anatomy, physiology

Not By Sight

As an ER nurse, my day begins and ends with IVs. Precious chunks of time can be either saved or spent in a patient’s room, all depending on the IV placement. My first day of orientation, it was my biggest fear.

“How’s your IV skills?” my preceptor (mentor/trainer) asked.

My heart rate quickened as a small sense of panic set it. Horrible, I thought.

At my first nursing job, a trauma/surgical intermediate care unit, I stuck people regularly for laboratory draws and new IVs. I was pretty good when I left. At my first travel nursing job, a medical/cardiac stepdown unit, I was not allowed to place IVs. That was reserved for a special team. At my second travel nursing job, a surgical intermediate intensive care unit, I rarely had the opportunity to try. When I did, I missed. Horribly.

“I’m rusty,” I admitted sheepishly.

“Fair enough,” he said as we walked into a patient’s room.

I watched my preceptor as he simultaneously assessed the patient, asked questions about the primary complaint, placed an IV, and drew labs. He paused at times to show me different tricks, like inflating a blood pressure cuff instead of using a tourniquet or how the catheter had a stop at the end so blood would not come pouring out.

“Next one’s you,” he said. Great, I thought sarcastically. I’m going to miss, and he’s going to think I’m an idiot.

I did miss. Horribly. On a patient with multiple, very obvious veins. But my preceptor did not think I was an idiot. He just thought I needed practice. The basic skill came back quickly after the first awkward attempts, much like riding a bike after putting it down for years or playing the piano after not practicing for weeks.

But I needed to see the veins, and many of my ER patients are dehydrated, have frail skin, winding vasculature, darkly pigmented skin, tattoos, and scarring from years of IV placement or IV drug abuse, all complicating the skill.

“You’re going to need to get used to not seeing veins,” he told me after another horrible miss, this time on a patient with no obvious veins, frail skin, and apparent dehydration. “You’re going to have to get used to feeling them and not seeing them.”

Over the next shifts, I had several patients with no obvious veins. I could feel some, but I still wanted to see veins. I opted to use a vein finder, a medical device designed to help medical professionals find a vein for puncture by highlighting them with light. Too bad the light that detects veins also detects tattoo ink and cannot detect veins well when a patient is dehydrated. Even using the vein finder and seeing my target, I missed. Horribly.

“Get used to feeling them,” he gently reminded me. “You’re going to have to get used to feeling them and not seeing them.” As if the 20 and 18 gauge needles that he placed by touch to very non-obvious veins were not reminder enough that I needed to change my method.

My comfortable methods of seeing veins was failing me, even with the fancy technology of the vein finder. I needed to try something else.

Another dehydrated patient with no obvious veins needed lab work and an IV. I lightly touched all anatomical points on his arm where I knew a vein would be cleverly hidden, finding a suitable spot after a minute of searching. As I stared at the patient’s skin, needle in hand, counting to three aloud, I was panicking. I could not clearly see where I was going. I did not know for certain if the IV would work. I knew it’d be painful for both the patient physically to have a needle jabbed in his arm and me emotionally to cause a person undue pain. I took a long breath in, sharply exhaled, and punctured his skin.

Miraculously, blood filled the chamber, the plastic tubing slid in easily, blood flowed into the rainbow of lab tubes, and a liter of saline dripped quickly. My leap of faith, my risk, my jump into the unknown had visibly paid off.

In both IV technique and faith life, it’s difficult to move from a sense of knowing and seeing to a sense of unknowing and hope before taking a risk.

Thankfully, both veins and our Lord follow a pattern.

Arm veins have a predictable anatomical layout. The radial vein runs up the wrist from the thumb. The inside of the elbow (the antecubital area, abbreviated as the “AC”) contains the median cubital vein, the cephalic vein, the accessory cephalic vein, and the basilic vein. The hand has dorsal metacarpal veins and the dorsal venous network.

In a given person, between their bilateral (left and right) wrists, ACs, and hands, most often at least one vein will pop up when compressed by some sort of tourniquet. They might not be visible to the naked eye, but they can be felt. Unlike tendons, muscles, ligaments, and nerves, veins have a certain feel to them. Muscles, tendons, ligaments, and nerves stand firm to light touch. Veins bounce.

So too, our Lord follows a predictable pattern: He loves us more than we’ll ever know and always wills our good.  He never stops loving us, listening to our voiced and unvoiced prayers, waiting for us to come home to home, pursuing us and our ambivalent hearts.  He never allows suffering without a greater good in mind. He never deprives us of anything we truly need without a greater plan in mind. He never abandons us, even when He feels far away and silent.

As my preceptor continually reminded me in my first week of orientation, IVs cannot always be placed by sight. So too, we must walk by faith, not by sight (2 Corinthians 5:7).  It reminded me of a favorite church song, “We Walk By Faith” by Henry Alford.

We walk by faith, an not by sight:
No gracious words we hear
of him who spoke as none e’er spoke,
but we believe him near.

We may not touch his hands and side,
nor follow where he trod;
yet in his promise we rejoice,
and cry, “My Lord and God!”

Help then, O Lord, our unbelief,
and may our faith abound;
to call on you when you are near.
and seek where you are found:

That when our life of faith is done
in realms of clearer light
We may behold you as you are
in full and endless sight.

We walk by faith, an not by sight:
No gracious words we hear
of him who spoke as none e’er spoke,
but we believe him near.

Our faith life cannot by lived in pure certainty in ourselves and our actions. Sometimes our next steps will be clear, like an obvious vein, but more likely than not, the veins will be hidden, even after pressure is applied. So too our lives will be filled with uncertainty, unknowing, and hidden opportunities for hope, even amid difficult times when we want certainty and clarity the most.

But it is in unknowing and uncertainty that the Lord calls us closer to Him.  The night is darkest before the dawn. So too in our lives, the Lord is most at work at a greater good and a closer intimacy with Him than ever before when He feels the farthest away.

Just as I must believe a patient has vein where I am going with a needle, even when I cannot see them or even feel them as I go to puncture their skin, as Christ’s followers, we must believe God is there, even when we cannot see Him or feel His presence. We must walk by faith and not by sight during our limited time on earth.

But what is it to walk by faith and not sight? It’s to take a risk on God. It is to believe, hope, love, and trust in God even when He seems far.

We can take a risk on God, believing in the cloud of uncertainty, hoping while the throws of despair, loving while our hearts ache of emptiness, trusting in the confusion of doubt. He is there, following his predictable pattern of perfect love for us. He is waiting. He is at work. He will come through, in ways we do not expect, in ways that will our good over anything else.

But we must take a risk. We must take those steps without knowing where we’re going. We must believe, hope, love, and trust. We must walk by faith, not by sight.

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