Kelly is as dispirited as I have seen her. “My veins are shot,” she says. “I can’t even get high.” IV users use 1 cc syringes which have a very small needle they only need to slip inside the vein. When they pull back and get blood they know they are in. They push the plunger slowly, sending the heroin directly into their vein and right into their circulation where quickly delivers its powerful payload to the brain. This is a faster and stronger route than swallowing a pill or inhaling the powder in through the nose. If however, the needle in not anchored in the vein, the drug goes into the tissue where it can cause damage and necrosis. The user still gets an effect, but it is less strong and comes at a price in damage to the tissues.
Kelly has shown me her veins before and they are challenging. I fancy myself an expert at inserting intravenous lines. I may be an average medic in some skills, but I am really good at IVs. I have been doing IVs for twenty five years on all types and ages and races of people.
There is a difference between doing an IV as a paramedic and inserting a hypodermic needle as a drug user. A paramedic has to insert the needle into the vein, and then they have to slide a catheter over the needle and anchor it in the vein.
One key is to find the best vein. The easiest vein is the AC in the crock of the elbow, but when this is not available, I look for the vein along the wrist or one of the many hand or firearm veins. Sometimes, I use a small needle. A 24 gauge is the smallest we use. The higher the number, the smaller the gauge. IV users typically use and go under the wrists or high up on the bicep for a superficial vein. I didn’t used to, but now I need to put on my reading glasses to see the smallest veins. I enjoy getting compliments from intravenous drug users who are my patients when I get IVs in after they tell me it is impossible. “Damn, you are good,” a woman says, and sends me a smile that makes my job worthwhile.
I don’t always use the arm. Sometimes I use the lower extremities. It is not an ideal place, but when an IV is needed, it will work. In extremis, I may also use the jugular vein in the neck. It is a large vein, but because it is deep, it requires a strong but sure touch to anchor the needle and not pierce the vein. Another difference between me and IV user is I get to practice on an endless variety of patients. An IV user is limited to their own body and to veins that they may hit too often. Some users -mechanics- may earn extra pay or free dope for injecting others. I think in another life, I would be good at this.
As part of my harm reduction efforts, I tell users how to inject safely. Rotate your veins I tell them. Clean them thoroughly before using. Ideally, with soap and water, but in a pinch an alcohol wipe will be better than nothing. Always use a fresh needle. Reusing a needle will blunt the needle and cause it to damage the vein. Never try to sharpen a used needle. Know where to get clean needles. I tell them where the needle exchange van is located. If they have money, they can also buy 10 clean needles for $3.99 at most pharmacies. Some bodegas will sell needles for $1-2. Sometimes other users who have gotten extra needles, by picking up dirty needles off the ground and exchanging them, will sell their extras for $1.
I don't know how many of them follow my advice or let my advice get in the way of getting their next fix if they lack the soap and water, the clean needle or a dormant vein. Users got to use, they say.
“Have you thought of trying your legs,” I say to Kelly. I ask this more to gage her reaction than to offer sage advice.
“No way, I’m not doing that. That’s bad for you. You can fuck your legs up.”
I am fascinated in her response. I am tempted to say you have no compunction about injecting a deadly drug cut with who knows what chemicals, but you don’t want to inject your legs. The legs veins are more likely to get infected and create clots that travel to your heart or brain or simply get stuck in your legs and cause swelling and tissue damage. But if your arms are shot, and you want to keep using IV, which as I have mentioned is the best bang for the rare buck, the legs are the next best alternative. The feet, the groin and the neck are all far more dangerous.
“I don’t get it,” I finally say to her, unable to hold it in. “You’re putting heroin and god knows what chemicals it is mixed with in your body. You get a bad batch and you can easily overdose and die, but you won’t even consider, shooting up in your legs, even though you are desperate for a fresh vein.”
“No, it’s bad for you,” she says, completely without irony.
There are a lot of users limping along Park Street with abscesses in their feet. Maybe she is feeling she needs to get around to get up her $4 to get her dope. She isn't ready for that yet.
***
We are called for a woman hemorrhaging on the side of the road. We arrive to find her sitting against a fence. I recognize her as a heroin user I have seen on Park Street. She is sitting in a lake of blood. Her skin is cool, clammy and diaphoretic. Gloved up, we get her quickly on the stretcher and on the way to the hospital. Her pressure is 70/40. Her heart rate 135. She is in shock from blood loss, but we are having a hard time determining where it is coming from. Not her vagina or rectum. When we press against her abdomen on the right side, she screams in pain. Her lower right abdomen is hard and rigid. When I press, I see a spray of red blood come from a tiny hole in her groin.
She is an IV heroin user and she admits she shot up in her groin, trying to hit the femoral vein. The problem with injecting in the groin is it is a blind insertion; you can hit a nerve, go into tissue or puncture the femoral artery. I am guessing she either hit the artery and it is now bleeding into her, or continued use of the groin caused an abscess that ate into the wall of the artery. In either case, she is in shock from blood loss. We hold pressure on her groin and race her to the hospital, calling a medical alert, and we go right past triage to a resuscitation room, where a gowned team goes to work on her. She is up in the OR before we leave the hospital.
***
I think about Kelly and wonder what she will do. Her arm veins are shot. She works hard for her 4 dollars and if she can’t hit a vein, she isn’t getting $4 worth of hit out of her dope. And it’s not that she needs to hit the vein just once. Minimum four times a day she has to shoot up. Four times a day, every day for the rest of her life or at least until she decides to go clean. What must go through her mind as she searches for a vein? At one time did she balk at injecting in the first place? And what was it that caused her to finally crumble through that barrier?
I ask her about the first time she injected drugs and she says she was with her boyfriend Tom and two friends. They scored some Vicodin, but not having enough to go around, he crumbled it into power, squirted some saline into a spoon, and stirred it down to solution which he loaded into a syringe. He hit her first vein. Then they went ice-skating. In the winter time in Bushnell Park, the city erects a skating rink for residents of the city. You don’t need money to rent the skates they have. She tells me about skating on the ice in the park high on IV Vicodin. She describes it as if she were in a snow globe floating through the blue and white sky.
I think about the girl who punctured her femoral vein and nearly bled to death on a Hartford street. What was it like for her the first time she injected? How many years did she inject before she killed off her arm veins? Her leg veins? The veins between her toes? When did she first inject in her groin? What will happen to her when she gets out of the hospital? Will they get her into rehab? How many times has she been before? Does she believe she may be able to one day break free? Or is hope no longer a word she knows?
When the time comes for Kelly and for this other woman to die will they will be alone in misery and pain? Or will they ascend into the sky peaceful like snow globes in the clouded hands of their god, their days of suffering on earth vanished?
