Wednesday, July 15, 2009

A really scary incident

Yesterday, my dialysis tech was going to be late. He's going through some pretty tough times professionally. He came early, primed the dialyser and tubes and got everything ready and left. I was to cannulate and start the treatment myself.

By the time I got back from work, he had already left. He was to return a few hours later and did not want to delay my dialysis session. I had dinner and then started the process.

I first cannulated myself. No problems. I was anyway doing this even when he was there. Then came the part where I connect the needles to the tubes. I connected the arterial tube and then realized that that the dialysate flow was off. This is usually done when there was a long gap between the time you primed and the time you started the session.

I quickly started the flow. But the conductivity takes time to come to the normal level once you start the flow. By the time the blood had reached the end of the line, the conductivity had not yet reached the normal level and gave an alarm. I connected the venous line and thought I would have to "reset" a few times for it to settle down.

For some reason the Trans Membrane Pressure (TMP) shot up to its maximum level and so did the venous pressure. I was surprised. This had never happened before. I tried resetting a few times. No change. Then suddenly, blood started coming out from the dialyser's two ends. I started to panic. I noticed that the tubes were not screwed tightly enough. I tightened both ends. The blood stopped leaking. The alarm however did not stop. The TMP and venous pressure continued to be at their maximum levels. Dialysis was not happening.

Blood had also gone through the venous line into the protector. The venous chamber was also full.

I shouted out to my mother and asked her to call the tech and put the phone to my ear. I got him on the line and explained the situation. By then the blood in the tube had become quite dark and was almost black. He asked me to check if the clamps on the tube and the needles were open. That was it. The venous clamp was closed on the tube at the point of connecting to the needles. I opened it immediately.

The alarms still did not stop. The TMP and venous pressure were still at their maximum levels. I removed the venous chamber from the Air Bubble Detector and also removed the venous line from the protector. To no avail.

The tech then said he was on his way. He sent his brother, also a dialysis tech who arrived in about 10 minutes. All this while, I had the venous chamber in my right hand and was resetting the machine with the left. The blood was regaining its natural color. But the alarms were not letting up.

He asked me to lie on my bed. I did. He then put the venous chamber back. With a syringe he cleared the protector of the blood and reduced the level of blood in the venous chamber. The alarms finally abated.

The brother of the tech wanted to leave as they were all having dinner out. My mother would have none of it. She said there had to be one person during my dialysis session. The tech came about an hour later and his brother then left.

The one mistake of not opening the clamp caused all this. I was quite shaken.

4 comments:

Nicky said...

That was really scary. Be careful and Take care - I hate the posts which have scary incidents. Please be careful. :(

I want you to have no incidents to write about except RJs and govt policies! :P :)

Madras Hash said...

Let us hope that you do not have a scare during dialysis again.

I have a suggestion. When pilots get in to an aircraft, they go through a Checklist in a Sequence. One person reads out and the other does it or confirms and Checks it. That way no step is ever missed. And it is human to miss something sometime.

You may want to create a procedure for yourself similar to the pilot's checklist to avoid a similar scare.

PDS said...

Thats a terrific suggestion by Madras Hash ! Do implement it TODAY Kamal.

Dr.Hariharan Ramamurthy said...

what madras hash says real sense develop a check list in the begining it may look like useless work but the problem with human brain is it tends to forget mundane everyday things like where you kept your purse or carkeys or whether you have tightened the caps on the dialyzer or removed thge clamps or not