Venipuncture as a med student

[TOcho118]

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Hey all, M4 here matched into a surgical subspecialty. I am quite embarrassed to admit that I have never performed a venipuncture on an actual person throughout my entire four years of med school. Sure, I have practiced on those fake arms many times but obviously that's no substitute for actual practice.

Has anyone else had a similar experience in med school? I am somewhat worried that this could hurt me next year when there's a tough stick and they look to me like "here, you're the doctor after all ." Any current surgical residents who can comment on how necessary this skill is intern year?

 

[Dranger]

From a nursing perspective I rarely see docs put in peripheral lines. Hell even the PICC lines are mostly done by nurses with CVCs done by residents/NPs. I can't see it as being detrimental, it's just a simple skill. Maybe it's different for surgery guys I don't know.

Advice: Walk into the ED you are doing your rotations at and volunteer to put an a I/O or EJ on the first patient you see

 

[Tired]

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[TOcho118]

Thanks guys. Just had a moment where I was like "how have I gone through med school without ever even placing an IV."

 

[Tired]

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[ACSurgeon]

You weren't hired to put in lines.

If you choose to get good at it, it will only benefit you. If you want to get good at it, you can put lines in your own patients (you're the doctor, just do it).

If you don't care, then don't.

But don't *ever* get suckered into, "I couldn't get the IV so you need to come try." That is not your job, and if the floor nurse can't so it, he/she needs to find a colleague who can (usually from the oncology ward).

I'll echo the above. IV teams and sometimes anesthesia are the IV back up people. As a doctor you can put in a central line in a pinch.

Now, if you develop ok IV skills, you're certainly able to try when nurses fail.

Even though I've put in far few IVs, NG tubes and foleys then a floor nurse, it's not infrequent that I'm able to get a tube/line in place that supposedly a couple of floor nurses tried and failed.

Always attempt your foley before calling urology (unless contraindication). Same should go for NG tubes before sending to fluoro.

 

[Dranger]

Most wards have a policy that peripheral lines get changed every 3 days. The wards belong to you come July. Just start changing your own lines if you want. That's the easiest way to practice if you feel like it.

Recommend against going to the ER as suggested above. The more you show your face there, the more they call. Your seniors will not appreciate their intern getting the reputation as "ER-friendly".

It was more tongue in cheek if anything. A 14g EJ stick probably shouldn't be your first veni attempt.

I'll echo the above. IV teams and sometimes anesthesia are the IV back up people. As a doctor you can put in a central line in a pinch.

Now, if you develop ok IV skills, you're certainly able to try when nurses fail.

Even though I've put in far few IVs, NG tubes and foleys then a floor nurse, it's not infrequent that I'm able to get a tube/line in place that supposedly a couple of floor nurses tried and failed.

Always attempt your foley before calling urology (unless contraindication). Same should go for NG tubes before sending to fluoro.

Urology guys have some serious foley skills but usually when we call them they have a the bright idea to recommend CBI for a day or so after placing it :/

NG usually aren't the problem, the dobbhoff/nasoduodenal tubes are usually who we send to IR after 3-4 attempts. Some pulm guys really want it in the second part of the duodenum or ligament of treitz before we prone ARDs guys.

 

[TOcho118]

Most wards have a policy that peripheral lines get changed every 3 days. The wards belong to you come July. Just start changing your own lines if you want. That's the easiest way to practice if you feel like it.

Recommend against going to the ER as suggested above. The more you show your face there, the more they call. Your seniors will not appreciate their intern getting the reputation as "ER-friendly".

Good advice. Thank you. Definitely going to try and stay out of the ED unless absolutely necessary

 

[tiedyeddog]

We practiced standard IV venipuncture on each other at the start of M3. I can't say I am good at it, as a graduating M4 I have attempted/put in 10X as many A-lines and CVC's compared to standard IV's.

Most residents I have seen just order a PICC line (if the team is still there) if multiple nurses have tried and failed. If the PICC team is gone they put in a CVC. I watched a resident do a US guided venipuncture just one time at night when the PICC team was gone and almost every nurse on the floor failed. This is just my limited experience so far.

 

[nap$ter]

I'll echo the above. IV teams and sometimes anesthesia are the IV back up people. As a doctor you can put in a central line in a pinch.

Now, if you develop ok IV skills, you're certainly able to try when nurses fail.

Even though I've put in far few IVs, NG tubes and foleys then a floor nurse, it's not infrequent that I'm able to get a tube/line in place that supposedly a couple of floor nurses tried and failed.

Always attempt your foley before calling urology (unless contraindication). Same should go for NG tubes before sending to fluoro.

outside of academics (where residents/cheap labor is avail) anesthesia is almost never the backup for PIV's.

PIV's on the floor/ICU are the job of nurses - we don't keep anesthesia people "available" for this. (although i hear a 2 year difficult IV fellowship will soon be sanctioned by the ACGME/Ivory Towers complete with a fanny pack full of 24g's, a tube of EMLA cream, and a swell turtleneck to wear under your scrubs).

when/if I (rarely) get called for a PIV I make sure that the primary nurse, IV team nurse, and person calling me have all tried to put in the PIV, and then I go place a central line (and I make sure that they have everything set up before I get there).

the hospital/nobody pays my group to be available for difficult IV's.

you do not want to start doing the nurses job - next thing you know you will be changing "difficult" bedpans while the Dr. Murse MSN RN DNP BAP CNN gives you orders based on his diagnosis and treatment plan.

 

[mmmcdowe]

You should practice the good old fashioned way, find a friend to put lines in. Preferably someone who has big veins.

 

[fab4fan]

Thanks guys. Just had a moment where I was like "how have I gone through med school without ever even placing an IV."

If you're really interested in learning how to place a line, find a nurse who's willing to help you. I did that with an anesthesia resident who hadn't started lines. We were in Day Surgery, so the whole day is stick, stick, stick. I had him do a couple of my IVs for me one day, and after that he felt more confident.

Many hospitals have IV teams, so usually that's who gets called if the floor nurses can't get a line.

Good luck in your residency.

 

[ACSurgeon]

outside of academics (where residents/cheap labor is avail) anesthesia is almost never the backup for PIV's.

PIV's on the floor/ICU are the job of nurses - we don't keep anesthesia people "available" for this. (although i hear a 2 year difficult IV fellowship will soon be sanctioned by the ACGME/Ivory Towers complete with a fanny pack full of 24g's, a tube of EMLA cream, and a swell turtleneck to wear under your scrubs).

when/if I (rarely) get called for a PIV I make sure that the primary nurse, IV team nurse, and person calling me have all tried to put in the PIV, and then I go place a central line (and I make sure that they have everything set up before I get there).

the hospital/nobody pays my group to be available for difficult IV's.

you do not want to start doing the nurses job - next thing you know you will be changing "difficult" bedpans while the Dr. Murse MSN RN DNP BAP CNN gives you orders based on his diagnosis and treatment plan.

You seem upset. That sucks.

 

[nap$ter]

You seem upset. That sucks.

you seem naive. that's kinda sweet.

 

[tiedyeddog]

Well this escalated quickly....

 

[TOcho118]

It's a necessary but infrequently used skill.

After you've dropped central lines and a-lines it most of the times seems easy by comparison. You can also use ultrasound.

The times when it is needed are:
(a) truly stat labs and nurse/phleb not immediately available (ex: transplant patient coming in for their liver, need a full panel of labs and going to the OR in 20 minutes)
(b) difficult stick and needs labs drawn. Usually can get just through persistence (i.e. nurses/phlebs often give up too easy or aren't comfortable with creative solutions). If you can't get it, you always have other options like an arterial stick or a fem stick.
(c) actually need an IV and nurse/phleb can't get it. Again sheer stickwithitness and willingness to entertain other solutions (e.g. EJ) gets you through most of the time. My preferred method for dealing with this situation though is to sweet talk one of the ICU nurses to come put an IV in. ICU nurses are among the most experienced at getting access in difficult patients. IMHO spending 5 minutes buttering up a SICU nurse is preferable to spending 15-30 minutes futzing around putting it in myself.

IMHO The biggest thing that differentiates a resident in these situations from a nurse or technician is their persistence/stubbornness. It's sad to say but there are very few people in the hospital as willing to push when things are difficult.

The wrong answer, of course, is "just get a PICC". PICCs are tremendously useful resources in clinically appropriate patients, but they are also not entirely benign and their risks and complications are being increasingly understood. Jumping straight to a PICC just because some inexperienced floor nurse says they are a hard stick and you're too lazy to work through any other steps of the algorithm yourself is poor patient care.

Unfortunately, I've never done these either….I assume this is something they teach you intern year? My med school was very hands-off with procedures, even during our EM rotation 🙁🙁

 

[LOVELLe9]

I have never seen a doctor attempt a peripheral. Typically an ER\ICU nurse or paramedic will give it a try if the patient is a hard stick. Or the nursing supervisor will know who the best person is at placing IVs and she will have that person try. If they can't do it then a PICC line or central line will be placed.

 

[LOVELLe9]

I have never seen a doctor attempt a peripheral. Typically an ER\ICU nurse or paramedic will give it a try if the patient is a hard stick. Or the nursing supervisor will know who the best person is at placing IVs and she will have that person try. If they can't do it then a PICC line or central line will be placed.

Actually I've seen a doctor offer to stick a patient during a code and the paramedic was offended.

 

[hmockingbird]

As someone who's a very hard stick and whose IVs don't stay in, I appreciate it when you try to butter up an ICU nurse or the nurse with the best reputation for IVs. Digging around for IVs REALLY hurts and they have the most experience. And I know that we don't do a lot of IVs (now as a med student and before because my dad was a doctor), though bringing the ultrasound machine in or even the "vein finder" could also be helpful.

I've only done venipuncture once and it was on one of my classmates during a surgery lab but when we were doing it the phlebotomy people said to stop by any time if we wanted to practice more. I admit I have not had time (maybe 4th year) but that might be an option if you just want to get some practice?

 

[Tired]

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[nap$ter]

There was a time when I was doing these. Intern year, usually at night. Postop patient on scheduled abx, loses access, floor nurse calls. No PICC team at night, not allowed to put a central line on the floor, anesthesia not helpful.

Being a fool, I would go up there and drop the line. Most of the time I was successful.

After a while I got sick of it. The nurses never got me stuff, so I spend 20 min just trying to figure out where everything is. Meanwhile pager is going off the whole time with actual intern issues. I finally just started telling them it was a nursing issue. They would get mad, threaten to document that I refused to help, threaten that the patient just wouldn't get their meds.

I held my line, politely told them that this was a an issue they needed to work through. And in nearly every case they did, and everything was fine.

Moral of the story: when you're the path of least resistance, you'll end up doing other people's work. There are patients that a PIV just isn't going to happen with, but they are few and far between. If a floor nurse was able to get the line on admission, it's unlikely that "nobody can get a line" now.

this a good post.

it's not that doctors don't want to help (and we will in emergencies... but then it will likely be a central line anyway), it's that most of us just don't have time to get sucked into PIV's and a lot of nurses are actually better than most doctors at this skill because they do it more often. it is a nurse's role.

that being said, it is a useful skill to learn in residency.

just for clarity, anesthesia is usually not helpful because we are in the OR providing 1-1 care the vast majority of the time we are in the hospital - we can't leave our pt/anesthetic to place PIV's on demand.

for what it's worth, my tips on placing PIV's:

-- pick a good vein. i see a lot of failures because folks don't "shop around" and they go for a vein that branches or squiggles downstream of the attempt site. match your IV gauge to the size of your vein. don't try to stick a 16 in a wee little spider. that being said, veins are stretchy and as you get better you will be able to put large catheters in small veins...
-- apply appropriate counter-traction. this is increasingly important in edematous folks or little kids. if you don't get good counter traction the vein won't stay straight when you shove your catheter into it.
-- most newbies (myself included when i learned) fail either because they advance the catheter too soon or too late (getting a flash is usually relatively easy - getting the catheter in the vein is the hard part). too soon and you push the vein off the needle and it blows. too late and you've gone through the back wall and it really blows.
-- my solution to this is to LIFT and LOWER your trajectory while ADVANCING the needle and catheter prior to advancing the catheter into the vein off the needle. imagine you are trying to advance a catheter into the lumen of an overcooked penne noodle. if your trajectory is too steep, you will pin the two walls of the noodle together and push your catheter through the back side. if however, as you just pass through the first wall of the noodle and get a flash of sauce level your trajectory and lift ever so slightly you will pull the front wall of the noodle away from the back wall and create a little extra space in which to pass your needle and catheter. this method/idea improved my success rate tremendously.
-- if you can't see/feel a vein with a regular tourniquet try wrapping an esmarch from proximal to distal on an extremity, milking a little extra juice into those distal veins.
-- use hot packs.
-- you can sometimes salvage a through and through miss with a wire - withdraw until blood flows then wire then advance catheter over wire.
-- use ultrasound (this is a whole other topic)
-- just place a central line or picc
-- reevaluate your need for an IV (couple of times as an intern (cross covering on call) got called to place IV's in pt's who were to be discharged the next day and were no longer receiving IV meds or IVF's.

good luck in your residency - the things i thought might be important early in my residency often turned out not to be important at all.

 

[Tired]

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[nap$ter]

Anesthesia doesn't get called at noon on a Tuesday, when the PICC team and the onc nurses, and everyone else is in-house. They get called at midnight on Saturday by some poor transitional intern who doesn't know what else to do. And you're not operating, you're maybe wandering through the PACU looking at overnight keeps, or maybe watching Hulu in your call room. Then you usually make some comment like, "We're not an IV starting service" and the intern is out of luck.

And don't get me wrong, you're absolutely right. You're not an IV starting service, and this isn't your job.

But I have to say, I have never met an anesthesia resident in any facility who is helpful outside of their clearly defined job requirements, almost regardless of the circumstances. They're not rude about it, the way surgeons can be; they're actually usually quite pleasant. But you won't help. Ever. This includes some fairly good friends, so I'm thinking it's something cultural in your specialty. Maybe you guys all have crappy experiences with medicine and surgery before your categorical years start? Or maybe it's that you only very rarely need a hand from anyone else, so no problem burning bridges? I don't know.

i think it's something unique to your institution.

when i was a resident and fellow, every single time i was asked to do a difficult IV and had time I answered the summons (not always successfully). so did my co-residents/fellows. as a private practice attending i never place difficult IV's outside of the periop arena (I do place central lines/alines occasionally in the ICU).

so don't say "you". say "they". as in the folks at your specific training institution. i would guess their mandate came from on high - the attendings didn't want their residents using their time placing PIV's for other services.

as for hulu and wandering through the pacu; wouldn't know/never dun that. as a resident i was either in the OR or (rarely) sleeping next to some snoring intern in the bunk bed above.

in pp i'm either in the OR or at home with the fam. we don't burn bridges either; my group has great relationships with other services, nursing, patients, and admin because roles are well defined.

 

[Ismet]

OP does your school not have a core rotation in anesthesia? Or are they just not keen on letting med students do the procedures? It's good practice for PIV placement.

Also see if you can hang with phlebotomy for a day. I did that on my family medicine rotation and it was really beneficial. Depending on how busy they are, you'll get 20+ venipunctures and they'll probably help you through the first several.

 

[Wordead]

OP does your school not have a core rotation in anesthesia? Or are they just not keen on letting med students do the procedures? It's good practice for PIV placement.

Also see if you can hang with phlebotomy for a day. I did that on my family medicine rotation and it was really beneficial. Depending on how busy they are, you'll get 20+ venipunctures and they'll probably help you through the first several.

I only did one PIV during anesthesia and that was because the original got pulled out during transport. Don't all the patients already have PIVs in usually? I just intubated on anesthesia, that was it.

 

[Psai]

I only did one PIV during anesthesia and that was because the original got pulled out during transport. Don't all the patients already have PIVs in usually? I just intubated on anesthesia, that was it.

some places have nurses do it, other places have residents from what i've seen
i've tried a few, way harder than it looks
also you can lose access in the OR and have to place one then like if someone pulls it out by accident when you're moving the patient or the table

 

[mvenus929]

Reevaluating the need for an IV is an important skill too. If the meds you are giving have a PO equivalent, and your patient isn't NPO or puking their guts out, you can usually make the switch. If you are just giving fluids, see if they can hydrate orally, or, if you're worried about airway issues, with an NG tube. It's generally better to feed the gut anyway.

Edit: not saying you should actively remove IVs, but if you are having difficulty getting access and more support will be arriving in a few hours, then it might be beneficial to wait.

Also, there are several groups of children who do not need IVs in the hospital.

 

[Ismet]

I only did one PIV during anesthesia and that was because the original got pulled out during transport. Don't all the patients already have PIVs in usually? I just intubated on anesthesia, that was it.

People on adult could go to the GI procedure center and put in IV after IV, it was like a rotating door. On peds, they had us place almost all the IVs on the same day surgery patients because they were induced first with nitrous. We had to log at least 5 IV placements so the preceptors who knew that made sure we had the opportunity.

 

[VisionaryTics]

I only did one PIV during anesthesia and that was because the original got pulled out during transport. Don't all the patients already have PIVs in usually? I just intubated on anesthesia, that was it.

I did my anesthesia rotation at the VA, where nurses do not put in IVs. It is the resident's/student's job in pre-op. I probably did 10 a day for 4 weeks. Haven't done one since.

 

[Doctor Bob]

I am always amused when the patient insists that they have difficult veins and they want the doctor to start their IV rather than the nurse (before anyone even takes a look).

I just shrug and say ok. I mean... if you don't want the person who does it 20 times per shift and would rather have the person that does it maybe once every 3 shifts, then sure. If the patient's nice or if it's really urgent that we get the line, I'll do the PIV myself. If the patient is a jerk I'll send in the intern.

 

[Tired]

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[ACSurgeon]

Reevaluating the need for an IV is an important skill too. If the mets you are giving have a PO equivalent, and your patient isn't NPO or puking their guts out, you can usually make the switch. If you are just giving fluids, see if they can hydrate orally, or, if you're worried about airway issues, with an NG tube. It's generally better to feed the gut anyway.

Central Lines- yes; assess need daily and remove ASAP. IVs should only be removed upon discharge. I rarely allow it for people going home the next morning and the IV gets pulled after midnight, but even then I wouldn't endorse that as common practice because of things that @Tired mentioned above.

Also, you comment about placing NG if airway concerns- I hope you mean swallowing rather than true concern of airway loss or aspirating after eating. Otherwise converting everything to oral as soon as it's safe is a good idea. I'd keep the IV nonetheless

 

[Kahreek]

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[Tired]

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[Doctor Bob]

😀, you are a terrible person

Hey, everyone has to learn.
In this case it's a two-for-one lesson... the intern gets to learn how to place an IV, and the patient gets to learn why social niceties exist.

But I don't disagree with your assessment that I'm a terrible person 😉

 

[Tired]

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[TOcho118]

OP does your school not have a core rotation in anesthesia? Or are they just not keen on letting med students do the procedures? It's good practice for PIV placement.

Also see if you can hang with phlebotomy for a day. I did that on my family medicine rotation and it was really beneficial. Depending on how busy they are, you'll get 20+ venipunctures and they'll probably help you through the first several.

No core anesthesia rotation. It's only available as a surgical subspecialty elective…that's a great idea about hanging with phlebotomy. I wish I had that idea at some point...

 

[mvenus929]

No. A thousand times no.

If the patient is in the hospital, they need access. End of story. Never allow a nurse to talk you into not replacing a line.

PEs happen. Sepsis happens. Falls happen. AMS happens. Healthy people don't hang out in hospitals. And trying to get a "quick line" in a crashing patient is a losing proposition on a ward.

The indication for an IV is hospital admission. End of story.

Ok, let's put it in better terms. If a patient loses access overnight, and multiple people have made attempts to get it and can't, a central line might not be the answer because it comes with a ton of risks. Finding alternative solutions until morning when there is more support and likely people with more experience or luck may be an option in some circumstances.

Central Lines- yes; assess need daily and remove ASAP. IVs should only be removed upon discharge. I rarely allow it for people going home the next morning and the IV gets pulled after midnight, but even then I wouldn't endorse that as common practice because of things that @Tired mentioned above.

Also, you comment about placing NG if airway concerns- I hope you mean swallowing rather than true concern of airway loss or aspirating after eating. Otherwise converting everything to oral as soon as it's safe is a good idea. I'd keep the IV nonetheless

As southernsurgeon mentioned, I'm a pediatrician. I have lots of children admitted to the hospital for relatively minor issues. If they lose an IV overnight and they are only here because their RR is elevated due to RSV, then we may do an NG instead of IV for hydration. My feeders and growers in the nursery usually don't need an IV once they reach goal feeds. I agree that I don't actively remove an IV until discharge for reasons mentioned, but if one infiltrates, I always consider whether or not it needs to be replaced right away, as do all the attendings.

And for airway things, I was mostly going for suck/swallow issues, and general tachypnea whereby feeding makes it worse and thus they choose to breathe rather than stay hydrated.

 

[ACSurgeon]

Ok, let's put it in better terms. If a patient loses access overnight, and multiple people have made attempts to get it and can't, a central line might not be the answer because it comes with a ton of risks. Finding alternative solutions until morning when there is more support and likely people with more experience or luck may be an option in some circumstances.



As southernsurgeon mentioned, I'm a pediatrician. I have lots of children admitted to the hospital for relatively minor issues. If they lose an IV overnight and they are only here because their RR is elevated due to RSV, then we may do an NG instead of IV for hydration. My feeders and growers in the nursery usually don't need an IV once they reach goal feeds. I agree that I don't actively remove an IV until discharge for reasons mentioned, but if one infiltrates, I always consider whether or not it needs to be replaced right away, as do all the attendings.

And for airway things, I was mostly going for suck/swallow issues, and general tachypnea whereby feeding makes it worse and thus they choose to breathe rather than stay hydrated.

That makes sense