1. Decide if you really need the line. You can use this simple test. Approach your senior doctor and say, “The patient has really tough veins… I don’t know if I can do it.” Maintain silence and hold eye contact for at least 6 seconds. No luck? There will be blood.
2. Consent the patient. A good metaphor to use is that their body is a theme park and you are building a special slip and slide for some very special medicines too short for the other rides. If this fails go for some pidgin English – “Needle. Hurt. Special medicine. Make you Good!”. The latter explanation is particularly effective if the patient has perfect English and already found the first explanation patronizing.
3. Collect your equipment by visiting 3-4 different wards and asking every nurse, resident and orderly you walk past if they know where a 20 gauge IV is. You should aim to have at least 4 people shadowing you in a loose pack, pretending to look for IVs. After you all ultimately fail to find the drip, just steal several from the resus trolley. Don’t worry about replacing these – that’s someone else’s job.
4. Spend at least 10 laborious minutes and several sterile IV packs to set up a huge sterile field.
5. Break that sterile field to answer your phone
6. Make awkward eye contact with the patient’s grieving daughter sitting across the bed from you. Decide that it is unlikely that she noticed you the break sterile field. Continue.
7. Search for a vein. You should also use this time to emphasize to the patient how difficult their veins are – a useful warning shot for all the painful failed stabs coming up.
8. Answer phone again. Repeat step 6.
9. Warn the patient about a sharp sting coming up.
10. Realize that you have forgotten to prep the drip line
11. Ask a nearby nurse/bemused senior doctor/the increasingly concerned daughter to prep the drip line for you while you wait with the needle hovering just above the anxious patient
12. Line up the needle at 45 degrees and insert as slowly as possible, Try to visualise the needle as a sadistic robot, slowly drilling itself into your patient.
13. Your pager will always beep at this time. The daughter is clearly watching you now. Reach down and turn it off anyway.
14. Burst the vein. Remember – you need multiple failures before you can safely handball the job. Your patient should end up surrounded by opened and barely used IV packs, bloody gauze and uncapped needles.
15. Repeat steps 7 to 14 at least twice.
16. After multiple failures ring anaesthetics. Say the following three things regardless of whether they are true or not, and he/she be forced to accept the job.
One – I have tried and failed
Two – I think the patient is an IV drug user/needed an ultrasound last time.
Three – Choose randomly between these options A, B and C.
The patient is … A. Hemodynamically unstable B. Septic or C. Annoying to spend time with,
and therefore they need … A. Urgent fluids B. Antibiotics or C IV morphine
so that I can … A. Keep them alive B. Treat their infection C. Go home and sleep.
17. Alternatively skip steps 1-15 and just go straight to step 16. This will lower the chance of the daughter making an official complaint against you and also get you started earlier on the urinary catheter insertion waiting anxiously for you in the next bed.
