When Pain Speaks Louder Than Words

Sometimes the most powerful lessons come from the cases that haunt us. Today I want to share two nerve injury cases that illustrate a critical truth: when a patient is in distress during a blood draw, the procedure stops. Period. These scenarios are composite cases based on several experiences I’ve seen in my work as an expert witness. The names are fake, but the injuries, the consequences, and the legal outcomes are very real.

Case Study #1: Maria’s Story

Maria Rodriguez, a 52-year-old woman, arrived at an outpatient laboratory for routine blood work. She spoke primarily Spanish, with limited English. The phlebotomist assigned to draw her blood spoke only English.

Maria extended her left arm—the universal gesture of consent. The phlebotomist applied the tourniquet and selected a vein. She inserted the needle.

She missed.

Rather than withdrawing the needle completely, the phlebotomist began redirecting it beneath the skin, probing in the area of the basilic vein. That’s when the needle struck Maria’s median nerve.

Maria’s reaction was immediate and unmistakable. She cried out sharply. Tears began streaming down her face. Her body tensed. She tried to pull her arm away, but the phlebotomist held it firmly.

“I’ve almost got it,” the phlebotomist said, continuing to manipulate the needle. “Just hold still.”

Maria’s cries continued. The tears kept coming. But the phlebotomist kept going, eventually obtaining the sample.

By that afternoon, the pain had intensified to the point that Maria’s daughter drove her to the emergency room. Maria described a burning, electric sensation radiating down her left arm. The ER physician documented nerve injury and prescribed pain medication.

The pain never fully resolved. Over the following months, Maria developed Complex Regional Pain Syndrome (CRPS)—a chronic pain condition characterized by severe burning pain, temperature sensitivity, and skin changes. Even after a surgery to try to fix the damage, her left arm was hypersensitive to touch, and any use of it caused extreme pain. She could not hold a gallon of milk, carry groceries, drive her car, type… Any daily activity worsened the pain. The arm she once used freely to cook, clean, and care for her grandchildren became a constant source of agony.

During her deposition, the phlebotomist defended her actions by stating she “couldn’t understand what the patient was saying because she didn’t speak English.” She claimed she didn’t know the patient was in distress and that some patients are scared of needles and can be dramatic during their draws.

But some things don’t require language to understand. Screaming is universal. Tears are universal. A patient trying to pull her arm away is universal.

Maria’s case resulted in a settlement. She lives with permanent nerve damage and CRPS to this day.

Case Study #2: Jessica’s Story

Jessica Chen, a 34-year-old master esthetician, went to her primary care physician’s office for a routine annual physical. She’d had blood drawn many times before without incident. She had what phlebotomists call “good veins.”

The medical assistant selected the basilic vein in Jessica’s right arm. When the needle entered the tissue, it struck the median nerve.

Jessica’s world exploded into pain. She described it later as “lightning shooting down my arm” and “like someone put a blowtorch inside my vein.” The burning, electric sensation was immediate and overwhelming.

“That really hurts,” she said, her voice tight with pain. Tears filled her eyes.

“I’m sorry it’s painful,” the medical assistant replied, not stopping. “But if I take it out, I’ll have to stick you again.”

Jessica didn’t move. She was a compliant patient—the kind we all think we want until we realize what that compliance can cost. She sat perfectly still, tears running down her face, as the tubes filled. She focused on breathing, trying not to think about the pain.

When the draw was complete, Jessica stood on shaking legs. “That was extremely painful,” she told the medical assistant. “It still hurts. A lot.”

The medical assistant offered a vague acknowledgment but seemed unconcerned. No incident report was filed. No follow-up was arranged. Jessica was sent home with a cotton ball and tape.

The pain didn’t stop. Like Maria, Jessica developed CRPS. Her right arm—her dominant arm, the arm she used for her entire career—became hypersensitive and chronically painful. As an esthetician, she relied on precise, controlled movements for facial treatments, extractions, and delicate skincare procedures. Many of these tasks became impossible. After multiple consultations with neurosurgeons, tests, and nerve conduction studies she was told she was not a candidate for surgery as it would likely not help and could potentially make things worse.

Her income suffered. Her career trajectory stalled. Her quality of life plummeted. All because a medical professional chose to finish a blood draw rather than stop when the patient was clearly in distress.

Jessica’s case also resulted in legal action and a settlement.

What Both Cases Teach Us

These weren’t unavoidable complications. These were preventable injuries that occurred because phlebotomists chose to continue despite clear evidence that something was wrong.

The Critical Errors:

In Maria’s case: redirecting the needle instead of withdrawing completely, drawing near the basilic vein without careful consideration of anatomy, ignoring obvious signs of distress, and rationalizing the decision based on a language barrier.

In Jessica’s case: continuing despite explicit statements of severe pain, prioritizing avoiding a second stick over patient safety, failing to recognize that nerve pain is qualitatively different from typical discomfort, and not documenting the incident. Jessica stated that the pain was so severe that she felt like she went into shock, and it was difficult to even speak to the MA. She felt like she couldn’t move, and she also felt like she had to listen to the MA.

In both cases, the first mistake was the decision to stick the basilic vein. Both women had other vein options available that could have been attempted first, but the more tempting basilic vein was chosen. The basilic vein is well known to be high-risk due to the close proximity to the median nerve and brachial artery. It should be the last resort during venipuncture. Unfortunately it is often the first vein chosen because it is typically very prominent. CLSI clearly states that there should be no lateral redirection of the needle in or near the basilic vein or medial (inner) area of the arm during venipuncture. Choosing a safer vein could have prevented both of these women’s injuries.

What Should Have Happened:

Ideally a safer vein should have been chosen to attempt the blood draw. But either way, in both cases, the answer was simple, as soon as the pain was obvious: Stop. Immediately.

When a patient experiences sudden, severe pain during a blood draw—especially sharp, burning, electric pain—it’s a red flag for nerve injury. The standard of care is clear: remove the needle immediately, document the incident, notify a supervisor, and arrange follow-up care.

A second stick is inconvenient. Nerve damage can be permanent.

The Real-World Consequences

While these cases are designed for teaching, the consequences are very real. Nerve injury cases in phlebotomy have resulted in substantial verdicts and settlements: $537,176 for a patient whose phlebotomist continued despite pain complaints, $140,000 for another similar case, over $700,000 for CRPS cases, and one $2.5 million verdict when a nurse kept the needle in place despite a patient screaming in pain.

These aren’t just numbers. Behind every verdict is a person whose life was permanently altered because someone chose to finish a blood draw rather than prioritize patient safety.

But What About “Dramatic” Patients?

I know what some of you are thinking: “I’ve had patients who scream and cry at everything. If I stopped every time someone said it hurt, I’d never complete a draw.”

I get it. We’ve all encountered patients who are anxious, hyperventilating, or convinced the needle will be unbearable before we even touch their arm. But here’s the key: there’s a difference between anxiety-driven reactions and nerve injury, and with good communication and observation, you can tell them apart.

When I have a patient who’s clearly nervous—sweating, hyperventilating, gripping the chair—I take their baseline anxiety into account from the very beginning. I’m watching their behavior before I insert the needle. This gives me context for what I see during the draw.

Then I communicate constantly. If they react strongly, I don’t just keep going. I talk to them:

“Is this just stingy, or does it feel different—like burning or shooting pain?”

“Do you want me to stop?”

“Is the pain bearable, or is this more than you can handle?”

I’m not just listening to their words—I’m watching their face and body language. An anxious patient might tense up, squeeze their eyes shut, or grip the armrest. But nerve injury reactions are different. The pain is sharp and immediate. Patients may try to pull away reflexively. The description changes from “ow, that hurts” to “something’s wrong” or “it’s shooting down my arm.”

Distinguishing Features:

Anxiety-related reactions typically start before the needle goes in, involve general distress about the procedure, respond to reassurance, and may include apologies. Nerve injury reactions begin suddenly at nerve contact, involve specific pain descriptions (burning, electric, shooting), include reflexive pulling away, don’t respond to reassurance, and the patient often looks surprised by the intensity.

My rule: If I ever question whether the pain is legitimately more than a normal stick, I stop. I’d rather err on the side of caution with an anxious patient than continue on someone developing nerve injury. Don’t ever get into the habit of dismissing a patient’s concerns, fears, or comments.

And here’s something I can tell you from my work as an expert witness: I’ve never seen a case where a phlebotomist was sued for stopping a procedure when a patient was in distress. But I’ve seen plenty where they faced legal consequences for continuing when they shouldn’t have.

Why Patients Don’t Always Advocate for Themselves

Jessica did what many patients do. She spoke up. She said it hurt. And then, when the medical assistant gave her a reason to continue, she complied.

Why? Because patients trust us. They trust that we know what we’re doing and that we’ll protect them from harm. When we say “if I take it out I’ll have to stick you again,” they hear that as medical guidance from an expert. They don’t realize we’ve just prioritized our convenience over their safety.

Most patients have no idea what nerve pain is or what it means. They don’t know that burning, electric sensation is a medical emergency. They don’t know that continuing could result in permanent damage. They assume that if it were truly dangerous, we would stop.

Many patients won’t explicitly tell you to stop, even when they’re in severe pain. Some are afraid of seeming difficult. Some worry about inconveniencing you. Some, like Jessica, trust that you know best.

This is why the responsibility lies entirely with us. We can’t wait for patients to advocate for themselves. We have to recognize the signs of distress and act immediately—whether the patient asks us to or not.

Patients come to us vulnerable and trusting. They don’t have the medical knowledge to distinguish between normal discomfort and dangerous complications. But we do. Or we should.

When we see tears, when we hear cries of pain, when a patient tells us something hurts badly—we have the knowledge and professional obligation to recognize what those signs mean. We can’t hide behind “the patient didn’t tell me to stop.”

Our job isn’t just to collect blood. Our job is to collect blood safely, and to protect our patients from harm they don’t even know is possible. That’s what makes us professionals.

The Bottom Line

Both Maria and Jessica suffered permanent injuries that changed their lives. Both cases resulted in legal action. Both injuries could have been prevented with one simple action (excluding choosing the basilic vein): stopping when the patient was in distress.

I share these cases to drive home a point that can’t be emphasized enough: when something doesn’t feel right during a blood draw—for you or for the patient—stop. Withdraw the needle. Assess. Communicate. Document. Get help if needed.

Your patient’s long-term wellbeing is always more important than completing a single blood draw. And your patient’s safety can never be their responsibility—it’s ours. They trust us to know when something is wrong and to act on that knowledge, even if they don’t have the words or confidence to demand it themselves.

Always.

Have you ever been in a situation where you had to make a split-second decision during a draw? What helped you decide what to do? I’d love to hear your thoughts and experiences in the comments.

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