Lab Girl (5 page)

When—during my first hour in the pharmacy laboratory—Lydia and I got to the courtyard, we sat down in the metal chairs at one of the outdoor tables. She pulled a pack of Winston Lights out of the fold of her sock and thumped it three times on the heel of her hand. She slid the pack over to me as an offering, and lit her cigarette with the communal lighter that was kept chained to a branch of a little birch tree that was serving hard time planted in cement. Lydia put her feet up and took a long drag with her eyes closed. I played with her pack of cigarettes, first shaking them out and then reloading them, although I didn't smoke.

In my eyes, Lydia was ancient, which meant that she was probably about thirty-five years old. At least thirty-four of those years had been hard years, I figured, given the way that she carried herself. I supposed that Lydia had also been unlucky in love, since she perfectly fit the type who would be sitting at a kitchen table nursing a coffee cup full of gin while waiting for the kids to come home from school, had she been blessed within a matrimonial union. Chapter thirty-six said it better than I could:
She gave me the idea of some fierce thing, that was dragging the length of its chain to and fro upon a beaten track, and wearing its heart out.

To my surprise, Lydia was also curious about me and asked me where I was from. After learning the name of my hometown she responded, “Yeah, I've heard of it; that's where that big hogkill is at. Cripes, you crawled right out of the armpit of the Midwest, didn't you?” I shrugged, and she continued, “Well, there's only one place worse than that, and it's the frozen shithole up north where I grew up.” She threw a smoldering butt on the ground, looked at her watch, and then lit another cigarette.

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 milliliters 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.