Taking blood

The first time I took blood from someone it came as a surprise to both of us. All medical students must learn to take blood at some time during their course, but phlebotomy – like other skills requiring the use of sharp instruments – is usually left until the third year. A supplementary class I picked at the very beginning of my studies, however, turned out to include a practical lesson in blood-taking. ‘Next week,’ the lecturer announced, ‘we’ll be giving you a chance to try out venipuncture for yourselves.’ After a short pause, as the meaning of the term ‘venipuncture’ sank in, everyone gazed dully at their desks or out of the classroom window: medical students affecting casualness, a sure sign of overexcitement. The six of us were thrilled. Putting needles into people’s veins falls into the category of ‘real medicine’.

The blood class was held in Brighton’s teaching hospital, the Royal Sussex County. We met in the haematology library, a small room on the sixth floor of a tower block. The window blinds had been pulled shut against the bright South-Coast sunshine; the room was warm, dim and stuffy. A long oval conference table had been laid with lecture notes and a rolled-up tourniquet at each place setting: neat pieces of elastic in jazzy colours like a 1980s duvet cover.

Several people were waiting for us in the room, including a consultant and two specialist phlebotomy nurses. One of the nurses, who was wearing a spotless old-fashioned white uniform with buttons all the way down the front, opened with a talk about Health and Safety. Used needles were to be put in the sharps bin, she said, ‘but don’t ram your needle in on top of an overflowing stack, like junior doctors do.’ And don’t walk about with unsheafed needles or syringes full of blood, ‘like junior doctors do’. In a recent study, a third of American medical students were found to have sustained a ‘sharps injury’ during the course of their clinical training. Most were gored by the little needles used for stitching up wounds in surgery, but a quarter had injured themselves on ‘hollow-bore blood-filled needles’. Eight of the students had amassed ‘two to four’ injuries apiece; they were presumably the type of trainee the phlebotomist was seeing in her mind’s eye at this moment, as she began to shake her head in time with her syringe-waving arm – no, no, no.

The phlebotomists wanted us to be aware of the danger of what the healthcare professions call ‘needlestick injuries’. Each scratch carries a risk of hepatitis, HIV and other blood-borne infections, and though rates of transmission are relatively low – most healthcare workers in the UK are vaccinated against hepatitis B – rates of needlestick injury remain resiliently high. This is despite phlebotomists’ best efforts, and the existence of many training aids, such as the ‘Ten Commandments of Phlebotomy’, a poster issued by the Indiana-based Center for Phlebotomy Education – one of a multitude of organisations devoted to the now little regarded but still essential art of blood-taking – which begins: ‘Thou Shalt Protect Thyself from Injury.’ The seventh commandment is ‘Thou Shalt Label Specimens at the Bedside.’ Labelling is a popular theme throughout medical education, and one with an equally poor profile: in another class the lab technician handed round a collection he’d made of his favourite useless labels, the winner being a bag of human fluids that had arrived for investigation marked ‘jane: female’.

The second phlebotomist showed us how to take blood, using her colleague as a model. ‘First, you need to clear your area,’ the trainer explained, moving desks and chairs out of the way like someone about to demonstrate a wrestling move. She showed us how to put on the tourniquet and tighten it before getting the patient to clench their fist: ‘Get them to squeeze, like this.’ The pumping motion helps to drive blood up the limb and plump up the vein. I remembered being told at school that the striped pole outside old-fashioned barber shops refers to this technique: in the days when patients were regularly bled, they would be given a pole to squeeze. The pole is coloured red for blood, and white for the bandages.

The trainer held up one finger of her gloved hand. ‘Choose a finger to be your feeling finger, and stay with it’ – she meant stay with it for ever, which seemed amazing – ‘because that one will develop the sensitivity.’ The consultant stood up to add a few tips of his own. ‘You’re not trying to go in like this,’ he said, miming a dagger thrust at the phlebotomist’s arm, ‘or, peow! in at too high an angle, like Concorde landing. No, softly, softly . . . shallow angle . . . coming in to land, and . . . glide her down onto the runway.’

‘You should listen to him – he can get blood out of anyone,’ the trainer told us, before going on to describe some patients from whom no one had been able to extract a single drop, so well-upholstered were their arms or so knackered were their veins, until our consultant came along and coaxed out ‘buckets’. ‘He’s better than an actual phlebotomist even,’ she concluded. ‘Oh, now,’ the consultant said, looking pleased.

The two phlebotomists described the different systems of blood-taking. The Royal Sussex County, like many British hospitals, has now switched to a method called ‘closed collection’. Instead of the needle being attached to a syringe, a sealed collection tube is used. First the needle is put into the patient’s vein, then the collection tube is attached to the needle. Pushing the tube onto the needle pierces its lid, much like pushing through the seal on a new tube of toothpaste, but in this case blood oozes in rather than anything squeezing out: a vacuum in the tube causes it to draw up a precisely metered amount of blood.

The system is described as ‘closed’ because the blood travels from vein to sample vessel without having the opportunity to splash wildly about in the air, as illustrated by the ‘wrong way’ diagrams in phlebotomy manuals. Once it is removed from the needle, the collection tube reseals itself automatically, ready to be sent off for analysis. If at this point you need more blood, you can attach another tube, and so on until you’re done. Using a syringe, by contrast, involves an extra step: having filled the syringe, you then have to empty it into something appropriate for the lab, giving you a chance to scatter biohazard as you trip across the room.

‘Blood gets everywhere,’ one of the phlebotomists said. ‘It travels. Even in a closed system, there are opportunities for it to escape. Please, please, please be careful.’ The problem of travelling blood is, of course, much less serious than it used to be when bloodletting was a therapeutic rather than a diagnostic procedure. In the late 18th and early 19th centuries, when phlebotomy was at its height, ‘taking blood’ could mean cutting a patient in several places with a heavily recycled lancet before draining as much as four pints into a basin or basins. In 1799 George Washington was relieved of nine pints of blood within 24 hours; he died shortly afterwards. In The Old Venetian Bleeding Glass, a late 19th-century paean to this vanishing tradition of extravagance, John Freeman Knott, a Dublin doctor, mourns the passing of such times, which he calls the ‘primrose days of phlebotomy’.

The consultant explained that the collection tubes are pre-filled with different chemicals, which allow the blood to be kept in the ideal condition for each test. He produced a set of cards coloured to indicate which chemicals were which. There was a moment’s undignified scrabble as he laid down the little stack of laminates in front of us: free stuff! He told us that blood being tested for some standard body chemistry – kidney function, for example – should be drawn into one of the orange-capped tubes, which contain miniature translucent balls that look like polystyrene packing granules and are in fact lumps of lithium heparin that stop the blood from clotting. Blood to be tested for glucose should go into a yellow-lidded tube containing sodium fluoride, which prevents the blood cells from metabolising all the available sugar during the journey to the laboratory. The purple tube is for testing the rate at which blood settles, and the green one for measuring coagulation. The emergency tube was a boring shade of grey, but would beat the prettier opposition in its race through the lab.

We went to off to the hospital’s new blood department, to try phlebotomy for ourselves. It was a small room down the corridor; the sea was sparkling through the window. There were three big leatherette chairs for people having blood transfusions: this was the club class of phlebotomy. Toy vampire bats hung from the curtain rail. With our usual misplaced conviction that we already knew what we were doing, we decided not to bother with the dummy ‘arm’, a pinkish beanbag taped to the arm of a hard chair. Always pink: in the world of medical models, patients are always Caucasian, with Band-Aid coloured skin. In the second year we practised on lifelike model arms crafted in firm pink rubber. The arms have veins that can be filled with ink from a reservoir stored where the armpit should be: this allows them to bleed realistically when poked, like those dolls that wet themselves and cry when given a glass of water. The brief practical class that introduced the arms was my second encounter with phlebotomy; by the end of the lesson each limb was caked in dried Quink, and the mats on which they lay were bristling with unsheafed, inky, discarded needles.

I sat in the beanbag’s chair so that another student could take my blood. I felt the needle go in, that hard pinch that makes you tighten up in anticipation of worse, then the feeling of relaxation as you realise it isn’t going to get worse. Everyone crowded in, fascinated, so I got to experience medical students as a patient does: a hot ring of faces fixed on part of you and ignoring the rest. There was some needle waggling and a discussion about collection tubes. Time began to stretch. My upper arm was solid with cramp but I was so happy to be, as doctors say, ‘well in myself’ that I didn’t mind. Then suddenly I wasn’t well in myself any more. There was cold sweat on the back of my neck, and pins and needles in my lips. ‘Oh boy. I’m sorry. I think you have to take it out now. I think I’m going to faint.’ And then that microsecond you can never remember – whether you actually pass out or not – and my head was between my knees. All I could think about was my hair trailing on the floor and how happy I was to have my hair covering my face and yet how sad that I couldn’t grow my hair all over me like a sack and somehow creep out of the room underneath it. I was retired to one of the big chairs: the chairs in which people sit to receive several litres of blood through needles the size of rolling-pins that are jammed in their veins for hours at a time. The phlebotomist gave me a plastic cup of warm, antiseptic-tasting water, but there was nothing for my shame.

‘It’s more likely to happen if you’re healthy, with low blood pressure,’ the consultant said, trying to be comforting. He’d seen a ‘great strapping hockey player’ laid out by a tiny pin-prick: this mythical sportsman – always young, always strapping – crops up a lot when doctors are trying to be comforting. But it is mysterious, this fear of needles, along with its cousin, squeamishness. What is squeamishness? What is it for? Some of the students don’t have any – the ones fighting for a go on the bone saw during dissection – but most of us do in some way.

There are places on the body that are renowned for turning people ill. You could call them the unerogenous zones, I suppose, though they’re often next to, or on top of, the erogenous zones. The delicate inside places: elbow, wrist, nailbed, groin, eyeballs, genitals. Among them are places that, if stroked, will make you squirm: perhaps this is part of it. Procedures involving these locations classically make medical students faint. They are our tenderest places, so perhaps the feeling of sickness is of some evolutionary advantage. But we all have our own special triggers, none of them rational. Reading a clinical examination book one night, I discovered that I found the idea of palpating a patient’s kidneys made me feel weak. You take their loin between your hands, McLeod’s says, and ‘roll’ the kidney between your grasping palms. For a minute I just couldn’t look. That’s squeamishness; it’s also physical empathy – sort of a good thing in a doctor, but not really.

When I felt better I got to stick my friend back. She is Irish, with beautiful white skin, and, as the phlebotomist pointed out, ‘wonderful veins’. She sat nicely in the chair, her arm with its wonderful veins turned up towards me. I pulled the trolley round next to her so that the cardboard dish and the collecting tubes and the tape and the cotton wool were easy to reach. I put on gloves and fastened the tourniquet tight round her bare arm and felt with my learning finger for her vein. It was a perfect warm hillock, almost bouncing out of her arm; not the blue vein I could see, but located just above it. My brain tried to solve that puzzle, but skidded off – it couldn’t seem to hold anything that was happening. I opened the needle packet. The needle is bigger than you expect: I had imagined it to be little more than a wisp of stiffened thread, but – like a wasp’s sting – it was more solid, more chunky, and, also like a sting, with a visible hole in the end, a distinct black gap in its slanting face.

I lined myself up with my friend’s textbook vein and brought the needle down towards her. My hand started shaking. I pushed the wobbling needle at her skin. It gave way easier than cloth, parting like a tissue – oh, it’s easy, I thought; but keeping hold of the needle was hard. ‘That’s OK, you’re doing brilliantly, that’s fine,’ she said. She looked at me with her mouth closed in a determined smile: I couldn’t see if she was gritting her teeth or not. I picked up the glass collecting-tube and tried to push it onto the needle without moving the needle about. But there was nothing to brace against, the bracing end being buried in her arm. The phlebotomist put her hand on mine. ‘You really need to push,’ she explained, and pushed. I couldn’t take my eyes off the needle sticking out of my friend’s skin. It looked very wrong, in the way that a person lying under a car with only their feet visible looks wrong. And each struggle with the bottle pushed the needle further in. I had a momentary vision of it breaking free from its plastic collar and shooting off out of reach, deep into the recesses of my friend’s circulatory system, fetching up in her heart, or no, it would be her lungs, would it? Jesus, her lungs, what would it do in your lungs? Or – God – what if I’ve gone right through and out the other side of her vein? Or like that Far Side cartoon with the mosquito swelling up like a balloon while the other mosquito screams: ‘Pull out! Pull out! You’ve hit an artery!’

‘Oh God, I’m so sorry, I must be killing you, sorry sorry,’ I gabbled. ‘That’s all right, you’re doing fine, really brilliantly,’ my friend said, ‘although you could maybe just move along a tiny bit with the bottle there.’ A thousand years later there was at last a sucking click. ‘That’s it! Now pull the needle back gently, just a little,’ the phlebotomist said, while I fought the instinct to snatch it straight back out, and the glass tube started to fill, magically, velvety dark blood easing its way in.