End-stage renal disease patients on hemodialysis like myself, who are fortunate enough to have arteriovenous (AV) fistulas, are much less prone to blood clots or infections. A vascular surgeon creates an AV fistula by sewing an artery onto a vein. Blood flows in both directions, causing the arterialized vein to grow larger and the walls stronger, making use of dialysis needles possible. I use 14-gauge dialysis needles, the largest in common use.
I’m on my second AV fistula. The first one — in my left forearm — was something of a lemon and rarely worked properly. It was difficult for the nurses and techs to place needles into (a “tough stick”) because the vascular surgeon failed to bring the vessel close to the surface or straighten it out. Whenever a nurse or a tech would get frustrated, they’d ask who the surgeon was. When I’d tell them, they’d just roll their eyes. After lasting nine years and about a month, my first AV fistula failed on 29 March 2009.
On 31 March 2009 I had surgery for my second AV fistula, this time in my upper left arm. By the end of June 2009 it was being used with 14-gauge needles without problem. A different vascular surgeon did a much better job and the fistula worked reliably for almost three years. Last April — 12 April to be specific — I had the first fistulagram and angioplasty on this fistula. The venous pressures had creeped higher from around 190 mmHg to 260 mmHg (at 500 mL/min blood pump flow rate) and I was experiencing significantly more venous site bleeding than normal.
Now the same problems have recurred — venous pressures around 260 mmHg at 500 mL/min blood pump flow rate and much more bleeding than normal from the venous site. Additionally, when I listen to the middle portion of the fistula with a stethoscope, I can hear an abnormal kind of whistle in addition to the normal thrill and bruit. I’m told the whistle is indicative of a stenosis — a narrowing — in the blood vessel.
So tomorrow, the day after Labor Day, I’m off to United Hospital’s radiology department, yet again, for yet another fistulagram and angioplasty. The fistulagram is mostly painless — a needle is inserted into the fistula and contrast dye is injected so the bloodflow can be seen on an x-ray. Any clots or stenosis are readily apparent. The dye is known to be hard on kidneys, and I worried about this a lot when I still had some residual kidney function, but that hasn’t been an issue for several years. The angioplasty is quite painful and feels just like you’d expect: A plastic tube is inserted in the fistula blood vessel and a balloon is inflated wherever a narrowing is found. Hopefully, the vessel doesn’t just snap back but stays in an expanded state.
When I go to United Hospital on an emergency basis, I find them to be highly professional, stunningly knowledgeable, and incredibly efficient. And I’m glad I had my valve job there. But when I go to United for fairly routine procedures on an outpatient basis, it’s like going to the circus. I suppose that’s better than the reverse.
To be clear: I’m overjoyed with the medical care that I receive at United Hospital (else, why would I go back); it’s just that the administrative staff clearly went to clown college instead of regular college. It seems like they see their jobs to make your experience within the hospital’s confines as needlessly frustrating as possible. In emergency situations, you never run up against them.
And the clowns are already out in full regalia. Last week I had to call to “register” for the procedure. “Can you coordinate with the dialysis center to have them draw the blood work you need for this procedure the day before? It would save me one out of the hundreds of needles I suffer.” Of course not. “You’re going to owe US$75 as your co-pay for this procedure. Would you like to pay that now?” No on two counts: I’ve already met my annual out-of-pocket cap and I never, ever pre-pay for medical procedures. I always wait to receive an explanation of benefits (EOB) from my insurer. Oh, and guess what: Last April I had this same procedure in this same hospital. My wife had what they thought was a heart attack just after the surgeon told her I was fine. We’re still waiting for you to straighten out the billing on that one, five months later.
The more I thought about it, the more being asked to pre-pay angered me. I called back and asked about the business process. Getting nowhere with the registration clerk, I asked to speak to a manager. After being disconnected, twice, the manager returned my call and said that they were asking for pre-payment merely as a “service to our patients.” Really? I asked if she had heard about the recent lawsuit that the Minnesota Attorney General filed against Fairview Health Services and Accretive Health, the former outsourced collection agency for Fairview. Of course she had. Everyone had. Accretive was accused of violating patient privacy and forcing patients — including emergency room patients — to pre-pay prior to being treated, in likely violation of federal law. In the end, Accretive agreed to pay a US$2.5 million fine and was banned from doing business in Minnesota for six years.
The manager, Leah Zacher-Anderson, steadfastly maintained that there was no insistence that I pre-pay, that this was just a “service to our patients” and it had been cleared with Allina Health System’s (United Hospital’s corporate parent) legal department. Queue the circus music. I have to clear their gauntlet before seeing the first medical professional.
Update: Tuesday 4 September 2012 6:47PM CDT: I’m home from my fistulagram and angioplasty procedure at United Hospital. I’m told it was successful and for that I’m incredibly grateful. There was an emergency that caused a severe backlog in the radiology department so it’s been a long day. Best of all, the sedative didn’t seem to kick in until after the procedure was finished. I was scheduled for a 9AM procedure but didn’t get in until 3PM. Six hours in a hospital holding pen is just not my idea of fun. Once again, the medical staff were delightfully competent and professional but the administrative staff is a collective piece of work. Once again, I was asked if I’d like to pre-pay my co-pay. This has never happened with an Allina unit in the past, but now it seems to be standard procedure. At best, it’s highly unethical and coercive — I pay outrageous health insurance premiums for myself and my wife/business partner — and I would never, ever pay a co-pay until I received a complete and final EOB.
Related articles:
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The blood vessel that makes up my arteriovenous fistula has - Fairview and Sanford sitting in a tree
On 26 March, Minnesota Attorney General Lori Swanson telegraphed her - Weaving fresh blood vessels for dialysis
After more than 12 years of dialysis, I've had numerous - VWING vascular needle guide cleared by FDA
Maintaining a proper vascular access is as crucial as it - My whole world lies waiting behind door number three
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Yet another fistulagram + angioplasty was originally published by ARTS & FARCES internet on Monday, 3 September 2012 at 7:32 AM CDT. Copyright © ARTS & FARCES LLC. All rights reserved. | ISSN: 1535-8119 | OCLC: 48219498 | Digital fingerprint: 974a89ee1284e6e92dd256bbfbef3751 (64.237.45.114)