Monday, March 2, 2015

Fool's Foils for Fasciculating Fingers

This problem was never addressed in nursing school and I have also never seen it in a textbook. It was never even discussed among nurses until I began working in the operating room.  We were like a family, albeit dysfunctional, but there was a sense of being more open with our problems. No, the problem isn't drugs or sexuality. It's hand tremors.

This is for you that have  been in a situation where someone is yelling, Get that blood going STAT.  You just got a beautiful dark red blood return in that flash camber of that #18 Angiocath.  Now it's time to start threading it into one of the last remaining veins and YIKES!  My fingers won't stop shaking.

If you're in nursing abomination administration, or any other non-bedside care area of nursing this is not for you. This is for nurses in the trenches, under stress, and that care about their patients to the point of being self-sacrificing. It's definitely disconcerting when you have to perform a task and your hands shake. Exacerbating factors include being tired, stressed, or harangued. Things you encounter everyday. Here are some tips that helped me with this problem.

When you're threading that angiocath, hold it between your thumb and index finger while your other 3 fingers are in contact and braced by the patients arm. Most everyone intuitively does it like this but it does help if you think about being stabilized by being in contact with the patient. This also helps if the patient jumps or moves.

Limit caffeine, this is hard but does work. Avoid alcohol.

Keep your arms adducted and braced against your body when possible. Limit the distance you reach out. For me, the further I reached away from my body, the worse the shaking.

Keep your hands warm. This is another good reason for handwashing. Being cold really exacerbates the problem of involuntary tremors.

In the OR practice handling the instruments. Be able to open and close clamps and needle carriers without  having your fingers in the holes.  Practice extending your index finger straight up to the pivot hinge on the scissor to guide and stabilize it. When loading a needle holder don't worry about getting it positioned in the jaws right away. Swing the needle over to contact the needle holder and slide it up the side to the jaws, finally adjust the angle of the needle in the jaws. You can do this very quickly without loss of speed.

If you have to do something one-handed like cut a suture for the surgeon don't over reach. Get in as close to you can and stabilize that free hand on something like a mayo stand or retractor. Think of that steady support as your anchor. This really helped me.

Verbalize  your shakiness if appropriate. Our chief of surgery would when the occasion warranted it yell out "My hands are getting tired and shaking"  His hands always stabilized after acknowledging the problem. This won't work in the ER with patients around, but you can say this to yourself and it does work.

When capping a needle, angle the cap upward, brace the base of your thumbs together and deliberately bring the needle down onto the cap, then slide the needle into the cap. That way you won't have to worry about exactly lining up the needle with the cap.

Put a calm relaxing spin on whatever is in your physical environment. I used to imagine those hot, bright OR lights were beaming down from heaven. I learned this trick from an old time surgeon and discovered you can put a good spin on just about anything. Whenever the s--- hits the fan, there are usually bright lights somewhere, so this can work in other places too.

If you're wearing gloves imagine them stabilizing your hands and fingers. I think they may actually do this, but that probably borders on being delusional.

I did google this issue for a contemporary take on hand tremors. About the only thing suggested was Beta blockers. This probably does work, but in critical areas of nursing you need all the sympathetic tone your nervous system can muster. Bad things usually happen very quickly and you don't need anything slowing your response.

Try not to develop spasmophobia where you overthink or worry about your hands shaking. You are in very good company if you have this problem. Florence Nightingale's hands probably shook  when she made her rounds in that Crimean battlefield hospital.

This problem is a manifestation of how much you care for your patients and that you are doing real nursing at a patient's bedside. Nursing bigshots, administrators, and indusrtrialists never had to worry about their hands shaking or even getting anything  under their manicured nails.  The bedside nurse is where the rubber meets the road.  You are the person getting things done.


  1. Great post, I hope you keep writing. Thanks!

  2. Well written and well-stated solutions to a common issue. We've all been there, I'd guess. Tiredness, stress, and, yes, caffeine add to it. Stabilization is, I think, the most important safeguard against shakiness, and the methods you mentioned are all important. It's amusing, isn't it, to watch simulations of surgery on medical TV shows. I stopped watching Grey's Anatomy a long time ago, but I remember seeing their "surgeons" operating with elbows out like a do-si-do, and holding their arms out as if reaching for a second helping of mashed potatoes at a family meal. And hauling the needle-drivers, after placing a suture, presumably, up toward the overhead lights. Amusing.

    And any post that has that much alliteration in the title is cool with me!

  3. Thank-you for your kind comment, Dr. Schwab. I always thought I was one of a foolish minority with this problem. I am humbled by the number of people that have viewed this post.

  4. Starting IVs became much harder for me when (gasp) we had to start wearing gloves. On the floor the gloves we got were non-sterile floppy one-size fits all. I finally gave up and started filching the surgeons gloves. When HIV/AIDs erupted we went through a period of glove shortages on the floors. Of course the surgeons gloves were locked up by then. I remember one night in ICU when a doc told us we should document when no gloves were available for the nursing staff. Of course at that time nurses thought nothing of wading in to whatever bodily fluid, emisis, stool or bloody mess that needed cleaning up. Now one feels naked without gloves on for most of the shift!

  5. We really got yelled at if gloves were used for anything other than being scrubbed in the OR. We would be accused of trying to bankrupt the hospital with an unnecessary expense and of fostering patient depersonalization. Our supply cabinet had sterile finger cots packaged in blue glassine envelopes that were to be used for procedures like foley cath insertion.

    I got off the bus before the widespread use of gloves!

    Thanks for commenting

  6. I was a Respiratory Therapist, prior to entering Nursing. I performed hundreds of blood gas punctures to the Radial, Brachial and Femoral artery sites, sometimes during the wildest situations, like an active Code Blue. When I switched to Nursing, I found the humble venipunture, much more difficult. However, after working my first 20 years of Nursing on the night shift, mostly in the ICU, I reached the expert level, When we switched to gloves-all-the-time, my venipuncture skills took a nose dive for a while, particularly because our cheap nursing gloves were so crappy. Now days our gloves, particularly the nitrile material, are more form fitting. When I see one of my senior partners (RN) without gloves on, I do speak up and admonish them to catch up with the 21st century.