Polite Dissent

Picking up the medical annotations of Naoki Urasawa’s Monster with Chapter Two (the annotations for chapter one can be found here and here).

Since last we left Dr. Kenzo Tenma, he has been appointed the Head of Neurosurgery at the prestigious Eisler Memorial Hospital. He and Eva, the daughter of the hospital’s director, have become engaged. At tea one night with Eva and her father, Tenma is stunned to learn that the director wants him to give up on his own promising research¹ and instead write a paper for the director to give at an important European medical conference. The director seems to feel that money and prestige come before research and patient care. Tenma disagrees but doesn’t say anything. Thoughts of that conversation flash though Tenma’s mind as he rushes to the hospital to treat an emergency patient.

A young boy and his twin sister are the only survivors of an attack that killed their parents. The girl is physically fine, but in a state of mental shock. The young boy, on the other hand, is in critical condition with a bullet through his forehead. He is brought to the emergency room where the x-rays and CT scan show the bullet deep in his brain next to the vital left middle cerebral artery². Dr. Tenma chooses to perform a frontal craniotomy to remove the bullet and repair the damaged artery³. As the surgical team begins to prep the patient for surgery⁴, Dr. Tenma is called out of the room.

It seems the mayor has suffered a stroke and is being brought to the hospital for emergency surgery to remove a suspected clot⁵. The hospital director orders Tenma to operate on the mayor and let another team handle the dangerous surgery in the child. He reminds Tenma that the mayor has promised an increase in funding to the hospital. Tenma is conflicted but ultimately decides to go against orders and returns to his original operation; he performs surgery on the injured child instead of the mayor

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Footnotes:
¹Dr. Tenma’s research is on vascular spasms after subarachnoid hemorrhages, a subject we beat to death last time, so I’m going to spare you and not repeat it here.

²The x-ray (though it looks more like an angiogram as x-rays don’t show blood vessels this well) shows that the bullet has gone in straight and lodged resting against the middle cerebral artery on the left, one of the key arteries in the brain.

Now, I haven’t read enough of the story to know who shot the boy, but let’s play forensic scientist for a second. First, note the bullet’s path: it’s at a slight angle, almost straight down. He must have been shot by someone above him. In addition, the bullet is still remarkably intact, providing important ballistics information about the power behind the shot.

³Dr. Tenma has chosen to perform a frontal craniotomy. He is going to go through the frontal bone of the skull to access the brain. He has two concerns with the injury the patient has sustained. The first is the bullet itself. It needs to be removed and any damage it might have caused to the middle cerebral artery repaired. Second there’s the danger of contamination. The area around the wound is filled with small chips of bone and other debris from the gunshot shattering the skull. These can lead to delayed healing and infection. Dr. Tenma is cognizant of these facts andfeels that his first priority is to remove the bullet and check the artery for damage.

⁴The patient is intubated and ready for surgery. Dr. Tenma has marked out his incision. He is utilizing the bullet hole because it makes access easier and provides less additional trauma to the patient.
The patient’s vitals are strong and appropriate for someone his age.

⁵The mayor has suffered a “cerebral blood clot” — in other words: an ischemic stroke. A clot has cut off circulation to part of the brain, and that part is dying from lack of oxygen.

Hospital Flunkie: There’s a possibility that his internal carotid may be blocked.

The internal carotid artery provides most of the blood to the brain, so a clot stopping its flow is very serious. Narrowed carotid arteries are an unfortunately common sign of atherosclerosis (cholesterol deposition and hardening of the arteries), and if they get narrow enough a surgery called a carotid endarterectomy can be performed to clean them out. Sounds like it’s too late for this for the mayor.

Tags: comics gunshot wound medicine stroke carotid artery cerebral artery naoki urasawa monster