Polite Dissent

War Games, Act One, parts 1-8
Detective Comics #797, Batman: Legends of the Dark Knight #182, Nightwing #96, Batman: Gotham Knights #56 , Robin #129, Batgirl #55, Catwoman #34, Batman #631

In War Games, a meeting between gang bosses has gone awry and the various gangs are hunting each other across the streets of Gotham City. The first five issues of the series were good, building momentum that lasted through Robin. Unfortunately, the story momentum faltered during the Batgirl and Catwoman issues, and by the time the story returned to the high school siege in the final part, it was almost too late to salvage the storyline.

Given the gang war scenario, much of the Act One storyline dealt at least indirectly with medical care ( and trauma care in particular).

Realizing the potential scale of the medical needs of the gang war (Detective Comics #797), Dr. Leslie Thompkins tells her assistants to call in all her favors and order “all the plasma and whole blood anyone can supply”.

• Having extra blood on hand makes good sense, but whole blood is rarely used when packed red blood cells are available. Fluid overload is a significant concern with whole blood and there is a greater chance of transfusion reactions when whole blood is given. Packed red cells are the best choice.
• I know I’ve said this before, but I’ll say it again: plasma is not used for traumas; its use is limited to patients with clotting disorders.
• On the positive side, it’s nice to see that at least one penciler (Pete Woods, in this case) knows how to draw a nasal cannula correctly.

Later, when Nightwing visits the Thompkins clinic (in Nightwing #96), this bizarre exchange occurs:

Nurse: “Dr. Thompkins, we’ve got four new penetrating traumas and we’re out of cervical collars.”
Dr. Thompkins: “Exsanguinated?”

Exsanguinated is the past tense of exsanguinate, which means to drain of blood. So Dr. Thompkins is asking if the patients were drained of blood. Since this isn’t a vampire flick, that really doesn’t make any sense. I can see her asking if they are bleeding or were bleeding (especially given the penetrating trauma), but not if they were drained of blood. I chalk this one up to the writer (Devin Grayson) incorrectly using a big medical-sounding word. (Or maybe the vampire crime family from Bite Club has moved to Gotham City.)

In Robin #129, Tim Drake and his friends are caught in the crossfire when several different gangs try to abduct their classmate Darla.

• When his friend Jimmy is shot in the leg, Tim correctly tells a bystander how to place direct pressure on the wound to stop the bleeding. He reassures Jimmy, though he should have been more concerned about the fact that he was slipping into shock (“Tim? I feel cold.”).
• Tim does an excellent job of calming potential panic among bystanders and directing them to call 911.
• Later in the issue when Darla is shot, Tim immediately begins performing CPR on her. He is using the correct ratio of 15 compressions to 2 breaths. However, his first concern should be whether Darla even needs CPR. She was shot in the right shoulder/upper back. Based on anatomy, she may have a lacerated subclavian artery (and/or subclavian vein) and a lung injury. The heart was not injured, so the only reason it would stop beating would be lack of blood. Tim needs to stop Darla’s bleeding first and then worry about rescue breathing and chest compressions.

In Catwoman #24, a neighborhood child is shot and Selina brings the patient in to Dr. Thompkins. Thompkins chides her about moving the injured child. As a general rule, it is best not to move an injured patient. If the spine or spinal cord is injured, moving the patient has a chance of worsening the injury. In some other situations (such as a pelvic fracture), moving the patient may increase the bleeding. There are certainly occasions where the patient needs to be moved immediately (a burning car or building, for instance), but this doesn’t seem to be one of them. On the other hand, it’s never mentioned where the child was shot, so it may have been safe to move him after all.

Finally, in the conclusion to War Games Act One (Batman #631), Tim has managed to move Darla to the nurse’s office where the nurse is putting direct pressure on the still bleeding wound (no CPR this time – good!). If Darla’s still bleeding that bad after all this time, it’s definitely not a good sign. According to the nurse she keeps slipping in and out of consciousness which is consistent with shock and the amount of blood she’s lost. It’s really no surpires when she ends up dying of her wound.