How to draw blood on "hard sticks"

[NewYorkDoctors]

Hello:
At my place, we have very good ancillary phlebotomy staff.

At times, if they are hard sticks, I get called for arterial puncture. My technique is solid and I can usually do it. But in a select number of patients with very edematous limbs, almost unpalpable arterial pulses, and arteries that easily collapse, I am at a loss.

Aside from getting a bedside echo (I am not buddy buddy with the MICU people at my current point), how can I find more training to improve this technique?

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[gutonc]

Wait...A sticks for basic labs? Seriously? If there's such a horrible stick and they're going to need regular labs more than once just put in a PICC. Otherwise, in an urgent situation (which is the only time I could imaging getting called for an arterial sample, just do a fem stick. Even in the fatties, a blind fem stick isn't too hard (even easier with US).

 

[NewYorkDoctors]

Femoral puncture. Got it. I'll review those.

 

[jdh71]

You can also usually find the AC vein in the crook of the elbow with a site-rite. Center the vien in the view of the probe in cross-section, then the vien is just immediately below the probe, in the middle of the probe.

 

[IM2GI]

Femoral puncture. Got it. I'll review those.

If you are going to stick someones groin, it better be for more than a PM K supp >4 or a trending troponin. In an otherwise stable patient there are not many scenarios where I would go for the femoral for just lab draws. If it is a code/critical patient you do what you have to do.

In a difficult lab situation where I atleast think there is a legit indication for PM labs (interns will signout tons of useless evening labwork), I will do a radial stick. If for whatever reason I cant get it, wait till the morning and get a picc if the patient is that difficult of access/draw and they will be admitted for a reasonable amount of time.

 

[Instatewaiter]

If you have to do arterial stick, carotid sticks are the way to go. Just stick the largest gauge needle you can find. For that matter just stick a cordis in the carotid so that you can get routine labs.

 

[Instatewaiter]

just do a fem stick. Even in the fatties, a blind fem stick isn't too hard (even easier with US).

Follow this up with page to vascular for the RP bleed your will cause to check that magnesium.

As someone who has seen his fare share of groin complications from people who know what the **** they're doing with groin sticks, an intern/resident shouldn't be sticking the femoral unless the person is peri-code.

If you have to do arterial stick, carotid sticks are the way to go. Just stick the largest gauge needle you can find. For that matter just stick a cordis in the carotid so that you can get routine labs.

I was obviously kidding. Please don't stick big red.

 

[gutonc]

I too was mostly kidding. The OP question is kind of ridiculous. But not unexpected in NYC.

 

[Instatewaiter]

I too was mostly kidding. The OP question is kind of ridiculous. But not unexpected in NYC.

Ah the glory of nursing unions

 

[gutonc]

Ah the glory of nursing unions

The thing is...there's something specific about the NYC nursing union. My RNs are unionized (as are virtually all of my clinic staff including MAs, Lab Techs, Pharm Techs and even the front office staff) and yet they do their damn jobs. Every day. And if they run into a problem they can't fix? I'm 5th or 6th on their list of people to call to fix it. Sometimes I wish they'd come to me a little sooner but overall I can't blame unions specifically.

Lazy nurses hiding behind a corrupt NYC union boss? Them I can blame.

 

[acceptmeplease]

I had a septic patient who was a transfer to our facility and 2 phlebotomists, a renal nurse, a nurse from CVRU, and myself couldn't get a line in..the doctor who recieved the pt wanted labs immediately and the PICC nurse on call wasn't answering.

Pulses sucked, respiratory got no flash on the radials bilat, so the doctor tried and failed carotids and ordered epi subq. Respiratory was able to draw labs from radial at that point.

Worked like a champ for a blood draw...pt was too far gone though, died 2 hours later.

The rural clinic who sent us this pt was shocked to find out her ph was 7.1, as it "perfectly fine at 7.2 last night".

 

[IMDoc607]

Follow this up with page to vascular for the RP bleed your will cause to check that magnesium.

As someone who has seen his fare share of groin complications from people who know what the **** they're doing with groin sticks, an intern/resident shouldn't be sticking the femoral unless the person is peri-code.



I was obviously kidding. Please don't stick big red.

Was thinking the same thing. Femoral sticks are easy if all you want is return but wait till they see the end result. I prefer doing caths via transradial approach. How about you?

 

[acceptmeplease]

Was thinking the same thing. Femoral sticks are easy if all you want is return but wait till they see the end result. I prefer doing caths via transradial approach. How about you?

From a nursing standpoint, I prefer taking care of post cath patients who were stuck radially.

 

[jdh71]

Follow this up with page to vascular for the RP bleed your will cause to check that magnesium.

As someone who has seen his fare share of groin complications from people who know what the **** they're doing with groin sticks, an intern/resident shouldn't be sticking the femoral unless the person is peri-code.

Just U/S the fem too. Stick the one that isn't pulsing. While I agree, might be silly to go after a mag recheck, it's not come crazy danger zone that physicians should be afraid to use if they think it's necessary - they just need to familiarize themselves with the U/S.

 

[Instatewaiter]

Was thinking the same thing. Femoral sticks are easy if all you want is return but wait till they see the end result. I prefer doing caths via transradial approach. How about you?

From a complications stand point I agree. From an ease standpoint (with exception of LIMA/RIMA) I prefer femoral.

Just U/S the fem too. Stick the one that isn't pulsing. While I agree, might be silly to go after a mag recheck, it's not come crazy danger zone that physicians should be afraid to use if they think it's necessary - they just need to familiarize themselves with the U/S.

Might as well just stick in a central line. It's gonna save you some time later on in the hospitalization.

 

[IMDoc607]

Yea I hear ya. I guess it cones down to my inexperience. I sleep better at night not worrying about RP bleeds or pseudoaneurysms.

However I have heard the efficiency viewpoint from many.

From a complications stand point I agree. From an ease standpoint (with exception of LIMA/RIMA) I prefer femoral.



Might as well just stick in a central line. It's gonna save you some time later on in the hospitalization.

 

[IMDoc607]

From a nursing standpoint, I prefer taking care of post cath patients who were stuck radially.

Also find it to be better for the patients.