frustrated with EMGs

[topwise]

I love doing EMGs but does anyone else get frustrated by the fact that the information you need to put the whole picture together sometimes just isn't obtainable? Either because the patient can't relax, has too much pain, or has too much swelling/SQ tissue. Hell, even in a young healthy person, it can be near impossible to get some of the LE sensory nerves.

I find it intellectually frustrating. Like those X-files where you're waiting for the mystery to be explained at the end, but then it isn't.

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[PMR 4 MSK]

I often feel like I'd like to have more info - limits of the exam, pt habitus, age, insurance restrictions etc. You just have to accept the limits of you testing and rely on your clinical skills.

 

[Ludicolo]

Hang in there. As you gain experience, you will learn that there is an art to making EMG tolerable: positioning and talking to the patient to make them more comfortable, letting them know what to expect, distracting them with conversation, not lingering in a muscle for too long, etc. If they can’t relax a certain muscle, sometimes having them contract the antagonist muscle works. Occasionally, I’ll use the sounds of MUAP activity as auditory biofeedback. With a patient who has difficulty relaxing, often I’ll assess MUAPs first, then try getting them to relax as I do my fib hunt. Nobody said you have to assess insertional activity first.

All you can do is be as technically proficient and efficient as you can be, which means practice, practice, practice. If you can ascertain more diagnostic info in a shorter amount of time, then it’ll be less uncomfortable for the patient, and you’ll be more productive in practice. You also have to know your limitations and how to roll with the punches. Some patients simply can't relax. Or can't follow directions. Or weigh 300 lbs. Or have constant 10/10 pain no matter what you do. We all get frustrated. Just when you start thinking you’re really technically good at EMGs, along comes a patient who cries out as you’re first placing the electrodes, or who seems to be a big bundle of 60Hz artifact.

If it were easy, anyone could do it.

 

[topwise]

Thanks for the pep talk. I vacillate daily between loving EMG so much that I want to do a fellowship and not wanting to ever do them again.

I get some referrals that really make me nauseated. Like in a CVA patient with hemiplegia: "Back and neck pain, please do bilateral upper and lower extremity EMG". (And that was a referral from a physiatrist!) So it takes forever to position the patient, all the nerves are abnormal, the patient can't relax, and I'm practically in tears by the time we call it quits. Then I think to myself: When I'm in the real world, what if ALL my patients are like this?

 

[Disciple]

I get some referrals that really make me nauseated. Like in a CVA patient with hemiplegia: "Back and neck pain, please do bilateral upper and lower extremity EMG". (And that was a referral from a physiatrist!)

Alright,

That kind of stuff has got to stop if this specialty is to go anywhere.

That's like writing "Eval & Treat, Dx: Chronic Lumbar Strain" on a PT presription.

 

[SSdoc33]

Thanks for the pep talk. I vacillate daily between loving EMG so much that I want to do a fellowship and not wanting to ever do them again.

I get some referrals that really make me nauseated. Like in a CVA patient with hemiplegia: "Back and neck pain, please do bilateral upper and lower extremity EMG". (And that was a referral from a physiatrist!) So it takes forever to position the patient, all the nerves are abnormal, the patient can't relax, and I'm practically in tears by the time we call it quits. Then I think to myself: When I'm in the real world, what if ALL my patients are like this?

i can understand your frustration. you want to do a study where everything makes sense and you can rationalize it logically. thats hard to do it you cant find a sensory response because the patient has too much edema or they cant take the needle. i think emgs appeal to a lot of us because there is some amount of objectivity to it. for some very strange reason, when a radiculopathy hits perfectly and everything makes sense in a study, i find it very gratifying.

there are a lot of reasons out there that physiatrists (especially interventional/pain physiatrists) move away from emgs. time/money/they arent good at them/old machines, etc. i am very glad that i have maintained it as a part of my practice, and find myself looking forward to the day/half day that i perform emgs. it definitely keeps you on your toes and makes you use your brain in a way that is more scientific, and less formulaic.....

 

[Ludicolo]

We all get consults where we scratch our heads and go WTF!? See PMR 4 MSK's "Surgeon unclear on the concept" thread. I recall an EMG consult for "r/o lumbar radiculopathy". Patient only had localized back pain and...





...was a bilateral AKA. You have to laugh at the absurdity of it all.

Alright,

That kind of stuff has got to stop if this specialty is to go anywhere.

That's like writing "Eval & Treat, Dx: Chronic Lumbar Strain" on a PT presription.

Agreed. It hurts more when it comes from our own.

 

[drusso]

Agree with the above. You really need to think of it as an extension of your examination. I tend to view it as a "semi-quantitative" neurological examination. It's got its limitations.

 

[neurologist]

Thanks for the pep talk. I vacillate daily between loving EMG so much that I want to do a fellowship and not wanting to ever do them again.

I get some referrals that really make me nauseated. Like in a CVA patient with hemiplegia: "Back and neck pain, please do bilateral upper and lower extremity EMG". (And that was a referral from a physiatrist!) So it takes forever to position the patient, all the nerves are abnormal, the patient can't relax, and I'm practically in tears by the time we call it quits. Then I think to myself: When I'm in the real world, what if ALL my patients are like this?

"Technically limited study due to . . . "

Wait until you start doing all the inpatient ICU EMGs . . .