Vein Care: Tips & Tricks

1. Vein Care:Tips & Tricks Lara Coffin

2. If you are alive you have veins

3. When working with a person, ask questions to get a shapshot of them. Don’t assume anything, like even if they feel comfortable reading Quickly examine the person with NO judgment. Make a mental note of special considerations, like: • Large person • Only has use of one arm • Lots of abscesses • Has a job and needs to hide track marks • Dehydrated Homeless or sleeps outdoors • doesn’t have good light • access to running water • can’t keep tons of supplies on them so may need to reuse needles Swollen ”cabbage patch kids” hands • Very bad circulation Dried blood on shirt or arms • not good with cleaning • Use alcohol wipes? • hurry

4. Drugs people inject Heroin Methamphetamine Cocaine Crack – add acid Methadone – use 3cc syringes Pharmaceuticals (pills) • Lots of fillers • Outer coating • New formulations that gel up when try to inject Steroid - muscle only Multi-drugs (speedball) TIP: Know the street slang for drugs. If you don’t know what something is, however, don’t pretend you do. Ask them.

5. Routes of administration • Intravenous (IV): into a vein, 45° • Intramuscular (IM): into a muscle, 90° • Subcutaneous (SC): under the skin or “skin-popping”

6. Where to inject? That is the question. Arms: first upper than lower Hands: veins are smaller so use a smaller gauge, rollers Legs: circulation issues can lead to blood clots or dvt’s Feet: smaller veins, close to tendons and nerves. Risk of infection and far away from the heart Groin: Blind shot. Risky because of artery & nerve Neck: Risky because it is right next to the artery that carries blood to the brain Other: breast, penis, chest – all bad ideas because poor circulation or erection problems Tip: Always shoot towards the heart Slide courtesy of Mary Howe

7. TIP: Sometimes it is impossible to inject toward the heart without help from a friend, like back of arm. In those cases, advise them to inject the way that is steadiest (remember this is harm reduction). In this case: • water down hit • inject s-l-o-w-l-y • pull out if it stings or hurts

8. VEINS, ARTERIES, NERVES…. OH MY Arteries • Carry oxygenated blood from the lungs and heart to other parts of the body • Have a pulse • Blood in them is bright red and frothy • Deeper in the body than veins Veins • Blood vessels that carry blood from the extremities of the body back to the heart and lungs • No pulse • Blood is a deep, dark red because it is low in oxygen Nerves • Not visible from outside the body • Will definitely know if you've hit one - experience extreme pain and no blood when register • Dangerous because could result in paralysis or the loss of a limb. Slide courtesy of Mary Howe

9. Valves • Veins contain valves to prevent the backflow of blood. Hitting a valve can cause irreparable damage to the vein leading to vein collapse or varicose veins. • To find the valve press your finger on the vein and run it slowly down its length. You should see a point where blood stops (i.e, the vein appears to stop as your finger passes that point). When you lift your finger, blood should flow again past that point. That point contains a valve so leave it alone. • Sometimes looks like a little pea under skin Slide Courtesy of Mary Howe

10. Getting to know syringes Gauge = thickness of the needle The higher the gauge, the thinner the needle. For example, a 31G needle is thinner than a 28G needle. Tip: Using the best syringe for the job will do the least amount of damage! Often people don’t know they are better syringes out there for their situation

11. Specialty Syringes 31 gauge 5/16” Great for hands and feet and tiny veins that get blown out easily, but clog 29 gauge 1/2” ½ or 1cc Good for folks who have smaller veins

12. Standard Syringes 28 gauge 1/2” 1cc (shorts) The standard. It is good for people with good veins (not long term west coast heroin users) 28 gauge 1/2” 1/2cc (halves) These have the same needle as the shorts but their barrels are ½ cc meaning they hold half the volume 27 gauge 5/8” 1 cc (longs) The needle on it is slightly longer and the gauge is slightly larger. These are ideal for deeper or scarred veins. Slide courtesy of Mary Howe

13. Muscle Syringes LITTLE musclers: 25 gauge 1” 3cc This is the standard syringe for muscling. BIG musclers: 23 gauge 1 ½ ” 3cc These are the standard syringe for larger folks and people injecting hormones. Tip: Lots of abscesses? Maybe not getting deep enough in the muscle, scared to use the muscling syringes or injecting near old abscesses

14. Muscling (opiates, hormones & steroids only) •Filter well, because high risk of abscess! •Use at least a 1” needle •Add a lot of water •Insert the needle at a 90° angle •Draw plunger back slightly to make sure no blood enters syringe. If blood appears, pull out and try again •Inject slowly

15. Booty Bumping Musclers are great for booty bumping because the needle is detachable •Draw up drug in a syringe barrel (take the needle off) and squirt it up there. •The anus has a lot of blood vessels that quickly absorb the solution •Will work almost as quickly as IV injecting and faster than muscling, but there is no rush. •It reduces risks associated with injecting including vein damage, abscesses and overdose. Tip: Women are much more receptive to this technique then men, although MSM men are open to it also. Slide courtesy of Mary Howe

16. Tourniquets & Ties… Use a slip knot, so the tourniquet can slip off (there is an art to tying your own tourniquet) When working with folks don’t keep tourniquet on one site more than 1-2 min It is best to untie tourniquet before injecting so don’t put extra pressure on veins. BUT… If untying tourniquet will cause more harm (i.e. pulling needle out or deeper in), don’t do it.

17. Femoral • Need 1 - 1 ½ “ needle • Fixed to the barrel is best to keep the needle from breaking off • Always wash the site • Sinus track Tip: NAVY – Nerve, Artery, Vein, Your crotch

18. Find the femoral PULSE Gently put the middle finger of your right hand on the pulse. (if injecting into your left groin, use the left hand) Let your index finger rest beside the middle finger. The vein should be below the index finger. Insert the needle next to the index finger pushing the needle in straight (at about a 90 degree angle to the leg). Register, inject and remove needleUse the clean towel or tissue to stop the bleeding. Press on the injection site for at least a minute then check to see if the bleeding has stopped or reduced. Keep the area clean after injecting.

19. Oh shit I hit an artery I know this because…. • The plunger is forced back by the pressure of the blood • Blood is bright red, frothy, and gushing. • It hurts and burns • Hand/foot blows up (Go to ER to get rings off!) I should… • Untie the tourniquet and pull the needle out • Raise the limb above heart to stop the bleeding • Apply pressure to the wound for at least 10 min • If bleeding continues seek medical attention immediately TIP: When in doubt pull out!! Slide courtesy of Mary Howe

20. Vein saving tips – the usual suspects • Rotate your injection sites • Drink lots of water • Don’t smoke before injecting • Exercise • Warm compresses or heating pad • Take tie off before injecting • Inject slowly • Inject towards heart

21. Other Tricks to make veins last • Clean hands also with soap/water or alcohol wipe • Let alcohol dry • Alcohol pads before not after • Use new needle whenever possible • Bevel up • Use the best syringe for the job • Water down hit (especially important if injecting something corrosive, like ascorbic acid)

22. Don’t bend needle with pressure when injecting – break off in body and/or destroys veins • Don’t “roto rooter” rolling veins • It is easy to puncture through veins or pull out a bit while injecting. Sit down. TAKE YOUR TIME. Be patient. • Learn how to use “other” hand • Learn how to inject self (if can’t) • Don’t inject near an abscesses or into a swollen area - will just clog up everything • Start up vein and work down so don’t have to go through swollen areas • Vitamin E, aloe or other healing salve • Epson salts on swollen, sore areas

23. TIP: Ask them to show you how they inject, what drug(s) they inject, what size needle they use and where they usually hit. Have them show you how they use a tie. Problem solve together. “So I don’t tell you stuff you already know, can you quickly walk me through how you inject?”

24. More Tips • Use simple, non-medical terms • Don’t over load person with new information. If vein care beginner, start with the basics. They will be back if you were able to help them and you can explain more to them then. If know a lot already, explain a little more. • Use mnemonics, like “Arteries Away” or “NAVY” • Do this in a private, warm place. If a friend wants to come, pull person aside and ask if that is ok. They will be taking off some clothing (shirts usually) and they need to feel 100% comfortable. • Use a sharpie or pen to mark their veins!

25. How to teach people to find their veins • Close eyes and feel • Use sensitive tips of fingers • like reading brail • If homeless or have calloused hands especially important • Hollow tube of pasta, spongy • Don’t use thumb (pulse in thumb) • Look when you don’t need ‘em so not in a hurry. Feel when watching tv, waiting in line somewhere or after you just got high. • Give copy of Getting Off Right, by HRC (if have them)

26. Weird stuff • Why do I sometimes get puffy, itchy areas when I inject when I KNOW I am in a vein? • Are my veins leaky? • I register perfectly, but then it stings and I feel like I missed. I even re-register to make sure! • I have abscesses in places I have never injected

27. Safety • Use your instinct • Never sit person closest to door. Always be between person and door for quick escape. • Have a buddy come in with you and sit quietly in a corner, if needed/etc. • Do not inject person! Not a supervised injection facility. OD risk, but more importantly, if word gets out you and organization will be in BIG trouble • Use your own discretion about femoral instruction. To show person that would involve taking off/down pants and moving underwear aside. • End session if gets weird

28. Special thanks to Mary Howe Phillip Coffin