blood draws

[tum]

the hospital i'm at sucks for stat blood draws.

problem is, when i try to go in and do the deed myself, i almost always screw it up. any tips?

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[TheAce]

Antecubital veins, external jugular vein, femoral vein, saphenous vein. If a patients veins are horrible, you could always do arterial sticks for labs.

 

[Blade28]

For simple blood draws? You'll likely have to do these yourself when phlebotomy/nurses can't do it. For awake patients, usually I'll stick with the wrist/forearm/AC veins. For patients that are sedated, I'll occasionally move to the more "painful" veins - feet, ankles, femoral. I tend to save the EJ for IV placements.

 

[DropkickMurphy]

Antecubital veins, external jugular vein, femoral vein, saphenous vein. If a patients veins are horrible, you could always do arterial sticks for labs.

Or just have RT do the arterial stick. That would probably be your best bet as we have a lot more experience doing this than any doc outside of perhaps an anesthesiologist.

An EJ for labs? Good god man...... Sadistic much?

 

[Tired]

Alternatively, you may just be getting taken advantage of. I spent my first two weeks of internship vainly trying to stick hard patients, until I realized that if I told nursing, "It's your job, you have a valid order, you're just going to have to get someone to do it," then voila! Suddenly they managed to get a sample . . .

 

[Dr JPH]

IV Team?

I drew blood more than 20 times yesterday.

"CBC, BMP, LFTs in AM - JPHazelton, D.O."

My hand hurt by the end of the day.

 

[Arch Guillotti]

Or just have RT do the arterial stick. That would probably be your best bet as we have a lot more experience doing this than any doc outside of perhaps an anesthesiologist.

What a joke, coming from a premed, no less.

 

[DropkickMurphy]

Yes, I am a premed but I happen to be one who is a practicing RT. Like I said, I don't know many ED docs, FPs or surgeons who do as many arterial sticks as we do. The only specialty I've seen (meaning the samples come into the BG lab drawn by someone other than an RT) where they do their own is pretty much anesthesia. I'm not being arrogant, just pointing something out. It's a skill that comes with practice (something most docs and med students lack in regards to this particular skill).....how that makes what I said a joke, I don't see.

 

[Dr JPH]

Yes, I am a premed but I happen to be one who is a practicing RT. Like I said, I don't know many ED docs, FPs or surgeons who do as many arterial sticks as we do. The only specialty I've seen (meaning the samples come into the BG lab drawn by someone other than an RT) where they do their own is pretty much anesthesia. I'm not being arrogant, just pointing something out. It's a skill that comes with practice (something most docs and med students lack in regards to this particular skill).....how that makes what I said a joke, I don't see.

Peripheral IVs are for wussies...thats why we leave them to RTs.

Central access is where the money is...go surgery!

 

[Blade28]

Central access is where the money is...go surgery!

Except for when you need a CT scan with IV contrast.

 

[Tired]

Central access is where the money is...go surgery!

At my institution, IV contrast cannot be administered through a central line, making them . . . well . . . useless.

 

[Dr JPH]

At my institution, IV contrast cannot be administered through a central line, making them . . . well . . . useless.

Useless!

Bah!

A central line should be part of every patients admission criteria

 

[Tired]

A central line should be part of every patients admission criteria

Bah. Every time you idiots drop a lung, it makes it that much harder to mobilize our hip and pelvis fractures. Worthless I tell you.

 

[Dr JPH]

Bah. Every time you idiots drop a lung, it makes it that much harder to mobilize our hip and pelvis fractures. Worthless I tell you.

Orthopods know about the LUNGS???

Wow.

 

[Freibi]

For simple blood draws? You'll likely have to do these yourself when phlebotomy/nurses can't do it. For awake patients, usually I'll stick with the wrist/forearm/AC veins. For patients that are sedated, I'll occasionally move to the more "painful" veins - feet, ankles, femoral. I tend to save the EJ for IV placements.

I`ve always been wondering a bit why foot veins are kind of a no-no in adults, but perfectly fine for kids if the hands don`t work. Is it because babies don`t have to walk on their bruised legs afterwards?

 

[plrae12]

the hospital i'm at sucks for stat blood draws.

problem is, when i try to go in and do the deed myself, i almost always screw it up. any tips?

First of all, don't go in there thinking you're gonna screw it up. Tie your tourniquet tightly, and if you still don't see any veins, drop the arm to gravity, that should do the trick!

 

[hyperbaric]

Or just have RT do the arterial stick. That would probably be your best bet as we have a lot more experience doing this than any doc outside of perhaps an anesthesiologist.

An EJ for labs? Good god man...... Sadistic much?

An arterial stick for labs? Another good laugh.

Just because some of us don't speak endlessly of our pre-med school experiences doesn't mean that we didn't have any. I promise that I don't need an RT to collect blood for me - venous or otherwise.

 

[bulletproof]

Or just have RT do the arterial stick. That would probably be your best bet as we have a lot more experience doing this than any doc outside of perhaps an anesthesiologist.

An EJ for labs? Good god man...... Sadistic much?

Going arterial for a simple blood draw is overkill. Also deferring to an RT/nurse is fine once you feel comfortable doing it yourself, and you are just too busy with orders etc. Incidentally, I am just finishing fourth year Med. and I feel quite comfortable with peripheral access and arterial sticks, as any med. student who has been through anesthesia/E.R. rotations should be. I have never HAD to ask an RT for help procuring ABGs etc, not that I would not ask, but it should be a basic component of every graduating physicians skillset.

To the OP:

1. I agree with the others who said AC, back of the hand, arm for peripheral access.
2. Using a butterfly really helps when starting off with blood draws
3. Agree with poster who said make sure you have a tight touniquet. I would add that tapping above the vein to help it pop up more can help. Wiping the area with alcohol wipe can help with visualisation as well as disinfecting.
4. Be patient. Don't get flustered. Half the battle with bloods/I.V.s is setting up right, and being patient.
5. Set the bed at a comfortable height so you are not bent over uncomfortably.
6. Learn how to feel for veins as you get better, as you will not always have visualisation.
7. Don't be afraid to ask a nurse/phlebotomist for help/advice when starting off. If you have some freetime in the hospital, volunteer to do sticks until you feel confident in your abilities.( should not take longer than 1-2 weeks)
8. Be confident, and methodical in your approach. You got through med. school. Drawing bloods is an insult to your knowledge base, and you will master it. Again, practice makes perfect.

Good luck.


BTW: Dropkick, ~ 9,500 posts, and you are not even in med. school yet? Wow....

 

[LanceArmstrong]

yesterday i stuck a patient in the FEMORAL ARTERY! - did he bleed much, no not at all. i've seen better blood returns from forearm veins.

 

[loveumms]

First of all - you need to practice. I was a phlebotomist prior to med school and I was scared s**tless every time I walked into a patients room to draw their blood for the first month. Then, I built up my confidence and got the hang of it. Here is some advice that really helps me:

- Feel for veins without gloves on ... it becomes difficult once you put on your gloves

- Like another poster said, try to have the arm dangling from the bed (if you are using the hand or forearm)

- Ask the patient to make a tight fist a couple time and DON'T be afraid to smack the site a couple times (it 'wakes' the veins up)

- Rub some alcohol on the site .. sometimes it helps you see the vein

- When you go to stick make sure you are holding traction on the skin. Older people tend to have veins that roll a lot and once it rolls you might have to dig around to find it again - and this is painful

- If you don't get it in two tries, ask someone else. Don't feel bad b/c even people who have tons of experience sometimes miss and don't let it break your confidence.

I'm an anesthsia resident and I've had my attendings miss IVs, that I got (more often though they are coming to do it after I miss). It's life. If you can try and get some of the phlebotomists to show you their techniques - these are the people that do it day in day out. Most of them will be more then willing to help.

Good luck - you will get it.

 

[swpm]

Orthopods know about the LUNGS???

Of course they do. They're the fluffy things that cushion the pre-osseous Ancef pump.

 

[DropkickMurphy]

Going arterial for a simple blood draw is overkill.

Agreed 100%. It has to be a pretty damn important test before I'll agree to stick arterial for that. I can count on both hands the times I've done it where I felt it really contributed to the case.

I have never HAD to ask an RT for help procuring ABGs etc, not that I would not ask, but it should be a basic component of every graduating physicians skillset.

Good for you, and I agree it should be a skill any physician should have. However, like so many other things, whether it actually happens is another matter entirely.

I`ve always been wondering a bit why foot veins are kind of a no-no in adults, but perfectly fine for kids if the hands don`t work. Is it because babies don`t have to walk on their bruised legs afterwards?

The reason I've always been given whenever I've asked is because of the "increased risk" of infection if you use the feet, the risk of ulceration in diabetics or the fact that it does limit the mobility of the patient afterwards. Now how much of a risk each of these really is I am not sure and frankly I've never given enough of a **** to bother to look it up.

I promise that I don't need an RT to collect blood for me - venous or otherwise.

Great.....that means less work for me.

 

[Tired]

Orthopods know about the LUNGS???

Wow.

Ortho knows lots of things: lungs, heart, even the GI tract.

We keep a copy of "Everybody Poops" in our library. It's next to the back issues of "X-men".

 

[Annette]

At my institution, IV contrast cannot be administered through a central line, making them . . . well . . . useless.

Bhaaa! Just get IR to put in a power picc!

 

[Blade28]

Bhaaa! Just get IR to put in a power picc!

But that can take several hours...or even 1-2 days! What if you need the CT scan soon?

 

[souljah1]

If gravity and warm compresses don't work, I like to bump up a BP cuff to in between systolic and diastolic and this often brings out the veins nicely.

 

[Tired]

Bhaaa! Just get IR to put in a power picc!

First of all, no IV contrast can be administered through a PICC either. Second, relying on other departments to get you what you need is the surest way to disaster.

 

[gutonc]

First of all, no IV contrast can be administered through a PICC either. Second, relying on other departments to get you what you need is the surest way to disaster.

Yes, you can put IV contrast through a Power PICC. The remainder of your statement is true.

 

[Blade28]

The Power PICC can be used for IV contrast - the other PICC type can't.

 

[Tired]

The Power PICC can be used for IV contrast - the other PICC type can't.

You guys aren't listening. My facility has a policy against it. I'm not talking about what the line is designed for, I'm talking about assinine policies that prevent me from getting what I need.

 

[gutonc]

You guys aren't listening. My facility has a policy against it. I'm not talking about what the line is designed for, I'm talking about assinine policies that prevent me from getting what I need.

No, you aren't speaking clearly.

You said...

First of all, no IV contrast can be administered through a PICC either.

Nowhere in there do you say anything about your radiologists being assclowns.

 

[Tired]

Nowhere in there do you say anything about your radiologists being assclowns.

That's because you have to read the whole conversation, not pick out isolated posts to respond to.

 

[Annette]

I guess I;m spoiled by my IR department. The lines are easy enough to put in, get yourself taught, and voila. As for the idiot radiologists who won't let you use a power picc, ask them why they don't like to make money. That might get them to reconsider. (You can put an IV catheter into an EJ. Just use some lido).

 

[Purifyer]

lol @ IV cannulation EJ styles.. I love it, sounds awesome.

I dont know why the above posters sound like the foot is a no go, I mean... obviously I try arms first, but (especially if on call) many patients have quite decent dorsal foot veins, Saphenous V is another option just anterior to medial malleolus.. I mean... obviously they cant walk, and its relatively painful... but no pain, no gain, right fellas? Let the day team waste their time on more convenient access

I wasted my life with a needle/syringe for blood drawing but a kind nurse showed me the light with the butterfly/vaccutainer combo a month or so ago... its like blood taking for ******s. I had a lot of problems before with needle and syringe in terms of while withdrawing I would accidentally move through the vein or something, so I only had half the amount of blood needed etc.

Drfunk's vein preference list
Antecubital veins (that go (\*/) where * is the middle of the right antecubital fossa, viewed from anterior aspect. Do not trust the vein that appears to go (\*\) or some such... it is lying. I prefer the right to left ACF... I presume its due to handedness.

Houseman's vein (lateral aspect of wrist... in a direct line down from ?EPL tendon... I prefer it for IV lines rather than bloods.. dont know why. Probably a good idea to adduct wrist to bring tension... also make sure you insert proximally enough that you dont interfere with wrist movement.. much.

Dorsum of hand... fairly self explanatory.

Anywhere else distal to AC fossa on extensor aspect of forearm

Weird veins that seem to run along biceps muscle (alot of people don't put the tourniquet high enough to see these - either on anterior or medial/lateral grooves... I dont like them.. except anterior one.

Then I go to feet... its a good place, especially for bloods where they arent even immobilised. Fat people often have relatively thin feet.

In general (for non resus situations) non ACF non joint lines last longest and cause least discomfort but to be honest I haven't done a non ACF in ages... its simply fastest and easiest.

PS. For some reason the flexor/anterior aspect (especially distal) of the forearm has been taught to me as a no go zone... anyone know why? Is it just because of pain like the foot?

 

[Tired]

I guess I;m spoiled by my IR department. The lines are easy enough to put in, get yourself taught, and voila. As for the idiot radiologists who won't let you use a power picc, ask them why they don't like to make money. That might get them to reconsider. (You can put an IV catheter into an EJ. Just use some lido).

The story is that a couple years ago, the power injector malfunctioned causing a death on the CT table (still not sure what cause of death would be, but whatever). Now no central line (a-line, central line, PICC) may be accessed in the radiology department except by a radiologist. Bleah.

 

[Purifyer]

Another tip for the newbie doctor needing to take bloods (only really works when your shift should have ended 15-30 minutes before)...

If the patient has no veins and you've failed fishing around once or twice (that part optional ) just get a large gauge needle, stick it in where the houseman's vein should be, then macerate the tissues until a haematoma forms. Aspirate said haematoma with said large gauge needle and voila... all the blood you need! Of course you have to hand it over to the on call guy to chase the bloods, so when they come back haemolysed he has to repeat it muahaha. Oh good times.

Disclaimer: this may piss off your colleagues

 

[Tired]

Another tip for the newbie doctor needing to take bloods (only really works when your shift should have ended 15-30 minutes before)...

If the patient has no veins and you've failed fishing around once or twice (that part optional ) just get a large gauge needle, stick it in where the houseman's vein should be, then macerate the tissues until a haematoma forms. Aspirate said haematoma with said large gauge needle and voila... all the blood you need! Of course you have to hand it over to the on call guy to chase the bloods, so when they come back haemolysed he has to repeat it muahaha. Oh good times.

Disclaimer: this may piss off your colleagues

How about this?

Teach yourself to do a saphenous cutdown, which no one except the docs over the age of 75 remember how to do. Perform one without asking permission, or getting supervision. When you get caught, just say, "What? I'm not allowed to do that? I had no idea . . . " Cite papers from the 1950's that call this standard of care when IV access is difficult.

 

[chimichanga]

What a joke, coming from a premed, no less.

well, he's right...

In my 13 year experience (lots of registry;lots of hospitals n>15) in 98% of the teaching and non teaching hospitals, RT (and on occasion, RNs) puts in all central lines (except OR), and does ALL ABGs...

I have worked in ONE hospital (in the sticks, old school mentality) where the docs do it, and 3/4 of the hospitalists won't (read - can't)...The ED doc does it, and they're usually not very good (except for femoral sticks - radial - forget it...call the RT please)

And working in many ERs, I have, on several occasions, asked RT, when they are getting blood for a necessary ABG, to grab extra blood for labs...It saves the pt a stick...

 

[chimichanga]

... I promise that I don't need an RT to collect blood for me - venous or otherwise.

exactly...you'll need a phlebotomist or a nurse...

 

[DropkickMurphy]

RT (and on occasion, RNs) puts in all central lines (except OR)

I want to work at one of those......

 

[DropkickMurphy]

How about this?

Teach yourself to do a saphenous cutdown, which no one except the docs over the age of 75 remember how to do. Perform one without asking permission, or getting supervision. When you get caught, just say, "What? I'm not allowed to do that? I had no idea . . . " Cite papers from the 1950's that call this standard of care when IV access is difficult.

*snorts* *wipes coffee of monitor*

Nice......

 

[NDESTRUKT]

Dropkick, why not just apply to med school - then you'll be able to put in centrals without anyone giving you crap. It sounds easier than finding a hospital letting the RT do it (if that's something you think is cool to do).

I mean no offense or anything in this post, just saying you seem to be someone that enjoys to do much more than the normal RT does...

 

[Purifyer]

How about this?

Teach yourself to do a saphenous cutdown, which no one except the docs over the age of 75 remember how to do. Perform one without asking permission, or getting supervision. When you get caught, just say, "What? I'm not allowed to do that? I had no idea . . . " Cite papers from the 1950's that call this standard of care when IV access is difficult.

Better yet, do a saphenous cutdown for difficult blood draw (leave site open for ease of future blood taking). Actually maybe thats against best practice.. stick an op site over it

 

[DropkickMurphy]

Dropkick, why not just apply to med school - then you'll be able to put in centrals without anyone giving you crap. It sounds easier than finding a hospital letting the RT do it (if that's something you think is cool to do).

I mean no offense or anything in this post, just saying you seem to be someone that enjoys to do much more than the normal RT does...

Working on it.....the RT thing is just one way of keeping myself fed (or it will be once Michigan coughs up my RT license) while finishing up undergrad.

 

[Dr JPH]

RTs putting in central lines?

When did the training of an RT begin to encompass central venous access?

You mean to tell me there are RTs roaming the halls sticking in subclavian lines? I have never heard of such a thing. Not in or near Philadelphia anyway.

But I guess if youre going to have an RT do that type of procedure it might be appropriate somewhere...afterall, when they drop the lung they will know how to properly ventilate the patient.

Stick to nebs, vents and gases.

(and call back within 10 minutes of being paged)

 

[Arch Guillotti]

well, he's right...

In my 13 year experience (lots of registry;lots of hospitals n>15) in 98% of the teaching and non teaching hospitals, RT (and on occasion, RNs) puts in all central lines (except OR), and does ALL ABGs...

I have never heard of any hospital where RT's do central lines.

 

[Tired]

When did the training of an RT begin to encompass central venous access?

You mean to tell me there are RTs roaming the halls sticking in subclavian lines? I have never heard of such a thing. Not in or near Philadelphia anyway.

I'm totally lost on this. When we place lines, we have to do an informed consent form. Do these RTs do this? Who trains them? Do they just place a line when they feel like it or does it require a physician's order?

Bizarre. Seems like a bad idea.

 

[Blade28]

I have never heard of any hospital where RT's do central lines.

I haven't heard of this either.

 

[Dr JPH]

I have never heard of any hospital where RT's do central lines.

Or RNs, as he mentioned above as well.

Peripheral lines and ABGs yes.

A-lines occasionally, but often the resident is called in on these.

Subclavians, EJs, IJs, Femorals...all done by physicians. Usually residents or a house doc, attendings in a pinch or if no one else is around.

Ive worked in over 15 hospitals and never once have I heard of anyone but a physician placing a central line.

IV team & IR do PICCs

In fact, I dont even know why you would call an RT.

If someone on the floor cant get a peripheral stick the IV team is called. If they dont get it then the intern gets the call...then the resident. Next step is the Surgery resident for central access.

 

[Tired]

If someone on the floor cant get a peripheral stick the IV team is called. If they dont get it then the intern gets the call...then the resident. Next step is the Surgery resident for central access.

Lucky you. Here's how it went my first week:

1) RN can't get peripheral IV, so he/she calls the intern
2) Intern realizes he's no better at IVs than the nurses, so calls the resident
3) Resident tells intern to tell nursing they have to do it
4) Intern tells nursing to just get it
5) Nurse asks someone else to try, who also misses
6) Nurse calls intern again, argument ensues
7) Intern calls anesthesia, who says, "We're not an IV team" and refuses to come
8) Intern calls resident, who refuses to do a central line, since the patient doesn't need a line that bad
9) Intern calls back nursing, argument ensues again
10) RN calls ICU nurse, who also can't get line
11) RN calls back intern, argument ensues again
12) Intern brings ultrasound to floor, looks for vein, then realizes he has no idea what he's doing
13) Intern begs chemotherapy nurse to try, and she hits it on the first try
14) Resident calls intern two hours later, and instructs him to discharge patient