Of Tattoos, Needles and Hematomas

My students are always shocked when they come to work for BHTC and get me as a trainer.

Why are they shocked? you might ask.

They're shocked because in the classroom we teach everything by the book with few variations, except for some anecdote we might tell that relates to the subject at hand. Even so, we point out the "mistakes" and emphasize to the students that the way we're teaching them is the proper way to do things.

Of course, anyone who's ever done anything in the medical profession knows that there's the book way and the reality way.

The new trainees are shocked because I tell them right off the bat that they are going to see some things that we emphasized was unacceptable in phlebotomy.

An example would be the book's stance on drawing blood through a hematoma. In the pristine world of the book, every patient would present themselves with nice, bouncy antecubital veins, popping right up with the application of a BP cuff or tourniquet. The patient would peacefully let us do all draws with a straight needle, and we'd be in and out of the room in 2.5 minutes. Same with a tattoo. In book world, you get the impression that seeing tattoos will be the exception rather than the rule. And, if you see them, you will probably find that the patient will be ex-Navy, and you'll find the tat on the upper arm or on the inside of the forearm. And, of course since you're going to find that nice, bouncy antecubital vein, you won't even need to worry about those tattoos!

It makes me think that whomever wrote the textbook has stepped over into academia, and has not seen the inside of a clinic or hospital for a good number of years.

Much to my dismay, (and to my patient's, I'm sure!) it's a pretty routine thing to have to draw blood somewhere in the vicinity of a hematoma. Infiltrated IV's, numerous sticks, and massive doses of blood thinners make it all too common to see badly bruised up arms, mainly due to the trauma we've put them through during their hospital stay. There's also the "laziness" and "hurry up" factor of the staff to take into account. Some folks forget that we are supposed to be doing our job for the patient's health, safety and well-being, but instead, when you're running short-staffed and you have 40 patients to draw in two hours, and you are really wanting coffee, it seems to be easy to forget what you've been taught. So, the "finer" points of the draw get pushed aside.

As stated, reality is not the same as the book. So, having been a student a few years ago, I was still in my "book larnin'" phase where I needed to question everything that did not match up with what I'd been taught. I'm sure I was a pain in the arse to my trainers; I try to remember that with my trainees and blend the book and reality with what I hope is some common sense advice.

So, I remember my first experience with phlebotomy and the tattooed patient quite well. The male, late 30's, was post surgery. He had two separate IV's running on his left side, so a right side draw was necessary if we could find a vein. He had a huge hematoma from an infiltrated IV which had been in the right AC. Neither above or below the stick site was usable - the vein was still rock hard and very tender to the touch and only a foolish person would have attempted to draw at that site.

We began to explore the rest of his arm. Nothing visible on the top of the forearm, absolutely nothing of worth in the hand. He was a diabetic, so a foot draw was out of the question.

We both palpated the antecubital gently, following the vein path to determine if there was anything at all viable. Nothing.

The man was wearing his religious belief on his sleeve, so to speak. He had a beautifully done tattoo of the Sacred Heart of Jesus. It looked similar to this:



We continued to palpate his arm, even over the tattoo. I was still so new at this that I had to verify it with my trainer that I was, indeed, feeling what I thought I felt - the cephalic vein - right under that tattoo. She agreed with me that there was a vein, and a good one, too.

So, I did the stick. Through a tattoo, the first of many since. And I had to bite my lip to keep from laughing at the irony of it all. Not only was it my "first" tattoo stick, it was Jesus. I had a brief moment of wondering if lightning would strike me down.

You see, the vein I had to draw from was placed in such a way I had to stick Jesus right through the heart.