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Posted by on Jul 17, 2016 in Rare disease | 0 comments

“Push” (17.07.2016)

“Push” (17.07.2016)

No, this post isn’t about delivering a baby! It’s about what happened when the anaesthetic wore off from my first Bier or IV [nerve] block for Complex Regional Pain Syndrome (CRPS; sometimes still called by its old name of Reflex Sympathetic Dystrophy, or RSD).

To try to reduce the stiffness that had set in in all the finger joints of my right hand, and my wrist, my neuro-anaesthesiologist and I decided to a different procedure last month. Then I had the same procedure again this month, this past Tuesday. This day-surgery procedure is a nerve block called a ‘Bier block’, or an ‘IV block’ (see the post “Bier not beer” for details).

Unlike the first 6 day-surgery procedures I had with my neuro-anaesthesiologist (ultrasound-guided stellate ganglion (nerve) blocks), the Bier block didn’t involve ultrasound. It seemed like something out of a horror movie in some ways; I had a ‘zombie arm’!

After each Bier block took effect, and my arm was almost completely ‘frozen’, a hospital physiotherapist would come into the day-surgery OR to ‘force’ the joints in my fingers and wrist. The goal was for me to gain some mobility and range of motion in my finger and wrist joints – for me to be able to use my hand again, to whatever extent possible.

This physiotherapy treatment lasted about 45 minutes during the first Bier block, and about 20 minutes during the second Bier block. There are a few reasons why the second treatment was so much shorter than the first; they’re called pain seizures!

It was a good thing that my neuro-anaesthesiologist had left orders for me to kept in an observation bay – in the day-surgery OR – until the anaesthetic had completely worn off from my first Bier block (last month). He hadn’t given me any long-acting pain medication before the procedure, because he wasn’t sure how far the physiotherapist would be able to force – or ‘push’ – my affected joints.

Apparently she was able to force them further than expected, because when the nerve block anaesthetic started to wear off, my legs and lower body began to buck and shake while I was lying on the gurney. I had no idea what was going on, and I was terrified. My lower body was literally bouncing around on the gurney, and I had no control at all over these movements.

One of the nurses came rushing over to check my vital signs, and another paged my neuro-anaesthesiologist. By the time he ran in a moment or two later, that bucking and shaking had spread to my entire body. As he was giving instructions to the nurses around me, I heard another physician explaining to one of the medical students (there are always a lot of medical students and other doctors around when I have day-surgery procedures, as they want to learn about CRPS as a rare disease) that I was having pain seizures. I heard him say that severe pain seizures were dangerous, as they could lead to a stroke or other complications.

(Because of my background in clinical/medical research ethics, I looked into this type of seizure a few days later; it turns out that they’re fairly rare(1). I suppose I shouldn’t be surprised that I had a rare reaction to a procedure to treat a… rare disease!)

How did my neuro-anaesthesiologist try to – very quickly! – get my pain seizures under control? He had a nurse administer Fentanyl as a “push” through my IV, while at the same time he was injecting Dilaudid sub-Q (subcutaneous) into the arm that doesn’t have CRPS. While a nurse took the syringe out of his hand, to set it down on a tray, my doctor put his hand on one of my legs and started to stare at his watch. All the while, we was asking the nurses for status updates on my vital signs, etc.

My body was still bouncing around on the gurney, and I was joking with one of the nurses that I should have entered a ‘bucking bronco’ competition. When I’m nervous or stressed I tend to make bad jokes, and by this time the OR nurses – and my neuro-anaesthesiologist – were used to my jokes.

This was my 7th day-surgery procedure with my neuro-anaesthesiologist in less than a month, and I was watching him carefully to see whether he seemed worried; I knew that if he was worried, then I probably should be as well. I asked why he was checking his watch, and he told me that he was counting off seconds on his stopwatch. As I was about to ask what he was timing, he called out to one of the nurses: “Push again on my count. 3. 2. 1. Push now!” The nurse injected Fentanyl – again – through my IV, while my doctor took his hand off my leg to inject another dose of sub-Q Dilaudid into my arm.

He again put his hand on my leg, and started to stare at his watch, while talking to the nurses. By this time, my seizures started to subside. As they did, he raised his eyes from his watch, and thanked the nurses who’d come to assist. He kept his hand on my leg, and told me that he was using his hand to check on the seizures. If they got worse, or changed in a specific way, he said he’d have to try another medication to stop them.

He warned me that I’d likely feel completely exhausted for at least the rest of the day, because of the seizures; that I shouldn’t drive at all, or be alone, because I could suddenly feel weak and fall. He told me that he’d extend my observation period in the post-op area by an hour, and offered to text my husband to let him know that he’d have to come pick me up at the hospital (at least) an hour later than expected.

Photo: Sandra Woods©

Photo: Sandra Woods ©

I very quickly found out, literally moments after my doctor left my bedside, that double doses of Fentanyl and Dilaudid – within 2 minutes – is likely to make a person feel very nauseated. It was a good thing my neuro-anaesthesiologist had me stay in the post-op area for an extra hour, as I vomited the entire time I was there.

At one point I was so weak from the seizures that I couldn’t stay sitting up on the gurney, but every time I’d lean back I’d be sick again. One of the post-op nurses paged my neuro-anaesthesiologist because she thought I was getting worse. When he ran over to me, I told him that I just felt sick as soon as I leaned back, even with the gurney in the sitting position. He quickly “MacGyver’d” a solution; he took some rigid seat cushions off the visitors’ chairs, wrapped them in blankets, and wedged them between my back and the gurney. I could lay back to rest, and still be upright enough not to feel nauseated.

By the time I was finally cleared to be released from the post-op recovery area, I was very glad that my doctor had written a note on my chart that my husband had to come to the recovery area to get me; I needed to lean on him for to walk from the hospital to the car (I didn’t want to use a wheelchair).

Despite all this, my neuro-anaesthesiologist ad I decided to go ahead with the second Bier block about a month later; this past Tuesday. I really want to regain as much use of my hand and arm as possible, and the first Bier block really improved my knuckles.  We had high hopes for this second procedure, but the results were barely noticeable this time.

(1) Seizures After Anesthesia. “Tahoe Doc”. HealDove. 2012. Web:
https://healdove.com/health-care-industry/Seizures-after-Anesthesia

(2) Mohr, B. Safety and effectiveness of intravenous regional anesthesia (Bier block) for outpatient management of forearm trauma. CJEM. Jul 2006;8(4):247-50. Web:
https://www.ncbi.nlm.nih.gov/pubmed/17324303

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