Buttonhole Advice Needed

Boy, 2005 did not start out well at all for me. On my last treatment both needles went in soooo easily, but last night I could not get in my arterial needle for the life of me (tried for 20 minutes then used a sharp), then had trouble getting my venous needle in too.

Why do they slide right in on some days and on others I can’t find them?? Does anyone have any hints? My fistula is so “bendy” it will be difficult to replace the ones I have so I want them to work, but it is frustrating to take 30 minutes getting my needles in.

To make matters worse for some reason my conductivity went low, had to completely take apart all the wands (they had just been cleaned so weren’t clogged), then finally put them back on the machine to get them working, taking up another 15 minutes, and then finally for the first time ever, one of my sites started bleeding after being bandaged and got blood over everything (of course I had already thrown away everything).

Oh well, just hoping this isn’t an indication of what 2005 is going to be like!!

I “lost” one on my arterial buttonhole sites over the holidays. I dialyzed once over four days as a visitor - so one buttonhole set went too long between uses and in that time it healed too much. Other times when I’ve had trouble putting in the needle I pause and take a deep breath (I start feeling frustrated which does not help) and try a steeper angle (about 60 degrees) to get the tip started and then wiggle the tip in - while bringing the angle back to normal (about 30 degrees). This has worked a number of times.

My thinking is that the way the scab is removed might mean that the initial angle is blocked. One thing I try to remember to do is remove the scab against the direction of the needle - it is my observation that this seems to help. So for the arterial needle - the arterial “points” towards my hand - I start on the hand side of the scab and peel it off going towards the elbow. For the venous needle I go in the opposite direction. My theory is that where I initially or start peeling off the scab, that area is deepest and so I think it helps to make sure that the hole is deep enough to get to the channel. This could just be superstition on my part but it seems to help and it is when I forget and go the other way that I seem to have trouble.

As far as the leaking I only have this trouble when I forget to swab around the site after cannulation. If there is just a drop of blood it is enough to wick and seep blood all treatment. Once it starts seeping I’ve found that placing an iodine pad over the needle helps to stop the seeping.

I think we all have days like the one you had Cathy. Hopefully this will be your worst run of the year.

Hi Cathy
I don’t think I can offer any advice but I can tell you I have been sticking with a button hole technique for about 5-6 years, when I started ‘button hole’ or dull needles were unavailable. So of course I just used regular fistula needles and have never used anything else. Tried the dull guys a few times but decided it was too much like trying to impale myself with a Bic pen (if your old enough to remember Bic pens)
I don’t have trouble usually but occassionlly scaring tends to cause the needle to be near impossible to advance more than a half inch.
usially my venous …my arterial has almost never disappointed.
Once or twice a year I may change the venous button hole if necessary.
Start a new one. I woud not be concerned about using a ’ sharp’ just keep your angle and do it like you always do.
I have usually no bleeding problems…if I do I look to my heparin…which I use as minimal as possible by experimentation…I use a wet stick…8-9 cc of saline with aprox. 1/4cc heparin just to prevent any clotting of the needle during the stick other than that no heparin goes in me …just enough to the dialyzer to coat the membranes and keep it from clotting …
beyond that any hepranized saline (or dialysate in my case of the PHD) is tossed and so I have very little heparin in my blood…
Perhaps you can get your RN staff to help you experiment with reduced levels of heparin.
Au revoir!

Bill seems to have a good view, Hi Bill,
It is true that I am never as frustrated in life as I am when my stick does not go well it is real ‘anger training’ to remain calm while the possibility of an easy stick and the possible consequences fade the longer it takes.

The idea that allows me to remain calm is 'I can do this I’ve done it successfully a thousand times and I can do it again and Breathe…and a little prayer to my personal Deva and my machines Deva helps too.

I remove scabs the same as Bill, although never thought about it …I’ve just done it the same way since it 1st started working. It probably is like baseball players: you do something that works and keep doing it as long as it does and when it doesn’t you look to see if you changed something …anything even your socks!
The most important thing for me is to put a few successful Tx between the bad experience. Then you relax into a groove.

Hi Guillaume,

Welcome to Home Dialysis Central, and thanks for all of your practical advice! We hope you come back and post often. If you haven’t signed up for our monthly e-newsletter, please do (just click the “Join Home Dialysis Central” button).

Cathy and Bill, I hope all of your access problems fade away as we head into 2005, and it’s smooth sailing.


Thanks everyone, just knowing others sometimes have problems sticking helps, I thought I was the only one.

Of course last night both slid right in!! I do think on my venous there is a bit of scarring or something in the “channel” as I have a hard time getting the needle started, but once I open it up it goes right in. Still have no idea why the arterial decided not to cooperate Sunday.

My bleeding usually stops within 1-2 minutes so I don’t think it was heparin overload that made my arterial start gushing after taping, I think it was just ol’ Murphy’s Law, since I had told my center on Friday that it had never happened!! I will admit to being much more cautious last night and of course it stayed nicely closed up!!

BTW Bill (and any others), you mentioned missing 3 days I think if I read your message right. Is this pretty much OK when we do daily? I want to take a 4 night vacation with my son in April, I would dialyze at home on Sunday, go on vacation and return on Thursday and dialyze. Provided I watch my fluid and potassium etc., will I need to try to arrange dialysis or should this be pretty much okay (of course I will check with my center, but would like to know others’ experiences).


Well that explains it. I once was showing someone how to self cannulate and made the comment that I never infiltrate, I of course then infiltrated.

I went to Chicago for Christmas, traveling on Wednesday and Sunday – four nights; during the trip I had one treatment near my Mom’s house. It was a seven hour, incenter nocturnal run Thursday night. So I dialyzed daily up to Tuesday night, had Wednesday off and then treated from Thursday night into Friday morning. I then took Saturday off before treating at home Sunday night.

My opinion is that you could do this – dialyze Sunday morning and then Thursday night. Some things to consider are the chance that you will encounter travel delays – I was traveling by plane to Chicago in the winter so I did not want to have to rely on the weather and the airlines cooperating (as it turned out I had a smooth trip). Another factor is: will following a strict diet impact the vacation – I was going “home” for the holidays so being able to be relaxed about eating and drinking was important. Like all things dialysis there are tradeoffs but I do think it is possible.

This was a duplicate post.

My opinion is that you could do this – dialyze Sunday morning and then Thursday night. Some things to consider are the chance that you will encounter travel delays – I was traveling by plane to Chicago in the winter so I did not want to have to rely on the weather and the airlines cooperating (as it turned out I had a smooth trip). Another factor is: will following a strict diet impact the vacation – I was going “home” for the holidays so being able to be relaxed about eating and drinking was important. Like all things dialysis there are tradeoffs but I do think it is possible.[/

Luckily I’m here in CA and would be driving for the vacation so I don’t think it would a problem with delays.

With regard to diet and fluid, I do still pee and even right before starting dialysis needed little diet restrictions, I would just go back to that instead of deliberately adding potassium and phosphorus to my diet due to them going low on daily, so again, don’t think it would ruin my time. I could even bring my scale with me so I can watch how much fluid I gain.

If we end up going with someone else, AND I can arrange dialysis then of course that would be first choice, but if just my son and I, I’m not sure I’d be comfortable leaving him unattended for 4 hours while I do an incenter dialysis, he’s only 10. It is hard now that so many centers are full and don’t take travelling patients. But you sure seem to find them, so I guess I shouldn’t give up.

Thanks for the official welcome, Dori. It was good to find the site (New Years).
I have been on Dialysis 25 years with some short time off for a Transplant that didn’t take and a PD for 6 months that allowed me to experience monthly episodes of peritinitis. When I say I’m happy with homo-hemo I mean it. I’m diabetic so the long term on Dialysis makes me feel fortunate. I have been at home twice, the 1st time in the 80’s when Medicare paid for Staff assisted in-home and then since '97.
My wife was my partner at first, fortunately I linked up with Zyblut Twardowshy who told me about buttonholes and his plans to design a dialysis machine specifically for the home patient. I started out at home with Cobe II, then III, Baxter prehistoric, Fresenius 2008H, which I did alone but never quite comfortably til the PHD. When it becomes a reliable machine I will be quite satisfied. I am interested in a Ready type machine that can be used for travel, or backup or in a ‘crisis’ situation.

I don’t know much about this site yet, and where it came from etc, but I’ll get the newsletter to educate myself.
Good Wishes to all in the New Year.
Guillaume LUAF

Hi Cathy,
in reference to your trip. I usually don’t like to go that long but I have in the past. I went to Australia on short notice a few times and they could not give me the time I needed except during the meeting I was there to attend, so I had to skip the middle Tx they set for me and it ended up a 4 day which I could do as I was in good ‘health’, watched my K and H2O and it worked OK although it gave me something to think about during my spare time. I don’t even like ‘weekends’ off Dx anymore though it happens when the PHD is down.
I was not peeing, so that should help you quite a bit.
And you’re right traveling is nice, arranging transient dialysis is not and has really changed in the U.S. in the past 10 years, probably a result of more folks and the financial climate.
Here is a ‘Bon Voyage!’ for you when you go.

Hi Cathy,
I hope you know that even though you’re a home dialysis patient, your social worker and your home training nurse are available to help you find a dialysis clinic where you can do one treatment. If you dialyze at a corporate clinic, perhaps there’s one of their clinics at your destination where you could get dialysis easier. You might look on this site for a clinic in the area where you’re traveling. I bet every clinic on Home Dialysis Central also offers in-center hemo and those with home hemo patients are used to backing them up. Some other resources to find clinics include:
– Dialysisfinder (www.dialysisfinder.com)
– The List (www.eneph.com)
– Dialysis Facility Compare (www.medicare.gov/Dialysis/Home.asp)
– Dialysis Units in the USA (www.nephron.com/usacgi.html)

I can certainly understand your concern about leaving your son while you’re on dialysis. Are you going to be staying at a hotel? If so, you could ask the hotel if they have (or can recommend) a sitter. When I worked in dialysis, we occasionally had children in our waiting room when parents were on dialysis and they did OK. Ask clinics if they ever have children his age who wait for parents while they’re on dialysis. I bet if he had a bag of games and other things to do and a walkman with earphones, these would keep him occupied while waiting for you.

I’d encourage you to do one treatment on your trip (on Tuesday if possible). I know that people sometimes skip or shorten treatments. However, research has shown that skipping or shortening treatments as little as 10 minutes a couple of times a month can risk your health and even your life. Besides, it’s more fun to go on vacation when you feel your best and to not have to be so strict with diet and fluid as you’d have to be if you take a 3.5 day break from dialysis.

Having problems with buttonholes is something I have wondered about. What would you do if you could not get a bh site to work? Who trained you for your buttonholes? Do you have anyone for backup support should you run into problems?

jane, Hi
There are times when using one of your buttonholes is not feasible,ie.
an infiltratration, a scaring or some unknown or unprepared for occurance, it happens. You(hypothetical you) have been cannulating your self for a
long time…years…you pick another spot. Some people have alternate site buttonholes plural(I do not) that they rotate sticks through…For many reasons buttonholing seems the way to go, not the least that it is much healthier for the longevity of your fistula. And yes it is less painful sometimes painless. But onc.e you have overcoming the ‘programming’ that makes it difficult to impale yourself with a sharp object (goes against the survival of the species gone …and individual)it is not that big a deal and can be done with little trauma. Like anything one gets used to it.

You will notice from my post that all I did was use a sharp needle on the buttonhole rather than the buttonhole needle and went on with my dialysis. I will probably be starting two more sites once I decide on where and alternate my sites as my particular unit thinks that is the best way to go. From my reading they say the sites are less sensitive when not used everyday, but mine don’t hurt much at all, just sometimes get a bit inflamed.

For an update, the last two nights have gone exceedingly easy (knocking on wood), I’ve been running within 45 minutes of starting my set up. I did stop trying to remove my tiny scabs and think that it is possible that I was irritating the buttonholes and making them swell which was making it hard to find my channels (especially the venous which I think might have a tiny bit of scar tissue at the opening which I was trying to remove as a scab). At least that is my theory and I sticking with it lol.

It really was helpful though to hear I wasn’t the only one who can’t get it in everytime, maybe that simply relaxed me a bit more, don’t know.

BTW for those of you who do home hemo and travel, are you allowed to self cannulate and use your buttonholes? Sounded as if Bill has to let someone use sharps and new sticks when he travels. I’d much prefer to bring my own needles and self-cannulate if at all possible.

I think that I have the choice and that I am in charge of my life and Dialysis, and I would not and have not allowed anyone else to cannulate me since I began self cannulate about 7 years ago. When I go in center for backup or travel I always take care of myself, I have my own ear thermometer, BP, my own ‘stick supplies’, most places will not let me operate their Dx machine even If I know how, although about 20% percent will and are fairly laid back.
I have a very friendly letter from my physician that asks them to give me as much freedom as posssible to the extent of self-care if policy permits.
I have a lot more confidence in being safe on my own and am more comfortable that way at this stage of my story.

So, if I understand correctly, if you can’t get into a site, you start another channel? Can EMLA Cream be used with BH?

Really like what you said about becomming totally independent. Might I ask what model ear thermometer, BP and other supplies do you use? I currently do in-center dialysis and I feel it is unsanitary when the thermometer is passed around from patient to patient, stethescope is not cleaned with alchohol etc. I would feel much better using my own equipment.

I’ve never let anyone needle me in 14 years. Since switching to the buttonhole I bring my own supplies, including an old style pressure cuff to oclude my fistula and all the tape and 4x4s I’ll need. I like to do everything - force staff to watch.

I’ve heard from a self-sticker that he was not allowed to self stick when he visited Japan. For myself I usually feel encouraged, I usually end up doing an in-service for the staff. In Utrecht I showed them the buttonhole needles/technique in '03 and last yer they had their own buttonholers.

Since switching to the buttonhole I bring my own supplies, including an old style pressure cuff to oclude my fistula and all the tape and 4x4s I’ll need. I like to do everything

I never oclude my fistula, when and why do you do this?? Doesn’t it risk damaging your fistula, I’ve been told to never stop the circulation through the fistula and to be careful not to hold my sites too tightly.

I should have written “partially” occluded. When I cannulate myself I pump up an old style blood pressure cuff (a manual pump with gauge readout) to a point between my systolic and diastolic blood pressures. I like the blood pressure cuff because I can be certain that I am not fully occluding my fistula. I’ve seen people use a tourniquet – a rubber strap – that I know works but it seems to me controlling the amount of force would be trickier.

When I was in center I use to let the staff do the occluding while I cannulated. Staff would use varying amounts of pressure and I am sure there were times when the fistula was fully occluded but I’ve used the same fistula for over 14 years with no problems or revisions.

After dialysis I do use a clamp to hold my venous site so I can remove and hold the arterial site. The clamp looks like a big ‘zip tie’; I have it prepositioned on my arm; once I have the needle out and the 4x4 in place I switch over to the clamp. I try to have to clamp only as tight as I need to stop bleeding.