A slight deviation today into a subject that I was introduced to two nights ago. After the initial occurrence, I have found learning about the various scales for classification helpful, and will address PCABI, the modified Rankin Scale, and Cerebral Performance Categories as I ran into them. It honestly took me a little time to locate the names of those scales again today, so I decided to write on Ranchos so I don’t lose it. I am still running on exhaustion.
There have been various instances over the last 2 weeks where Neil has seen me and reacted in ways that surprised me, and being honest, also hurt. The first couple of weeks in the ICU, once he regained consciousness, he responded only to me. Then the neuro-storming began, and things began to change. He has at times looked at me with so much fear in his eyes that it breaks my heart. Two nights ago while the tech and I were cleaning him up for bed, he was reacting that way to both of us -recoiling with eyes wide with fear, crying out. When we were done, the tech asked “Has anyone explained Ranchos Levels to you yet?” I replied “No, I haven’t heard that term yet that I remember.” “What we just saw is a Ranchos response, and is actually a good sign that he is healing. He’s moving up the scale. Patients will move from comatose to various stages, and one of them often includes actions and words that are hurtful to family, but he won’t remember any of it. I’ve seen a patient in the past not recognize his own mother and say all kinds of accusatory things to her that really hurt her, then the next day he didn’t remember any of it and knew who she was. I recommend you look it up, as it can be very helpful to the family. Its easier when you know what is happening and why.”
I absolutely agree with that assessment. If I have at least some degree of understanding what is happening and why, it is much easier to rationalize what is happening. Besides, I was the kid that always drove my teachers crazy asking “why” things did what they did, or were what they were, and I am still much the same numerous decades later!
The Ranchos Los Amigos Scale (RLAS), often simplified to Ranchos Levels or Ranchos Scale, is “a widely accepted medical scale used to describe the cognitive and behavioral patterns found in brain injury patients as they recover from injury” per an NIH article written by Katherine Lin & Michael Wroten. Patients move through the scale in a sequence, although they may skip a level, or sometimes demonstrate behaviors in two sequential levels. I share the levels here in case you are walking a similar path and have not heard of them.
Level 1: No response, total assistance. If I am understanding this correctly, it would be a comatose or vegetative state.
Level 2: Generalized response, total assistance. The patient responds inconsistently and non-purposefully to external stimuli. I am understanding this as the stage where they would apply a pain stimuli (prick, pinch, etc) and he may or may not recoil instinctively, for example.
Level 3: Localized Response, total assistance. Responds inconsistently, and specifically to external stimuli. Responses are directly related to the stimulus, ie withdraws or vocalizes to pain. Responds more to familiar people than to strangers. This sounds similar to L2, however I am seeing some nuance. Neil has passed through L2, where he didn’t always respond to the stimuli they applied, and what response he did have was automatic, there was no recognition of what was happening. I would say he is now in L3, at least partially. His responses are more than inconsistent, they are actually quite consistent now to certain external stimuli. He will consistently withdraw from pain, and vocalizes with increasing volume to unpleasant external stimuli – if he is hurting somewhere, or needs to be changed, for instance. He will laugh at some jokes, or funny animal videos. He will cry if death is discussed in his hearing, esp his death. He has, however, specifically done *that*(crying if his death was discussed in his hearing) since week 2 in the ICU.
Level 4: Confused/Agitated, maximal assistance. The patient is in a hyperactive state with bizarre, un-purposeful behaviors & demonstrates agitation that originates from internal confusion rather than external stimuli; short term memory is absent. This is the stage the tech was explaining to me. He stated that sometimes the patient becomes combative, primarily due to fear and not understanding what has happened or is happening to them. They may say things like the teen did to his mother, or act afraid of people they know well and loved, and then a short time later be completely fine with the same person.
I would say this is probably the most frightening and concerning phase next to comatose, but now knowing what is coming I can prepare mentally and understand that Neil will not recall any of it, and none of it is his choice, it is simply a step along the way. This helps me tremendously in processing what is transpiring, as he appears to be moving slowly into L4, straddling L3/L4 currently. He has this week definitely become more agitated, and a medication named Seroquel has worked extremely well, even allowing him to sleep.
I am going to stop there for tonight, as I am having a hard time keeping my eyes open.
The Time We Have Been Given 