The Business of Blood

Orders for blood have been trickling in since morning rush hour. Five pack cells of red, 10 units of plasma. By noon, the Memorial Blood Center's fax machine sounds like the ticker tape in an off-track betting office. The numbers look normal, routine, no alarming spikes that might indicate a pile-up on the freeway, a plane down, a ruptured aneurysm on the surgical table--any of the infinite scenarios that would require extra blood and throw off last week's calculations enough to wipe out the inventory reserves. Human bodies are, after all, unpredictable things; they crash into railings, they fall from the sky, they break and leak and come apart in all kinds of ways.

At nonprofit banks like Memorial in south Minneapolis, where Connie Adams manages the blood supply for nearly the whole of Hennepin County and several hospitals upstate, the quantity of blood needed to put bodies back together is always a guess. When she took the job two years ago, Adams says trying to divine the demand for blood was like looking into a crystal ball--a foggy one. It still is. All you need is a single catastrophe out there. A single round of gunshots. A single speedboat running head-on into another, out there where all the intricate calculations she and her lab technicians and donor recruiters made last week come down to mathematics and, finally, best guessing.

The margin of error in those guesses is designed to be thin. Delivered blood components, like milk, have a limited shelf life, even with a round of anticoagulants and stabilizers added--42 days is the common figure for red pack cells, and less than a week for platelets, after which they spoil. Draw too many and the surplus goes to waste; too few, and a patient runs out of blood. Last year, the bank moved over 80,000 pack cells from hundreds of bodies to hundreds of others, each tracked by computer from the moment a donor rolled up his sleeve in the Mall of America parking lot, the corporate lunchroom, or the union hall to the moment it was transfused on the operating table, the paramedic's stretcher, the hemophiliac's couch.

"But what happens to our attempts at precision between point A and point B," says Adams, "is that so much can go wrong. For one, every time you transport units, you run the risk of losing them." Maybe the shipment gets loaded onto the wrong airplane and ends up at point C, in Cleveland; it could take a couple days until anybody realizes the mistake, and by then the optimum temperature range has been topped and it's lost. Or a box gets dropped. Or it's 30 below and the insulating blanket wrapped around a shipment slips off in transit. Or it's 90 above, and the blood's been accidentally left out in the sun. "So there's those kinds of errors. And then there's just plain expiration. The shelf life runs out. Time's up. That's more rare." Usually, she says, they get it right.

"Getting it right" means that the blood the bank draws gets used and, more crucially, that it doesn't run out. It means estimating the demand accurately, recruiting enough donors, and moving enough units from station to station to stay in that narrow margin--a five-day inventory at most hospitals--without wasting components as surplus. But even this is difficult, Adams adds. Hospitals have limited storage space, and smaller ones may have stricter budgets that don't allow for much state-of-the-art refrigeration in which to keep extra pack cells on hand.

Some, especially those with oncology facilities and busy trauma centers, go through blood products so fast they often order out twice, three times on a fast day. And at some sites, blood is purposely overstocked, up in Sandstone or Ely or Moose Lake, say--remote posts an hour or two from Duluth, where staffers figure travel time for emergencies into their equations; blood that goes unused, in a calm month, circulates back to busier metro hospitals in a kind of recycling operation.

Of course the best-case scenario for any blood bank is a world in which every "bleed" is predictable, a closed-circuit system of prophesy and delivery. And it does sometimes happen--not decisively, but with enough regularity to give them what Adams calls "an occasional cushion of security in an otherwise tricky business." On the one hand, there are the anticipated cyclical peaks: early summer weekends before people get their sea legs on boats or the hang of their motorcycles again; full moons, during which both anecdotal and scientific evidence point to an unusual number of freak accidents; elective surgeries postponed until after the holidays. All of which call for extra blood, and can be stocked for in advance. On the other hand, there are the valleys: namely February in Minnesota, when non-emergency operations are put off while physicians and surgeons conference in Cancun, and donors, too, head south, taking their blood along with them.

These seasonal trends figure into the numbers when the bank gears up for a drive, or as some in the blood trade put it, a "harvest." In regard to those drives, it's almost unheard of to pay donors for whole blood anymore. The tactical change came, according to Memorial's associate medical director, Elizabeth Perry, back in the early 1980s, when the HIV epidemic was just beginning to break and its modus operandi understood.

"At that time," she says, "we began to link HIV with blood donation, whereas hepatitis and syphilis had already been marked as contaminants. It became clear that there were some donors who gave blood for money, and who might not if it were considered a charitable contribution--and these were higher-risk people for HIV. And so we began a PR campaign, if you will, that pictured voluntary blood donation as a form of altruism, a civic calling, even a way to endow part of one's body as a natural resource, available to anyone in need."

While blood banks don't as a rule target what some consider "desirable" populations--in Perry's book, "the nun who lives in New Ulm would be ideal"--there is in effect a stringent culling procedure of "self-selection." Some donors don't get past the needle barrier. Some balk at the hour-long, pre-draw interview sessions, complete with general questions about high blood pressure, hepatitis, and medications, and more pointed, intimate ones about sex with prostitutes, other men, and drug use.

"With those disqualifications accounted for, what we end up with when it comes to blood," Perry says, "is a pretty sophisticated system of screening and drawing, of lab work and tracking, and finally of sizing up what is and isn't moving out there so we can keep the stuff in-dated, useful, and fresh. In that regard, the new surgeries--on the receiving end of blood--have made our guesswork a bit less tenuous." For instance, she explains, take the new cancer surgeries, which sucked up a phenomenal number of platelet transfusions when they first hit the market. Or take today's bone marrow transplants--even 25 years ago, they were relatively experimental. And bloody. Component usage was a straight line going up, and a big drain on banks as surgeons were trying to speed up and perfect their steps--"but in the meantime, transfusing like crazy." By now, Perry says, these practices are fairly standard--"routine in-and-out sorts of things, and in terms of blood, clean. Which means, for us, predictability."

What's still not predictable, besides all the current variables, is the future of blood research. There's testing under way in the military on blood substitutes--a kind of just-add-water, oxygen-rich C-ration troops might pack with their combat gear for short-term use on the front lines. And there's promise on the horizon of sterile components, such as fresh-frozen plasma treated with solvents that act to denature viruses. The image has the eerie aura of science fiction to it--high security industrial plants housing great cisterns of human plasma and detergents, rinsing and packing and shipping products out for citizen consumption. It's a far cry from the pre-World War II days of direct human-to-human transfusions via metal tubing, perhaps, but the image has a kind of fascination for those who work in blood.

"I suppose such a system is possible. And even desirable for plasma, which isn't technically a live substance," Adams agrees. "But not for the main course. Not for blood." No matter what futuristic innovations may lie ahead, notes Adams, blood can't be made to live forever; even under ideal conditions, red cells perish after 120 days, tops. "That much we know. That much we can predict. So on the chance there's a big catastrophe out there, we can calculate and design emergency drive procedures. We can put the mechanism into effect fast. We can put out the call for blood. And we can hope the public brings it in."

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