Drawing Without a License

"We practiced on each other," explained Wharton -- something she called critical to building confidence . . . and technique. "The first time I stuck one of my classmates I was terrified. I was shaking. It was very hard. If a patient were to see me doing that, they probably would have gone crazy."

The Sample

Getting the needle in is only half of the job. Handling the blood sample to avoid contamination or mix-ups is the next challenge. The goal, said Harris-Lyne, is to get a quality blood sample: the right amount of blood, drawn the right way; properly labeled, sealed and preserved; and delivered to the appropriate address for the appropriate test.

The National Committee for Clinical Laboratory Standards (NCCLS) lists 32 steps that, if followed, almost guarantee a successful blood draw. But skip a step or two, even accidentally, and bad things can happen, said Ernst.

An imperfect draw, for example, can result in a specimen that isn't sterile. This can happen if a patient is not adequately "prepped" -- if the site where the needle goes in is not properly cleaned in advance. An unsterile sample can result in a false positive for certain conditions, meaning a healthy patient may think he is sick. Or a doctor may prescribe medication for a patient based on an incorrect blood test result. "That," Ernst said, "can have life-threatening consequences."

This was the concern a few years ago at the Alameda Country Medical Center in California, where a lab manager noticed an unusually high rate of contaminated blood cultures. Senior lab staff members recognized the problem and brought in trained phlebotomists to take over.

They recruited new people and trained them beyond what was considered "routine." Within two years, the contamination rate for blood cultures in the lab had dropped 70 percent. With fewer false positives triggering unneeded treatment, the hospital's costs went down, too.

Under-trained phlebotomists can also be a hazard to themselves. When a phlebotomist accidentally jabs himself, or has contact with blood and other bodily fluids, he can be exposed to HIV, hepatitis or other pathogens.

The Mayo Clinic in Rochester, Minn., takes such risks very seriously. A training program that was begun there in 1994 reduced "occupational exposures" for phlebotomists from a high of 1.5 exposures per 10,000 sticks, to 0.2 per 10,000.

Certifying What?

Consumers have a right to demand that a qualified professional draw their blood, said Ernst. But how to know when you've found one?

A diploma hanging on the clinic wall is no guarantee. In an unregulated field, said Ernst, "there are some entities that claim to certify phlebotomists" but have substandard eligibility requirements. "It is one thing to mandate certification," he explained, "but without minimum standards for what that certification entails, it's just window dressing."

The only alternative may be to ask the phlebotomist, point blank, about her credentials. "That way," said Ernst, "the patient can protect themselves from the unskilled until the legislators make it a given that all specimens are drawn by qualified personnel."

At NVCC, Harris-Lyne discourages students from seeking certification by any but the most highly regarded and widely accepted certifying bodies. The American Certification Agency, for example, requires applicants to have completed either a year of on-the-job training or an accredited training program, to have documented at least 100 successful venipunctures and to have passed a two-hour written and practical test.

In California, where certification has been required since last spring, consumers appear to be benefiting. According to Robert Miller of the California Department of Health, the number of phlebotomy complaints has decreased "from 17 percent of the total [number of medical complaints of all kinds] we receive each year to about 5 percent of the total" since the new regulations went into effect.

Why don't more states follow California's example? Gaynor thinks the reason is simple: Quality costs money. Phlebotomists are generally paid from $8 to $12 an hour, depending on location, demand and training. Higher personnel costs for well-trained workers are eventually borne by the consumer in terms of higher prices or less covered care.

But Ernst thinks there's another reason the field remains so unchecked: People either don't know or don't care who is sticking needles in their arms, and governments reflect that complacency.

"Does every state have to have a phlebotomist caught reusing needles in order for them to act and implement legislation?" he asked. "Of course, the answer should be no."•

Ranit Mishori, a family-practice resident at Georgetown University Medical Center, last wrote for the Health section about aichmophobia, the fear of needles.