Essential IONM O.R. Awareness

For IONM Interns and Observing Students

By Diana Chen

Copyright © 2007 by Diana Chen. All rights reserved.

Ideal Candidates

Observing students: Should have successfully completed IONM Part 1

past Mid-term exams. Intern

Should have successfully completed Functional Human NeuroAnatomy, IONM Part I and/or Part II.

Attire

Change in locker room: Scrubs (shirt-pant set) will be provided Shoe covers, place over sneakers Hair cap, conceal all hair strands Wash your hands well Bring a combination lock, if desire

Before O.R. entry must wear mask with shield (unless eye glasses are worn) Interns: also wear gloves in O.R.

Must wear lead apron if C-arm present, or stand behind someone who is.

Introduction

Observing Students and Interns: Must call Head Surgical Nurse 30-60 min. prior to surgery

Patient must approve of your presence After getting dressed check-in at the Nurses Station

Write your name and Surgeon you will observe Upon entering O.R. must introduce yourself to Circulating

Nurse as “student with NeuroTrend” Staff awareness

Finally Introduce yourself to NeuroTrend Technologist

Environment Zone

Observing students: Semi-restricted zone Must wear full scrub attire and mask Permitted 5 feet away from Patient and 3 feet away from

Sterile tables. Interns: Restricted zone

Full scrub attire, mask and gloves Work permitted near (>12 inches) sterile setup If Sterile Surgical group begins to approach Patient zone,

Intern must allow Tech to resume, if further work is to be done.

Sterile Equipment

Tables with blue sheets Trays on top contain sterile items

Any Instrument with transparent plastic covering, for example: C-arm Microscope

Anesthesiologists Table Patients bed/linens

Access Revoked

Observing students and Interns know that you could be asked to leave by: Head Nurse Circulating Nurse Surgical Team

Causes: Entering without proper attire, must have mask on Disturbing interruptions Crossing any prohibited zones Doing anything you are not there to do, unless asked by

any of the above persons or the Technologist.

Persons in O.R. during Surgery Surgical Team

Surgeon Physician’s Assistant Scrub Nurse Anesthesilogist

IONM Technologist (and you) Circulating Nurse Radiologist Brain Imaging Specialist, if needed Hardware Representative

Basic IONM tools

Surface and/or Needle electrodes 3M Tape Pods for leads (# depends on case need) Stimulators (depends on case need) Pre-amp box Junction box Internet connection/PC Printer, if not electrically stored Folding table

Basic Surgical tools

Cutting Scalpels Scissors Bone cutters Powered drills

Grasping Tissue forceps

Clamping Hemostats; control bleeding Crushing

Skull clamp Non-crushing Vascular Clamps

Artery clamp

Irrigating (always cold)

Exposing and Retracting Electrocautery (hand held or

foot pedal) Low Voltage heat produces very fast, result vaporized tissue. Hi Voltage pulse AC current, heat produces slower, causes blood coagulation Monopolar Bipolar

Suturing Internal staplers Skin staplers

Viewing Microscope with Monitor

Common IONM Modalities

SSEP MEP BAER EMG (free run and triggered) EEG TceMEP

Spinal Cord Nerves and their Innervated Muscles C3-C4; Trapezius (neck muscles) C4-C5; Rhomboids (diaphragm) C5-C6; Biceps and Deltoid C7-C8; Triceps and long muscles of forearm C8-T1; Abductor Pollicis Brevis, First Dorsal

Interosseous (fine hand movements) L1-L2; Iliopsoas (flexors of thigh) L3-L4; Vastus Lateralis L4-L5; Anterior Tibialis L5-S1; Gluteus Maximus, Hamstring S1-S2; Gastrocnemius (plantar flexors of ankle) S2-S4; Anal Sphincter

Supplementary info

Nerves vs. Vertebrae Cranial 8:7 Thoracic 12:12 Lumbar 5:5 Sacral 5:5 Coccyx 1:4

Sensory & Motor innervation of reflexes Bicep reflex; C5, C6 Brachioradialis reflex; C6 Tricep reflex; C7 Finger reflexes; C8 Knee reflex; L3, L4 Adductor reflex; L2 Cremasteric reflex; L1,L2 Plantar reflex; L5 Ankle reflex; S1 Anal reflex; S4, S5

SSEP Nearfield/Farfield (NF/FF) Median/Ulnar

EP: NF, peripheral nerve N13: NF, stationary

record ref., cervical P14: FF, subcortical N18: FF, subcortical N20: NF, cortical

Tibial/Peroneal PF: NF, peripheral nerve N34: FF, subcortical

record ref. from Fpz P37: FF, cortical

IONM Basics

Stimulating electrodes placed close to nerves: (-) Cathode: black; active

Depolarizes in one direction, away from anode (+) Anode: red

Placed 3 cm distal to cathode Ground: green Recording electrodes

From nerves From brain waves

For Your Use

Student Obligation Part I

Visit www.ASET.org Each student participating must read and understand the following competencies: National Competencies for Performing

Intraoperative Physiological Monitoring ASET Position Statement on

Electroneurodiagnostic Technologists in the Operating Room

The Role of Electrodiagnostic Technologists in the Operating Room

Student Obligation Part II

HIPPA (Health Insurance Portability and Accountability Act) Regulations Each student participating must understand this regulation is the Law.

Highly summarized: Patient information is not to be discussed in the presence of anyone that is

not in the O.R. and even then Patient name should not be used in the conversation ever!

Patient record should never leave the users location. Do not ever write down or exchange any Patient Identification data. Pre and Post surgery do not discuss a surgery case in ear shot of family

members or public persons period. Violators of the Law go to JAIL! For more detailed information visit:

http://www.hipaaps.com/what.html http://www.hhs.gov/ocr/hipaa/finalreg.html

Signature of Compliance

Before entering any Hospital we will need you to sign a Student Obligation’s Checklist indicating you agree and understand all items on the checklist.

Turn the form in, in exchange for scrubs. If your going to be absent for your appointed date,

please email in advance or call Diana Chen.

Thank you for your interest