Written Statement
concerning the Jan-24-2003 accident with the patient Lyuben Stanchev in the Ward of Haemodialysis at St. Marina State Hospital, the city of Varna, Bulgaria

Translation from Bulgarian: 		Original in Bulgarian Back to chronology

Written Statement by Reneta T. Stoyanova, R/N,
concerning the 24-Jan-2003 accident with the patient Lyuben Stanchev in the Ward of Haemodialysis at St. Marina State Hospital, the city of Varna, Bulgaria

26-Jan-2003

Re: My connecting a patient to a haemodialysis machine while it is in Disinfection Mode

I was on duty in the evening of 24-Jan-2003 in the haemodialysis room No. 436 which houses three dialysis posts so I was in charge of three patients respectively: Malin Vlasev, Ivan Stankov and Lyuben Stanchev.

A few minutes before 22:00 Lyben Stanchev’s machine signaled a high venous pressure. I was just opposite the patient. Straightaway I infused a saline solution into the blood lines to get them flushed and thus to decrease the venous pressure by diluting the blood but it continued to go quickly upward and, despite my quick reaction, expelling the blood from the extracorporal circle back into the patient's body proved impossible: the blood had totally coagulated in the lines. I apprised immediately the doctor in charge, Dr Zorcheva, about the accident (which, incidentally, had been the fourth case of coagulation with the same patient recently, as he himself claimed) and Dr Zorcheva ordered me to get a new dializer and blood lines so that the dialysis session be resumed (there was another half an hour left until the end of the assigned time) telling me to apply this time 4,000 IU Heparin Braun at the beginning of the half-an-hour session, which was by 1,000 IU less than the whole usual dose applied to the patient at the beginning of each 4-hour session. [This is relevant to the whole story but the accident proper is yet to come. Read below.]

All the time during the events that followed I was at my post in the room and shall describe here only what I myself witnessed. Eng. Nenov brought me a new dializer, probably at Dr Zorcheva's order, because I myself had not ordered him to do so. I did not attend the conversation between Dr Zorcheva and Eng. Nenov concerning the resumption of the session and cannot claim either that there was such one or that there was not. The dializer which Eng. Nenov brought me when I was already loading the machine with blood lines had been taken out of its sterile package, i.e. ready for being connected. I placed the dializer in its holder and connected it to the blood lines. The patient was sitting on his chaiselongue waiting for his dialysis to be resumed, his arm exposed on the rest with the two dialysis needles, duly flushed with saline. [A dialysis needle is a metal needle prolonged by a plastic tube of about 20 cm length with a plastic clamp on it]. In the process of my loading the machine I was giving simple explanations of my activities to the patient to reassure him that everything would be all right very soon, and Eng. Nenov was meanwhile handling something on the same machine not uttering a word as usual. [Haemodialysis technicians have their own responsibilities for the machines, we work in such a close team that often rub our bodies against each other while working at the same machine and we like to joke about our close relations, but no nurse enjoys that particular technician's closeness because he absolutely neglects his body hygiene and is repulsive altogether in more ways than one. In fact Nicky, as we call him, is a moron: he will go silently around the ward like a lunatic, a strange vacant look on face, repeating, "Is everything all right?" or, "Calm down, calm down". No one can stand him, even his brother, one of our doctors, but Nicky is strongly protected by his father, a well-known professor and our ex-boss, who managed, just in time before his retirement, to appoint both his sons to work in our ward. However, the younger of them two, Dr Vesco Nenov, is an intelligent man and a good physician, while Eng. Nickolay Nenov is a disaster with his abysmal technical incapacity and strange behavior. How he was able to get a university diploma in engineering is something that everybody marvels at, well, we have our guess but this is another long story. Anyway, up to the night of the accident with Lyuben, Nicky had made a number of annoying mistakes but nothing as dangerous as that] I had not filled the lines with saline yet when he silently left the room without informing me what he had just done, and I, busy with preparing the machine and comforting the patient, did not assume even for a second that there might be any possibility of Eng. Nenov's having set the machine to the mode of disinfection.

Having primed the dialysis lines with saline solution, I connected the dialysate hoses to the dializer – an activity which, generally, is a responsibility of the technical staff but which, in our ward at least, is often done by a nurse, especially when there is no technician available in the room – then I made sure that the dializer was warm as required and proceeded to connect the patient to the machine. Two technical circumstances contributed to the further development of the events: The connection was carried out in exact compliance with the established rules. The venous end was put into the container for collecting of the lavage liquid while the arterial one was being filled with blood from the patient. Everything was going normal up to the moment when the blood flow entered the dializer. At first the dializer filled with blood in the usual way, but the next second the color of the blood in the upper part of the dializer began to change its color and from bright red turned into turbid red with yellow-gray hues. I also noticed a stronger than usual turbulence within the dializer. The next second the blood entered the venous end and my look quickly moved to get focused on it as usual at that stage of the operation. I clamped the tube of the venous end with fingers (all the nurses clamp it with fingers because there are not enough clamping tools) and began to screw it to the patient’s venous needle. Without releasing the clamp of the needle, i.e. without letting any of the dangerous solution go into the patient’s blood circulatory system (of course I did not know yet it was dangerous), I cast a glance back at the dializer for the last check and froze. The dializer was half-emptied from blood, the venous bubble-catcher was foamy and the foam was moving toward the venous end which I was going to connect to the patient. The blood pump of the machine was stopped but nonetheless SOMETHING was methodically compressing the blood in the lines. [There is another pump hidden inside the machine which does not operate in the connection mode but is in motion during the disinfection.]

It was at that moment when I realized, in a part of the second, that the machine was in disinfection. The realization came as a blinding blow. I felt I would burst with tension and resentment. I reacted promptly. Disconnected the venous end from the patient, or rather began to disconnect it for it had screwed unexpectedly tightly and its loosening required great efforts and at that moment, to my horror, another nightmare: the clamp on the needle began slowly to yield just as it was in closed position (most of the needles from the last batch are faulty: their clamps cannot not close properly) and I saw a small amount of the lethal solution advancing toward the patient’s vein. I made it, but I can never describe what I experienced until I managed to separate the venous end from the patient and direct it to the trash bin by the machine. No sooner had I released my clamping grip than a jet of compressed foamy blood mixed with disinfectant splashed into the basket. What I had prevented in the last second could have been fatal for the patient the very moment when I – IF I! – (had) released the clamp on the needle and without turning back had started the heamodialysis session. Fatal with no chance of survival for the patient would have received not only a mixture of blood, disinfectant and air but also the same mixture under pressure.

I disconnected everything and removed all the equipment from the machine, then flushed the needles of the patient without giving him other explanations than, "Sorry, a sudden technical problem", and called for Eng. Nenov. We spoke in the corridor just outside the room. His first reaction, after he knew what had happened was a guilty entreaty to me not to betray him before the doctor in charge. "I thought that the dialysis is terminated", he said in his justification. My indignation increased. I told him that I had no intention either to “betray” or cover him and insisted on his immediate finding Dr Zorcheva and reporting to her about the accident himself. He obeyed my order. I was not present at the conversation between Dr Zorcheva and Eng. Nenov concerning the accident and do not know what explanation of his behavior he gave before her. I was all the time by the patient doing my best to comfort him. Lyuben Stanchev is known for his quick temper. He is capable of raising a noisy scandal about a real petty problem and if he had become aware of what could have befallen him I can hardly imagine what he could have done. In one thing, however, I am certain: he would have been thankful to me for having saved his life.

The accident ended with still another connection of the patient, that time to a new machine in another room. I had preserved the needles, that time as the previous, by flushing them so there was no need to puncture him again. Everything went smoothly. He managed to lose his superfluous kilograms as well. Said in brackets, Eng. Nenov had not set the filtration on the new machine, because the patient "had no more kilograms." I had to raise my voice reminding him that I myself had taken the patient’s weight before he moved to the other room. Eng. Nenov had not understand as usual. He had made an unsuccessful attempt at weighing Lyuben during the dialysis, still while before his blood coagulated (unsuccessful because the patient felt sick and had to be helped down to lie back in his chaiselongue) but Eng. Nenov was left with the impression that the patient had freed himself of all his kilograms. In the end, after two times in a row of throwing the blood from all the lines, Lyuben still had a kilo and 300 g above his lean weight. This meant that the continuation of the procedure was imperious even for the only purpose of removing his extra weight. Luckily, the hemoglobin, checked urgently after the second massive loss of blood, proved satisfactory and there was no need for an urgent blood transfusion. And while the whole team on duty was thrilled by the event and indignant at Eng. Nenov's culpable negligence, the same stated before all three of us, nurses Rositsa Dimitrova, Krasimira Stamova and me, verbatim: "Calm down! What has happened after all?"

On 25-Jan-2003, about 9:00 a.m., Dr Zorcheva called me at my home telephone insisting that I tell everything to her in full details again, and I told it in the same way as I am describing it here, in these written statement. Dr Zorcheva informed me that she was obliged to submit a report on the case.

On 26-Jan-2003, I read Dr Zorcheva’s report about the night duty of Jan 24/25th, 2003 (the report was exposed open on the desk in our nurse room No 448) and I was surprised to discover that Eng. Nenov’s inadequate behavior was never mentioned and his name, unlike mine, was absent in the account. Moreover, my efforts to prevent the dangerous solution from entering the patient’s body were completely ignored and some strange explanation had been given instead. Dr Zorcheva had written in the night duty report that the blood lines had disconnected “spontaneously”, i.e. the machine presumably had created such a pressure within the blood lines that they failed and in that way, by suddenly getting disconnected on their own, had prevented the patient from a possible connection to haemodialysis during the disinfection mode of the machine. I felt sick and thought that most probably a scapegoat was wanted for Eng. Nikolay Nenov is son of Prof Nenov, the former head of the Chair of Haematology Nephrology and Haemodialysis.

I hold it be known and noted that: The nature of our profession requires team efforts and mutual confidence. This accident could have been prevented, if: Signature: