ALMOST PARALLEL A shorter angle of entry helps keep the needle in the lumen, instead of going through the opposite wall of the vein.

ometimes it's hard to say who's more nervous, the patient who's about to get stuck with a needle, or the nurse whose job it is to do the sticking. Misses aren't a big hit with anyone.

I spent 9 years teaching nurses at an endoscopy center how to start IVs, and I've realized over the years that the ways we're taught in school aren't always the best ways. In fact, I've developed and refined several techniques. And while I don't want to sound boastful, when there's a really challenging IV at my hospital, I'm the person they call.

I can't honestly say that I succeed on the first try every time, but I'm close. I can do 10 sticks a day for a month without missing. (And on the rare occasions that I miss, it really ticks me off.) Fortunately, there's nothing like that consistent success to help you get over the fear — and instill confidence in patients. Here are some of the secrets to my first-stick success rate.

Have a good one
Some say pick a vein quickly and just go for it. I disagree. Once, early in my career, I was having trouble with a vein. When a doctor walked in, he said, "I wouldn't have even tried that one." Lesson learned. Don't be hasty. Always take the time to find a good vein before you attempt the stick. Put a tourniquet on the arm and feel and look. See if you can make the vein stick up. Sometimes wiping with the cleaning solution will help you see the ridge of the vein. You also want to make sure the vein travels in a straight line that's at least as long as your cannula, because veins can twist like the letter S. If you don't, you may find that the cannula won't advance because the vein turns a sharp corner right after the insertion site.

EASY ACCESS Lightly flicking, as an alternative to slapping, helps bring veins to the surface, open the lumen and numb the area.

Flick, don't slap
Most of were taught the traditional 2-finger "slap" to "wake up" veins. But I find that lightly flicking — using my middle finger after pressing it against the inside of my thumb — works better. Not only does it help bring the vein to the surface and help open the lumen, it also seems to numb the area a little bit. Patients often ask, "When are you going to poke me?" They're usually surprised when I tell them I already have.

Let it hang
If you're having a tough time finding the vein, let the patient's arm hang down below the heart. The vein will fill up a bit and become easier to palpate and locate.

Make an impression
When you're dealing with a vein you can feel, but can't see, make small parallel fingernail impressions in the patient's skin on each side of the vein. Obviously, you don't want to hurt the patient, but a gentle impression won't disappear immediately and will help you see where your target is. Clean the site, wait for the solution to dry and insert the needle. This is especially effective with younger patients with healthy skin, but doesn't always work on older patients with loose skin. (It shouldn't be done with fragile skin.)

Know how it rolls
Most veins don't roll, but every nurse has dealt with ones that do. You can end up missing a vein because when you tried to stick it, it rolled to one side and completely disappeared. To prevent that from happening, first try palpating to determine if the vein rolls, and if so, which direction it's more likely to go. If it rolls, apply pressure on the other side, and instead of entering from above, go in from the side that moves it in the other direction. In other words, if the vein rolls to the right, come in from the right. Now the vein won't run away from you.

Work the angles
My angle of entry is lower than what they teach you in nursing school. In fact, instead of coming into the vein at the traditional 30- to 45-degree angle, I like to come in at 5 to 15 degrees, almost parallel with the lumen. That way if I go too far, the needle stays in the lumen instead of going right through the opposite wall of the vein. Then, after the flash, lower the angle of the needle to match that of the lumen before you advance the cannula.

Additionally, with veins that roll — especially those in the hand — once you've just barely inserted the needle on a parallel trajectory, I recommend pulling the needle upwards a tiny, tiny bit to lift the skin. Then advance it. The lift opens the vein and makes sure you don't compress it, and the needle goes right in. You'll get a large flash of blood and will be able to quickly advance the cannula.

Anchor away
Anchoring the skin can make all the difference in your IV start. Using your thumb, push against the skin a good distance away from the insertion site. That will stop the upper layer of the skin from moving when you're trying to do your stick.

WELL TAUT Anchoring skin with your thumb stops the upper layer from moving while you try to stick.

Think one notch on a ruler
Inexperienced nurses sometimes stop too short once the needle's in the vein, leaving the cannula in the wall of the vein and preventing it from advancing. To make sure both the needle and the cannula are in the lumen, once you see the flash, advance it a little farther and picture it going into the vein (parallel to the lumen). Then advance the cannula.

Use a tripod
Stabilize your hand by resting your 3 available fingers (not the thumb or index finger) on the patient's arm while you insert the needle.

Say hello to ultrasound
This is relatively new to me, but it's really quite amazing, especially for patients with hard-to-find veins, such as pediatric patients, IV drug users and chemotherapy patients. When you have a really difficult stick — one where you can't palpate or see the vein — vein finders that use either ultrasound or infrared light work wonders in locating difficult-to-access veins. Many vein finders come in both handheld and hands-free models. You just point the device at the skin and click to display the superficial veins closest to the skin's surface.

Lasting impression
Remember, confidence is contagious and plays a big role. Patients may not remember much about their surgical experiences, but they'll likely remember a painful or unpleasant IV start. With patient satisfaction at a premium, it makes sense to master all the first-stick tricks you can.