Saturday, February 9, 2013

January 4 through 16, 2013 - Dry buttons

Ok, it's time to start blogging about 2013. It does feel strange to be writing about stuff that happened just last month.

January 4, 2013 (Friday): Mom has not seen the nephrologist at the dialysis clinic since before Christmas. Typically the nephrologist sees each patient weekly, so this is a little out of the norm, but I suppose some allowances should be made for the recent holiday period.

Before proceeding I need to explain what "dry weight" is. Since dialysis removes fluid from the body, it is important that they do not remove too much or too little fluid. If they don't remove enough then the excess fluid builds up in the body, causing edema. If they remove too much fluid that can lead to low blood pressure. The nephrologist determines a figure called "dry weight" for each patient, which is what the patient would weigh without any excess fluid. There are various formulas for determining a person's dry weight, so it's not an exact science and it can take a bit of trial and error to get it right. Dialysis patients are weighed before and after a dialysis session to determine exactly how much fluid has been removed, with the goal being to get them back down to their dry weight.

Mom has lost some more weight since her dry weight was initially determined, which she believes should affect her dry weight. (If she has lost body fat or muscle mass instead of simply fluid weight, I would tend to agree.) Unfortunately the patient's dry weight is part of the dialysis prescription and the nephrologist has to make those changes. Mom knew they had removed 2.3 pounds of fluid during her dialysis session in Austin on Wednesday, but the tech at her home clinic today was only going to remove one pound of fluid. She convinced him to remove two pounds after explaining how much was removed on Wednesday and that she felt fine afterwards. Hopefully she can talk to the nephrologist about her dry weight soon.

Also, her hemoglobin is still low at 7.4. I wonder if that will ever get back above 10 and stay there.

January 7: Mom saw Dr. K this morning about her fistula. (We don't need it to look like this any more.) He said the fistula itself is fine, and based on what she described to him it sounds like they didn’t hold pressure on it long enough at the end of dialysis, so it continued to bleed under the skin. He said they can start using the fistula again, which will be today. Regarding Mom’s thin blood, allergy to heparin and inability to take Coumadin, she told him that she was given vitamin K before her tonsillectomy when she was a young girl because of her thin blood, and he was surprised to learn about that. Dr. K said her fistula should be ok if her blood is indeed that thin. That was a relief to hear, and hopefully he's right. I suppose only time will tell.

When Mom went to dialysis today she told the tech what happened the last time they used the fistula, and the tech was extra careful with it, especially at the end of the session when she removed the needles and made sure the bleeding was stopped. It's nice when she gets a tech that cares and listens to the patient.

Before proceeding, it's time for yet another dialysis terminology lesson. (That's two lessons in the same post. You guys are so lucky.) Our next term is "buttonhole technique." When a fistula is used for dialysis, the needles are inserted under the skin and angled toward the vein or artery. (In Mom's case these needles are inserted in her upper arm.) This is different than simply getting a shot because the needles are larger and because they go through more skin due to the angle. The needles need to go in at such a narrow angle (almost parallel to the skin) so they can be taped down. Another thing the tech inserting the needles has to do is use a different location each time, because if a blood vessel is frequently punctured in the same general area it can get weak and fail to heal properly, possibly leading to rupture and causing massive bleeding under the skin.

According to Mom, it is really painful when they put these needles in her arm. She has a very high tolerance for pain, so if she says it hurts, it hurts. And here is where the buttonhole technique comes in. The buttonhole technique is when the exact same needle location is used repeatedly. This causes scar tissue to eventually form sort of a tunnel in the skin such that it no longer hurts when the needles are inserted. I don't fully understand why this isn't a problem for the blood vessel to have the needle in the exact same spot each time, but I think the key is that the needle goes in the exact same spot vs. "close to" the exact same spot. So the blood vessel only has one hole to heal repeatedly instead of becoming perforated by multiple holes in one area.

Anyway, they talked to Mom about the buttonhole technique and gave her some literature, and she told them she would like to try it. Until the scar tissue is fully formed, it is important that the same tech inserts the needles in her arm each time so the same "tunnel" is being used repeatedly, and also so the blood vessels are being pierced in the exact same spot each time. This dialysis clinic has one tech who does this, and Mom is comfortable with him, so hopefully they'll start that soon. (I did recently find out that they don't start the buttonhole technique until they are using the largest size needles, so it will be awhile before they actually start it on Mom.)

January 14 (Monday): So far so good with the fistula, although her blood pressure was a little low after dialysis on Monday.

January 16: The first needle in the fistula went ok, but the tech (the good one) didn’t like the way the second one felt going in, so he had to use the permacath for the second needle.

So we begin 2013 with some good news that the fistula has not been compromised and they can start using it again. But it seems like it's not always a given that the tech will be able to get the needles in, so we can't get rid of the permacath just yet. I guess we'll just have to see how that evolves each week.

Next up: Fun with insurance!

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