Phlebotomist

A haematoma is a collection of localised blood, usually in liquid form, outside the blood vessels, and is generally the result of a hemorrhage within the tissue. A haematoma is distinguished from a simple bruise or ecchymosis in that it forms a sac or pocket of blood, rather than a thin spread of blood immediately under the skin. The word “hematoma” is devised from the Greek terms hema- referring to the blood + -oma, from the root word oma – meaning body, or a bloody body, i.e. a collection of blood.

Hematomas mostly occur within skeletal muscle and can form into A hard mass under the surface of the skin. Typically the sac of blood or hematoma eventually dissolves; however, they may continue to grow or show no change. The very slow process of reabsorption of a hematoma can allow the broken down blood cells and hemoglobin pigment to migrate into connective tissue. If the haematoma does not disappear, then it may need to be surgically removed if it is restricting the mobility of a joint or causing unsightly embarrassment to the patient.

Phlebotomy haematomas may be caused by the perforation of the bottom or sidewall of a vein causing the release of blood and localized inflammation. This can be avoided by applying better technique i.e. inserting the needle in at the correct angle and depth, and keeping the needle steady throughout the procedure whilst attaching and changing tubes. Attention must also be given to the removal of the needle after the collection taking care to withdraw smoothly and straight. Haematomas may also be caused by forgetting to remove the tourniquets before removing the needle and therefore not allowing a reduction in the pressure at the wound site.

Following the procedure pressure must be applied to the wound site until bleeding has stopped. This may take a few minutes if the patient is taking any anticoagulant medicines, and if so time allowed for clotting factors must be considered. If there has been inadequate pressure applied or for not long enough then a haematoma may develop. If a heamatoma is present then apply a fresh dressing to the site, secure tourniquets, apply pressure and supervise the patient with the same technique. It’s important to stay with the patient, reassuring them, and to suggest gentle massaging of the swelling, or perhaps ice packs if appropriate.

Phlebotomist training involves paying very close attention to what may appear to be minor details, but which can have a major impact on the health and safety of their patients and colleagues.

Infection control is a great area of concern in the NHS. Armstrong-Esther (1982) stated that ‘The prevention of infectious diseases is a much more sensible method of control than waiting until a disease or epidemic occurs and then attempting to deal with the consequences in a hurry.’ He also argued that the success of vaccines and antibiotics leads to increased pressure for their abandonment as mutating bacteria become resistance to the overprescribing of generic antibiotic drugs and thus weaken our efforts to control them.

While most medical problems are associated with infections, and are the result of immunological mediated hypersensitivity reactions to protein component common in the environment, a number of serious healthcare-associated infections continue to be a high priority. Although the H1N1 and SARS viruses continue to create newspaper headlines, the MRSA outbreaks with UK hospitals continues to claim lives. The Health Protection Agency 2010 reported a total of 1,898 cases of MRSA bacteraemia in 2009/10, which represents a reduction of 35% in reported cases from the previous year when 2,935 cases were recorded, and demonstrates the efforts made to reduce the risk as a result of extensive and collaborative research.

Phlebotomists are usually in close proximity with large numbers of patients and are especially vulnerable to cross infections. Particularly at risk are the very young, elderly and those receiving immunosuppressive treatments, where regular blood collection samples may be critical to the accurate diagnosis and monitoring of those treatments. As government budget cuts impact heavily upon NHS resources the problem is to develop a method of infection control that is safe, effective, and can be repeatedly delivered at low cost. The Royal College of Nursing (1995) states that correct hand washing is the single most effective measure in which a healthcare worker can control and prevent the spread of infections in hospitals.

The Integumentary system consists of the skin, hair, sweat and oil glands, teeth and nails, and has multiple functions including sensory reception, thermal regulation, insulation, absorption and excretion. However its primary role is that of protection from the millions of potentially harmful bacteria, viruses, fungi and parasites that aim to gain entry. The skin is the largest organ in the body and forms the outer surface of the entire body. It functions to keep internal tissues free from infection by forming a physically protective water proof layer.

It also has another defense mechanism by providing a home to millions of comensual, ‘friendly’ bacteria that create conditions unsuitable for potential pathogens to grow or establish themselves. Senior K 2011. Each and every individual has a different complement of comensual bacteria on their skin surface. As many as 180 different species can be growing there including benign species of Staphylococcus hominis, Arcanobacterium haemolyticum, Staphylococcus epidermidis, and Micrococcus luteus.

Removing all dirt and infectious contaminants from the skin is particularly important. Hands and other soiled areas of the body, clothing and equipment should be cleaned at least at the end of each working shift, prior to and after meal breaks, and after visiting the toilet. It is usual to wash the hands before any direct contact with a patient, after contact with blood or bodily fluids, after removing gloves, and before any aseptic techniques.

The correct method of hand cleaning is essential to reducing infections and developing a good hand washing technique will to ensure hands are cleaned thoroughly. Special attention should be paid to the backs of the hands, fingertips and the thumb areas as these are the most frequently missed. Avoid scrubbing the hands as this will remove many of the comensual bacteria offering protection to the skin. For heavily soiled hands most manufacturers recommended applying an appropriate specialist hand cleanser directly to the skin before wetting.

To avoid the risk of drying out and chapping of the skin especially during cold weather the hands should always be properly dried. The use of barrier creams and emollients can also reduce damage to hands from the continued washing and drying. Clean towels should always be available as dirty, ‘communal’ towels would expose the skin to more dirt and lead to the risk of infection. If possible, Antibacterial paper or ‘single issue’ disposable towels should be used, and also the liberal use of alcohol based gels and sprays to further reduce contamination.

Regular hand washing will become an unconscious behaviour or ‘habit’ if practiced repeatedly for around twenty one days. It takes approximately three weeks for new neural pathways are to created and strengthened for any new learned behaviour or skill,  and hand washing is an extremely useful behaviour worth developing in the control of the spread of infection.

Phlebotomists are among a main group of healthcare sector workers considered most at risk from  transmission infections by what is more commonly referred to as a needlestick or ‘sharps’ injury. Needlestick injuries also occur in other fields of work such as the police, prison and probation services, social work, body art and piercing industry, customs and excise, and the funeral industry. Phlebotomists follow a standard safety procedure adopted in the UK for the prevention of needlesticks.

The major risk posed by needlestick injury to workers is exposure to blood-borne viruses (BBV).  The main viruses involved are:

Hepatitis B (HBV)

Hepatitis C (HCV)

Human immunodeficiency virus (HIV)

Phlebotomists may acquire a BBV infection if they are exposed to infected blood or body fluids. This could be either via the mucous membranes (eyes, inside of the mouth and nose), through broken skin or through an inoculation injury route, where the skin is punctured or scratched by a needle or ‘sharp’ that has been used in a medical procedure.

In the case of HBV an effective protective vaccine is available; however no such protection is available for other BBVs.  These other infections are difficult to treat, the prophylaxis or treatment is unpleasant, may cause significant side effects, and there is no guarantee that treatment will be successful. As the prevalence or carriage rates of BBVs in the general UK population is generally low, therefore the risk of infection from needlestick injuries remains minimal.

Phlebotomists are required to become familiar with different types of tourniquets and how to correctly apply them to a patient. A tourniquet is used first to compress a limb, usually the upper arm, and to swell the veins. After a suitable vein is identified a needle is insertedand  a syringe or collection tube may be used to draw blood samples.  Often a medicine  may be injected and for intravenous infusion a cannula, a small plastic tube is inserted via the needle. After the first or second specimen blood has been withdrawn,  the tourniquet is usually loosened to allow the blood to flow frely until all specimens are collected and the cannula is then removed. The wound site is then covered and pressure applied to prevent any bleeding. The procedure is not usually painful however it may cause some patient discomfort.

There are currently two types of tourniquet in used in phlebotomy procedures. Disposable tourniquets are much preferred for reducing the risk of transferred infection and as they can be more freely available, however they are often of poor quality to keep costs low, and can be more of a challenge to learn to apply safely and effectively without using them with a knot. Disposable tourniquets like certain types of examination gloves have a high content of latex, and proteins in the structure which may cause an allergic reaction.

Reusable tourniquets have the advantage of being adjustable, and can provide very small increments of pressure through the use of quick release clips. Although more expensive they can allow more ease and speed of use, finer manipulation of pressure upon the veins, and may be more comfortable for individual patients. These tourniquets have an inside and outside dictated by the position of the release clip, and can be put on from the wrong side so that rather than abduct or draw the tape out and away from the patients centre, the phlebotomist may adduct, and draw a length of tourniquet across the face or chest of the patient. This increase the risk of an eye injury if the tourniquet snaps back, as it’s made of elastic material, and also the phlebotomists hand would be very close to a female patients breast which if contact were made may be misinterpreted as a sexual assault.

In all circumstances tourniquets should be placed 1-2 inches above the collection site and just tight enough to be able to place a single finger between the skin of the patient and the inside surface of the tourniquet. Tourniquets have been used for centuries by soldiers in battle and surgeons to slow down or stop the flow of blood. They can be potentially dangerous and result in serious injury if not applied correctly or left on for too longer period of time. For this reason tourniquets used in paediatrics are used only by specially trained clinicians.

Typically a tourniquet is only left in place in tension for two minutes. Left in place longer than this may cause hemolysis and additional edema within the surrounding tissues resulting in the collection of inaccurate blood samples. Once the blood collection has started the tourniquet should be released and then removed from the limb when finished. A correctly applied tourniquet will allow the phlebotomist to obtain the best possible sample of blood quickly, efficiently and with the minimum of stress and discomfort to the patient.

Phlebotomists regulary collect bloods for DNA testing as paternity disputes can be quickly determined with simple and irrefutable DNA results. Blood tests can also identify genetic abnormalities which may affect fertility or to eliminate potential hereditary diseases and disorders. Bloods are routinely screened for sexually transmitted diseases (STD’s).

Phlebotomists are

Phlebotomists are acutely aware of how critical blood pH levels are in maintaining life. Even a tiny deviation in the acid/base balance can have major consequences on the organs of the body, and often with fatal results.  The very narrow parameters

Phlebotomists understand that blood tests can identify the causes of several gastrointestinal disorders. The digestive system functions to break down food physically and chemically into nutrients which can be more easily absorbed and utilised by the bodies cells and tissues. It also serves to elimiate the waste products of digestion.

The gastrointestinal (GI) tract consists of 21 seperate structures that includes the mouth, pharanx, stomach, intestines, and several accessory organs such as the salivary glands, liver, gall bladder, and pancreas.

The passage of food begins at the mouth and ends at the anus. This route is known as the alimentary canal and in the averages adult is around 8.2 meters in length, and a meal can take between 15 – 48 hours to complete the journey.  The digestive process begins in the mouth with teeth providing the cutting, chewing, and grinding force to reduce the food into appropriately sized pieces for ease of swallowing. This process is termed mastication.

Saliva secreted during mastication contains enzymes which facilitate the digestion and absorbtion of solid and liquid food. Phlebotomists may be required during blood collections to take swabs of patients mouths for various culture examinations.

Phlebotomists collect blood specimens for numerous laboratory tests done to assess the efficiency of the cardiovascular system. Haemostatic disorders are a serious threat to life. Overactive clotting can cause a thrombus, an embolus, or disseminated intravascular coagulation (DIC) disease. Anticoagulant drugs such as heparin or warfarin are used to suppress clotting factors. Conversely, if clotting factors are deficient, as in haemophilia, then excessive bleeding can occur following a simple injury.

Tests for blood typing and cross matching are typically done in a transfusion, blood bank or immunohaematology laboratory. Plasma and serum that are tested for repiratory gases, regulatory hormones, metabolic wastes, and nutrients are usually carried out in a chemical laboratory.

Phlebotomists have an important role in respiratory medicine. Respiration refers to the exchange of gases that take place between air and the blood. Oxygen makes up 20% of our atmosphere and the average person inhales and exhales between 12-15 times per minute, or around 20,000 times per day. As oxygen (O2) and carbon dioxide (CO2) enter the blood, the circulatory system transports them between the lungs and body tissues. The repiratory and circulatory system function together delivering O2 to the cells and removing CO2.  At the cellular level oxygen is require for burning nutrients and releasing energy.

The main structures of the respiratory system are located in the head, neck, and thorasic cavity. They consist of the nose, pharanx, larynx, trachea, bronchi, and lungs. As each breath is taken the air travels through the nasal and pharangeal air passages into the lungs. A major change of gases takes place in the lungs  where O2 is exchanged for CO2, and then the air is exhaled.

Phlebotomists are actively involved in the education of their patient who have a history of smoking. Respiratory diseases directly caused by smoking kills over 100,000 people every year in the UK.  Around 20% the UK adult population still smoke. The government’s plans to further ban cigarette advertising through the restrictions on brand packaging is aimed at reducing the treatment costs to the NHS.

Phlebotomists frequently encounter patients with disorders of the endocrine system. The most common being diabetes. The human body has two types of glandular tissue. Exocrine glands secrete fluids such as saliva, mucus, digestive juices, and sweat. These fluids are transported through a network of channels or ducts. Endocrine glands release their secretions (Hormones) directly into the bloodstream, and are therefore referred to as ductless glands.

The Pituitary, or Hypophisis is a pea sized endocrine gland weighing 0.5 g and situated at the base of the brain. The pituitary is functionally connected to the hypothalamus as a protrusion, a tube referred to as the infundibular stem or pituitary stalk, and secretes 9 hormones that regulate homeostasis.

The Posterior Pituitary or Neurohypophysis stores and releases 2 hormones:

ADH, the Antidiruetic hormone is also known as AVP, Arganine vasopressin although much of this is relesed by the supraoptic nucleus in the hypothalamus.

Oxytocin,  is one of the few hormones that provide a positive feedback loop. During labour, this feedback loop continues throughout as uterine contractions stimulate the release of oxytocin, which in turn, further increase uterine contractions. To hasten a difficult labour oxytocin IM injections are often given.