Five Quarts: A Personal and Natural History of Blood (4 page)

Although Steve never makes an appointment for a blood draw, he almost never has a wait at IDL. He needs to fast for certain tests, so we’re there first thing in the morning. Seriously groggy, Steve is like a big sedated dog that’s followed me into the waiting area. The receptionist’s window slides back, a courteous hello rings out, and Steve hands over his lab write-up. Usually, once he’s called inside, I sit down and use the time to catch up on ancient celebrity gossip. Today, with the permission of lab manager Rosemary Cozzo, I’ll be a fly on the sterile office wall.

IDL’s inner offices are as bright as a new refrigerator and divided into cool, white compartments. Steve, a foot taller than Rosemary, squeezes into one of the draw-station chairs as she studies the lab form. There’s not much room for spectating. I could easily get in her way. Fortunately she is someone over whose shoulder I can actually look, my five-eight to her five-one. As if someone has just said
Go,
she starts plucking empty vials, three purples, two yellows, and assembles the other equipment she’ll need.

Rosemary, who’s in her late fifties, could illustrate the dictionary definition for
nurse
(see also,
efficiency
). In her starched white, monogrammed lab coat, skirt, and low pumps, the only thing she’s missing is an old-fashioned nurse’s cap bobby-pinned to her no-fuss hair. She has a heart-shaped face and a warm smile. As she snaps on latex gloves, my eyes are drawn to a prominent vein on her left temple, a blue squiggle under her ivory skin. If Galen were here, I can’t help thinking, he would want to bleed from it. He devoted tremendous attention to mapping the body’s veins as sites for letting, everywhere from behind the ears to the roof of the mouth to the ankle. These days, by comparison, blood is almost always drawn from a vein in the crook of an elbow. If one is difficult to access—say, if a patient is obese—a vein on the leg might be used. There’s no such problem with Steve, who has lean, muscular arms and the big, ropy veins of a gladiator. Rosemary looks pleased, as does Steve, though for a different reason. Some days a newly trained staff person draws his blood, and that rarely goes well. Even before the needle is unsealed from its packet, Steve’s told me in the past, he can tell just how new a novice is.

“A newbie looks at your arms with a great deal of indecision, as if weighing a dozen options. But there are really only two: right arm or left,” he’s pointed out. “And when the person starts poking at your veins, self-narrating about which one looks best, this one, no, maybe this one, that’s when I think,
This isn’t gonna be pleasant.
It’s also a bad sign when the person rubs the alcohol on your arm like they’re trying to remove a tattoo.”

There have been mornings when I’ve been able to tell how rough a blood draw was by how damp Steve’s T-shirt is. “Three times,” he’d say, for instance, joining me in the waiting room. “Three times to get the needle in right.” Or sometimes he’d say nothing and just flash me his two bandaged arms.

With Rosemary, no uncertainty is betrayed, and this translates into a confident spearing of his vein. “It’s like cracking an egg without smashing the shell or breaking the yolk,” Steve has said; “swift and decisive.” I now watch her technique. The needle and housing come packaged like a vending-machine sandwich; Rosemary pops open the seal. She then ties a tourniquet to his left arm, swabs the distended vein, and, in the blink of an eye, slips in the three-quarter-inch needle. Steve doesn’t flinch. (I do.) He’s had this procedure done at least fifty times in the past dozen years; he’s used to steeling himself against discomfort and potential bad news. That he’s had to learn this skill, I find heartbreaking. In this context I appreciate Rosemary’s gentleness and competency. Unlike some phlebotomists, she always uses a “butterfly,” a needle stabilized against the skin with tapered “wings” and connected to a narrow, eight-inch tube. At the end of this tubing is a barrel into which consecutive vials are inserted. The vacuum in each vial sucks Steve’s burgundy-black blood up through the thin hose. He loves butterflies. Without one, each vial has to be jammed directly into the base of the needle, which tends to rip up the vein. Butterflies are expensive, so not all labs use them.

Every piece of equipment Rosemary employs has evolved from basic bloodletting tools. The pressurized vials, which look like test tubes with color-coded caps, are a counterpart to bleeding bowls, large clay or pewter basins placed below the incision site to catch the blood. These were often graduated like measuring cups so the phlebotomist could tally the amount removed before discarding it. The modern syringe has a mixed heritage: Its housing is descended from the small glass cups used for suctioning blood from tiny cuts made in the skin. “Cupping” has a history almost as long as bloodletting. In practice these cups, heated over a flame, were applied to different parts of the body; a partial vacuum held them in place. Doctors used cupping for localized pain or if a patient was too young or weak to be bled properly from a vein. The syringe needle actually has the most ancient origins, reaching all the way back to the earliest human’s use of a thorn or animal tooth to break the skin. Jumping forward to the early eighteenth century, the preferred implement for piercing a vein was the new spring lancet, as compact as nail clippers, with a trigger-activated blade. One Baltimore bloodletter so adored his spring lancet that he was driven to poetry. “I love thee, bloodstain’d, faithful friend!” one stanza began.

The most cringe-inducing tool of the bloodletter was the leech, although nothing in Rosemary’s work space is remotely related, thank God. Like cupping, leeches had been used since antiquity as an auxiliary to venesection. Placed on the skin, these bloodsucking creatures, close kin to earthworms, fed on a patient until sated. After about an hour, they’d drop off. A doctor would typically employ five to ten at a time, although to be covered with fifty wasn’t unheard of. Leeches were handy for hard-to-reach spots, such as up the anus, down the throat, or inside the vagina. Tiny thread leashes kept the leeches from getting lost. The leech of choice was the European
Hirudo medicinalis,
exported worldwide from Sweden and Germany. In 1833 alone France imported 41.5 million of the suckers. A standard part of medical practice, leeches were kept close by in water-filled clay or glass jars.

A woman self-medicating with leeches, as depicted in a seventeenth-century woodcut

One would think that the huge gains made in understanding human biology from the Renaissance forward would’ve curtailed the popularity of bloodletting. But no. In fact, the practice reached its height in the eighteenth and nineteenth centuries. The Western world’s most powerful people, receiving what was considered the very best of care, were needlessly bled, cupped, and leeched. Retired president George Washington’s death in December 1799 was hastened by excessive bloodletting, for example, historians conclude. The president, sixty-seven and suffering from a severe throat inflammation, was tended by three top physicians who could have saved their patient’s life had they had access to two things not yet invented: antibiotics and steroids. Instead, they bled Washington four times within a twelve-hour period, a total of 2.5 quarts. He died that day. It sounds like manslaughter to me, but the doctors’ actions were considered both medically appropriate for the time and even heroic. Under less grave circumstances, the rule of thumb for a single letting session was to keep the vein open until the patient passed out. “Bleeding to syncope,” this was called. In a statement of near Galenic aplomb, the English physician Marshall Hall wrote in 1830: “As long as bloodletting is required, it can be borne; and as long as it can be borne, it is required.” Dr. Hall and his fellow physicians were, of course, a few facts shy of our modern understanding. A healthy person can, in fact, replace a lost pint of blood in about an hour, but it takes weeks for the oxygen-carrying red blood cells to return to normal levels. Thus, frequent and copious lettings served only to create in patients an endless cycle of chronic anemia. These days the amount of blood a phlebotomist withdraws for testing is minor, about half an ounce per vial. And rarely more than seven vials are collected. If a patient does faint, more than likely it’s from a touch of hemophobia, fear of the sight of blood and/or needles.

Rosemary became a licensed phlebotomist in 1965 and thinks of herself as an old-timer in the field. “I started in a little mom-and-pop lab across the hall,” she recalls, gesturing the direction with a tilt of her head. “In those days I’d both take blood and perform basic tests. Everything was done manually—cholesterol levels, blood sugar, enzymes, pregnancy tests.” Wistfulness is just a flash in her eyes. Of course, she explains, the whole field changed virtually overnight with AIDS. Safety procedures tightened. New tests were introduced, others replaced, most now performed with computers at a facility across the Bay. The patients changed, too. For the past fifteen years the majority of Rosemary’s clients have been gay men, like Steve.

“You must have lost a lot of patients,” I say quietly.

Without glancing up from her work, Rosemary considers this. “Oh, gee,” she begins, then changes course. “I’ve gotten to
know
a lot of patients,” she replies with a smile to Steve.

“Okay, you’re about done for today,” she adds, watching the last vial fill.

Rosemary withdraws the needle while pressing down with a wad of cotton so large it looks like a chunk of pillow. “Hold that, will you?” she tells him. She deposits the butterfly and tubing into a Sharps container, a receptacle for used needles, and then affixes the clump of cotton to the site with half a foot of tape. And that’s that. The whole procedure has taken no more than five minutes. I back out of the cubicle, Steve rises, and, while the three of us small-talk for a moment, I am struck by this tableau: Rosemary stands between us cradling in her hands the vials of his blood.
That’s a part of his body,
I think;
it has passed through his heart.
Those five finger-shaped vials must still be warm, like she’s holding his hand in hers. We say goodbye as she gingerly places each one inside a shipping container emblazoned with
BIOHAZARD
signs.

T
HREE

Biohazard

PRIOR TO IDL, STEVE HAD REGULARLY HAD HIS BLOOD drawn at a SmithKline Beecham lab near his doctor’s old office. He stopped using this lab in 1994 and we didn’t give it another thought until one day five years ago when I brought in the mail, which included a special-delivery packet from the blood lab.

“Nothing good ever comes by certified mail,” Steve muttered, frowning, as he tore open the manila envelope and pulled out a letter from SmithKline Beecham’s president, dated May 27, 1999. According to the letter, a phlebotomist who’d worked at the lab Steve frequented had reused needles from blood draws (butterfly needles, it turned out). The woman had admitted to doing this “occasionally,” thereby possibly exposing uninfected patients to HIV, hepatitis, and other illnesses. (It was unclear whether her actions were intentionally criminal or inexplicably ignorant, but a year later she would be indicted on multiple felony charges of assault with a deadly weapon—dirty needles.) Records showed that Steve might have been one of her patients, the letter suggested; she wasn’t named, so Steve wasn’t sure himself. Those who wished to get tested for possible exposure could do so and receive counseling at SmithKline Beecham’s expense.

While the letter was addressed to Steve, it wasn’t written
to
patients such as him, I noticed. It never mentioned, for instance, that the phlebotomist, by reusing needles, could have exposed HIV-positive patients to mutated strains of the virus. It is not just HIV that can be passed on, but an infected person’s entire drug-resistance history. Through reinfection, a patient already low on treatment options could be left with none. Steve put the letter aside and dug up his SmithKline Beecham records, finding he had used the lab eighteen different times.

The investigation of the phlebotomist became a sensational local news story. Reports focused chiefly on the possibility that uninfected patients had been exposed to HIV and hepatitis, which was neither inappropriate nor surprising. The accused had had contact with more than twelve thousand people over a period of many years, so the pool of potential victims was sizable. Even if they weren’t infected, there would be grounds for lawsuits for their emotional distress. But Steve helped me see a perspective never addressed in media accounts—that of a man whose blood could have been the source of infection for another, or even for many others, making him feel like an accessory to crimes he’d been powerless to stop.

“The idea of someone treating my blood so carelessly . . . ,” he said to me, pausing to steady his words. His eyes narrowed. “The possibility of my infecting someone else is horrifying.”

I’ve seen that look in Steve’s eyes one time since, late on a Saturday morning. A few moments earlier, I’d told him to sit down at our kitchen table. “Honey, I’ve gotta tell you something,” I’d said shakily. “It’s really important.”

A lifelong insomniac, I’d been struggling through an awful week of sleeplessness, as Steve knew. I’d rolled out of bed early that morning feeling exhausted yet again. I took a look at my face in the bathroom mirror. My red-rimmed eyes were so bloodshot, I imagined they’d sucked my veins dry, left me iron-poor, a bit anemic. So, I reasoned sleepily, I would be a patient of my own Dr. Feelgood: I would give myself an injection of Steve’s B
^₁₂
.

With the exception of sleeping pills, I’d never once considered taking any of his medications—and there were a couple of tempting ones, including Vicodin, which he used to treat his neuropathy pain. But this was different: a little instant vigor.
It’s just a vitamin shot,
I told myself as I reached for the vial in our kitchen cabinet.

The B
^₁₂
injections were a new therapy for Steve. At his doctor’s suggestion, he had been using over-the-counter oral B
^₁₂
supplements together with a B
^₁₂
nasal gel, intended mainly as an antidote to drug-induced fatigue. He’d found the nasal gel messy, though, felt no less tired, and wondered, understandably, how much of the vitamin his body was even absorbing. His doctor’s solution: a prescription for full-strength B
^₁₂
, a single one-milliliter injection per week. We picked it up that same day along with a year’s supply of needles, a box of multiple pouches, the syringes within loose like Halloween candy. Steve’s doctor had taught me how to give him the shots, and I’d already done it several times, the last one just the day before. I was a natural, even a tad smug about it. I had no fear of needles, never have, a trait reinforced by the fact that Steve, unflappable in most things, was creeped out by them. He couldn’t even look when I gave him his shot.

In the semidarkness I grabbed one of the syringes, popped off the cap, and jabbed the needle through the glass vial’s gray rubber top. I felt weirdly proud of myself; I’d come up with a brilliant solution for being sleep-deprived.
This is going to make me feel so much better!
I pulled back the plunger and watched, ebullient, as the syringe filled with the bright red medicine, foaming at the top like a glass of Strawberry Crush. I tapped out the bubbles. Oops, I’d forgotten the rubbing alcohol. I set the syringe on the countertop. Returning from the bathroom, I decided not to give myself a shot in the arm, as I would Steve, but in my butt, so he wouldn’t notice. I wanted to hide it from him.

I pulled down my sweats, swiped a soaked cotton ball on my right cheek, pushed the needle in, pressed the plunger, and just as quickly pulled it out. There: a dewdrop of dark red blood, visual proof that the injection had dived through my white skin. I could almost see fizzy particles of B
^₁₂
swimming to my heart, my eyes, my limbs, revitalizing me. I smiled at the imagined bursts of energy that would take me through the long day ahead. I slapped on a small bandage, restored the cap to the syringe, turned on the overhead light, and opened the kitchen cabinet.

And that’s when I looked closely at the box of needles. Inside were two open pouches, one with new syringes, one with used. I had reached in blindly, grabbing the first needle I’d felt—a dirty one, I was now sure.

Already, I pictured, a speck of Steve’s blood had entered my circulatory system. I shivered uncontrollably as it raced through my veins, pumped through my heart, seeped into my lungs, swept into my arteries, all the while multiplying, infecting every cell, flooding my body with HIV. What rose from the pit of my stomach and caught in my throat was not bile but blood, thick and sour. It tasted like fear.

I held my breath, as if to choke off all emotion. The moment I exhaled, fear filled the room. Had Steve walked in at that second, rubbing the sleep from his eyes, he’d have been overcome, too. I was having a panic attack; heart thrumming, ears ringing, it took all my strength just to sink into a chair.

Adrenaline was not living up to its reputation. It wasn’t the superhuman jolt I’d have expected—that surge that allows a mother to lift a crumpled car off her injured child or that burst of mental clarity that lays out the world like precise moves on a chessboard. The reality was far from the fantasy, the latter owing heavily to the late-1970s TV show
The Incredible Hulk,
a guilty pleasure when I was in college. The transformation from scrawny scientist David Banner into the green behemoth was ignited by overpowering emotion. (“Don’t make me angry,” actor Bill Bixby would say, more warning than threat; “you wouldn’t like me when I’m angry.”) Muscles bulged, pants ripped, the shirt shredded, but the Hulk’s transformation was never complete till he smashed through a wall or two.

In my case, my energy imploded. Thoughts raced, getting nowhere. I’d latch on to one and it was irrational.
I should suck out the HIV at the injection site, but how do I get my mouth to my hip? I should down a mouthful of Steve’s AIDS drugs,
I told myself next.
Wouldn’t that stomp out the infection?
At some point my mind had ground down to nothing, and I was aware of my heartbeat shaking me awake from myself.

I thought perhaps calm could be restored by my going through the motions of everyday normalcy—showering, eating breakfast, getting dressed.
Breathe,
I coached myself.
Breathe.
In the weird fugue state of the guilt-ridden, I watched Steve get up and go through the same rituals I had. But then I couldn’t bear the pretense of ordinariness any longer. I told him I had something to tell him. I asked him to sit down.

Once I’d spilled all, Steve pushed back from the table, stood, and turned toward the kitchen cabinet. He didn’t say a word or, at least, none that I heard. I watched him pull the box of needles from the cabinet, place it on the table, and silently begin counting. He looked up.

“Needles come in bags of ten,” he said, cool and clear. “I opened this new bag yesterday and we used one for my shot. If you’d taken a used needle, I’d be able to find only nine in the bag.”

My mind was fuzz.

Steve was talking to me. I heard “ate.”
Ate
?

“There are eight in the bag, Bill. See?”

I was starting to understand, coming to ground.

“You used a new needle—you’re fine. Thank God. They’re all here, except the one you took. Where’d you put it?”

Now fear gave way to shame, burning my face. “In the garbage.”

“The garbage?” Steve pulled back, appraising me. “Oh, the trash man’ll love that.”

Steve went silent, clearly expecting me to speak.

“I’m so sorry,” I responded. “I—I’m an idiot. I didn’t sleep. I—”

“Look, I’m glad you’re all right. But . . . do I have to hide these?” He tapped the box.

I didn’t reply. I was still checking Steve’s math in my head. “Eight in the bag? Are you sure that’s right?”

He walked away from the table. “Count ’em yourself.”

I counted. And did so again, later, while Steve went to Walgreens to get a Sharps container. Still, it took me a couple of days to shake the conviction that I’d used a dirty needle, that I might be HIV-infected. Likewise, it took Steve as long to understand my reaction, why my fear lingered. I felt as if I’d nearly been in a car crash, I was finally able to explain to him. And even though I knew I was perfectly safe, I could still hear the screech of tires, still feel the blood rush from the near hit, my pulse racing.

When declaring a person clinically dead, the attending physician or EMT must note in writing that there is no pulse. The carotid artery, just below the curve of the jaw on either side of the neck, is the site most often felt. The pulse is both the last and, in the living, often the first of the vital signs checked. It is the heartbeat by proxy, each throb caused by the powerful contractions that propel oxygenated blood out into the arteries. This outward surge of blood carries such force that the vessels swell to accommodate it; hence a palpable, visible, sometimes even audible pulsation. In all, seven pairs of arterial pulse points dot the human body: at the neck, inner elbows, wrists, and both sides of the groin; in the pit of the knees; behind the ankles; and atop the feet. Typically, arteries are buried deep within the body, but at these points they lie near the skin’s surface and over a bedding of bone. This makes them ideally situated for palpation, examination by touch.

In American Sign Language, the sign for “doctor” is the finger-spelled letter
d
tapped inside the wrist, which captures in a simple gesture the most fundamental part of a medical exam, the iconic act of taking the pulse. Performed in every culture, this basic diagnostic test is as old as the practice of healing itself. The careful placing of two or three fingers along a tiny stretch of artery used to be considered an art form, a notion largely lost in the mad shuffle of contemporary health care. One needs to page back a good hundred years or so to rediscover a time when this vital sign retained all of its, well, vitalness. I’ve found no more erudite an advocate than Sir William Henry Broadbent, personal physician to Queen Victoria and author of a unique monograph,
The Pulse
(1890). In its pages Sir William is a spirited defender of what he calls “the educated finger.” In an early passage he subjects the wrist and its pulse point to a curious clinical analysis, as if describing a patient with an odd case history. He is long-winded, but endearingly so: “At first sight it seems strange that the radial artery, which supplies [blood to] merely the structures of a part of the hand—a few small bones with their articulations, a few muscles and tendons, the skin and nerves distributed to it—should afford the varied and far-reaching knowledge we look for in the pulse. The hand is not essential to life, it contains no organ of any importance, and
a priori
it might have been supposed that the variations in the circulation of the blood in so small a member could have no significance.” There is little about this passage I do not love, from the doctor’s crisp visual dissection to the delicious irony he’s blinded to in his academic fervor: If not for the irrelevant hand, he could not even take the pulse, let alone write about it. But I digress. The distinguished doctor, who’d practiced medicine for more than thirty years by the time his book was published, goes on to state without equivocation that the wrist pulse is a “trustworthy index,” a reliable gauge for the entire circulatory system.

A portrait reproduced on the frontispiece of his memoirs broadens my sense of the man: Seated, he looks the very essence of “bedside manner”—compassionate, patient—as though he’s just asked, “What seems to be the problem?” A stout gentleman in his late sixties, I’d guess, the doctor is dressed in a dark formal suit with a wide satin cravat. A pocket watch is comfortably secreted in his closed palm. Perhaps he can feel the tick of its clockwork against his skin.

In his day the pulse opened a personal dialogue with the body, and a skilled clinician could glean an astonishing array of insights, far beyond a tally of heartbeats per minute. With nothing but his fingertips, Broadbent claimed he could assess the condition and health of the arteries, calculate blood pressure, and discern the emotional well-being or physical ailments of a patient. Even a person with profound sleeplessness was implicated by his pulse. The insomniacal artery, Broadbent wrote, was “full between the beats” and could be “rolled under the finger,” while the pulse waves themselves ended abruptly, as if exhausted from the effort.