Blue Beetle #31: A Medical Review

September 29th, 2008

Filed under: Comics, Medicine

cover, Blue Beetle #31Blue Beetle #31 “Boundaries, part three: Primum Non Nocere”
Matthew Sturges, writer
Andre Coelho, penciler

After several years of reviewing comics with bad emergency room scenes, it’s a pleasant surprise to find a comic which does a good job. Plus is has Dr. Mid-Nite, one of my favorite characters.

Since Sturges doesn’t give me much to criticize1, I’ll take few moments to translate medical-ese into English, and add some thoughts of my own.

The Scene: The gang members Blue Beetle fought last issue are rushed to the hospital, nearly dead:

Paramedic: Pressure dropping fast despite wide open fluids and epi, 70/40 now. Bradying in the 30s. Apneic respirations.

goodThe patient’s blood pressure is dangerously low (70/40). Hypovolemic shock (shock due to low blood volume — generally because of severe bleeding) is a common cause of low blood pressure, so the paramedics have pumped the patient full of IV fluids (i.e. running the IV “wide open”). The patient has also been given epinephrine (adrenalin), a medication which can raise the blood pressure3, but it’s had no effect.
good“Bradying” refers to bradycardia, an abnormally slow heart rate — in this case a pulse in the 30s. Normal heart rate is 60-100, but can vary due to such things as athletic conditioning and certain medications. Regardless, a heart rate of 30 is bad in this situation.
goodApneic respirations are ragged gasping breaths that occur in between long moments of no breathing at all4. Generally this is a sign of things going south5.

The paramedic mentions that the patient’s temperature is 110°F (43.3°C). At this point, the ER doctor steps in:

Doctor: Okay. Pan-culture him. Call I.D. just to be safe. Start vanco, Zosyn, cooling blanket and get me a stat echo.

Because of the patient’s high temperature, the doctor suspects he has some sort of infection. All of his subsequent orders are based on this assumption.
good“Pan-culture” basically means to run every culture available on every fluid accessible to look for an infection. This includes: aerobic and anaerobic blood cultures, urine culture, spinal fluid culture, and possibly a couple more.
goodI.D. refers to a specialist in Infectious Disease.
goodVanco (stands for vancomycin) and Zosyn (piperacillin + tazobactam) are both powerful broad-spectrum antibiotics. Hospitals usually limit their use except in the most severe of cases, but since this patient could very well be in septic shock (shock related to an overwhelming bacterial infection), their use is appropriate here.
goodA cooling blanket will help to lower the patient’s temperature.
goodThe stat echo6 (echocardiogram) is an ultrasound of the heart used to look for vegetations (bacterial growths) on the heart valves, a sign of bacterial endocarditis, a sneaky infection.

End notes

Notes:
1. There are a few nit-picks of course, duly noted. Plus, Dr. Mid-Nite speaks some destined-to-be-classic technobabble (tiny electromagnets! In cells!)2
2. But at least he mention ribosomes, so that’s worth a point.
3. Epinephrine is not commonly used as a pressor (a medication used to increase a patient’s blood pressure), and certainly not in the field by paramedics. It is a second- or third-line agent used to treat unstable bradycardia, and that may be the case here.
4. If the patient’s breathing is as bad as described, he should be intubated, or at the very least placed on oxygen.
5. Sleep apnea is somewhat similar (intermittent gasping breaths during long periods of not breathing), and while it is not healthy, it is not as bad as the apnea described in this scene.
6. Endocarditis usually presents as a long-term, subtle infection and doesn’t present acutely with a high temperature and shock like the patient seen here, so the echo seems overkill. On the other hand, acute bacterial endocarditis is common in intravenous drug addicts, so that may be the doctor’s reasoning here

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9 Responses to “ Blue Beetle #31: A Medical Review ”

  1. Your Obedient Serpent
    September 30th, 2008 at 10:44 am

    I think it’s a nice touch that the “real” doctors and emergency workers get the technically accurate terminology, and it’s the Super-Doctor who spouts out all the dubious technobabble.

  2. Ryan
    September 30th, 2008 at 11:59 am

    I.D…I hope House turns up…speaking of which I can’t wait for your review.

  3. scott
    September 30th, 2008 at 5:48 pm

    Hi Scott, this is Scott. I am a hospitalist and I helped the great Matt Sturges (writer of Blue Beetle) with some of the medical jargon on that page.

    You obviously know your stuff and your site has a very cool concept and insightful analyses.

    Good point about the apnea requiring some sort of oxygen or intubation.

    I have to disagree about the epinephrine. It is not always first line, but sometimes it can be. In the ICU setting, levophed (epinephrine) and dopamine are generally the first two agents given for hypotension. In the most extreme cases, levofed tends to get hung first as often as dopamine does. This may vary in other areas but it’s been my experience in the past couple hospitals I’ve worked at.

    Good call on the 2DEcho for infective pericarditis and you are correct again in your 6th footnote regarding subacute vs acute valve infection. On the other hand, if there’s little history about the time frame of the illness (like if someone just drops into your ER with fevers and hypotension), a 2DEcho would be warranted. In acute hypotension, it could also pick up other causes such as a pericardial effusion (even without tachycardia), a ventricular wall aneurysm (caused by MI or infection), a massive MI (drug use), or even a massive PE (if there’s right ventricular strain).

    I’m happy that you were satisfied with most of the jargon though. It was certainly an honor to aid Matt with this as I am a big fan.

  4. » SUCK ON THAT ROBERT DOWNEY JR. Medea’s Memoirs: half-Corean dad, doc, artist who is not afraid of going to Hell
    September 30th, 2008 at 5:54 pm

    [...]  [Third Addendum:  I found this cool website that reviews comics and shows from a medical analyses and they reviewed this medical issue of Blue Beetle as well.  The webmaster seemed impressed with Matt’s medical dialogue, which makes me proud as well.  I did politely defend a couple points he criticized but all-in-all it’s an interesting review and site.] [...]

  5. scott
    September 30th, 2008 at 6:01 pm

    I also wanted to say this is a REALLY COOL site. I think I’m going to stay here awhile. I am enjoying your reviews.

  6. Graham
    September 30th, 2008 at 8:43 pm

    Yay, two Scotts! Medical debates by people who actually have knowledge of medicine AND comic books? This is great!

  7. Comics Should Be Good! » Quick Reviews: Blue Beetle and Immortal Iron Fist
    October 11th, 2008 at 6:48 pm

    [...] Blue Beetle #31- I really like how topical writer Matthew Struges is working topical elements in to this very enjoyable teen superhero comic. He’s even able to make our hero’s deputization as a Border Patrol agent a real great piece of awkward humor at our hero’s expense. My only real problem with the script is the medical-ese, which made as much sense as Morrison and Ellis’s technobabble can. Luckily everyone’s favorite blogging doctor was around to help sort that out for me. Maybe Struges expected him to pick up the slack, but I think he was just shooting for authenticity. [...]

  8. Jbird
    October 12th, 2008 at 3:14 am

    I’m really surprised that there hasn’t been a recent stab at a Doctor Mid-Nite series with some sort of vague attempt at medical accuracy. You’d think shows like House would push sales among pop culture nerds.

  9. Anonymous
    January 16th, 2010 at 3:25 am

    levo= norepinephrine

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