EMG

Initial acceptance to the NYU Langone Clinical Neurophysiology Fellowship Program is for the standard, combined EEG/EMG (i.e. clinical neurophysiology) 1-year fellowship. The year’s rotation schedule will reflect the fellows’ primary interests; those focused on a career in EEG/Epilepsy will have more EEG-dedicated service time, while the schedules of those fellows planning a more EMG-centric career will reflect this career goal accordingly.

EMG-Track fellows will rotate through two sites during their first year: NYU Langone Health and The Hospital for Joint Diseases. EEG/Epilepsy-based learning takes place at NYU Langone Health while EMG rotations take place at The Hospital for Joint Diseases. NYU-Langone Health is a large 879-bed hospital located on 1st Avenue on the East Side of Manhattan, and is home to the adult and pediatric inpatient video-EEG monitoring units. NYU Langone Health also possesses an active epilepsy surgical service, as well as an epilepsy consult service. The Hospital for Joint Diseases is a 190-bed hospital located in the Gramercy Park neighborhood near Stuyvesant Square; Dr. Aleksander Beric oversees the Hospital for Joint Diseases rotations.

EMG-Track fellows spend 8 months at The Hospital for Joint Diseases and 4 months at NYU Langone Health. One month of vacation time is provided, typically taken in 4 separate 1-week blocks throughout the year.

EMG/NCS/Evoked Potential Experience

EMG/NCS Laboratory Rotation:

The EMG track is directed by Dr. Aleksandar Beric, M.D., D.Sc. and features an EMG and Evoked Potentials (EP) rotation, which includes daily participation in the administration of NCS, EMG, as well as somatosensory, visual and auditory EPs. There is a dedicated Intraoperative Monitoring (IOM) rotation, and there are also opportunities to evaluate movement disorders and attend pallidotomy surgical procedures.

All fellows learn proper techniques for performing and interpreting NCS and EMG studies under the supervision of both the attending physicians as well as the senior registered technician prior to performing studies. Testing of both routine and less frequently tested nerves and muscles will be reviewed and discussion of the appropriate indications for the procedures is an integral part of training (i.e. when does one do a single versus multi-limb study, how does one choose the muscle(s) for needle examination). Similarly, exposure to the setup, testing and interpretation for evoked studies is provided so that all trainees have the fundamental understanding of the underlying neurophysiology as well as the technical expertise to both perform and interpret studies. Additional exposure to specialized testing, including single fiber EMG, quantitative sensory testing and intraoperative monitoring procedures is also available.

The Hospital for Joint Diseases provides an outpatient population with referrals from both orthopedic and neurologic colleagues providing a broad array of entrapment and neuromuscular cases. In addition, Dr. Mary-Lynn Chu provides the opportunity to participate in pediatric cases and address the additional challenges of the peripheral neurophysiology testing in young populations.

The Outpatient Experience:

All EMG-Track fellows will participate in a weekly, half day clinic at The Hospital for Joint Diseases. In this clinic a wide array of neurological diseases are present. Fellows will staff all patients with an attending physician and discuss appropriate referrals for further diagnostic testing, evaluation and treatment. Patients referred for EMG/NCS/Evoked Potentials typically have their study performed by the same fellow to improve both continuity of care and the learning experience for the fellow.

EEG/Epilepsy Experience

Inpatient Services:

The EEG/Epilepsy track is directed by Dr. Deana Gazzola. During the EEG/Epilepsy training months, fellows will rotate through several core services and gain extensive clinical experience with both adult and pediatric video-EEG monitoring, invasive intracranial monitoring, and epilepsy consults in both ICU and non-ICU settings. NYU Langone Health boasts one of the largest video-EEG monitoring units in the country with 18 state-of-the-art hard-wired beds in the adult unit and 8 hard-wired beds in the pediatric unit; this provides fellows a vast array of seizures and electrographic data from which to learn. We are also proud to feature one of the most active epilepsy surgical programs in the United States, performing electrode implantation and/or surgical resections on approximately 60-80 patients annually.

During their time at NYU Langone Health, fellows will rotate for 1-month intervals on the adult video-EEG service, Pediatric Service, Consult Service, and the surgical service. During their time on the adult video-EEG monitoring unit, which is located on the 12th floor of the Health Care Center (HCC-12) Building, fellows will practice and perfect their EEG-reading skills during their daily morning review of records with the service attending; EEG review is done in the morning directly with the service attending to provide one-on-one interaction and feedback on EEG review skills. They will also learn the verbiage necessary to write a proper EEG report, a skill they will use throughout their careers as clinical neurophysiologists. Fellows will encounter a variety of patient cases on the adult inpatient service, including but not limited to: temporal lobe epilepsy, frontal lobe and other extra-temporal epilepsies, multifocal epilepsy, primary generalized epilepsy and symptomatic generalized epilepsy, Lennox-Gastaut Syndrome, and cases of focal status epilepticus. Indications for admission include but are not limited to: Differential diagnosis, characterization, pre-surgical evaluation, and the acute management of seizure exacerbation. Fellows can learn a tremendous amount from the wide array of cases and underlying etiologies observed on the epilepsy unit, including brain tumors, stroke, malformations of cortical development, and CNS-inflammatory diseases such as lupus encephalitis and NMDA-receptor antibody encephalitis. Non-epileptic seizures are also routinely encountered, as well as other psychiatric manifestations of refractory epilepsy. We have a dedicated psychiatrist who works on the unit and consults on all inpatients in need of psychiatric evaluation and care. In addition, our neuropsychologists are an active part of the HCC-12 team, and are invaluable in providing comprehensive patient assessments. The clinical exposure on the HCC-12 service is tremendous and will contribute greatly to the epilepsy fellows’ knowledge base. On the adult floor, around 80-90 patients are admitted for monitoring per month.

Fellows will learn to read pediatric recordings while on the inpatient pediatric video-EEG service, working directly with our pediatric epileptologists. On this rotation, as with the adult epilepsy monitoring unit, EEG review will be done directly with the attending physician. The pediatric unit reviews around 40-60 patients per month including neonatal cases. Cases often include temporal and extra-temporal neocortical epilepsies, infantile spasms, metabolic/neurodegenerative diseases, tuberous sclerosis complex, malformations of cortical development, hemimegalencephaly, absence seizures, benign rolandic seizures, status epilepticus and non-epileptic etiologies.

On the consult service, fellows will encounter a wide range of epilepsy clinical scenarios. They will have the opportunity to manage routine “bread-and-butter” cases, providing guidance with antiepileptic drug management and in some cases make new diagnoses. Fellows will also take part in the management of acutely ill patients in the medical, cardiac, surgical, and neurosurgical Intensive Care Units, which can provide some of our more challenging epilepsy cases.

EMG-Track fellows do not have a formal rotation on the epilepsy surgery service (“Special Procedures”) for intracranial monitoring, cortical mapping and intracarotid amobarbital procedure experiences; interested EMG-Track fellows are encouraged to discuss their interest with the attending on service and/or the program director and every effort to accommodate the fellows clinical or academic interests is made and time to observe and participate in procedures can usually be arranged.

Call:

All fellows are scheduled to take call while they rotate at NYU Langone Health. During the weeknights, fellows take call from home. They cover calls from the hospital as well as the outpatient services. An attending is always on-call with the fellow, available to discuss any problems and answer questions. Fellows have online access to patients’ outpatient clinical records via the Epic EMR system from home, and they are also able to review live video-EEG recordings through remote access, if needed. On-call fellows round with the on-call attending on weekends, but resume home-call when the day’s work is complete.

Goals:

By the time the first year of EMG-Track training is complete, fellows will be competent in the setup, performing and interpretation of EMG, NCS and Evoked Potential Studies. They will be able to identify appropriate utilization and documentation of the tests to provide valuable consultative and diagnostic services for referring physicians. Fellows will also develop clinical competency in adult and pediatric EEG and video-EEG interpretation. These skill sets will foster the development of a very capable clinical neurophysiologist. After this year of training, fellows are both eligible and encouraged to take the Clinical Neurophysiology Board Examination offered through the American Board of Psychiatry and Neurology. At present, this examination is offered on an alternating year basis.

Fellows are also eligible to take ABEM (American Board of Electrodiagnostic Medicine) exam certification.