Missed the Buttonholes, TWICE!!

[Black]

I am so upset.  Two days ago, after taking one day off, I missed the arterial buttonhole and the blunt went in UNDER the channel.  Tonight I did the same thing with the venous!!!  OUCH!!!!  Both times they did go into the vein and got good flow but I am so upset and frustrated about missing the channel we have worked so hard to create.  He said it was painful but not much more than usual.  His buttonholes have always hurt more than I think they should.  What is going on?  Is this "normal"?  He is part Native American and does scar easily, forming hypertrophic scars, almost like small keloids, but not as bad as real keloids.  Is this what's happening with his buttonholes?

A little background:  Mike has been using the same buttonholes since his first dialysis session on Feb 5, when he started training on the NxStage.  I have been sticking him since about the end of the second week.  We have been using the blunts for months.  His buttonholes seem to get tighter as time goes on, especially the arterial.  It has gotten harder and harder to get the blunts in after his day off.  He seems to heal too well, and the holes are very tiny and the scabs recessed into the opening and hard to remove.  There have been many times that the needles take more force to put in than I think they should, and I've been thinking that they would get easier.  A few weeks ago the venous seemed to have improved a lot but now it has gotten difficult again.

We don't usually use a tourniquet, so we tried using one and it made no difference.

Any information and/or suggestions greatly appreciated.

[BigSky]

I don't know if this will work, but some of the nurses do it when buttonholes heal up like you describe.

They put the tip of the buttonhole needle at the start of the buttonhole and then kinda make little circle motions with it and then it seems to slid into the channel most of the time.

[Black]

Thank you!!  Will try that tomorrow.

[del]

Do you have sharp needles. We sometimes have to use sharp BH just won't go in

[Black]

We are still battling the buttonholes.      

It is still very hard to insert the blunts and tonight I had to use a sharp again and DID NOT hit the channel on his arterial.  I am so frustrated.  I hate hurting him every time,  and it is still very painful every time.  Sometimes I have to push the blunts so hard that the skin around the buttonhole starts to wrinkle/buckle  and then suddenly it slides into the channel and the pain is over.  He swears there are toe prints on the bottom edge of the PureFlow where he braces his foot in order to keep from tensing the muscles of his fistula arm.

He wants to self-cannulate but says while it is so painful he cannot even attempt it! 

Anyone have any ideas or suggestions on getting this to be as easy and painless as it should be?

There is no one in our circle of medical professionals we can ask about buttonholes, as they know less than we do.  
 Our training nurse, who started the buttonholes in Feb 2007, now works for Merck.

If there are hypertrophic scars forming in the channel and that is why it is so hard, will they eventually occlude the fistula?