Category Archives: Medicine

Mr. Fantastic is a Menace to Your Skull!

From Death of Wolverine #1, Written by Charles Soule, Art by Steve McNiven, Published by Marvel Comics
From Death of Wolverine #1, Written by Charles Soule, Art by Steve McNiven, Published by Marvel Comics

I guess that Wolverine is going to die because he’s getting his medical advice from a PhD instead of a medical doctor???  Mr. Fantastic, genius leader of the Fantastic Four and holder of multiple doctorates in science fields though, to my knowledge, no actual medical degree to his name (M.D., D.O., M.B.B.S, or otherwise) is contemplating cutting into someone’s skull for a concussion.  Okay, to be fair, a “serious concussion”.  (Maybe for non-serious concussions he would just tap out a couple of holes?)

So what is a concussion, Reed?  Simply, a concussion is a head injury that results in a temporary change, impairment, or loss of mental functioning.   The more technical explanation is that a concussion is a type of mild traumatic brain injury, or MTBI.    In general, traumatic brain injuries are just like they sound —

concussion_graphicAll that soft brain shifting around in the hard skull, banging up against the sides of its non-adamantium covered “house” (in most of us), is…well…no good.  TBIs can be classified in multiple ways — time of unconsciousness, amnesia, and/or the most common Glasgow Coma Scale (GCS) — and are usually graded as mild, moderate, or severe.  TBI can also be categorized by the location of injury, how widespread the injury is, etc.

Again, by classification, concussions fall within the mild category of TBI.  The formal definition of concussion from the American Academy of Neurological Surgeons is:

“a clinical syndrome characterized by immediate and transient alteration in brain function, including alteration of mental status and level of consciousness, resulting from mechanical force or trauma”.

From the American Medical Society for Sports Medicine consensus statement, a concussion is:

“a tramatically induced transient disturbance of brain function and involves a complex pathophysiological process … a subset of mild traumatic brain injury (MTBI) which is generally self-limited and at the less-severe end of the brain injury spectrum”.

And, one more, this time from the American Academy of Neurologists, a concussion is:

“recognized as a clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation, which may involve loss of consciousness”.

So, all in all, we’re talking about transient symptoms with changes in mental status.  Symptoms can include headache, confusion, amnesia, dizziness, nausea and/or vomiting, blurry/double vision, light and/or noise sensitivity, and tiredness/drowsiness.  People who get a concussion may also lose consciousness, but this is NOT “required” and, all told, most people who suffer a concussion do NOT pass out.

To go back to Mr. Fantastic’s assessment of Wolverine, he’s talking about the “usual procedure” for a “serious concussion”.   What would a serious concussion be exactly?   Keep in mind that, by definition, a serious concussion would still be a mild TBI, meaning that we’re still talking that this is minimal in the “Brain Injury Spectrum” (or BIS, a term I just made up now).  The main grading scales for concussion all include loss of consciousness in the highest grade (Grade III), but again remember, that for a concussion, this is a transient thing (seconds to minutes for the most part).

As for the “usual procedure” for concussion?  Physical rest, cognitive rest, and observation are the standby norms.   Pain can be treated with common analgesics such as Tylenol.    You know what’s missing from this list???

080512-inca-skulls_big
Yes.  That’s right.

What Reed is talking about is called a decompressive craniectomy, a surgical procedure in which a bone flap is removed in order to allow the brain to freely expand.  In severe (for the most part) TBIs, pressure could build up inside the hard, non-expandable skull due to brain swelling.  As the soft brain expands, it’s looking for somewhere to go less it be crushed within its “house”.  The only real option, though, is downward through the hole in the bottom of the skull where the spinal cord leads.  The main problem with this, though, is that the very important, life-maintaining functions of the brain are contained in the part that gets wedged down there first.  Yeah, bad either way you go.  BUT, if you remove part of the skull and allow the brain to expand outward (instead of down or not at all), this may save the person’s life.

PE-TBIfig6

I would say, though, that while people who present to a hospital with a concussion could go on to have more severe brain injuries than first expected, such as bleeding (hemorrhage), this takes the diagnosis into a new place, away from a concussion (even a “severe” one).

So, NO, Reed.  The usual procedure for a concussion is not to do cranial surgery.  But it may be for you to stay far away.

(Note: Charles Soule, the writer of this dialogue, is no dummy.  The guy is an Ivy League undergraduate and a lawyer with a degree from one of the most prestigious law schools in the country.  This is a smart dude.  No question.  HE SHOULD NOT BE MAKING THESE MISTAKES.  Drop me a note, Charlie.  Let’s talk.)

Sphygmomanometering For Dummies

From Worlds' Finest #26; Written by Paul Levitz, Art by Tyler Kirkham, Published by DC Comics
From Worlds’ Finest #26; Written by Paul Levitz, Art by Tyler Kirkham, Published by DC Comics

Wha–huh?

We’ve talked about vital signs before and what they are, but in short, medical professionals take an initial assessment of patients based on their objective examination in association with some subjective parameters called “vital signs”, which include temperature, heart rate, respiratory rate, blood pressure, and pulse oximetry.

In this picture, following the explosion of Karen Starr’s (Power Girl) lab, a medical team has come in to examine those affected by the blast.   Here, the doctor or nurse or whoever she is (I don’t exactly remember because I was just so shocked by the picture itself) has placed a blood pressure cuff around her patient’s arm.

UPSIDE-FREAKING-DOWN

Yes, that’s right.  The thing is on upside down.

blood-pressure-thinkstock-464676259-617x416
Okay, am I being picky, you may ask?   Sure, the cuff will still inflate with the pump at the top versus the bottom, yes.  That won’t matter.   But to really understand the problem, let’s go over real quick what a blood pressure cuff (or sphygmomanometer) is checking and how it works.

blood-pressure
Blood pressure, as this lovely stolen schematic explains, is measuring the pressure that the blood exerts against the walls of the arteries (the main blood vessels that transport blood from the heart to the organs).   The basics as why we as physicians care about blood pressure is that both high and low BP can represent abnormalities in the heart, the fluid/blood/hydration status, the kidneys, etc. etc. etc.   blood-pressure

When a BP is checked with the sphygomanometer, the cuff is inflated to the point of cutting off circulation to the arm.  Air is let out of the cuff slowly while listening for the pulse (a whooshing noise, called a Korotkoff sound) in the arm (the brachial artery) with a stethoscope.  When you can hear that “whoosh”, it means blood is flowing through the artery; the pressure (measured by that small dial hanging off the cuff in the picture above) at which this happens is the systolic blood pressure.  The pressure at which the sound disappears is the diastolic blood pressure.

SOOOOOO, let’s forget about the fact that the cuff is on upside down.  What about that the cuff looks to barely fit on his arm?  What about that there’s no pressure dial on that cuff at all so how would you even be able to measure the pressure at which it is inflated?  What about that the “doctor” isn’t using a stethoscope so, unless she has unrevealed super-hearing, she wouldn’t be able to hear any Korotkoff sounds.  WHAT ABOUT THAT SHE IS INEXPLICABLY LOOKING AT HER WATCH FOR NO REASON SINCE TIMING ISN’T PART OF CHECKING A BLOOD PRESSURE???

I just can’t believe that the comic big shots haven’t called me yet for consultation…

Press Ganey Comics

From Outcast #2, Written by Robert Kirkman, Art by Paul Azaceta, Published by Image Comics
From Outcast #2, Written by Robert Kirkman, Art by Paul Azaceta, Published by Image Comics

Okay, sure the IV is in her hand backwards (like all too often depicted) and the IV tubing is looped near the pole (which may not be art error but really should be fixed if this was real life), but the scariest thing in this panel?

Strive For Five

STRIVE FOR FIVE

That phrase, “STRIVE FOR FIVE”, may be three words that ring true to hospital/medical administrators and create chills for hospital/medical employees.   The “five” refers to a grading score that patients (read: customers) give to their hospitalization/physician/nurse/medical staff/etc (read: customer service representatives) as part of a survey distributed by the Press Ganey organization.

Press Ganey was founded in 1985 by Dr. Irwin Press, PhD (anthropology) as a way of measuring patient satisfaction in order to improve performance.  The concept makes sense (and was revolutionary in terms of changing medicine from a paternalistic model to one of the “medical team”, including the patient in decision making), though many hospital systems have placed a TON of focus on getting those “5s”.  Physicians who are fearful of getting lower scores have been known to, albeit hopefully infrequently, do things to help improve satisfaction scores that may not be in the true medical best interest.  The best example of this is prescribing antibiotics to patients with simple viral colds (antibiotics work against bacteria, not viruses) because patients tend to feel like “the doctor did something” when they get a prescription.

While I believe that patient satisfaction is important (and has been shown that patients involved in their own health care are more satisfied and sicker for shorter lengths of time), the satisfaction ratings are misleading.  An unhappy patient is much more likely to fill out the survey about their bad experience than a happy patient is to about their great experience.   That is the purpose of these signs in the patient rooms, letting them know their doctors’/nurses’/PCAs’ names (information and disclosure is power!) and bringing up the idea of the Press-Ganey survey right from the start.

And, on a side note, Kyle’s mother is running a very authentic-looking bag of normal saline.

Overall, not a bad job here — for a horror/thriller comic, Outcast may have made their scariest panel yet.

Terminal Hero – Multiple Medical Infractions

Brain
From Terminal Hero #1, Written by Peter Milligan, Art by Piotr Kowalski, Published by Dynamite

Dynamite’s newest series, Terminal Hero, centers around a “young physician” (I’m guessing a resident) who is diagnosed with an inoperable brain tumor and, after secretly being experimented on by a “friend”, he “unlocks the potential” of his brain, gaining superpowers.  Written by Peter Milligan, I’m prepared for some crazy, but inventing areas of the human brain?  That was a surprise.

First off, the top illustration of the brain needs to be taken with some understanding of the artist’s style, so I’m not expecting an accurate and/or very detailed image of the brain — no worries.  But, looking at that image, if I had to pick what area looked like there is a large, inoperable tumor, I would pick here:

Brain Circle
whereas the parietal lobe is here:

Brain Circle 2
Which, if you ask me, looks completely normal.  Really, if you wanted to show the “right parietal lobe” in an illustration, the area is mostly visible from the lateral (or “outside”) view of the brain, not the cross section that is drawn in the comic.

combine_images
Sorry for the colors being different, but the parietal lobe is GREEN on the LEFT image (cross section) and YELLOW on the RIGHT image (lateral).

Though the pictures aren’t the greatest here, the point is that for looking at images of the parietal lobe, you’d likely see more worthwhile stuff on the lateral.  Even though you may see something on the cross section, especially if it is large enough, this illustration looks completely normal.

Okay, fine, maybe I’m being nit-picky here, artistic license and all.  So let’s move on to the name of the area — “Humboldt’s region of the right parietal”.  When I read the issue, I could not for the life of me remember anything called that from WAY back in my neuroanatomy classes, but it’s been a while.  So I went back and did a bit of research.

I CANNOT FIND ANY REFERENCE TO THIS AREA.  Anywhere.  No joke.  There is a Humboldt State University in California that has some neuroscience stuff on their website and a Humboldt University in Berlin but I can’t find anything else.  If anyone has any info on this, please comment below BUT I’m thinking that Milligan just invented this?  Why???

But maybe I’m wrong.  Maybe I’m mislead.  Maybe I’m just an ignorant endocrinologist.

BUT WAIT HOW ABOUT THIS ONE MORE PANEL???

Brain 2HOLY GOOD GOD HER IV BAG IS DRAINING INTO HER NOSE NO WONDER SHE DIED SLOWLY AND BREATHLESSLY

Reduced It!

From Lazarus #8, Image Comics, Written by Greg Rucka, Art by Michael Lark
From Lazarus #8, Image Comics, Written by Greg Rucka, Art by Michael Lark

Pretty good one, huh?  Michael here has just successfully reduced a nursemaid’s elbow, one of the most satisfying things to do in pediatrics (at least in my opinion).  A nursemaid’s elbow, medically known as a radial head subluxation, is simply a dislocation of one of the forearm bones (the radius) at the elbow.

In adults, the radial head is held in place at the elbow fairly strongly by the circumferential annular ligament.  In children, though, this ligament is not fully formed (and therefore not fully strong), allowing the radial head to slip out from under its stability and become entrapped.

nursemaids_elbow-13ED157A2B06AD51468This can happen, and commonly does, in young children less than 6 years old (typically toddlers) who sustain a quick pull — for example, being lifted up by the arms:

family-swinging-kidOr when a father needs to yank his kid out of the way of an oncoming wagon.  (There’s no leg equivalent, I believe…):

parent-disasters-fail-pics-0117The child typically presents with arm pain or refusal to move the affected arm/elbow.  Many kids are content to just keep the arm steady, turned in and held close to the chest, and appear fine until the elbow is manipulated.  The trauma to the arm can be so mild that the family may not even remember what happened.  This father remembers a “pop” — good for him! — but that is not common.  Many parents/caregivers/older siblings don’t know anything happened until the child is crying.  But, anyway, that elbow has got to be fixed…

The treatment is a manual reduction with the intent to put the radial head back into place.  There are two main methods for reduction — the supination-flexion technique and the forced pronation technique; one can be used following the other to ensure the radial head is back in place.

Michael is demonstrating the supination-flexion technique in which pressure is placed over the radial head (in the elbow), the palm is turned upwards, and the elbow is flexed.  The other method, which reportedly is more successful and less painful, is to turn the palm facing down and extend the elbow.  I personally have had more success with Michael’s method (including my son’s own nursemaid’s elbow).

And Three Cracked Osseous Structures Too…

From X-Men, Volume 4, #12 -- Written by Brian Wood, Art by Kris Anka
From X-Men, Volume 4, #12 — Written by Brian Wood, Art by Kris Anka

Though M means to let her tough-gal act scare Enchantress, she should know that a “fracture” and a “broken bone” are the same thing.  Like, exactly the same exact thing.  Exactly.

On a side note, M has a crap-ton of powers, but I don’t remember x-ray vision being one of them.  Tertiary mutation?

Oxygenation and Circulation

TMNT 23

This installment of poor medicine in comics doesn’t just contain itself to a single panel; rather, the “quack” team of Teenage Mutant Ninja Turtles #23 works really hard to frustrate me.

This issue focuses on the aftermath of the fight between our heroes and the Foot, specifically on Casey Jones’ injuries and Leonardo’s capture.  The Leo stuff is actually pretty interesting, but for our purposes here, let’s take a look at the horror show hospital that Casey gets brought to.

photo 1(1)

Okay, so our “hero” Casey has been stabbed through the chest and is currently bleeding to death.  Just another day in the TMNT New York City, but we better hope that this surgeon decides to not finish his tuna fish sandwich and actually scrub into surgery sooner that five minutes from now.

The biggest glaring error in this panel is the physician taking care of Casey’s airway.  Remember folks, breathing (and oxygenation) is important!  As he’s being ventilated right now, I’d be surprised if he’s getting much oxygen at all.  First off, in the absence of neck injury, the correct way position his head would be in the “sniffing position”, which anatomically keeps the airway open.  This is done by slightly tilting the head backwards (extension of the neck), putting the ear in line with the sternal notch.

fig2
This looks a bit extreme and more likely for tracheal intubation, but you get the hint..

In addition, the hold on that bag and mask is improperly done.  The right way, per the ACEP (American College of Emergency Physicians), AHA (American Heart Association), and the other major medical groups is the EC hold.  For one-person ventilation (meaning you don’t have a second person to compress the bag), this is how it would look:

Screen shot 2013-07-04 at 5.46.14 PM
From the AHA

It’s called the EC because the 3rd-5th fingers from the shape of a “E” along the mandible and the thumb and pointer form a “C” around the actual mask portion.  This ensures a good seal of the mask around the face of the patient, helping effective oxygen delivery.  Poor Casey already isn’t doing so well…

Oh, and I love the look of complete indifference on the face of the guy holding the IV fluids, who I have to guess is a surgical intern who had the unfortunate luck to match residency in a hospital that caters to ninja and mutant fight victims.  The beds in this hospital don’t come with IV poles, sadly.

photo 2(1)

Casey is now in surgery, seemingly being wiped up with a white cloth and a large Planters peanut.  This great hospital has opted not only to not intubate him (place a breathing tube in his windpipe to protect his airway), but they’ve simply placed a mask on his face, hoping that it remains delicately balanced on there for the duration of his surgery.  See!  No face straps!

Screen shot 2013-07-04 at 5.55.27 PM

And I really have no idea what facemask has two tubes attached to it.  Granted I don’t spend much (read: any) time in the OR, but I have no clue what the second tube would be for.

Lastly for this panel, the IV.  Oy, the IV.  This is one of the biggest medical mistakes in comics.  IVs are placed TOWARDS the heart.  This one is backwards, placed going towards his fingers.  What’s even more infuriating is that IT WAS DRAWN CORRECTLY IN THE FIRST PANEL.

photo 3(1)

Miraculously, Casey survived surgery and made it to recovery.  For some reason, he is now intubated (which I’m guessing was done in a panic intraoperatively when the oxygen mask slid off his face) and also has a nasogastric (NG) tube in place, maybe to decompress his stomach, maybe to add more drama.  I just love the physician’s comment that he suffered “significant trauma, particularly to the abdominal region”.  I am guessing that this is Dr. Noshit Sherlock, M.D.  “Oh, thank you for telling me that, doctor!  I thought that all that red stuff covering his abdomen when I brought him to the hospital after he was stabbed in the gut was just some ketchup!”

One big facepalm for this terrible attempt.

Oxygenation and Circulation

TMNT 23

This installment of poor medicine in comics doesn’t just contain itself to a single panel; rather, the “quack” team of Teenage Mutant Ninja Turtles #23 works really hard to frustrate me.

This issue focuses on the aftermath of the fight between our heroes and the Foot, specifically on Casey Jones’ injuries and Leonardo’s capture.  The Leo stuff is actually pretty interesting, but for our purposes here, let’s take a look at the horror show hospital that Casey gets brought to.

photo 1(1)

Okay, so our “hero” Casey has been stabbed through the chest and is currently bleeding to death.  Just another day in the TMNT New York City, but we better hope that this surgeon decides to not finish his tuna fish sandwich and actually scrub into surgery sooner that five minutes from now.

The biggest glaring error in this panel is the physician taking care of Casey’s airway.  Remember folks, breathing (and oxygenation) is important!  As he’s being ventilated right now, I’d be surprised if he’s getting much oxygen at all.  First off, in the absence of neck injury, the correct way position his head would be in the “sniffing position”, which anatomically keeps the airway open.  This is done by slightly tilting the head backwards (extension of the neck), putting the ear in line with the sternal notch.

fig2
This looks a bit extreme and more likely for tracheal intubation, but you get the hint..

In addition, the hold on that bag and mask is improperly done.  The right way, per the ACEP (American College of Emergency Physicians), AHA (American Heart Association), and the other major medical groups is the EC hold.  For one-person ventilation (meaning you don’t have a second person to compress the bag), this is how it would look:

Screen shot 2013-07-04 at 5.46.14 PM
From the AHA

It’s called the EC because the 3rd-5th fingers from the shape of a “E” along the mandible and the thumb and pointer form a “C” around the actual mask portion.  This ensures a good seal of the mask around the face of the patient, helping effective oxygen delivery.  Poor Casey already isn’t doing so well…

Oh, and I love the look of complete indifference on the face of the guy holding the IV fluids, who I have to guess is a surgical intern who had the unfortunate luck to match residency in a hospital that caters to ninja and mutant fight victims.  The beds in this hospital don’t come with IV poles, sadly.

photo 2(1)

Casey is now in surgery, seemingly being wiped up with a white cloth and a large Planters peanut.  This great hospital has opted not only to not intubate him (place a breathing tube in his windpipe to protect his airway), but they’ve simply placed a mask on his face, hoping that it remains delicately balanced on there for the duration of his surgery.  See!  No face straps!

Screen shot 2013-07-04 at 5.55.27 PM

And I really have no idea what facemask has two tubes attached to it.  Granted I don’t spend much (read: any) time in the OR, but I have no clue what the second tube would be for.

Lastly for this panel, the IV.  Oy, the IV.  This is one of the biggest medical mistakes in comics.  IVs are placed TOWARDS the heart.  This one is backwards, placed going towards his fingers.  What’s even more infuriating is that IT WAS DRAWN CORRECTLY IN THE FIRST PANEL.

photo 3(1)

Miraculously, Casey survived surgery and made it to recovery.  For some reason, he is now intubated (which I’m guessing was done in a panic intraoperatively when the oxygen mask slid off his face) and also has a nasogastric (NG) tube in place, maybe to decompress his stomach, maybe to add more drama.  I just love the physician’s comment that he suffered “significant trauma, particularly to the abdominal region”.  I am guessing that this is Dr. Noshit Sherlock, M.D.  “Oh, thank you for telling me that, doctor!  I thought that all that red stuff covering his abdomen when I brought him to the hospital after he was stabbed in the gut was just some ketchup!”

One big facepalm for this terrible attempt.

Tell It To Frank Netter

From Uncanny X-Force, Volume 2 #2, written by Sam Humphries
From Uncanny X-Force, Volume 2 #2, written by Sam Humphries, published by Marvel Comics

Sorry, Puck, but maybe you hit your head too hard on the landing.

The longus capitis is a deep muscle of the anterior neck that functions to flex the head and neck when contracted.  Here it is in all its glory:

Longus Capitis

As you can tell, not only is Puck holding the wrong area of his neck (the back instead of the front), the longus capitis is so deep (and thin) that it would be near impossible to have a direct injury to only this single muscle.