About an hour before finishing dialysis on Thursday 2 November, Wes
was feeling dizzy and had been feeling nauseous. To complicate
matters, he also wished to visit the bathroom. Before disconnecting
him, the nurse took his blood pressure, which was about 90 systolic
lying down. She ran back all his blood to him and had him get up
slowly. The dialysis nurse was concerned enough to have him taken by
ambulance to Geelong Hospital Emergency after completing dialysis.
The ambulance people found his pulse was 160. At Emergency, I was
allowed to visit him after a while. I noted from the monitor that his
systolic BP was now 77 lying down. He also had tachycardia. The
renal registrar visited him and suggested he stay in hospital
overnight, which Wes did not want to do. They agreed that if an hour
later the BP had not improved, he would stay overnight. The renal
registrar thought autonomic neuropathy might be the cause.

Wes was kept on the Emergency trolley until 5 am the next morning, when
a bed was available in the Renal Ward. He had not slept a wink and
the blood pressure cuff was left on all night. He has a gigantic
bruise from this.

[If blood pressure is to be taken frequently then it is normal to leave the cuff
in place. However, since it is normally deflated, this should not normally cause
any bruise. I can think of only three explanations for this - either Wes bruises
very easily, the cuff was put on too tight or it tightened as his blood pressure
rose back to normal (or maybe any two or all three of those). --Paul]


In the morning, the blood pressure was again normal
and he was allowed to go home.

We wondered why this had happened, as it never has before. Wes
wondered whether I had given him anything new in supplements. I had -
bilberry. I have been giving him this for about 10 days. In the
process, I had dropped off the R-ALA, so that there were not too many
capsules to take. Maybe the R-ALA was exerting a protective effect
which was lost when I stopped giving it. In any case, I have resumed
giving him 150mg of R-ALA (mito Gold) twice daily and the bilberry
whenever it can comfortably be given. - Jessie Neagle


[I think it is unlikely that either the addition of bilberry or the lack of
R-ALA would cause this dialysis hypotension. For one thing, as I recall Wes had
dialysis long before he even began taking R-ALA and did not get hypotensive at
that time. --Paul]

[This episode was, I'm sure, quite a disturbing one for Wes and you. Wes is not
new to hemodialysis (and I'm assuming this is the same facility he has been
using for quite some time), so the procedure for him is probably pretty much
routine. Even so, this response to a question at Medscape regarding hemodialysis
induced hypotension may provide new information for you:
http://www.medscape.com/viewarticle/463204 (signin: KittyA; password: morelife)

While you don't mention that you and Wes wondered about anything other than any
new additions to or changes in his supplement regimen, there is an another area
to consider and investigate.

If what you relate had happened to someone very important to me under the same
circumstances as occurred with Wes, I would request a copy of all records at the
dialysis unit from the date of the occurrence and on the last previous dialysis
treatment. (In the US, such a request must be satisfied by the provider - a form
must be filled out and signed by the patient or approved representative - and
there may be a charge for copying.) Then I would look for anything that was done
differently between the two dialysis procedures - equipment, supplies,
medications, personnel etc. Something to keep in mind, though, is that if an
error was made - something not specifically ordered by the physician or part of
the established or modified (in writing) procedure (you should be able to obtain
a copy of this procedure) - you may not be able to detect any notable difference
that is suspect. Unfortunately, many errors in hospitals/clinics/doctor's
offices are not recorded and the patient or family never notified - - it is not
uncommon that no written record of them is even made, even that no one but the
person who made the error knows, especially if no immediate untoward effect is
observed.

You may find the Introduction and possibly the Discussion in this article in
Medscape interesting. "Disclosure of Medical Errors: What Factors Influence How
Patients Respond?" 07/17/2006 The frequency of errors and their current
disclosure is what I am drawing to your attention.
http://www.medscape.com/viewarticle/540425 (signin: KittyA; password: morelife)
While this next article is geared towards Critical Care Unit nursing, the
problems related leading to errors are applicable to almost every other area of
health care provided in a hospital or clinic setting. "First, Do No Harm" 2005
http://www.medscape.com/viewarticle/500821
Although I haven't fully read this next article, you may find it particularly
interesting since it is based on a 2001 study survey done in South Australia.
"Consumer Perceptions of Safety in Hospitals" 05/09/2006
http://www.medscape.com/viewarticle/531072

There have also been Medscape reader polls regarding errors.
Here's one on causes:
http://www.medscape.com/px/instantpollservlet/result?PollID=803&BackURL=/px/inst\
antpollservlet/result?PollID=1940
On the likelihood of increased hospital reporting after a high-profile media
incident:
http://www.medscape.com/px/instantpollservlet/result?PollID=824&BackURL=/px/inst\
antpollservlet/result?PollID=1940
Views on impact of healthcare provider reporting of errors if legislation were
passed promoting sharing of information on medical errors without fear of
lawsuits:
http://www.medscape.com/px/instantpollservlet/result?PollID=1202&BackURL=/px/ins\
tantpollservlet/result?PollID=1940

There are well over a thousand articles showing in a search on Medscape
addressing the subject of errors in diagnosis, procedures and medication. I
can't imagine a health practitioner who doesn't want to avoid an error. Everyone
involved will work diligently to mitigate the damage when one occurs, but there
are plenty of times that the patient and family will never be told that an error
was actually made. **Kitty]