Portal de Periódicos da CAPES

Leave No Vein Behind

2018; Allen Press; Volume: 23; Issue: 4 Linguagem: Inglês

10.1016/j.java.2018.10.002

1557-1289

Ramzy Nasrallah,

Nursing Education, Practice, and Leadership

Last month I decided I was paying too much for life insurance, so I switched carriers to a more competitive policy (please, don't turn the page yet—this story will get relevant and better).Making that change required a mountain of paperwork, signing my name on it close to 100 times and then, finally, a Saturday morning visit from an agent representing the new insurance company. They wanted to check me out and determine if my inevitable mortality was a sooner-or-later thing.That makes sense, however grim. Dead clients not only stop paying their premiums—they get paid! Insurance companies are basically at the track, examining all the ponies before deciding which ones to bet on.My Saturday morning visitor brought a large bag with her, along with more paperwork. This was a fasting interview, so I sat at my own kitchen table without any food to season. Ironically, it was me being peppered with questions about my health and wellness:The agent removed a scale from her large bag and weighed me twice in my kitchen, recording the second weight. She took my blood pressure three times and recorded the third reading. Then she took out a clear plastic bag containing blood collection supplies.Insurance companies need labs too. I was about to get phlebotomized.Over the years I've given thousands of in-services around the world demonstrating best practice for dressing changes and hub decontamination. In that time, I've also perfected a theatrical version of what bad looks like when it comes to using alcohol pads, whether it's on a device or on the skin.This demonstration involved me holding the pad by the corner and just sort of quickly slapping it toward whatever needs disinfection, rather than applying some pressure, friction, and actual time to clean it. It always got a chuckle because it was just so ridiculous. Once the laughter stopped, I'd show what good looks like: Friction. Time. Actual disinfection.So, my Saturday morning visitor unpacked her blood collection supplies, placed each tube and component in a convenient spot, and then surveyed my arms. I don't want to brag, but I've got the kind of veins that vascular access nurses can't ignore. I've caught many of them staring. Hi, hello, my eyes are up here. When I donate blood, they stop short of whistling.My visitor did not make any comments about my veins which, fine, I wasn't insulted. But then she tore open her alcohol pad, removed it with her index finger and thumb—and slapped it sort of near my cubital fossa interior. Thwap. Less than 1 second.That's it. She did what bad looks like. Hey, that's my move! I did not laugh.“Hey, could you do me a favor?” I asked her. “Can you apply a little more friction and time to cleaning the site where you're going to do your blood draw? I once got a fungal infection at my doctor's office on my arm from this.” That's true, by the way. It happened last year. The CEO of the Association for Vascular Access (AVA) got a local infection from a procedure where a needle spent all of 90 seconds accessing his vasculature.She seemed startled from her routine being interrupted. “Okay, sure!” She applied some pressure using her index and middle fingers to the top of the pad, going back and forth with her cleaning. “Thank you,” I told her.“No problem. I've been doing this for 35 years,” she said, trying to reassure me but not realizing that my jaw was dropping in my thoughts. “What do you do?” I told her. “Ah.”She gave me a squeeze ball and tied off my arm, two vein-popping interventions that I generally don't need for the procedure. She then aimed her needle at my median cubital vein, and I braced for the normal split-second pinch. One second. Three seconds. Eight seconds.“Hey,” she said to me, “tell your vein to stop jumping.” Her monotone suggested to me that over her 35 years of experience, she has made this request to patients far more often than she has not. I was now sitting at my kitchen table with my arm outstretched toward a clinician who was blaming my veins for her inability to properly execute one of the most common procedures in healthcare, and one she should have nailed in her 4 decades of doing them. A blood draw.Over the next ten minutes, she stopped and started twice. When it was clear my vein wasn't at fault, it shifted to the needle and the syringe. “Operator error” never entered the equation. Every blood draw I've had in my life, combined, took less time than the one I endured in my kitchen for the sake of saving some money on a life insurance policy.It resurfaced a question I've asked myself over the years: Why isn't phlebotomy an area of focus for AVA? Shouldn't it be? I ran the question by Judy Thompson, AVA's Director of Clinical Education:It's taken decades for peripheral IV (PIV) access to finally make noise as an area of focus in healthcare, as it's been taken for granted for so long. Insertion, care and maintenance, clinical indication, an overlooked and underappreciated source of complications—PIVs are finally getting notice. Why has it taken so long? Is it the word peripheral? Is it that PIVs are marginalized in nursing and medical school curricula as “one of those things you just sort of learn as part of your career after school is over.”That sounds a lot like phlebotomy, doesn't it? Blood is drawn so often that it can't possibly be a source for complications. It's a ubiquitous procedure, and yet it's one that virtually every patient can identify with as part of the healthcare experience. And like PIV complications (prior to the current era) data on outcomes related to blood draws are scarce. It's not really something that's being investigated.But it is yet another area of practice that AVA should be equipped to improve. AVA is a multidisciplinary organization for experts, novices, beginners, and patients. We should be able to bring phlebotomy into our ecosystem seamlessly. We are protecting patients, educating clinicians, and saving lines.So yes, phlebotomy is within AVA's scope. We will leave no vein behind.