User:Bron766/Cannulation

Teaching intravenous cannulation often occurs in stages, including:
 * Simulation skills lab: introducing the basic technique
 * Bedside teaching: the early student
 * Bedside supervision: the semi-independent student

Tips for early bedside teaching of peripheral cannulation include:


 * Before reaching the bedside, assess the student's existing knowledge by asking them to assemble the required equipment. Ask them to lay this equipment out from left to right in the order they will use everything (this is a good organisational habit to form before learning complicated procedures like central line insertion down the track). Ask them if they have forgotten anything! When you are happy they have planned the procedure and have enough knowledge to perform the skill on patients, proceed to the bedside.
 * Model everything yourself before expecting it of your student. Don't wait for them to perform an inadequate rendition of 'informed consent' before you establish your expectations.
 * Establish the importance of good positioning. Outside of the skills lab in the real world, where the arms are actually attached to real people, students easily forget about setting up the environment so that they and the patient are comfortable. Raise the bed, lower the rail, place the arm on a pillow and have the equipment and sharps bin all within reach.
 * Put your gloves on before they run in to trouble. Expect to be involved in the first few attempts. Let the student choose a vein, but check it is adequate and the best on offer before the needle comes out. Give advice on cannula grip but let them find a way that is comfortable for them.
 * Demonstrate various ways of tethering the vein so that it will not roll to the side as the needle is inserted.
 * Consider teaching with a hand-over-hand technique if they have had limited simulation experience or are very nervous. The idea is that the student holds the cannula and you guide their hand. This is a technique in itself! Basically if they are on the right track you hang back, but you have a measure of control over the angle of entry, speed and depth if required. The aim is to let them feel the cannula enter the vein, get them in the right spot (and not too far), then the student advances the cannula and proceeds to remove the needle, attach bungs/lines and finish.
 * Emphasise 'slow and steady' because the nervous student is often prone to exaggerated jerks that do tend to launch a needle straight through and out the other side of a vein. If they are in control, you should be able to say 'stop there a moment' and they will be able to pause without withdrawing the cannula at all backwards.
 * Don't forget to take the tourniquet off! Once the cannula finally goes in successfully, both student and teacher tend to feel quite relieved and are more than happy to move on to something else. If you stay one step ahead of the student until the whole procedure is finished, you will quickly spot the missed tourniquet before the patient starts grumbling.

Tips for teaching the semi-independent student:


 * Correct bad habits, but allow for individual style.
 * Reinforce planning ahead and organisation (as above) so that over confidence and haste does not lead to being caught without a cap/bung for the cannula!
 * Suggest alternate sites so that students develop the ability to place cannulas in various locations. Often students who have some initial success in one site, e.g. cubital fossa, will stick to that site no matter what. Encourage them to place lines in the dorsum of the hand, wrist, forearm, cubital fossa or foot as clinically appropriate. Each of these sites requires slightly different positioning and tethering the vein takes different grips. The student who can master every location has a much more flexible repertoire for the difficult patient.
 * Discourage blaming the patient who has 'bad veins' or 'lots of valves'. Discuss common errors, e.g. missing the vein due to poor finger palpation /eye coordination, going straight through to the other side ('blowing the vein') or not advancing far enough into the vein before advancing the cannula.
 * If you stock various styles of equipment, make the student practice with the full range to broaden their skills. Resist premature attempts to develop 'favourite' pieces of equipment.
 * Continue to set them up for success. If a patient is truly looking very difficult, involve the student in selecting a vein and size of cannula, but step in if inserting it is likely to be beyond their skill level.
 * Thank the patient for helping to teach the student and ask them to give the student their feedback.