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{ "pk": 52204, "title": "Stopping Fistula Hemorrhage without Bleeding Time and Money - A Low Cost, Low Resource Hemodialysis Fistula Model for Emergency Medicine Residents", "subtitle": null, "abstract": "<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify;'><strong><span style=\"font-family: Calibri, sans-serif; color: black;\">Audience:<span class=\"Apple-converted-space\"> </span></span></strong><span style=\"font-family: Calibri, sans-serif;\">This bleeding fistula model is designed to instruct emergency medicine residents and third- and fourth-year medical students on their emergency medicine rotation.<span class=\"Apple-converted-space\"> </span></span></p>\n<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify; vertical-align: baseline;'><strong><span style=\"font-family: Calibri, sans-serif; color: black;\"> </span></strong></p>\n<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify;'><strong><span style=\"font-family: Calibri, sans-serif; color: black;\">Introduction:</span></strong><span style=\"font-family: Calibri, sans-serif; color: black;\"><span class=\"Apple-converted-space\"> </span></span><span style=\"font-family: Calibri, sans-serif;\">The prevalence of end-stage renal disease (ESRD) has increased since 2001 (808,536 people in 2021 versus 409,226 in 2001).<sup>1</sup><span class=\"Apple-converted-space\"> </span>About 14% of the United States population has a decreased glomerular filtration rate (GFR), and the overall presence of ESRD in the population as of 2021 was 2,219 per million population.<sup>1</sup> <span class=\"Apple-converted-space\"> </span>As of 2021, 87.7% of patients receiving dialysis were on hemodialysis.<sup>2</sup><span class=\"Apple-converted-space\"> </span>Around 60% of dialysis patients use a fistula for access.<sup>3</sup><span class=\"Apple-converted-space\"> </span>Patients with ESRD have a high emergency department utilization rate, and emergencies related to dialysis include hyperkalemia, volume overload, bleeding at the dialysis site, infection, aneurysm, and pseudoaneurysm .<sup>4-9</sup><span class=\"Apple-converted-space\"> </span>It is important for emergency medicine (EM) physicians to be able to intervene quickly on life-threatening complications related to dialysis, including vascular access hemorrhage. There are approximately 250 deaths related to vascular access hemorrhages yearly, and it accounts for 0.4% of deaths in patients on dialysis.<sup>4</sup><span class=\"Apple-converted-space\"> </span>Patients with an initial presentation of hemorrhage from their vascular access site are also at risk for re-bleeding, and 80% of patients with bleeding die at home.<sup>10</sup><span class=\"Apple-converted-space\"> </span>Due to the high acuity and low occurrence (HALO) of bleeding fistulas, procedural knowledge of hemorrhage control and a thorough understanding of dialysis-related complications is paramount for EM physicians.</span></p>\n<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify; vertical-align: baseline;'><span style=\"font-family: Calibri, sans-serif; color: black;\"> </span></p>\n<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify; vertical-align: baseline;'><strong><span style=\"font-family: Calibri, sans-serif; color: black;\"> </span></strong></p>\n<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify;'><strong><span style=\"font-family: Calibri, sans-serif;\">Educational Objectives</span></strong><span style=\"font-family: Calibri, sans-serif;\">: After using the task trainer bleeding fistula model, learners will be able to: 1) identify vascular access hemorrhage as an emergency presentation in dialysis patients; 2) execute a stepwise approach to manage a bleeding fistula; 3) demonstrate effective hemorrhage control for a patient with uncontrolled bleeding from their fistula, including choice of appropriate suture material and suturing technique; and 4) discuss pitfalls of hemorrhage control in patients with fistulas, including risks of tourniquet use and complications related to clot formation at the fistula site. <span class=\"Apple-converted-space\"> </span></span></p>\n<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify;'><span style=\"font-family: Calibri, sans-serif;\"> </span></p>\n<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify;'><strong><span style=\"font-family: Calibri, sans-serif;\">Educational Methods:</span></strong><span style=\"font-family: Calibri, sans-serif;\"><span class=\"Apple-converted-space\"> </span>The novel bleeding fistula model was embedded within a high-fidelity simulation for learners as part of weekly EM resident didactics. Learners received a pre-brief session to the simulation case. They then participated in a simulation scenario using a high-fidelity manikin with the bleeding fistula model on the manikin’s arm. The bleeding fistula model allowed learners to progress through a stepwise approach to achieve hemorrhage control in a patient presenting with bleeding from a dialysis access site. After the simulation, learners participated in a simulation debrief, which included a procedural skills workshop.<span class=\"Apple-converted-space\"> </span></span></p>\n<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify;'><span style=\"font-family: Calibri, sans-serif;\"> </span></p>\n<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify;'><strong><span style=\"font-family: Calibri, sans-serif;\">Research Methods:</span></strong><span style=\"font-family: Calibri, sans-serif;\"><span class=\"Apple-converted-space\"> </span>This simulation scenario and model have been used in two academic year didactic sessions to collect learner data. Across the two years, a total of thirty-two learners consisting of fourth year medical students, post-graduate year 1 (PGY-1) and PGY-2 residents have participated in the high-fidelity simulation at a Society for Simulation in Healthcare (SSH) accredited, state-of-the-art simulation center. Learners performed a self-assessment survey using a three-point Likert scale after participating in the high-fidelity simulation case. A retrospective pre- and post-simulation survey was conducted. They answered survey questions related to their confidence of identification of a bleeding fistula and knowledge of treatment of a bleeding fistula before and after the simulation.<span class=\"Apple-converted-space\"> </span></span></p>\n<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify;'><em><span style=\"font-family: Calibri, sans-serif;\"> </span></em></p>\n<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify;'><strong><span style=\"font-family: Calibri, sans-serif;\">Results:</span></strong><span style=\"font-family: Calibri, sans-serif;\"><span class=\"Apple-converted-space\"> </span>Over two years of implementation, we had thirty-two learners participate in the simulation and use the model for demonstration of hemorrhage control of a bleeding fistula. Based on self-assessment, learners overall felt that their overall knowledge regarding hemodialysis access hemorrhage increased. Prior to the simulation, eighteen learners rated their confidence in identification of a bleeding fistula as “average,” and fourteen learners rated their confidence as “below average.” After participating in the simulation, seventeen learners rated their confidence in identifying a bleeding fistula as “above average,” and fifteen learners rated their confidence as “average.” Prior to the simulation, thirteen learners rated their knowledge of the management of bleeding fistulas as “average,” and nineteen learners rated their knowledge of the management as “below average.” After the simulation, eighteen learners rated their knowledge in the management of a bleeding fistula as “above average,” and fourteen rated their knowledge of the management as “average.”<span class=\"Apple-converted-space\"> </span></span></p>\n<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify;'><span style=\"font-family: Calibri, sans-serif;\"> </span></p>\n<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify;'><span style=\"font-family: Calibri, sans-serif;\">In the composite score, learners self-reported knowledge and confidence in managing bleeding fistulas improved. The pre-simulation score had a mean of 2.17 and a median of 2.0, increasing to a post-simulation mean of 3.31 and a median of 3.0. This difference was statistically significant (p < 0.00001), indicating a robust improvement in learners perceived comfort and knowledge following participation in the bleeding fistula simulation, hands-on task trainer, and debriefing workshop.</span></p>\n<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify;'> </p>\n<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify;'><strong><span style=\"font-family: Calibri, sans-serif;\">Discussion:</span></strong><span style=\"font-family: Calibri, sans-serif;\"><span class=\"Apple-converted-space\"> </span>This novel fistula model helped residents practice a HALO procedure that closely simulated a real bleeding fistula. The model bled akin to a real fistula, with the ability to make the bleeding pulsatile and occlude with suturing, direct pressure, and tourniquet placement. In the literature review, there are no current simulation models or task trainers to get hands-on experience with management of hemodialysis access hemorrhage. This scenario tested resident knowledge of management of dialysis emergencies, and there was a good discussion regarding the subject. Residents stated that this simulation was helpful. They learned new information and were able to get hands-on practice to reinforce that knowledge through this activity and the use of the bleeding fistula model.</span></p>\n<p class=\"MsoNormal\" style='margin: 0in; font-size: medium; font-family: \"Times New Roman\", serif; border: medium; color: rgb(0, 0, 0); font-style: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-line: none; text-decoration-style: solid; text-align: justify;'><span style=\"font-family: Calibri, sans-serif;\"> </span></p>", "language": "eng", "license": { "name": "Creative Commons Attribution 4.0", "short_name": "CC BY 4.0", "text": "Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.\n\nNo additional restrictions — You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.", "url": "https://creativecommons.org/licenses/by/4.0" }, "keywords": [ { "word": "dialysis" }, { "word": "end stage renal disease" }, { "word": "End stage renal disease complications" }, { "word": "Bleeding fistula" }, { "word": "hemorrhage control" }, { "word": "Simulation" }, { "word": "Fistula model" }, { "word": "HALO Procedure" } ], "section": "Innovations", "is_remote": true, "remote_url": "https://escholarship.org/uc/item/08t3x488", "frozenauthors": [ { "first_name": "Mary", "middle_name": "", "last_name": "Jordan", "name_suffix": "MD", "institution": "Medical College of Wisconsin", "department": "Department of Emergency Medicine" }, { "first_name": "Thomas", "middle_name": "", "last_name": "Yang", "name_suffix": "MD, MBA, Med, MS", "institution": "Icahn School of Medicine at Mount Sinai", "department": "Department of Emergency Medicine" }, { "first_name": "Michael", "middle_name": "", "last_name": "Collier", "name_suffix": "CHSOS", "institution": "Froedtert Hospital, Froedtert and the Medical College of Wisconsin", "department": "Simulation Center" }, { "first_name": "Lacie", "middle_name": "", "last_name": "Bailey", "name_suffix": "MD, MHPE, MS", "institution": "Medical College of Wisconsin", "department": "Department of Emergency Medicine" } ], "date_submitted": "2024-09-23T19:38:27+03:00", "date_accepted": "2026-02-11T01:49:58.057821+03:00", "date_published": "2026-04-30T15:28:00+03:00", "render_galley": { "label": "PDF", "type": "pdf", "path": "https://journalpub.escholarship.org/uciem_jetem/article/52204/galley/49475/download/" }, "galleys": [ { "label": "PDF", "type": "pdf", "path": "https://journalpub.escholarship.org/uciem_jetem/article/52204/galley/49475/download/" } ] }