We’ve all told anecdotes about the burly muscle man with tattoo sleeves who cringes at the thought of a 20-gauge IV catheter piercing his skin to provide access to pain relief medications, antibiotics or some other form of intravenous medication therapy. This same guy has a bone nearly sticking out of his leg, or multiple piercings all over his body, and may even have some scars from a prior bar fight. Yet, the thought of a teeny, tiny, angiocath being introduced into the equation in the back of your ambulance has him crying for exodus. So, how do you handle this?
Whether it’s starting an IV, providing a COVID-19 vaccine injection, or delivering some much-needed epinephrine to an anaphylactic response patient, needles are a necessary component in each equation. So when your patient’s wanting care – just not with a needle – here are some ways to calm their fears about this itsy-bitsy, piece of hollowed-out metal (Note: this author is not a fan of needles aimed in his direction, either).
Right size for the right job
For starters, let’s be professional and appropriate when it comes to the appropriate needle size when you’re going to utilize any form of injection procedure. A 20-gauge, 1.5-inch needle for an intramuscular injection is grossly inappropriate. The objective here isn’t to embed the needle into the patient’s bone, nor is it to leave a fountain hole in their shoulder after the needle is retracted. Instead, you can certainly draw-up your medication from its vial with this type of needle, but make sure to utilize a more polite 25-guage, 5/8 to 1-inch needle for the actual injection.
Along this line, be careful with what your patient sees. If they see you drawing your medication with 20-guage needle (which looks like a piece of electrical conduit, in their eyes), make sure to clarify that the needle that is actually going to be poking them is the itty-bitty one with the orange wrapper next to them. In fact, show them the needle! Let them see how small it truly is (this typically works better with adult patients, not with pediatrics).
No, there’s not a needle left inside of you
One of the most common misconceptions about IV angiocaths and starting an IV on your patient – from the patient’s perspective – is that there will be this ginormous needle still remaining inside of the blood vessels (which are inconveniently located inside of their body). The fact is, however, there’s no needle remaining, just a tiny, flexible piece of plastic tubing that allows for the medication to flow – without poking through anything.
In situations where your patient is curious, show them! Take a 20-guage angiocath (I recommend a 20-guage because you typically have a lot of these lying around, and they’re not as intimidating as an 18- or 16-guage) and demonstrate what you’ll be doing. Then, slide the catheter off of the needle and let them take a close-up look at what will actually remain – which is not the larger needle. Then, grab a new one out of its package and begin (never, ever, using the same demo needle for the actual injection).
One, swift motion
We say that animals can smell fear. Well, people can see it! A shaking hand, change in the pitch of your voice, or even a hesitation while you curiously look at your equipment – or at the patient – can set off alarms in your patient’s mind that you’re not confident with what you’re doing, which will likely (immediately) equate to them not being confident in what you’re doing.
Don’t be arrogant; but also, don’t be hesitant. Squinting, grimacing and other non-confident facial expressions will bode you no brownie points when it comes to piercing the skin of another person. Be confident! If you need to review the steps in your head before you do your first “live” IM injection, then do so while the patient isn’t watching your every move.
Make your poke in one, swift motion. Hold the “dart” in your hand and then “throw” it (but don’t actually throw it – only maneuver like you are). Digging, jabbing or gently – slowly – piercing are not the maneuvers to embrace with any of your standard injections.
Talk, inform and be a person
In this line of work, I can certainly be unemotional, disconnected and task-driven like the best of ’em – but now’s not the time to be a cruddy EMT or paramedic. Talk with your patient. A key element to obtaining/expressing informed consent is to actually inform your patient regarding what you’re doing (after all, they have a right to know). Keeping this in mind, do not lie to your patient – it’s unethical, not truthful and paints an incredibly negative light on both you as a provider, and your agency as a service/system. It’s OK to tell them that “this may hurt a little bit.” Talk is cheap, but truthful talk holds value.
Talking also allows for the beautiful art of distraction to take place (hopefully for them, not you!). Tell your patient what you would like to do for them (e.g., treatment plan), what you anticipate will happen as a result, and allow time for acceptance or refusal. Now, there’s a time and place for this process to occur – and prior to administering IM ketamine to an excited delirium patient probably isn’t it. But, in most other clinical, urgent or emergent situations, remember that whatever you’re doing is truly considered a form of treatment – and patients have the right to be informed about, accept and deny that treatment (after all, they are a person – and once you inject whatever it is into their body, you can’t take it out).
