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Fear and the Phlebotomist
By Jason Franklin, CPT, (ASPT)

 2005 Membership Newsletter

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As phlebotomists, we've all seen it.  As human beings, we can sympathize with it.  Needle-phobia is real, and it's something we, as medical professionals, must deal with every day.
 
Needle-phobia is a recognized medical condition that affects more than 10% of the population and, in some cases, cause many people to avoid seeking medical treatment altogether. One-third of all needle-phobics developed their fears due to the fears and reactions of other family members.  When faced with a procedure that causes extreme anxiety in a trusted friend or family member, those anxieties and fears become anticipated and are easily passed on.
The procedure then becomes larger than life and each aspect can become overwhelming.
A patient once told me, "Nothing can scare a person more than a piece of metal in your body."
Needle-phobia can often be the result of an early traumatic experience, most often from childhood. I have spoken with patients who relay stories of a phlebotomist who "dug around" or probed excessively, causing excruciating pain.  You can reassure the patient that you will never probe, and will take the time necessary to find the best vein possible to improve the chances of immediate success.  When told these stories, I often let the patient know that it is not within the industry standards to probe, and they have the right to tell the phlebotomist to pull the needle anytime they feel that they are exceeding normal standards of performance.  The reaction has often been one of surprise and relief.  They felt they had no right to interfere with the procedure, further reinforcing the feeling of being victimized.  By letting them know they have some control, they have often relaxed and the procedure has gone on quite smoothly.  In some cases, patients with an extreme phobia can be given an anti-anxiety medication by their doctor to relax them for a procedure. Because the duration of a venipuncture is short, and the effects of the medication can be lingering, this is not too common.  The doctor and patient will normally have decided the appropriateness of medication prior to arriving for the procedure. 
 

The vasovagal reflex reaction, which includes plummeting blood pressure and syncope, and can be accompanied by convulsions or respiratory distress, is one of the patient reactions the phlebotomist must anticipate, yet hopes most to avoid.  Most common in post-pubescent males, this is a frightening reaction for the patient, as well as the medical attendant performing the venipuncture. This requires a quick, level-headed response on the part of the phlebotomist, who must remove the needle without being stuck themselves, and get the patient in a safe position to protect them.  In mild cases, this would involve having the patient place their  head between their  legs, or lie their head down on a clean surface.  In more severe cases, especially where a seizure is involved, the phlebotomy technician should have them lie down on a bed or gurney if available, or help safely guide them to the floor. This can be a difficult task to undertake in a short amount of time with little or no warning.  It is essential to stay calm and not panic.  It is very easy to react emotionally in stressful situations, but as medical professionals, we must learn to stay focused and follow protocols.  This will make any difficult situation easier to handle, and will certainly make the patient feel more comfortable and in capable hands.  If the patient appears to be under stress, ask if there is a history of syncope, and if so suggest they lie down for the procedure.  Explain that this will help minimize the drop in blood pressure that often causes their symptoms.  This act alone will often prevent an adverse reaction, which is much more favorable to dealing with one after the fact.  Another fairly common practice for patients who have vasovagal reflex reaction is for them to take beta blockers (Tenormin, Inderal, ect.) before the procedure.  Though these are commonly used as blood pressure medication, they work with little or no side effects.  Again, this is something that the patient and doctor should have determined before arriving for the procedure.
 

Needle-phobia can also be attributed to Agliophobia, or the fear of pain. This is more common than many imagine, as many patients equate the venipuncture procedure with pain.  However,  with proper techniques and equipment, the procedure can be virtually painless.  Many times, this is an anticipated response, as they come into the situation convinced that the procedure will be painful.  As phlebotomists we must try to empathize with each patient, respect their feelings and state of mind, and do all we can within our power to recognize and calm their fears.  Under no circumstances should we downplay those fears or belittle them.  This will only serve to accentuate them and cause the patient to distrust your ability and sensitivity.  By recognizing the signs of fear, and acknowledging them to the patient, you may now suggest ways to help minimize those fears.  Reassure them that they are not alone in their fears, that you have dealt with many similar situations in the past, and will do all in your power to make the procedure as non-traumatic as possible.  Ask them if they have any preferences in drawing sites.  This will often make them feel more of a pro-active partner, and less of a victim.  The act of acknowledging their fears, respecting them, and giving them a way to cope with them, will often turn a traumatic situation into one more easily handled.  With each successful procedure, their fears may slowly become lessened and more easily coped with.  A few facilities offer a topical numbing solution (EMLA cream, iontophoresis, etc.) as a way of comforting the patient and making the procedure more tolerable.  These are not widely used, as they must be allowed time to numb the site, and greatly increase the time involved with each draw.  If they are available in your facility, make sure to offer them to your needle-phobic patients per your facilities protocols.
 
It is important to point out that needle-phobics should never be attended to by beginning phlebotomists. They lack the technical skill and have very little experience with patients of this caliber. If there is sign that the patient may be phobic, they should be referred to a more skilled and experienced technician.
 
The most common group of needle-phobics are children.  They present unique challenges when it comes to phlebotomy, and they typically are the ones with the most fear.  Children are commonly restrained in an attempt to draw blood quickly with a minimum of movement and resultant complications. This restraint often leads to needle-phobia. They feel trapped and out of control in an unfamiliar setting, and often pick up on the anxiety the parent feels over the need to "hurt" their child.  Parents and healthcare workers will often be met with anxiety and resistance in their attempts to talk to the child.  It is very difficult to have a logical, calming conversation with someone who doesn't normally communicate with adults on this level, and is now being held down and feeling trapped.  The best ways to accomplish a smooth pediatric blood draw is through positive reinforcement and parental coaching.  It is always a good idea to try to see the situation from the vantage point of the patient.  The child is in a very large, hectic, unfamiliar environment filled with unusual odors and busy people dressed in unfamiliar clothing.  White lab coats can sometimes seem very intimidating-especially when worn by a tall stranger standing over them and blocking their route of escape.  We are often taught to be professional, but forget that professionalism can seem unfriendly to a child.  By kneeling down and getting on eye level with the child, you are no longer viewed as such a threat.  Smile reassuringly, and let them know you are happy to meet them.  Explain that you have to draw their blood, but if they can be a good helper, it will be over very quickly and they will be able to leave soon.  Children love to help and be seen as more grown-up and responsible.  Let them know they have a very special job to do, and you will help them do it.  You can gain their trust in increments by explaining every step of the procedure as you go.  I ask if they have ever had a sliver, or stepped on a tack or something similar to that.  If they have, I remind them that it hurt, but only for a short while, and then the hurt went away.  I show them a piece of tubing and explain they have tubes like this in their bodies that carry their blood around to make sure all areas of their bodies get the food and air they need to be big and strong.  I tell them we need just a little of that blood to test to make sure it is doing it's job the right way.  I then let them see the needle and show them how little it is in relation to the tube, and point out how sharp the end is.  I let them know that because it is so sharp and small, it can slip in thru their skin and go in the vein and only hurt a very little bit.  I tell them their main job is to hold as still as possible so that I can make sure I get into the 'tube' as fast as possible and get back out.  Most children from the ages of 3-4 on up are fascinated by this, and watch in rapt attention.  I then tell them I need to tie an elastic around their arm, and tell them it will feel very tight, but shouldn't hurt.  Then I let them know I have to clean their arm with something cold and that smells "funny".  By this time, they usually have relaxed a little, since everything I've told them so far has been true.  When I get ready to do the draw, instead of telling them I'm going to have someone hold them down, I tell them I'm going to have someone hold their hand and help them be brave.  This takes them from being a victim, to being helped.  Have the helper or parent hold their elbow by gripping both sides between their thumb and fingers, with their palm around the back.  This will keep the elbow steady and keep them from twisting.  Then have the child grab the thumb of their free hand and tell them to squeeze it as hard as they can-you want to avoid telling them to make a fist, because most children equate fists with hitting-and you don't want them to think of hitting you!  I often tell them if they squeeze hard enough, they can sometimes make the helper's eyes change color.  I tell them to look very hard at their eyes and squeeze as hard as they can-by this time, when ready for the draw, even when I tell them 'here comes the poke now',
I have had some who have become so distracted by the eyes, and trust me so much, they hardly notice the actual draw.  I've had many children exclaim that not only did they make their eyes change colors, they tell me color they changed to!  By the time they notice the stick, the needle is in and they often realize it doesn't hurt that bad and watch in amazement as they see their blood come out.  If they still seem apprehensive, I tell them to count with me, and it will be all over by the time I reach "10", or what ever number you feel appropriate for the number of tubes or amount of blood to be drawn.  This lets them know that it will very soon be over.  Distraction is a wonderful tool that works on adults as well.  Striking up a fun conversation, or  telling an appropriate joke, if it seems appropriate, can help ease tension.   Humorous and colorful pictures and posters offer a great distraction from the procedure.  Having fun bandages or small toys they can choose from turns the negative experience into one much less stressful.  I've found even adults laugh and enjoy 'kid band-aids'  after a stressful situation.
 
Needle-phobia will always be a factor. Most people do not like needles.  In fact, when a patient comes in and the first thing they say is, "I hate needles!"  I respond by, "Good-it's the ones who like them that I worry about!"  In every instance, they have laughed and visibly relaxed, even if only a little.   We must always remain confident, calm and professional.  If we seem relaxed and under control, our patients will be less likely to fear us and the needle.
 

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Copyright 2005, N.A.P.P.A. USA