Jeremy Johnson

It is just such a hardship for a lot of patients that don't have easily visible and palpable veins. They really suffer. And so, you'll see these patients come in that have been stuck 12, 13 times, and they're just blown away by what can be done with an ultrasound. It's really a rewarding job because you get to be on that end where you're coming in and saving the day every time.

Narrator

Welcome to the PDSA podcast, Bruised But Not Broken, Living with ITP. The diagnosis of a bleeding disorder like immune thrombocytopenia may leave you wondering, how can I really live my life with ITP? PDSA's podcast, Bruised But Not Broken, Living with ITP, brings empowering stories, the latest research and treatment updates, lifestyle tips, and answers to the real-life questions the ITP community is asking. Here’s your host for this episode, Barbara Pruitt.

Barbara Pruitt

Hello, this is Barbara Pruitt and thank you for joining me on Bruised But Not Broken, Living with ITP. Being an ITP patient, we are subjected to a lot of lab work. Depending on our situation, Our platelet counts need to be checked sometimes as often as a couple times a week. Some treatments require you to have an IV. So, getting poked with a needle is something none of us look forward to and we all would love to make it easier. So, today's guest is actually a vascular access RN at one of the largest hospitals in South Florida.

He's an expert at finding your veins. I'd like to welcome registered nurse, Jeremy Johnson, to Bruise But Not Broken. Welcome, Jeremy. Thank you for joining us today.

Jeremy Johnson

Thanks for having me.

Barbara

No, I'm glad you're here. This is a topic that I think hits all of us patients, ITP patients, because the thought of getting a needle stuck into your body is not something that we relish. It's just unfortunately part of our life and moving forward with this disease or disorder. Tell us a little bit about your history and how did you become a vascular access RN, which is something I've actually never heard of.

Jeremy

Well, I started at bedside. I graduated in 2009. And I started at the biggest hospital in South Florida, Baptist Hospital. And I worked on a floor, I worked on a respiratory step-down floor, which takes care of patients basically on respirators, ventilators, lot of end of life, a lot of patients that have very difficult venous access. When I started, they really didn't give me any kind of formal training for starting IVs. And I still kind of see that practice today that new grads come out; they really don't know how to do it. They just have to learn on the job. So that's kind of how the team started, because believe it or not, there was never a vascular access team, never a dedicated team at Baptist Hospital for placing IVs. There were some in other hospitals around, but not at our hospital. You know, there was just several patients that kept coming in that they were never able to get an IV on. So they realized they needed a dedicated team. And I was fortunate there enough to get on that team and get some real formal training using ultrasound guidance to place IVs with ultrasound, which is really, really amazing and incredible. And when patients first see it, they're blown away by just the efficiency and how quickly it can be done.

Barbara

So, tell me about the ultrasound. This is so new to me. I've never seen that in action. And, and is it usually only in a hospital setting? Is that where you find this? 

Jeremy

For the most part? Yes. It's inpatient, unless you're getting some kind of outpatient procedure done, but mostly yes, it's in the hospital. So, what we do is we use a low frequency ultrasound that doesn't go too deep below the skin and you can see from, you know, a cross-sectional view from the side, basically, and it shows veins and shows arteries and it shows tissue and it shows nerves. And you can basically be super precise and accurate, and you can find pick out the perfect vein. and go in at the perfect angle and be successful on the first time 99% of the time.

Barbara

That is what we all hope for and wish that, you know, the first time you'll get it. And I know we're talking about IVs, but the same issues arise when you're dealing with having blood drawn because you're looking for that vein and sometimes it is not readily available or readily seen. I know that there's some tips that you could give us regarding what should a patient do before they go to get their lab work drawn?

Jeremy

Right. So, if you're going into like a clinic, you probably are not going to have the ability to have, you know, ultrasound guided blood draw. I don't think that really happens very often. So, you know, best tips I would say are to wear something warm probably because you want to, you know, make sure your arms are warm and because the warmth brings dilation, the veins are gonna dilate, it's gonna fill up with blood, it's gonna inflate the veins a little bit. The next best thing would be to, if you know you're difficult stick, make sure you ask for a specialist. I don't think there's anything wrong with asking the person who's gonna be drawing your blood if they're a specialist. Now, if you're just going to get your blood drawn, they probably are a specialist.

But if you're going into the emergency department, that's not necessarily the case. So, I think it's okay to say, look, I'm a very difficult stick. And they'll understand what that means.

Barbara

You need to advocate for yourself. You need to say, this is difficult.

Jeremy

Yes, it's very difficult. It can be even for seasoned nurses and seasoned techs and phlebotomists. It can be very difficult. So, you want to make sure you have, you know, the most experienced specialist doing it if you know you are difficult. And knowing your body, if you know where you have a good vein, you know, point it out to them and say they've had a lot of success here. And I think, ah so you know, a professional would take that into account. I certainly do. tells me, you know, where they know they've had a lot of success. You know I'll say I'll certainly take a look there and see how your veins are doing.

Barbara

I know one thing that I always... tell patients, tell people is make sure you stay well hydrated because, You know, if you drink 16 ounces of water on your way to the lab, great, because then your blood volume is going to be a little greater and hopefully those veins will stick out a little more and you'll make it easier and the person that's drawing the blood. And also, I mean, they usually tell you to make a fist and they put the tourniquet around your arm.

Jeremy

That's going to be what do. They're probably going to tell you to make a fist, which is going to help draw the blood to the area. They're going to put a tourniquet around it. They might tap it a little bit, you know, to kind of try and wake up the vein. But as a patient, I would say, wear something warm to keep your veins dilated and really just tell them where your good veins are. I think that's the best thing you can do if you know you're going to have trouble.

Barbara

That's all good advice, all of that. And I know that as an ITP patient, we also suffer from bruising after we get needle stick. And I know myself, I've been doing this for so many years. What actually happens is when the needle goes into the vein, afterwards, there's a hole there and that's where the blood can leak out.And that leaking blood is what causes the bruise. So, let's talk a little bit about the blood flow and exactly what happens because veins are the vehicle that is carrying your blood back to your lungs and heart. So, when you are looking at your fingers and there's veins down there and then there's veins up your arm, realize that the blood that we're they're going for in a vein is traveling towards the trunk of your body, right?

Jeremy

So, the blood is flowing right peripherally towards the central when you're accessing the veins. Arteries, they go the opposite direction. So, the arteries are pumping from the heart outside towards your arms and your legs. So, the venous return towards the heart is not going to have the same amount of pressure that is being pumped into the arteries. So, I know some issues we have with ITP patients is holding pressure when you draw blood, right? That can cause extra bruising. And that is the first line of defense against bleeding when you puncture someone with, you know, who's more prone to bleeding people on anticoagulation or have clotting factor issues as you hold pressure. Now with venous blood draws, you know, that venous return is not that powerful of flow comparatively to arterial flow. So, they don't have to squeeze too hard.

And some techniques that phlebotomists use is they'll go in what's called antecubital space, which is kind of the inner elbow, where a lot of the veins are popping out most of the time, and it's easy to draw blood there, is they may just put a little cotton swab and just kind of tell you to close your elbow up and hold it yourself with your own amount of pressure versus squeezing tightly. And, you know, that may help reduce some of the bruising.

Barbara

What I have found is that when you then constrict the blood flow by bending your arm. If they go to the antecubital space, the inside of your elbow, which is the most common place that they draw blood, I've found that when you press on it and bend your arm, it actually causes more bruising. And my rationale for that is that you are like putting a dam on that blood that's trying to flow back to your heart. And when you release it, when you open your arm or you take the pressure off, that blood's going to go strongly. There's going to be pressure behind it because you've been blocking it for so long. And when that release happens, it's going to find its way out of that little puncture hole. And that's where the bruising is. My own personal technique and this has been this has happened over years and years of experience and also getting IV treatments and speaking to the girls that, you know, or the nurses that do the medications with the IVs. What I do is after the needle comes out, I just lightly dab if there's any blood there, but immediately I raise my arm. If it's in my arm, I raise my arm high. And it might take a while before some platelets find their way to that little puncture hole. But I raise my arm sometimes for 15 minutes. If my counts are really low and I think I'm bruising a lot, I'll probably keep it up for even longer. But I try not to bend my arm. But the reason I raise my arm is to keep it above my heart so that the pressure is even lower as far as the circulation is concerned. Your blood pressure in your arm doesn't have to work so hard when your arm's elevated because just gravity is going to take that blood down to the central part of your body. Does that make sense to you?

Jeremy

Yeah, I think that makes a lot of sense. That's pretty smart. I'm going to recommend that to some people in the future.

Barbara

Well, especially... especially if they don't have platelets, because actually I had blood drawn this morning and I use a vein in my forearm um just because it's a good spot to get my blood drawn. You can see the vein, you know, and I do all the things. I make a fist and I drink water and all of that type stuff beforehand. And, you know, this morning i kept my arm up actually for about; I think it was almost an hour. I know that sounds kind of silly to do it for that long, but I was in a situation where I could, it didn't matter to me. And you can barely see where I had the blood drawn. So, for me, that works.

Jeremy

I like it. Yeah. That's good. And that just goes again to kind of learn, you know, if you're having freaking blood draws, know, you can probably learn a good way to make sure you don’t bruise.

Barbara

Right. nice see And I talk to the phlebotomist always. I tell him that, you know, why don't you try here or there? Because I've got my special places where I know they can get the blood, where I know they're not going to have to stick once or twice or whatever. And they do. They're really pretty good about listening. I have had a few cases where you know, I've said, you know, use this vein in my forearm. And they look at me like, oh no, I don't want to do that. And I go, hey, you're professional. You can handle it. I want you to know this is a really good vein. And then they do it and they're pleased and happy, you know, that they were able to do it. But sometimes you might run across someone that might be hesitant, but they're listening to your input. They're listening to what you are telling them, hopefully.

It works. It works for me. Maybe it will for other ITP patients.

Jeremy, I know that when you and I spoke earlier, i was telling you about the PDSA, Platelet Disorder Support Association, that we have a poker club for the children with ITP. And that's poke, P-O-K-E dash r dash club. And it's actually to alleviate some of the anxieties with children having needle pokes. And one of the things, well, there's a couple different parts to the poker club. First of all, every time a child gets a needle stick, they get a poker chip. And after they collect like 10 poker chips, they send them into the PDSA and the PDSA sends them a prize. So, they look forward to getting those rewards for their bravery. The other thing that they do is they have this thing called Buzzy Bee. And I know I was explaining it to you. What it is it attaches to your arm above where you're getting your blood draw. It has a little frozen, like an ice pack on it, but then it has like a vibrating motor in it. So that it takes the brain's attention away from where the needle would be going in, which is really remarkable.

 Jeremy

I love that.

Barbara

It is great. A doctor devised this and it is like a game changer for people that have needle phobia that you know are really afraid of a needle coming towards them. And children swear by it.

Jeremy

We have you know so many patients that that is their biggest phobia coming into the hospital is the pain of needle sticks. We do use touch techniques. We try and distract them you know by kind of rubbing their back or their head you know to kind of take their focus off. And I think that's brilliant that you have a device like that that just buzzes and it really distracts the brain away from you know the pain from a needle stick.

Barbara

It does. It works. And actually, when I spoke to the PDSA's office last week, and I said, you know what? They have these Buzzy Bees for adults also. So now the Platelet Store at the PDSA is carrying the Buzzy Bees for adults also, not just the with the kit for the POKE-R club, um because I don't know that Adults who are wanting to join the poker club, that's really meant for the children. But they are now going to have available the Buzzy Bees for adults. So, you know, whether you as a patient needs one, or if you know someone that needs that because they have needle phobia, it might be a really neat thing to buy. I don't know exactly how much they run, probably between $50 to $75, but being that they're so successful, Jeremy, you might want to get one to put on your cart or whatever.

Jeremy

I could get one and use it for my patients for sure. That's awesome. Especially, especially the ones that recommend patients that are that are phobic about this.

Barbara

Yeah. It, cause right, right now in the PDSA organization, they've got like over 200 kids that are enrolled in this poker club. And it it's just one it's just a great thing for the kids. Because I know when I was a child and I used to get my blood drawn, I would save the little plastic caps for the needles. And those were kind of my rewards. I don't know what I did with them. I just saved them. You know, they were colorful and pretty. But um anyways, well, I know you are a very busy guy. And that hospital is so huge. And what, do you run around? Do you get called all day long? You go end to end wherever you need it?

Jeremy

We're a small team for now. Hopefully we grow a lot bigger because there is a huge need.

 But we're over a 900-bed hospital. So, we don't really have the capacity to do everyone. So, they really only call us for the patients that really need our expertise, the ones that the nurses can't get on their own. And so, yeah, really we've all trained on the most difficult of patients and we still have over a 99% first stick success rate. ah and which That's wonderful. And so you'll see these patients come in that have been stuck 12, 13 times, you know, like net and they're just blown away by what you can be done with an ultrasound.

And so it's just really, it's a, it's really a rewarding job because you get to be on that end where you're kind of coming in and saving the day every time. So, I do like that part of it, but you know, it is just such a a hardship for a lot of patients that don't have easily visible and palpable veins. They really suffer and people who have good veins, it's such a blessing. They don't realize it, but it is such a blessing to have veins that are easy to access. If you don't, it can be one of the worst experiences, worst parts of being in the hospital is just the repeated blood draws and the dread of knowing, oh, I'm going to have to be stuck so many times for an IV. And really having a dedicated IV team is the way to go. And I think that's going to be the way the future for, for everywhere. I think ultrasound guidance is, should be the standard everywhere. I mean, it's really pretty common now. Ultrasound guided IVs, it's, it is pretty common. And it should be everywhere. It's just such a, such an improvement above the traditional way of accessing veins.

Barbara

It sounds like that's the way to go. I mean, if your hospital has that and you need an IV or if you know you're a difficult draw, that definitely sounds like the thing to ask for. But I know you do more than just IVs. You put in PICC lines and more.

Jeremy

Right. We do PICC lines. So, a PICC line is for peripherally inserted central catheter. So, it's a central line, which means it is a line that travels to the superior vena cava, which is the large vein above the heart. And it is a safe way to deliver medications that need to be highly diluted. That is because the superior vena cava can pump two liters of blood per minute. So, it dilutes the blood very quickly. Certain medications have such a high osmolarity and then for pH level, they, they can basically kind of fry your veins if they're not diluted quickly. So that's what these medications are for mainly like your chemotherapies. A lot of times we do a lot of pick lines for chemotherapies. There's not as many port-a-calf placements as there has been true in past. We do a lot of pick lines for chemotherapy now. For patients that are going to be on long-term antibiotics, so people that need to go home basically don't want to stay in the hospital for, they may be on antibiotics for say six weeks. They can go home and have an infusion nurse come to their house and they can use the PICC line for that the entire time. And then people who have you know frequent transfusions, they may have need for a PICC line. And it's placed peripherally. So, it's placed in the large veins in the arm. And we travel a catheter through those veins all the way into the superior vena cava. So that's what makes it a peripherally inserted central catheter. There are other central catheters that we don't place. In Florida at this time, we don't believe it's yet approved for nurses to place other type of central catheters, but they can be placed in the jugular veins or the subclavian veins or even the femoral veins. But our team specializes in the peripheral, so we use what we call the PICC line. And we also do what's called midlines that are shorter versions of a PICC line. They only travel to the just below the shoulder, they call the axillary. And we use those sparingly for very, like, patient she needs to go home for maybe five days or a week of antibiotics. We'll use a midline for that.

Barbara

Well, that sounds very technical.

Jeremy

Yep. And I love it. You know, we use ultrasound guidance for all of it. And so that way we were just always pretty much, pretty much always getting the veins on the first attempt.

Barbara

Well, that's great. Well, this has been very interesting to talk to you. It's also interesting for me as a nurse because none of this was available back when I was working, but that's been eons ago. And it's nice to know that things are progressing and hopefully, you know, every little step is making it easier for the patient. And unfortunately, oftentimes ITP patients end up in the hospital and they end up with an IV. And we all know that we get blood draws and we get stuck by needles a lot and that will continue to happen. So, all of this is great information. I'm glad you've shared it with us.

Jeremy

Oh, my pleasure. I think that you know one thing that they should definitely take away from this is don't be afraid to ask for the specialist. There's someone who's dedicated their career to accessing veins and they're available out there.

Barbara

I'm sure you've done thousands of these by this time, right?

Jeremy

Yes, thousands and thousands.

Barbara

Wow. Wow. Well, that's very good advice. And I hope that our listening audience will heed that advice. Thank you again, Jeremy, for joining us today. It was great. And for your input and your wise advice, we really do appreciate it. So, thank you for joining us.

Jeremy

You're welcome. Bye-bye.

Narrator

How do you live your life with a bleeding disorder like ITP? From working in the kitchen with knives, to navigating sharp corners in your house, going out to eat in a restaurant, traveling on a plane, attending a sporting event, even dancing at a wedding. ITP patient Barbara Pruitt shares her tips and tricks for moving through life with ITP for more than 60 years. Here's her lifestyle lesson for the day.

Barbara Pruitt

Hi, I hope that you have just listened to our podcast on blood draws and IVs. But I'd like to kind of go over the specific points on what I do when I have to get my blood drawn, because one of the things that I really hate is if they can't get the vein the first time, and then you end up with two pokes or three pokes, and I think my veins are pretty easy to get to, but sometimes you'll get somebody that just isn't that good at it. You really hate that part of it, but then I also hate the part of the bruise that gets left behind afterwards. And the more pokes you get, the more chance of having a big bruise. So, a few things that Jeremy, the RN, spoke about in this podcast, I'll go over those. And then Let me review what I do specifically. He said the things that we need to do as a patient is number one, know your body and know which veins have worked well for you in the past. And that's important information to share with a phlebotomist when they're getting ready to poke you.

Secondly, be well hydrated. If you want to drink half a quart of water before you go to the lab, that's great. It'll keep your veins full and hopefully easier to get to. You need to make a fist, and that's what they usually do. They tell you to make a fist before they put the tourniquet on. So those are all very important things prior to getting poked. Now, for me, because I do not like to get bruised after it, when they take the needle out, I do not press on that blood vessel. I might just wipe away any blood that has come out, up to the skin, but I immediately raise my arm. I mean, that's assuming that you're having the blood drawn from your arm. I raise my arm above my head and i keep it up there for 20 minutes or more. And then by the time I do let it come down, hopefully it has clotted, that little hole has been plugged up and I won't get a bruise. Because the bruise comes from where you get poked, blood seeping out of that little hole. Now, since we don't have a lot of platelets, we have to kind of wait for a platelet to come along to clog that hole up. So, by elevating your arm, you're making it easier for your blood to flow back towards your body, and you're not giving it the advantage of leaking out of that hole. When your arm is hanging lower, the blood pressure in that arm is going to be greater to get that blood back to your body, to the trunk, to your heart, and to your lungs. And that extra amount of blood pressure can work against us as far as pushing the blood out of that little poke. That little hole that the needle made. So that's why I really like to keep my arm up afterwards. And if you're getting your blood drawn in the inside of your elbow, i suggest not putting pressure on it and not folding your arm up because that's like a dam. You're blocking that blood flow. And when you release it, it's going to be much stronger and the probability of you bruising is even higher.

Let me know if this works for you. want you to contact me at podcast at pdsa.org. And let me know if you've tried this and if it has helped. I'm really interested because I know it's been very successful for me. The other thing is, if you have some ideas for future podcasts, if you have questions, please send them to me. at podcast at pdsa.org. I want to thank you for listening, and I hope you join me next time. Have a great day.

Narrator

Thanks for listening to the PDSA podcast. Bruised but not broken. Living with ITP. Made possible by our presenting sponsor, Amgen. Special thanks to Gus Majorga for composing our theme music. To see what's coming up, visit our website at pdsa.org and subscribe wherever you get your podcasts. Please share this podcast through social media with anyone who you think might benefit from the information and stories we share with the ITP and other platelet disorders community. As always, please speak with a healthcare care professional before making any treatment decisions. But know that PDSA.org is a wealth of information and resources to help you navigate life with ITP and other platelet disorders. Remember, you are not alone.