One of the nice perks I’ve found to blogging is that every now and then I get to rant. This piece might fit into that rant category. Not necessarily the full blown, foot stompin’, leave the caps lock key on, kind of rant, but a rant none the less.
I’ve started a bunch of IVs. Some were really good. Some were, I can’t believe I got that, there must have been some divine intervention involved, good. Of course I never say anything like that at the time. I tape it down nonchalantly and act like I get the hard ones all the time.
I’ve had my share of bad ones as well. I’ve missed IVs in veins so big that I should have been able to throw the needle dart style and still hit the vein. I’ve chased veins across peoples arms and left them with bruises to remember me by for weeks to come. I’m not proud of it, but I’ll take ownership of it. IVs aren’t my favorite thing to do. I didn’t become a caregiver because I liked causing people discomfort with needles. (Though some of my patients have seemed convinced otherwise.)
Along the way I’ve picked up some pet peeves about starting IVs and I’d like to share them with you. This is a list of my top four, please don’t do this, IV pet peeves.
When starting an IV please:
Don’t blame your missed IV on the patients veins.
This is an insidious habit. I don’t care what the patients veins look like. I don’t care if they are buried, if they roll of if they dance around like a hula girl. The patient didn’t miss the IV … you did. Don’t ever tell the patient, “You have brittle veins, deep veins, small veins, rolling veins.” (Whatever that means) or anything else to make it seem like the missed IV is the patients fault and not yours.
If you miss it, you miss it. Say sorry and move on. Those pitiful remarks about the patient being a hard stick will only make you look worse. Other popular versions of this bad habit are the medical history question asked right after the failed attempt, “Are you on blood thinners?” or looking aggravated at the drivers compartment as if to suggest that something in your partners driving cause your failure. Suck it up. Correctly document the failed attempt (hopefully on your free EMR) and move on.
Don’t clean the puncture site and then touch it again with your dirty glove or finger.
I know how it goes. You massage the vein. You poke the vein. Then you poke at it a little more. You feel it under there just waiting for your needle. You pick your angle and site of attack and then you dutifully swab the area to prep it before you stick. And then … you just have to touch it again.
I know. Believe me I know. Sometimes the urge is just irresistible. You want just one more feel of that vein to confirm it’s still there waiting for you. But don’t. You’re only recontaminating the site. Trust yourself. Trust the vein. It didn’t leave for vacation while you were picking up the needle. It’s waiting for you. Just stick.
Don’t ask the patient to open and close their hand
- It does nothing.
- No … really. It does nothing. (If you really want to, hang their arm down. That stands a much better chance of making a noticeable difference in vein size.)
Don’t blow the vein and then leave the tourniquet on while you look for a 4X4 etc.
We all blow veins. It’s never pretty when it happens. But when you see the vein blow, the very next move should be to pop that tourniquet. This will decrease the amount of bruising and swelling the patient experiences.
I see folks make this error all the time. The vein is blown. They know the vein is blown and the start looking around for the gauze 4X4. Then they do the one handed maneuver to tear open the package. Then they put pressure on the wound and remove the IV needle. Then at some point, while trying to stop the flow of blood they reach up and pop the tourniquet.
Pop the tourniquet first. Your patient might not thank you but I will.
I know all of these sloppy errors well. They are all bad IV habits that I had to break for myself at one time or another. Now I urge you to do the same.
I think I have my little problem with my comments box fixed. Give it a try. I’d love to hear what you think about sloppy errors or pet peeves with IV start technique or anything else.
Steve
I had a nurse put in an IV. She blew my vein. Instantly my wrist puffed up. She left the needle in, turned on the iv to see if it would run, then taped it down wiped off my hand and said, “Oh I might want to remove the tourinquet.” My hand is now swollen and black and blue from my thumb halfway up my arm. Im in so much pain I can barely make a fist. This happened on a Friday, it is now Monday and I have no relief. I am a CNA studying to be a nurse and even I know to remove the tourniquet and remove the needle. My IV was never removed and restarted. it was left in during my whole 3 hour procedure.
Hey Steve, I have a question.
About a week ago I was hospitalised for two days and two nights for a Kidney infection. Im fine now, but they put an IV in my wrist and it ended up getting clogged the next day so they took it out. Which was fine because I was allowd to go home that day. But now my vein is still all hard and swollen and soar. Is this normal? This is the first IV I’ve ever had and would really apriciate some help.
Thank you!
G.O.
Is it possible to have part of the iv left in hand after removal ? I dont want to sound crazy but after it being out for a week it is getting swollen and becoming painful only the last two days and my vein feels like it has a long skinny object in it when I touch it. This just started the first 5 days after removal it was just a little sore now I have to wonder… Thanks for any input.
Your tips are a big help. Thanks!
For patients talking about knowing where their good veins are-
As a paramedic on an ambulance I would like to share why i may not go for that good vein on your right arm other preferred location:
1. The back of the ambulance is a tight place ,especially on van type ambulances. The set up in most ambulances provides best access for the paramedic to your left arm. This allows us to best visualize and manipulate your left arm while in the back of the ambulance. Depending on your anatomy or on ambulance configuration getting to your right arm start an IV in it may require a great deal of awkward positioning and acrobats to attempt, increasing the realitive difficulty of your “easy” site
2. Paramedics hear this frequently, right before getting a good IV elsewhere on your body
3. Some veins DO roll, not everyone knows how to properly apply traction (often an untaught or undertaught component of paramedic training). It’s not malicious to say your vein rolled and certainly not a personal attack any more than telling someone with heart failure that they have a bad heart.
4. I’m definitely guilty of this one. Some paramedics have their bread and butter sites. Mine is the anterior forearm and I have great success here. It’s not you, or your request for a certain spot, its just me and my desire to start a fast and effective IV as I do not start “precautionary” or prophylactic IVs in the field. Along with this point I’d also like to admit another weakness of mine. I CAN NOT hit an intern vein in the wrist, I don’t know if its the angle or the anatomy, I just can’t. Sorry (5 years of starting IVs. Ugh). Maybe other paramedics can relate?
5. There might be rules or protocols were are required to follow based on your.symptoms. Our protocls.call for AC or EJ placement for things like stroke symptoms.
So give us a break. If your sick enough you’ll get an IO, so count your blessings that your not acute enough for that next time your medic misses.
nurse missed my vein twice, got in on the third attempt . First in my hand, second in my elbow joint (I have huge veins btw). One the second failed attempt I saw 3 good pumps of blood come out of me. Idk what she was doing but she didn’t do it right. After she missed and started pulling the IV out she didn’t keep any pressure on it, I saw 3 pumps come out of out the end of the piece. My arm blew up where the IV was. I now have a huge bruise on my arm and arm is sore as hell. Very upsetting experience.
I have had a lot of illnesses throughout my life. I know my body than any nurse and I am tired of sloopy IN insertions. It has been years since anyone could get an IV in the crease of my arm, to many illness and fat too many IV, that areas now has too much scare tissue. When having an MRI and needing an IV for dye, they automativally send me to IV therapy at the local hospiatl to have a samller IN inseted. Once they blew my veins several times, they finally listedened to me. IV therapy on the surgical floor flins the vein, injects a little lidocaine, then inserts the IV on the first shot. I had to go for an MRI Arthogram; I have special needs due to my injuries and severe pain. It took almost a month to get all those special needs authorized. When I arrived the nurse let me undress and get into a gown that does not cover the patient and allow them to keep their dignity. Before she started the IV I told her that I am a hard stick and nurses keep blowing my veiins, that a smaler needle needs to used and that she needed to call vein therapy upstairs (that is where I am alwasy sent), she stated, I am IV theraypy. Well she made be the nurse who does the IV insertions for an MRI, but she is by no way IV therapy. The first thing she did wasto immediately blow the vein on top of my hand. Then she attempted to insert the IV in the indise of my forearm. It immediately was burning and painful even when I didn’t move my hand. Well, this site got extremely angry, hot and painful. It was left in plae but all through the proceedure she would say to other personnel that the site was angry. I can tell you I will never have another Arthogram. The person setting up the proceedure not only lied to me and deceived me, not one of the specail needs that was prior approved was done. The Doctor blamed the scheduler, saying she was only the receiptionist and nobody talked to me about this. That we will keep you are comfortable as possible. That scheduler has been their for years, in 12 phone calls to each other all my specail needs were clearly spelled out and she would check with staff, call me back and we would go over it again that all my needs would be met. As far as I am concerned, I will try to never go to Doctor no matter how serious my condition is. Its like we treid to set up my needs in one phone call. There were 12 calls back and forth. As for the paramedic, I have been stuck up to 6 times because the paramedics did not listen to me, I know my body. Every single IV I have had by a paramedic had to be replaced as soon as I got to the hositpal because of poor location, poorly inserted and so on. If a patient tells you they have special needs or they know where an IV works, then listen to them and work with them. Don’t act like GOD and think you know a persons body,
While i do agree a lot of iv misses are from simple technique flaws or just being human and missing. The one thing that I can is that some of the cases is that a lot of Americans have taken poor care of there bodys. Which in return causes large amounts of fat in the places medic’s and nurses go for the iv sticks. As for people with chronic illness yea you have had your veins poked over and over again the human body isnt ment for it. I understand a lot of people are born with medical conditions that they have no control over. But a vast amount of Americans have abused their bodys there entire life. Eating fast food every day never working out or taking care of them selves. I hate to say it but yes that person is going to be a harder stick. But you cannot always blame the medic or nurse for missing the iv They did not force them to make unhealthy life choices.
wow!! thanks very much… It’s a big help for my job… SOME OF THE mistakes should avoid like blaming the patients vein, i always said that.. because their vein was too brittle..And when I read your site… aaw!! i realized, it’s very wrong and unethical..Now if I did not get the right vein… i just start to say sorry and look for the other vein… thank you very much.. Oh by the way thanks also for the tip that you should find a good vein within 12 seconds only…
I love your rant. It was perfect. I have been a phlebotomist for a few years, but the small techniques that I have picked up were bad ones. I am now desperately trying to break myself of a lot of those bad habits as I head into my RN program. I have yet to blow a vein. I pray to God I never do, but I will keep in mind what you said. Thanks for posting this. It was very helpful.
There are a lot of things I could go on about this post (like how in the hell you got your state certification if it’s ever been a habit of yours to touch the site after you’ve already steralized it, or the fact that you don’t know what a rolling vein is).. But the one that shocks me is: “Are you on blood thinners?” . I don’t know why you would blame blood thinners for you missing a vein but you not thinking this is a vital piece of medical information for a phlebotomis to ask (or whomever is doing a blood draw), you have no right to be holding a needle. It is imperative that I know weather or not someone will have trouble clotting with in a normal range. If you ever let some one sit there and continue to bleed and bleed and it was because you didn’t do your job and find out the medical history, you need to be fired. Not finding out proper medical history is why mistakes happen and how people die.
Ok so i dont want to sound paranoid but 2 months ago i was in hospital and went into theatre. I got this lump in my vein its very large feels like something is in there if i press it, it moves around and just above it is another small lump. Both are just getting bigger and more purple and it is starting to feel like pressure in that hand right up into my arm where they put needle in. Im wondering what is. Please help
Cirsten, please see my post on Looking for medical advice on the internet.
http://theemtspot.com/2012/11/19/what-should-i-do-looking-for-medical-advice-on-the-internet/
Michelle, I got my state certification over twenty years ago. About ten years before I became an EMS educator. Perhaps standards were more lax back then. And, while I appreciate your input, I also suspect you haven’t made peace with the fact that prehospital care is imperfect. (And that’s OK) Michelle, it’s OK. You can stop pretending like you are the one ems provider that doesn’t make any mistakes. Touching a semi-sterile IV site with a gloved finger is not a fire-able offense. Neither are any of the dozens of minor mistakes that you made last shift. It is, however, a frequent error that is worth teaching others to avoid. Recognizing our errors and discussing them is part of learning and getting better at what we do. That can’t happen when we decide to redicule and threaten those who make mistakes. Good EMS caregivers make mistakes too. That’s how we learn.
Also, blood thinners are a perfectly acceptable question to ask. The timing and intention behind the question are the problem. And yes…I know what a rolly vein is and what it does. My point is that all veins, to one degree or another, roll. That’s why we apply traction. Just don’t blame the patient.
When unable to see or touch the vein, your only option is to guess. Having the layout of the anatomy in mind helps the guesswork, but when you proceed to stick but unfortunately miss, you are forced to probe. How would you describe your probing techniques?
Steve, Just because you make plenty of offenses that are deemed “not a fire-able” does not mean everyone is so careless. What, in your mind, is not so obvious is a clear red flashing light to others. I have never touched a site after cleaning it; that’s just plain common sense, what the hell is the point in cleaning it if you’re going to touch it. If you’re making “frequent errors” you need to go back to school. Yes, everyone makes mistakes but mistakes are few and far between, not with every patient and not the same mistake every time and not to be blamed no poor teachers or “lax standards”. And I seriously hope you don’t think finding out if someone is on blood thinners is “not a fire-able” offense. that is very serious and can lead to termination. Good luck with your career, I really hope you’ve rectified these mistakes. At least we agree on one thing, a patient should not be blamed for a phlebotomist not being able to get the vein.
Actually Michelle, I think we’re pretty much saying the same thing here. I wasn’t tacitly giving people approval to do these things, I was recognizing that they are typical errors and trying to educate people to avoid them. I’m not sure where along the way I became an advocate for touching clean IV sites.
The difference I do see is our views on responding to the errors we do make. This is an educational blog. I am an EMS educator. I choose not to address people with the “If you do this you should be fired” type of tone. Someone, somewhere taught you the importance of a clean IV site prior to needle insertion. I applaud them. At some point it wasn’t obvious to you and now it is. Thank you for being an advocate for sterile technique.
I don’t write from the standpoint that we shouldn’t attempt to educate providers about things that seem obvious to us. I also didn’t always recognize how imperfect my care was, but the more I learn, the less I know. Medicine is a bottomless pit of knowledge. That’s what makes it so great. There is always room to learn and grow. But that will only happen if we come to the well with humility and a recognition of how far we all still have to go.
Thanks for being a reader. I hope you find some of the other articles more useful.
Thanks for the tips! I was slightly shocked to see the “Don’t ask the patient to open and close their hand” tip, because I have been told to do that everytime I get blood work done. Or just to squeeze a ball. When I was trained to do phlebotomy for my CMA, I didn’t blow anybody’s vein (Thank God!), but I’m rusty on my skills and will be put in the lab at my job next week. I’ll admit, I’m nervous (It’s been over a year since I’ve stuck anyone!) but I’m excited! Thanks again for your helpful tips!
The thing you didn’t address is the habit of nurses (including myself until I was taught correctly) to get the tape ready before we stick the patient. That means you are sticking clean tape on a dirty table, bedrail, etc. then cleaning the patient’s site, sticking them and putting dirty tape around the IV site. I was taught in nursing school to get the tape ready first and a nurse during clinical taught me this was incorrect. Also my mom was in the hospital and the tech that came in started her IV without wearing gloves. Those gloves are to protect the patient and the nurse–wear them!
My brother suggested I might like this web site. He was totally
right. This post truly made my day. You can not imagine simply how so much time I had spent for this information!
Thank you!
Anyone ever realize it may not be the patient or technique….but the equipment ? Have you practiced on another colleague or simply patient or a model? Some of the more popular safety needle products have depleted in quality since being intoduced; the catheters have jagged edges or raised edges that prevent a…difficult and uncomfortable advancement. Have a fellow employee practice on you and vis a vis….if you feel the snagging discomfort, it may not be simply technique..
I clean my gloved finger-tip with an alcohol swab just before I’m about to stick, because I do need one last feel to make sure the vein is where I left it. It almost always is, so I should probably take your advice and avoid touching before sticking. It’s a hard habit to break, though…
Michelle did you not understand the whole intent of this post? You consistently seem to be missing the point of Steve’s comments. It was clear he was referring to “avoiding” placing blame on a patient when having difficulty either finding or sticking a vein. His point is that it’s the job of the medical personnel to start the IV, draw the blood, etc. And regardless of rolling veins, depth of the veins, or blood thinners don’t turn those into reasons to blame the patient. And to his point about touching the semi-sterile site with a gloved finger – I can’t tell you how many times I’ve seen phlebotomists do exactly that when drawing my blood. Steve was simply sharing it should be avoided.
I have my blood work done every 2 weeks , and some nurses and techs are just lazy and careless. But some are excellent.
Oh, forgot tell u my last nurse did blow my vein. And she told me to keep squeezing and the pain was very bad in my whole arm. After 10 years of frequent blood tests this is the first time some one did so much damage to my arm. She thought she knew everything about drawing blood. I said nothing because I was so frustrated…but just to let you know ..its not very nice for the other patients that are not aware of these mistakes. This is a good blog ..keep it going
I had an IV put in my hand on May 1st and them removed on May 2nd, today 5/9 I noticed a place that feel like a plastic tube in the vein. My question is where should I go to have it checked the hospital where it was inserted or go to the emergency room??? Help.
Asking a pt to make a fist repeatedly can skew test results, it’s theorized to result in a localized dumping of potassium into the blood stream.
Hello Steve, my name is Sy and I have a quick question.
I recently had a biospy yesterday as a matter of fact and had some issues when the nurse tried to find my vein to start an IV. She said my veins were thin.. Any way she was able to find one in my left hand. Then I was wisked away for the biospy. But, something weird happened. I’ve had 3 biopsies and 4 surgeries and usually I can feel when I’m going to put to sleep. This time I didn’t. I asked the nurse when are you going to give me the meds to put me to sleep she said, “I already did” . I felt no affects but was able to dose off to only wake up to the doc digging in my spine for a piece of bone to biospy. My question is… Could it have been possible that the needle was not in my vein well. The doctor said he gave be 100cc of Demerol and 50cc of morphine during the procedure. But I felt every waking pain. This has never happened, ever! What are your thoughts?
i had an i.v put in and it was dong wrong the nurse hit a nerve and it was very painful (still is) this was done on may 29th and now i feel like i am having electric shocks on my arm why is that?
Opening and closing the hand DOES work when the arm hangs.