Polite Dissent

In X-Treme X-Men #24, Sam Guthrie (Cannonball) is assisting in the rescue effort after the terrorist attack in the Chunnel. The panels discussed are reproduced below, in the “more” section.

Things to remember: The role of the first responder is to stabilize the patient and transfer them to definitive medical care. The priorities are the ABCs (Airway, Breathing, and Circulation — in that order). In trauma care, time is crucial, and every second counts.

Sam comes out of the rubble carrying a victim in his arms. He really should be providing more neck support. Even if he couldn’t fit a cervical collar on the her, he should provide more support for her head (look at it just lolling there — ouch!)

In the next panel, the medic calls for a “line of ringers, line of plasma”. Ringer’s lactate is an IV fluid commonly used for fluid resuscitation, so that’s good. However, plasma is only used in patients who have clotting problems; it is never used for fluid resuscitation. Additionally, plasma is a blood product, and blood products are not carried into the field due to stringent storage requirements.

No pulse can be detected in the patient (but remember Sam has just said he was talking to her). The medic says to start an Ambu-bag, which is used for rescue breathing. He never checked her airway (remember A B C), but maybe someone else on the team did. An Ambu-bag makes good sense, but sooner or later, this patient is going to need to be intubated (i.e. have a breathing tube put down her throat).

Next he says to inject “Atropine, 1mg, direct to the heart!” Bad, bad idea. First, atropine is probably not the right medicine. It is used in some pulseless situations, but not most, and no one has stopped to check why the patient has no pulse. There are many reasons: her heart may have totally stopped beating or have a bad rhythm, her heart may be injured, or maybe she’s bleeding so much out that no pulse can be detected (remember, Sam says he’s covered in blood). Before injecting any medicine, her heart rhythm needs to be determined. They have a defibrillator, and those have heart leads attached, so it will take only a few seconds to check her rhythm. Second, atropine is not supposed to be injected into the heart. Only a few medicines, such as epinephrine, can be injected into the heart (a la Pulp Fiction), but not atropine. It’s never been approved for that, and a search of the medical showed no reports of atropine ever being used that way. Finally, and most importantly, injecting a medicine into the heart is dangerous, and only used as a very last resort. It can irritate the heart, tear the heart muscle, or sever a coronary artery – causing a heart attack. Two IV lines have already been started, just use those to deliver the medicine. So again, atropine into the heart: wrong, wrong, wrong.

200 Joules is the appropriate starting level for defibrillation. But whether or not defibrillation is the right thing to do depends on why there is no pulse. Certain rhythms require immediate defibrillation, while others warrant medication first, then defibrillation. No amount of shocking is going to help a severely injured heart, and she still needs plenty of fluids. Plus, if has no pulse, then someone needs to be doing chest compressions while waiting for medicines/paddles.

Overall, the emergency medical care shown here is very poor. It may look exciting, but it’s also borderline negligent. Sam is right to be worried about her care.