Buttonhole Cannulation

Recently met up with a senior nephrologist from Chicago US. During our conversation he mentioned something called buttonhole cannulation technique. I was surprised as I had never heard of it. When he mentioned that its a painless way for dialysis when compared to Fistula needles, I came back and did some research.

I am pretty surprised that these techniques are not prevalent in India. If buttonhole access are used to connect to fistula then there is no pain, its so easy that patients do it themselves. Such techniques is what India requires where there is lack of skilled medical workers. I spoke to a few players here and they said it doesn't work in India, its tough to do it etc.

Research shows that Buttonhole access doesn't affect quality of dialysis, but patient satisfaction is very high due to lack of pain. If something like this is so useful for patients, then patients should be taught about it and therapy should be made more popular even if it means little more work initially for the medical professionals. After all healthcare sector is about the patients. Here is a link on youtube about self cannulation using buttonhole access - http://www.youtube.com/watch?v=a1ed9DifSmU

Phases

If I may divide the phases of a venture I would call them - Surviving, Expanding and Sustaining. We are in the surviving phase right now.

There was a long delay between the last post and this. In between we opened our second dialysis center. We also changed our business model a bit which reduces our return but also reduces our risk. In our second center Sparsh took over the operational responsibilities while the marketing responsibilities remained with the hospital. This model is unlike our first center where we just have rented space in a hospital and take over all the responsibilities.

Trying out different models is a necessity while you are growing. Its better to make a mistake now than later. From the small experience that we have gained so far, the most important thing for a startup is the cash cycle. Getting payments from customers (in our case hospital who collect the cash from patients) and making payment adjustments with vendors is most important. The less time you spend in these activities the more you can focus on your core job. Although entrepreneurs initially are skeptical regarding off loading stake for cash, I would suggest its better to have the cash cushion so that you are free to pursue value-added activities. This will help the firm grow faster. One advice which I have heard numerous times and now have started believing in it "100% of 25 is better than 50% of 100". If you have access to personal cash to fund your venture then nothing like it else offloading stake to get cash helps you to grow.

More on HR issues in the next post.

Power of Ideas - Winners

As previously mentioned, we were finalists at the "Power of Ideas" contest of Economic Times to identify most promising startup ideas in India. The panel of judges voted us as one of the 35 winners of this contest. It feels good to know that lot of investors think our idea is of merit.

One of the good things about being a winner was to get to meet Mr. Narayan Murthy over lunch. Although a very busy man, he did spare some time talking to the finalists. But we were lucky enough to hear the most well known Indian entrepreneur speak. Later there was a panel discussion on entrepreneurship in India which covered vast topics like "today's youth impatience", "right age to become an entrepreneur" and "the importance of values". This afternoon which will remain one of our most cherished memories.

Dialyzer Reuse

Although on dialysis for sometime, still lot of patients are clue less about the best practices about reusing of a dialyzer. This results in two options -

• Deferring the decision to the doctor or technician
• Only using dialyzers one time

In the case of the first one, many patients just go by the number of reuses with the thought that the lesser the number of reuse the better dialysis they get. On the contrary, every dialysis effects the dialyzer little differently. Now a days there are dialyzer reprocessing machines which throw up technical specifications which can be used to determine if the dialyzer is good for reuse. Sometimes they might last for 20 reuses and on other times they might not be good even after 2. Hence, getting fixed on the number of dialyzers is not the right decision.

In case of the second option, the quality question doesnt arise. But its like paying high unnecessarily. The classic analogy I think of is HD televisions. Lot of people buy 32 inch HD television at a premium. But the funny thing is that at around a distance of 8-10 feet, our eyes can not actually distinguish between pixels that small and hence 32 inch HD is not different from any normal TV. What I am getting at is paying the premium is unnecessary as the gain in quality of picture is just in technicality and not in reality!

Hence many times a reused dialyzer is as good as a new one for the purpose of dialysis and hence paying a premium for a new dialyzer is not required. But before re usage make sure that all the guidelines of reusage are followed and hopefully its not done manually but using a reprocessing machine which can exactly tell if the dialyzer is good enough for reuse.

Here are few FAQs about reuse from davita's site (one of the biggest chain of dialysis centers in the world)
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What are the advantages of reuse?

Reuse can be helpful to the patient and to the planet.
Patient advantages of reuse Since each dialyzer is inspected by a reuse technician, the technician can note any blood clots in the dialyzer and alert a renal nurse. Blood clots could mean you are not getting enough heparin, which is a medicine given before and throughout hemodialysis. Heparin thins the blood to allow it to pass easily through the dialyzer and prevent it from clotting, which would reduce the dialyzer’s ability to remove wastes and fluid. Blood clots in the dialyzer may make your dialysis session less effective and can lower your Kt/V.
Environmental advantages of reuse Dialyzer reuse helps to reduce negative environmental consequences in several ways. On average, it only takes 9.6 reuse dialyzers to treat one patient for one year, versus an average of 153 single-use dialyzers. The reuse of all dialyzers in a single year would eliminate the production of up to 46 million dialyzers and reduce the amount of medical waste ending up in landfills by more than 62 million pounds.
Dialyzer reuse also reduces the amount of harmful toxins created by waste processing. In order to be properly disposed of, dialyzers first have to go through a decontamination process requiring they either be incinerated or microwaved before being sent to landfills. When dialyzers are incinerated, the process produces emissions and ash that have negative health effects on the surrounding communities. While the microwave process does not produce harmful toxins, it does nothing to reduce the amount of medical waste that ends up in landfills.
By choosing dialyzer reuse, you can dramatically reduce the negative impact on the environment. Dialyzer reuse reduces your carbon footprint, helps relieve America of its dependence on crude oil, sends less non-biodegradable waste to landfills and ultimately benefits the dialysis patient by keeping costs lower without compromising clinical outcomes.

What are the disadvantages of reuse?

If proper procedures are followed for inspecting, cleaning and disinfecting your dialyzer, you should have no problems. If the reuse procedure is not followed properly you may have problems with your Kt/V levels or a physical reaction. However, these problems are rare, and because you are being closely monitored during treatment, if these issues arise, they can be resolved quickly.

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So go ahead and talk to your doctors and technicians about reusage of your dialyzers. Necessary quality need not be out of the reach of your pocket.

That feeling of first time!

Apart from a few procedural delays which we will sort out soon, we came out of our first out patient dialysis unscathed . Infact feels nice to hear from patients that this is really nice center and we should do some advertising to get more patients! Direct customer feedback is the best data.

Before the dialysis was started, we seemed to be more tensed than the patient! But the experienced patients are so calm that you don't feel like its a big deal. The blood comes out of the body, gets cleared of toxins and goes back in - six times during one dialysis session. 

On a different account, budding entrepreneurs looking for seed funding should look for CGTMSE loan scheme of SIDBI and SBI. There are pros and cons of the scheme -

Pros

• No collateral required
• Low interest rates
• Good moratorium period

Before you start jumping up and down thinking they are better than VCs, here are the cons -

• Lot of bureaucracy
• Very rigid, once you have given them the project report, you have to file quotations for any capital investment and if you get a better deal later its no good; they only will pay for the vendors you get the initial quotations
• They only give debt for capital investment

If you need investment for non capital expenditure like advertisement, marketing then they are no good. VC money is good in several ways as they give you the flexibility to spend it in the best possible way. And they are patient with the returns. Hence, depending on your project CGTMSE might or might not be a good option for you.

The humble beginings

1st day is always fun at work. For us it meant a little bit more and hence we went ahead and took pictures to remember this day. Here is a guided tour of the album.

The picture on the left is of our reception. This is what the patient sees straight ahead as soon as he enters. 

The co-owner with his workhorses!
I can vouch GP tried hard but as you all know his problems with keeping a smiling face :). The machines are dialogue + from B Braun (A German company). For the uninitiated these are the latest line of machines from one of the leading suppliers of dialysis machines in India. We hope to run them round the clock some day!

A long shot into the dialysis unit.

Here it begins

After a long and arduous journey we come to our first milestone. We start the operations of our first center tomorrow. Along the way there are several memories which will be etched in our brains for a long long time. Although there is a sense of satisfaction but when I look back I can see so many things which we could have done in a better way. So many days of angst could have been wiped out with some good planning at our end.

The best part of the journey so far, has been the interactions we have had with several people - doctors, distributors, vendors, investors to politicians and other entrepreneurs. Each one had a part to play in our overall business plan as it is right now. I cant help but smile at our immaturity when I see our very first business plan. Right now we have much better insight into what are the gaps in the present system and how can we fill them but as confident as I might be I am sure I will laugh at them again 1 year or so down the lane.

What I am getting on to is - you can plan as much as you can but until you actually jump in and start doing the things that you planned, you will never have a good business plan to execute.

To a new start tomorrow!