Cannulation /venepuncture and doctors in the NHS

DIFFICULT CANNULATION/BLOODS 

This is a pain for everyone. When I started in the NHS, I used to struggle a lot. Just like everyone else. However with time I learnt some tips:

1. EQUIPMENT  

Prepare everything beforehand. Equipment varies from trust to trust but the basics remain the same 

- Torniquet 

- Cannula : I always use a blue 22 G one UNLESS the patient needs a CT scan ( in which case a green 18 G or pink 20 G is needed) OR the patient needs agressive fluid resuscitation ( in which case I go for a grey 16G cannula) 

I always take at least 3 cannulas ( I always take the blue 22 G one in case I cannot get a bigger one in , I go the smaller one)

- Alcohol wipes: take at least 3 in case you need to clean another area.  

- IV bung 

- Flush : take at least 2 - connect the bung to the IV flush and prime it. 

- Tegaderm 

- Sharps bin 

- Disposable tray 
In COVID-19 season, we should be wearing PPE as per local policy

2. THE PROCESS 

Prepare your equipment 
Wash hands 

Put on PPE as per hospital policy 

Switch on the light - very important. NEVER EVER cannulate a patient in dim light. 

Greet the patient, introduce yourself and take verbal consent 

Talk them through the procedure:

- 'I am going to feel for a vein now' - Palpate the vein if it is visible. 
- 'I am tying a torniquet tightly around your arm. Just bear with me.' ALWAYS ensure the skin is not folding which may cause abrasions especially in frail patients who have delicate skin ( Putting your fingers underneath the torniquet while tying it helps - or gauze pieces) 

-'I am going to clean the area with an alcohol wipe. You will feel a cold sensation'

- ' Now you will feel a sharp scratch' - take the needle out of its sheath and insert it. You will see blood flowing through the tubing. Slowly remove the needle while insterting the tubing into the vein.  

- Remove the torniquet 

- Connect the bung with flush ( primed beforehand) and flush the cannula 

- Apply the tegaderm 

- Date the cannula 

- Dispose off the sharps 

- Clean any spillages 

- Thank the patient and switch the light off 

This process takes a minute - It took me 15 minutes to do my first cannula. 

3. INSERTION POINT - IF THE VEINS ARE CLEARLY VISIBLE 

Examine the upper limbs thoroughly.

My favorite vein is the cephalic vein ( I had to Google the name of this as I call it the big 'hot' vein on the front of the forearm ( I am not very good with anatomy). Here is a picture to show which one I am talking about:

The advantage of going for this instead of let's say, the big juicy median cubital vein is that the cannula will remain intact if the patient bends her/his arm. 

I then tie a torniquet

IF THE VEINS ARE NOT VISIBLE 
Tie the torniquet, see if a vein pops up, palpate for a vein. 

I tie a torniquet and warn the patient that I will be tying it very tightly so that I can see the veins clearly to avoid multiple tries. This way, I avoid the usual oohs and aahs I would get had I not warned them. 

I then wait for a few seconds to see a hidden vein pop up. If I still cannot feel anything, I palpate for the median cubital vein. If i cannot find that, I look at the posterior part of the arm to look for basilic or accessory cephalic veins 

If I still cannot find anything, I look for one on the hand and wrist- usually I find a nice one on the lateral side of the wrist - the cephalic vein. 

Although be aware that this can be painful especially if there is bone underneath and the patient may dislodge it by moving the wrist. 

If I still cannot find anything in the arms uptil the elbow, I look above. Sometimes there is a juicy vein above the elbow - be careful not to go too cephalically either. 

If I cannot find any vein in the upper limb, I go for the lower limbs. This is not ideal and would never go for it if the patient is diabetic ( to avoid infections), has active cellulitis in that area or needs IV antibiotics or IV contrast - which basically leaves these limited to IV fluids. 

IF I STRUGGLE TO FIND A VEIN IN THE UPPER LIMB 

I call my ITU colleagues to help with an ultrasound probe. Some of my SHO colleagues know how to use the ultrasound but I will very honest - at the time of writing this blog post, I am not very competent or comfortable with using a probe - mainly because I am worried I will break the probe and have not been able to familiarize myself with the ultrasound due to COVID-19 ( I promise I will - if my supervisor is reading this post). 

My colleagues in ED are very good with the USS machine and hence I ask for their help if I struggle. 

IF YOU HAVE TO TAKE BLOODS FROM THE CANNULA 
Attach an adapter which may look like this BEFORE FLUSHING THE CANNULA :

Attach the vacutainer(s) to it and take out the necssary amount of blood. 

After removing the adapter , clean the cannula with an alcohol wipe and attach the primed bung and flush and proceed as explained before. 

BLOOD CULTURES 

Bloods cultures should NOT be taken from cannulas and you should take them from a different peripheral access. However sometimes, this is not always possible so if you take then from the cannula BEFORE FLUSHING it, always mention on the request form that you have used a cannula to take the cultures. 

VENEPUNCTURE 

Most trusts have this butterfly to which you attach the vacutainer holder ( already attached in this pic):

The method is more or less the same after washing hands, wearing appropriate PPE, greeting, consenting the patient and ensuring you have enough light:
1. Apply torniquet 

2. Palpate for a vein

3. Clean the area 

4. Attach the butterfly to the vacutainer holder 

5. Attach the vacutainer(s) 

6. Remove the needle, retract the butterfly so that the needle is no longer exposed and put a cotton wool on the insertion site. 

7. Remove the torniquet at the same time.

8. Dispose off the used equipment 

9. Label the bottles and send them to the lab. 

SOME TIPS:
1. If you are doing bloods on a newly admitted patient, ALWAYS do a VBG. This will give you an idea of the pH, Hb, lactate, potassium and other parameters immediately. Attach the VBG syringe after step 5 above. 

2. Always use the blue 22 G butterfly - it is the thinnest one and hence least painful. 

3. If you are doing a cannula, you can do bloods from the same cannula as explained above hence saving the patient multiple pricks 

4. If you are struggling to get blood from anywhere ( especially in IVDUs), there may not be any other option but do a radial stab. Rememeber to put pressure on the cotton wool/gauze as blood may ooze out. 

5. If you are struggling to cannulate a frail patient just for IV fluids, you can consider subcutaneous fluids. 
6. NEVER EVER do cannulas/bloods from an arm where there is a functioning, active AV fistula for dialysis. If you struggle to get bloods from elsewhere, the dialysis nurses are more than happy to do bloods from the AV fistula site ( only the renal team and other trained health care professionals can do this as special precuations need to be taken)

7. If a patient is agitated, give some mild sedation (lorazepam vs haloperidol) to calm them down. They will pull their cannulas out as soon as you put it in.

8. Bandage the cannula in confused patients so that they do not pull it out. 

IF YOU ARE STRUGGLING WITH CANNULAS/BLOODS

Everyone struggles initially. However with time and practice, our technique and confidence improves. 
1. Practice as much as you can. Good, visible veins are the easiest to cannulate and will build your confidence.

If you have just started in the NHS, observe your colleagues do a procedure, then do it under their supervision, then do it independently and then teach others. This is the best way to learn. 

The best way to learn is to let your colleagues allow you to do bloods and cannulas. They will be relieved that there is someone else on the ward who can do them. 

2. Practice on mannikins. There are plenty of oppurtunities for new doctors in the simulation lab to familiarize themselves with techniques and local equipment which may vary in other places they have worked or in the PLAB 2 exam. So talk to your supervisor to see if you could practice in a safe environment. 

3. Ask someone else to have a go after trying a few times. My cut off is twice. If I struggle, I ask for help. And even as  ST4 trainee registrar, I sometimes struggle. 

4. Be patient - never rush. This is when mistakes happen. Like leaving the torniquet on for a long period of time and forgetting about this ( it can cause lack of blood supply to the limb if left on for long ), not disposing off the sharps properly , etc. 

5. Keep doing it. I worked as 18 months as a non trainee SHO and 2 years as a core medical trainee, 1 year as a ST3 and now as a ST4 trainee, I still try to do as many cannulas and bloods as I can. I hated those registrars who used to ask the nurses to bleep the SHOs when they could have done it themselves! 

And in your free time, do this.....

MY EXPERIENCE

When I was a non trainee SHO, I used to struggle a lot initially. So I started doing cannulas by requesting the CCU nurses to allow me to do them and observe me. In a few days, I got competent enough and then started to take up the challenging ones - I used to give my number to my FY1 colleagues when I was a core medical trainee and used to ask them to call me if they struggled when we were on call. I showed them how I did it and they too learnt some tips and tricks and now they do the same as SHOs. 

As a registrar, especially during COVID-19, I requested the FY1s and SHOs to attempt cannulas maximum twice and if they did not get them in, I asked them to call me to avoid prolonged viral exposure. This is where my previous SHO experience came into play and I was able to cannulate a majority of the patients others were struggling with. 

I still do struggle from time to time and my other FY1 and SHO colleagues easily get one in - a second pair of eyes always helps.

But is it our responsibility? 
As doctors, yes it is our responsibility however this should not impair our learning and other skills. 
For example , expecting to do bloods on 20 patients on the ward or when on call  when you come in to work is unacceptable.  
Solution ( which I have witnessed in the different trusts i have worked in ) 
Out of hours 
Have a clinical support worker who is a HCA who is trained to do bloods, cannulas , ECGs and catheterization out of hours. I had such a team in Scarborough hospital and they carried a bleep out of hours. The nursing staff would bleep them first and if they struggled ( very rarely ) , the on call doctor would be bleeped. 
On the wards 
Have a dedicated phlebotomy team. I witnessed this in York and Scarborough. There were a team of 10 phlebotomists who did the ward rounds at 8 am ( hence we had to make sure bloods had been requested for inpatients a day before) 

What about the nurses ? 

Yes nurses above a certain band are trained to do bloods 

Then why can they not do them all the time then? 

If you work in the NHS you might notice that they are extremely busy and short staffed as well. They have been trained to do bloods but that have so many things to do. Some of which include 

1. Documentation- their documentation is more thorough than our ward rounds. We do not get to see this often in our notes as they have separate notes to document their care on. 
2. IV medications- half the ward is on IV medications. This takes time to prepare and only certain band of nurses can do this. 
3. They are responsible for controlled drugs - hence if any patient is on a controlled drug , they need to open that cabinet, document how much they have taken and then administer it 
4. Drug rounds - administrating medications takes ages especially with everyone being on secondary prevention these days 
5. Updating families - they take phone calls and provide an update by going through the medical notes. 

This list in no way complete and I have mentioned more points here 

http://omarsguidelines.blogspot.co.uk/2018/01/nurses-in-nhs.html

But they are trained to do it and hence it is their responsibility.

Unfortunately they are trained however due to being so busy and understaffed, they cannot help here. Hence they usually request doctors to do it. 

In my trust, nurses do it. 

Yes. In some trusts and wards, we have student nurses, ACPs, ANPs and friendly nurses in charge who do them. 

Then why can't they do them all the time ? 

Because it is not the same situation all the time. They are extremely busy as explained before. 

What is acceptable? 

Every ward should have a phlebotomists ward round in the morning and then any additional bloods cannulas should be done by the doctors if the nurses is busy. There will be a maximum of 5 to do in one day. And if you divide this among your colleagues, you will do maximum 1 or 2. 

Do you think it is my job as a SHO to cannulate/do bloods ? 

Your job is to learn new skills, maintain patient flow , take care of patients and manage them well as per the GMC guidance. 

https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/duties-of-a-doctor

This falls under this as well. You can argue that it is not specifically mentioned in it however you can ask any FY1 or SHO working in the NHS whether they do bloods or not. You can also as consultants if they expect junior doctors to do bloods. They will inform you that this is the case. However you as a doctor are NOT expected to do bloods for ALL patients on the ward - a few ( let's say 5 or 6) is acceptable. 

What if I cannot do the aforementioned things as there are no nurses, phlebotomists, clinical support teams to do bloods and cannulas ? 

You need to talk to your colleagues and then write a joint email to the management so that they can help. 

https://omarsguidelines.blogspot.com/2020/01/bullying-and-stress-in-nhs.html

What is it like for you, as a registrar?
When I am on call and based in ED resus where we get loads of patients ( we have 10 beds which can be filled up quickly with trauma patients, overdoses, unwell COVID-19 patients, upper GI bleeders) and sometimes, out of hours there are 2 ED registrars and 3 ED nurses looking after all of these patients with extra support from th ED consultant and ED SHOs. Despite this, it can still be busy hence I see the medical patients directly. If the nurses are busy, I just take the bloods and cannulate the patients myself. 

In ambulatory care, we have 2 nurses who can do bloods but sometimes they can be doing ECGs and taking bloods from other patients and if a patient needs a repeat troponin, lets say rather than waiting for my nursing colleagues to finish, I take the bloods myself. 

On the medical shift stay wards, I do senior reviews for patients who have been post taked already to assess whether they are fit for discharge/transfer to another speciality. As my FY1 and SHO colleagues are busy with the consultant ward rounds, discharges and doing other jobs, I do the bloods for the patients I see unless I am very busy - in which case, if it is non-urgent, I add it to the job list which we all plough through together after the ward rounds. 

When I am on call on the COVID wards, if my FY1/SHO colleagues struggle ( they can try maximum twice), I take over as I do not want them to get over-exposed to this horrible virus. 

For me, after 5 years in the NHS, it is not a big deal. Just like typing up a discharge summary is not an issue. 

When I started in the NHS , I expected nurses to do bloods however I quickly learnt how busy they were and was lucky to work in trusts where I didn't spend the whole day doing this. I tried to do as many as I can and I actually used to give my contact details to my colleagues to let me know if they were struggling when I was a core trainee as I wanted to develop this skill so much to avoid multiple attempts on patients ( i am needle phobic hence I can relate ). 

As a registrar, I still do my own bloods and cannulas unless I am very busy in which case I request my nursing colleagues if they are free or my other colleagues. 

This is an important skill to have and with practice I can confidently do this within 2 minutes and can cannulate most difficult patients. If I struggle, I always ask for help. 

I as a registrar would have not been able to help with difficult cannulas and venepunctures had I not learnt and practiced well as a SHO. However I delegate tasks if I am busy and I used to do the same as a SHO. 

I have also seen some amazing consultants do their own cannulas and bloods occasionally I too , will always try my best to support my team no matter which level I am working at. Working in the NHS is a team effort and we are all here to help each other for the betterment of patients. 

So the bottom line is, 

If someone asks you to do a cannula/do bloods, do them! However if you are asked to bleed the whole ward, escalate it. And when you are a registrar, help your colleagues by doing cannulas and bloods whenever possible- be the registrar you wanted to work with when you were a FY1/SHO.