Arm amputation from a rare sarcoma

Harold was 51 years old and needed his left arm amputated. A year ago he noticed some swelling in his forearm and went to his primary care doctor.

An MRI showed something. It was small and hard to define, hard to categorize, probably a collection of blood, but there was an outside chance it could be a sarcoma, a tumor originating from muscle tissue.

His primary care doctor sent him to a surgeon who agreed, probably a hematoma, a collection of blood, no need for further intervention as long as things didn’t get any worse.

Harold was a simple man. He lived alone and worked as a janitor at an elementary school. He could not read or write. Harold had a sister. His sister lived nearby and made sure he had everything he needed, signed his legal consents and came to his appointments.

The something in Harold’s left arm grew. It grew and grew. Finally he was diagnosed with a rare sarcoma, so large it tensed and tightened his cherry-brown skin. I met Harold on a Monday morning after I had been home with a sick four-year-old during a long, rainy weekend. I had watched the movie Cars twice, I had baked three kinds of cookies, and I had measured out a teaspoon and a half of Tylenol countless times. I opened the door to my son’s room when I went to bed on Sunday night and was happy to finally feel a cool, dry forehead. Tiger and doggie were clutched tightly in his hands. I pulled up the blankets. At bedtime he loves it when I lay down next to him and make up stories. My stories usually involve a family of small animals – turtles, hamsters, pigs – exactly two parents and two children, like us, somehow evading certain doom in the hands of a much larger, meaner animal – cheetah, jaguar, Tyrannosaurus Rex – and realizing how much they love each other and how lucky they are and then all falling asleep. My husband tells stories about the two of them visiting the outer planets on a rocket ship. He loves stories.

Despite my love of rain, Tylenol and the movie Cars, I was happy to be back at work on Monday. Harold was not what I had expected when I got the email from the Anesthesia Scheduling Office about him. “Illiterate/mentally disabled. Sister is his power of attorney.” Fully awake and alert, Harold was also kind. He understood that his arm had to come off, that the tumor was just too big to salvage the lower half of his left arm. I introduced myself by name and by job. I checked through the paperwork, double-checked his allergies and his medication list. His sister made damn sure that I was good at putting IVs in before she let me go anywhere near him with a needle.

Harold squeezed the nurse’s hand when I put his IV in and drew blood for labs. On the first try the IV went in smoothly and I was able to draw blood off of it for the labs and spare him a second needlestick. His sister liked me now. The labs sent at his preoperative testing appointment were horribly deranged, so we would not start the surgery without rechecking them.

Thirty minutes later the labs came back unchanged. High white blood cells, low red blood cells, high platelets, poor blood clotting, low sodium. These and the mild fever were most likely due to the tumor enveloping his right arm. His entire body was on high alert, sensing the inflammatory insult of tissue growing unchecked. We spoke to the surgeons and decided to proceed. The tumor, the arm – it had to go.

After the surgery was done, Harold had an incredibly high chance of still having pain in the arm that was gone. Phantom limb pain is a well-described mystery. Many modalities have been employed to both prevent and treat it, but one of the best ways to prevent it from ever happening was in our hands.

By completely numbing his arm before the surgeons made their first cut, we could block all nerve signals bringing pain sensation back up into Harold’s spinal cord and brain. Many studies have shown that this simple act can prevent the development of phantom limb pain. Numb the arm before you cut it off and somehow this makes the body forget about the arm: the arm wasn’t causing much trouble when it went, I’ll just forget about it. People who have painful neuropathy in their arm before it is amputated are much more likely to develop phantom limb pain that people whose arm never caused them any pain.

Our goal was complete numbness of his left arm until he left the hospital. This long period of complete arm anesthesia would increase his chance of never feeling pain in the arm that he had lost. It would be hard for Harold to go back to work, to learn to use a prosthesis to guide a mop, to polish a floor, but he had a friend at work, another janitor, who had an arm prosthesis so he understood that after his arm came off he would be okay because he could keep working. I found the ultrasound machine and gathered up the drapes, gloves and needles we would need. Two anesthesia attendings and I, the resident, washed the left side of his upper chest with sterile solution and covered his head, arm and belly with a sterile plastic drape.

On the ultrasound machine, the nerves of Harold’s brachial plexus stood out as white circles surrounding the large artery just under his collarbone. After we had given him enough sedation so he was sleepy and comfortable, I numbed the skin just above his collarbone and inserted a 4-inch-long needle through his skin, aiming toward his feet, ducking underneath his collarbone and then appearing as a bright white stripe on the screen of my ultrasound machine. Keeping the thin, linear ultrasound probe directly over my needle, I watched as the needle tip ducked under the artery and landed near my target: the three white circles, the nerves of the brachial plexus, which would divide and recombine to supply nearly all the sensation and movement to Harold’s left arm.

The nerve roots exiting from the side-holes of the vertebrae in the lower neck come together, divide, come together and divide again, eventually giving off myriad small branches that innervate the arm. At several points in their course we can put an ultrasound probe on the skin, identify the nerves directly underneath, and put concentrated local anesthetic next to them. In fifteen minutes, the arm is numb. It is the most amazing thing.

As I held the needle entirely still with my right hand and my left hand seized up on the tightly clutched ultrasound probe, my attending injected two syringes of local anesthetic. A black circle formed around the white circles on the ultrasound screen: the fluid spreading around the three nerves. After the injection was done he threaded a thin plastic tube through the needle and pulled the needle out. The little tube would keep him comfortable for days, supplying a continuous drip of numbness to his nerves.

With the nerve block complete, we brought Harold to the operating room. After moving him to the operating room bed and attaching all the monitors, we asked him if he could move his arm. Limp. It feels funny too. Perfect. He took big breaths of oxygen for three minutes and we put him to sleep, put a breathing tube in, attached a warming blanket, put another IV in, positioned him on his side. The anesthetic was perfectly plain. No uptick of his heart rate with surgical incision: the sign of a perfectly numb arm.

I hoped that he would be lucky. It doesn’t always work, but by muting the nerves bringing sensory signals to the spinal cord from Harold’s arm, there was a good chance that his entire life would go more smoothly. Harold was a simple man. He needed his arm to not hurt, he needed a good prosthesis and he needed to go back to work. I sat in my chair behind the surgical drapes, watched his blood pressure and hoped.

He woke up smoothly and kept asking for water in the recovery room. His arm was still numb from the infusion of local anesthetic the next day. He stayed in the hospital for a few days, worked with the physical therapists and met with the prosthetists to see what the plastic arms looked like and how they would fit onto his new stump after the bandages came off.

A month later he came back to see his surgeon. Sometimes he felt the strangest thing, his fingers itching at night, but other than that the arm was gone. It was frustrating to get used to, but it didn’t hurt and he was ready to meet with the people that were going to make him a prosthesis. His stump was healing well. Harold’s sister came to his appointment.

Addendum: My patient and his sister gave me permission to write this article. Although all patient identifiers have been altered, the case was unique and therefore difficult to fully de-identify.

Felicity Billings is an anesthesiology resident who blogs at One Case at a Time.

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