How did you learn to put in your own needles?

Hi y’all,

We know that learning to put in your own needles is one of the barriers for doing home hemo. Some clinics get around this by using catheters, but most prefer to use a fistula if possible, or a graft.

– How did YOU learn?
– How hard is it to do one-handed? How about with your non-dominant hand?
– How did you get over whatever fears you had about it?
– Have any of you seen a video that teaches patients how to put in their own needles and SHOWS someone doing it him or herself?
– Do you use medications to numb the needle pain? Why or why not?

– How did YOU learn?

Simply by doing it. I watched one needle going in then put in the second one on my first day of dialysis. I will admit that I did learn to put my father’s needles in 30+ years ago. Back then I remember them having us practice on an orange, but the reality is that you just “do it”.

– How hard is it to do one-handed? How about with your non-dominant hand?

One handed is easy, my left hand is actually getting quite nimble, however, for needling I do use my dominant hand. If I ever lose my fistula though and they go to my other arm, I will certainly learn using my non-dominant hand since I do self-dialysis.

– How did you get over whatever fears you had about it?

I think the longer you wait the worse, just decide and do it.

– Have any of you seen a video that teaches patients how to put in their own needles and SHOWS someone doing it him or herself? /quote]


[quote]-- Do you use medications to numb the needle pain? Why or why not?

No I don’t, it wasn’t recommended for a fistula or for a buttonhole. I don’t find the pain bad at all and I have an upper arm fistula with “tender” skin. I find removing the tape to be more painful than inserting the needles, although sometimes the buttonhole gets sore, but generally it gets better after a few days. I have a theory that concentrating on putting in the needles “occupies” the brain so it is less sensitive to pain receptors. Just a theory, totally unresearched.

I had a graft, when I did I did use the cream. I have never seen any video and the other poster was right you just have to try thats the best way.I n ctr they would always stick when they felt it the best but the reality is just because they don’t like how it feels in a certain area doesn’t mean it s not there so, This is how I do it, I imagine a hose like a water hose under the skin then I imagine the direction it must be going in and just go for it and I have gotten so good I never miss.

I learned in like one minute. My nurse put in the arterial needle while explaining it at the same time on my first day training for home hemo, and I immediately put in the veinous myself, with some guidance. The next day, I did both myself. There really isn’t much to it. If you don’t already have a well-used fistula from previous dialysis, you might want to use some Emla cream on it, but otherwise, I had no pain at all - but I have a 3 year old fistula. There isn’t much technique really, just a matter of the nurse picking the right spots for your eventual buttonholes, and then all you have to do is go in at the direction and angle they show you on day one. It’s probably the easiest thing about home hemodialysis.


there is what is known as the buttonhole technique where you use the same hole everytime. the nurse started it and when it was developed I started cannulating myself.
the way it is done is each treatment you pick off the scab (like your mother always told you not to do) and insert the needle into the same spot at the same angle. it takes practice but it hurts far less than breaking new skin each time.
also, when the buttonhole is established there is far less potential for infiltration since you are using “blunt” needles rather than sharp.

LOL, I was only 12 years old when I first did it… :twisted:

I am in the process of learning to do my own sticks. My in-center nurse has developed 2 buttonholes for me. I have had some trouble putting in the dull needles because I have to push so hard and I get woosy. I am ashamed that I am so whimpy but I know I will get it right soon. I use emla cream for the pain. Sometimes my arm is sore all the next day - is that right?

It is not recommended that someone else create the buttonholes, you need to do it so that you know the right angles etc.

Can your nurse get the needles in easily?? I would never push so hard I got woosy. If it doesn’t go in pretty easily I use a sharp until I can get it to go in easily, usually only one day, but sometimes two. My arterial in particular seems to create scar tissue that is difficult to get through, but again I will not push too hard.

My arm is seldom sore. I do have allergic reactions to the tape and possibly the alcohol so sometimes the site is sore due to hive-like reactions, but certainly not my arm or from the sticking.

I have never used any kind of emla or lidocaine fwiw.

I learned this very recently (5 weeks), but, I don’t think you should push down too much with buttonhole needles. Put it in the hole, at the right angle, holding it by the wings, and once it’s in a little, let go of the wings and hold the needle by the tube. Holding the tube just above the wings, you should rotate the needle back and forth with your fingers (twirl it, so to speak). If it’s in the buttonhole tunnel, it should go in fairly easily. If it doesn’t after twirling it like that a bit, it’s not a good idea to force it too much, as you are bound to damage the buttonhole. You should never have to force the buttonhole needle much. When you encounter resistance with the buttonhole needle, back out the needle a bit, and try again, twirling it as I explained above. If that doesn’t do it, use a sharp needle that day. Like Cathy, I’ve already had the experience of tough scar tissue forming on the off days, and only a sharp needle will penetrate that.

I don’t use any freezing or Emla at all. My buttonholes don’t hurt, and i prefer to be able to feel what I’m doing. I don’t see how your arm could hurt that much the next day if you’re doing it right. It sounds like you may be bruising yourself.

Personally, I suspect that it can take longer than the standard six days of needling to really form the buttonhole tunnel.

Good luck.


Hi JWC, I’m glad to see you here. Can you run us through your technique? I don’t think your arm should be sore. Do you occlude the fistula - I was trying to think how one would occlude an upper arm fistula. I occlude but Cathy and others don’t - I can’t remember if Pierre occludes. Like Pierre said a bit of a twist can help sometimes if the site is being difficult and as many on this board have noted sometimes you have to go back to a sharp needle for a stick or two or three.

What home options do you have?

I was taught to use a tourniquet on mine, which I do. If I don’t, it seems to change the angle a bit, but the main thing I find is that it makes it easier to needle simply because it firms it up.

Hi Everyone:
Thanks for all the feedback about buttonholing. Bill I’m not sure what occlude means. Is it tourniquet? If yes, I do use one. Could the Emla cream cause my fistual to become tough? As far as technique - I hold the wings place the needle in the same hole. When I push I am hoping that I am going in the right way - but I’m not really sure. It seems to go in easy to a point and then I hit “hard pan.” Then I have to push really hard - if I get through there is a “pop” and the blood splashes in to the tube. The nurse that created the buttonholes went on vacation for a month, so I’ve been doing it with a different nurse. I think I am sore because when I start to get whimpy the tech takes over and sometimes has to change the direction of the needle becuase I started to go the wrong way. I am going to a lecture on cannulation next week given by the NW Renal Network, I hope to get some answers about my problems.
I will try your suggestions everyone - Thank You.
Judy (JWC)

Hi Judy. There’s no roadmap. You just try to be as close as you can to the same angles every time. It’s not an exact science. You just do the best you can. If your buttonhole needle goes in but then hits a tougher spot, grabbing it by the tube and twirling it in your fingers should get it through. But, you should not have to punch really hard through tough tissue. If you do, just switch to a sharp needle that day. If you have to fool around with it too long, you will probably end up damaging your buttonhole tunnel, and, a clot may form in the needle itself. So, on my needle tray, I always have a sharp there (still in the package), in case I need it.

Like I said, you just do the best you can. If it doesn’t work, it doesn’t work, so use a sharp. Try to use it at the same angle as the buttonhole, though - you don’t want to damage that buttonhole tunnel any more than you have to. You could also just needle in another spot. On my 3 year old fistula, there are many zigs and zags, and, since I can’t needle anymore in the two aneurysms that have developed from poor needling at the dialysis centre, it doesn’t leave a lot of needling room.

Should the day come when bh’ers have to have an access in your dominant arm, do you think you will be ok using your non-dominant hand to stick the needles?

1)When you are trained in buttonhole, are you also trained the conventional way in case you have a time when your bh doesn’t work?

  1. How long does it take to be trained to self-stick?

  2. How experienced was the nurse who trained you for cannulation? The nurse who will become my home training nurse has to be trained in order to train me on how to operate the machine and in how to self-stick. Is it possible for a nurse who is inexperienced as a self training nurse, to become trained in a short period of time in order to competently train patients for a home program?

  1. Yes. I know how to needle the conventional way if I have to. It’s very simple. If needling into a buttonhole, whether it’s a dull or a sharp needle, you go straight in, at a relatively low angle. If you should have to needle in a different spot with a sharp needle, the technique is only slightly different. You go in a bit at a steeper angle and then once into the skin, you level off - sort of like an airplane lands. I dont know about anyone else, but I was trained to do both. That way, if I should ever have a problem with my buttonhole, I can still needle myself and carry on with dialysis at home. Buttonhole is the preferred method for home hemodialysis, but you can still use the more traditional stepladder technique with sharps if you really have to.

  2. It only took me one demonstration with one needle stick, and then guidance from the nurse for the second one (but I did it). So, I learned in just one dialysis treatment. Then, I did it myself from the second day on, with some supervision for the first couple of weeks. That’s all.

  3. My training nurse has been a dialysis nurse for 21 years. I don’t know how to answer your question about how much dialysis needling experience a nurse should have before teaching patients. It’s really not that complicated. The more complicated aspect of it is just having some experience with fistulas in general, so that, first, the best locations are chosen to make the buttonholes in, and two, to recognize any problems that might need attention. For example, at the dialysis centre, there’s no continuity, so, unless a problem is very obvious, a patient might not get any follow-up. This is what happened to me. Once I started my home dialysis training, with one-on-one training with the same nurse every day, she was able to tell I was showing signs of having a stenosis at the outflow end of my fistula, and so I was sent for a fistulagram and then for an angioplasty to correct the problem. So, I guess it helps if the nurse you get has some basic experience with fistulas. Where I go, there are a number of training nurses, and so, they consult together on that sort of thing. The accumulated years of experience are considerable.


I have heard some home patients say if they can’t get in bh with a dull needle they go in with a sharps. Is this what you would try, Pierre, before going to another spot with conventional sticking? And if you had to start another bh site, would you be able to do it yourself, or would you require help from training nurse?

When you are taught to stick, are you shown how to feel the direction of the vein, the pop and where you are in the vein as you advance the needle ( this is re conventional sticking). In center, I’ve noticed not many nurses/techs do this, They just sort of aim and hope it is going in right.

Re what I meant in terms of experience of the nurse trainer, I have nurses who have long dialysis experience, but they have no experience with the BH technique. So, I meant do you feel they can easily be trained in BH so they can train me?

How is it determined where the best spots are to place BH sites?

I’ve already had to do it a few times, that is, the buttonhole needle just wouldn’t go in, and I switched to a sharp needle that day. But I still inserted it the same way I would have the buttonhole needle, ie. in the same buttonhole.

No. If for some reason my buttonhole didn’t work, I would not choose another spot myself. I would call the home dialysis unit and follow their instructions. I suspect they would have me come in for a treatment there in order to establish a new buttonhole, or decide that I should use sharps and the stepladder technique. They are the experts.

I was taught to put on the tourniquet, feel for the direction of the vein at the buttonhole, and then insert the needle. If I feel a pop, fine, but most of the time, I don’t feel anything. The needle just goes straight in, and I know it’s in by squeezing the needle tube just above the needle a bit, which, should bring up some blood. If it doesn’t, either I’m not in the vein, or the buttonhole needle has clotted (the latter can happen if you have to play with it too long while trying to insert it).

I really don’t know how long it takes an experienced dialysis nurse to learn how to buttonhole a patient. I don’t think it would be very long, since it’s pretty easy for the patient to learn in only one treatment. The only difference really, is that you don’t use the land and level out method of inserting. For a buttonhole, you simply go straight it at a constant but relatively low angle of about 20 degrees.

When choosing a site for a new buttonhole, they just seem to look for a spot that allows enough room in the vein, preferably away from bends and dips as much as possible. The two buttonholes also have to be a certain distance from each other, and, you can’t buttonhole on an existing aneurysm such as you might have, like me, from 2 plus years of stepladder needling at the dialysis centre. I know my nurse was also thinking ahead, selecting two spots that would also leave room for a couple of new buttonholes if needed eventually. Whatever they do, in my program, they also have the patient seen by the vascular nurse. She has more experience with fistulas than even the vascular surgeons.

The current Medicare regulations that govern dialysis clinics require that the nurse in charge of a home training (HD or PD) program must have 3 months of experience training dialysis patients for self-care as part of his/her overall 12 months of general nursing experience and 6 months of dialysis experience OR 18 months of nursing experience working totally in dialysis [405.2102(d)].

The proposed regulations require that a nurse in charge of a dialysis clinic must have 12 months of nursing experience and 6 months of dialysis experience. If a nurse is in charge of home training he/she must have 12 months of nursing experience and 3 months of experience in the modality for which he/she will be training patients [494.140(b)].

By the way, under the existing regulations and the proposed regulations, a staff nurse in a dialysis clinic needs to be a registered nurse or practical nurse who meets the state practice requirements as a nurse. There is no requirement for dialysis experience.

The reason why I believe it is better for patients to learn to do home dialysis is because technician qualifications were not addressed in the existing regulation that has been in effect since 1976. In the proposed regulation, a patient care technician needs only to have a high school diploma or GED and 3 months of experience following a dialysis training program. The training program must only be approved by the medical director and governing body. There are no additional requirements for technician education, training, certification, competency testing, or standards of practice unless the state requires it. Some technicians are excellent at what they do, while others think of their work in dialysis as merely a job. For you, it’s your life.

Although I understand how difficult it might be for a dialysis clinic to start a home hemo program and have appropriately qualified staff, your experience wtih needle sticks shows just how important it is for a nurse who will be training patients to have enough dialysis experience himself/herself. Although experienced staff may believe it’s easy to teach a new staff member, teaching a patient how to do his/her own needle stick takes more than “see one, do one, teach one.”

Beth writes: Although I understand how difficult it might be for a dialysis clinic to start a home hemo program and have appropriately qualified staff, your experience wtih needle sticks shows just how important it is for a nurse who will be training patients to have enough dialysis experience himself/herself. Although experienced staff may believe it’s easy to teach a new staff member, teaching a patient how to do his/her own needle stick takes more than “see one, do one, teach one.”

Not fully sure what you are saying here. My concern is, I have nurses with years of in-center dialysis experience, but they have never trained patients for self-care, home hemo or buttonhole technique. So, I’m not clear on what preparation they will need in order to train me.

For example, I recently read of a situation where a patient was advised by his primary care doctor to have his dialysis staff use the BH technique with him. Eventhough his care was overseen by the unit admin. RN, she did not correctly undstand BH and evey tx is a problem now.

I also heard where a nurse educator for the company that sells the BH needles said, they train home training nurses over the phone for BH. Is that sufficient to train established dialysis nurses over the phone?

So, who trains the nurse who will be the home training nurse and how long should it take for her to learn how to become trained in BH so she can train patients?