TSR Med Students' Society Part VI

How on earth is final year half finished already? 16 weeks left... not in any way terrifying. 😖

If anything it'll only accelerate post-christmas...

Bit of phlebotomy advice please?

I struggle with 2 things:

1. When you cannot see the vein, I really struggle to remember exactly where it was after cleaning. More so than others it seems. I have a lot of doubt whether it's 3cm this way or 3cm that way, my brain just seems incapable of remembering the spot

2. Swapping bottles on vaccutainers, the art of not moving the needle at all? Although I feel this will improve, I'm more concerned with the other point!

Basically, I got 10 bloods done, and now due to a combination of not being able to see the vein (Which I know, palpation is better - but only if you remember where it was!) and a gap of almost a year without taking any due to how my placements have fallen (GP/Psych/Summer Hols/Peads) makes me feel back to square 1 Then I don't want to try again as I don't want to put the patient through unnecessary suffering when a doctor would have got it first time as there is something palpable, I just missed it. I'm going to turn up to an A&E tomorrow where I've been on placement for 1/2 a day in the past, to hopefully brush up on clinical skills if they are not too busy to let me tag along

Bit of phlebotomy advice please?

I struggle with 2 things:

1. When you cannot see the vein, I really struggle to remember exactly where it was after cleaning. More so than others it seems. I have a lot of doubt whether it's 3cm this way or 3cm that way, my brain just seems incapable of remembering the spot

2. Swapping bottles on vaccutainers, the art of not moving the needle at all? Although I feel this will improve, I'm more concerned with the other point!

Basically, I got 10 bloods done, and now due to a combination of not being able to see the vein (Which I know, palpation is better - but only if you remember where it was!) and a gap of almost a year without taking any due to how my placements have fallen (GP/Psych/Summer Hols/Peads) makes me feel back to square 1 Then I don't want to try again as I don't want to put the patient through unnecessary suffering when a doctor would have got it first time as there is something palpable, I just missed it. I'm going to turn up to an A&E tomorrow where I've been on placement for 1/2 a day in the past, to hopefully brush up on clinical skills if they are not too busy to let me tag along

I find using a butterfly a lot better for taking bloods (for numerous reasons) but also because it makes it a lot easier to swap bottles of vacutainers. The needle is not really physically connected to the vacutainer which means any twisting and prodding you do at that end whilst you connect the bottle isn't going to be transferred to the needle which might make you displace it from the vein. Might be worth trying that. As a rule, butterfly >>>>>> everything. I think it's a lot nicer for the patient and gives you more control too and very rarely do you need a huge needle for bloods unless it's an acute situation, and in that case you'll either 1) not be the primary person taking bloods and/or 2) have had enough practice in general technique using a butterfly that using a bigger needle and juggling bottles isn't a problem. I feel this may be a contentious issue though so just my opinion.

I think I'm one of the few people who didn't like butterflies that much. I find it much harder to change bottles because I'm having to try and find the end while stabilising the flimsy needle (I know the point is that should be fairly stable on its own but I don't trust it). I find the blood flow a lot more temperamental with butterflies.
Unless I know they are difficult to bleed, or visibly have crap/tiny veins, I avoid butterflies. I have a much better success rate with needle and vacutainer.

I'm weird, I know.

Posted from TSR Mobile

Bit of phlebotomy advice please?

I struggle with 2 things:

1. When you cannot see the vein, I really struggle to remember exactly where it was after cleaning. More so than others it seems. I have a lot of doubt whether it's 3cm this way or 3cm that way, my brain just seems incapable of remembering the spot

2. Swapping bottles on vaccutainers, the art of not moving the needle at all? Although I feel this will improve, I'm more concerned with the other point!

Basically, I got 10 bloods done, and now due to a combination of not being able to see the vein (Which I know, palpation is better - but only if you remember where it was!) and a gap of almost a year without taking any due to how my placements have fallen (GP/Psych/Summer Hols/Peads) makes me feel back to square 1 Then I don't want to try again as I don't want to put the patient through unnecessary suffering when a doctor would have got it first time as there is something palpable, I just missed it. I'm going to turn up to an A&E tomorrow where I've been on placement for 1/2 a day in the past, to hopefully brush up on clinical skills if they are not too busy to let me tag along

Fair enough. Personal preference!




Sorry, missed your first question! Once you palpate the vein, tether it as you would immediately prior to inserting the needle. Then, indent the skin with the needle cover (the round circle side) of the vacutainer needle. Then clean the skin etc. as you would. Then tether the skin and insert the needle in/around the circle - this should be almost dead on. If you do miss - don't worry too much, since the needle is in the vein you're welcome to re-palpate for the proximal vein to see how you need to angle the needle within the skin. Then fish around a little until you find it - just be careful not to touch the actual needle which then may enter the skin. If it's a really difficult patient try using sterile gloves - you can re-palpate then.

Firstly, thank you both!
The doctors prefer us to use needles with vaccutainers over butterflies due to the price difference unless absolutely necessary or a vein in the hand. So I'll try to get that nailed.

The mark the skin with the plastic of the needle cover is a fab idea for me although I might get a few odd looks from doctors ("Don't you realise the needle cap is still on"!?". I guess from a patient's perspective, I'd have to explain each time I'm just gently marking the spot otherwise they see "device" and think i'm about to stab them with the needle I've never seen anybody do as you suggested, but then I'm worse at visualizing it IMO than most.

As you mentioned "fishing around", I'm not confident at all and the med school never taught it - I withdraw the needle in and out a little bit but then give up, I don't ever change the direction at all under the skin. ?Worried i'll hit something I shouldn't. So I basically either get it straight away or not at all.

Thanks for all the advice and I'll do my hardest to put this into practice tomorrow.

Fair enough about the cost aspect, but don't use pieces of equipment that don't work with you for the sake of it. Using 2 or 3 vacutainers will likely equal the cost of a successful butterfly...!

With the plastic needle cover - I mean remove it first. Then use the bottom circle of it to mark the skin - I probably wouldn't use the sheathed needle to mark the skin because it might concern the patient a little (as you say). If you just have a small bit of plastic it doesn't really matter, and it isn't something you're going to do every time just until you feel a bit more confident. I've seen a lot more people use that technique when taking an ABG but I've used it a couple of times for a difficult venous blood.

Yeh the medical school rarely teaches you anything more than the basic technique. When I say fishing around I mean withdrawing out (only a bit - never so much as the needle exits the skin; if that happens you start again) and then putting it in more. Also fish a bit laterally and medially, guided by your palpation. When you initially went in with the needle, you might have glanced the side of the vein and caused it to move laterally out of the way. Moving in further or withdrawing won't help, but moving slightly laterally will help and you may get it in.

When I say move laterally, I mean withdraw slightly, angle needle slightly laterally or medially (i.e. 1 degrees or so - not massive swings) and then re-insert.

Why I assumed with the needle still attached to the plastic cap... Your way would of course need to unsheath the needle.

Logistically: unsheathing the needle at this point would be before you have cleaned the skin, you've now got a sharp (needle) that isn't sheathed in your tray. Not sure if I would be frowned upon for either:
a) Potential needlestick injury albeit sterile needle
b) The needle is touching the tray. The tray should be 'clean' but it's not sterile.

Unless you're suggesting to re sheath the sterile needle immediately after marking the skin, which I think they frown upon too.

I do like this idea to help me in the short-term, just not quite visiualising the practicalities of it.

I think you're over-thinking it a little! If I needed to mark the skin before the procedure, I would 1) tourniquet, 2) palpate vein, 3) unsheathe needle (N.B. I think you should unsheathe the needle at this point even if you're not marking the skin - I've had a fair share of vacutainer needles refuse to unsheath and it's better to discover this earlier rather than later), 4) re-palpate vein, mark with sheath, 5) clean skin, 5) take blood, 6) etc.

I'd usually rest the needle inside the packet it came out of (this is sterile). As a rule I'd never place something sterile into a non-sterile pot, and then use it as sterile (as you say, it isn't sterile anymore).

I worked it out after writing my post hence the cheeky edit

Thanks again

I don't ever change the direction at all under the skin. ?Worried i'll hit something I shouldn't.