Neurodiagnostics & Sleep Disorders Medicine

Neurodiagnostics has been the focus of my professional life. It all started with an interest in EEG while I was working in Dr. Blaine Nashold’s neurosurgical research laboratory at the VA Hospital in Durham, North Carolina when I was in high school. Dr. Nashold’s interest in those days was finding a treatment or cure for Parkinson’s disease and he had a particular interest in stereotaxic surgery. Before using these methods on humans, we used stereotaxic surgery to implant various substances such as alcohol and carbon as well as ablative surgery (cutting out small sections) deep in the brain around the globus pallidus, the thalamus, and the putamen. This was just before the discovery of dopamine and how it can be used to treat Parkinson’s disease. After the surgeries, the animals were sacrificed and we looked at their brains under the microscope to see the various changes. Dr. Nashold had trained with Wilder Penfield at the Montreal Neurological Institute and became my first mentor.

In order to see if the surgeries were working in humans, it was necessary to develop objective methods of measuring muscle rigidity and together with the physical therapy department at Duke, he developed a machine to stretch and measure the resistance of the biceps muscle which he called the myograph. After leaving Duke and Durham, my first job was at the Parkinson Institute in Miami, Florida in 1963 where I used the myograph in the treatment of Parkinson patients.

Following my 2 year tenure at the Parkinson Institute, I branched out in the EEG (Electroencephalography) full time. This eventually led to EMG (Electromyography) and evoked potentials which I specialized in until 1985 in Florida.

Next, after over 20 years in the Miami area which progressed from Paradise Found to Paradise Lost, I decided to return home and my farm (Lady Slipper Cove). Then I used my neurodiagnostic background in the Sleep Diagnostics field as I set up the first Sleep Disorders Lab at UNC-Hospitals in Chapel Hill, NC. Under my leadership from 1986 to 1992, this lab grew from a basic research one-bed lab to a two-bed clinical lab.

In 1992, I relocated to Wilmington, NC to be Director of Neurodiagnostics at New Hanover Regional Medical Center, where we provided EEG, EMG, EP, LTM (epilepsy monitoring), intra-operative monitoring, and sleep diagnostics.

Then in 1996, I branched out on my own as a Neurodiagnostic Consultant which eventually led to full-time employment as an Applications Specialist for Nicolet Biomedical (now VIASYS NeuroCare) based in Madison, Wisconsin, though I continued to live in Wilmington.

More about my professional life following its chronology during my exciting life in service to my fellow man.


Parkinson’s Institute, Miami, Florida

In 1963, I left Duke and Durham, NC and moved to Miami, Florida to start a new job at the Parkinson's Institute. While working with Dr. Nashold, I was on the team that developed the "myograph," an instrument designed to measure the rigidity of the arm muscles of the Parkinson's Disease patient in order to quantify the rigidity. One of these instruments was built at Duke for the Parkinson Institute and I went there to clinically monitor the progress (worsening) of the rigidity. At the Institute the patients had regular out-patient physical therapy, occupational therapy, and speech therapy in an effort to slow the course of the disease. It was also about the time L-Dopa was discovered.
Next in 1965, I wanted to expand my horizons by moving into EEG (Electroencephalographic) Technology clinically. I had already done some of that on a research basis at Duke (and the Durham VAH). So I started working with Michael Goodson, MD in Miami providing clinical EEG services at a number of hospitals by carrying around a portable EEG machine. These hospitals included Cedars of Lebanon, North Shore, North Miami General, Parkway General, St. Francis, Mt. Sinai, and the Miami Heart Institute. At that time, I believe that only the large Jackson Memorial Hospital had their own EEG laboratory. After a couple of years on Biscayne Blvd., we moved the office to Lincoln Road on Miami Beach.
EEG


The best part of this job was our extra-curricular activity on Thursday afternoons, when Dr. Goodson closed the office to go sailing on Biscayne Bay. The craft was a little too large for him to maneuver it in and out of the marina at Dinner Key, so he needed another crew member and that was me. First thing, every Thursday morning, I checked the weather report to find out how choppy the waters would be. One trip was out to Fowey Rocks and on the way back, the wind died and we were becalmed. The water was like glass. Dr. Goodson started up the tiny outboard on the back, which we usually used to only maneuver in and out of the marina slip, and we proceeded back into Dinner Key. Hours later we arrived, but Dr. Goodson was too late for the Medical Board meeting at the hospital that night. On another trip, we were out in the middle of shallow Biscayne Bay at low tide when our keel ran aground. We sat there a couple of hours waiting for the tide to lift us off the sandbar. Probably the most memorable trip out on Biscayne Bay was watching this large catamaran approaching us rather fast. As it went by, Richard Nixon and Bebe Rebozo waved to us.
Have EEG, will travel! Dr. Goodson and I flew to Nassau, Bahamas, where a preacher had murdered his wife. The preacher's attorney was hoping that the neurological exam and the EEG would provide some fodder for his defence, but alas he turned out to be normal. So that our trip would not be a total loss, he asked if we could do an EEG on a high school girl who for no reason would suddenly start shouting obscenities in class. Well during her EEG, abnormal rhythms started coming from her temporal lobes, she sat up, and started shouting those obscenities. I went to her side of the narrow exam table fearing that she might fall off; she grabbed me and pulled me down on top of her, shouting f**k me, f**k me, f**k me! Indeed, she did have a seizure disorder.
Another patient who was having headaches was Jackie Gleason, and I performed an EEG on him.
About this time, my wife, Sara, and my son, Brian (born 27 Oct 1965), and I moved into a home we bought in Coral Gables, where we would live until 1985, with a move back to North Carolina. My son, Greg, would be born later on 20 June 1970.
EMG & EP
Though it was difficult to give up those Thursday afternoon sailing outings, again I needed to expand my horizons to encompass some additional neurodiagnostics, so I went to work for Wayne Tobin, MD in 1968. Now I had the opportunity to add new procedures to my arsenal in addition to EEG. Dr. Tobin now became my second mentor as he had studied EMG with Fritz Buchthal in Copenhagen, and then set up the EMG lab at NIH. He had returned to his Miami hometown to set up a private practice. His teaching approach was "See one, Do one, Teach one!" Dr. Tobin led me into the EMG exam room and told me to lie down on the exam table. He then performed a median nerve conduction velocity and shocked the hell out of me! Next, he told me to get up from the table, and he proceeded to lie down on it with his arm outstretched and told me to do the same nerve conduction velocity test on him. So here I was shocking my new boss. He told me to turn the voltage higher, as it was not enough, so that it would be supramaximal. With trepidation, I did so and learned how to perform a median nerve conduction velocity. So as he left the room, he told me to clean it, and in a moment returned with a patient, whom he asked to lie down on the exam table. Looking at me with a twinkle in his eye, he told me to perform a median nerve conduction velocity on her and walked out the door closing the door behind him. From that experience, I learned that I had to be observant and learn all that I had seen. Some years later, he was bragging on me to some of his colleagues telling them that of all the students he had ever had including his medical students, that I was the fastest learner than he had ever had. I looked at him and asked, "What choice did I have?" His training helped me to pass the first ever technologists registration exam given by Jasper Daube, MD of the Mayo Clinic, in EMG/NCV in Philadelphia in 1980 with the registration number of R.NCS.T#6, and helping him to train others in neuromuscular disorders over the next 15 years. Dr. Tobin loved to express his little truisms. One of them was "The Hammer [ed. reflex] Never Lies". Another one I remember was "When One Diagnosis Won't Do, Try Two!" Once while doing an EMG with him, I said, "Oops" in front of a patient about something that had just happened. After the patient left, he was quick to reprimand me to NEVER say "Oops" when with a patient. Dr. Tobin also held the philosophy that "bigger was better" especially when it came to growing the practice, and when something went just right, he would utter "Just like downtown!"
Later the practice expanded as Howard Zwibel, MD and Michael Aptman, MD joined the practice. Dr. Zwibel collected historic antique medical instruments and displayed them in a curio cabinet in his office, which was quite impressive. Dr. Zwibel never ate lunch, but could be seen reaching into his lab coat pocket for M&Ms. We were afraid that patients might get the wrong idea and think he was popping pills. He also had a habit of having his patients walk down our long hallway to evaluate their gait. I might be at the other end of the hall, and as the patient walked away from him toward me, he would mimic their gait comically. Then he would put on his straight face, and tell them to turn around and come back toward him. It was not easy for me to look professional and keep my composure. Dr. Aptman flattered me after joining the practice by calling me "Professor!" The practice grew and grew adding more physicians, technologists, and support staff, and it all started with just Dr. Tobin, myself, and Reva, the secretary who became the business manager.

One of my more memorable experiences was with Dr. Zwibel, when again I had EMG machine, will travel. This time we went to Haiti to perform an EMG and NCVs on Jean Claude ("Baby Doc") Duvalier. From the airport we were transported to the home of the embassy official where we spent the night. The next day we were taken to a theater in Port-au-Prince where we transferred into three black Buicks (we weren't allowed to ride together) escorted by the Tonton Macoute on a high speed trip on narrow back country roads to the villa that Duvalier had some distance from the capital. We sped by the locals cooking their meals alongside the road, and I feared that the cars would hit some of them, but I was just as sure that if it happened, it would be a hit and run. Arriving at the villa, Baby Doc and his wife Michelle, were watching videos of which Baby Doc had a large collection. The doctors interviewed the patient who only spoke creole french, but Michelle interpreted with her fluent English. Her primary concern was that some medications that a local doctor had prescribed might cause impotence. His medical history revealed that after spraining an ankle, the local doctor had put a cast on it for months, and when the cast came off, he had severe weakness in the leg, which had prompted our visit from the states by the State Department. The testing proved that no great harm had been done, and that his weakness was just from long disuse atrophy resulting from the cast. To show his appreciation, Baby Doc gave each of us a collector's set of gold and silver coins that had been cast in his honor.

While at the Tobin, Zwibel, Aptman, PA medical practice, I would go on to learn evoked potentials, biofeedback, and thermography. Just as in Dr. Goodson's practice, I would travel around to hospitals in the Miami area (primarily Cedars of Lebanon, Doctors Hospital in Coral Gables, South Miami Hospital, and Baptist Hospital in Kendall) providing EEG and EMG/NCV services along with other technologists that joined us.
Though I enjoyed my association with Tobin, Zwibel, Aptman, PA medical practice, I was becoming less enthusiastic about the Miami area. When I had arrived in 1963, Miami was "Paradise Found" and by 1985, Miami was "Paradise Lost." We had recently seen the Coral Gables police in front of our home having discovered a Columbian body from a supposed drug deal gone wrong. In addition, the Cocaine Cowboys had just had a shootout at a drugstore in Dadeland Mall across from our office in the Dadeland Medical Building. One evening, at 10 PM, Miami Vice had portrayed a cocaine lab explosion, and following that in the 11 PM news, the reality of the same story which had occurred just that day was reported. Thus, I had come to the conclusion it was time to relocate my family to North Carolina.

So I pulled up stakes and returned to my family farm in Person County, North Carolina which I now call Lady Slipper Cove.

Unfortunately later in 1995, tragedy struck Dr. Aptman's family.


Sleep Disorders ~ UNC-Hospitals, Chapel Hill, North Carolina

In 1986, Brian Boehlecke, MD of the Pulmonary Medicine department at UNC-Chapel Hill, already was director of the Pulmonary Function Laboratory and he wanted to add a sleep disorders program as well. What the pulmonary department lacked for this endeavor was the neurodiagnostic expertise needed for recording EEG and scoring sleep; thus, I was hired to become Technical Director of this new venture. It started out rather slowly, partly because Dr. Boehlecke wanted me to spend time in the Pulmonary Function lab to learn more about respiratory function, as it would be critical in studying many sleep problems, especially sleep apnea. So, I learned to do PFTs: spirometry, lung volumes, drawing and analyzing arterial blood gases. The relationship between oxygen and carbon dioxide balance during sleep became of critical importance. At first, we did sleep studies in the evenings in one bed in the Pulmonary Function Laboratory. Most of these patients early in sleep disorders medicine were extremely obese patients, often with tracheostomies, and children with various kinds of respiratory distress, which became worse during sleep. Soon, we needed more equipment which we begged and borrowed from the medical school, and moved the lab to the eighth floor, where there had previously been an ICU. It continued to be a one-bed laboratory, but we began to see a wider assortment of patients, including neurodiagnostic cases such as narcolepsy and nocturnal seizure disorders. Soon, Brad Vaughn, MD, a neurologist became involved in the department. Sleep disorders medicine was growing not only at our hospital, but everywhere and we needed more space because the clinical demand was increasing over the research demand. Next we shared space with the peripheral vascular lab, where they used two of the exam rooms by day and we used them at night. We were also becoming more sophisticated with new equipment and the ability to monitor our patients using infrared closed-circuit TV with VCR recorders. This picture shows me at the 16 channel Grass polysomnographic machine watching and documenting the wave forms as they were printed on over 1,000 feet of paper each night for each patient.
I worked in this capacity for six years, which was demanding on my own sleep needs, because I worked Monday, Tuesday, and Wednesday night shifts from 8:00 PM - 6:00 AM and then a daytime shift from 8:00 AM - 6:00 PM on Friday. The Friday morning was for case conference, followed by the Sleep Clinic where I saw the patients along with Dr. Boehlecke, Dr. Vaughn, and other physicians. Friday afternoons were spent scoring, preparing reports, and administrative functions.
During this period in 1990, I sat for my RPSGT boards, passed and became RPSGT # 480. I was getting burned-out because of the schedule and because I was the only sleep technologist. In 1991, the physicians saw the need for help and hired another sleep tech to help me. My schedule did not change however, and not being a "spring chicken" any more, I decided I had paid my dues working nights, and started looking elsewhere.
New Hanover Regional Medical Center, Wilmington, North Carolina

Next in 1992, I was offered the position of Director, Neurology Lab at the New Hanover Regional Medical Center in Wilmington. Unfortunately, this meant leaving Lady Slipper Cove, but some sacrifices have to be made sometimes on our journey in life. Wilmington became my new home town and I still love living here. So now I guess it was not a sacrifice at all, because I have the best of two worlds! Living on the coast means warmer winters and cooler summers, being near the beach, and many other amenities.
As the new Director of the Neurology Lab, I was given responsibility for neurodiagnostics and sleep disorders with the seventh largest regional medical center in North Carolina. When I arrived in 1992, there was not a computer anywhere in the department, just some old typewriters and analog equipment. Just before my arrival however, the hospital had purchased a new two-bed computerized sleep system from Nicolet Biomedical in Wisconsin. The highest priority on my agenda was to get this new computer acquiring data, so that we could catch up with the huge backlog of scoring that needed to be done. Next, I hired a secretary for the department and purchased a computer system for her to prepare reports and keep databases. As time went on, my boss, Dick Jones, one of the VPs of the hospital was very understanding in helping me to budget purchases to completely digitize the Neurology Lab, including EEG, EMG-NCV, long-term epilepsy monitoring, evoked potentials, and intraoperative monitoring. So during my tenure, we went from the dark ages of analog to the present age of digital technology. Patient advocacy and technologist education were also my focus during this period. I was a founder of the Carolina Sleep Society, served as its president, as well as the president of the Southeast-Southwest Association of Sleep Technologists. At the national ASET oganization level, I served as journal and newsletter chair. The Neurology Lab grew in staff and services being provided with outstanding quality. Technologists attended more educational seminars and became registered with REEGT, REPT, RPSGT credentials. At one time, we had more RPSGTs on staff than any other sleep center in North Carolina. My biggest failure however was to get the sleep center accredited, because I could not succeed in getting one of our sleep physicians board certified. Our sleep center hosted several regional sleep conventions and one of them was at the Blockade Runner hotel on Wrightsville Beach. Our keynote speaker was William Dement, MD, who is famously known as the "father of sleep medicine" because of his pioneering research. After picking him up at the airport, he wanted to freshen up before an appearance that afternoon on local TV, so I brought him to my home. We had a wonderful discussion over a cup of tea, and he autographed my copy of Principles and Practices of Sleep Medicine.
In 1995, I began to consult for Nicolet Biomedical as time allowed. Most of our equipment was the Nicolet brand, and I had become an expert user of the products, so the company wanted me to consult and teach new users how to perform various tests. I would take my vacation time and travel to labs around the country to consult with them. Then in 1995-1996, under the leadership of Jim Hobbs, the hospital embarked on a downsizing campaign, which in my opinion was being very detrimental to the hospital. Early retirement and severance were offered throughout the ranks of the hospital, but mostly I saw my management colleagues deciding to leave including some of my own employees, so though a painful decision as I had thought this would be my last job, I joined them. Unemployed, I hung out my shingle as a full-time neurodiagnostic consultant.

Nicolet Biomedical, Inc., Madison, Wisconsin
So in March, 1996 I started my own Neurodiagnostic consulting business. As a part of that, I approached several hospitals to start scoring their sleep studies that might have a backlog because of vacations, and lack of personnel. Soon I was scoring regularly for three hospitals, who overnighted their studies on disc and with quick turnaround time, I returned the scored studies scored on disc with hardcopy reports. This was an excellent way to keep busy while at home and not on the road traveling. But Nicolet Biomedical who had already used my services while I was employed at NHRMC, began to call me more often to help salesmen sell their products and also to teach lab personnel on site how to use the equipment after the sale.
Nicolet also started using me as their regular instructor for Madison-based classes for Ultrasom, and other neurodiagnostic products. So I was at the company headquarters in Madison six to eight times a year for a week at a time. In no time, my calendar was completely filled. Perhaps, the most surprising part of this was that hospitals and labs who used to view me as just another technologist, now viewed me as the expert! Most of all, I really enjoyed teaching; and every teaching experience led me to new discoveries as local technologists taught me their techniques and shortcuts, as well as having to research deeper into the software code of the products I was representing to find answers. Increasingly, I did become an expert and more valuable to Nicolet Biomedical. In 2000, the company was without a product manager for EEG and sleep, so the vice-president, Dave Stephenson, asked me to represent those products at the three annual regional "2000 and beyond" sales meetings in Acapulco, Athens, and Bangkok. What a great time I had traveling that year and previous to that in 1996, I have done the same in Seoul, Korea and Beijing, China. Now I was traveling to almost every state in the USA (except for Alaska and New Mexico), but to Canada, Mexico, Europe, and Asia!
Then in December, 2000, while I was teaching a course in Madison, Dave Stephenson asked me to join the company full-time as an Applicatons Specialist. Actually my duties did not change, but I was now working for the company with benefits, instead of working for myself. This rigorous pace continued until 2004 when my limb-girdle muscular dystrophy became so severe that I could no longer handle the travel requirements. From then until my retirement in 2006, I provided full-time customer phone support from my home in Wilmington.






4 comments:

Erick said...

If you are suffering from sleep problems such as insomnia or obstructive sleep apnea, you need to consider this problem seriously and adopt specific measures at the earliest to get back your sleep. Regular exercising is one of the options to ensure sound sleep at night. Altogether, if you are unable to get adequate sleep during night, you can undertake certain initiatives to overcome your sleep problems such as fixing your sleeping as well as waking schedule and abstaining from alcohol, nicotine, tea, coffee et al before hitting the bed.

TM said...

Hello, David!

Thanks for making it so pleasant to find you online. I really enjoyed learning all the background I had always expected, but never managed to get out of your own modest conversations.

Congratulations on retirement- you look nice and relaxed!

Best Regards,
Tom Maloney
RPSGT318 at AOL dot COM

Hannah said...

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Hannah Bevills
hannah.bevills@gmail.com
www.Hospital.com

Ashok Kumar said...

The sleep apnea dental appliance are usually fit in by a personal dentist according to an individual’s condition. Selecting a dental mouth piece to use for treatment of sleep apnea condition mainly depends on the person’s preference, sleep physician or personal dentist. However, to get the best fit, it is more advisable for the dentist and the sleep doctor to work closely together.