Polite Dissent

Nightwing #145 “Freefall”
Peter J. Tomasi, writer
Rags Morales, penciler

At the end of the Resurrection of Ra’s Al Ghul storyline, Al Ghul had been defeated by Batman and locked in Arkham Asylum. Batman had the asylum staff convinced that Al Ghul was a dangerously psychotic schizophrenic who required constant heavy sedation with multiple drugs. This way Batman figured it would be a long time before Al Ghul was a threat to anyone again. This may come as a surprise — but he was wrong.

In the recent Nightwing #145, Al Ghul surreptitiously grabs a pen dropped by a guard and uses it to lacerate his “brachial, ulnar, and radial arteries.” By the time the wounds are noticed, he’s already lost a tremendous amount of blood. The doctors at Arkham work feverishly to fix the lacerations and stop the bleeding, and they pump Al Ghul full of multiple units of blood to replace what he has bled out. This basically acts as an exchange transfusion. His drug-tainted blood has been lost and been replaced with fresh blood, eliminating the psychiatric drugs from his system. This allows Al Ghul to overcome the residual effects of the medication, slay the helpful doctors and nurses, and escape Arkham.

I give full credit to Al Ghul (and to writer Tomasi) for developing such a fiendishly clever plan. Assuming one ignores that fact that Al Ghul would have been too drugged up to conceive it — let alone carry it out — the plan should work well. The blood he lost would have been the blood carrying whatever drugs he’d been given, and the new blood transfused into him would have been drug free. For all intents and purposes, this would have purged the sedatives from his system — though probably not as fast as shown in the comic.

Al Ghul’s exchange transfusion plan wouldn’t work for every drug. For instance, drugs that are strongly bound to their receptors are likely to stay bound even with a transfusion. Additionally, drugs that are injected into the muscle and then slowly absorbed by the body (Depo Provera or Depo Medrol, for example), would see their levels drop right after the transfusion and then build back up as more drug is released into the circulation. Neither of these seem to apply in this case. While it’s never clear exactly what drugs Al Ghul has been given, the guards mention that he’s receiving them five times a day, suggesting that they are very short acting and should flush from his system quickly in an exchange transfusion.

A few nit-picks:
The brachial artery splits into the radial and ulnar artery, so it seems a bit redundant for Al Ghul to cut all three.

You don’t suture with your hands, you use instruments. But that could explain why the doctor seems to be so slow. He should have been long finished with his suturing by the time the seventh unit is transfused. Then again, he’s probably a psychiatrist who hasn’t sutured since medical school.

If the patient has lost that much blood, there should be multiple IVs running, not just a single bag of blood.

A unit of blood is 450cc. It looks like the nurse is just hanging the seventh unit, so he should have received only 2.7 liters by then, not 5.6

There are 5 liters of blood in the human body. That means it takes just over 11 units to completely replace someone’s blood. The doctor should have repaired the wounds in time for some of Al Ghul’s blood to remain, so he shouldn’t have needed the full 11 units (meaning some of the sedative would still be in his system, just very less concentrated). On the other hand, the doctor is clearly very slow, so Al Ghul might have needed more than the 11 units if he was still bleeding while they were transfusing more in.

What kind of asylum has their own blood bank? Wait, no need to answer that, it’s Arkham.