What should i do tomorrow re: mid-formation buttonholes - HELP!

[fearless]

I've been attempting to find some advice on this problem, and still don't know what to do tomorrow when I go to the clinic for Dx.

I have a shallow forearm fistula which has limited length for good, comfortable sticks.  Going to buttonholes was a great way to preserve my fistula.

A few weeks ago my tech started the process.  All was well until, on the 7th cannulation, because it seemed ready, we tried blunts.  They didn't go into the vein, even though the needles were inserted all the way up to the hilt.  (I believe they must have found their way along the top of the vessel - where else could the whole length of the needle go with the fistula being just below the skin?)

So, we went back to sharp for that treatment and the next, figuring we'd wait a week and try the blunts again.  All was well for that treatment and the one after.  Then, when I came into the clinic for the third treatment since the mishap (the mishap was last Monday, and this was my Friday treatment)  I learned that "management" had decided it was time to use blunts! 

Well, the blunt didn't go in, but again went all the way in without entering the vein.  When the tech tried then with the sharp, she couldn't get in the vein.  First, there was no blood, then, she got blood, but could not push it in or out.  There was a vibrating feeling.  We used my catheter that day.

Has my buttonhole been trashed?  Where did the needle go in when she got blood but couldn't get back flow?  I'm very concerned that misrouting blunts twice last week, and then misrouting a sharp through one of the tracks may have really messed up the track.  Of course we'll have to use a sharp tomorrow, but should we even try again at the spot that's been abused?  If you "lay off" a buttonhold - how long can you "lay off" before you can't use it again?

I've lost faith that the process is being conducted by experts, although if the management had left us alone I think my tech and I could have made this happen much better.  I won't let them interfere again, but WHAT SHOULD I DO TOMORROW?
Can anyone give me some advice?  I know it will be based on personal experience or thinking, but I will appreciate anything!
thank you

[amanda100wilson]

I have had issues where the needle skims above the vein and my buttonholes work.  How experienced is your tech..  Do you have the best tech. In your unit cannualting?  I had one of the techs at my unit, who could never cannualte me and infiltrated me on the occasions that she tried.  Wouldn't let her near me after the second time.

It can be tough to get into the vein sometimes, particularly at first, before,the buttonhole tract is fully developed.  How long have they stuck you with sharps for these buttonholes?  I was stuck three times a week for a good two weeks before they attempted to use blunts, and there were still a couple of times when theymhad to revert to sharps a coup,e of times early on.  It was only whenI got home and they were being cannulated five times a week, that they really developed.

Has your vascular surgeon seen you since you had the fistula made? Maybe worth a reassessment by him to make sure that all is well.

Sorry I can't be of more help,.

[fearless]

Actually Amanda, part of what i really need right now is some assurance that using a sharp tomorrow (even though we had the trouble on Friday) won't do permanent damage.  So having you relate your experience that you may have had something similar happen but your buttonholes still work is comforting to me.  I have been rather stressed all weekend, not knowing if there' been permanent damage.

My fistula is very good right now.  Vascular surgeon examined it before I started with cannulation a few months ago.  I even think part of the problem with trying to get the blunt in is that my vein is actually pretty strong and I heal quickly.  I can feel it's firmness and it's not distorted in any way.  I'd very much like to keep it that way!  Even with the needle on friday going in wrong, then getting blood but not being in the vien - no infiltration!  I was so freaked out because a couple of months ago that probably would have meant a massive black and blue.

My tech has been cannulating me with no mis-steps for a couple months now.  She seems very skilled to me.  i know how important it is to her to do everything right: I could see her sweating when she first began to cannulate me!    And I could see how depressed she was when I had to use my catheter on Friday because i didn't want to try again with the needles.
(I know just being empathetic doesn't make a good cannulator, but I at least trust her intentions and standards for herself.  She just said she'd hadn't had something like this happen with earlier patients who she'd created buttonholes for, and she doesn't really know why it happened)

Last week was my third week in the buttonhole site.  But obviously I'm going to need a bit more time i guess.

Again, I really appreciate that you've related to me that even though it sounds like you've had a quite similar experience, you still have a functioning buttonhole at that site.  It does a lot to ease my mind, which, as you can probably tell is the worst part of what I'm feeling right now - that is: very negative anticipation for tomorrow. 

thank you Amanda

[amanda100wilson]

I was very concerned when my buttonholes were being formed.  Mine was a new fistula that was very small and thhey had to develop before they could start on buttonholes, and even then not big.  My dialysis nurse developed my buttonholes and I was terrified that he was making them at the wrong angle for me.  I used to lie there awake udring the night eorrying about it.  Even now,if I run into problems getting the needles in, I worry the next day, until I can do it. 

[MooseMom]

I hope everything goes OK for you tomorrow, fearless.  Let us know, OK? 

[fearless]

Amanda,
Last Monday, after the first problem, I laid awake two nights worrying about what were the consequences of that mis-step.  Then, after a good session on Wednesday, i went back to my typical, calmed-down self. 
But after Friday - it's all I can think about.  I've been trying to exercise my "zen" practices, but the worry continues to intrude.
So you know how very reassuring it is to hear from you about your similar experiences (with the worry, which I sometimes criticize myself for, 'cause as we know worrying doesn't help.)

MooseMom,
I will surely come back to report here.  Thank you for your concern.  In a matter of 24 hours I'll either be super-psyched and relieved, or I'll be thoroughly depressed.  But either way, I'll still be hanging in and looking to solve the next problem (which we all know by now is waiting around the next corner) with the help of my IHD friends.

[fearless]

MooseMom,
I am home, in my usual post-dialysis state of vibrating and mild depression (I think it's purely physical - I'll be fine tomorrow - until it's time to think about going back! ARG

The needles went in fine (sharp) the tech tried to reassure me that they're still following the same track.  Apparently if they go down the track - always using the same angle should assure they go through the vein in the same spot.  i still have my doubts, like there's actually a sieve forming in there, especially after having a couple needles actually GO down that track but not go in the vein!  But I know it's a very bad idea to picture something bad, so starting tonight I'm going to do some positive imagery for my buttonholes 

I think at this point I've stressed so much over it that I can't stress anymore.  Too tired.  Until I'm putting in the needles myself I won't stop worrying.  Perhaps that will motivate the transition for me: I'll be so sick of imagining the worst that I'll just take those needles and shove them in myself!

Thanks again for your kind concern.  It's like you're everyone's Mom here.  I hope you can feel like you can get a little mothering yourself when you need it. 
Peace out woman!   

[Desert Dancer]

fearless, I've had my buttonholes for over a year and sometimes I STILL have to sharp stick them. They like to close up from time to time (I'm convinced it's connected to seafood).

I was a nervous wreck at first because I was convinced I was going to ruin them, but it's never been a problem and my buttonholes are just fine. I can't say I take it in stride - I still dislike sharp sticking out of the fear I'll ruin something - but I no longer go through five or six blunts before I give up and sharp stick; if I can't get in the first or second time I just do it. So far, so good.

[MooseMom]

Fearless, thanks so much for getting back to us and letting us know how it went.  You know, I think it's a great idea to visualize success!  I'm going to remember that. 

I know what you mean about worrying so much that it just exhausts you.   

I've read so many posts from people who have said about self-cannulation, "OMG, I don't think I could EVER do THAT!"  But I've also read a lot of posts from people who have come to WANT to learn to self-cannulate ASAP for the very reasons you've outlined. 

I wish I had more knowledge about buttonholes and self-cannulation to be able to give you lots of advice, but I don't, but Desert Dancer does!  I've actually seen her buttonholes when we were in LV, and they look to be in really great shape, so when it I come to need advice and support, I'm going to chase up both of you!  You're going to be a pro in no time at all.

I hope that by the time you read this, you will be feeling a bit more reassured and confident.   

[Hemodoc]

I had to use sharps on my upper (venous) buttonhole for over a year before we could get it to stop "trampolining." That is going through the skin down the track but bouncing off the vein. Yes, you can use sharps even in a buttonhole long term but it does increase the risk of aneurysm formation and local clotting around the buttonhole.

You may wish to consider trying TOUCH CANNULATION. I have known about this technique for a couple of years probably. Since I am a doc, I always felt I could feel my needle and guide it myself. Man, have I been wrong or what. After getting tired of going back and forth with my latest buttonhole between sharps and dull, I decided, why not. I will just let go and try this underutilized technique.

I couldn't sing the praises of touch cannulation any louder than shouting at the top of my lungs in a library all day long. WOW. IT WORKS WELL!!

I have been using touch cannulation for about two weeks on a very finicky buttonhole and it just finds its own sweet way with just a little nudge on the tubing about 1/2 to 3/4 of an inch behind the wings. I dare say, I bet no one in your unit has ever heard of touch cannulation, but it is so simple and works so well, it is absolutely worth trying. I actually start by stretching the skin with the heel of my hand in exactly the same direction and the same degree while holding the needle by the wings. Once it is gently in the correct hole, I then move my fingers back on the tubing then just very gently give a little push holding the needle at the correct angle and direction. I wait until I feel the needle self tracking and never force it. It just sucks it right into the proper hole and I see a flash back very quickly. If you have an established track, this is the best way to help the needle find its own way. Really, Really neat way of getting around the trampoline issue of bouncing off the vein.

I would definitely not force a blunt before it is ready. That can definitely damage the fistula. Just plain stupidity as far as I am concerned for administrators to make such a decision. Once again, it took me a year to develop enough scar tissue to hold the upper vein in place without rolling away from the needle. Not everyone has a vein that will take a buttonhole with 7 sticks with a sharp. Give me a break!!

One issue for me was how we stretched the skin tight. I began self cannulating shortly after my fistula could accommodate a 15ga needle. I had the tech stretch my skin tight pulling down with one finger, up with the other finger. I don't do that anymore. I pull down with the same hand I cannulate. Once again, Stuart Mott has an excellent article in great detail on this technique. You may wish to read and discuss with your medical team.

Good luck, go gently with your fistula so it will last for years.

http://www.fistulafirst.org/LinkClick.aspx?fileticket=u7wBDCUDeEQ%3D&tabid=127

Figure 15 in this second article shows the one handed technique of pulling the skin tight with the lower part of your hand and pushing gently on the tubing once you have it seated in the right place.

http://www.esrdnet17.org/FF/AHowToManual.pdf

Lastly, one issue that is difficult is keeping the scab in the same exact spot each time. I have found that it is easy to migrate the scab just a little bit every day and then you end up outside of the track. I am VERY careful to remove only the scab and I have "landmarks" that help me locate where the hole is. It took me quite while to figure out I kept moving the scab and then the needle was outside of the track. Very difficult to keep it exactly in the same spot especially with the venous needle. The arterial tends to get a little nipple making it easier to see where the hole is.

There are a lot of subtle things you have to do exactly the same each time, but once you know to pay attention to these things, it is not difficult at all.

I hope this helps. Spend some time on the Stuart Mott articles. You can also speak to him directly at Home Dialysis Central on their ask the experts section. Read his articles and pose some of your same issues to him. I suspect he will have a lot of good advice for you.  The buttonhole cannulation is GREAT method. Be very diligent with infection control and your technique and it will work well in almost all instances. On the occasions it doesn't, well that is why God gave us sharp needles.

http://forums.homedialysis.org/forums/15-Ask-Our-Experts

[del]

Hubby has been using buttonholes for almost 6 years now and he still has to use a sharp sometimes.

[fearless]

thanks to all for the additional comments.

Hemodoc, I especially appreciate the links.  I am familiar with Stuart Mott's instruction, but the links you've provided are new to me.  I knew exactlly what you were talking about with the scabs.  My tech actually pointed this out to me (bless her) - that the scab was wider than the buttonhole "entrance" - and that I should try to remove only the part that was directly over the hole, otherwise the opening to the track would grow wider (not desirable).  But it's true, my tech doesn't seem aware of touch cannulation, and I'm going to have to press on that one, maybe tomorrow even. 

Desert Dancer:
For someone like me, it really helps to have others relate their experiences.  It reassures me more than any amount of reassurance i can get from my caretakers who are on the other end of the needle.