Vent: "I should warn you, I'm a tough stick..."

LindsayRNer · Dec 1, 2011

I think the point is, there is no magic information revealed by the patient stating, "I'm a hard stick". If that is truly the case, I can conclude that after about 20 seconds of examining you.
Some people truly have very poor venous access options, either from medical conditions, lifestyle choices, habitus, or simply quirky venous anatomy.
But as this is a vent -- we ER nurses hear that repeatedly throughout any given day, and many times from patients whose veins I can see from the doorway, and who seem almost put out when I pop one in with no effort at all. I don't understand what the psychological secondary gain is from being "a hard stick", but I've seen this phenomenon too many times to discount that it is a factor in a suprising number of patients.

I like these ones where you pop in an 18g no problem in their wrist or forearm, one shot and DONE!

I did however have a pt who neglected her health the other day (shocking!) 1st time I ever saw one get started towards the breast. It was frustrating to me cause that day I was just "off" on my IV starts. Couldn't get them anywhere but the AC.

LovePeds12 · May 18, 2012

Seriously? If I had a dollar for every time I heard this and got it on the first stick, I'd be retired.

I am a VERY hard stick and luckily I don't have to deal with people like you very often. My veins actually ARE super, super deep and they love to roll or stop giving blood mid-draw. I've had blood taken from my wrist when dehydrated, I've had veins blown more times than I can count. I've had nerves hit and purple bruises for weeks. It is super rare that someone can get me first try and when I say "please use the butterfly I MEAN it..use the effing butterfly. I've had grown men sweat bullets trying to draw blood and I am cool as a cucumber and super patient...even when I've been poked 8 times because I know it is not their fault. I will always be good about it as long as the nurses keep listening to me. I am a nightmare stick, I pray I never get cancer because it would be a nightmare. Getting an IV w/out lidocaine is pure hell for me, my veins spasm and it hurts like a (*$#*)($ but I remain calm because I know not all places use it and you bet I want to KISS the ones that do.

Anna Flaxis, BSN, RN · May 18, 2012

I am a VERY hard stick and luckily I don't have to deal with people like you very often.

Really? You'd rather get the nurse who isn't good at IVs and has to poke you a gajillion times? Okay, to each their own.

It is a myth that veins "roll". If a nurse tells you that, they're making excuses for their poor technique. Also, you can prevent veins from blowing by not using a tourniquet, by choosing the right gauge and length of angiocath, and by minimizing having to manipulate the angiocath once you hit the vein. You can usually tell just by looking if someone has veins friable enough to blow, and adjust your technique accordingly.

Also, you can't use a "butterfly" to start an IV. You need an angoicath for that. So, sorry, if you need IV access (because you're dehydrated, for instance), I can't use a butterfly on you (which, by the way, "butterfly" is a type of venipuncture needle; they come in the same exact sizes as angiocaths). If you come to the ED, chances are you need peripheral access. I can't just draw blood and pray the doc doesn't order anything IV. That is not serving you well, and *will* result in multiple pokes, because it is much harder to place an IV than it is to draw blood.

It's super easy to hit a nerve when going for a wrist vein, which is why it's a practice that is discouraged. The key there is to use tons of alcohol wipes to make the veins more visible, to go super shallow, and to use the smallest angiocath you have. I have never hit a nerve going into the wrist.

And, if you had cancer, you'd get a port, so you wouldn't have to worry about being a pincushion just to check your labs. Be thankful you don't need a port, though.

But, whatever, luckily for you, you don't often have to "deal with people like me", who maybe know a thing or two, right?

Altra, BSN, RN · May 18, 2012

Ah, the secondary gain provided by being a "tough stick" ...

Anna Flaxis, BSN, RN · May 18, 2012

Ah, the secondary gain provided by being a "tough stick" ...

Exactly.

theantichick · May 18, 2012

I don't know what they teach anymore, but when I was in paramedic school years ago, we were told if we had any indication that the patient would need blood, they needed an 18 or better if we could at all manage it. And yes, field personnel seem to have a preference for the AC, it's easier. When I was in the field, I didn't like going to the AC unless it was dire, because I knew if it blew, I'd toasted the entire arm for the hospital staff, which would end up causing the patient more problems. I was an oddity because most of my fellow paramedics had disdain for nurses, I hold out hope that's no longer the case, but I'm not holding my breath.

I usually have decent veins, not great but not super horrible, most experienced nurses get me on the first stick. The only thing I dislike is starting them in my hand - they're always super positional in my hand and my hand veins blow very easily. I'd rather you start near my wrist/low forearm. I've always made that request very nicely, and I've yet to have a nurse insist that she just HAD to start it in my hand.

Anna Flaxis, BSN, RN · May 18, 2012

Typical protocol outside the emergency area (on the inpatient unit, for instance) is to start distally, with the smallest reasonable gauge angiocath. Of course, the choice of veins and gauge is dictated by considerations such as the patient's clinical condition, diagnostic imaging requirements, medications likely to be infused, etc. For EMS providers, "worst case scenario" dictates practice, and so practice is not to start distally, but to get a large angiocath in a large vein. If your patient codes on the way to the hospital, you don't want to be fluid bolusing and pushing ACLS meds through a 24g. in the hand.

I don't like using hand veins unless that's all there is, or if the patient requests it and their clinical condition doesn't contraindicate it. If they need IV contrast, I can't put it in the hand. It has to be above the wrist. IV contrast extravasation is not pleasant.

I try to give the patient as much choice in IV placement as possible, but I have had to explain to many a patient why their preference is not going to work for the intended purpose. Most people are *very* reasonable when you explain the whys of it all.

glutton4punishment · May 18, 2012

Yep. EVERYONE says it where I work as well. I am only 6 months in ER, and when I first started, it made me all self conscious until I realized that more often than not, my patients immediately tell me that. For some reason, some people enjoy it when they are a hard stick, I don't get it. Maybe it makes them feel special or whatever..or maybe that's just my perception of it. Anyway, yes! It cracks me up now when someone says that.

And just to continue agreeing with the OP, some patients actually are a REALLY hard stick. Especially the ESRD folks.

BTW, do y'all use lidocaine freely? I have never once used it. If it's a child that is around the 6-7 year old range, I will put EMLA cream on. I really don't like that age because they are old enough to understand, but not really understand and it traumatizes them.

Anna Flaxis, BSN, RN · May 18, 2012

No, we do not use lidocaine for adults. Kids get EMLA.

thelema13 · May 19, 2012

I don't like the hand either. I am quite fond of the saphenous vein, hard to miss and doesn't roll often. Even if they are a hard stick, I can usually weasel a 20g in. And in the case of the 16 year old that came in by EMS with 10/10 abdominal pain before school with 94 year old grandma in tow, laughing and calling me 'that white cracker' behind my back, who was constipated and wanted to eat breakfast 10 minutes after he arrived, I got a 14g in him.

CrashED · May 19, 2012

If I had a dollar for every time I said that and a nurse rolled her eyes, and then had to stick me eight times before calling in a SWAT nurse to do it, I'd be retired.

Does your hospital not have policy for venipuncture?? We are only allowd 2 attempts per RN unless its an arrest/emergency situation and then we pull out the old IO to get things going until we can get IV access!

I personally am a difficult stick, lets say my arms are well insulated since I am from the North! And I find the worst thing you can say to a nurse is "I am a hard poke"...if they know what they are doing when assessing for a vein then will know that you roll, have tiny crappy veins or are dehydrated!

BelgianRN · May 22, 2012

Kids get EMLA.

A regular: our wonderful diabetes nurse putting Emla on the hands of a nice kid only to bring him to the ER "oh I found this new type I he needs an IV and a load of labs drawn but I smeared Emla already..."

You take one look at the hands and look over at the ton of labs she wants drawn and look at your straight cath that isn't making the same circles as the hand veins and think *grumble*. I hate it when others decide where the kid should be sticked I prefer to choose my own site.