Christopher Doughty (center) demonstrates an electromyography test for Nichole Bluemle (right).

Christopher Doughty (center) demonstrates an electromyography as Nichole Bluemle (right) observes.

As a physical therapist at Northern Navajo Medical Center in Shiprock, N.M., Nichole Bluemle, PT, DPT, MS, OCS, CSCS, saw a need for improved diagnostic testing for her patients experiencing neuromuscular disorders, such as carpal tunnel syndrome or unexplained tingling in the limbs.

The specialized tests she had in mind, including nerve conduction studies and electromyography (EMG), are typically performed by a neurologist or physiatrist. But with only one neurologist on staff at her rural, limited-resource hospital — operated by the Indian Health Service (IHS), which provides health care for Native Americans living on or near their native homeland — Bluemle knew that colleague was already stretched exceedingly thin.

After learning that physical therapists in many states could become specialty certified and safely perform nerve conduction studies and EMGs, Bluemle dove into the literature herself. She pursued training opportunities through Rocky Mountain University of Health Professions, and she was mentored by a board-certified physical therapist during her schooling. Soon enough, she became qualified to begin offering the tests, and today she remains the only provider at Northern Navajo Medical Center able to perform them.

But without anyone in house to call upon for advice and limited time to practice the procedure within her regular physical therapy schedule, Bluemle felt she would benefit from shadowing someone more experienced with these tests, which use very thin needles to detect electrical activity in the muscle.

Last month, that opportunity came to fruition through the Brigham and Women’s Outreach Program, a clinical collaboration between Brigham Health faculty volunteers and IHS clinicians that aims to address health disparities and improve access to high-quality care in underserved Navajo Nation communities in Arizona and New Mexico.

‘Not a One-Way Street’

Through the program, Bluemle was introduced to Christopher Doughty, MD, a Brigham neurologist who specializes in neuromuscular diseases and an expert in nerve conduction studies and EMGs. After connecting with Doughty via email last year, the two arranged for Bluemle to visit the Brigham in mid-June, during which time she shadowed Doughty and his colleagues for five days in the EMG Laboratory in the Hale Building for Transformative Medicine.

The visit was profoundly rewarding and informative, Bluemle said.

“I can read case studies and textbooks, but watching the actual exam in person and going over the report with the staff is much more realistic,” she said. “I provide this test only one day a week and in a small population. Some conditions I might see once a year at Northern Navajo Medical Center I saw three times in the week I was at the Brigham.”

Launched in 2009, the Brigham and Women’s Outreach Program supports volunteer opportunities for Brigham physicians interested in providing training, shadowing or consults for IHS clinicians or participating in medical missions at IHS facilities in Arizona and New Mexico.

“The clinicians and their patients in the Indian Health Service face many challenges, including the systematic lack of access to specialty services, such as nerve conduction studies,” said Thomas Sequist, MD, MPH, medical director of the Outreach Program, a primary care physician in the Phyllis Jen Center for Primary Care, and chief quality and safety officer at Partners HealthCare. “Our collaboration with the Indian Health Service is helping to address this gap by providing access to our wonderful network of specialists at Brigham Health.”

Reaching Out

Doughty said he was delighted to share his knowledge and help Bluemle advance her practice, noting it was equally beneficial for him to see another professional’s approach to performing the exams.

“The learning experience was not a one-way street,” Doughty said. “Nichole’s been doing this for a while now, so she’s developed her own style, tips and tricks. Anytime you get to work with somebody doing the same thing as you, you’ll both learn from each other. It was informative to see how she’s tailored her practice for a very different setting from ours and with fewer resources.”

Coming from different disciplines enriched the learning, he added.

“Her perspective as a physical therapist brought a lot to the table. As a neurologist, I don’t have as much experience working up and treating musculoskeletal conditions, such as arthritis, which can often be confused for neuromuscular conditions,” he said. “On the other hand, what was probably the most valuable for Nichole and fun for me was teaching her more about the anatomy of the nervous system and diseases more traditionally in the realm of neurology.”

Bluemle said she hopes the visit marks the beginning of an ongoing collaboration.

“Because no one else at my hospital does these studies, I don’t have anyone in house to bounce questions off or provide a case review,” she said. “This will be a great opportunity to benefit from the expertise at the Brigham and ensure my technique remains evidence-based and adheres to the highest degree of quality and safety.”