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Posted by on Jul 27, 2018 in CRPS / RSD | 0 comments

Double-block (27.07.2018)

Double-block (27.07.2018)

It’s 0300 and I’ve been up for over an hour, feeling nauseated and generally ill, after a medical procedure this past afternoon. Well, 2 procedures to be exact – but it was the same procedure twice; so twice the feeling of… being unwell.

But if this can help lower even some of the excruciating pain I experience every day, then it’ll be worth it! I have a rare disease called Complex Regional Pain Syndrome (CRPS, but its old name is often still used; Reflex Sympathetic Dystrophy, or RSD). For information about CRPS, read Code breaking; a diagnosis. It affects my right hand & arm, which is rough because I’m right-handed. Murphy’s Law, right?

So, what was the type of procedure I had earlier today – or yesterday, now, because it’s past midnight? It’s called an ultrasound-guided axillary brachial plexus block. Try to say that quickly – 10 times in a row! The short description is that my doctors put a longish needle into the base of my armpit, and pushed it in towards the centre of my body, as I was lying in a hospital bed.

For the doctors to be able to put the needle into my armpit, I had to raise my arm over my head, so it’s like lying on the bed and reaching for something above my head. They used an ultrasound machine to see the path of the needle, as it moved through me. They used the images on the screen of the ultrasound to find my different nerves, so they could inject 2 different kinds of liquid anaesthetic into the nerves that the needle went near as it passed through me.

This sounds painful, but it’s really just uncomfortable – the needle part. The anaesthetics are released, from the needle, to temporarily numb the nerves. That removes the neuropathic pain from parts, sometimes all, of my affected hand & arm. Sometimes it gets rid of all the pain, and that can last for up to 2 days. But this isn’t done for temporary relief of my pain.

The procedure’s done because each time I have one of these blocks (or the other 2 types of nerve blocks I’ve had), my overall pain level goes down. And hopefully my pain level stays lower than it was… bit by bit. What’s called incremental improvement.

Photo of an ultrasound machine cabinet in a hospital

Photo: Sandra Woods

To learn more about my ultrasound-guided axillary brachial plexus block, keep reading! I was lying on a hospital bed, in the Pain Management Unit (PMU) of the large university-hospital where I’m treated for this neuroinflammatory disease.

To set the scene, there were 3 different doctors in the room with me. My left arm had a blood pressure cuff, and a small clip over the tip of one finger. That clip’s called a pulse oximeter, and it checked my heart rate and the level of oxygen in my blood during the procedure. The blood pressure cuff and pulse oximeter were both connected to a small (beeping!) machine that showed the readings.

That machine is a small box-like screen, or monitor, that you’ve probably seen in every hospital TV show or movie you’ve ever watched. I usually joke that if it’s beeping, it means I’m breathing!  ‘-)  That machine was on a shelf behind my head, and slightly to my left. 2 of the doctors were standing to the left side of my hospital bed. The ultrasound machine & its screen were to my right, at the level of my waist to shoulder as I was lying on the bed. A nurse was coming in & out of the room.

The 3rd doctor – visiting from Australia to learn from the 2 experts treating me – was standing to my right, near the end of my bed. That’s right, both of the doctors doing the procedure are world-class experts in pain medicine. I’m really lucky to be a patient at this PMU, and that’s why I post my stories here – to help others with this disease by sharing information that they can bring to their doctors. This disease is hard to treat, so I’m hoping to help other patients who’re also struggling with CRPS.

I could see the monitor of the ultrasound machine if I turned my head slightly to the right. But if I moved during the procedure it could have made the needle move the wrong way, which could make the doctor hit a vein or artery with the needle. That wouldn’t be good, because it would cause internal bleeding.

So I couldn’t move – not even my head – until the doctors said it was okay. I’m used to these nerve blocks now, so they usually let me turn my face towards the monitor after they put the needle inside me.

Once I could see the ultrasound image, I could easily find the needle while it moved through my body. It’s the only straight line on the screen, so it’s easy to see against everything else on those images!

Because the 2 expert physicians were explaining the nerve block to their Australian visitor, I also got to hear the explanations again. The first few times I had blocks, I wasn’t even able to see the needle on the image; now I can spot it right away. So I guess I learn a bit more each time, too  ‘-)

So there I was, lying on a hospital bed, with doctors and equipment all around me. The doctor doing the injection was beside my left shoulder; I’d never met him before, but knew that he’s the Associate Director of the PMU.

My specialist was standing near my left hip; he’s the senior doctor at this PMU, its Director. There was nothing at the foot of my bed, except a big cabinet full of medical supplies on the opposite wall.

To my right was the visiting doctor, standing near my ankles. Next to him, was the ultrasound machine, and then the beeping machine showing my blood pressure, etc. was at the top of my bed.

That feeling of being surrounded – by doctors and equipment – used to make me kind of nervous, but now I find it reassuring. I’ve come to appreciate that all these people, and all the medical equipment & supplies, are there to help me.

Seeing it all as being surrounded by help & support made it all seem less threatening. When you’re lying in a hospital bed, having a medical procedure “done to you”, even small things can be kind of scary.

Okay, are you ready for the actual procedure? The doctor doing the injection had already cleaned a large patch of my skin, where the needle would go in. He’d also already put the ultrasound ‘wand’ against my skin, and moved it around to find the nerves – before even starting the procedure. He and my specialist agreed on where he’d place the needle, the path he’d push it along (through my body), and how much anaesthetic to put into the needle.

a woman in a hospital bed, looking up

Photo: Sandra Woods

Then the visiting doctor brought me a consent form to sign – always a challenge when you’re lying down in a hospital bed, but especially when your hand doesn’t work properly! So there was quite a lot going on before the needle was put in. My doctor explained to the visiting doctor that it’s impossible for this procedure to be done without touching my breast; he told him that it’s really important for the doctor doing the procedure to warn the patient before starting.

That’s because the specialist doing the imaging has to hold the ultrasound wand in his hand, and press it down into my skin. They often have to hold the wand sideways to get a good image, which puts the doctor’s hand against my body (through the hospital gown or loose camisole). The doctor has to move the needle from my armpit towards the centre of my body, so my right breast is kind of ‘in the way’ of that.

I don’t think the doctors even notice when that happens, when my chest gets kind of ‘squished’ by the side of their hand, because all their focus is on the ultrasound monitor above me. So it’s good that they always remind their patients about that, because that feeling could really catch a woman off-guard.

One thing I want to mention, that I really like about my specialist, is that he doesn’t make me wear a hospital gown for the nerve blocks. If I wear a really loose camisole (sleeveless top), the doctors have a really good view of the armpit area, to put the needle in.

In some ways I think it’s easier for them; otherwise they have to unsnap the whole shoulder of a hospital gown, and then pin it out of the way so the fabric doesn’t fall back onto the needle.

So I get to avoid wearing a hospital gown, and can stay fully dressed. That also helps it not to feel so strange when the side of the doctor’s hand, holding the ultrasound wand, presses against my breast. Because I’m wearing my bra, and my own clothes, it doesn’t feel so… intrusive.

If you’re a woman & are going to have a nerve block for your arm or hand, ask the doctor – beforehand – if you can wear a sleeveless top with a really wide armhole. If you can, then wear a padded bra as an extra layer. It’s a much better option for this procedure, for a woman, than wearing a really thin hospital gown.

Sometimes 2 specialists work together during this procedure, one doing the injection while the other handles the ultrasound wand. This time one doctor did both. So he had the ultrasound wand in one hand, and used the other hand to insert the needle into the skin of my armpit, near the left edge. I only felt a bit of a pinch when the needle went it. Then he moved the ultrasound wand around, to get the needle into the image on the screen.

From that point, it’s kind of like a treasure hunt. The specialist goes looking for different nerves, watching the needle and images on the monitor of the ultrasound machine. And avoiding parts of the body that shouldn’t be hit – or nicked – by the needle. The doctors don’t want to cause any internal bleeding, so they have to thread the needle around ‘obstacles’ in the body; like arteries or veins.

The nerves that my specialists looked for in this procedure are the ones that go down the arm; the median, ulnar, and radial nerves. The radial nerve is, more or less, for the left side of the hand when it’s facing palm down (the thumb side). The ulnar nerve is for the right side of the hand, The medial nerve is for the tips of the index and middle fingers (and a bit of the tip of the thumb).

During the nerve block, the specialist doctors talk to each other. They’re discussing which nerve they’re seeing on the screen, body parts to avoid, or places where they should let some of the anaesthetic out of the needle (into a nerve). Sometimes they don’t agree, so they’ll move the ultrasound wand around on my skin – or push it in more (or less) – to get a different view/angle of what they’re seeing.

It’s kind of fun to hear their conversations, and what happens when one was wrong the first time. They just say “You were right” or “Good catch” and keep going. No one gets mad about being wrong, or takes it badly if another specialist interrupts them.

These expert doctors just want to do what’s best for me. I guess the rest of us could learn something from that; sometimes it’s a good thing if someone tells you that you’re wrong, because you can look at the situation again – and try to see if from a different viewpoint or angle!

Once they got to the main area of nerves, the doctor injected all the anaesthetic that was left in the needle. then he slowly pulled the needle back out, still being careful not to bump it into anything like a vein or artery.

Then my 2 specialists talked about doing a 2nd nerve block, to follow a slightly different path through my body. I quickly agreed to that: I’m usually game for anything that can help reduce my pain levels! So they started all over again… and instead of getting 1 dose of anaesthetic, I got 2 doses.

I’m awake the whole time, and can feel the needle moving through me (and can usually watch it, on the ultrasound monitor!). It doesn’t hurt, but feels very uncomfortable.

The worst part is that I sometimes feel really nauseated, like I’m going to be sick, for a few hours or days after the procedure. That’s what happened this time, but about twice as bad – because I had twice as much anaesthetic! I feel like I’m going to be sick, still. Like a bad case of seasickness.

Ducks floating in a lake

Photo: Sandra Woods

 

 

And I often end up losing my voice a bit after these nerve blocks; it kind of comes & goes for a day or so. That’s because the anaesthetic can move around a bit inside the body, after it’s injected. Some of it can be injected near my neck, so can move towards the vocal cords. That’s what I was told at another hospital, for another type of nerve block.

So now I have to wait, to see how much of the pain will come back after all the anaesthetic wears off. Sometimes one kind of pain will completely go away, sometimes another type of pain won’t be as bad as it was. I still hope that one day the pain will ALL go away, but after 2½ years I’m starting to accept that it won’t happen. So whatever helps is great!!!

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