Home hemodialysis training arrives in India - finally!

Discussions for Patients, Family, and Friends HD For Patients
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I am off to Chennai for a week this coming Monday, the 2nd of August. Guess why? Yes, Fresenius, the world leader in dialysis machines is starting a training program for home hemodialysis. I will be the only person undergoing this training to start with. My needs are slightly different because I have been doing daily nocturnal home hemodialysis for more than four years now. I have had a tech to help, of course, but I am able to do most of it myself. So, I have a specific set of training needs which the Fresenius team will be fulfilling.

Subsequently they have plans to start home hemo training spread over 6 weeks for those who want to take up this modality. That training will be from scratch.

This is huge!

I honestly did not expect this to come to India so soon. Well, it is really not that soon but judging by the way things were going - a urologist had once asked me why I needed so much dialysis - I really did not expect things to fall in place so quickly. The Fresenius team is very committed to this and let’s hope this commitment continues.

The other person who is involved closely with this endeavor is Dr. Georgi Abraham, senior nephrologist in Chennai. Dr. Abraham is widely considered to be one of the pioneers of peritoneal dialysis in India. His contribution to home hemo will be most welcome.

What am I looking for from this program? The main thing I am hoping to learn is about managing emergency situations. For example, how do I handle a needle that has dislodged from the site? How do I handle hypotension and cramps? What do I do if I need to discontinue a session midway?

I am hoping I will be able to learn these things and get a little practice too.

I hope to have a reasonably good internet connection while I am in Chennai. I will blog the progress and happenings each day. I am really excited. Hopefully this should open the floodgates for home hemo in India!

Kamal

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Thank you so much for sharing your view from the ground in India about home nocturnal training. I’m looking forward to seeing how it goes!

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Day 1: Confusion worse confounded

I took off for Chennai on Monday morning for the home hemo training. The hospital apparently had organised an inauguration and a small ceremony which I did not know about and so had to miss. I got some rest and reached Madras Medical Mission (MMM) hospital around 4:30.

There was a small room that was setup for the home hemo training. I should be able to post a picture of the room soon. It was a very nice little room, very different from your general hospital rooms. It had a small cot at one side, next to which was the Fresenius 4008S. There was a wash basin and a table to keep things.

I met the team, Dr. Georgi Abraham, the chief nephrologist, Thiagarajan Thandavan, the head of clinical coordinators for Fresenius in India and the driving force behind this entire program, Geetha from Fresenius’ home therapy program and Sugan Raj, clinical coordinator from Fresenius. They were all very affable people with a passion for their work and a genuine desire to make this program a success.

We got started with a very touchy topic - to use xylocaine or not. Xylocaine is a local anesthetic. Many people on dialysis like to inject a little at the point of cannulation to avoid the pain of the thick needles going in for dialysis. Most medical professionals discourage the use of xylocaine saying that it is harmful in the long term. I have used it for the most part. It makes the pain less. Thiagarajan suggested we try not to use it. I hesitatingly agreed. Next was the technique to wash hands effectively. I was given a presentation about the importance of washing hands well and the six step washing method. I was given a demo of how to wash hands before a dialysis session and then made to do a dry run.

We then broke for dinner and I got back to the hospital at 9:30.

We decided to start dialysis. There was general confusion because this was the first time this was being done. We put the machine to test and in the meantime I started connecting the dialyser and the blood lines. When I started connecting the bloodlines, we realised that they were ‘pre-pump’ type. I have always used the ‘post-pump’ type. I got a little flustered. This entailed a slightly different priming method. The team guided me as I primed the dialyser and the bloodlines.

The machine self test however failed. The temperature and the diasafe tests kept failing. The service engineer from Fresenius was immediately called. It was close to 11 in the night when he came. Sugan Raj, the clinical coordinator assured me that they had tested everything that morning and it was all in order. The service engineer came and fixed the problem by opening the machine up and doing some calibration.

We then proceeded with the treatment. The team watched as I injected xylocaine (we agreed that I would use it as we hadn’t had a good start and we wanted to reduce any further pain and discomfort). I then cannulated myself. The tape that was used (micropore) was also different from the one I was used to (transpore). This made things a little unwieldy. But in a few minutes I was on dialysis!

We did a five and half hour run. I took a mild sedative to get some sleep.

The treatment completed at around 5:45 in the morning. I did most of the closing on my own with tips from Thiagarajan on how to remove the needles and hold the gauze with one hand. He taught me a nice little technique where we tape the other end of the needle to a trolley or a firm place and then move your arm away from it so that the needle is removed and you can press the gauze on the site with the free hand. I will try and post a video of this some time.

All in all, it wasn’t the start that I had hoped for. But the team, of course, did all they could and sometimes, things take a little time to settle down. The plan today is to have a discussion on trouble shooting at around six in the evening, break for an early dinner and then begin by around nine.

I got a chance to swim at the place I am staying. That felt really good! We also went over to the Murugan Idly shop at T nagar. The food there was truly heavenly. I took a quick nap to make up for the lost sleep. Let’s hope tonight is better!

4

It’s hardest to go first Kamal, you’re making it easier for everyone who will follow.

I’ve been out of the loop for a while - What spurred the switch from self management to FMC?

5

Yes Bill, I know. But last night was much better. I will post the details in a bit.

As for the switch, well, it is not exactly a switch. I will continue to self manage. This one week training is to learn how to handle emergencies and situations without any assistance.

Thanks
Kamal

[QUOTE=Bill Peckham;19985]It’s hardest to go first Kamal, you’re making it easier for everyone who will follow.

I’ve been out of the loop for a while - What spurred the switch from self management to FMC?[/QUOTE]

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Day 2: there are alarms and then there are alarms

Day 2 was much better than Day 1. We had to use the pre-pump bloodlines because the post-pump ones were still not available. Thiagarajan had a totally different style of priming the dialyser and the bloodlines. I do not think there is anything wrong with my style however and plan not to change. Learning this new style may take a long time and especially since there is nothing wrong with what I am doing, it probably does not matter.

I was on dialysis by around 10:20 in the night.

Next, Thiagarajan explained that Blood Leak alarms and Air Bubble Detector alarms are the two most common alarms that dialysis machines give out.

Blood Leak alarms occur when blood leaks out of the fibres within the dialyser into the adjoining compartment for the dialysate. Should this happen, you need to change the dialyser. I was told orally how to change the dialyser.

Air in the blood can be very dangerous. Even a small amount of air in blood can be fatal. The design of dialysis machines and procedures makes sure that the chance of air entering into the blood stream is close to zero. Should air enter into the blood stream despite this, machines are designed to detect this at the point where blood returns to the body through the venous line and clamp the line to prevent the air from going into the body. I was taught orally how to handle situations where air enters the blood lines.

I was quite sleepy by then! We decided we would simulate these two situations the next morning and practise how to handle them.

The night was uneventful apart from a couple of small alarms that required a simple press of the reset button. I had a reasonably good sleep without any sedative.

In the morning, around 5:00, the machine alarmed to signal that dialysis had completed. I returned the blood back through the venous line and disconnected the bloodlines and removed the needles. I did everything pretty much myself including removing both the needles and tying the tourniquets using the trick Thiagarajan had taught me the previous day.

Then I had to practice the handling of the Blood Leak alarm and the Air Bubble Detector alarm. This was a little tough as it was the first time and my left upper arm was sore from the needles that had just been removed after a gruelling seven hours of hard work!

We first did the Air Bubble Detector alarm which meant that air had entered the blood lines. This involved disconnecting the bloodlines from the needles, going into recirculation mode and then ensuring that the air is removed by forcing all the air out by aspirating it from the chambers and hitting the dialyser to force it out from within. Piece of cake? Not exactly! But then, Chennai wasn’t built in a day!

Then I practised handling the Blood Leak alarm which involved changing the dialyser. This was an equally dangerous problem albeit with an easier solution. You basically clamped the lines going into the dialyser and then took a new dialyser, primed it with saline and then replaced the old, defective one.

We quickly did this and then did one more round of air bubble handling just for kicks. Practice, they say, makes a man perfect. Whoever coined that probably had home hemo training in mind!

I was done for the day by then. With a promise to meet at five this evening, we wound up Day 2.

I did my swimming soon after, followed by a sumptuous breakfast at Murugan Idli Shop. Gosh, that place can be addictive! I take it as a reward for the hard work I am putting in through the night!

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[QUOTE=kamalshah20;19986]Yes Bill, I know. But last night was much better. I will post the details in a bit.

As for the switch, well, it is not exactly a switch. I will continue to self manage. This one week training is to learn how to handle emergencies and situations without any assistance.

Thanks
Kamal[/QUOTE]

So it is like a dialysis adventure vacation - every night a different emergency.

:slight_smile:

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Day 3: Causes of the alarms and how knowing that helps fix the issue

Thiagarajan and I met at around 6 on Wednesday evening to have a session where we would proceed with our discussion. Thiagarajan explained the other types of alarms such as high and low arterial and venous pressure alarms. His explanations were based on first principles which made things very easy to understand. For example, he explained how the arterial and venous pressures were sensed and what caused them to change. This made it easier to figure out what might be the cause of an alarm.

Many people try to fix these alarms without figuring out the cause. They have a list of causes that they have memorized or know from experience and they go about the fix ruling things out one by one. This may result in the alarm being silenced only for a short period of time and return in a few minutes. Alarms can cause a patient to be quite rattled since it is his/her blood that is out of the body! So, it is important to know what the cause is before attempting to fix it.

After a dinner break, we started dialysis. I requested Thiagarajan to allow me to use my style of priming. He readily agreed. I was on dialysis by around 10. The next morning, when dialysis finished, we simulated an air bubble detector alarm and I fixed it on my own. I needed little guidance from the team. I was fairly confident of the technique to do this.

I also closed the dialysis session entirely on my own including closing the sites with one hand.

At this point we decided that we needed just one more session of discussion where we could wrap up the training.

The next day, Thursday, we met at the hospital in the morning around 11. This session was mainly a discussion on any doubts that I had left. I had a few questions which Thiagarajan clarified. I also went through some of the procedures with him one last time to make sure I got them right. The procedures are so similar that it is easy to get confused with which to use for which situation.

The key is to start from first principles. What has happened? What is the cause? What should I then do to fix it? It will all follow if you are clear about the basics. It is striking how many things in life work this way!

I was done with the training!

We took a couple of pictures. I thanked him for all the help he had given me by doing this training. I left for Hyderabad that evening.

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[QUOTE=kamalshah20;19983]Day 1: Confusion worse confounded

The treatment completed at around 5:45 in the morning. I did most of the closing on my own with tips from Thiagarajan on how to remove the needles and hold the gauze with one hand. He taught me a nice little technique where we tape the other end of the needle to a trolley or a firm place and then move your arm away from it so that the needle is removed and you can press the gauze on the site with the free hand. I will try and post a video of this some time.[/QUOTE]
Sorry there was so much confusion around your first treatment. I hope the swim and good food made up for it. :slight_smile: I would LOVE to see this needle removal technique! Did you remove one, hold the site, and then remove the other?

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[QUOTE=kamalshah20;20000]Day 3: Causes of the alarms and how knowing that helps fix the issue
For example, he explained how the arterial and venous pressures were sensed and what caused them to change. This made it easier to figure out what might be the cause of an alarm.

Many people try to fix these alarms without figuring out the cause. They have a list of causes that they have memorized or know from experience and they go about the fix ruling things out one by one. This may result in the alarm being silenced only for a short period of time and return in a few minutes. Alarms can cause a patient to be quite rattled since it is his/her blood that is out of the body! So, it is important to know what the cause is before attempting to fix it.[/QUOTE]
I think you’re absolutely right, Kamal. In fact, this is what makes me very nervous about many in-center US dialysis. I don’t think most nephrologists, nurses, or techs necessarily learn the WHY behind what’s happening–just how to shut off an alarm. There are people who know dialysis down to the ground–as your training fellow did–but not most. We wrote the Core Curriculum for the Dialysis Technician to help train US techs (free download from http://www.meiresearch.org/core_curriculum.php). If the Core Curriculum is used, the WHY’s may be understood. Not everyone uses it–some clinics may still be using only a “preceptor” model, where a new tech shadows a more experienced one. This can work if the more experienced one really knows what s/he is doing. Most nephrologists don’t get this level of training at all–they expect that the nurses have it. The nurses may or may not…

11

Totally agree Dori. I will download the book too. With my Fresenius 4008 S as opposed to a NxStage, I should know probably as much as a tech!

Thanks so much for the link!

Kamal

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I think the DIALYSIS Fellowship Northwest Kidney Centers funds at the University of Washington School of Medicine is the only dialysis focused nephrology fellowship in the country.