes and the educational background, all combined that let somebody be successful in this career.

[00:13:57] DS: Gotcha. So, that training process for you, was it coursework? Was it kind of on site? Where you kind of thrown into it? What did that look like? What would it look like for someone interested, I guess, too?

[00:14:10] CW: For that caveat, yes. For me, it was a little bit more freeform, I'll say. That's just because that's what we were able to do. We were very small as an organization then, to be able to provide the fundamental curriculum when we could and the majority came on the job and hands on clinical training. It is very different as to the way that we approach it now which is we do a mixture of online and in person coursework, with regular check ins very close to what most people experience in like a clinical training setup in the audiology world where you get the didactic work along at the same time that you're doing some of the clinical work, so you can get those aha moments as you progress through.

Ours typically, for the current training program that we have at Specialty Care, it takes about one year in time, and that the beginning is very intense, predominantly focused on fundamentals, and making sure people have a good solid neuroscience understanding, and then start to build in clinical progressions and work towards competency.

And then typically after about somewhere between 10 months and one year, folks have had enough cases to be able to have separate IONM certification, in addition to whatever they came to us with.

[00:15:25] DS: Gotcha. So, the curriculum starts off with a lot of neuroscience. I'm assuming, like a lot of neuroanatomy. We're going to break down a little bit more like what it looks like in a day to day for you. But I'm assuming you have to have your cranial nerves down pretty well. 

[00:15:38] CW: Yeah, that's a great start, for sure.

[00:15:40] DS: That's a good starting point. And then I guess, just understanding evoked potentials in general, kind of understanding recording systems, I guess, in terms of – I mean, honestly, my understanding is pretty limited to the ABR which I do regularly, but I can't imagine is as complex as some of the structures you're looking at, especially beyond wave five, or the ABR structures that we're looking at. So, I'm curious, is there anything specific curriculum wise, that you think might be surprising to someone in the audiology world, or I guess I should say, something you didn't really learn in an audiology focused program that you were surprised to learn was so regularly a part of your job?

[00:16:16] CW: It's probably the most and I don't know if it's surprising, or just one of those moments of understanding more of the fundamentals as it leads to how best you can troubleshoot a situation. We tend, in my memory, and while it feels rushed, when you're in the process of training and going through your traditional audiological training, that it is a lot of time when you compare it to what you have to kind of fix an issue intraoperatively. It's not that we as audiologist don't have a sense of urgency about getting great data, but the approach is very different when you're looking at it to build your diagnostic test battery, as opposed to being able to give real time feedback in the middle of surgery.

[00:16:59] DS: Sure.

[00:17:00] CW: Yeah. I mean, that's probably the biggest surprising is just that, it's not so much that you didn't learn it, it's just kind of thinking about it –

[00:17:08] DS: How to use it, I guess.

[00:17:08] CW: Correct. Yeah, thinking about how you time and how you communicate, because the communication is probably the most vital part of what we do day in and day out in the OR, in that professional to professional communication. And that's not always something that is at the forefront of what we do in traditional audiology.

[00:17:27] DS: Gotcha. Again, I'm really excited talking about the day to day, but I'm curious, you said that there's a certification, was it the CNIN?

[00:17:34] CW: Yeah, that's one is that is typically what we call a technical certification. That is what we consider the entry level, most people consider that the entry level. That's not my company thing. That's pretty much in the industry that that's kind of your first step towards saying, “Hey, I've done not only some academic work, but also have plenty of experience. This many cases under my belt and have passed a board certifying exam.”

[00:17:57] DS: Gotcha. Is is regulated in terms of you need CEUs in the world of IONM? Is it licensed separately from like your audiology license?

[00:18:07] CW: So, fantastic questions. There is no licensure that specific to IONM right now. So, the only licensure that we have in the world of IONM sits with the physicians, and it kind of gets covered under their broader medical license. But the certification exam itself is regulated by a body within the industry of interoperative neuro monitoring, and you nailed it right on the head. There are continuing education requirements that you have to meet in order to be eligible to sit for the exam. There's also a certain number of cases of experience that you have to have in order to sit for the exam. And there's a few different pathways to be eligible to sit for certification. Some of it are focused on folks who have their training through a traditional neuro diagnostics school, or many of them are associate's programs for EEG techs or electrophysiological, like EP techs that only focus on very small aspects of the broader neuro diagnostics world.

And then there's other pathways to certification for people who have a bachelor's degree who have then also done additional formal coursework in IONM. And then there are other pathways for programs like the one that we have at Specialty Care that we formalized our curriculum enough that it's recognized by the certifying body as a pathway to eligibility. But those all do require still, case experience in order to be eligible.

[00:19:33] DS: Gotcha. So, at the end of the day, you've got to be getting the hands-on experience, otherwise, they don't know that you had had – it does sound like one of those jobs where you have to kind of do it to get it. I feel like that's how it definitely was in my electrophysiology class learning about ABRs. It's one thing, they’ll be in the lab with a fellow student trying to get them to fall asleep, trying to figure out what I'm looking at at the computer screen. It's an entirely different experience to have a screaming baby and a stressed-out parent. It's just a whole different learning experience. So, that makes a lot of sense.

[00:20:03] CW: Yeah, it's once you get to put your hands on, you can kind of see – I call it those aha moments where all of a sudden, it snaps into view. You're like, “Okay, now I get why I need to make sure my impedances are good”, or, “Now I get why I want to manage where the cable is sitting compared to everything else.” Because you're ready for the baby to wiggle, things like that, putting that all together and getting it to translate to patient care.

[00:20:27] DS: Absolutely. Okay, so now, this is the part I've been looking so forward to. Can you just break down a typical day for you?

[00:20:35] CW: Sure.

[00:20:35] DS: Because surgeries can start pretty early. And one thing I remember I was in a pediatric hospital setting at one point, and we might be doing an ABR after some other procedure was done. Maybe they're doing like a spinal tap or some other sedated procedure. So, you might just keep getting bumped because the family arrived late, and they didn't follow their NPO and then the surgeon got stuck in traffic, and then you're doing your ABR at like 6:30 PM and it was scheduled at 2:00. So, I'm curious, maybe that hasn't happened to you, because everybody runs it real well, but I have to imagine it's real life over there, too. So, what is a typical day like for you?

[00:21:10] CW: Yeah, and first of all, absolutely, definitely happens. I'd like to say that it didn't happen on a regular basis, but things like that life happens. The NPO part happens, or the lack of NPO part happens. So, yeah, and I will preface this with in case some of my IONM friends listen to this. I'm personally not in the OR as much as I used to be anymore. So, what I'll do is I'll give you a day in the life of when I was going in and out of the OR, just because that way, they won't send me a text later to be like, “Don't act like you go in there every day.”

[00:21:45] DS: I appreciate that. I appreciate that.

[00:21:48] CW: But when you're of the mind, on the schedule on a daily basis, most folks typically don't get their confirmed schedule until the evening before, which is probably for most of our planners tends to set them a little crazy. But due to all those things that you talked about, the changing surgical schedule is real. So many times, we would love to set schedules further in advance. But there's so many different things that happen all the way up to the evening before, that we tend to not publish a schedule to associates until the evening before.

So, you would get your schedule the evening before, take a look at it. I would then look at the procedure to make sure I had a good understanding of what's going to happen and figure out like, “Hey, maybe this is something I have to do a quick refresher on to make sure that I understand the anatomy at risk and what's going to happen.” Once I've gotten my mental checklist, they're complete, I'd wake up in the morning, get there about an hour before the case starts. So, you're absolutely correct. Surgery schedules are very early. So, if you have a 7 AM start, that means you need to physically be there in the building and we say typically an hour in advance, but plenty of time to get your equipment in, many times you're bringing your equipment with you. And it's going to depend on the facility. Sometimes there's equipment on site, but many times we're bringing the equipment with us, which may mean you have to check in with biomed to make sure that everything's working properly, the hospital says, “A, okay, you can go ahead and bring it in.” But also, then get set up because the majority of the business that I work in is outsourced, we don't work for the hospital.

So many times, we have to go through a different check in process just to get in the door. That affects you even from where you park towards, you know how you can get into the hour and actually get scrubs. Just making sure you give yourself that plenty of cushion time to be able to get all that done before you have to go speak to the patient.

[00:23:36] DS: I'm curious, before we get to the point where you talk to the patient about the equipment. I know that there's a lot of electrophysiology equipment that can do multiple tests at once, but you're probably doing things I've never even heard of. So, are you having to manage a lot of different laptops or test boxes, or how many different pieces of equipment that you think you'd have to bring with you for like a day of surgery?

[00:23:58] CW: So, it's typically only one consolidated piece of IONM equipment. So, the good news is you don't have to have multiple laptops. It is basically – if you think about your basic instrumentation back to your basic instrumentation days, it's basically a big amplifier, right? And you can plug in different aspects to be able to be able to record from and let the laptop kind of do the division of labor there.

But you are right. The way that we look at our IONM equipment is I don't want to say it's like your ABR on steroids. But it has the ability to generate the clicks for ABR. It has the ability to generate the electricity that we use to stimulate for a motor evoked potential. It has the ability to produce the electricity that we use to do somatic sensory evoked potentials. But it's all kind of done on the same software platform and from various different peripheral components that we attach. So, it's not too much of a hassle to deal with.

[00:24:53] DS: Are you on a cart or do you have like a nice bag that rolls? I'm curious, how you get around the hospital.

[00:24:58] CW: Yeah, it's typically a rolling bag that we’ll wheel in. Sometimes, you know, back in the old days, we used to wheel our own carts in, in the times of ongoing infection control hospitals like less and less for you to bring things in externally. So, a lot of the times we’ll solicit a table from the folks in the OR to be able to set our stuff up and make our way to our little corner of the room to be able to take care of the patient.

[00:25:21] DS: Awesome. Okay, so you've gotten in, you had to park 50 blocks away, because that's the closest parking lot for you and you've scrubbed in. And so, what happens next?

[00:25:32] CW: Yeah, so once we get in there, we get everything set up in the room. Part of it's just the regular kind of you got to stake your claim in your particular quarter to be able to get your stuff set in. Typically, the first thing, like for myself would be to go see the patient, to make sure that they get an introduction, make sure they know who we are, that they understand what's going to be happening. We are a separate kind of service or a separate procedure alongside their surgery. So, we want to make sure that they understand those components. And then we'll verify that everything still is the way it was scheduled, because at the last second, anything could change. And then if we need to make any adjustments to our mental plan, then we'll know.

So, once seeing the patient, I would then zoom back to the room and get everything set up for the first kind of baseline test, make sure that all my equipment is up and working, all my electrodes are laid out and ready to go into the patient when that time comes. But also, to make sure that all those peripheral components that I need to be able to plug those electrodes into our in a spot that is appropriate for how like the next steps are going to progress. Because the patient structure is going to have to come in, we may have to position the patient in a different position rather than them laying on the stretcher. So, all those things need to come in, need to be understood so we can kind of set ourselves up to not tangle everything up or get something run over or something along that line.

[00:26:52] DS: Absolutely. I can imagine it's a lot of wires a lot of the time with all the different structures that you're looking at. What would be some of the most common procedures that you would be called in on?

[00:27:02] CW: Yeah, absolutely. Everybody that does IONM, they're the bread and butter case are the majority of what we do are actually spine procedures. So, they would be a lumbar laminectomy. So, they're going to go in and make sure that they clean up any herniated disc, or potentially put hardware in. That's probably the most common that we do or sometimes you'll hear people getting an anterior cervical discectomy, and fusion. So, cleaning up discs in the cervical part of the spine. But the spine tends to be the highest volume of cases that we do in the world of IONM, which is typically a surprise for most people in the audiology world.

[00:27:38] DS: I was going to say, that's extremely surprising, because I'm guessing you're not really looking at any cranial nerves if you're down in the lower part of the spine. I guess, actually, you know what, I don't know enough about the spine to even speak it. To me lumbar is lower than the lower part of the back.

[00:27:51] CW: Yes. You’re on target. That's correct.

[00:27:54] DS: But I'm thinking, so I'm guessing you're not necessarily monitoring any cranial nerves or anything of the head or neck that we might be familiar with. I guess you're looking maybe a motor function of the legs and more things like that?

[00:28:04] CW: Absolutely. Like I said, keep back to the fundamentals about what's at risk and what we could watch. But yeah, you're on target as far as that goes. So, the lion's share of the cases that we do aren't necessarily in the wheelhouse, like we were talking about an audiologist, but the understanding about the evoked potentials in general, all those things still apply. All those things still prep somebody very well for being successful in a career like IONM.

[00:28:29] DS: Got it. Got it. Got it. That's so cool. So, the procedure starts. Okay. I guess before the procedure starts, I guess the patient comes in, and then they’re sedated. Okay, so, when audiologist think of typical prep for an electrophysiologic test, we are doing some skin prep, maybe some new prep, or I personally like that 3M tape. I think that's a little bit more effective. But I'm assuming if they're sedated, and you're looking at things a little bit more closely, you could even be using leads that are like I guess inserted under the skin even or what kind of prep? What does that look like for you?

[00:29:02] CW: Absolutely. So, when you asked about, did I have any tips to be able to prep well?

[00:29:07] DS: Get those impedances down.

[00:29:08] CW: Those impedances are down because we use needles just like you said. So, it’s kind of a cheater way. It’s kind of a cheater way to get great impedances. But the benefit of a patient being asleep, putting a few needle electrodes is kind of the least of their worries when they're there for a bigger surgical procedure. So, that tends to not be problematic.

There are a handful of procedures where the patient may not be fully asleep or may be slightly awake for some other aspect of testing. So, in those times, sometimes we can use stickers or use a more traditional kind of head lead setup that audiologists would be more used to. Our EEG techs that work with us who do like longer term EEG studies tend to be the ones who are the people to ask about how do you get the best impedances because they're putting on 25 plus electrodes on these patients heads that need to stay on there for a week at a time. And they use all kinds of tricks, whether it's new prep, or adding on additional kind of stick-em with collodion and things like that to make sure that things stay.

But it's a little bit different of approach. Their patients are typically in the ICU. But in the OR, we tend to lean towards using all needle electrodes.

[00:30:20] DS: Got it. Wow, that's so interesting. I need to Google this to see what it looks like. Because I can't even really picture the needle electrodes. I'm just so used to the big fat stickers. And I guess the placement, everything would probably be a little bit different, too.

Okay, so you've got them prepped with their needle electrodes, I'm jealous of your impedances they're probably nonexistent. So, okay, beyond that. So once the tests or I guess it's a surgical procedure that starts, you are literally monitoring. So, you're watching, and you mentioned that communication is a really important aspect of it. Could you tell me kind of what happens once the surgical procedure begins?

[00:30:53] CW: Yeah, sure. Sometimes our testing starts before the surgical procedure starts and that's just because, as you mentioned, we are doing real time testing throughout, or as close to real time as we can get right. We're not looking at our tests the same way that an audiologist does in a traditional diagnostic setup. So, we tend to not be making a statement as to whether this patient is normal or abnormal. We want to know what their baseline function is like and make sure that it doesn't divert from baseline function throughout the procedure, if that makes sense.

[00:31:26] DS: Yeah, definitely.

[00:31:27] CW: So, it's just a different approach of looking at the same kind of testing. So, we want to make sure that we work really fast to get a great baseline before surgery actually starts, and that's because the electrosurgical instruments tend to put off a lot of electricity and feedback and noise and things that are difficult to record our testers. So, we want to have a good set of baselines before that really gets underway. Plus, it lets the surgeon know that we have a good set of baselines to watch, and that we can give them comfort that they know we can give them good information throughout the procedure.

[00:32:00] DS: Gotcha.

[00:32:01] CW: Yeah. So, we usually work very hard to get that done. But before they start to, we call it exposure, before they're starting to expose, whether it's the spine or some other aspects of the procedure. And we'll have hopefully a set of baselines across all the different modalities that we're using to be able to kind of give them that initial update, like, “Hey, this is what we're starting with.” Most patients that are there for a procedure aren't there because they're problem free. They typically have health problems that have brought them in for whatever they're having. So, it's not always picture-perfect signals from the beginning.

[00:32:33] DS: Gotcha. I want to get into the picture-perfect signals, especially when it comes to electrical noise and artifact. But before I ask that, which test or modality, which one do you think, I guess if you're doing a lot of spine things, you're not doing a lot of ABRs in that instance. So, what is the name of the modality or test that you are using the most often in IONM?

[00:32:51] CW: Yeah, and we tend to use a conglomerate of, we call it a multi-modality approach. But for a typical spine procedure, we would look at somatosensory evoked potentials, electromyography, and maybe even motor evoked potentials depending on what level of the spine they're working on. So, that would give us both active tests as well as passive tests. And that's what I said, when we can get as close as possible to real time information as we can. Because those active tests, if you picture like when you're running your ABR, that's an active test, that you can only see what's happening at that point in time, and then you'd have to be able to save that and start again, and anything can happen in those minutes, or even seconds in between.

So, that's why we try to use a combination of different tests. So, our EMG, we can either look at that, what they call spontaneous EMG, or free run EMG. So, that's going all the time. So as long as there's no electrical interference, we can actually see the response from those muscles, which are associated to specific nerve roots. And then the somatosensory evoked potentials and the motor evoked potentials are two other active tests that we can stimulate – for the somatosensory evoked potentials, we stimulate, typically at the wrist throughout the ankles, and then record from those electrodes on the scalp, and get the somatosensory pathway to be able to tell us about the status of the spinal cord as well as those nerves that we're stimulating. And then the motor evoked potentials, think about that going the opposite direction. We have other electrodes on the scalp that stimulate as close as we can get to the motor cortex of the brain, and then record from those other muscles. So, it basically tests the cortical spinal tract all the way from being able to stimulate up the brain and then recording from out on the periphery. So, it gives us not only spinal cord function, but also nerve root function in addition.

[00:34:42] DS: Gotcha. So, what you're saying is there's a way to stimulate my ab muscles while I'm sleeping so I can wake up with a six-pack abs, right?

[00:34:48] CW: Absolutely what I said. 

[00:34:51] DS: That's so cool. But I'm guessing so a lot of these muscle related evoked potentials, those I guess, can't be continuous, would they fatigue? I haven't seen that in action before. I'm curious how long you can go with some of those motor pathways.

[00:35:03] CW: I guess if you did it enough, it probably would fatigue. But for the way that we utilize them, that does not tend to be the overall issue. But like you said, it only gives you a snapshot at that moment in time.

[00:35:13] DS: Sure, it can't be that continuous look.

[00:35:15] CW: Right. So, in essence, we tend to keep that for pertinent events or in follow up or verification. So, one of the things, the other thing that it overlaps with is looking at spontaneous EMG so we can kind of see what's happening in real time. But if you were to irritate a nerve root, that's what we would see on the EMG. We'd see activity on the associated muscle, and the conversation would be I'm seeing activity on this particular muscle, are you near that nerve root, or something along that lines. If that goes away, what the EMG can't tell me is that went away, because they cut the nerve, whoops, or that went away, because the irritation stopped. So, that's why we use them in combination. “So, it's like, okay, that activity is gone. I would like to run a motor now.” And you can double check it with your active response.  So, kind of using them in tandem that way to give us the most full picture of what's happening. 

[00:36:13] DS: Sure, don't let me forget, because I want to ask you more about that kind of communication in the moment and what that looks like. But I do want to ask you really quick before I forget electrical noise. So, even just doing an ABR and the OR like, we've had to do some weird things. What if we just turn the bed by like 90 degrees? Oh, suddenly the electrode noise it's gone. Or what if we dim the lights by this much? It's gone. It's like you find the weird little things that click and then you're able to run. So, I'm sure you've had to do some weird things or make some weird requests to the people in the room to get those levels down. Can you tell us a little bit about that process?

[00:36:45] CW: Absolutely. We turn things off all the time. We've unplugged the bed, things like that. So yeah, mostly, the way that we try to approach it is to maintenance of your electrodes and maintenance of your actual kind of equipment to kind of avoid the noise before it starts. But the benefit that we get from most of the motor evoked potential, somatosensory evoked potentials and the EMG is those signals are so much bigger than the tiny, tiny ABR. So, it’s just not – you said it early on thinking that ABRs are simple, and I know that you don't mean that. But in the overall grand scheme of our other evoked potentials that we look at, they are very complex, with a lot of things happening recorded on that same waveform. But also, the signal itself is so small, I mean, by ridiculous orders of magnitude, comparatively to EMG activity or a muscle action potential. So, you just don't have to battle noise quite as hard for those as you do when you're recording the ABR.

[00:37:50] DS: That's a great point. I think your needle electrodes are probably helping you get a lot closer to the origin of the wave, when I think of like a VEMP, oVEMP or a cVEMP, like how much bigger those are, the scale of the Y axis is just so different on that kind of a thing. So, that makes total sense that you're not fighting it, just to find that little teeny little peak, that 20 milliseconds in. So, that makes a lot of sense. That's so cool.

Okay, so thank you for clarifying that. I'm also curious, so in those moments where you do you see something change, what is that communication look like? Are you communicating with the surgeon directly? Is there like a point person like the nurse? What does that look like in the moment?

[00:38:27] CW: Yeah, absolutely. So, and the other thing that I should mention is on our side of the world of IONM, there's typically two parties, right? There's typically the person who's in the room, whether that's an audiologist or one of these other professionals who have been cross trained and there's also somebody on the other end of the remote connection. So, the other end of the remote connection, could be a neurologist, or could also be an audiologist, depending on what additional training.

So, we have two kind of aspects of care. The first conversation typically happens between the person in the room and the person on the other end of the remote connection. Those two people are having that conversation in as close to real time again, as possible, usually be a chat. That team has already decided, “Okay, the next conversation needs to happen with the surgeon.” So, the verbal conversation in the room is directly between the person providing the IONM care and the surgeon themselves rather than through an intermediary.

[00:39:21] DS: Gotcha. Okay. So, when you said remote and chat, are you more saying like that these are literally not in the same room?

[00:39:28] CW: Correct.

[00:39:28] DS: Okay, gotcha. Because I know that there's more – I haven't necessarily done it, but I have some friends who are doing tele ABRs, where you have the spoke, and I don't even remember the terminology. One person who's there in person who does the prep, and then the audiologist is, however many miles away on the computer actually running it. So, I wasn't sure how that looked in real time for this kind of situation. That's really interesting. That's pretty traditional in the world of IONM. I apologize, I should have probably said that earlier on that there's two aspects and if you think about it, just the way that you talked about it, it's meant to represent a technical component of the service and then the professional interpretation of the service.

So, a tech, like an audiology tech providing care who communicates in a tele audiology manner to an audiologist for the reading of the ABR would be a very similar kind of relationship. For us, we have audiologists who work on both sides of that sphere. Some of them do everything in the OR, on their own. Some of them work in tandem with our neurologist or other audiologists, and then some of them work alongside the neurologists on the remote side only, if that makes sense.

[00:40:33] DS: Sure. That makes a lot of sense. Wow, that is really, really interesting, just to think of that whole setup and how complex it is, but how critically important it is for that surgery. I'm curious what the longest time in an OR for one patient was for you?

[00:40:48] CW: For me, personally, it was 23 and a half hours, just short of a whole day. Yep. 23 and a half hours. For all things, HIPAA, I probably won't go into more detail than that. It's not typical. Thank goodness. There are points in times, especially, we try to – and this is also not to make myself sound old. But we try to avoid putting anybody in that kind of a situation just for overall safety reasons. But that’s my personal record, unfortunately.

[00:41:15] DS: Oh, my goodness, I cannot even imagine.

[00:41:19] CW: All you want to do is brush your teeth. That's what I remember thinking going on. I'm really tired. But you can stay awake. Because there's things happening during the surgery. It’s not like –

[00:41:26] DS: Boring.

[00:41:26] CW: Exactly. But the whole time you're like, “Okay, I'm just going to stand up.” And it's typically so cold in the OR, most of the time, you're not at risk of falling asleep anyway. You're just trying to shiver and not freeze.

[00:41:37] DS: That is so interesting. Okay. All right. So, this has definitely given me a much better picture of what's going on in there. Darn. Okay. So, I'm curious, then, kind of switching, is there anything else from the typical day that you'd want to share anything like that?

[00:41:53] CW: No, because you did say, we'll talk more, or if you want to talk more about the overall kind of communication back and forth. But the majority of times, everything goes smoothly. So, we hook up, we get our baselines, we monitor throughout the procedure, there are no changes and kind of at the end to say, “Hey, Doctor so and so we didn't have any changes throughout the entire procedure. Life is good.” And they say thanks and we monitor for as long as the patients at risk. We finish collecting our data, we clean up electrodes out from the patient, clean our stuff up, write up our report and kind of submit in whatever system that we happen to be working within. And then, throughout that entire time, we would be also communicating with that other half of our team. So, back and forth and chat, that's all part of our medical record. Once that got all consolidated, then that would be it. Once you clean up and then you can go on your merry way back home.

For the most part, there are occasions where you might have to do multiple procedures in the same day that could make the day longer, and that just comes down to surgery schedules are what surgery schedules are.

[00:42:55] DS: So, are you typically ending at a nice 5 PM or is it usually running a lot later? 

[00:43:02] CW: Well, it could be anything. That's the hard part. Probably the biggest difference is just not being able to predict. So, there'll be days where you'll go nonstop and work for 11 hours. There'll be days where you work for two, or there may be days where your case cancels and you don't work at all. I mean, if you could just kind of sit in that Limbo status. So, I think the biggest struggle overall, in this time in healthcare in general, where everybody talks about burnout, probably the hardest part is not being able to get a handle on it because of just an understanding of how the schedule is going to be. We spend a lot of time as leaders trying to be as gentle as we can, but we get stuck in a position of being reactionary quite a bit, rather than being able to kind of do a whole lot proactively to kind of control it, other than staffing, right? Do you know what I mean? And do what we can as far as that goes.

But I like to try to help folks who are struggling because it is tiring. That's kind of the reality of working that surgery schedule in the OR life, to try to keep an arm's length view of all of it, step back a little bit and try to see it in a bigger picture. Because comparing day to day sometimes gets kind of tough. You kind of have to look at it over time, like week by week or sometimes even month by month to see it all kind of balance out.

[00:44:20] DS: Gotcha. I think that's a really good perspective on that. I think that'd be helpful. I'm actually hoping when we finish up in a few minutes here, I want to round it out with whatever advice you have for either students are seasoned clinicians who want to get into this field. So, if you want to start thinking of that, tell me about what's important about that communication in the OR, like when have you seen communication breakdowns? What kind of skills are important in navigating those conversations? Because I imagine I mean, I've met some surgeons, some surgeons are going to have really big personalities. And so, having to say, “Hold up, you might be doing something wrong in this moment”, or you know what I mean? I just have to imagine that that can be sometimes a little tricky to navigate.

[00:44:57] CW: Absolutely. Absolutely. That's probably the A1A thing that people have to keep in mind. Surgeons do have big personalities, it's probably also then keeping in balance the multiple hats that you have to wear, right? You’re an advocate for the patient. You're also there with distinct information that the surgeon doesn't have. But you hit it on the head, you're there most of the time delivering bad news.

[00:45:22] DS: If you're talking, it's not good.

[00:45:25] CW: Correct. Exactly, then that's kind of – in the surgeon’s brain, if you think about all they're worried about going through that procedure, whatever it is, is they want it to go well. They're invested in that patient having a good experience and being as healthy when they leave if not healthier than when they came in. Like you said, when we talk, it usually means that something terrible is happening. Being able to be cool under pressure is probably the biggest thing that we need out of someone and being able to deliver information, very clearly complex information very clearly but also effectively. I think it's that balance that probably is and I don't know what the right word for that is, to point out as a particular skill, to say like, can you deliver this complex information and can you do it in a way that your voice gets heard without being confrontational, without being –

[00:46:14] DS: Yeah, definitely.

[00:46:15] CW: So, it takes a certain amount of charisma to be able to do it, and also competence because it’s –

[00:46:21] DS: Sure. You have to have some authority.

[00:46:23] CW: You have to be competent in what you're seeing to be able to translate that. Because even if you have that other team member on the remote connection, whether they're a neurologist or an audiologist, even if you have them, the person in the room is the one who's in the room that's standing face to face, delivering the information to the surgeon.

[00:46:39] DS: Wow, I have to imagine that stressful. Any experiences come to mind?

[00:46:44] CW: Oh, I mean, I've had it run the gamut, where I remember when I was first training, and a surgeon looked at me and I had to – we call it an alert. I was giving him the information like, “Hey, Doctor so and so, we have an alert. I have problems with this particular signal.” He looked at me and said, “Cheryl, I can't tell.” He was like, “Other people get really excited.” He's like, “But you're being weirdly calm. Is it time for me to actually worry?” I just remember thinking, you're terrified that you have to interrupt them at all. I remember looking up and I was like, “Yes, it's time to be worried.” And he's like, “Okay, well, thank you. I'm now worried.”

So, that one was kind of awkward, but in my defense, I was relatively new. And then there's other times where you've worked with people for a very long period of time, and everybody's very, very comfortable and they know when you're stressed and you know when they're stressed and that communication goes much smoother, or on occasion, maybe too comfortable. It may get lost and they think you're teasing. There are all kinds of strategies. I have had a surgeon, not one that I've worked with on a regular basis, just not believe what I was telling them. Regardless of how knowledgeable I am, regardless of how much emphasis that I could give and then it's about knowing who else you can talk to, so to speak. Sometimes it's great. I mean, there are other medical professionals in the room, like you mentioned. There's nursing staff in the room, not that they're going to like throw themselves at the feet of the surgeon to change their mind. But you can solicit help from anesthesiologists or other folks to kind of, I want to say, make your announcement more broadly, so to speak.

But I will say that it's not typical. Most often, surgeons have you there for a reason. So even if they don't want to hear your message, they hear it.

[00:48:29] DS: Okay, that's actually one of my other questions. As you mentioned, this is kind of like a separate service when it comes to the surgical procedure. Is it ordered by the surgeon? Is something families seek out? How do you often end up in the operating room?

[00:48:40] CW: It most typically is ordered by the surgeon. So, the same way that your surgeon would say, “Hey, I want you to get an MRI before you come in.” At the last minute, they would also, rather than doing preoperative testing, it's typically ordered by them to save during these procedures. I also have IONM and whoever happens to provide the IONM is who gets called in order to be put on the schedule. Sometimes the relationship is there with the surgeon, sometimes the relationship is with the hospital, if that makes sense.

[00:49:08] DS: Yeah.

[00:49:08] CW: That's just kind of the business side on the IONM front.

[00:49:12] DS: Gotcha. Speaking of the business side, I know that you're involved with specialty care and it just sounds like even within this really tiny bubble of audiology, there's still a lot of room to do different things, which is really cool. What would you say to someone who's interested in terms of like, they've been in private practice for however many years or in pediatrics for however many years they're feeling burnt out, they want to dive into the IONM world, would you say the prognosis is good? How would you explain to someone who might be interested?

[00:49:42] CW: Yeah, I mean, I think the prognosis is always good. Meaning that there's definitely a pathway to kind of diversify what you want to do if you know regardless of how many years of audiology training that you have to come into the world of IONM in the sense of it is a change. Can't be understated that in some aspects, it will feel like and will need to be kind of going back a few steps to kind of start your training again. So, as long as that part is that people keep a realistic mindset around that part, I think the world's your oyster. As far as that goes. 

[00:50:16] DS: Gotcha.

[00:50:16] CW: There are skill sets that we talked about throughout this that audiologists have that translate very well to this field. You understand how to differentially think around; all these different modalities are giving me this information and that flexing those muscles that audiologists do through their diagnostic thinking translates very well to being very quick at thinking about IONM modalities in real time. Understanding professional communication, and overall professional patient care is another thing that is a checkmark on the audiologist side for being able to train in IONM. And then understanding all the other aspects of good healthcare, how to properly document, no time needs to be spent to understand what HIPAA is. Some of those basics that when you pull somebody from a bench science world, that you kind of still have to make sure that people understand what a medical record is, and what that means and why it's different.

So, there are lots of things that give audiologist a leg up. And then obviously, last but not least, is just a basic understanding of evoked potentials. While we may be looking at different nerves or different muscles, you do have the fundamental understanding. So, it translates very well. All that being said, it still is a massive change, as I'm sure you can predict between providing day in and day out officer diagnostic care to patients versus living this or life. So, there is still a learning curve.

[00:51:40] DS: It’s a big shift. But I think it sounds really, really exciting. If there were either audiology students out there listening or seasoned clinicians who were considering taking the plunge, is there a piece of advice you'd have for either of those groups?

[00:51:53] CW: Yeah, I would do your research. Definitely for both sides. For students, we have done fourth year rotations for folks. We do have audiologists who maintain their accuracies can sign off, if that's something – you know what I mean, like that you need as part of your fourth-year placement. We don't regularly do fourth year placements for folks unless they're planning on staying in the world and working for us and IONM, if that makes sense, because –

[00:52:16] DS: They got to know they're interested in this one.

[00:52:18] CW: Yeah, absolutely. Because it is just such a resource commitment from us to be able to kind of go through that training. We have worked alongside some other folks to help support the education in different Au.D. programs as well. So, there are a smattering of our folks who help with curriculum for Au.D. programs who also have some IONM coursework in it. So, that part's a little bit easier over translation. For the seasoned professional, do your research, check out our website, and we do have other materials that will give you a better glimpse or a better understanding, or absolutely can can reach out to me personally, either on LinkedIn or email me, and I'll be happy to answer any questions that you may have. In case you have thoughts about or concerns around training, what that would entail and what that would look like.

[00:53:01] DS: Gotcha.

[00:53:01] CW: Did that answer your question, Dakota?

[00:53:04] DS: Absolutely. And I feel like you've really helped demonstrate what some of the more important clinical and interpersonal skills are for someone who's interested in this. For the students out there, I'm assuming you would say focus on your electrophys classes, make sure you actually understand what you're doing. That's probably an important one. But also just, I mean, like you mentioned, all of those other clinical skills that you pick up in the clinic, whether it's an old person with hearing aids or a child with a cochlear implant, like those skills that you gain in report writing, and rapport building, all of those things are also going to be professionally useful if you're going to follow this career path too.

[00:53:37] CW: A hundred percent. Yeah, don't underestimate those aspects of your career training and your learning that you've gone through to that point in time. Yeah, so you nailed that.

[00:53:45] DS: For those who are seasoned clinicians, don't feel like those skills are going to go to waste if you go into a more OR heavy world.

[00:53:53] CW: Yeah, absolutely. Yes.

[00:53:54] DS: Wow, this has been a super enlightening conversation. Like I said, like I told you before we started tonight, like, this is something I just know so little about, but I've always been so intrigued by. When it was first mentioned, in our electrophys 1 class, like people actually do this all the time. I was like, “Really? What does that look like?” And up until this point, I hadn't really met anyone who does. So, you have just been such a great teacher and I'm so happy to have had the chance to talk to you about all of this.

[00:54:21] CW: Oh, fantastic. I really appreciate it. I tend to be biased, but I like to talk about IONM and I am very proud of my audiology heritage as well. So, I like to be able to meld the two of them together.

[00:54:33] DS: Yeah, absolutely. I truly think that we're going to have – because we do have a fair number of students who listen to the podcast, and I know that they are going to be really intrigued by this and I think you're going to get a lot of people who reach out to you and try to learn a little bit more. What would be a good way for people to reach you if they had more questions?

[00:54:47] CW: Yeah, absolutely. Like I said, please, you can email me directly at my email address. Is it better, Dakota, just to say it out loud or will it go –

[00:54:55] DS: Yeah, we can say it out loud. If that's works for you.

[00:54:56] CW: Okay, that's fine. So, it's my name, which is cheryl.wiggins@specialtycare.net. The other place can find me is on LinkedIn. So, you can Specialty Care and all the different services that we provide on LinkedIn. And then you should be able to find me personally. Cheryl Wiggins, Au.D, D.ABNM, CNIM, on LinkedIn as well.

[00:55:21] DS: I'm telling you, it's a lot of letters –

[00:55:22] CW: It is a lot of letters.

[00:55:23] DS: – but it sounds like you’ve truly earned them. It's awesome. All right, Cheryl, thank you so much for joining me. I'm excited. I'm wondering if there's a context, I'm hoping to do some episodes in the future that are a little bit more like a grand rounds style where we just kind of talk through some clinical cases. And I'm wondering if it might be fun to have you back, if there's any memorable cases that we can get rid of any PHI, but talk through some things and hear what your thought process was at the time.

[00:55:46] CW: Certainly, that's always a big hit amongst our own folks. I know that it's another great way to keep people interested in the world of IONM. So, that would be fantastic. We'd be happy to participate.

[00:55:57] DS: Yay. Awesome. Well, thank you again for joining me. I looking forward to talking to you again. Have a great rest of your day.

[00:56:04] CW: Thank you so much, Dakota.

[END OF INTERVIEW]

[00:56:08] DS: That's all for today. Thank you so much for listening, subscribing, and rating. This podcast is part of an audio course offered for continuing education, through speech therapy PD. Check out the website if you'd like to learn more about the CEU opportunities available for this episode, as well as archived episodes. Just head to speechtherapypd.com/ear. That’s speechtherapypd.com/ear.

[END]
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