Dialysis care brings big challenge to doctors and nursesBy DIANE COCHRAN
Of The Gazette Staff
Sunday, April 29, 2007
HERIDAN - It's midmorning, and two nurses are bustling between four dialysis stations in a narrow space on the second floor of Sheridan Memorial Hospital.
Mary Gligorea and Lynnet Rede are multitaskers. They're taking vital signs, pressing buttons on beeping machines and chitchatting with patients.
By noon, their workday still is less than half over. The dialysis unit's third registered nurse is on vacation, which means Gligorea's and Rede's shifts will stretch to 15 or 16 hours.
"We cover for each other," Rede said. "It's the only way to get a day off."
Even when all three nurses are on duty, the dialysis center cannot meet demand.
Thirteen patients rotate through the unit's four stations on Mondays, Wednesdays and Fridays, each sitting for three or four hours while machines cleanse toxins from their blood.
At least four more people are on a waiting list because there is no one to operate the unit on Tuesdays, Thursdays and Saturdays.
Running dialysis centers in rural Wyoming and Montana isn't easy.
"There are not qualified people that will cover these dialysis units," said Dr. Grace Kim, a nephrologist with Montana Nephrology Associates in Billings.
And that's only half the problem. As the number of nephrology nurses is declining, the number of dialysis patients who need their care is rising.
Across the country, 3,000 nephrology nursing positions are vacant, and more probably will be soon, according to Sandra Fladmo, director of dialysis for Billings Clinic, which operates the unit in Sheridan.
The average nephrology nurse is in her 50s and nearing retirement, and there aren't enough new nurses to replace retirees, Fladmo said.
The gap can be attributed to several factors, including a penchant by younger workers for a new job description every couple of years and wage increases that lag behind other specialties because of a complex federal reimbursement system.
But it is also because dialysis nursing is a different kind of job.
Dialysis care is chronic care: Caregivers see the same patients multiple times a week for multiple hours a day over the course of years. That sort of work doesn't appeal to everyone.
"It's an area of nursing you either love it or don't, and I'm a love it," Rede said.
Without more nurses like Rede and Gligorea, the future looks grim for people whose kidneys fail, and experts say America is poised for an epidemic of failed kidneys.
Fully one-third of diabetics eventually lose kidney function, and more people than ever are developing diabetes.
The diabetes epidemic is linked to another worsening problem - America's expanding waistline. Almost 70 percent of us are overweight or obese, according to the Centers for Disease Control and Prevention.
In short, obesity leads to diabetes, which leads to kidney failure and dialysis, and all of it is on the rise.
"The impact on our society is unbelievable," said Dr. Christopher Sorli, an endocrinologist at Billings Clinic. "It's incalculable, actually."
Younger kidneys failing
Kidney failure occurs when the pair of bean-shaped, fist-sized organs lose their ability to filter waste and excess fluid from the blood.
That can happen for a number of reasons, but the most common one is damage to tiny blood vessels inside the organs from high blood sugar levels associated with diabetes. Diabetes is the leading cause of kidney failure in the United States.
When the kidneys can no longer perform their filtering duties, dangerous amounts of fluid and waste build up inside the body. Without dialysis, the condition can be fatal.
Most people who need dialysis receive hemodialysis, in which their blood is passed through an external artificial filter. Hemodialysis is performed in a clinical setting.
Fewer than 10 percent of dialysis patients dialyze themselves at home using peritoneal dialysis, in which blood is filtered through the abdomen.
About 400,000 people across the country undergo regular dialysis, a number some experts predict will quadruple over the next 20 years.
In Montana, there are more than 600 dialysis patients, and Wyoming has almost 250. More than half of them are diabetic.
Americans are developing diabetes at higher rates and younger ages than we were a generation ago, according to Sorli.
"We used to talk about diabetes in 60-, 70- and 80-year-olds," Sorli said. "The complications of diabetes, including kidney failure, take 15 to 20 years to develop."
That meant most diabetics whose kidneys failed didn't need dialysis until they were in their 80s or 90s.
But over the past decade, people in their 30s have been the age group to see the largest increase in diabetes, and people who are even younger, including children, are developing it, Sorli said.
That puts people at risk for dialysis much earlier in life, a situation that should worry all of us.
Dialysis taxes the nation's health care system - people with kidney failure automatically qualify for Medicare regardless of age - and it drastically reduces quality of life for patients and their families.
"The current generation of 25- to 45-year-olds, we predict, is going to be the first generation in recent history to live shorter life spans than their parents completely due to the obesity phenomenon and its complications," Sorli said.
Road weary
Living with kidney failure is especially challenging in rural Montana and Wyoming, where the nearest dialysis center can be hours away and transportation iffy in bad weather.
John Mysse, 55, has logged 375,000 miles on three vehicles driving from Harlowton to Billings for dialysis three times a week for 12 years. He was born with polycystic kidney disease.
"It's a lot of windshield time," said Mysse, who dialyzes at the private, nonprofit Dialysis Clinic Inc.
Some out-of-town patients move into Billings during winter months to avoid driving on snow and ice altogether. Others wait until the weather turns sour and then stay in town overnight before or after their treatments.
Those forced to miss dialysis sessions follow dietary restrictions and tweak their medication intake to reduce stress on their bodies.
Larry Yellowtail, another Dialysis Clinic Inc. patient, compared dialysis to a full-time job. Yellowtail, who is 54 and diabetic, travels an hour one-way from Crow Agency to Billings three times a week.
"Sometimes, you hate your job and hate going, but you've got to make a living for your family," he said. "Sometimes you hate coming up here and just laying here after working all your life, but you take it as a job and accept it as best you can."
It takes Leola Whiteman, a member of the Northern Cheyenne Tribe, an hour and a half to get from her home in Lame Deer to the dialysis unit at Billings Clinic.
The unit in Crow Agency is closer, but Whiteman, 61, can't dialyze there because Billings Clinic was forced to downsize the patient load when six of the nine staff positions became vacant.
Whiteman's travel days are at least 11 hours long because she also does physical therapy while she's in Billings.
Rates of diabetes and kidney failure are increasing faster among American Indians than in other ethnic groups, a trend Whiteman chalks up to poor diet.
"There's been a change in lifestyle," she said. "We don't go out and work, chop wood and carry water. Our diet, the kinds of food we eat now ... we don't eat like we used to, from scratch."
Whiteman learned she was diabetic more than 20 years ago, but basically ignored the diagnosis. That undoubtedly hastened her kidney failure.
"At first I didn't see anything out here," she said, gesturing the length of her body. "So I didn't pay attention to my diet or exercise or take medication on time."
Both of her parents and her sister died from complications of diabetes.
"When they said I had to control my diabetes, I just really didn't know (what that meant), but now I know you have to watch what you eat," Whiteman said. "Now I'm paying for it."
High turnover
Whiteman has moved her treatment back and forth between Crow Agency and Billings two or three times because of staffing problems at the Crow dialysis unit.
"It's hard to find quality staff, especially in real rural places," said Nancy Pierce, dialysis director at St. Peter's Hospital in Helena and chapter coordinator for the western region of the American Nephrology Nurses Association.
It can take a registered nurse anywhere from six months to five years to become versed enough in dialysis care to work in a satellite unit where guidance from more-experienced caregivers is not always available.
Sometimes nephrology nurses are ready to move on almost as soon as they're ready to work independently.
"Us baby boomers, we chose a career and stayed in it for our whole lifetime," said Fladmo, the dialysis director at Billings Clinic. "The 20- to 30-somethings aren't doing that."
There's another serious challenge, too - financing. Pierce and others said Medicare doesn't pay enough to cover the cost of care.
At the St. Peter's unit, a single dialysis treatment costs about $156, and Medicare pays $139, Pierce said.
"We just barely make it with supplies and staff costs, and that's no overhead," she said.
Dialysis is costly - it runs $20 billion a year in the United States - but that should come as no surprise, said Kim, the Billings nephrologist.
"There's no other medical procedure we do on a regular basis, indefinitely, that keeps patients alive," she said. "It should be expensive, but it's actually, comparatively speaking, relatively cheap."
Ninety percent of people on dialysis are covered by Medicare, which has been required to cover treatment for end-stage kidney failure since the 1970s.
But unlike most other covered expenses, the reimbursement schedule for dialysis payments is not regularly reviewed and updated. It literally takes an act of Congress to do that, and providers say Congress doesn't act often enough.
With reimbursements lagging behind costs, hospitals are left to absorb losses from their dialysis units, and stand-alone units struggle to break even.
St. Patrick's Hospital in Missoula recently closed two satellite dialysis units, in Polson and Hamilton, because they weren't financially viable, said Joyce Dombrouski, the hospital's vice president of nursing.
"We just were never able to achieve the volume," Dombrouski said. "It was certainly a very, very difficult decision to make."
Asking the government to change the way it calculates payments could help ease what some see as a mounting crisis in dialysis care, but there is a simpler, less expensive solution, said Sorli, the Billings Clinic endocrinologist.
Sorli's logic goes like this: If obesity leads to diabetes, which leads to kidney failure and dialysis, why not tackle obesity?
Convincing Americans to eat less and exercise more is no easy task, especially when tens of thousands of years of genetics are working against us, Sorli said.
Americans are fat because changes in our genetic makeup haven't kept up with changes in our environment, he said.
"We're genetically programmed to be hunter-gatherers and store energy," Sorli said.
Life has gotten a lot easier for most humans in the past hundred years, but we haven't compensated. We are eating and saving many more calories than we need.
Meanwhile, we're far less active than we used to be, Sorli said.
Half of Americans admit to no regular physical activity, while another 25 percent consider a daily walk to the mailbox a workout.
"The only solution we have right now is to get younger kids to be active," Sorli said.
And the only way to effectively do that is for parents to be active, too.
Even if we all got up off the sofa tomorrow and completely overhauled our lives, it would take at least a decade to reverse today's trends.
Chances are it will take longer than that to change our behavior, Sorli said. After all, look at how long it took for the tide to turn against smoking.
"No matter what we do, it's going to take 20 to 25 years to change anything," Sorli said.
Contact Diane Cochran at dcochran@billingsgazette.com or 657-1287.
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