hi there folks,
my name is Sinead and I am currently training for home haemodialysis in Dublin. Ireland. Its a new pilot program in Ireland (finally!!) and I am the second person to get the opportunity to avail of the treatment. Anyway in order to be passed as competent for going home, needling my fistula is the final hurdle. I’m just wondering if anyone has any suggestions re video links or forums specifically on buttonhole technique.
My last AVF (radiocephalic) stenosed after approx 3 years and could not be ‘rescued’ unfortunately. Now I have a brachiocephalic fistula (my upper arm). It is mature at about a year old. My buttonholes are about 2 months old, rope ladder technique with sharps were being used until then. I do 3 hours 3 days a week currently and don’t have any problems with clotting on the machine.
The problem is some days I have no problems with my needling and other days when I don’t do anything differently that I know of it just takes forever to get the needles in. I am so frustrated and even though everyone is telling me it will happen, from where I’m sitting its just happening fast enough. The irony of this is I am a phlebotomy nurse, and without wishing to sound arrogant, I am very good at my job. I find veins on a regular basis, where patients insist there are none
Bye for now
Sinead
Hi Sineed,
Congratulations on starting home hemo. How many days per week will you be dialyzing at home?
Many people have the type of issue you described with the buttonholes. There are several reasons why it can be difficult.One reason is called the trampoline effect where the needles are bouncing off of the flap where the needles goes into the vein.
Also buttonholes are very positional. Try to stay at the same angle and position everytime you insert the needles. Are you currently using the buttonholes every other day, or are you using them daily now that you are traiing for home hemo? Some people tend to heal very fast. If you will be using them more often, then you may see an improvement when you try to cannulate yourself.
///MM
[QUOTE=Sineadee;18735]The problem is some days I have no problems with my needling and other days when I don’t do anything differently that I know of it just takes forever to get the needles in. I am so frustrated and even though everyone is telling me it will happen, from where I’m sitting its just happening fast enough. The irony of this is I am a phlebotomy nurse, and without wishing to sound arrogant, I am very good at my job. I find veins on a regular basis, where patients insist there are none
Bye for now
Sinead[/QUOTE]
Hi Sinead, and welcome to Home Dialysis Central! It definitely is ironic that you’re a phlebotomy nurse having trouble getting needles in. We do have some resources here that may help you.
– Here’s a video of Bill Peckham self-cannulating with the Buttonhole. Maybe watching him do it will help give you some tips? http://www.homedialysis.org/resources/links/BillMovie1.flv
– We have two different webinars on cannulation (mostly Buttonhole) by Stuart Mott, who is a cannulation nurse. You can view those on the home page (http://www.homedialysis.org–just scroll down under Webinars.
We can also put you in touch with some U.S. Buttonhole experts if none of these things help–just message me privately if you need that.
[QUOTE=MiracleMan;18736]Hi Sineed,
Congratulations on starting home hemo. How many days per week will you be dialyzing at home?
Many people have the type of issue you described with the buttonholes. There are several reasons why it can be difficult.One reason is called the trampoline effect where the needles are bouncing off of the flap where the needles goes into the vein.
Also buttonholes are very positional. Try to stay at the same angle and position everytime you insert the needles. Are you currently using the buttonholes every other day, or are you using them daily now that you are traiing for home hemo? Some people tend to heal very fast. If you will be using them more often, then you may see an improvement when you try to cannulate yourself.
///MM[/QUOTE]
Hey miracle man,
much appreciate the reply.
I hope to dialyse 2.5 hours 7 days a week. They’re (ie nephrologist and my mentor nurse) happy for me to do that in the hospital but are saying that 6 days will be enough. I also have the option of doing 2 hours instead of 2.5. I think they are thinking that 7 days will just be a bit too much. I hear them but at the moment I am really excited and enthuastic so I will take it as it comes and not worry if its 6 or 7. I know long term it will be more beneficial healthwise to do more dialysing. So if I feel really well and I have more energy, well thats the reward. I think mentally, just being able to drink freely, and eat more healthily will instantly take a lot of the stress away. That in itself will allow me to feel more energised.
While training I dialyse 3 days a week. I am hoping they will let me home by the end of this week even if it takes me a long time to get my needles in, and then doing daily dialysis will develop the button holes even more. I’m not so sure they are as keen on that idea as I am unfortunately. I do honestly understand it from their perspective also.
Our machines aren’t portable yet, we’re using Nikkiso Dbb-05 machines. They are pretty user friendly, I would say from my experience. I have had lots of my supplies delivered, just a few items they forgot but thats just the nature of all start ups. Our appartment looks a bit medicalised right now. To me it’s second nature, I’m so used a medical enviroment with work. For Michael, well he knows it’s what I want but he must think it’s all a bit surreal at times. My chair, whilst very comfortable and easy to manouvre, is a bit little ole lady like, no offence to any little ole ladies, but I’m not quite there yet! I just love that I am in charge of it all. I do my own ordering every three weeks and my delivery arrives the 4th week or each month, it is my total responsibility. Bring it on 
We are supplied with everything in Ireland even down to the weighing scales, we are so lucky. Obviously when I am transplanted all that equipment goes to the next candidate on the list. It is currently only a pilot project here and there are 5 places. I had been asking when it might be a possibility in Ireland for the last 5 years, and had been continously told there is no funding available. So it is nothing short of a miracle that this is happening at all. I see there are funding issues ongoing in the States, I wish you guys well with that. I can only imagine that it is incredibly stressful waiting for the final outcome. It would be soul destroying to be doing home dialysis and then to have that freedom taken away. Dialysis is hard enough for people, no-one given a choice would want it as part of their lives.
I see you are on peritoneal dialysis for the last 13 years. How is that going for you? I didn’t think you could stay on peritoneal for so long, so maybe you have been transplanted during that time. I don’t know a lot about the experience of peritoneal dialysis. I guess for everyone its different. Why did you choose that option? or was it your choice? You also have had 3 transplants, I am currently waiting for my third. Have you ever been on haemo dialysis? Are you currently waiting for a transplant? If my questions are too personal, don’t worry about replying. I really appreciated what you’ve written already.
Bye for now
Take care
Sinead
hi Dori
much appreciate your reply. I have seen Bills video, he makes it all look so easy. I will check the others you have mentioned tomorrow. It’s 22.20 nhrs here now so a little late tonight.
Al the best
Sinead
[QUOTE=Sineadee;18738]I see you are on peritoneal dialysis for the last 13 years. How is that going for you? I didn’t think you could stay on peritoneal for so long, so maybe you have been transplanted during that time. I don’t know a lot about the experience of peritoneal dialysis. I guess for everyone its different. Why did you choose that option? or was it your choice? You also have had 3 transplants, I am currently waiting for my third. Have you ever been on haemo dialysis? Are you currently waiting for a transplant? If my questions are too personal, don’t worry about replying. I really appreciated what you’ve written already.
Bye for now
Take care
Sinead[/QUOTE]
I am curently on Home Hemo. I have been doing Home Hemo for the last 3.5 years. Before that I was on PD for 13 years until I developed Encapsulated Peritoneal Sclerosis from long term PD that damaged my peritoneal cavity. Before the PD I had 3 transplants (2 living related from parents ) from the age of 11 until 18 with a few months of In-center Hemo in between transplants when they failed.
It was my choice to choose PD at the time. I was very independent and had much freedom during my PD years until I developed the EPS which forced me to switch to Hemo for my peritoneal cavity is now scarred.
I would definetely look at the resources that Dori had suggested in her post. I found them very helpful.
Good Luck and let us know how it goes…
///MM
Dori
ps can I just mention in my defence 
I have no problems using sharp needles, but buton hole needling is the current needling protocol of the program I’m on.
S
The biggest trick with the Buttonholing is to use exactly the same angle. In one of Stuart’s webinars, he covers “touch cannulation”, which is holding the tubing behind the butterfly of the needle. This helps guide the blunt Buttonhole needle into the tunnel.
Hi Sineadee,
With buttonholes the angle is everything. I understand your frustration. I have had the same two original bhs for 4+ yrs now. I have had days when one or the other would not cooperate. I was convinced it had closed off so had to go in with a sharp. But with experience I found that I was simply missing the angle. it is exactly like a pierced erring. If one does not have the angle right, one keeps bumping in to skin tissue next to the hole. With bhs it helps to watch how you are sitting on a day when it goes in right. If you use a side table, notice where your body is in relation to the table. Notice where your arm and hand are placed. Is your arm/hand swiveled too far in one direction or another. You want to come back to the correct angle every time. You may think you have the angle right only to find that the placement of your arm/hand was a smidgeon off. Its like getting a golf ball to go in the hole. Sometimes the ball flies right past the hole and will not go in. But when its dead center that’s when it drops in. This observation takes some time. Keep practicing it and you will see you will get your needles in much faster, maybe even with the first try. Practice makes perfect. Swiveling the needle a little when you are going in also helps to allow the needle to drop in if your angle is close enough. Most interesting that you are a phlebotomy nurse yet have had problems with your own bhs. That is because correct technique must be taught with instruction like I have provided here for how to align ones body and otherwise maneuver the needles when the tunnel doesn’t seem to be available. It’s there, just hiding. One of my pet peeves is teaching/training that is incomplete causing the patient or nurse to wonder what’s missing and/or have stress problems, A good teacher doesn’t leave anything out, or at least makes sure to update the patient.
Are you removing the scab completely before inserting the blunt needle? If the scab is not removed the needle will not go in. If you force it you could introduce a piece of scab into your blood stream.
I also dialyze 7 days a week for 2 hr 15 min. My precription is for 5 days but I feel better on 7 days. I miss a day here and there due to schedule.
hi there all,
yup I totally removed scabs I do realise the importance of that. The needles slipped into the holes no problem, it was after that the problems began!
I think part of the problem was that my venous button hole was created by 4 different nurses using a protractor to get the angle right. I really think thats not a great policy, no-matter how conscientious people are in using the protractor. I am the first patient to have a button hole on the unit. In fairness to staff on the unit, who have been incredibly supportive in getting me on the training program, a protocoll has not yet been developed and I am sure that will be rectified, I think you really do need the same nurse every time or the patient themselves. My arterial was created by the same nurse everytime. So mostly my problem was with the venous, as probably false tracks had been created.
Anyway the good news is, I have mastered the technique it seems. I’m sure there will be days that it may be a little tricky in the future (hopefully not), but lets face it does anything in life ever run completely smoothly, and how boring would that be!! All those valuable lessons we learn through challenges are worthwhile in the end.
I have to say a big thank you to Dori for the links to the videos. It was great to watch and realise that I was on the right track, I also felt more confident in my knowledge of button hole needling after watching, and as a result it was empowering. I just needed to ‘relax the head’ (a common Irish phrase lol) and go through the steps. I went in for my next dialysis session convinced I could do it, before I even lifted the needle up in my hand. I had them both in within 5 mins! And the next couple of sessions have proved equally as successful.
So I have been given the all clear to go home, wahoo I have all my equipment including my machine. I am just waiting for the lab to give their final safety check report on trace element levels in my water supply.
So thanks to everyone for their replies, I really appreciate you took the time.
Bye for now
Sinead
Hi Sinead,
Awesome! I’m so glad the videos were helpful–and strongly suspect that you’re right about the venous Buttonhole being troublesome because it was formed by several different nurses. Using a protractor is a new one–I’ve never heard that before–but it sure does give a great feeling for how conscientious the nursing staff! They are really trying to get the same angle. This would probably be easier if they would rest their hand on the patients’ arm, though. We are putting together a training manual for staff based on info from Stuart Mott’s two webinars that should help them to help you. It will be ready soon.
We also strongly urge folks to start their own Buttonholes rather than have staff do it. That way, it’s easier to ensure that the angle is correct.
Write back and let us know how things go for you at home.
Sorry to hear of your woes - but congratulations on the new endeavor! I have been buttonholing for close to 4 years know, and every so often, have to cannulate with a sharp, to re-cut/re-establish the track. Though medically/tecnhnically speaking, it is not SUPPOSED to be necessary, I have found that every so often, I get a tonne of resistance, when all the pushing/prodding/chisteling in the world won’t do it. Sometimes I find, using a sharp for 2-3 treatments (in a row) is all takes.
Best of luck!
Kidney_Mom in Canada
hi folks
well first session of home haemodialysis is ‘in the bag’. Admittedly my nurse mentor was supervising, but I just got on with it as if I was on my own. I love being in my own home enviroment. I know I can do this, there isn’t a hint of doubt in my mind. It is a great feeling, to gain that independence back, the sense of I am in control here of my life again. For sure it is time consuming but I will work it into my schedule, and I’m sure I will get faster at set up and it will become more automatic. Safety first speed second.
So provided nothing new goes wrong!! life will be a little better a lot of the time. Hope you’re having a good day today. Once again thanks for all the replies.
Bye for now
Sinead
Hi Sinead,
I’m sure you can do it, too, and your attitude seems very realistic. It IS hardest at first, and then becomes routine over time (like learning to drive). And confidence seems to be the key.
Which part of Ireland are you from?
Hii Dori
hope all is well with you, and you’re having a good day.
I’m from a place called ‘Tickincor’, it’s abput 3km outside the town of Clonmel, Co Tipperary. I guess you may have heard or Bulmers Cider (or not). Well I grew up about 300 yards away from those orchards. It’s a beautiful place, a valley surrounded by mountains with a river running through it (river Suir). One of the mountains is Slieve na mBan, and I don’t know if U have any Irish friends but theres a story and a very well know song written about it. The story attached to goes like this…once upon a time there was a beautiful Prince,and he feel in love with one of the local women, but in those days you couldn’t just marry whomever U wanted. So clever Prince (although I suspect it was more like clever young local woman or at the very least they came up with the plan together!!) arranged a competition, the women of the area had to climb up to the top of the mountain and whoever got their first got to marry the Prince. There were no such thing as hiking boots or sat navs in those days! those women climbed their hearts out, but of course the lady he loved knew the shortcut and they lived happily ever after. So translated the mountain is called ‘Mountain of the women’. Ironically the song shares no correlation to the story, but thats the romance of the Irish. The song is ultimately a sad one, an emigrants song about missing the mountain and home ultimately. Blimey and U thought U just asked where I am from! I guess I love Ireland, I’m proud of where I’m from, with all its imperfections, its beauty is far greater to me. Even though I love to travel, I always love when the wheels of the airplane hit Irish soil.You probably feel the same way about America. Where are you from Dori? I’ve only spent any significant time in Seattle, which I loved. Before I went on the transplant list this time I was supposed to move there for 3 to 4 years but it wasn’t meant to be. Well as a result of having to go back on the transplant list. In Ireland the average wait for a kidney is approx 2.5 years currently. The wait in America was longer, potentially. Little did I think then I would still be waiting 5 years later. Now I just think, today I am waiting, maybe tomorrow I won’t be, so really it’s never longer than a day at a time.
Bye for now
Sinead
ps Forgot to mention I now live in Dublin and jhave done for the last 15 years.
Ahhh. I’ve actually heard of Dublin! I have a couple of friends from Ireland (from the Dublin area, I think), but haven’t ever been to Ireland. It’s on the list for sometime… What a terrific story! I’m from Madison, WI, in the middle of the U.S. Many people love it here, but it’s cold about 6 months of the year! I actually love both coasts far more, and one day plan to live on one of them. (This probably comes from growing up in Orlando 'til I was 8). No wonderful fairy tales, though.