“Ulnar Dependent”

I learned a new term this week, “Ulnar Dependent”.

So about a month and half ago I started developing severe pain in my right arm. It was hard to pinpoint the exact source or location of the pain, because sometimes it would radiate down my arm and other times it seemed to be coming from my elbow. The pain was near constant and sometimes excruciating. At first I ( we) thought it might have something to do with my neck surgery, but subsequent MRIs didn’t show any nerve impingement. With no improvement in the pain we decided to do an ultra sound of my arm to make sure I didn’t have some kind of blood clot.

Low and behold, it appeared that I indeed did have a clot. Not in a vein, but in my radial artery. The radiologist was so alarmed by the ultra sound images that they had me go to the nearest ER for a CT scan to make sure I didn’t have any blood clots in my lungs.
per the Radiologist notes:
“Nearly occlusive thrombus in the right radial artery extending from the mid forearm to the level of the wrist. The study was performed after hours and the ordering provider could not be reached. The patient was instructed (at 1839 hours) to report to the emergency room for vascular surgery evaluation and plans to drive himself to the UCSF Parnassus campus emergency room. The emergency room has been notified (at 1850 hours) and is expecting the patient. Of note, the patient does not complain of a cold or blue hand.”

A couple hours later I made it to the ER and thankfully they didn’t see any clots in my lungs on the CT scans, so they instructed me to take baby aspirin and follow up with a vascular surgeon as soon as possible.

3 weeks later I finally saw the Vascular surgeon and it turns out that I didn’t have a blood clot after all, but rather intensive scarring in a portion of my radial artery that extends from my elbow half way to my wrist. As suspected, repeated arterial line insertions and/or blood gas draws over the years had pretty much wiped out my radial arteries. I was reassured that this is not a big deal. I just have to make sure that the collateral artery (the ulnar artery), doesn’t become occluded or that my hands dont start turning blue. That would not be a good thing.

As far as the pain I was experiencing, it was probably unrelated and coincidental, as my left arm is affected as well and there was no pain there. I think the pain was due to good old tennis elbow. In a way it was good that I was having so much pain, because it prompted all these other tests which led to a diagnosis.

It’s interesting that this would happen to me, because during my career as an Respiratory Therapists Ive probably done thousands of arterial blood gas sticks and never encountered a problem like this in a patient. In RT School we’re taught that before doing arterial blood draws, to always check to make sure that the patient has good collateral circulation in case we cause a clot to form during the stick. We do this by performing what’s called an “Allen’s Test”. Here’s a Video showing how that test is done.

During my visit with the Vascular doc, he actually did a fancy version of the Allen’s test by using a doppler device to amplify the sound of my pulse. Sure enough after he occluded my radial artery with his hands, the sound of my pulse in my hand disappeared. My hand turned white until he released the pressure on the ulnar artery. Even though I still have a palpable pulse in both wrists, the pulsation is actually coming from a different part of my arm. Weird.

After dealing with all this first hand ( no pun intended) I can fully appreciate understand why the Allen’s test is so important. Which raises another question, why was this not done on me more often before poking me for blood gasses for putting lines in.
In all fairness, since Im an RT, I know that with the hustle and bustle of the hospital setting, sometimes we’re too busy or simply forget to do it. From now on though you can bet that Ill be paying more attention if the words A line or blood gas comes up.

Those little white blemishes are scars from all the A-Line insertions Ive had over the years.

Radial artery occlusion, just another side effect we can add to the growing list of secondary problems related to asthma and/or the medications used to treat it.

Occluded radial arteries The result of too many arterial catheter insertions for asthma
Posterior Glottic Stenosis. The result of too many intubations for asthma.
Cervical Myelopathy Result of chronic steroid use to treat asthma.
Osteopenia Result of Chronic steroid use to treat asthma
Airway remodeling/Lung scarring The result of frequent severe asthma exacerbations.
Permanent airflow obstruction The result of airway remodeling.
PTSD Psychological trauma from being on life support so many time for asthma.

In any case, thank goodness that these magnificent bodies we have are designed with lots of back up systems.

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