Dialysis Nursing Expert Opines on Failure to Recognize Life-Threatening Condition

This case involves an elderly man in Iowa who had been receiving dialysis treatments multiple times a week. A few days before the incident in question, he presented to the dialysis clinic and informed his nurse of symptoms that appeared to be indicative of a pseudoaneurysm before beginning his treatment. In response, the nurse made an appointment for the man to see a doctor regarding the symptoms, but at no point considered this an emergency and failed to direct him to the emergency room for immediate evaluation and care. A few days later the aneurysm burst, and the man bled to death in his home. It is alleged that the patient should have been sent to the emergency room immediately by the dialysis nurse.

Question(s) For Expert Witness

1. Are you familiar with the proper steps and protocols to follow when patient has a pseudo-aneurysm? Please explain.

2. Please explain your experience working as a dialysis nurse.

Expert Witness Response E-007683

A pseudo-aneurysm is a descriptive word for the appearance of an arteriovenous fistula. The goal of a well-functioning fistula is to have it develop, mature, or enlarge the vein to make cannulation of large bore needles easier and therefore able to tolerate higher blood pump speed, which consequently achieves more efficient dialysis and clearance. An experienced dialysis nurse can assess the access for signs of increased risk of prolonged bleeding, as well as weak or thin areas to avoid so that rotating the needle sites will extend the life of the vascular access. It is prudent to note that when an access bleeds longer than 5-10 minutes, and it's not related to taking blood thinners (anti-coagulants), and that access appears to have areas of thinning, that nurse should have surgeon examine it urgently. The reverse is also true that if clotting of access is suspected - then it would be urgent as well to notify nephrologist as soon as possible to preserve the function of access by doing a fistulagram.