A review of the medical scenes in Doctor Strange. There will be spoilers, so be warned!
I. DR. STRANGE’S INJURY
The heart is surrounded by a tough fibrous membrane called the pericardial sac. This membrane fits tightly around the heart, with just a few milliliters of fluid in between the two. If extra fluid gets into the pericardial sac, say blood from a stabbing injury, then a situation known as “tamponade” occurs. Because the pericardium is too tough to expand, all the extra fluid instead pushes down on and compresses the heart. Compressed, the heart is unable to expand, or even beat, leading rapidly to an emergency situation. Clinically, tamponade presents as acute heart failure with Beck’s triad1: distended jugular veins, muffled heart sounds, and pulsus paradoxus (a large drop in blood pressure during inspiration).
The treatment for tamponade is to drain the extra fluid out of the pericardial sac, but it’s a tricky procedure because the heart is hidden behind the rib cage, and even in tamponade situations, the pericardial sac is not separated from the heart by much. The doctor needs to get the needle into the pericardium and drain the fluid without damaging the heart in the process. A needle can be slowly advance through the chest under fluoroscopic (i.e. x-ray) guidance, but this takes precious time to set up and not every hospital has access to the equipment. Cardiac tamponade is a life-threatening situation and time is of the essence. Emergency physicians needed a way to get the needle to right spot quickly and with equipment already on hand; they came up with an ingenious solution: a long needle is attached to a syringe and an electrical lead is attached to the back end of the needle and plugged into the heart monitor already attached to the patient. The needle is pushed into the chest and slowly, ever so slowly, advanced towards the heart. When the needle just barely touches the heart, there will be a noticeable blip on the heart monitor. The needle is then pulled back just a smidge so it is no longer touching the heart — at this point it should be in the pericardial sac2. The syringe is then used to remove the blood filling the pericardium.
You’ll notice this is just what Dr. Palmer did to treat Dr. Strange’s tamponade: she got a syringe with a long needle and attached an electrical lead to it3. But then, before she could get much farther, Strange used his magic to make his skin translucent, so she could actually see what she was doing and was able to drain the fluid and relieve the tamponade.
At this point, Strange’s heart flatlines, and Dr. Palmer grabs the paddle and shocks it. I hope you all yelled (or at least thought), “Don’t shock a flatline!” Tamponade can certainly cause asystole (a flatline) but you treat it by relieving the tamponade, which she had already done, not by shocking the heart. Again, don’t shock a flatline — then she did it again! Admittedly, the reasons were story driven and not medical, but still she’s taking a chance, shocking a heart that’s beating normally — she could cause a dangerous heart rhythm, or a flatline, or even directly injure the heart. I’d also worry about the metal in the Eye of Agamotto causing a nice electrical arc, but maybe sorcerous metal isn’t conductive. The settings she used, 200 and 360 Joules, were reasonable — if you were shocking an actual fibrillation and not a flatline.
As a final thought, you’ll notice she sewed up the skin laceration from the stabbing, but doesn’t appear to have done anything (or had the time to do anything) to fix the internal injury — the one that bled into the pericardial sac causing the tamponade. Strange is likely to develop a tamponade again quickly if this internal wound is still bleeding.
II. THE ANCIENT ONE’S INJURY
When the Ancient One crashed to the ground, she suffered either a subdural or epidural hematoma4. These hematomas are caused by damage to the arteries surrounding the brain, which causes bleeding into the area around the brain. The pressure from this bleeding can’t expand outward — the skull is there — so the pressure pushes down against the brain. This increased pressure can decrease blood flow to the brain, causing brain damage. If the pressure is raised high enough, it can actually push the lower part of the brain — the brainstem — down through the foramen magnum (the hole connecting the skull to the spinal column) severely damaging it in a situation known as a tonsillar herniation. As the brainstem plays an important role in, well, life (such as breathing, the heart beating, the nervous system transmitting, etc.), damage to it can quickly turn fatal.
The emergent treatment for an acute hematoma like this is to carefully drill a hole in the skull to relieve the pressure. Even with quick treatment, these injuries are all-too-frequently fatal, not just because of the bleeding around the brain, but because of all the other injuries that are usually suffered at the same time (look how far she fell — and through a glass awning too — you know she was smashed and broken all over, not just the brain).
III. MISCELLANEOUS THOUGHTS
I know wearing glasses or goggles hides the actors’ all important eyes, but everybody in an operating room needs to wear eye protection — OSHA is really firm on this. Hell, in one OR scene, Drs. Palmer and Strange weren’t even wearing surgical masks.
There is a set procedure of scrubbing before surgery (seroiusly: we had classed on this in medical school). It is purposefully designed so that a clean area never comes into contact with a dirty one. Masks on first, then scrub in the sink fingers down to forearms. Then into the OR. If you put the mask on after you’ve scrubbed, then you’ve touched an unclean area (the mask) with your cleaned hands and need to start over.
Transplant teams are carefully regulated and have numerous guidelines to follow. They don’t just swoop in as soon as the patient is declared brain dead — that’s the last thing they’d do. They work hard to foster goodwill with the deceased patient’s family.
Exactly what kind of doctor is Doctor West? Neurosurgeon? Hand Surgeon? Transplant Surgeon?
A glaring HIPAA violation or two, in sharing patient information with Dr. Strange when he’s not involved in the patient’s care.
Is Dr. Strange even on the hospital medical staff when he start to operate on the Ancient One? Exactly how long was he gone?
Notes:
1. Long before the internet, facebook, and listicles, doctors developed numbered lists of signs and symptoms for dozens and dozens of different diseases and conditions. Most seem to be triads, but there’s the occasional pentad just to keep things interesting. Think of Beck’s Triad as the listicle associated with cardiac tamponade. You won’t believe number two!
2. This “advance the needle until you’re just a little too far, then pull back” is a common technique in medicine. I use it when injecting steroids for tennis elbow or trochanteric bursitis. In those cases, it’s advance the needle slowly until you feel the bone, then pull back just a little and you’ll be in the right spot to inject the steroids. And yes, there is numbing medicine involved as well.
3. So kudos to whoever was the medical consultant for Dr. Strange for getting them to include this technique in the film.
4. There are several layers of membranes and blood vessels surrounding the brain — the level at which the injury/hematoma occurred gives the injury its name. There are some slight differences in cause and symptoms between epidural and subdural hematomas, but for the purpose of this post, either could be the cause.
More PSAs
Subscribe to Polite Dissent
