#fandommedical

Thanks for the question!

Your easiest course of action here is that one of Matt’s many wounds gets badly infected. It makes a lot of sense- he’s getting hurt left right and center in pretty dirty places. It was only a matter of time before cleaning out his wounds wasn’t going to cut it. 

Claire’s an ED nurse. From what we’ve seen of her, she can also do sutures, which is slightly above the pay grade of your average RN-BSN (nurse with a 4-year degree who has taken and passed national licensure (NCLEX)). I’d guess she’s a Clinical Nurse Specialist (CNS), because if she was a Nurse Practitioner (NP) or Doctor of Nursing Practice (DNP), she would have introduced herself as such. 

What all this means is that while she’s really freaking good at what she does, and has training outside of her degree, she still doesn’t have something called prescriptive privilege. Which means that if Matt needed a drug, she couldn’t legally write him a prescription. 

Which would suck if, say, he had an infection and needed antibiotics. 

And because Matt is Matt and his “hey this kinda hurts and might be infected” is most peoples’ septic shock, he’d probably need IV antibiotics. 

If she couldn’t get him to go to the hospital for this, she would need to do some pretty hard-core wound management, including debridement using a wet-to-dry dressing (waiting for the packing to dry and then pulling it out will take out any dead tissue from the infection), draining any abscesses, and getting him antibiotics of some kind. 

Two ways to get antibiotics without Claire fully breaking the law and losing her nursing license: 

1. She pretends to have her own infection, and asks a doctor she has a good rapport with to write a prescription without doing an exam. Since she wasn’t asking for a narcotic, the doc might be willing to do it (NOTE: Illegal, but the kind of illegal that usually slips through the cracks...). Hell, depending on how good of a friend they were (or how morally questionable of a doctor they were) she might be able to tell the truth, that the antibiotics were for a friend, and they might still be willing to write the prescription. Failing this…

2. Now, this is really actually very dangerous so DON’T DO THIS IN REAL LIFE. SERIOUSLY. IT COULD KILL YOU AND I’M NOT JOKING AROUND HERE. But I know a nurse who has done it (for financial reasons, my country’s healthcare system is fucked up), so on some level, even though it is HELLA DANGEROUS, it can work. You’ve been warned… 

…Some antibiotics (depending on the kind of infection he had, which Claire may or may not be able to figure out by symptoms alone) are sold at pet stores without a prescription in powder form for fish tanks. They are the same drugs as given to humans, and doses and generic drug names are listed on the bottles. Theoretically, if she couldn’t get antibiotics for him any other way, she could get them this way and either mix the powder in a drink form (it was taste awful, so maybe mix it with something else) or if she had them put the powder in capsules. Both ways she would have to weigh and measure the powder very, very carefully to make sure it was the right dose, and he would have to take these orally. They may or may not work…

Wow, that was long… 

Anyway, other things that should really be treated in a hospital but could possibly be treated at home would be any condition that could (but would not necessarily) complicate into one of the H’s&T’s (reasons people crash/code) because she really doesn’t want him to die on her couch…: 

Hypoxia

Hypovolemia

Hyper or Hypokalemia

Hyper or Hypothermia

Hydrogen Ions

Tension Pneumothorax

Tamponade (cardiac)

Thrombosis

Thromboembolism

Toxins

The ones most likely in Matt’s case would be the following. The treatment for these then would be preventing him from crashing/coding: 

Hypoxia- Any injury to the chest (prevention of code by keeping him still, medicating for pain as much as possible and doing frequent vitals checks), breathing in a toxin that caused swelling in his respiratory tract/lungs (prevention by again doing frequent vitals checks, providing him with some form of OTC anti-inflamatory)

Hypovolemia- due to bloodloss ‘cause Matt (prevention here would be by monitoring vitals and keeping him hydrated if possible. Oral would be best, but if he was really in danger, IV equipment can be ordered online or (and again don’t do this, its illegal and just generally wrong- Claire would be fired if she were caught) stolen from the hospital). 

Tension Pneumothorax- Due to a punctured lung/other chest injury (happened in episode 2)

Thrombosis/Thromboembolism- Due to increased risk of clotting/damage to blood vessels with multiple severe injuries (prevention would involve getting him up and moving as soon as possible (counterintuitive, but evidence based practice says it works because it stops blood from staying in one place too long) or giving aspirin (though don’t do this if he’s at risk for bleeding, which he usually is)). 

Toxins: Cause hey he might get poisoned who knows… 

If she couldn’t get ahold of one of the antidotes, treatment would be symptom management and keeping him breathing (or breathing for him) until his body was able to filter out the toxin/drug. 

This might also give you some ideas if you haven’t seen it yet.

Good question. This answer goes into a little more detail than I think you were initially hoping for but enjoy:

It makes sense to me thatPietro would have a slower resting heart rate. As I’m sure you’re awarebecause you asked the question, the resting heart rates of endurance athletestend to be lower than those of ordinary couch potatoes. 

This is because while weare running (or swimming, or biking, or parkouring) our muscles need moreoxygen and nutrients to function. The way the body supplies this is throughblood. The average adult heart pumps about 50 milliliters of blood per beat,and it generally can’t pump any more than that at one time. So if the body needs moreblood (or oxygen, or glucose), the only thing the heart can do to meet this demand is to speed up.Eventually, though, it reaches the point where demand outweighs the body’s ability to supply it and the heart beating faster can no longer both compensate and continue working. At this point, we either stop or fall over. 

Now, if everything is running normally, our bodies like to please us, and if they can adapt to meet our needs then they generally try to. This is particularly apparent with increasing endurance. One of these adaptations is an increase in red bloodcells. Because red blood cells carry oxygen, the more red blood cells, the more oxygen those 50 mL of blood per beatcan carry, the fewer beats per minute needed to supply the body’s demand foroxygen, and the longer the body can go without needing to fall over. This alsomeans that when the body is at rest, it still requires fewer beats per minuteto meet oxygen demand, and so you end up with a slower resting heartrate. 

Now for the tangent…

Pietro from AOU (I don’t know anything about him from the comics) didn’t work up to his incredible runningspeeds, but rather had an incredibly high metabolism thrust upon him by experimentation.With this higher metabolic rate, his body would have significantly higher oxygenneeds, higher water needs, higher energy needs and probably a higher body temperature.

Because there were no initial limits and recovery periods like there would have been if he’d been training to run a marathon, there probably would have been a pretty sucky adjustment period where he had low oxygen concentrations (his body was using it up faster and his lungs and heart couldn’t supply enough to keep replacing it), moderate to severe dehydration (his body was using water up faster and he didn’t know and so didn’t yet know to replace it), low blood glucose levels (he would suddenly be burning a ton more calories than he was used to and his body wouldn’t be streamlined to consume/create it as quickly) and had a significantly higher body temperature (because the dehydration would limit his ability to compensate for increase in temperature caused by metabolism). He’d also be having problems with acid-base balance which is a whole other can of worms I don’t want to get into right now…

During this adjustment period, his body would still be trying to compensate for all of these things, or he would have died. Meaning he would have had a very high respiratory rate and a very high heart rate and would probably be sweating pretty profusely until his body realized he was too dehydrated for that. The first hour or so of whatever they did to him to give him such a high metabolic rate he’d have tons of energy and feel amazing. After that, possibly for several weeks, he’d feel like he was probably dying. 

As his body finally adjusted, and he figured out new standards for taking care of himself, he would start to feel better (there would probably have to be some other kind of super-power intervening to make such complete adjustment possible, but...). 

Post-adjustment, his new normals would include much greater food and water intake (including high iron requirements to create and replace red blood cells), slower heart rate to compensate for bursts of speed (initially, before he started using his metabolism to run, he might have a normal or slightly elevated pulse rate- the slow heart rate comes from occasionally, but not consistently, having a greater oxygen requirement), and probably a normal or slightly lower resting respiratory rate as well. 

But anyway, that’s my analysis of Pietro’s increased metabolism and why he would have a slower heart rate.

At first glance I liked that episode’s whump a lot, and ultimately, it stacks up pretty well on the medical side of things compared to other shows:

This is me being really nitpicky, but I’m a nursing student, and I’ve spent several years now learning how nurses think and react to things, and since Claire’s a nurse, here’s what I got:

First of all, Claire’s an ER nurse in a New York City hospital, and she seems to be a pretty dang experienced one if she’s sewing him up later in the series (usually she’d have to have at least a post-graduate certificate to be allowed to suture, though it ultimately depends on state and hospital policies. She could also just be saying hell with the policies because there’s a guy bleeding in her kitchen and she knows how to help him.). 

A tension pneumothorax is an accumulation of air in the chest cavity that puts too much pressure on the lung for the lung to be able to expand. Treatment involves relieving that pressure by evacuating the air and healing/sealing whatever was trapping the air in there in the first place.

Tension pneumothorax is SERIOUS, and she’d be looking for it. It would also come on slowly enough that there would be signs. Being such an experienced nurse, Claire wouldn’t have let Matt get to the point where he was gasping for air before doing something to relieve the pressure. 

She’d be checking vitals every 5 minutes initially, and if he seemed stable, she may increase that to as much as every 15. 

She’d be paying special attention to rate and depth of breathing (because of the broken ribs she found in her initial assessment), blood pressure, and heart rate (because she doesn’t know how deep that stab wound goes, and increased HR and a change in BP would give an indication of internal bleeding). 

In between that, she would be assessing peripheral vascular (again assessing blood loss, and looking for early signs of shock) and central nervous systems (because he’s beat to hell and she doesn’t know if he had a blow to the head or neck at some point during this). 

Even before the real classic signs of a tension pneumothorax (one-sided diminished breath sounds, hyper expanded chest that doesn’t move with respirations, trachea deviating away from the side of the pneumo) set in, she’d notice fast heart rate and fast, shallow breathing. While she may initially connect this to blood loss, worsening symptoms of decreasing oxygen saturation such as blue lips and mental status change (even if she didn’t have a pulse ox device to measure o2 saturation more exactly) might encourage her to do a more thorough respiratory assessment, where she would notice the difference in breath sounds and finally suspect the pneumo. 

As for the needle thoracostomy “chest dart” Claire performed… Its not always indicated without an x-ray or other imaging to confirm the tension pneumo, because of the risks associated with placing a large-bore IV catheter in someone’s chest. Of course, Matt was in significant distress, so this might even be bypassed even in an emergency room type setting. 

See how one side is darker than the other? That’s air in the chest cavity and what Claire evacuated when she stuck Matt with the needle.

Here’s a video on how that would be done in real life. Claire would have probably learned it with a lot more sterile technique and equipment that was made for the task instead of the more improvised equipment in the video, but I felt it fit the spirit of the scene. And Claire did it completely correctly (with the exception of the 1-way valve which is kinda important, but her technique was great from what I could see!). 

While they do provide fast relief (if you can access any episodes of the military documentary series “Inside Combat Rescue” on netflix, there are several good examples of this procedure performed in a real-world situation), even similar to Matt’s recovery in many instances, needle thoracostomies are not the end of the treatment for tension pneumo. Until whatever is causing the leak is healed or at least sealed (and I think in this episode it was a lung punctured by broken ribs??), the patient would need a chest tube placed. If the only thing Matt had gotten for this was the needle thoracostomy, the pneumo would probably have returned and he would have suffocated during one of the fight scenes later. 

Thanks for the question!

Here is a link to a previous ask about concussions. That should give you what you need to know as far as causes/symptoms (especially for a severe concussion involving loss of consciousness).

Grading concussions:

Grade 1: Symptoms last for less than 15 minutes following trauma. There is no memory loss surrounding the incident, and no loss of consciousness.

Grade 2: Symptoms last for more than 15 minutes but there is still no loss of consciousness. 

Grade 3: Loss of consciousness (usually for no more than a few seconds, but can be longer), other symptoms may last for days or weeks afterward. Memory loss may be involved, including surrounding the injury itself and problems forming new memories.  

After sustaining a concussion, precautions should be taken to not re-injure the brain. If a second injury is sustained while the brain is still healing, it can cause something called second-impact syndrome, which, while rare, involves rapid and life-threatening swelling in the brain (no bueno). 

Characters should also be watched for a period of time depending on the severity of the concussion. Sleep is allowed, but if the concussion was a grade 2 or 3, the character should be woken up every 2-3 hours for the first 12-24 hours and reassessed for changes in mental status (can the character say their name and birthday? Tell you where they live? Who the president/head of government is? Are their pupils reactive to light (note- if someone’s pupils are not reactive to light, they have brain damage that goes VERY deep. They would definitely not be able to answer the other questions and may actually be in a coma (EDIT: dilated (large), fixed (non-reactive to light) pupils also indicate an increase in intracranial pressure, especially in children, so basically the brain is either badly swelling or the brain’s ability to drain excess cerebrospinal fluid has been compromised. Both of these would require immediate intervention))? Can they walk in a straight line? Has their headache gotten worse?). This is because concussion complications tend to happen quickly and/or need rapid intervention, and when the person is sleeping, they may not notice changes in their own neurological status or be able to get help.

Treatment involves managing symptoms and resting until symptoms resolve. This may mean antiemetics for nausea and non-NSAID pain relievers like acetaminophen (Tylenol) (NSAIDs increase the risk of bleeding, which is the cause of several concussion complications) for pain (stronger pain medication may be given as well, at the provider’s discretion due to possible sedative/mental status altering effects of the medication). For more severe concussions, especially those involving loss of consciousness, the character should be admitted to a hospital for observation and more intensive symptom control.

Thanks for your question!!

Wrist sprains are damage to (tears or breaks in) the ligaments around the wrist. Ligaments are the fibrous connective tissue that attaches bone to bone around a joint.

Sprains come in three grades, according to severity:

Grade 1: No loss of function, or loss of function only because of pain. Some mild pain due to ligament damage and some swelling, but damage is limited to a minor tear and will heal on its own. 

Grade 2: Mild-moderate loss of function due to pain and structural damage to the ligaments. Pain and a feeling of “looseness” in the joint, along with swelling and some bruising. Damage is moderate to severe tearing of the ligament. May need x-ray to differentiate between sprain and hairline fracture, but will probably heal on its own without surgery. 

Grade 3: Complete loss of function due to structural damage. Pain, extreme weakness and looseness in the joint, swelling and bruising. Damage is complete tearing or snapping of ligament. Will require more extensive imaging (x-ray and/or MRI) and surgery to correct. 

Any kind of sprain will require Rest Ice Compression and Elevation (RICE) to control pain and swelling and prevent further damage to the tissues, though for how long depends on the severity of the sprain. Anti-inflamatory painkillers like ibuprofen, aspirin and naproxen will help with this as well.

(Fun extra info on NSAID painkillers in case your lute-playing hero is not from modern day: 

Aspirin (more specifically salicylates, the kind of chemical aspirin is) in tea/ extract form (from spiraea, willow, poplar and black haw) was the first non-steroidal anti-inflamatory (NSAID) drug and has been around since well before Hippocrates. I could not find much about its use in the 15th-early 18th centuries, when lutes were popular, but it was probably used to some extent during this time. In tea or extract form, the gastrointestinal side effects like nausea and stomach ulcers are worse, but it would probably be somewhat effective against pain or swelling. Aspirin in the form we know it today was “discovered” in 1763 and was synthesized in 1852.

If you give me a specific time period and location where your story takes place, I can give you more historically-appropriate treatment options, I’m a bit of a self-proclaimed medical history buff.) 

If your character has a Grade 1 sprain, he should be okay to continue playing after about 48 hours of rest. Symptoms would probably go away in about 3-4 days and be completely healed in a week or two (he could probably continue playing right away but he would be in pain and it would probably prolong healing time). 

If your character has a Grade 2 sprain, he should be healed enough to play in about a week. He might have a hard time continuing to play right away due to structural damage, but might still ultimately be able to power through with some sort of brace (can you play the lute with a brace???), though this too may be painful and extend healing time. 

A Grade 3 sprain might take two weeks to a month to heal enough for him to play with. He would not be able to power through immediately at all, but after a week or so post-surgery, he might be able to play with a brace, but he shouldn’t. 

Its completely and utterly fan service. I’ve spent a lot of time in hospitals (working at them in high school and now doing nursing clinicals in college) and while patients are technically allowed to go shirtless (or wear anything they want, really, as long as we don’t see boobs or genitals hanging out- I walked in on a patient once who was wearing a full formal suit), not many of them choose to. Off the top of my head, I can think of two specific people who weren’t wearing something on their top half- one of them had just had a double lung transplant, and the other had six (yes, six) chest tubes. So mostly it depends on patient preference and comfort. If they feel better shirtless, we’ll get them some scrub bottoms to wear. If patients are unconscious, though, and its our choice, they’re covered up.

Most people get to wear these sexy things while they’re in the hospital:

These are convenient to healthcare professionals because they can be ripped off at a moments’ notice for medical emergencies or (more likely) when they become contaminated with large volumes of bodily fluids. They’re inconvenient to patients because they don’t cover much in the way of backside. 

No problem!

So, in today’s hospitals (again, at least in the US), pain is treated according to what the patient says their pain is. Your character is absolutely allowed to refuse pain medicine, and he is absolutely allowed to ask for it regardless of his history as an addict. 

If the hospital is running anywhere close to normally, his pain will be assessed on a scale of 0-10, with 0 being no pain and 10 being the worst pain he’s ever experienced, and then a series of other questions. Based on his answers, he and whoever assessed the pain would determine what the best course of action would be to relieve it. 

Not gonna sugar coat it though, your character will be in hella pain. Chest tubes are horribly painful, and if he had the collapsed lung, he probably has one. Not to mention the wound itself and all the reconstruction work. Like, there’s very little chance he’d make it without pretty hard core pain meds. 

Generally, post-op for this type of surgery, he would be given morphine (or something stronger, even) along with a high dose of tylenol or ibuprofen. The tylenol or ibuprofen actually work with the narcotic painkillers to better relieve the pain (they help a lot when mixed in this way, but likely they would not relieve the pain on their own.). Other pain management, such as repositioning, massage or guided imagery may help too, but also would probably not adequately relieve the pain on their own. 

Like I said, he would be allowed to accept and refuse any offer of painkiller. Refusing painkillers, however, can have consequences:

High blood pressure and everything that goes with it (increased chance for heart attack, stroke, deep vein thrombosis/embolism, especially since trauma and surgery increase the risks of these anyway.)

Increased chance of bleeding

Chipped teeth (from gritting teeth) 

Delayed healing

Muscle soreness/headache (from constantly tense muscles)

(Author note: I had a bilateral mastectomy (double boob removal) about 4 months ago, and I’d basically never had surgery and was scared to death of taking painkillers (like literally any painkiller. I hadn’t even taken ibuprofen or acetaminophen for 5 years). So I tried to see how long I could go after the surgery without taking any, hoping that maybe I could just push through and not have to take any at all. The answer was 11 hours, but in that time, I was in some pretty intense pain, and my blood pressure got pretty high because of it. Because of that I ended up breaking a blood vessel and bleeding into the space where my left boob used to be (hematoma), which filled up (that half of my chest stuck out about two inches, which is a lot on a chest) and started leaking out of the incision. It was a long, painful trip back to the hospital and I don’t recommend it. Don’t make my mistakes.)

Thanks for your question!

Part 1- Could a person be extubated after waking up from general anesthesia?

Yes. In fact, most people are only extubated after they wake up from anesthesia, though most people don’t remember actually being awake at this point. 

General anesthesia is a mix of many drugs, all doing different jobs like making the patient sleep, keeping them pain-free, making sure they don’t remember anything from the procedure, and keeping them still/paralyzing them. This mix is tailored to the patient and to the surgery or procedure the patient is having (see here for more). 

People who aren’t me have full blown degrees in exactly how this mix works. These people are called anesthesiologists (doctor version) or anesthetists (nurse version) and work with, but independently from, the people performing the surgical procedure (at least in the USA, I don’t know about elsewhere). They are in charge of keeping the patient unconscious but alive throughout the procedure, and control the patient’s airway (i.e., perform the intubation/extubation procedures). 

One or more of these drugs can paralyze muscles needed for breathing, making artificial respiration (in this case an endotracheal tube (ETT) and ventilator) necessary (though a lot of the time it’s just convenient to be able to completely control a patient’s breathing during the surgery). Patients shouldn’t be extubated after surgery until they are fully capable of breathing on their own, and this is often after they “wake up.”

Part 2. Would it harm/hurt the person? 

I mean, it probably wouldn’t be comfy…

Most likely, the tube for intubation during surgery is a full endotracheal tube (though there are other kinds), which enters all the way down to the trachea, and is held in place by a balloon (the wider part by the “c” in the diagram): 

The balloon is inflated when the ETT is placed and needs to be deflated prior to the tube being removed. Honestly, though, people have pulled out ETTs on their own without deflating the balloon, and while not recommended (and easily avoided), damage is minimal. Your character would probably experience discomfort from a rough extubation where the balloon was properly deflated, and pain/a brief suffocating feeling if the tube was yanked out without deflating the balloon, but there would be no lasting damage. As long as the character could breathe on their own after being extubated, they should be fine.