Words of Wisdom from and to Phlebotomists

The secret to being a good phlebotomist is NOT to look for the vein, but to feel for it. If you feel for it, you will find it! -- Anonymous Know whether there is any new information about the collection. -- Hussam Make sure to balance COMPASSION with DETATCHMENT! -- Melissa Roe (PBT ASCP) Remember the patient! If you are having trouble getting blood, then please suck up your pride and ask someone else. It is ok to have an off day!!! -- Angie Smile and talk to your patient. If you act confident and calm, you will help your patient feel at ease. -Jen If you can't find a suitable vein in the bend of the arm it's ok to draw from an alternate site, but remember not to draw from anyone's foot if they are diabetic! -- Anonymous ABG's must be drawn from the wrist but remember it is painful for most patients! -- Anonymous One of the preconditions for dealing successfully with difficult patients is an initial analysis of the possible reasons for their behavior! -- Anonymous In case you didn't know the difference between Vacutainer Blood Collection Tubes: SST refers to the Serum Separator Tube containing clot activator and serum separator gel. PST refers to the Plasma Separator Tube containing lithium heparin and plasma separator gel! -- Anonymous Vacutainer is a registered trademark of Becton, Dickinson and Company. The proper name for the device is needle holder. -- Regina Brown If you want to use a 22 gauge needle to do a hand draw using a separator tube, release the vacuum in the tube. It will allow for 1/2 of the tube to be filled with blood, and will also decrease the possibility of a hemolized specimen, and a hematoma on the patients hand! -- Michael The United States Postal Service has changed their shipping requirements for dried blood spots effective January 1, 2004. These revisions are for implementation of the new packaging requirements for diagnostic specimen mail pieces using a business reply format. Mailing envelopes must now have a biohazard label attached to it. You can read details about this USPS revision under 8.0 Infectious Substances (Hazard Class 6, Division 6.2). -- Robin Rotating the patient's wrist gently in either direction while palpating can move the vein away from a close by tendon or bone, reducing the risk of hitting something other than the intended vein. -- Sue If the patient feels dizzy or faint in the middle of the venipuncture procedure special precautions should be taken immediately. The procedure should be discontinued at once and the patient should be asked to place the head between the knees. After a brief resting period the patient should the be asked to lie down on the examination table. Here it is recommended to take a blood pressure reading and record it

into the patient's record. Chances are the patient recovers after a period of monitoring and agrees that the procedure will be continued. -- Anonymous To put an apprehensive patient at ease, tell them that you're going to count to 3 and that they should take a deep breath at that time. Wait for them to start to take the breath and stick them at same time. Their mind will be at taking the breath that they won't be thinking about the stick. Make sure not to hesitate when sticking. The slower you are at inserting the needle the more it will hurt the patient. Be swift! -Estela When drawing blood, right before the actual stick, I ask the patient to take a deep breath. Number one, their concentration is on the breath more than the actual stick and they do not notice it so much, number 2, it gives them something to do. This is repeated as the needle is withdrawn, also. All this diverts their attention and has worked successfully on apprehensive patients as well as pediatric patients. -- Susan No fist pumping! Having the patient making a fist and holding it for better vein fill as opposed to pumping the fist. Pumping can increases the potassium release thus elevated K. It's worked better for me in my nine years as a phlebotomist! -- Anonymous Not only should you not bandage the puncture site until bleeding has completely stopped you should also first inspect the site carefully to see if a hematoma is forming -- in the event that it does, it must be entered into the patient record (chart it!) -- Frank A word of caution: placing a Band-Aid on baby's finger is not recommended. It could be swallowed! -Ramona Direct pressure is best in reducing formation of a hematoma. Keep your finger on the phlebotomy site after the draw instead of letting the patient do it. Your finger was there first! Tape the cotton ball down tight for added pressure. And don't let them bend their arm up either. -- Anonymous ATTENTION: Whoever suggested to put the tape over the COTTON BALL has not reviewed the latest NCCLS standard that refutes the use of cotton balls in favor of a 2 by 2 gauze pad. -- Anonymous

If you can't find the vein after the tourniquet has been placed, have the patient bend the arm slightly up. This will make the vein pop up better. -- Anonymous After two unsuccessful sticks no further attempts to draw blood should be made without the patient's consent! From then on forward any further attempts also depend on the policies of the laboratory, supervisory guidance, and the experience and training of the phlebotomist. For example, having another health care worker such as a laboratory technician, nurse, or physician try to collect the blood sample when a phlebotomist has failed is very appropriate. -- Anonymous I use the butterfly needle on elderly and children like everyone else. But when I use it on elderly I normally pull back on the patient's skin to straighten out the vein or make the skin more stable before I put the needle into the skin. This helps me when it's time to stick, and the patient feels less pain while the procedure is done. -- Mauldine P.

Most injections or draws are all in your mind. If you know you can get it chances are you will!!! You must do it in your head first! Start by visualizing. -- Jesse C. When drawing on a patient with "rolling veins" ask them to lay their arm down but instead of palm up, have them twist their wrist palm down. Great for elderly patients!!! -- Bethany Never "smack" the arm of a patient to make difficult veins more pronounced---this can cause hemolysis of the blood cells, and therefore give inaccurate results. -- Helen COMMENT: Smacking any site is completely unnecessary and will cause hemoconcentration of cells (resulting in erroneous and misleading lab results). It also elevates a patient's white cell count because the body perceives this as an injury! -- Lynn

If you rest the tube loosely in the holder before the poke and leave it in the holder (after releasing it from the needle of course) after the poke, you can complete the draw faster and save yourself unnecessary steps. This is very important when drawing combative patients (and children!) as you want to get the draw done as quickly and efficiently as possible. -- Susan Students should also learn how to hold the second tube and cotton/gauze in their other hand instead of relying on setting things down. In real life (settings like isolation room, drawing a prisoner, mental health patient, gurney in the ER, Alzheimer's patient in a wheelchair, etc.) you do not have the luxury of setting your tubes down on a table after filling them! In reality we shouldn't be setting anything in a patient's bed either. Therefore, it is helpful to practice holding your supplies while switching tubes from the very beginning, if you plan on working in any setting other than an outpatient drawing center. -- Susan When you come across a very difficult stick have the patient hang the arm down to the side to let the veins fill up. This works nine times out of ten! -- Elizabeth Rodriguez When you insert the needle into the patient's arm it is good practice to switch the hand that's holding the barrel. This way the dominant hand is the one inserting, and changing the tubes. This stabilizes the needle holder/barrel better and prevents the needle from moving each time the tube is changed. -- Natalie COMMENT: Any phlebotomy textbook will tell you that hand-switching is not recommended (although it is sometimes done by experienced phlebs). Hand-switching results in less control and more likelihood of moving the needle; it is just one more unnecessary step that makes the draw take longer than it has to. Try being drawn by someone who switches hands: I've had patients report that it makes them nervous to see someone reach over their arm where the syringe is. -- Lynn

Always keep in mind that part of your job is to remain confident and to make your patient feel comfortable in knowing a professional is behind the needle! -- Tanya Go into every phlebotomy with "nothing to prove". Listen to the patient's concerns and helpful advice. After all, it is their body. If they request a butterfly use one whether you think it is needed or not, remember you have "nothing to prove". -- John Wright

The most important part of this job is self confidence. If you begin to doubt yourself, your work suffers. "Hello. I am here to collect a blood sample." sounds so much better than "I have to try and collect a blood sample."("May I," or "Is it okay if I collect a blood sample from you?" is also no good. You'll get more "NO"s than you will specimens.) Also remember that fear and negativity are communicable. A patient will pick up right away on any nervousness or uncertainty, be it a look on your face or a shaky hand or a quivering voice. -- Nick The second most important thing is looking and sounding as if you know what you are doing. Don't use slang words, be mindful of what you are doing at all times, and always make sure you look prim and proper in your uniform, clean, and with neat hair. Health care professionals should hold themselves to a higher standard. The patient's lives are in our hands! And never take anything personal. Remember that to them you are an unfamiliar person and you have sharp needle. -- Nick Venipuncture area should be cleansed with prep pad prior to applying tourniquet to avoid possible hemoconcentration. -- Angela Remember, when using a vein in the hand, use smaller tubes also! Do not try to get a 10 mL tube from a vein that you had to use a 23 gauge butterfly needle to access. The size of the tube should be compatible with the size of the vein. -- Cheryl Coverdale Remember to always make sure that you have the correct patient before you... You are required to have two patient identifiers such as medical record number, DOB, name etc.. Also, ask the patient's name and DOB (if able) as you look at the arm band and double-check the requisition slip. After drawing the blood, it is mandatory that the sample tubes are labeled at the bedside, thus ensuring the correct patient was stuck. -- Jessica S Wear a closed lab coat as it is for your own safety and reflects on the reputation of your lab. If you look or act sloppy the patient will question the quality of their results. -- Anonymous

Errors Seen In the Phlebotomy YouTube Videos

The YouTube videos are NOT HERE TO TEACH phlebotomy techniques, but merely to show different scenarios of the phlebotomist's daily routine. Here are some of the mistakes fellow phlebotomists have noticed and reported to us:

Of the videos I have watched, not one person released the tourniquet before removing the needle. That is why they are all messy! Insert, get flashback, remove tourniquet, then remove needle while putting pressure on the vein. -- Matt Wegner from Connecticut I noticed that the phlebotomist did not invert the tubes with blood samples in it... inverting of tubes facilitates the proper mixing of the additive in a certain tube. -- L. Carlos from Toronto The phlebotomist collected the sample in incorrect order of draw. She collected the lavender first, instead of the red first, then last the lavender. -- L. Carlos from Toronto

COMMENT: Sometimes tubes are not drawn in order, because the patient is a poor draw; therefore the most important test tube is drawn first and then the rest are filled as long as the vein cooperates. The tubes should be annotated accordingly. -- Mary

ATTENTION: This is grossly incorrect. Order of draw set by CLSI (Formally NCCLS) is done so for specific reasons - primarily additive crossover. For example the anti-coagulant EDTA found in the lavender tops is potassium enriched and it also binds calcium. Therefor, if a lavender tube was collected before a chemistry tube then several results including K and calcium would be inaccurate. Please follow all CLSI H3-A5 standards completely. -- Joshua M. Hinton, CLPlb (NCA) Phlebotomy Specialist Here are some of the errors I found: 1. She collected the samples in the incorrect order. The lavender should never come before the SST. 2. She did not immediately invert (mix) the tubes. Just tossing the LV to the side. 3. She did not place pressure on the site long enough, and she never checked to see if stasis was complete. The positive things of this video are: 1. Her attitude. She was very pleasant and even received the best complement a phlebotomist could get - "That didn't even hurt at all." 2. She properly anchored the vein by pulling down with her thumb - Not by making a "window" or a "C" - pulling down with her thumb below the vein and up with the forefinger above the vein. This puts the forefinger at risk for a needlestick. 3. She immediately started to label the tubes. -- Joshua M. Hinton, CLPlb (NCA) Phlebotomy Specialist

Policies require that the amount of time the tourniquet is left on the patient's arm is limited. All supplies should be set out and ready for use. It has even been suggested to release the tourniquet as soon as flow is obtained, however, I find this a bit premature. On the flip side, extended use of the tourniquet can give inaccurate values. -- Natalie The phlebotomy instructor did not cleanse the site of puncture after she touched it with their gloved finger. You must not repalpate the area after cleansing it. -- Cindy Unlike as shown in the video, the correct way of venipuncture is to locate the vein, clean the site, and never touch it again before entering it with the needle. Touching the site again after cleansing contaminates the site. -- Lalyan Carlos COMMENT: It looked to me as if the instructor touched the site after cleansing, however, if you watch closely you might notice that she first swiped her gloved finger over the antiseptic cleanser. I have seen this done and was told it was acceptable in hospitals by the RNs. -- Mary

There are several errors with this video. Here are the main ones that I noticed:

1. Tourniquet placement. It needs to be higher. 2. The amount of time the tourniquet was in place. A tourniquet should never be on longer than 60 seconds. Hemoconcentration will build and alter test results. 3. I cannot tell how old this video is, but there was no safety device on the needle. In 2000 congress implemented the Needle Stick Safety and Prevention Act requiring that all needles have a safety devic (Engineered sharps injury protection.). 4. The use of a cotton ball. CLSI (formally NCCLS) suggest against the use of cotton balls for a few reasons. The most prevalent is, the fibers of the cotton can cling to the stasis clot. When it is removed it can take the clot with it, reopening the venipuncture site. This can result in minor discomforts such as a bruise or small hematoma. -- Joshua M. Hinton, CLPlb (NCA) Phlebotomy Specialist

Never place your finger directly above the puncture site to anchor the vein as shown in the video. You could wind up sticking yourself if the patient makes a sudden unexpected move, or if you get distracted! It happens in a blink of the eye. -- MDR The phlebotomist should never make a "window" with her fingers to access a vein. If the patient were to jump, the phlebotomist could stick him/herself. Use proper technique to anchor the vein! -- Rhonda Huskey According to NAACLS standards, the tourniquet should be placed 3-4" above the venipuncture site; the tourniquet should never be left on for more than one minute to avoid hemoconcentration; and you should only anchor below the venipuncture site, no fingers above the needle as the instructor did in the video. Also, it is acceptable not to remove the last tube from the hub when withdrawing the butterfly needle; otherwise the needle may drip blood, because the tubing is full (as seen in the video at the very end). -- Lynn I noticed the tourniquet was left on the student too long. Also, a gauze pad should have been applied before pulling the needle out. -- Jennifer Pietkiewicz The Phlebotomist should NOT have used COTTON to apply pressure. She should have used a GAUZE PAD. (Cotton fibers may stick to the wound, and when pulled off, reopen the puncture site.) Also, She used an alcohol pad to prep the area, let it dry like she should have, but then right before the puncture she wet her fingertip w/ alcohol so that she could "Find the vein" and punctured while it was still wet. This should not be done because it's unnecessarily painful for the patient. -- Trixie COMMENT: NAACLS may suggest gauze over use of cotton balls, but many facilities provide only cotton so you have to be able to do your job with whatever supplies you are given . . . -- Lynn

The phlebotomist did not invert the tube after collection and to make things easier, items should have been placed on the other side so she wouldn't have had to reach across the patient's arm. -- Derek Griggs I find it unusual that the phlebotomist finishes up the puncture site with what looks like vet wrap wrapped tightly over a cotton ball and around the entire circumference of the arm. One thing to consider when wrapping any type of bandage around a limb is that this might constrict blood flow to the rest of the extremity. -- Paul Rice

The site was cleaned improperly. Cleaning should have been in a circular motion starting from the center out. Next, the tourniquet should have been applied and then the site cleaned -- Todd