• The Cycling News forum is still looking to add volunteer moderators with. If you're interested in helping keep our discussions on track, send a direct message to @SHaines here on the forum, or use the Contact Us form to message the Community Team.

    In the meanwhile, please use the Report option if you see a post that doesn't fit within the forum rules.

    Thanks!

Let's form a hypothetical doping regime during these 21 days for Lance

Page 2 - Get up to date with the latest news, scores & standings from the Cycling News Community.
Alpe d'Huez said:
And we all assume JV is the other rider who confessed to EPO alongside Andreu, right? It was either he or Livingston, and JV and Frankie are closer friends.

I assume it is not Jemisen because he punched out Dr. Prentice Steffan at the Tour of Utah. He is still ****ed years later that Steffan spilled the beans about him and Hamilton asking for medical help.

I have heard different things about Livingston, everything from in private he talks about what was going on to he won't admit to anything even though his blood profiles were found in Dr. Ferrari's files.

I have always assumed that it was Vaughters.
 
Mar 13, 2009
16,854
1
0
Visit site
Cobblestones said:
Here is a reasonably up to date article on oxygen carriers. You doubt their efficiency. However there has been progress since the time of Museeuw. Emulsions of PFC reach much higher concentrations nowadays. HBOC seems to be even more promising for clinical applications.

What I wonder is whether overuse of, say, PFCE could have serious side effects (I'm thinking about the liver and central nervous system), which are then managed by some of the heavy medication such as pentoxifyllin and liver detoxifiers which you mentioned in your first post and whose presence in the teams medicine cabinet seems a mystery to everybody.
I know about a story submerging a mouse in PFCs. Party trick, not sure if apocryphal. But how have they worked as a PED. Much different to trauma medicine. Talking hear, adding a point or so onto the exhausted hamoglobin capacity when a rider is at threshold. When at threshold, the body will be acting differently.

My thought on the experimental stuff, just drugs to make their current capacity more efficient in uptake. The transfusions become enough, so they near or surpass limit of exhaustion of hemoglobin. That is, O2 does not become the limiter. Power becomes a limiter, and the strength and power from training.

Could be far wrong on this. Am not a wise seer, and very much a lay person on the alchemy of peds.
 
Mar 13, 2009
16,854
1
0
Visit site
Alpe d'Huez said:
Good links there Cobbles. Informative.


This reminds me. Anyone recall when OP broke and someone from La Gazetta tracked down a former Italian racer who had raced well at the Giro, and this man said that it was impossible to compete on the top level of any GT without doping. He was now working in construction or carpentry of some sort. Anyone ever track that down?

And we all assume JV is the other rider who confessed to EPO alongside Andreu, right? It was either he or Livingston, and JV and Frankie are closer friends.


My understanding and limited experience says no, though it's a complex issue. If you took a long time off you'd be in a heavy and specific training program more than anything. When you got close to racing, most of your boosting would be in the form of altitude training and hyperbaric tent sleeping. There are benefits from doping in that you can train harder, get better recovery, etc. But doing a transfusion, say, in March, won't give you any benefit or "ramp up" for your race in July, other than you may be able to train harder. If I'm wrong on this, I'll let Blackcat or Cobbles correct me.
Armstrong would have been on a big program for 12 months. Since he decided to come back. He went over to the TDU ready to kick but, and was one of the two strongest. Him and Rogers. Bread and water? Gimme a break. He was charged then. He needed the enhancement to hit the power mark in training. He could not come to the Tour, without that high threshold training in his legs. That is why Rasmussen was so good, read about what he was doing when he was in "Mexco". 250km days JUST climbing HC Dolomiti. How much gear would he have been popping down then. He would have never need a support team, he could have done a Landis every mtn stage on the Tour, if they never had any valley flats.
 
Jul 8, 2009
82
0
0
Visit site
blackcat said:
That is why Rasmussen was so good, read about what he was doing when he was in "Mexco". 250km days JUST climbing HC Dolomiti. How much gear would he have been popping down then. He would have never need a support team, he could have done a Landis every mtn stage on the Tour, if they never had any valley flats.


Do you have a link to information about his training?
 
Mar 13, 2009
16,854
1
0
Visit site
sorry, you will have too google it yourself. But he really was driven, and doing long days in June. Remember he had skipped the Dauphine or Suisse, to just train by himself in the Dolomites. He would have been on so much gear then. I think Menchov popped over for a few days.

The young Danish mtb'er at Saxo, Jakob Fuglsang trains with him in Italy ;)
 
blackcat said:
Armstrong would have been on a big program for 12 months. Since he decided to come back. He went over to the TDU ready to kick but, and was one of the two strongest.
Clarify. to make sure we aren't saying opposites.

I'm not saying if someone took a few years off, they'd start their program the day they started racing, with The Big Race six months out, if that's how it sounded. I'm saying the program would have started before race 1. Not so much for some form of hematological prepping, but for training purposes.

If there were no controls, at all, guys could jack themselves to where they could go out and hammer double century after double century day in and out, without feeling that exhausted or that worn. Where's that link...
 
May 13, 2009
3,093
3
0
Visit site
blackcat said:
I know about a story submerging a mouse in PFCs. Party trick, not sure if apocryphal. But how have they worked as a PED. Much different to trauma medicine. Talking hear, adding a point or so onto the exhausted hamoglobin capacity when a rider is at threshold. When at threshold, the body will be acting differently.

My thought on the experimental stuff, just drugs to make their current capacity more efficient in uptake. The transfusions become enough, so they near or surpass limit of exhaustion of hemoglobin. That is, O2 does not become the limiter. Power becomes a limiter, and the strength and power from training.

Could be far wrong on this. Am not a wise seer, and very much a lay person on the alchemy of peds.

This is precisely the question. There is no open research on PFCEs or HBOCs as PED. No ethics committee would ever allow that. Maybe there's military research? Maybe a few rogue scientists? I do not know.

What I know, I know from open sources, and they're silent about PFCEs and HBOCs as PEDs. So, it goes without saying that all of this is speculation.

Now, fact is that the limitation for power output is oxygen availability. That's why there's aerobe and anaerobe power output, the latter being higher. That's also why additional Hb (by whatever means, increased production via EPO/CERA or transfusions homologue/autologue) will increase power output so dramatically.

With this as a starting point, it sounds logical that PFCEs and HBOCs would increase power output as well possibly up to the anaerobe threshold (but sustained!!), but as I said, we're not on firm ground here any more. Both PFCEs and HBOCs are smaller than RBC, they dissolve in the plasma, meaning they can enter the smallest capillaries more easily. Ironically, this effect is used experimentally in cancer treatment :D . It helps inner tumor cells (which are typically O2 starved) to get up to a normal O2 level, so they start to divide more frequently at which point e.g. radiation therapy can take them out.

So, due to their flow properties (their small size really) PFCEs and HBOCs would be more ideal O2 carriers than RBCs. However, they wont last more than, say, a day (and I think Dr. House was ignorant on this point in his rants about cowblood) which is a problem in terms of effect and for the body to get rid of metabolites (the latter will take a week, within which one really shouldn't take another dose).

Now, when you look at very recent performances in GTs (say since the CERA test), what struck me is that most good riders have 1-2 really good days, but not typically a freakish third week as in, say, the early 2000s. Consistent with PFCEs/HBOCs. Also, some riders might take greater risks and take more than 1 dose per week (maybe 2 or 3) and in order to manage possible side effects (e.g. possible liver toxicity, kidney problems, effects on the central nervous system) they have to take some heavy hitting other medication which you brought up in your first post. Now, maybe I've arrived in fantasy land here. There's little known in the literature of side effects of overuse of PFCEs and HBOCs in trauma patients. And even then, things might be different for healthy endurance athletes. So who knows.

Anyway, I'm interested in your speculation. I'm not sure I understood what you were hinting at. An experimental drug to increase O2 carrying efficiency of Hb? That would of course boost the effect of transfusions as well. Could you point me to a write-up on it, aimed at the interested layman?
 
Mar 13, 2009
16,854
1
0
Visit site
Cobbles, I am a layman. I don't know what I am talking about. I thought there are experimental drugs that work on the end point, the muscles, ie. the efficiency in what you deliver. Not you endogenous red cells or the artificial carriers or perfluorocarbon emulsions. I AM A LAY PERSON. Put as much stock in what I say as BB, but BB is wrong on heaps.

I just think the cases of Gianetti and Museeuw, blunted the use of that stuff. Ofcourse, it may still be prevalent, but I doubt it. The transfusions and EPO are so effective, those seem to be risks.
 
Jun 15, 2009
8,529
1
0
Visit site
Cobblestones said:
This is precisely the question. There is no open research on PFCEs or HBOCs as PED. No ethics committee would ever allow that. Maybe there's military research? Maybe a few rogue scientists? I do not know.

What I know, I know from open sources, and they're silent about PFCEs and HBOCs as PEDs. So, it goes without saying that all of this is speculation.

Now, fact is that the limitation for power output is oxygen availability. That's why there's aerobe and anaerobe power output, the latter being higher. That's also why additional Hb (by whatever means, increased production via EPO/CERA or transfusions homologue/autologue) will increase power output so dramatically.

With this as a starting point, it sounds logical that PFCEs and HBOCs would increase power output as well possibly up to the anaerobe threshold (but sustained!!), but as I said, we're not on firm ground here any more. Both PFCEs and HBOCs are smaller than RBC, they dissolve in the plasma, meaning they can enter the smallest capillaries more easily. Ironically, this effect is used experimentally in cancer treatment :D . It helps inner tumor cells (which are typically O2 starved) to get up to a normal O2 level, so they start to divide more frequently at which point e.g. radiation therapy can take them out.

So, due to their flow properties (their small size really) PFCEs and HBOCs would be more ideal O2 carriers than RBCs. However, they wont last more than, say, a day (and I think Dr. House was ignorant on this point in his rants about cowblood) which is a problem in terms of effect and for the body to get rid of metabolites (the latter will take a week, within which one really shouldn't take another dose).

Now, when you look at very recent performances in GTs (say since the CERA test), what struck me is that most good riders have 1-2 really good days, but not typically a freakish third week as in, say, the early 2000s. Consistent with PFCEs/HBOCs. Also, some riders might take greater risks and take more than 1 dose per week (maybe 2 or 3) and in order to manage possible side effects (e.g. possible liver toxicity, kidney problems, effects on the central nervous system) they have to take some heavy hitting other medication which you brought up in your first post. Now, maybe I've arrived in fantasy land here. There's little known in the literature of side effects of overuse of PFCEs and HBOCs in trauma patients. And even then, things might be different for healthy endurance athletes. So who knows.

Anyway, I'm interested in your speculation. I'm not sure I understood what you were hinting at. An experimental drug to increase O2 carrying efficiency of Hb? That would of course boost the effect of transfusions as well. Could you point me to a write-up on it, aimed at the interested layman?

Could somebody shortly explain what PFCEs and HBOCs are. Coz i like to follow the conversation:)
 
Mar 19, 2009
1,311
0
0
Visit site
FoxxyBrown1111 said:
Could somebody shortly explain what PFCEs and HBOCs are. Coz i like to follow the conversation:)

Perfluorocarbons (PFCs) are fluorocarbons, compounds derived from hydrocarbons by replacement of hydrogen atoms by fluorine atoms. Its possible to use them as a blood substitutes, along with being used in refridgerators, ski waxes, etc, etc.. Not sure that somebody could succesfully dope with them. I wouldnt try it. :)
 
May 13, 2009
3,093
3
0
Visit site
PFCE=perfluorocarbon emulsions (and artificial O2 carrier)
HBOCs=hemoglobin based oxygen carrier

blackcat, I'm an interested layman as well. I don't have a medical degree. My degree is in physics, with some excursions into chemistry and biophysics. I can read and understand pharmacological stuff when it's written up for the interested layman and of course I profit from my general science background. I would love to run some of my speculations by a practitioner in the field (sports medicine, preferably a little bit on the dodgy side), but so far no real luck. I've been following cycling for a good 30 years (sometimes more sometimes less). I don't really follow any other sport any more. And cycling made me interested in the physiological/pharmacological aspect of sports in general. Now, the internet is a great tool to get information on all of that stuff, but you have to be able to separate science from lunacy (and that's not always as simple as it sounds, is it BB?).

I remember the Gianetti case, I actually found a now historic document on that.

''His symptoms were difficulty breathing, muscle pain, gastroenteritis and what we call intravascular coagulation,'' the doctor said. ''It was a very dangerous problem.''

This is probably the only published record of side effects on PFCEs overdosing. It seems to me muscle spasm, gastroenteritis, difficulty breathing point to effects on the nervous system (direct or indirect b/c as side effect of coagulation I don't know). The intravascular coagulation, I don't know. Maybe something went wrong with the emulsion? Maybe he got a botched transfusion on top of it?

Anyway, this was likely Oxycyte, a first generation PFCE. They've all hit the market in the meantime (with varying success); researchers are working on the second generation PFCEs with much higher O2 saturation level. Likely they get the side effects better under control as well. But no open research in PFCEs as PEDs, so we don't know.

I think your speculation of increased efficiency sounds as likely as mine (I guess we're both shooting in the dark, unless you have inside information). What I would be interested in is some simple write-up of an existing drug, or something in the lab which roughly does what you're proposing, so I can get informed.

Btw. I don't remember the Museeuw case precisely. I think he admitted use of a first generation EPO product and was banned (after retirement). What was his involvement with PFCEs again? Do you have a link where I can refresh my memory?
 
Mar 19, 2009
1,311
0
0
Visit site
I dont think they work either. PFCs need to be administered with strait up oxygen from a a mask. Flusol for example, needs to be "loaded." Not sure how long that has to be done, the whole time...
 
Mar 19, 2009
1,311
0
0
Visit site
but BB is wrong on heaps.
How am I wrong? If you look at what the riders say (Andreau, Jesus Manzano, Decanio, Kohl, operation Puerto, etc, etc) I think I'm fairly accurate on how they blood dope with their own blood to jack their crits...As far as "chaperones" as BroDeal says, if he knew what he was talking about he'd know the UCI cannot legally take a blood sample for your passport for atleast 2 hours post stage. And there's no chaperones for that period, and if you need some IV saline and lactate ringer there's no one that can do a damn thing.

Just like Flyer used to google info and pretend to be an expert, I get the same feel about BigBoat. I don't trust much of what he says.

The riders are all doped. Your living in a Never Land Ranch if you somehow think otherwise after all the good info thats even been released by the media in operation Puerto, and by "from Lance to Landis" and other books. The UCI is totally corrupt, and its peanuts for them to get some good PR out there with this passport program. Fans lap it right up, but common sense should tell you that things have not changed!

blackcat said:
Cobbles, I am a layman. I don't know what I am talking about..

Why dont you quit flaming me then?! If you look at the last 15 years in Cycling its pretty obvious the riders were either jacked on epo or blood doping after 2001 and they used saline, volume expanders, etc to get below 50. Even David Walsh wrote of this in "From Lance to Landis." "Breaking the Chain" by Willy voet...The list goes on and on.
 
May 13, 2009
3,093
3
0
Visit site
BigBoat said:
How am I wrong? If you look at what the riders say (Andreau, Jesus Manzano, Decanio, Kohl, operation Puerto, etc, etc) I think I'm fairly accurate on how they blood dope with their own blood to jack their crits...As far as "chaperones" as BroDeal says, if he knew what he was talking about he'd know the UCI cannot legally take a blood sample for your passport for atleast 2 hours post stage.

Fine, that could explain how you can dilute after the stage. What do you do when the vampires come in the morning just before one?

Where I don't agree with you are the insanely high crit values you're speculating about. This forces you to make all kinds of additional assumptions such as draining before going to bed (so it doesn't clog in your arteries), and re-injecting the next morning. That's a pretty complicated logistic exercise for 3 weeks. And how would you time the expander, drain, and re-injection such that the officially measured crit values change at most by a few points throughout the tour (around a value in the lower-mid 40s nonetheless)? Furthermore, as far as I understand, Kohl was getting simple transfusions, nothing more.

Btw. one piece of data I would love to see are Kohl's crit values from last tour. Are they available?
 
Cobblestones said:
Btw. I don't remember the Museeuw case precisely. I think he admitted use of a first generation EPO product and was banned (after retirement). What was his involvement with PFCEs again? Do you have a link where I can refresh my memory?

Thanks for the good posts, Cobbles. Appreciate.

If Blackcat doesn't find the info on Mussew's case, I'll look into it. He'd been under scrutiny for some time, and caught up in a web. Keep in mind though that his confession was only at the end of his career, and a blanket statement that he doped the last year he raced, with few specifics. He did this under a mountain of evidence. But to his credit he did say he would talk more if someone like WADA approached him and that he wanted to help. Doubt the UCI looked into that though.

BigBoat said:
How am I wrong? ...the UCI cannot legally take a blood sample for your passport for at least 2 hours post stage. And there's no chaperons for that period, and if you need some IV saline and lactate ringer there's no one that can do a damn thing.
Not bashing you here, but can you provide a link for that?

The riders are all doped. Your living in a Never Land Ranch if you somehow think otherwise after all the good info thats even been released by the media in operation Puerto, and by "from Lance to Landis" and other books. The UCI is totally corrupt, and its peanuts for them to get some good PR out there with this passport program. Fans lap it right up, but common sense should tell you that things have not changed!
This is what I think upsets people BigB. You're painting a very black and white picture. Your facts are facts, and you're treating your opinions as facts. I for one don't think the riders are ALL doped. Many, yes. Some very much so. I also think it's a huge problem, and I agree to a large degree the UCI is corrupt and out to save their own face and are akin to a political party.

You still didn't answer my question to if Brad Wiggins were doping, he'd do fairly well on Stages 4 and 5 in the Giro, finishing in the top 30 and 20 - this indicating to you he's jacked. But if that's the case, and he's more than happy to dope and can't be trusted and is a liar, etc. why did he lose so much time after that? So badly - with no indication that he was sick or injured - that he could barely keep up with the autobus later. Like it's impossible that he got into the right breaks, and wore himself out, therefore he must be doped, and ran out of drugs?

I can't say for certainty that Brad is on bread and water clean. I'd like to think he is. But you say with certainty that he's doped. Along with Martin, and others even at the back of the autobus on every stage.

Look, I'm not so naive to trust every rider who speaks out against doping and says "I'm clean", Kohl said it for God's sakes. And I do agree with you that doping is still a way of life. And as I said, I don't think it's like everyone is either completely jacked, or on a vegan diet. There's a lot of gray in there. But I don't think I'm being unreasonable here.

If you look at the last 15 years in Cycling its pretty obvious the riders were either jacked on epo or blood doping after 2001 and they used saline, volume expanders, etc to get below 50. Even David Walsh wrote of this in "From Lance to Landis." "Breaking the Chain" by Willy voet...The list goes on and on.
I get along with you pretty good, and believe a lot of what you say, and acknowledge that you've been deeper into the core than I have, even if others don't. But I'm trying to say that we're all saying pretty much the same, you just paint with such a broad brush and leave no room for anything else while hitting them over the head with a hammer at times, and I think that's what bugs people.

Anyway, stay cool and keep on posting. There's a lot to be brought to the conversations from a lot of people. :cool:
 
Mar 19, 2009
1,311
0
0
Visit site
Cobblestones said:
Fine, that could explain how you can dilute after the stage. What do you do when the vampires come in the morning just before one?

?
They get on IV saline, or lactate ringer... The "vampires" will come 2 hours before a key stage. The rules do not allow any testing during the night.

Where I don't agree with you are the insanely high crit values you're speculating about. This forces you to make all kinds of additional assumptions such as draining before going to bed (so it doesn't clog in your arteries), and re-injecting the next morning. That's a pretty complicated logistic exercise for 3 weeks.

It IS somewhat complicated to train off and store blood... But with millions in the bank its more than possible with a well trained physician and some fancy toys. All you need is one guy to do it with you in all honesty, and if you have 30 units of frozen packed red cell its do-able without even saving draw off blood. They could just dump it.

The example I use about training off blood comes from actual accounts from riders.... They've been doing this for cycling eons (since the UCI set the 50% limit.)

Furthermore, as far as I understand, Kohl was getting simple transfusions, nothing more.

Kohl admitted in his numerous interviews to using human albumin to hemodilute down...his doctor or manager likely though in saline as well.

And how would you time the expander, drain, and re-injection such that the officially measured crit values change at most by a few points throughout the tour (around a value in the lower-mid 40s nonetheless)?
His red cell count was very high, his plasma volume was expanded through the roof to hemodilute down to his biological passport "norm" for his controls. They have all morning long to do this, and it can be properly dosed out to keep his previous values. The UCI sends them their values as they come in.
 
Jun 9, 2009
140
0
0
Visit site
Cobblestones said:
Fine, that could explain how you can dilute after the stage. What do you do when the vampires come in the morning just before one?

Where I don't agree with you are the insanely high crit values you're speculating about. This forces you to make all kinds of additional assumptions such as draining before going to bed (so it doesn't clog in your arteries), and re-injecting the next morning. That's a pretty complicated logistic exercise for 3 weeks. And how would you time the expander, drain, and re-injection such that the officially measured crit values change at most by a few points throughout the tour (around a value in the lower-mid 40s nonetheless)? Furthermore, as far as I understand, Kohl was getting simple transfusions, nothing more.

Btw. one piece of data I would love to see are Kohl's crit values from last tour. Are they available?

To expand on this point, and to follow up on a post I made earlier, blood removal or the introduction of any agents directly into the circulatory system require veinapuncture or the insertion of catheters into a vessel, which even under ideal (clinical) circumstances with expert technicians often result in complications such as collapsed veins, edema, "blown" veins and very visible resultant bruising. Multiply this by the high frequency of procedures that are being suggested here, and if nothing else you begin to run into the practical limits of finding veins that have not been weakened or ruined by previous use. I cannot imagine how they could conceal the noticeable bruising and "track marks" on the arms and legs of riders after 3 weeks of racing in a grand tour unless they had a surgically implanted port like a Port-A-Cath.

Just my opinion after having been on the receiving end of more IVs and blood draws than I would care to remember, and I'm an easy "stick", as they say.
 
May 13, 2009
3,093
3
0
Visit site
BigBoat said:
They get on IV saline, or lactate ringer... The "vampires" will come 2 hours before a key stage. The rules do not allow any testing during the night.



It IS somewhat complicated to train off and store blood... But with millions in the bank its more than possible with a well trained physician and some fancy toys. All you need is one guy to do it with you in all honesty, and if you have 30 units of frozen packed red cell its do-able without even saving draw off blood. They could just dump it.

The example I use about training off blood comes from actual accounts from riders.... They've been doing this for cycling eons (since the UCI set the 50% limit.)



Kohl admitted in his numerous interviews to using human albumin to hemodilute down...his doctor or manager likely though in saline as well.

His red cell count was very high, his plasma volume was expanded through the roof to hemodilute down to his biological passport "norm" for his controls. They have all morning long to do this, and it can be properly dosed out to keep his previous values. The UCI sends them their values as they come in.

At best you're answering my questions very obliquely.

I asked you: what are you doing when the vampires come in the morning? You answer, they cannot come in the night.

I brought up the point of logistic and you answer by waiving around 'millions of $' and 'fancy toys'.

I asked you how to time expanding, draining, and transfusion so to post roughly (within a couple of points) the same crit, and you answer that 'it can be done'.

Your answers are non-answers stated as facts. Read Alpe's post.
 
Mar 19, 2009
1,311
0
0
Visit site
I asked you: what are you doing when the vampires come in the morning? You answer, they cannot come in the night.
Their hemodiluting their blood with albumin or regular saline like Bernard Kohl said. They do this an hour or so before the "vampires" take samples. 8-9 in the morning. They use desmospray sometimes to keep fluids in for longer, and they rush to controls pronto.
I brought up the point of logistic and you answer by waiving around 'millions of $' and 'fancy toys'.

They transport their blood by motorcycle pannier or bicycle pannier. They use blood pumps (mechanical IV pumps) or pressure bags to slam blood in at 200 mm Hg through the IV drip, they can do 5 units in 25 minutes if blood doping with whole blood , peanuts to slam 3 units of packed red cells into a healthy man in 15 minutes through an 18 gauge needle. Kohl did his transfusion in 15-20 mins. The riders do have needle marks. Little stress with autologous blood doping as long as the blood is stored and thawed properly...
I asked you how to time expanding, draining, and transfusion so to post roughly (within a couple of points) the same crit, and you answer that 'it can be done'.
Yes it can be done without much practice. If you look at Lances crit, his varies from 39-46% from week to week. They throw in IV saline and hemodilute big time into the 40s. Nuff...

Kohl admitted in his numerous interviews to using human albumin to hemodilute down...his doctor or manager likely through in saline as well.
The rider admitted to doping. He said he did this. He finished 3rd place in the TDF.
 
Jun 22, 2009
24
0
0
Visit site
BigBoat, how exactly does the timeline work with the transfusions, draining, racing, dilution, doping controls??

I'm confused why they would infuse packed cells then dilute to meet the 50% rule and then bleed the excess at night so they don't die during their sleep.