by Hope Jahren
We passed the next five minutes in silence. Finally, she exhaled and said, “You ready to go back?” I shrugged by way of answer, and we both stood up. “You just do what I do, okay? I’ll go slow, it’ll be fine,” she said, and thus concluded my formal training in pharmaceutical medicine. I still didn’t have a crystal-clear idea of how I was to assemble a sterile mixture of medications that could be injected into a desperately sick person’s vein, but I guessed that I would pick it up as I went along.
Sitting next to Lydia and carefully mimicking her actions didn’t turn out to be a bad way to learn sterile technique, which is more like dancing with your hands than it is like making something. The air through which we walk, both outdoors and inside our buildings, contains plenty of tiny organisms that would feed quite happily on our insides but don’t usually bother us because they can’t get close enough to our juicy parts, such as our brains and hearts. Our outer skin is thick and whole, and any openings, such as those for our eyes, nose, mouth, and ears, are coated in protective slime and wax.
This also means that every needle in every hospital might be the winning lottery ticket for a lucky random bacterium who, after recovering from the initial rush of injection, finds himself swishing along within a jolly river of blood until he disembarks in some quiet cul-de-sac of the kidneys, perhaps. There he will breed and also produce one bumper crop after another of toxins that are all the harder for us to fight because they were produced near our organs. The bacteria represent only one hostile faction, with viruses and yeasts capable of their own similar modes of destruction. A sterile needle represents our best defense against such an onslaught.
When a nurse gives you a shot, or draws your blood, it’s a relatively quick puncture, in and out, and afterward your skin closes over and reestablishes multiple firewalls against reentry. Your caregiver ensures against bacterial stowaways by using a syringe with a pointed tip that’s been sterilized and then sealed into a protective plastic cap. She rubs your skin with rubbing alcohol (isopropanol) in order to cleanse your outermost layer of any bacteria that might otherwise get shoved into your body during the injection.
When you are given an intravenous medication, it’s a little different. The nurse cleans your skin, inserts a needle, and then leaves it there for hours, effectively making the needle, the tube, and the entire bag that is attached to it an extension of your vein—and all the liquid in the bag becomes an extension of your bloodstream. She will hang the bag over your head in order to encourage fluid to flow from the bag into you and not vice versa, and she’ll activate a pump to very gently force it in if the doctor recommends it. The entire contents of the bag will mix with your bloodstream, and any excess from the two pools will be stored in the overflow chamber that is your bladder.
Under this configuration a bacterium now has a lot more territory in which to ready itself for action. It’s not just the tip of the needle that could harbor infection; now it is the entire inner surface of the bag and tubes—not to mention the fluid itself—an expanse more than one hundred times larger than that of the syringe alone. Of course this means that the entire apparatus must be kept sterile, but it also means that everything that has ever touched the whole mess, while the medications were added and mixed—and even before that, when the chemical ingredients were synthesized and stored—must be kept sterile at each step along the way.
The great thing about an IV is that it allows your doctor to deliver medicine to your body quickly, and for a sustained period. During cardiac arrest, your brain doesn’t have a couple of hours to wait around for oxygen while your heart stands in a long queue behind your stomach and intestines, hoping for its share of the medication to seep out of the pill you somehow swallowed. So how to combine a liter of fluid with active agents, customized according to the patient’s weight and status, while keeping everything sterile? If this is for the ER or the ICU, we have about ten minutes to make it happen. Fortunately for the patient, there is a sleep-starved teenager apprenticed to a chain-smoking barmaid in the basement who is ready for action.
***
The first step is to create a clean workspace. Although it’s hard to picture, bacteria, yeast, and other tiny things can be removed from air by forcing it through a mesh with holes that are three hundred times smaller than the diameter of a human hair. When I make intravenous medications, I sit in front of a wall that blows air through the mesh and toward me. The area between me and the wall, therefore, is a clean space where sterile items can be opened, mixed, and resealed.
The first thing I do after I pull on gloves is to liberally wash down my entire work area using a spray bottle of isopropanol, bathing the counter and my gloved hands over and over and wiping with tissue after tissue. I leave all surfaces damp with isopropanol, knowing that the sterile air stream will dry them, mainly by blowing it straight into my face.
I go to the Teletype and select a medication order in the form of a two-inch-by-two-inch sticker, upon which is typed the patient’s name, gender, and location and a code that specifies the mixture of medications required. I pick out a sealed bag of fluid, which has the approximate shape and feel of a packaged pork loin, from the pile produced by the tech who is “pumping bags,” filling them by the liter with either normal saline or Ringer’s solution—a weakly sugared saline named after Sydney Ringer, who in 1882 found that he could make a dead frog’s heart beat by repeatedly bathing it in this very formula. Reading the medication order, I pick up the bag, peel the backing off of the sticker, and attach it to the top side such that the text will be upside down when the bag hangs and drips into the patient.
I carry the bag to the stock table and pick up the concentrated drugs that I will need, and I restock my own personal stash of the ones that I use very frequently. These drugs come in little bottles with rubber-stoppered tops, color-coded for quick recognition. The tops are crimped shut with aluminum, and the glass and metal sparkle in the unrelenting brightness of the lit laboratory. Some of the bejeweled bottles are indeed precious, containing only the tiniest drop of liquid protein concentrated from the bodies of heroic human donors or hapless animal subjects. Each of these miniature glittering bottles contains a day, or perhaps a week, of frustration for a ruthless tumor—perhaps just long enough for an ill-remembered animosity to thaw into a critical goodbye, or so I fantasize while I work.
Returning to my workstation, I place my materials in front of me, in a straight line across the front of the bench. I set the bag of fluid that I will inject down on my left, careful to point the site of injection toward the panel of blowing air. The upside-down sticker is now facing toward me so that I can read it, and I widely space the medications from left to right, in the order that I will inject them into the bag. Beside each bottle I place a syringe sized to accommodate the amount of the drug specified on the sticker. I double-check the entire setup, left to right, comparing the words on the sticker with the words on the bottles, one after the other, the first three letters of each word only in order to prevent wasting the time it would take to read the whole name.
I take a deep breath and grab a stack of alcohol wipes, the kind ever so slightly foiled within their tear-open package, as is my preference. I steady my hands, reach around the bag, and pull the seal of off the injection port that faces away from me. I raise an alcohol wipe in front of me, tear it open, and bring it down in front of the bag. I clean the rubbery port that the needle is to penetrate and swab the wipe up and back, careful not to let my hands pass between it and the blowing wall. Then I clean the first bottle of medication the same way, using a different wipe.
While turning the small vial of medication upside down with my left hand, I pop the cover off of the syringe with my right hand. I clutch the items securely but strangely in order to keep my fingers to the back, as if I was exposing each item to some holy light. I draw the exact amount of medication printed on the sticker into the syringe, making sure that my eyes are level with the fluid line so that I do not misread the number of milliliter
s that was measured. I pull the bottle up and off of the syringe by flexing the muscles in my left hand, careful to simultaneously relax the muscles in my right hand in order to avoid losing a drop of medication out of the tip of the needle during separation.
I set the bottle down carefully and move the needle up and over the front of the bag; then I inject the medicine into the bag and toward me. I move the needle up and out, and it is instantaneously useless. I position the syringe’s plunger back at the level of medication that I injected and set it down empty on a tray outside my workstation. I carefully seal the bottle of medication that I just injected and then place it on the tray just to the right of its syringe. I do this until I have used each bottle, and thus completed the recipe. Then I carefully reseal the bag with a plastic cap and lay it across the same tray, on the side facing away from the needles.
I take off my gloves, pick up a pen, and sign my initials in one corner of the sticker on the bag, assuming partial responsibility for I-don’t-know-what. I place the tray in the queue that is serviced by a senior Pharm.D., who methodically double-checks every label, every syringe, and every bottle to ensure that the bag contains what was ordered. If a mistake is found, the bag is discarded, the sticker is reprinted, the whole thing is now a rush job, and a lifer intercedes.
It doesn’t matter that this is my first day in the laboratory. There are no practice bags. There is just doing it right or doing it wrong. While we work we are watched to make sure that we don’t preferentially draw out the simpler orders from the Teletype, and that we use up the entirety of each bottle of medication before we open a new one. We are constantly reminded that any mistake we make could kill someone. The number of medication orders far exceeds what we can complete by the time they are needed, and we are constantly behind. The more people who call in sick, the fewer of us are in the lab working, the faster we have to work, and the further behind we get.
There is no time to discuss the fact that this horrible, horrible system is not working, or to assert that we are neither criminals nor machines. There are only endless medication orders, given by other exhausted people with nobody better than us to depend upon.
Working in the hospital teaches you that there are only two kinds of people in the world: the sick and the not sick. If you are not sick, shut up and help. Twenty-five years later, I still cannot reject this as an inaccurate worldview.
***
Lydia was magnificent at her workstation, possibly because she’d been doing this sixty hours a week for almost twenty years. Watching her sort, clean, and inject was like watching a ballerina defy gravity. I watched her hands fly and thought…in an easy amateur way, and without any book (he seemed to me to know everything by heart), from chapter seven. On that first day I witnessed her shooting at least twenty bags, sometimes with her eyes closed. I never saw her make a mistake. I was certain that she worked while in some kind of trance, as there was no way that her brain could have been sufficiently oxygenated. One of the worst things one can do is sneeze or otherwise spray bodily fluids into a sterile space, and Lydia, for whom the very act of exhaling was basically a cough, exhibited breath control that was positively superhuman while mixing medications.
Within my first couple of hours at my workstation, I had successfully made a few bags of simple electrolytes, and the supervisor had started pressuring me to pick up and shoot some of the more difficult orders because the lab was running severely behind. I tried an order for a simple “benzo bag” but then panicked after I injected the sedative, knowing that if I had somehow injected more than I thought I did, I could be curing the patient’s anxiety with much more finality than anyone expected. Terrified as a trapped animal, I actually considered bluffing my way through it, putting the bag on the tray in the queue and then moving on with my life. But I came to and all at once realized just how crazy that instinct was. I took the bag over to the sink, sliced it with a scalpel, and dumped its contents down the drain while the Pharm.D. gave me the evil eye. I walked back to Lydia and suggested that we take a break.
“I don’t think I can do this,” I confessed when we got to the courtyard. “This is the most stressful thing I’ve ever done.”
Lydia chuckled. “You’re making way too much out of this. Remember, it ain’t brain surgery.”
“Yeah, brain surgery’s on the fifth floor.” I completed the joke that the runners told each other at least five times a day. “Still, what if I just can’t get it?” I groaned. “Half the time I don’t remember if I did something right or wrong.”
Lydia looked around and then leaned forward and spoke. “Listen, I’m gonna tell you something about sterile technique.” She leaned back and continued in a low voice. “Now, don’t go licking the needle or anything, but if you’ve got something on your hands that’s gonna kill them—they’re gonna die anyway.” I had no answer for that, and Lydia seemed to think that she’d explained what needed to be explained, and so we sat in silence while she smoked.
After a while I rubbed my temples and said, “Man, I’ve got a headache. Lydia, don’t you ever worry about what breathing all this alcohol is doing to our lungs?”
Lydia had a cigarette hanging out of her mouth at the time, and the look she gave me showed that she now had proof that I was terminally stupid. She took a long, long drag and then answered while exhaling. “What do you think?”
Right after we got back from break, I threw myself into the fray and drew out an order for a complicated chemotherapy bag, determined to make good on what was left of my first day in the laboratory. I made the bag accurately and was very proud of myself until an enraged Pharm.D. walked up to me and held a tiny bottle of precious interferon an inch from my face.
“You just wasted this entire bottle,” she hissed with fury. A few minutes before that, I had injected the valuable immunity promoter and then removed the bottle from my workspace without sealing it, thus contaminating the remainder of the supply. In one stroke I had wasted at least a thousand dollars of the medication, and also created a big paperwork problem. I felt a rush of shame such as I hadn’t experienced since I was a little girl getting caught reading on the wrong page by yet another teacher who was sick and tired of dealing with me. As the protagonist of my own private chapter seven, I looked up with a flush upon my face and remorse in my heart.
Lydia, smelling opportunity, stepped in and assured the steaming Pharm.D., “She just needs a break—she hasn’t had a break all day. C’mon, kiddo, let’s go.” She led me to the courtyard, and we commenced our umpteenth break for that very shift.
When we got there, I sat down and put my head in my hands. “If I get fired, I don’t know what I’ll do,” I said, hiccupping as tears threatened.
“Fired? Is that what you think?” Lydia cackled. “Jesus, relax. I’ve never seen anybody get fired from this hellhole. In case you haven’t noticed, long before people get fired, they quit.”
“I can’t quit,” I confessed with anguish. “I need the money.”
Lydia lit a cigarette and took a long drag while looking at me. “Yep,” she said sadly, “you and me are the type that can’t quit.” She waved her pack of Winston Lights toward me and I declined for the sixth time that day.
When Lydia dropped me off at my apartment later that night, I asked her what she sat and thought about during those long hours when we worked silently in the pharmacy.
She considered the question for a moment, and then answered, “My ex-husband.”
“Let me guess,” I ventured, “he’s in prison?”
“He wishes,” she snorted. “Bastard lives in Iowa.”
As we sat there and laughed at a joke that’s as old as Minnesota itself, chapter seven echoed in my head: miserable little dogs, we laugh, with our visages as white as ashes, and our hearts sinking into our boots.
When the medication orders slowed down in the pharmacy and I was tired of sitting, I would go and visit the blood bank to see if they wanted me to carry some pints over to the emergency room. This affor
ded me the opportunity to burn off some energy, since there was always a lot of time for pacing while waiting for the number and type of blood units to be verified repeatedly by all parties.
The lifer who worked the three-to-eleven shift behind the counter was named Claude, and while not as ancient as Lydia, he still qualified as a senior citizen in my eyes, having arrived at the ripe old age of twenty-eight. Claude fascinated me, both because he was the only person I’d ever met who had been to jail and because he was easily one of the most harmlessly nice guys I’d ever known. His hard life had left him physically the worse for wear, but he didn’t seem to harbor any resentment, and I supposed this was because his attention span was so short and shallow. Working the blood desk was hands down the easiest job at the hospital, Claude had boasted to me with a sort of confused pride.
Claude explained that there were only three things that he had to remember how to do: thaw blood, check blood, and dump blood. Claude began each shift by wheeling several pallets, each stacked high with bricklike bags of frozen blood, out of the deep freeze and into the plus-five-degree room to thaw. Immediately after it was donated and processed, the blood had been frozen and stored, and now it had to thaw slowly in order to be usable. By moving the blood, Claude was preparing the stash that would be available for use three shifts hence. The next thing Claude did was to man the counter for about seven hours, waiting for someone to come down with a blood order. Before signing anything out, he had to check and double-check the blood type on the bags against the order form, and sometimes call the operating theaters to double-check. He explained to me that there were “at least four or six” different types of blood and that sending off the wrong type “could waste it by killing somebody,” and it troubled me that the two consequences were not entirely discrete within his mind.
When Claude slammed down the limp yellowy bags of blood plasma in bundles of three, I couldn’t help but think of the butcher shops that lined the Main Street of my hometown, and particularly of the meat counters where Mr. Knauer whumped down whatever my mother’s note requested before sending me back home to help administer dinner to my family. Near the end of his shift, it was Claude’s job to discard any unused thawed bags, which amounted to gallons and gallons of blood, down the hazardous-materials chute, where they would be incinerated along with the rest of the day’s medical rubbish. It seemed a waste to me, and I commented on what a shame it was that good-hearted citizens had gone out of their way to donate the blood that he was heaving by the armload into the Dumpster.