Practicing on Patients

My hospital recently decided to ask nurses, rather than the phlebotomy team, to handle blood draws. This wasn’t a big deal, except that I’d never done it before, and to learn, I would have to practice on patients.

Surprisingly, drawing blood is not something they teach you in nursing school. I signed up to learn at one of our outpatient testing centers, and the night before I felt nervous. I have always had trouble with moments in health care when we hurt people in order to help them, and now, as I learned how to stick a needle into someone’s vein, I would most certainly end up hurting a few people.

When I arrived in the morning, I met my teacher, who I later learned was called “the master’’ by our patients. He started my instruction by putting a tourniquet on my arm and having us look together at my veins. Then I put the tourniquet on him and looked at his. He gave me a diagram of the usable veins in the arm and talked to me a little bit about which veins are better than others, and how the needle should go in.

My first patient was a retired steelworker who talked interestingly about political demonstrations and union work while I slowly set out the needle I would use and organized my alcohol wipes, colored lab tubes, plastic access device, gauze and tape. With a little help from my instructor, I got the needle far enough in, got the labs I needed, undid the tourniquet before taking out the needle, and applied the gauze and tape quickly enough to keep the blood from dripping. The patient never complained, never once questioned my obvious lack of expertise.

Other patients weren’t so sanguine. One woman gestured to my instructor and asked, point-blank, “Why is he sitting there watching everything you’re doing?” And an older gentleman looked at my instructor, who had drawn his blood many times, and then at me, and flat-out refused to let me try.

In the book “Complications: A Surgeon’s Notes on an Imperfect Science,” Dr. Atul Gawande describes the unique challenge health care workers face in honing their skills. “Like the tennis player and the oboist and the guy who fixes hard drives, we need practice to get good at what we do,” he writes. “There is one difference in medicine, though: It is people we practice upon.”

Dr. Gawande described how he practiced on patients to learn how to put in a central line, a potentially risky procedure that involves inserting a catheter into the neck or chest. Although the procedures I’ve learned on patients aren’t as technically complex, there have still been many “first times,” like the first time I inserted a urinary catheter, the first time I gave a blood transfusion, the first time I changed or maintained a patient’s drainage tubes. All of those were lessons learned on patients.

We don’t usually tell patients when we are practicing on them because it makes them hesitant and nervous, but they often figure it out anyway. If they ask, we don’t lie, but we try to answer in a way that puts them at ease. To the patient who asked why someone was watching everything I did, my instructor explained that I was a nurse, and that we were just “reviewing peripheral sticks.”

I wish I could say I remembered all of my patients from that day perfectly — those from whom I managed to draw blood effortlessly and those from whom I didn’t. The truth is, I was there for eight hours, and the day was a blur of talking about veins, looking at veins, thinking about veins and the final feeling of accomplishment when, at the end of the day, I had a pretty good idea of what to do to get blood out of someone’s arm.

During my next shift on the oncology floor, I was ready to try out my new skill. My first patient was having horrible nausea and felt terribly weak and spent most of her days lying in bed with the lights off. She was also diabetic, which meant her veins weren’t easy to access. I didn’t tell her that I was practicing on her, but my slowness, and my need for guidance from a more experienced nurse, tipped her off that I was still a novice.

Despite my obvious inexperience, and how horrible she was feeling, she agreed to be my guinea pig. “Everyone has to learn sometime,” she said.