Jonathan M Glass: Blood taking is so much more than phlebotomy

jonathan glassBlood taking is so much more than phlebotomy. It’s so much more than the mere act of putting a needle in a patient’s arm. It’s so much more than filling up a syringe with the most wondrous liquid that will ever be created. It’s so much more than filling out a form and requesting an order for someone else to carry out.

The taking of blood is an example of a job not thought to be appropriate for the future doctors we are producing in Great Britain. That is because the act of taking blood or gaining venous access, and their importance in the development of our future colleagues is so misunderstood. It is so valuable an opportunity in the creation of the caring physician and surgeon.

Clearly anyone can be taught to find a vein. But the repeated act of doing so teaches so many lessons. Every time you pierce the skin with the needle there is an opportunity to enter into the lives of patients and discover things about them you might never otherwise have seen. As a house officer at St Mary’s, poised with a tray ready to take some blood, I remember the delight and fascination in discovering a patient had fought in a tank unit with the author Arthur Koestler in the second world war. I looked forward to the next time I could enter his former world by simply being asked to pierce his skin. Taking blood wasn’t a burden, it was a pleasure.

Without taking blood I may never have realised the huge imposition of any intervention in invading the personal space of patients who are dying. I may not have understood the fatigue they suffer and the discomfort they sense from every needle, the burdensome journey to and from every scan, the invasion of their space by every examination and invasive procedure. I may never have learnt to think so carefully about the indication of every test I request; would I have let that imposition be placed on my brother, my father or my uncle if it wasn’t really needed.

I will never forget getting venous access in a four month old with CHARGE association on the neonatal intensive care unit at 11pm only to be bleeped four hours later as the drip had tissued. I went to his bedside knowing that resiting the drip may take some hours, but being motivated to do anything I could to make his life less of a burden. In my head I could remember the four year old I had met as a medical student saying in a plaintive voice, “I don’t like the prickles;” my four month old couldn’t tell me, he would never speak. He would rarely, if ever, smile. But in that contact, that moment I would learn about commitment, about individualized patient centred care. That moment was right in the development of me as a doctor.

The relationship between a test and the knowledge of the result, the logical sequence of investigations, the opportunity to influence and to ease in some small way the journey of a patient through their care, the development of the fine motor skills, the prioritization of tasks, the ability to become the last stop where others had failed, to interact with patients beyond the issue in hand to put them at their ease; all this could be learnt by simply putting a needle into the flesh of another human being. Medical training wasn’t flawed, it didn’t produce bad doctors. Take away all that we did and we will become less good for it. It’s so much more than phlebotomy if you recognise the opportunities.

Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.

 Jonathan Glass is a consultant urologist and lead clinician for urology at Guy’s & St Thomas’ Foundation Trust.

  • Sue Hawes

    What a delightful and sensitive blog. I wish more physicians and physicians-to-be had the same approach as do you. With many people having had bodily trauma inflicted by others, entering that space and ‘piercing the vein’ has a lot more emotional content that one might realize.

  • David B. Karpf

    Very thoughtful (and accurate, from my experience) commentary. Thank you!

  • Jane Harmon

    I have long done phlebotomies and have had so many similar experiences. The last time a physician drew my blood, however, was a nightmare. When the needle swung around to a position perpendicular to the vein and very deep to it, with a hematoma beginning to fill the antecubital space, I had to firmly call a halt to the proceedings. Physicians and nurses need to keep up with such basic skills for many reasons.

  • Dick Ansell

    So new doctors will now connect even less with patients?
    Sounds like a non-involved management decision.

  • Dick Ansell

    As one who has regular blood tests I can feel lucky that our GP has a skilled vampire. (cannot spell phle… The difference in skill is directly proportional to the pain inflicted. But I suppose you are taught to ignore patients pain, it would certainly appear so anyway, from past experience.

    Doctors do not lower themselves to take blood and as a patient I would far rather the experienced vampire than the doctor. The poor doctor skill in this is self perpetuating.

    Is there not by now, an artificial arm with realistic vein, skin, etc on which the art can be learned?
    As an engineer I would envisage a small header tank pressurised by “air over”, a cam acting on a bulb to provide pulse, motor speed and cam pressure to be adjustable. The vein a piece of artificial vein/ artery as used to replace real clogged ones in surgery. Then plastic skin, ballistic gel and and moulded bones. Place in warm water to reach blood temp before use, A project for the Mythbreakers who would knock one up in a couple of days for a couple of hundred quid. OR an NHS outsourced project, 3 years and a million quid.