So after my IV Start Lab a couple of weeks ago, I headed to the ER for an evening shift. As a newly "certified" (whatever that means, lol) IV starter - and bedazzled with my official IV Certification Pin (no, I wasn't wearing it, I just think it's hilarious that I now have one) - I was pumped to get my 3 supervised starts in and become proficient at that most intimidating of nursing skills: IV starts.

[mini-rant]
I wish that laypeople would stop using the "IV Experience" as the sum evaluation of their interaction with nurses. How many times have people found out that I'm in nursing school, only to launch into a tirade about their latest hospital stay -

"I had a terrible nurse! She had to poke me with the IV TWICE!", or
"This one nurse was useless, she couldn't get an IV started, so she got another nurse who got it on the first try!", or
"The last time I was here the OTHER nurse had no problem.", or
"The nurse got it in but she must have done something wrong because now I have a BRUUUISE" or,
"My nurse was great. She got the IV started and I barely felt it."

How many other factors are involved here? Location, skill, gauge, hydration, BLIND LUCK? Seriously!
[/rant]

Obviously I'm a little miffed.

So, that shift I picked up a chart and was positively beaming when I saw it was a pt in for IVT who needed a new line put in. So I hustled in there and got all set up, grabbed one of the senior RNs to observe me, got allllll prepped and then....

Tourniquet on.
Examine arms. Nothin'.
Dangle arms. Warm compress to arms. Nothin'.

Except.... the RN peers over my shoulder and points out one tiny thready vein over the patient's knuckle. My very first stick - this could be it! I grab a 22 and try not to sweat onto my patient as I hover the ONC... take aim.... GO GO GO!! And I went. Flash in the chamber and I attempted to thread it and.... nothing! The catheter stopped dead like it hit a wall. Or a knuckle.

Pasting on a smile I deferred poke #2 to the RN. To my relief, though, she also had a lot of trouble finding a good vein - it wasn't just me! That pt took about 5 pokes before we got her with a 24.

That was it for my tries that night.

Sunday morning I'm back in the ER and I told everyone that I was ready to get my 3 starts!!

So the charge RN grabs me at about 1100 to start a line on a guy who was in for severe abd pain. She gives me a 20 and I get to vein hunting. I find a decent one on the back of his hand and prep for the insertion. I am positively STRESSED, though, because the guy was writhing in pain and anxious++ about getting the stick. I'm stressed because he's watching, his wife's watching, and the RN (a very intimidating woman with no real tact filter) was hovering over my shoulder giving very very precise instructions and I just about stroked out from the pressure. I go for the stick and he is actually kicking his feet on the bed. I feel pretty much as bad as can be felt because I can't get the vein. I don't want to be "THAT nurse", the one who fishes the needle around, so I give it about 2 more seconds and I pull the needle out. The RN says she'll take over and she gets a line in. She then yells out and asks one of the RNs to help me do an ECG on him.

That pretty much did it for me. I'm quite confident with ECGs. I do at least 5 of them a shift. So, shellshocked and fighting back my feelings of inadequacy, I "help" the other RN get the leads on him and then bail out of there before I do something embarrassing like cry on my patient.

The charge RN calls me up to the desk - "I need you to document the unsuccessful starts." As I'm standing there, reeling from the overwhelming emotions from the last 15 minutes, she began critiquing my IV attempt. "That's not how WE learned it in school," she says, and I kind of croaked out an answer while trying to keep my cool. She kept critiquing my approach and then one of the newer grad nurses caught my eye with sympathy and that pretty much did it. Yup, I started sniffling, and then a wee tear escaped my eye, and then the emotional dam burst and I got all kinds of upset.

The charge kind of gave me a side hug and told me I'd get it next time, and to go sit down in the back and collect myself. So I went, to try and pull myself together.

But I wasn't upset that I didn't get the IV. It wasn't that at all. It was this overwhelming sensation of being completely UNETHICAL - here I was, barely a full day out of the IV lab with a mere 2 starts on my young male lab partner with great veins, and essentially PRACTICING on patients. Really, that's what it was (and is). I don't know what I'm doing, so I'm practicing on human beings, and it HURTS them, and that's what bothers me most of all. I am hurting people in my attempts to learn. I am more okay with it hurting AND a successful start, but to hurt people like that and to miss the vein.... wow, I hate that so much.

Don't get me wrong. I do completely understand that the only way to learn this skill (and any nursing skill, really, but this is kind of the Big Deal) is by practicing on anybody and everybody. Nobody was born knowing how to thread an 18 into a capillary (I jest ;) but it just really bothers me that my learning is coming at the expense of someone's well-being. More or less. You know what I mean?

I just wish there was a way to get real experience without real people. Those dummy arms are a joke. They help you get the psychomotor action of retracting the needle and applying Tegaderm but that's about it. The "skin" is riddled with holes, the "veins" are rigid and approximately the size of fire hoses, and there is no traction required.

So I was quite emotional from all of these thoughts, plus the incident with the charge, plus another incident that morning where I'd sent a female pt to xray before her preg results had come back (not entirely my fault, plus what the hell does BRV mean, but I still felt awful and had these pictures in my mind of a 17 year old boy with severe deformities because I'd sent his mom to xray without realizing he existed). The results were negative. But still.

Nursing is a tough job. Emotionally tough. There really aren't that many jobs in the world where if you made a mistake, any mistake, someone is instantly and often severely affected. Even if you had no idea you were making a mistake (like how I did not think to check the chart for other orders before I took the pt to xray), BAD THINGS can happen. And they can happen to good people, be they patients or healthcare providers.

Anyway. After all of this went down, all I wanted was for 1530 to come so I could go home and forget this day ever happened.

I was charting when someone tapped me on the shoulder. I turned around to see Michelle, one of the younger nurses on the unit. I'd been buddied with her before and found her to be kind, knowledgeable, and pleasant to be around. She beckoned me into the clean utility room and gave me a great big hug.

"I understand how you're feeling today. We've all been there. But you can do this! You CAN start an IV! You WILL start an IV! And you will be good at it! In fact, it is my personal mission to get you an IV start before I go on holidays."

We discussed my technique and what I was doing wrong. Michelle thought I was blowing the veins by going in at too steep an angle. "But school said we should enter at 45 degrees until we hit the vein, then drop down to 15 degrees to thread it?"

"Forget that!" she laughed, "I almost ALWAYS go in at a low angle, especially those superficial veins."

It was pretty close to the end of the shift so I didn't think that would happen. However, 1500 rolled around and Michelle was waving a chart at me from across the unit. "Do you want to try?" she asked excitedly, "it's an 80 year old man!" She handed me a 20.

Wow. A 20 gauge in 80 year old veins. And with my 6-inch-tall confidence and emotional lability.

"You can do it!"

I walk in the room and find the guy there with his wife. Michelle is right behind me. She's offered to smoothly swoop in if things don't look like they are going well.

Tourniquet on.
Examine arms.

HOLY SMOKES there are ropes of blue up this guy's arms. I feel like I could thread a gauge the size of my pinky in there. Confidence surges briefly. Here we go....

Patient starts muttering that he hates needles. Wife tells him to suck it up.

I aim the needle at 45 degrees, catch myself, and drop it down to 20 or less. One, two, three, POKE! GO GO! I hit the vein right away. I remember to push the needle in a tiny bit more and then thread the catheter, which slips right in. We draw the labs. The vials shoot full of red. We hook up the line and run the bolus, which drips rapidly in the chamber. It was a good one!!!! :D :D I have to stop myself from beaming at this guy and dancing out of the room because I am SO glad that I got my first IV on a real patient on the same day as my bad experience.

So Michelle, although you'll probably never read this, THANK YOU.

For the record, I've had more failed attempts than successful ones, but I've now started 5 IVs, and all the ones I started I got on the first poke. It's getting easier, especially now that I can start them independently. I remember a post I was reading on allnurses to help me get better at IV initiation. One nurse said that when she was working, she told everyone that she got the first 2 pokes on every patient to come in the doors. She didn't shy away from the scary ones because how else was she going to learn?

Truth.