Saturday, February 02, 2008

Be Hep B Free

This morning I volunteered at the new hepatitis B clinic at Mt. Zion, run by the San Francisco Hepatitis B Collaborative (SFHBC).
Some of my favorite classmates poured their hearts and souls this year into establishing outreach clinics to screen and vaccinate the San Francisco population against hepatitis B. Two clinics have been running once at month since last November, and today the clinic had a record of 59 people screened (read: phlebotomized) and about 20 people vaccinated. I am so impressed by the time, effort, organization, cooperation, and dedication exhibited by students from the school of medicine, pharmacy, and nursing. Building this clinic from the ground up was a labor of love and patience, and I could already see the impact of spreading awareness and administering vaccines to improve and prolong people's lives -- so incredibly inspirational. :)
As an educator in the morning, I was surprised by how many strangers come into clinic after hearing about the free screening from a friend or advertising with very little knowledge about hepatitis B. People were confused about the difference between hepatitis A and B, didn't know that there is a hepatitis C for which there is no vaccine, and did not know what damage hepatitis could inflict. For more information, visit the SFHBC SITE at Talking to patients and teaching them about hep B was even more gratifying than I thought, because you got to spend some quality time with them and gave them some knowledge that would serve them indefinitely (until the next scientific breakthrough). Educating people about hep B is as important as drawing their blood or administering vaccines, because their knowledge dictates their autonomy.
As a phlebotomist later in the morning (we switch roles halfway), I partnered with a nursing student to draw blood for hep B testing and administered IM injections for the hep B vaccine. I lost count of how many phlebotomies I performed today, but I definitely gave 3 vaccine shots. Sorry to switch gears, but here's the story in vignette form:
A married couple entered the narrow exam room, ready to receive their first hep B vaccinations. S, the nursing student, had already administered the first injection to the husband and now it was the wife's turn to be stuck Watching S carefully screw the needle onto the syringe and drawing 1 cc of the refrigerated hep B vaccine, squirting a bit out to expel air, helped me prepare -- the last time I learned how to administer vaccines was in the fall of 2006 and we practiced injecting water into oranges. It saddened me because the oranges were inedible afterwards.
A friend of mine working for Teach for America mentioned how small children can sense fear and uncertainty in elementary school teachers, and now I realized that patients can also smell uncertainty. It makes them unhappy and nervous; and I've learned to never make sudden movements or giggle nervously. I smiled at the wife and said, "Have you had any problems with needles or blood before?"
She lifted her sleeve, exposing her petite deltoid muscle. I swabbed her arm with alcohol in a Starry Night pattern and hefted the syringe like a dart. To cause the least amount of pain, we're taught to stick the needle quickly. I held my breath and swung the needle into her muscle as fast as possible, pushed in 1 cc of vaccine, and held a piece of gauze against the point of entry while I withdrew the needle with my right hand at the same initial angle (for some reason, I convince myself that this causes less pain). The patient pressed the gauze against her wound and a band-aid was applied. She didn't seem perturbed at all, while I tried not to act too elated -- it was the first IM injection that I had ever administered to a live person. In medicine, we play it a cucumber wearing a white coat.
Administering vaccines turned out to be easier than drawing blood! After the first IM injection, it was like throwing darts but much more satisfying. My goal was the cause the least amount of discomfort, because I feel that poking needles as painlessly as possible is a valuable and admirable skill. But drawing blood requires more coordination and skill in selecting and coaxing the right vein to give up some sangre. Asian women are notorious for having no vasculature in the antecubital fossa (behind the elbow). One woman in our exam room seemed to have a promising vein, but it collapsed and S had to pull out. An MD tried to draw blood in the opposite arm, but to no avail. The woman was a bit upset at this point, because we had poked her twice without success, but a third try was the charm.
After the patient left, another Asian lady arrived and it was my turn to draw her blood. In front of a TV camera. For the first time, I tried chatting with the patient to distract her and we made small talk while I set up the supplies and searched for a good vein. I've become convinced that a sucessful phlebotomy depends less upon the skill of the health care provider and more upon the juiciness of the patient's veins -- big, blue, hydrated veins that feel spongy to the fingertip. I harbor a suspicion for veins that look too close to the surface, bright blue sirens that appear to be an easy mark, tempting you to puncture them, only to shipwreck you on a fruitless "stick." I was equally suspicious of a dark blue "Y" shaped vein on her right forearm, was it scarred down? Was it eager for a blood draw? The MD told me to go ahead, and I carefully slid the butterfly needle into the skin -- saw that ever-gratifying "FLASH" of blood in the butterfly needle and slid on the vacuum tube to pull blood into the container. There was a video camera pointed at the patient's arm less than 3 feet away, but the only mishap occurred when the vacuum tube lost suction and blood stopped pooling into the container. I nervously told the MD about the problem before tightening the syringe and seeing blood flow. Then I started breathing again.

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