Weeks 48 & 49: The Blood Draw

Although I couldn’t see the normally blue-colored vein of my ‘patient’ (a classmate), once I tied the tourniquet around his upper arm, I observed a distinct bulge develop beneath the skin overlying his inner elbow. As I gently pressed over this bulge, it became clear that I was touching my patient’s vein, which was notably distended, elastic, and bouncy. I next popped the cap off the needle I would be using to draw a sample of blood from my patient. Positioning the needle slightly below the vein I aimed to puncture, I quickly penetrated the skin at a 30-degree angle, attached a test tube to the end of the needle, and watched as the test tube filled with my patient’s blood. As quickly and painstakingly nerve-racking as that, I had performed my first ever, successful venipuncture.

As is apparent, we have begun learning procedural techniques in my Clinical Skills course. The past two weeks have focused on blood drawing and insertion of intravenous (IV) tubes. The blood draw I described above was my second attempt on a classmate. My first attempt did not go as smoothly as the second…I got a blood sample, but I entered the skin at too low of an angle, so it took a bit of re-positioning of the needle to actually puncture the vein before the blood started flowing into the test tube. Drawing blood really is not that difficult. The first misperception I had though was that if you are able to visualize a vein, it would be much easier to draw blood from it, but this is definitely not the case. The only time you can be somewhat comfortable before puncturing a vein with a needle is if you can actually feel the bulge and bounciness of the vein, otherwise there is no way to predict how far to penetrate into the skin, and the likelihood of passing a needle into a flat vein is slim to none. Inserting an IV tube into each other proved to be much more difficult. This technique is no doubt going to take a bit more practice to master. In addition to drawing blood and inserting IVs, we practiced performing intradermal (into skin) and intramuscular (into muscle) injections, not on each other, but rather on an orange. The peel of the orange served to mimic the thickness of human skin, so when practicing intradermal injections, the needle did not pass any deeper than the thickness of the orange peel. For intramuscular injections, about an inch and a half of the needle was directed straight down into the orange. It was nice to take a break from poking each other with needles for two weeks and rather use a fruit. Fortunately, the orange won’t suffer from bruises and soreness for days following the practice!

All of my other classes have continued over the past two weeks as usual. In Emergency Medicine, we learned how to manage patients who present to the emergency department with shortness of breath and those who present with acute abdominal pain. In Family Medicine, we reviewed the outpatient work-up and treatment for respiratory complaints (cough, asthma, COPD…etc.), anxiety/depression, back pain, and peripheral arterial disease. In Pathology, we learned the process of wound healing and scar formation, as well as the formation and metastasis of various cancers, and the formation of vascular diseases (for example, atherosclerosis). I really appreciate this course in that it reviews all of the disease processes we have learned how to diagnose and treat over the past one and a half years, but focuses on the “what,” “how,” and “why” of each disease process. It’s extremely important to understand these disease processes to be able to communicate these important facts effectively to patients. In Pediatrics, we’ve been focusing on newborns and potential complications that may occur soon after birth (infections, birth trauma defects…etc.). In Clinical Decision Making, I’ve been working in a group with two other classmates to solve our first medical case. Our patient presented to the emergency department in the early morning with a report of severe chest pain and shortness of breath. After two weeks of questioning (history and physical), it’s nearly clear, based on the professor’s answers, that our patient is suffering from a pneumothorax (air leakage into the chest, which can ultimately collapse a lung if pressures rise high enough). We present our case, findings, and ultimate plan for this patient next week.

Overall, I cannot complain about the first month of this semester. Things will pick up a bit over the next couple of weeks. I will have to attend two nine-hour training sessions next Sunday and the following Saturday for renewal of by Basic Cardiac Life Support certification, in addition to training for my Advanced Cardiac Life Support certification. Other students have taken these courses earlier in the semester, and I’ve heard really cool things about the advanced training course, so I’m looking forward to that.

Question of the week: You just received an injection of your annual influenza vaccination. Was this injection intradermal, subcutaneous (between the skin and the muscle), or intramuscular?

Last week’s answer: Injury is the leading cause of death in children over one year of age. The two most common injuries accounting for these deaths are motor vehicle accidents and drowning.

Clinical Phase Update: This week I received the first draft of my schedule for rotations! As it stands now, the order of my rotations are: Summer: Psychiatry (4 weeks), Pediatrics (4 weeks), Family Practice (8 weeks), Fall: Internal Medicine (8 weeks), Emergency Medicine (4 weeks), Winter: Endocrinology (4 weeks), Surgery (8 weeks), Spring: Orthopedics (4 weeks), and finally OB/GYN (4 weeks). Some sites are much closer than others, but I’m content with the schedule as it stands now.

Clinical Phase Countdown: 107 days

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