A Shot in the Light

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One of the common situations we share is the taking of our blood for lab tests or the placement of IV lines. These instances of fraught with our dread.

We're afraid of the possible pain of the stick itself, the fear of repeated sticks, the fear of "blowing" a vein with its attendant pain as the blood seeps into our tissues, and the possible loss of that vein.

All these issues are absolutely dependent on the skills of the individual performing the "stick."

With full disclosure, I spent most of my career in Intensive Care Units back when the laboratory personnel were seldom called upon for blood draws and where we were responsible for all IV placements. Additionally, I spent the last years of my career as a Home Health IV therapist, as the Supervisor of other IV therapists and then owner of my own Home Heath IV therapy company before my under-treated Fibromyalgia, CFS, and undiagnosed Lyme Disease's symptoms made me realize I had to stop working.

Hopefully your blood drawer has been taught well and has experience. Of course, it's easy to know whether they have the necessary skills by surveying the results.

Did you suffer through repeated attempts? Did you suffer with more pain than necessary? Did a hematoma (bruise) form? Did the person ruin the vein?

While we may not be able to prevent these things from occurring, we do have rights and legitimate expectations. The essential right and expectation is "First, Do No Harm."

If you've ever gone to an established laboratory to have your blood drawn, you can be certain that the individuals there have had a thorough education and earned certifications before they are even allowed to touch you.  They then go through an externship where a supervisor oversees their blood draws until the laboratory's standards have been met. These individuals are called Phlebotomists.

(My years of experience mean nothing to such laboratories. Before I could be employed I, too, would have to go to an accredited school and earn my certificates just as though I was fresh out of high school. And I'm gad that they have such standards!)

Compare those laboratories' standards to the possible opposites who are taking your blood in a doctor's office. While you may have the same expectations, you really don't know whether they've been taught in a school setting or whether they just had on-the-job training by someone who may or may not have been qualified. And few have gone through a certification process.

I've found that the office setting is the place most filled with technique errors and therefore the most danger to our veins.

To help us, the following are the techniques involved in a Simple Blood Draw with a Vacutainer.
(From: http://www.phlebotomypages.com/multi_vtainer_system.htm)

Properly identifying the patient by name and date of birth, or medical record number

Assessing the patient and environment before proceeding
  Properly completing the lab requisition slip and labels
  Considering special needs and different approaches for children and the elderly
  Special needs of the psychiatric patient
   Verifying order, and deciding on appropriate collection method
  Assembling proper (safety!) equipment
  Applying tourniquet
  Selecting an appropriate site (palpate the site
  Wearing Personal Protection Equipment and using Universal Precautions
  Properly preparing the site (cleanse the site)
  Performing the skin or venipuncture
  Recognizing and appropriately intervening with complications
  Controlling of bleeding
 No fist pumping! Having the patient making a fist and holding it for better vein fill as opposed to pumping the fist. Pumping can increases the potassium release thus elevating K+.
 After two unsuccessful sticks no further attempts to draw blood should be made without the patient's consent!

**A patient should be offered the option to return to the office on a different day for another try after two failed attempts of finding the vein.** (How many times has that been offered to you at your doctor's office?)


COMMENT: Smacking any site is completely unnecessary and will cause hemoconcentration of cells (resulting in erroneous and misleading lab results). It
also elevates a patient's white cell count because the body perceives this as an injury!

You can find examples of both good and horribe technique on YouTube, but be careful if you're squimish,
If the technician withdraws from the vein while the vacutainer is still "plugged" in and the tourniquet is still on, your vein will blow. The 3 steps in the exact order are necessary for insuring your vein will continue to be good:
(1)The tourniquet is removed,
(2) then the vacutainer must be "unplugged"
(3) the needle is then removed from your vein.

If these steps aren't followed in that order, that bruise you have may signal that the vein will be lost for months or years.


Starting an IV

The procedures for starting an IV are essentially the same as those for drawing blood.  The major difference, of course, is that a catheter is taped in place and that IV tubing is attached (if ordered).

Prepare the tubing by filling it with normal saline and making sure there are no large air-bubbles.

(The most frequent patient question is "How big of an air bubble is dangerous?" I only get worried if the nurse hasn't eliminated the largest air bubbles by running the solution all the way through the tubing first.)

If using off the shelf IVtubing, be sure to clamp it so that the saline doesn’t drip out onto the floor.

Apply a tourniquet high on the upper arm. It should be tight enough to visibly indent the skin without causing patient discomfort.

Once a suitable vein is found, then it is necessary to clean and disinfect the area by swiping it several times with two alcohol wipes.

Use one hand to apply counter tension against the skin. This hand, generally the left hand, will be pulling the skin distally towards the wrist in the opposite direction to the needle will be advancing. When applying counter tension be careful not to compress inflow to the vein which may cause the vein to collapse.

Advance the catheter through the skin over top of the vein or adjacent to the vein. You will know you have "hit" the vein if you see blood in the catheter's plastic applicator. Once you see this "flash" of blood, began advancing the catheter.

Once the catheter is advanced in the vein up to the hub, release the tourniquet. Attach the male end of the Smart Set to the female hub of the angio catheter. Lock the IV tubing to the catheter by advancing and rotating the luer locking mechanism. It requires a clockwise twist to fully lock. At this point, quickly test the IV with a small injection of saline to make sure it is working properly.

Tape the IV in place using three or four strips of tape to prevent accidental removal. Place one or two pieces over the actual skin puncture site. Place additional pieces over loops of tubing so that there is some strain relief.

The important message here is your educating yourself about what is considered normal and what is not.

Never let yourself be a guinea pig without your consent! Do not be afraid of stopping someone who is not using proper technique on your veins.