Always Tip Your Phlebotomistby Chris Battle, survivor on May 14, 2011
Note: This article is cross posted from The Kidney Cancer Chronicles.
Some people are simply better at certain things than others. For example, I am not particularly good at math, construction work or snake handling. As a consequence I have avoided careers as a computer programmer, stone mason, or ordained minister in the Pentecostal church. And those of you who have followed the blog closely are also probably aware of why I have resisted the urge to become a phlebotomist – most hospitals would consider it unseemly to have the person drawing blood to be regularly passing out on his patients. But, in my defense, I feel that I have contributed to the advancement of this particular profession by forcing my phlebotomists to work creatively in finding ways to draw blood or otherwise insert needles into a person balled into a fetal position and weeping like a little girl. Or crumpled on the floor unconscious and drooling. Or wielding a sharpened credit card and trying to slice out their eyeballs as they approach.
Thus, I must give a shout-out to Sir Robert, my phlebotomist at Johns Hopkins. He drops a needle into your vein as effortlessly as dipping a ladle into melted butter. It is almost unnoticeable. I don’t think enough patients really appreciate the value of a skilled phlebotomist. (In case you don’t already know, a phlebotomist is defined by Webster’s as someone who takes pleasure in stabbing other people with pointy objects.)
All it takes is a few run-ins with less skilled practitioners to appreciate a truly good one, and I have had my share, during the last couple of years, of those who could use some continuing education. A good sign that you may be in for trouble is when a nurse approaches, needle highly visible in hand, squinting at the inside of your arm, slapping at it as if trying to revive a corpse, and commenting, “Oh my, you really don’t have good veins. You should hydrate before you come in.”
This is particularly frustrating as most nurses and phlebotomists have commented on how impressed they are with my veins. To a point where I’ve become quite proud of them. When I’m out having a drink at a bar, I will often turn to the person on the stool next to me and inquire if they’d like to see my veins. Admittedly, this rarely goes over well, but I can’t help myself. During meetings at the office I like to roll up my sleeves, rubber tourniquet wrapped tightly about the bicep, and do a lot of pointing to maximize exposure to the roadmap of blue that crisscrosses my forearms. Some clients are initially taken aback, but I know they’re secretly envious.
Despite the prowess of my veins, I am still generally considered “high risk” when I walk into a phlebotomy lab. They’re worried I’ll go vagovasal on them. Vagovasal, you ask? An STD? No, a vagovasal episode is “malaise” mediated by the vagus nerve – also known as Cranial Nerve X. Very CIA. Let me impress you with my medical vocabulary (also known as Wikipedia): Upon leaving the medulla between the olivary nucleus and the inferior cerebellar peduncle, it extends through the jugular foramen, then passing into the carotid sheath between the internal carotid artery and the internal jugular vein down below the head, to the neck, chest and abdomen, where it contributes to the innervation of the viscera.
Almost as impressive as my veins, right? Evidently, the vagus nerve is responsible for controlling the heart rate. And blood pressure. And other things, when screwed with, that lead to passing out. Nothing to be trifled with. In fact Taber’s medical dictionary describes it as the “feeling of impending death” caused by expansion of the aorta, drawing blood from the head and upper body.
Bottom line, while vagovasal is not generally life-threatening, hospitals tend toward a policy of being opposed to this “malaise” on the general principle that it sounds disgusting and tends to hurt the image of hospitals to have people collapsing under their care.
And because the vagus and I don’t always get along well, hospitals tend to prepare for me as if setting up fortifications for war. Most patients are seated in chairs specially designed for bloodletting. They look a little like electric chairs traditionally used to send men to their deaths, including large flat armrests and a bar that drops horizontally across the front of the chair as if positioned to prevent you from escaping. Such intimidating furnishings are no match for me, however. I am spirited away to a separate bed, reserved in advance and hidden behind curtains. Apple juice and cool wet towels are strategically placed, and the more sociable nurses – or random patients from the waiting room, if necessary – are recruited to chat me up at the time the needle is plunged veinward. Usually Fabulous Alice, my trial nurse, does the trick. She and Dena do a little comedy routine to prevent me from eyeballing the needle. You know you’re in for some good entertainment with Alice, as many of her comments are prefaced with “I probably shouldn’t say this, but …”
After the deed is done – the various vials of blood tucked into their stands, the IV line wrapped up with gauze and tape – I am prohibited from leaving my foxhole immediately. I am usually coaxed to lie back to be monitored for the tell-tale signs of an approaching vagovasal response. At times I will sit up and say how great I feel and am allowed to stand. Time before last, as Alice, Dena and I were chatting, Alice stopped mid-sentence: “Are you all right, you look a little white.” Back down on the bed.
This past week Fabulous Alice was absent for the first time. I believe she abandoned me for the Kentucky Derby. Evidently she cares more about her horse than me, so I’ve struck her from my Christmas card list. I will admit this caused some anxiety for me, as I was concerned that I would be separated from Sir Robert. The last couple of times Alice has managed to stall until Robert has arrived. I’m supposed to start the bloodletting by 7:30 a.m., but Robert doesn’t get in until about 8 a.m. Even Dena wasn’t there to provide distraction by yelling at people or throwing things – she claims she had a hearing to go to, but I oddly enough I saw two women on tv that looked remarkably like Dena and Alice watching the horses and drinking mint julips. In any case I was on my own, except for my friend Doug Larkin who drove up with me. (Dena fears I might pass out on the way back from Baltimore and drive into the harbor or a random storefront; thus, she refuses to let me go by myself.)
However, I lucked out because Alice’s stand-in, Susie, just happened to be a rockstar blooddrainer herself. She’d been briefed by Alice and was appropriately petrified that I might go dark on her, but she soldiered through and did about as good a job as Robert. Next time Alice is out, I will ask for Susie by name and hope it’s not misconstrued. I’ve been confused for a stalker in the past and have had my share of restraining orders. But, what, hasn’t everyone?
Ultimately, though, there’s no matching Sir Robert for sheer arm-stabbing mastery. He has a PhD in Jabbery. Others come to him for difficult jobs. I’ve seen him step in when one woman was literally howling in pain because the nurse trying to slip in a needle couldn’t get it into the vein. Robert told me of one incident in which a woman’s IV “blew out” and he had to fix the situation. And yes, he used the term “blow out.” Which brings horrific and gruesome images to mind – blood and bone and flesh and needle and IV plastic splattered on the wall in a horrible soup. I harbored such nightmares during the days of IL-2 when I lived with a variety of tubes in me for weeks at a time, fearful that in my sleep I’d turn the wrong way and have the line ripped from my arm.
“They’d had a hard time getting the line back in,” he said. “When I got there, she had been stuck about eight times.”
Unfortunately, not even Sir Robert would be able to fix me should something like that occur. On the fourth stick, I would have projectile vomited on the nurse and hurled myself from the hospital window, probably passing out on the way down.
Which is why I say: Always tip your Phlebotomist. You want a happy needleplunger. The bitter ones carry shanks.