These notes are from an episode of 7 Things EMS, a podcast created to give you CE while providing important, relevant information to make you a better provider. This episode is 7 Things Renal Emergencies with Bill Young.
Things for EMS Providers to Know about Renal Emergencies
This 7 Things episode highlights one of the unsung heroes of the body— the kidney. From balancing electrolytes and acid-base to controlling blood pressure and removing toxins, the kidney is a workhorse that is often misunderstood. Here are a couple of insights into working with kidney transplant patients.
Renal failure patients who are on dialysis NEVER feel good.
Renal failure patients are known for being challenging: Rude, abrupt, maybe combative. That’s because they never feel good! They go to dialysis feeling awful and come back feeling worse. Dialysis patients are chronically tired. They’re chronically thirsty because they have to minimize fluid intake to keep from going into heart failure. Pretty much all good foods have been taken away from them. It’s a physically and mentally tough condition. Early morning transports and transports after weekends and holidays are the toughest: their renal numbers are all going to be messed up, their electrolytes are either going to be really high or really low, and their body has a buildup of waste products because the kidneys can’t filter them out. Who they are during their dialysis transports is likely not who they are as a person. Show these patients extra compassion and patience.
If you cannot establish an IV or IO during a cardiac arrest, there is nothing sacred about the dialysis shunt. Use it.
This is a little bit of a sacred cow, but hold off on the pitchforks and torches for a moment. Now obviously, this is a discussion to have with your agency and your medical director. We ask students to always, always follow their local protocols.
In the podcast, Bill Young shares a conversation he had with his nephrologist while he was on dialysis. Bill asked the nephrologist about accessing the shunt during a cardiac arrest. At that time, EMS wasn’t using IOs; it was literally you either got a peripheral IV or an EJ – or you got nothing. It’s better now that we’re able to routinely access IO, but we always prepare for the worst case scenario. This may sound like heresy, but what the nephrologist said was, “During a cardiac arrest, there are degrees of dead.”
”During a cardiac arrest, there are degrees of dead.
For all means and purposes, the patient is dead: They’re pulseless and apneic and if we don’t do what we can to get them back, they’re going to take a perfectly good dialysis shunt to the grave.
So this has led to a bit of change within some EMS protocols. Accessing a dialysis shunt is quite a bit different than accessing other types of central lines (PICC line, subclavian line or peripheral IV). Remember that within a dialysis shunt, the fistula comes in where the vein and the artery are grafted together. That doesn’t mean there’s co-mingling of oxygenated and deoxygenated blood like we would see in a pediatric or a neonate patient, but they’re grafted together so there’s a larger area for the dialysis nurse or technician to gain access. To access the shunt, make sure you access the side that does not have the pulse: the artery side. The artery brings blood away from the body and that’s where you’re going to feel a pulsation. The vein won’t have a pulsation.
Again, do this only if you can’t get a peripheral IV or an IO to begin with, and only if your agency allows shunt access during cardiac arrest.
Bonus Note: Burn Patients and Renal Failure
This isn’t directly related to renal failure or transplantation, but it is an important tip. If you have a patient who has a severe burn and you are concerned about renal failure from the passage of proteins through the nephrons, an administration of 0.5-1 mcg/kg/min of dopamine will dilate the renal artery and may provide enough blood flow to keep your patient from renal failure and, ultimately dialysis.
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About the Expert
Dr. Bill Young is an Associate Professor in the Emergency Medical Care program at Eastern Kentucky University and has worked in emergency medical services since 1978. He began his career running calls for a small fire department near Williamsburg, Kentucky long before the term “first responder” existed. Young has worked as a street medic, training officer, supervisor, state regulator and educator. Bill is also a recipient of a kidney transplant. His combination of EMS certification and real-life experience as a transplant recipient provide a detailed and unique perspective to this topic.
