Surgery, and the Rancho Los Amigos Levels of Cognitive Awareness

My dad went into surgery today. He got a tracheotomy (to help him breathe without the breathing tube) and a “stomach plug” (to feed without the feeding tube). These had been delayed in the hope that he would be “responsive” by today.

He was under some anesthesia for the surgery, and the surgeon prescribed pain killers in case he needs them afterwards. So it may be a bit before we see further progress, just because of the sedation.

I was a bit down after coming into intensive care today. I did not see much difference between 8:30 this morning and 5:00 PM last night. His legs were still restless, so I rested his right foot on my leg. That calmed him. During that time the nurse came in and points out the PVCs (premature ventricular contractions — irregular heart beats) my dad was giving off.

So I was worried. At least the doctor was cutting back on the nitroglycerin — my dad’s blood pressure had been cut from 200/100 to much lower. They wanted to raise the “factor” (the systolic blood pressure) to 160.

Later in the morning, as we went to see him before surgery, we saw encouraging signs. He now kicks, hard, and nearly whacked my mom’s head with his knee on the uptick. My attempt to calm him by placing his foot on my leg were met with two hard kicks to a sensitive region that is vital to my father’s plans to have grandkids someday. Additionally, when we were talking to him, his shoulders lifted up. (Another, bittersweat, sign is that my dad’s arms are in cloth restraints. His arm movement’s disconnect some monitoring equipment. This is a sign of increased strength and activity, but likewise prevents the “arm wrestling” I’ve enjoyed with my dad.)

After seeing him for the second time I came across the Rancho Los Amigos Levels of Cognitive Function. I’d come across this measure while looking up the Glasgow Coma Score, but this improvements of the past few days have happened without change to his GCS number. However, they do indicate a transition (in my opinion) from Level III to Level IV. Below is a summary of the Rancho Los Amigos scale, paying special attention to Level 3 and Level 4:

Level I No response: unresponsive to stimuli
Level II Generalized response: nonspecific, inconsistent, and nonpurposeful reaction to stimuli
Level III Localized response: response directly related to type of stimulus but still inconsistent and delayed

In this level, the response to stimulation is known as decorticate rigidity or flexor posturing in which:

Shoulders adduct, internally rotate, and flex slightly; elbows flex; forearms pronate; and wrists and fingers flex
Lower extremities extend, adduct, and internally rotate
Hip, knee, and ankle may flex in a spinal reflex known as triple flexion

Level IV Confused-agitated: response heightened, severely confused and could be aggressive

The 4th level response to stimulation is withdrawal in which shoulders abduct and there is more rapid movement than in decorticate rigidity

Level V Confused-inappropriate: some response to simple commands, but confusion with more complex commands; high level of distractibility
Level VI Confused-appropriate: response more goal directed, but cues are necessary
Level VII Automatic-appropriate: response robot-like, judgement and problem solving lacking
Level VIII Purposeful-appropriate: response adequate, subtle impairments persist

The “Rancho Los Amigos- Revised,” apparently a restatement of the original scale, gives the following info for III and IV:

Level III – Localized Response: Total Assistance

Demonstrates withdrawal or vocalization to painful stimuli.
Turns toward or away from auditory stimuli.
Blinks when strong light crosses visual field.
Follows moving object passed within visual field.
Responds to discomfort by pulling tubes or restraints.
Responds inconsistently to simple commands.
Responses directly related to type of stimulus.
May respond to some persons (especially family and friends) but not to others.

Level IV – Confused/Agitated: Maximal Assistance

Alert and in heightened state of activity.
Purposeful attempts to remove restraints or tubes or crawl out of bed.
May perform motor activities such as sitting, reaching and walking but without any apparent purpose or upon another’s request.
Very brief and usually non-purposeful moments of sustained alternatives and divided attention.
Absent short-term memory.
May cry out or scream out of proportion to stimulus even after its removal.
May exhibit aggressive or flight behavior.
Mood may swing from euphoric to hostile with no apparent relationship to environmental events.
Unable to cooperate with treatment efforts.
Verbalizations are frequently incoherent and/or inappropriate to activity or environment.

What gives me hope is that while my dad has not completely met Level III in the Revised scale (1974), raising his shoulders appear to be the abduction of the shoulders part of Level IV in the original (1972) levels.

But ultimately, the “scale” used is less important that the improvement, than the learning, than the new behaviors we are seeing. I would not have thought that I was ever hoping for my dad to be “Confused/Agitated,” but what I’m really hoping for is him to recovery.

I want my dad back. I want him back healthy. I want him back happy.

And I have hope that I will.