The practice of bloodletting, which has a lengthy history of about 3000 years, began with the Egyptians,1 but was embraced by people all over the world (e.g., Africa, Asia, and Europe). It was employed as a treatment for numerous conditions, including an imbalance of the four “humors,” migraines, fever, and epilepsy. To induce bleeding, special instruments (e.g., a lancet, fleam, or even leeches) were used to open a patient’s vein or artery. While bloodletting was a common practice until the late nineteenth century, it wasn’t without its problems or risks. For example, it’s widely believed that George Washington, the first president of the United States, died from excessive blood loss in 1799 after he requested bloodletting be used as a treatment for his failing health.2 In contemporary medicine, bloodletting has been almost entirely abandoned as a medical therapy as it has been deemed useless and even dangerous for patients.3 However, despite this shift, bloodletting continues to be a treatment option for a few medical conditions. For these specific conditions, the procedure is typically referred to as “therapeutic phlebotomy.”
My first blood donation experience was uneventful. My high school hosted a blood drive in the gymnasium and the process was quick and easy. The next time I tried to donate blood, however, was when the trouble started. I was in college and my university was hosting a blood drive, but before I could be seated for the donation, one of the workers pulled me aside. Your numbers are high, she said. You should talk to your doctor. They still let me donate and I didn’t think much of what she said until the same thing happened several years later. I went with my husband to the local blood donation clinic and, after testing a drop of blood pricked from the tip of my finger, the worker reiterated what I was told in college: Your numbers are high. I was able to donate that time, as well, but my husband noted the slowness of my blood as it flowed into the bag. Thick blood? he questioned later as we walked to the parking lot.
At my next checkup with my primary care physician, I asked what the “high numbers”—the elevated red cells, hemoglobin, hematocrit—could mean. She told me it was nothing and not to worry about it, so I didn’t. However, the next time I tried to donate blood, they turned me away, so I never went back. My yearly blood tests continued to show a gradual climb, but my physician never reached out to me, never brought it up during appointments. Additionally, whenever I looked “erythrocytosis” or “polycythemia” up online, the results didn’t indicate anything I saw as plausible: myeloproliferative disorders, conditions or behaviors that lower oxygen levels (e.g., living at a high altitude or smoking), taking certain medications (e.g., performance-enhancing drugs).4 There was another cause mentioned—dehydration—and while I always thought I drank plenty of water, I made a mental note to drink as much water as possible right before any blood tests.
In April 2023, I had surgery coming up and was driving to the hospital for pre-surgery bloodwork. I had a twenty-four-ounce bottle of water with me in the car and drank the whole thing before I went into the lab. Later that day, I was at the grocery store and got the notification that my test results were in. I expected the high numbers to be lower, but they were higher than they’d ever been. At my first post-op visit with my physician, she referred me to a hematologist.
At that first visit with the hematologist, she mentioned all the same possibilities I had read about online. She ordered numerous tests, so I went back to the lab where a phlebotomist filled a stack of ten vials, told me she’d never even heard of some of the tests before. The next day, I flew to Washington, DC, for a work conference; in between sessions and workshops and luncheons, I checked my phone, my heart rate increasing each time I saw a notification indicating a new result was ready. When I returned from my trip, the hematologist’s office called and asked me to come in to discuss the results. At that appointment, we talked about the iron overload, the referral for a therapeutic phlebotomy to lower the iron, the red cells.
As mentioned, modern bloodletting is typically referred to as “therapeutic phlebotomy.” While the procedure had broader applications in the past, it is now reserved as a therapy for a narrower list of conditions, including polycythemia vera (a myeloproliferative disorder that causes an increase in red cell production), hemochromatosis (iron overload), and sickle cell disease.5 Therapeutic phlebotomies are often performed at infusion clinics, and patients are instructed to eat a snack or meal and drink plenty of fluids prior to the procedure. As with a blood donation, the blood in a therapeutic phlebotomy is removed via a needle and attached collection bag. While the amount of blood removed in traditional bloodletting wasn’t as regulated (and, oftentimes, too much blood was taken), therapeutic phlebotomies remove a specific amount (based on the patient’s needs). Once the right amount of blood has been removed, a compression bandage is placed over the needle site.6 Side effects of the procedure include lightheadedness, low blood pressure, and nausea, so patients are encouraged not to get up or change positions too fast after the procedure. In addition, patients should keep the bandage around the needle site for at least an hour, drink plenty of fluids, and avoid exercising or lifting heavy objects for at least five hours.7
After a therapeutic phlebotomy, patients will continue to be monitored via blood tests and visits with their physician, and additional phlebotomies will be scheduled based on their condition and needs.
My first therapeutic phlebotomy appointment was on a Saturday afternoon in June. I arrived at the infusion clinic and was escorted to a reclining chair in a room full of reclining chairs. My husband came along, sat on a bench next to the chair as we watched the nurse pull on gloves, prep the tubing and collection bag, search for a vein in my right arm. Even though I remembered the size of the needle from blood donations years before, I still looked away as the nurse slipped it into my vein. The collection bag sat on a scale on the floor, and the nurse held the needle in place and eyed the scale throughout the procedure, ensuring the correct amount of blood was being taken. At times, the blood slowed, so she had to move the needle around or back it out of the vein to get it to start flowing again. Once it was over and the bandage had been applied, I asked about the removed blood. We have to throw it out, the nurse said. It felt wasteful, almost devastating, to dispose of something so necessary, something my body worked so hard to create. She gave me a Styrofoam cup of soda and I drank as I watched her take the blood away to some unknown disposal area. After about thirty minutes, the nurse came back to check on me, helped me up, made sure I was steady on my feet, and sent me on my way.
Before my next blood test, I already knew the numbers would be high again, could feel a heaviness in my head and behind my eyes. When my suspicions were confirmed, I was back in the chair at the infusion clinic, the needle in my arm, nurse steadily holding it in place until the right amount of blood had been released into the collection bag. I’m sure I will eventually become accustomed to the cycle of blood tests and phlebotomies, will develop a routine and, hopefully, an acceptance of the large needles and the floating feeling that comes right after the procedure is over. For now, I can’t help but think of the necessity of blood, how difficult it can be to reach equilibrium (not too much or too little), and how strange it is that bloodletting, something that harmed so many people of the past, is part of what keeps my condition controlled, my body in balance.
Guiding Questions
Consider the following after reading the essay:
- Why might the author have intersected aspects of medical history with personal narrative? What is the impact of this intersection?
- What metaphors or imagery does the author use to convey her experience, and how do these shape our understanding of her perspective?
- What does the essay communicate about patient experience? What does it communicate about the importance of empathy in clinical practice?
