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  • #16
    Imaging tech here.

    Quoth Miss Maple Leaf View Post
    I wouldn't recommend telling people that the sharp scratch is coming up, especially if the person you've got is obviously nervous.
    If I can tell someone is nervous about the needle, I will ask if they want a 1-2-3, or just do it. Most of them say just do it. I've had people look away or babble on about nothing in particular. Whatever helps.

    Quoth kpzra View Post
    Yup, don't let someone who says they are a hard stick scare you. I had one pt tell me that in the ER and it was one of the easiest draws I've done. Take your time, talk to them, and try to warm their hand if you are using it.
    I've had both ends of the extreme. From patients who say they're a hard stick when they've got a garden hose running through their arm all the way to one poor lady who took 8 techs/nurses (all of whom tried at least twice) over an hour to get a line in. That was way fun, let me tell you.

    A warm washcloth helps, as does letting the limb in question hang down so gravity can assist. Also, the type of needle/IV set you're using can have a huge effect on if you actually get in the vein. My favorite are the angio caths. The butterfly ones, IMO, aren't as good. They are especially flimsy (I've missed more often with those than the bayonet angios). Though the butterflies used strictly for blood draws aren't bad. They're just really sharp so it's easy to go right through the vein. Right now, my facility uses the these crappy things and I hate them. They splatter and I'm not convinced they're safe for preventing accidental needle sticks.

    TL;DR, depending on what needles you're using, there's a learning curve. So if you're having trouble with a particular kind and you have access to a different one, try it.

    And if you have coworkers who are willing to let you practice on them, take advantage of it. I have good veins, so I don't mind the students practicing on me. Blood draws/IV starts really are more of an art than a science.

    Quoth trailerparkmedic View Post
    Oh, and if a patient has an implanted port and they need more than a simple blood draw, just get somone to access the port. Their veins are probably crap and it's good to preserve them.
    Even with a simple blood draw, I'd see if I could get the port accessed. Those things are a godsend both for patients with crappy veins and the tech/nurse who otherwise would have to keep poking them.

    Quoth trailerparkmedic View Post
    EJ is external jugular; when we can't get peripheral IVs, that's a good place. In my state, only doctors can start them.
    Yunno, I'm not needle-phobic or anything, but nobody is coming at my jugular with a needle.
    I am no longer of capable of the emotion you humans call “compassion”. Though I can feign it in exchange for an hourly wage. (Gravekeeper)

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    • #17
      Quoth trailerparkmedic View Post
      Feet are fair game if they aren't diabetic. Even IV drug users usually have a good vein posterior to the malleolus.
      I only use this in emergencies. The rest of the time, you can usually find something worth using. The shoulders/breasts often have usable veins if the arms are all burned up.

      Quoth trailerparkmedic View Post
      Use two tourniquets (one above the AC, one on the forearm) if their hand veins won't pop. Be patient; veins take a minute to appear. I find rubbing hands works just as well as slapping them and is more respectful. Don't hesitate or wimp out once you start the stick; slow wobbling is more painful than a quick stab.
      No disrespect intended, medic, but it is a bad practice to use two tourniquets. You increase the risk of reducing arterial circulation to the distal extremity. This is especially dangerous if they can't pass the Allen test.

      Rubbing is better than slapping. Slapping can injury fragile veins and make them more prone to blowing.

      I agree that a decisive stick is better than slow going.

      Quoth trailerparkmedic View Post
      Thumbs are usually good (I've seen 14s in them) and I can usually eek out 20 ccs (a blood culture) out of a knuckle. When butterflying hands,emphasize the importance of not moving the hand and put the hand in a comfortable position for the patient before sticking them.
      Again, the thumb is a site I only use in emergencies. I would not use it for routine practice, especially not for starting an IV. It is very positional and uncomfortable for the patient.

      Quoth trailerparkmedic View Post
      If you can't find the vein and you get someone else, stay and watch them do it. Ask to feel what they feel. Go for veins you can feel, not the visible but not palpable superficial ones.
      I concur. This is what I do as well.

      Quoth trailerparkmedic View Post
      For anxious patients, I tell them when I put the tourniquet on that I'm only looking and won't stick them until I find a vein I love.
      Also good advice.

      Quoth trailerparkmedic View Post
      Honestly, learn EJs and ultrasound if you have the chance. Those are far more likely to be things you're doing unless you do anesthesia.
      EJ's are inappropriate for drawing blood, especially routine phelbotomy. There is a risk of pneumothorax when you start an EJ. It should be accessed for IV's in emergencies only (though of course you can always draw blood when you do the stick).

      Quoth PandaHat View Post
      Thanks for the advice guys! I'll make more of an effort to find out how the patient prefers to handle bloods being taken before going for it. Unfortunately, I'm still at the stage of concentrating really hard to take it, so I'm not quite able to chat about inconsequential things simultaneously, but I'll work up to it!
      Definitely work on that. How you relate to patients, regardless of what you are doing, will set the tone for your entire practice. This is especially important if you are going into psychiatry. I think you'll find you project more of an air of confidence if you can manage a friendly chat while working on a patient, and that will help patients relax.

      As I often tell my nursing students, "If you can't dazzle them with dexterity, baffle them with bullshit." I don't mean you should lie to your patients; just make them think you are confident and know what you are doing even if you question it within yourself. People really do transmit their inner anxieties to patients if they don't work on this skill.

      Question: are med students taught anything about therapeutic communication, on techniques for how to get patients talking, and what shuts them down from talking?

      Quoth PandaHat View Post
      @Trailerparkmedic: I'm a UK medical student, I have only ever seen ultrasonographers do ultrasound outside of obstetrics and gynaecology. I can tell when there's a baby there, but that's pretty much the extent of my ability to view USS. Glad they send reports out! I hope to become a Psychiatrist, so hopefully my inability to understand USS won't hinder the patients' care too much.

      Is EJ elbow jerks? Fortunately, I'm on a neurosurgery block at the minute, shadowing the junior doctors so plenty of opportunities for practice!
      EJ= External Jugular Vein. It's a great site for emergency IV access, and some docs will use it for central line access. However, it has its own set of risks for complications, so use with care. You can't use a tourniquet, for obvious reasons so you have to be able to see and palpate the vein well in order to be able to use it.

      Nurses sometimes can access it in the US, depending on the culture where she works. I did it all the time in California, and only once in North Carolina. Everyone was so shocked when I suggested it on a case (the doc said sure, go ahead, so I got the line) that I never did it again.

      There is some new equipment for finding veins, but they're not available everywhere. One is an U/S device (I've not seen it yet myself), and the other is a fluorescent light that can highlight veins with a black light (doesn't work well on the obese).

      There's two suggestions I didn't see anyone else make, so I'll make them:

      1) use a heating pad on the extremity. Leave it on for about 15 minutes. It will engorge veins and make them easier to see/palpate. Don't leave a tourniquet on while the heating pad is on, for obvious reasons.

      2) In extreme cases of needle phobia, consider Ativan (lorazepam) 0.5 mg Sublingual. It'll work in about 10 minutes, and calm the patient enough to get the draw. Be sure they have a ride home, though.
      They say that God only gives us what we can handle. Apparently, God thinks I'm a bad ass.

      Comment


      • #18
        Quoth trailerparkmedic View Post
        Oh, and if a patient has an implanted port and they need more than a simple blood draw, just get somone to access the port. Their veins are probably crap and it's good to preserve them.
        Overall I second this, but ask the patient first. Porta caths are designed just for this purpose, and generally should be used for routine blood draws (lab tech's can't access them, but nurses can and you might be able to as a med student). Some docs are very protective of implanted ports because they are intended for a major purpose such as chemotherapy, and don't want to risk an infection or occulsion of the line if it is not flushed properly.

        This is especially important with a Quinton Cath and an AV shunt. Both are meant for hemodialysis and never, ever, ever should be used for anything else! If you lose that access, they can't get dialysis and that's life threatening.

        But in general most patients who have Porta Caths, PICC lines, Hickman Broviacs, or other lines would prefer you use them for access than get a stick. Since they are all forms of central lines, extreme caution with aesepsis should be used. My experience is these ports are under used by staff who are inexperienced in dealing with them, which is not good for the patient.
        They say that God only gives us what we can handle. Apparently, God thinks I'm a bad ass.

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        • #19
          @fireheart - Why do you think I bought an ipad?

          For drawing blood we either use one of these vacutainer needles or one of these butterflies. I tend to take both and have a nosy at the veins. We only use the venflon catheters for IV. I have to put an apron/incontinence pad under it because I haven't yet inserted one where I've not spilt blood all over the patient or their bed.

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          • #20
            Personally, my best experiences(excluding the magic needle nurse who actually WAS completely painless) are those who tell me exactly what they are doing, are relatively prompt about it(to give me less time to hyperventilate) and don't get upset by me getting upset, or blow me off when I tell them the above. It isn't the pain, it's the fear.

            I only use this in emergencies. The rest of the time, you can usually find something worth using. The shoulders/breasts often have usable veins if the arms are all burned up.
            Both my surgeries ended up with me rolling into the surgery with a needle next to my toe. I think the iv placement took longer than the surgery- were they avoiding my chest because they were operating on my upper arms, do you think? I can't remember what they told me, I was pretty far gone after that long a time spent being stuck with needles.

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            • #21
              The shoulders/breasts often have usable veins if the arms are all burned up.
              Seriously??? Oh HELL no!
              When you start at zero, everything's progress.

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              • #22
                Quoth MoonCat View Post
                Seriously??? Oh HELL no!
                I can look right now and see a few that could be used. I've noticed it more on larger chested ladies. I'd take one there over a spot that makes it hard to move.

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                • #23
                  Quoth MoonCat View Post
                  Seriously??? Oh HELL no!
                  The breast, not the nipple
                  They say that God only gives us what we can handle. Apparently, God thinks I'm a bad ass.

                  Comment


                  • #24
                    Quoth PandaHat View Post
                    @fireheart - Why do you think I bought an ipad?
                    Just make sure that the kiddies don't accidentally click on the "adult" apps....you really don't want a child trying to kill all humans with the "Dora The Explorer" bacteria. (Plague Inc.)
                    The best professors are mad scientists! -Zoom

                    Now queen of USSR-Land...

                    Comment


                    • #25
                      Use the thumb of your non-dominant hand to pull the skin downwards, parallel to the vein. That can help reduce rolling. Remember to hook the needle - first you have to get it down to the level of the vein, and THEN you slide it in.

                      Sometimes I ask people about their kids or their pets, or I get them to recite the alphabet backwards. It isn't so important that you listen - if you lose track of what they're saying, you can always laugh afterwards and sheepishly tell them you were concentrating so hard on the draw that you didn't hear. People never mind.

                      Taking a relaxed attitude really helps too, I've found. If you tense up, so do they.

                      And if you really can't hit a vein, find out what their PO and fluid status is. It's hard as heck to draw on a dehydrated person. Sometimes getting a fluid bolus in them changes everything.

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                      • #26
                        When my gall stones decided to say hello, I had attempts made to take blood on both elbows, both hands and both feet. I was warned that the next attempt would be my groin, followed by my neck.

                        Shockingly at that point the blood vessel in my foot decided to stop playing around and just give up my precious red stuff.

                        Ain't no one getting near my neck or groin with a sharp pointy thing!!!
                        "Bring me knitting!" (The Doctor - not the one you were expecting)

                        Comment


                        • #27
                          Here's how I cope with getting needles. (Note that I'm usually a hard stick, and that I have a pain disorder (fibromyalgia) which makes it even worse.)

                          I bring one of my comfort toys (I have two plush tigers) to cuddle with whichever arm they're not attempting. Even if you're not in a pediatric unit, it might be worth investing in a generic, friendly-expression teddy bear. One that can take some serious washing.*

                          I lie down if possible, sit down if not. I'm usually easier to stick if I'm lying down.

                          Immediately after I'm torniqued, I start pumping my fist. (making a fist then releasing it)
                          Note: the torniquet is inevitably quite painful for me. To be tight enough to be useful, it has to be tight enough to hurt quite a bit.

                          I always look away.

                          I babble at the phlebotomist. About anything or nothing.

                          I ask not to be told when the needle insertion is about to happen.

                          I conscious-meditation relax the arm.

                          This technique has taken me from being a hard stick (six attempts across both arms) to a medium-to-easy stick (usually first attempt, sometimes two). But I HAVE to do it every time, or I become a hard stick again.


                          *If you're able to spend the money, our own spark makes plushies, and I'd trust one of hers to last - especially if you told her it was for this sort of heavy use. I'd definitely trust it over a generic toy store plush.
                          Seshat's self-help guide:
                          1. Would you rather be right, or get the result you want?
                          2. If you're consistently getting results you don't want, change what you do.
                          3. Deal with the situation you have now, however it occurred.
                          4. Accept the consequences of your decisions.

                          "All I want is a pretty girl, a decent meal, and the right to shoot lightning at fools." - Anders, Dragon Age.

                          Comment


                          • #28
                            Quoth Sapphire Silk View Post
                            The breast, not the nipple


                            still, the idea of a needle going into my boob is a bit scary....
                            The best professors are mad scientists! -Zoom

                            Now queen of USSR-Land...

                            Comment


                            • #29
                              I didn't know that two tourniquets was contraindicated. Good to know.

                              Our docs really don't like it when we go for breasts; I don't know why, and we still do it. I mean, we don't go deep so the chances of a pneumo are really low. When the doctors get snarky about any IV site, we politely offer to get supplies for them to start a new site. It's funny to see their responses. I usually get someone else to go for the chest because superficial veins are not my strong point.

                              Also, most of these sites might sound barbaric, but if we're hunting that hard for a site we really, really need your blood and you really need some medicine. Even dilala comes in tablets; when it comes down to it, there's only a few medicines that really MUST be given IV.

                              Comment


                              • #30
                                Tell them to get over it and then stab it in fast!
                                Just kidding! (I'm going to hell for that one I'm sure).


                                But on a serious note ... if you have to draw from kids, don't forget to make sure the adult is good with it too. One of my coworkers always overreacted with hisses of fear, or other such sounds when her kids got shots of any kind. Surprise surprise... her kids ended up scared of needles. Even they all admit it was because of how my coworker reacted.

                                I asked my own mom what she did when I had shots because... I have no fears of needles. She said if it bothered her, she'd turn her head away and just not watch.

                                The only thing that really bothered me was when it was painful. I gave blood once and the old bat was pretty rough with the needle to begin with and then she left the pressure band on my arm despite the fact that it hurt... and didn't understand that I didn't need one. (my blood was pretty fast flowing - about 5-6 minutes to fill the bag). ended up with an ugly bruise inside my elbow, when normally there's nothing there but the puncture wound.

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