Originally Posted by Natkat
Anyway, from what I understand the nurse in the story drew up the bleach into syringes. I've been in dialysis four years and I've never drawn bleach up into a syringe for anything. This had to be deliberate.
I have seen dialysis nurses and techs draw bleach into syringes, and I have done it myself. Let me explain.
I worked from 1999-2005 in an outpatient dialysis clinic for a company that was later bought by DaVita. We used COBE dialysis machines, which are cleaned internally with bleach (and once a week or month, respectively, also disinfected with other chemicals) at the end of the day, i.e., after the last patient is off the machine. The daily bleach cycle ended with a rinse cycle, which was to remove the bleach. However, because this rinsing could get interrupted (e.g., power problems), it was imperative that the machines' drain fluid be checked for residuals before they were turned off for the day. In addition, workers had to check the drain fluid again for chemical residuals (bleach or others, depending on which was last used) first thing in the morning. For this, we had special test strips for each chemical. These procedures were spelled out in great detail in the company P&P and drilled into all workers who worked with the machines (RNs, LPNs, PCTs, reuse techs) during their training period.
The machines also had a special drain, called the "WHO", that was used when a patient's treatment was started (the dialysis lines and dialyzer were primed with saline, which had to be removed at the beginning of dialysis to avoid adding additional fluid to the patient's circulation. The worker had to be vigilant during this procedure ("dumping the prime") to prevent some of the patient's blood entering the WHO. However, occasionally this did happen and even a few blood cells in the WHO (the line was pink) required the that the WHO be disinfected with a syringe of bleach
before the next patient was put on this machine. Therefore, you would draw up a syringe, 10cc usually, from a bleach bottle (there are many in a dialysis unit, bleach has many uses) and inject it into the WHO. Done correctely, there was absolutely no danger that any of this bleach could get to a patient (it was possible to do this procedure withthe current patient on the machine, since the WHO was just a drain, but I normally put a note on the WHO reminding me to do so after the pt was off. However, this wasn't mandatory.)
Eventually, a new procedure was mandated for starting a dialysis treatment (forbidding "dumping the prime"*) which would make it unlikely that the WHO would have to be bleached during the workday.
That said, there are also some facts about outpatient dialysis clinics that need to be considered.
In my experience, dialysis does attract some troubled nurses (e.g., hx of substance abuse). In general, it's difficult to attract nurses to outpatient dialysis. The work is hard, exhausting, sometimes demeaning (the lines between nurses and UAPs are very
blurred in dialysis; many techs have bad attitudes and are difficult to deal with. Due to staff shortages, this insubordination is usually tolerated by management.) The patient load is heavy (assembly line nursing comes to mind, especially during 'turnover' when one group of pts is taken off while the next group has to be put on the machines) and the hours are bad. If you like to do things right, avoiding "shortcuts" and following the law (e.g., that UAPs cannot give meds), it is very difficult. Plus, RNs have a lot of responsibility as there is rarely a physician on the premises, and often only a single RN.
So why do I think dialysis is attractive to nurses who have problems? Well, I have seen it in several of my coworkers (one RN was in an intervention program for diverting drugs in her previous job - there are no narcs in a dialysis clinic; another was an alcoholic). Most nurses allowed their assigned UAPs to illegally give heparin boluses and other meds (so they wouldn't have to leave their own assigned pts to do so for the UAP) and many took short-cuts violating P&P and, sadly, patient safety. It is a high-stress, very fast-paced environment. Checks and double-checks are in place, but what good do they do if they're not followed? (e.g., to avoid putting a pt on another pt's dialyzer, two staff members had to verify the pt's name on the dialyzer. I know of several times when a pt was put, or almost put, on the wrong dialyzer (and those are only the ones that were caught). In each case, the LPN in question was "written up". Several times for the same no-no offense (remember, staff shortage). Common short-cuts also included not checking the machines for chemical residuals
(essentially trusting that the rinse cycle had worked, or that "someone else probably did it").
And my point? Well, I find it very hard to believe that a nurse, even a trouble one with a hx of drug divertion, would deliberately inject syringes of bleach into a pt's blood lines. I don't see that such a deed would not be immediately caught (for instance, there has to be an RN on the premises, she could never have been the only nurse there). Injecting even a trace amount of bleach directly into the bloodstream would cause intense burning and pain immediately, not something that would manifest later.
More likely, P&P was not being followed here. This relatively new nurse may have felt the pressure of having to keep up with the frantic pace ("team mates" are very unforgiving when you're "slow") and took irresponsible short-cuts, including not checking bleach residuals (bleach in the machine would affect the pt's blood indirectly, via the dialysate, and cause hemolysis. The bloodline could show traces of bleach). She may have dumped the prime, contaminated the WHO, and drawn up bleach to inject into the drain (dumping the prime is no longer allowed, but I know this doesn't always mean much in a clinic; I had nurses try to encourage me to use forbidden procedures - e.g., squeezing the bag; dialysis nurses know what I mean).
* * *
I guess I find it hard to believe someone with no previous hx of pt harm (I assume) would use bleach to try to kill pts... why not simply use air? This could easily happen and be more easily covered up. My guess would be extreme negligence and carelessness - and who's to say that this one nurse wasn't made the scapegoat for others who were equally careless (e.g., not checking residuals). The very limited facts given in the media make it difficult to say (I assume the nurse did not confess).
DeLana *Rumor had it that this was because a careless worker had walked away from a patient while dumping the prime and much of the patient's blood drained out of his body, leading to his death. This was never officially confirmed, however. Please note that I have focused on the "bad" in dialysis here. I have to add that there are also some excellent nurses and techs who work in this field and would never take short-cuts or do other unethical things that could put pts at risk.