Drawing Without a License

The biggest problem is nerve injuries: The needle sticks a nerve, not a vein, which can lead to chronic pain, sometimes severe, that can lead to disability or paralysis. But Ernst said he also sees punctured arteries, lacerations and serious bleeding and bruising. Poorly trained phlebotomists can also make simpler, but still devastating mistakes, such as turning their backs on a patient at the wrong time.

"I see a fair amount of injuries, including paralysis from patients who pass out during or immediately following the procedure and fall and fracture bones," he said. "One of them, in fact, was a lady who fell out of a chair in her home. She was being drawn for an insurance examination. The medical assistant turned his back on the woman and she fell out of her kitchen chair, fractured her vertebrae, and she is now paralyzed. [Passing out] is something that happens quite commonly. . . . They're not taught that passing out is a risk of the procedure, and they turn their back on the patient."

Bad Blood

Then there is the case that brought sweeping changes in California, after a phlebotomist's felony conviction for assault with a deadly weapon: a phlebotomy needle.

It was 1999 when the phlebotomist, working at a Palo Alto lab, was found to be using the same needle on multiple patients in thousands of cases over a period of four years. When the investigation ended, more than 3,000 patients had to be tested for HIV and hepatitis.

Soon after, California passed a law that set new standards for phlebotomy. One requirement is that phlebotomists train for a minimum of 80 hours and be tested and certified before they approaching their first patient.

But except for California and Louisiana, which took similar steps in 1993, phlebotomy training varies widely, ranging from 10-hour crash courses -- in some places, said Ernst, even that is considered a lot -- to a 200-hour program. As a rule, phlebotomists are trained on the job, not in programs like Peloquin's. So standards are set by the clinic, hospital or doctor's office that has hired the individual. Almost by definition, said Ernst, a phlebotomist trained this way is going to get the basics and not much more: Where does the needle go in, how deep, and at what angle? How much blood is too much, too little? How do you label and sort the vials?

In the three-month program at Northern Virginia Community College (NVCC), phlebotomy students learn basic anatomy. They are also exposed to physiology, medical terminology, medico-legal issues and patient communications.

Peloquin was surprised at how much psychology was involved. "Every patient is different," he explained, "so you never know what you're going to get with your next stick. . . ." Some patients, he said, are afraid of needles; others, anxious about the purpose of the test. "Depending on each individual patient, you have to adapt to the patient's moods and dislikes."

For April Wharton, one of Peloquin's classmates, the surprise was the complexity of the paraphernalia. "There are so many different kinds of anticoagulant stuff, so many different tubes," she said. "You have to know what every test does and is."

When NVCC students finally begin sticking needles in arms, they aren't the arms of patients.