This is another in a series of articles that explore some of the medical myths and errors that have been perpetuated in fiction, both in prose and on screen. Our guiding principle is that getting the facts correct should be a fundamental rule for all aspects of writing fiction. Chekhov’s rule could be updated to say that if a loaded gun is introduced in Act 1, it should be established as having the appropriate model and caliber before it must be fired in the next act, lest the knowledgeable reader or critic take the author to task. So, too, if an injury or medical condition is mentioned within a tale, then the symptoms, signs, and treatment of that condition should be reasonably and accurately depicted.
These essays collectively form a medical primer through which writers may learn common pitfalls to avoid, and all readers may realize that certain things they’ve always believed about the human body simply aren’t true. A writer may seek to gain specific background knowledge that is central to the plot or setting of a planned story but may not realize that additional background knowledge is needed. In adult learning, “perceived needs” are what you know that you need to learn, whereas “unperceived needs” are things you should know but don’t realize it. Donald Rumsfeld might call these the “known unknowns” and “unknown unknowns.” The “unperceived needs” are the most challenging because if you don’t know what you need to know, how and when will you learn it?
We take a light-hearted approach in these essays in order to make the reading as enjoyable as possible. Our intent is not to ridicule or offend anyone. Instead, we want to educate by using illustrative examples from published works that we have recently read or been reminded about. Our main message is that an author’s background research should include double-checking significant medical/surgical facts for plausibility and correctness. Relying on the Internet or Hollywood depictions may lead to perpetuation of myths and errors, whereas running it by a physician with expertise in that area may rescue the author from potential embarrassment. The author should avoid an unintended “WTF?” moment that throws the reader or viewer out of the story.
Confusing hearts with brains
Ancient philosophers argued as to whether the heart or the brain is the seat of consciousness, but we shouldn’t have trouble distinguishing these two organs or their function in the present day. Even in The Wizard of Oz, the Tin Man wanted a heart while the Scarecrow knew that he needed a brain instead. But in Joe Hill’s NOS4A2 (NOS4R2 in the UK), hearts and brains have been confused.
The first problem occurs in the opening pages of the novel. A series of tests confirm that the villain, Charlie Manx, is deeply unconscious or in a coma. “The doctor ... bent to shine a flashlight in Manx’s eyes. His pupils did not dilate.” His eyes also do not blink in response to a loud sound. They run an EKG and determine from it that “There’s nothing here that’s any different from any of the last dozen EKG readings. Patient scores a nine on the Glasgow scale [a measure of the depth of coma], shows slow alpha-wave activity consistent with alpha coma.” The doctor disparagingly concludes that Manx is “a gork,” meaning that he is in a vegetative state with reduced brain function. But he is breathing unaided and, therefore, is not brain dead.
Unfortunately, the specific use of EKG is a hilarious error because an EKG assesses the heart and not the brain. EKG is an abbreviation for electrocardiogram, a read-out of the electrical rhythm of the heart. Sticky pads fix electrodes to specific areas around the heart and elsewhere on the body, and a characteristic spiking rhythm appears with each electrical impulse that induces heart muscle contractions. A standard EKG consists of a single page readout of the viewpoints obtained from twelve different electrodes during twelve seconds of elapsed time. From this it can be determined if a patient is currently experiencing a heart attack or had one in the past, while an abnormal heart rhythm or the propensity to develop one can also be identified. A standard EKG is a little different from a heart rhythm monitor, a familiar sight and sound from motion picture and television dramas that depict someone in an intensive care or coronary care unit. (ICU or CCU) Fewer electrodes are used to continuously monitor the heart rhythm in those situations. The monitor beeps with each spike in the electrical rhythm, and alarms will sound if an abnormal rhythm appears or the electrical activity ceases. (Occasionally such heart rhythms are heard or seen to be still actively marching along despite the character being dead, but that’s a specific problem about medical errors on-screen.)
Joe Hill should have had that doctor obtain an EEG or electroencephalogram. What a difference a single letter makes! In this procedure, 10 to 20 different electrodes are placed on the scalp, and a readout of electrical potentials in the brain appears. The test typically lasts 1–2 hours but can also be set up to last several days. There are characteristic changes that occur during or after seizures, and with brain tumors, Huntington’s disease, other neurological disorders, normal sleep, and coma. The doctor in NOS4A2/NOS4R2 describes a slow alpha rhythm and correctly states that it’s consistent with a coma, but he used a heart readout (EKG) to measure brain activity!
The logical abbreviation for electrocardiogram would be ECG, but when said aloud ECG and EEG sound so similar that confusion has resulted over which test the doctor actually ordered. For this reason many hospitals have substituted the abbreviation EKG (from the German elektrokardiogramm) to better distinguish the two. But unfortunately Joe Hill confused EEG and EKG, and none of his copy editors noticed the mistake: the error persists in the hardcover, limited editions, paperbacks, and electronic editions of NOS4A2 and NOS4R2.
A second confusion over hearts and brains occurs later in Hill’s novel. The character of Lou Carmody is at high risk for vascular disease because he is morbidly obese and likely has high cholesterol, hypertension, and diabetes. He develops severe, disabling symptoms, but it’s confusing as to whether Hill intended for Lou to experience a heart attack (in which a portion of heart muscle dies from lack of blood flow) or a stroke (in which a portion of the brain dies from lack of blood flow). Admittedly, Lou’s obesity puts him at risk for both problems, but the symptoms of heart attack and stroke are quite distinct. When first afflicted, “He found himself grabbing at his chest, the pain there suddenly doubling, jabbing at him with sharp edges. It was as if someone had fired a staple gun into one tit.” Lou collapses to the floor and passes out. This description is consistent with a heart attack, although a duller, crushing, or squeezing chest pain is more typical.
When the symptoms recur, Hill describes Lou’s heart as beating very slowly and irregularly. “There was nothing for a long moment, and then his pulse whapped, a single big kick, and then another stillness, and then a flurry of rapid beats.” This is an abnormal heart rhythm that can occur as a result of a heart attack in progress or with angina (heart pain due to blood flow being transiently reduced to part of the heart muscle). Overall, all of these symptoms suggest that Lou has been having either a heart attack or severe angina. There have been no neurological symptoms (weakness on one side, numbness and tingling, confusion, trouble speaking) to suggest that he has been experiencing a stroke.
But the doctor tells Lou that he didn’t have a heart attack. Instead, he had a transient ischemic attack, “a kind of mini-stroke.” She describes “a hollow whoosh in your carotid artery ... what I’m hearing is serious plaque buildup.... You have to have an angioplasty. Possibly a stent. If you don’t receive one, you could suffer a major, even fatal stroke.” Lou is given an intravenous “blood-thinner” (likely heparin) in advance of having that angioplasty.
A transient ischemic attack (TIA) is similar to a stroke except that the symptoms disappear after minutes or hours, because the reduction in blood flow to part of the brain was only temporary. A narrowed carotid artery is where a small blood clot or bit of plaque can break off to cause that TIA, and it is a warning that a larger piece may break off later to cause a permanent stroke. An angioplasty uses a balloon to expand the narrowed carotid artery, after which a tube (stent) may be left in place to help prevent the artery from narrowing again.
And so Hill intended Lou to be having the symptoms of a stroke or TIA, but he described the symptoms of a heart attack instead. And he used an EKG where an EEG was intended. The example of NOS4A2 / NOS4R2 reaffirms that when describing the symptoms, diagnosis, and treatment of common medical conditions such as heart attacks and strokes, it is important that the information be consistent and correct.
Which side is my heart on?
A chest x-ray shows the white silhouettes of the ribs and backbone contrasted against the black emptiness of normal lungs. The heart forms a white, boot-shaped silhouette, positioned largely in the left side of the chest. A chest x-ray is properly viewed as if the patient is facing toward you, which means that the patient’s heart will be pointing to your right. A large R and L are normally placed on the image to confirm which are the patient’s right and left sides. There are limits to what can be determined from a chest x-ray. A shadow or spot on the lung suggests such things as a lung tumor or inhaled foreign body; an enlarged heart can be seen; fluffy infiltrates appear in the lungs with pneumonia or heart failure; and fractures may be seen in the ribs or back.
These radiographs are a common staple of medical scenes in movies, and more people are likely to have seen them there rather than in a doctor’s office or hospital. Unfortunately, the chest x-rays are often shown backwards in movies. Is this a 50–50 chance error made through ignorance, or is it a deliberate inside joke, a thumbing of the nose to knowledgeable viewers? We think that the practice reached an extreme in the 1960 film Ocean’s Eleven. An upside down and backwards chest x-ray is framed prominently in a key scene early in the movie. The medical specialist dramatically turns off the light illuminating the chest x-ray just as Richard Conte’s character says:
“Give it to me straight, Doc.... Is it the big casino?”
“I can’t tell until I see the biopsy report, but ... “
“What if the report says it is? How long?”
“Well, I ... “
“How long, Doc?”
A crescendo of ominous music tells us that this character doesn’t have long to live. And indeed he doesn’t. His partners in crime later use his coffin to hold not only his body but the money they’ve heisted from the casinos.
But it isn’t possible to determine the diagnosis or prognosis from a chest x-ray, unless it’s an extreme situation, such as a patient coughing up blood whose lungs are obviously riddled with tumors on the chest x-ray. A biopsy—a tissue sample from the tumor—is needed to determine if a spot seen on a chest x-ray is a cancer and exactly what type, and more extensive tests (such as CT or MRI scans in modern practice) are used to determine where the cancer has spread to and what the prognosis might be. What’s especially funny about Ocean’s Eleven is that the chest x-ray is otherwise normal except for its upside-down-and-backwards positioning. We are to trust a fatal prognosis from a doctor who cannot read a normal chest x-ray? At the very least, the chest x-ray should have been abnormal, and the doctor should have described the results of a biopsy and not an x-ray alone.
Although the right-sided heart in movies is often an error due to backwards placement of the chest x-ray, occasionally the heart is positioned on the right side of the body in a condition called dextrocardia. In some of these patients, all of the internal organs and blood vessels are mirrored to the opposite side of normal, a condition called situs inversus. For example, the appendix and liver will be on the left side instead of the right. This condition isn’t completely benign because in cases of partial situ inversus only some of the internal organs are mirrored, which means that certain blood vessels or the bowels may be critically kinked at the site of right-left inversion. Patients with complete situs inversus are also more likely to have infertility and a severe form of lung disease.
Roger Zelazny described situs inversus in his amusing novel Doorways in the Sand. In this case, Fred Cassidy develops it after he passes through an extraterrestrial device that inverts objects into their mirror images. Zelazny has the surgeon correctly describe the consequences:
“... you are a very lucky man. You were shot in the chest, you know.”
“I had sort of figured that out myself.”
“Anyone else would probably be dead as a result. But not good old Fred Cassidy. Do you know why not?”
“Your heart is in the wrong place.”
“Have you actually gotten this far along in life without becoming aware of the peculiar anatomy of your circulatory system?”
“Not exactly,” I said. “But then, I’ve never been shot in the chest before, either.”
“Well, your heart is a mirror image of an average, garden-variety heart. The vena cavae feed from the left and the pulmonary artery receives the blood from your left ventricle. Your pulmonary veins take the fresh blood to the right auricle, and the right ventricle pumps it through an aortic arch that swings over to the right. The right chambers of your heart consequently have the thickwalled development other people have on the left side. Now, anyone else shot in the same place you were would probably have been hit in the left ventricle, or possibly the aorta. In your case, though, the bullet went harmlessly past the inferior vena cava.”
I coughed again.
“Well, relatively harmlessly,” he amended. “There is still a hole, of course. I’ve patched it neatly, though. You should be back on your feet in no time.”
The only problem with this scene is that Zelazny describes the surgeon as being so excited about a rare discovery that he is eager to publish a report describing Cassidy’s state. Zelazny may not have known that this is a real condition. In reality, dextrocardia and situs inversus are uncommon but not so rare as to warrant a publication to describe each individual patient. However, affected patients become trick questions during live examinations for medical students and residents. They will struggle to feel and hear the heart on the left side of the chest, and fail the exam if they claim that everything was normal. An “Aha!” moment occurs for a student who, after some puzzled exploration, reaches for the right side of the chest.
Blood pressure during sexual excitement
Two values are obtained when your blood pressure is measured. The peak (systolic) level of pressure occurs when the contracting heart forces blood forward, and the lower (diastolic) level of pressure occurs while the heart is resting between contractions. Normally the systolic pressure is about 100–120 mm Hg in healthy individuals, whereas the diastolic may be 60–80 mm Hg. And so a normal reading can be described as 120/80, 110/70, etc.
High blood pressure means that the systolic, diastolic, or both pressure levels are increased above normal values. An untreated hypertensive person might have a blood pressure such as 150/90 or 180/100, for example. Extremely high levels such as 200/100 and 300/200 can occur. Chronically high blood pressure stresses the heart and the walls of the blood vessels and becomes a cause of heart attacks, strokes, and death. Extremely high blood pressure is a medical emergency.
Conversely, lower levels of blood pressure such as 90/40 may still be normal. However, in most cases, a systolic pressure less than 100 results in someone feeling lightheaded and dizzy or passing out. This is especially true in someone accustomed to normal or high blood pressure; a value of 90/40 or lower is not enough to sustain normal blood flow to the brain.
During sexual arousal in men and women, the heart rate increases, the heart contracts more forcefully, arteries constrict, and blood pressure rises significantly. The highest level of pressure is reached during the plateau phase before orgasm, while the fastest heart rate occurs at the onset of orgasm (Xue-Rui, et al.). After orgasm, blood vessels rapidly dilate, heart rate slows, and blood pressure falls. Dilating blood vessels and the fall in blood pressure contribute to the post-coital headache and lethargy that affect some individuals.
With all that aside, in Dan Simmons’s compelling tale “Dying in Bangkok,” the narrator, Merrick, details what is happening to a sexually aroused man who is approaching climax:
Now, after years of experience as a physician, I know precisely what was occurring ... If I’d been taking his pulse, I would have found his heart rate climbing to somewhere between a hundred and a hundred and seventy-five beats per minute. His systolic pressure shot up to somewhere close to 80 mm Hg while his diastolic elevated to 40 mm Hg or higher.
Notably, Simmons describes the blood pressure as “shooting up” to 80 systolic, which implies that it was previously much lower. This is another laughable error for anyone familiar with normal blood pressure values. If readings of 150/90 had been mentioned, that would have been more realistic. Nor was Simmons referring to blood pressure in the penis, which is normally about the same as in the rest of the body but rises much higher during an erection (Engel, Burnham, and Carter). The error is underscored by the narrator’s emphasis that he is an experienced physician. And why would a physician have years of experience measuring blood pressure in patients during sexual arousal anyway?
It’s puzzling that this error has appeared in all editions that we could find, including the first appearance of the complete story in the collection Lovedeath from Warner and its recent limited edition rerelease from Subterranean Press. Is this simply Simmons’s medical error that every copy editor and proofreader has failed to notice? Or could it be a deliberate error, a clue that we are dealing with an unreliable narrator that we would encounter in a story by Gene Wolfe?
Under certain circumstances, blood pressure could conceivably become lower during sexual arousal. Urban legend has it that porn star John Holmes was so well-endowed that he could not become fully erect lest his erection cause him to lose consciousness. But others claim that he was simultaneously fully erect and conscious in his earlier films. We don’t know whether anyone ever measured the blood pressure in any of his five limbs during these on-screen exertions. But low blood pressure can occur during sexual arousal as a result of medications used to treat erectile dysfunction. These medications dilate the arteries within the penis to allow it to become engorged with blood, but arteries in the rest of the body can also become dilated instead of contracting as they normally should during sexual arousal, and that will cause the pressure to fall. The risk of low blood pressure is greatest in patients who are also taking certain prescription medications that interact with drugs used to treat erectile dysfunction. But neither of these scenarios can explain Simmons’s description of blood pressure that “shot up to ... 80 mm Hg” in a man approaching orgasm.
Driving nasal cartilage into the brain
How many times have we seen or read about the fictional martial arts expert who adeptly kills an assailant by driving nasal cartilages or bone into the brain? Here are a few samples:
Ramez Naam, Nexus: “Kade’s body came all the way around, free hand lashing out in a palm heel strike to break Nakamura’s nose and drive the shattered fragments into his brain.”
Richard Morgan, Altered Carbon: “I needed to see to stop me reaching across the cab and smashing her nose bone up into her brain with one stiffened hand.”
Orson Scott Card, Ender’s Game: “I remembered the way he looked after I jammed his face with my head. I think I must have pushed his nose back into his brain.... I think he was dead right then.”
Some authors have their martial arts expert authoritatively claim that it is a two-stage assault. First, a downward or sideways blow to break the nose, and a second upward strike with the stiffened palm to drive the fragments of cartilage into the brain.
This is nonsense. Nasal cartilage is a soft tissue compared to bone. Driving it through the skull would be the equivalent of saying that you’re going to punch a plastic credit card through a brick wall.
But wait, some will say, the very base of the nose is bone, we can see it on a human skull. It’s that bone that our character will dislodge with the first strike and drive into the brain with the second strike.
This is still nonsense. The nasal bone is a thin, short sliver compared to the thick skull that lies between it and the base of the brain. Viewing a cross section of a skull makes this clear. Driving the short nasal bones through the skull would be the equivalent of saying that you’re going to punch a short, thin fragment of brick through the greater depth of a solid brick wall. It can’t be done. A punch doesn’t turn that fragment of bone into a propelled missile. If it could happen, a lot of boxers would have died in the ring from noses penetrating their brains.
However, a significant blow to the head in that region can certainly kill a person. A skull fracture, a brain contusion, a hemorrhage within the brain, the impact of the stunned victim’s head striking the floor—all of these are potential serious consequences of any significant blow to the head. But these deaths don’t require a fanciful penetrating wound from the nose. The next time you see or read about a character punching the nose into the brain, your proper response should be to laugh at the absurdity.
Awakening after surgery
Many readers will have seen that their loved one is drowsy and confused upon awakening from surgery. The patient may seem to rouse, ask questions (“Is it over?” “What did the surgeon say?”), and then drift off again. Upon awakening later, the patient repeats the same questions, and prior conversations or visits are not remembered. The patient may hallucinate and have vivid dreams. The combination of anesthesia, age, surgical pain, shock, analgesic medication, and stress responses to surgery contribute to the patient not being coherent for hours or even into the next day or two after routine surgery. For major surgery such as open heart surgery, the duration of unconsciousness and confusion can be much longer. This results from such factors as the severity of the surgery, the use of cardiac bypass machines, temporary stopping of the heart, and the deliberate use of medication to keep the patient unconscious during the early hours or days post-op. If it is emergency surgery in the setting of severe shock and significant blood loss (such as after a stabbing or gunshot wound to the chest), the brain may be stunned from prolonged hypoxia and low blood pressure, and the mental downtime afterwards will last far longer. If the heart stopped for a time before or during surgery, consciousness and normal mental functioning take even longer to be restored.
Whenever a patient undergoes general anesthesia for surgery, the muscles of breathing are paralyzed, and a breathing tube is placed and connected to a ventilator. Without this, the patient would die from the inability to breathe. That tube won’t be removed until the patient is conscious enough to breathe unaided and able to protect the airway by coughing. After routine surgery, the breathing tube is usually removed in the operating room. But after open heart surgery, the breathing tube may remain in place for twelve hours or longer, during which the patient is monitored in an ICU because the combination of chest tubes, split and stapled sternum, pain, and analgesics all make it difficult for the person to be awake and breathe unaided.
So many novels and movies get these post-operative scenarios wrong. In one recent sf thriller, the U.S. president is shot in the chest, suffers massive blood loss, and his heart stops for a prolonged interval on the operating table. He is effectively dead. The surgeon cracks his chest open and uses his hands to massage the heart to mimic contractions—a power outage further complicates the scene—but he eventually saves the president. It is a heroic and dramatic set of scenes. Amazingly, the president is deliberately awakened within an hour or two to answer questions, give orders, and spend a half hour on the phone with his chief of staff and then with his science advisor. His throat is bone-dry upon awakening (no breathing tube in place), he doesn’t describe experiencing any chest pain, he’s not in an ICU, there are no chest tubes in place, but he does have an intravenous going into his left arm. It’s quite an unbelievable set of scenes from the medical viewpoint.
Compare this to the more realistic and accurate outcome in Spider Robinson’s light-hearted Lady Slings the Booze (1992). The narrator, private dick Joe Quigley, is stabbed with a knife and falls unconscious. When he awakens, he doesn’t recall prior visits and conversations with Lady Sally and others over the several days that have elapsed since his emergency surgery. He’s in pain and also indignant about what he perceives to be their lack of concern over his recovery. “I’ve been out of surgery three days now. About time you came by for a visit.” But Lady Sally understands perfectly what has happened: the pain medication (morphine) prevented him from laying down new memories. “You were making memories, you simply weren’t saving any. Like a RAM disk in a computer: every time you cut power by going to sleep, all the data vanished.” That’s a realistic outcome from a stabbing and post-operative use of morphine to control pain, and it reads almost as if Spider Robinson were lecturing the reader from his own post-operative experience. Had Joe Quigley been shot in the chest and experienced massive blood loss, chest cracked open, and heart stopped for a prolonged interval, we expect that Robinson would have known to describe Quigley as being mentally out of it for days on end and in far more discomfort.
Medical errors in Sherlock
Television may take more liberties with the medical truth than written fiction. One has only to watch an evening’s worth of “medical dramas” to list the inaccuracies: tests that take days or weeks are completed in minutes; highly skilled clinicians are suddenly able to perform procedures far outside their area of expertise; rare and usually fatal conditions are cured without experts; invariably victims survive CPR when the real-life likelihood is close to nil; and the list goes on. All this is accomplished while looking perfectly coiffed, made up, and tottering in high heels. Real life it is not.
The BBC series Sherlock generally pays close attention to getting the facts right or at least as right as possible within the confines of the story. Corpses look like real dead bodies with attention paid to wounds, pallor, and blood pooling. The acting is superb, and the actors correctly portray how a person with certain medical conditions would behave. The scene where Sherlock diagnoses his own internal bleeding while arbitrating Mary and John’s domestic dispute is a master class. However, there are two recent instances where the medical facts just don’t fit the story, and because the arc of the tale depends quite heavily on these key issues, more care should have been taken by the writers.
In “The Sign of Three,” a would-be murderer plans what should be the perfect locked-room crime: a man stabbed to death who (a) didn’t realize he’d been stabbed and (b) suddenly bleeds to death hours later, long after the murderer has scarpered. The murderer does a practice attempt in broad daylight on a young private in Her Majesty’s Household Guard. Sherlock and Dr. John Watson serendipitously save this victim while they are investigating what they believe is an unrelated case. The true intended victim, Major James Sholto, John’s former commanding officer, is invited to Watson’s wedding. While in full view acting as the wedding photographer, the would-be murderer stabs Sholto in the back with a thin, stiletto-like blade through a heavy, tight fitting belt and formal military uniform, and Sholto doesn’t notice. Hours later and with seconds to spare, Sherlock realizes that if Sholto removes his belt, the release of pressure on the wound will be like releasing the cork from a champagne bottle, resulting in massive external bleeding and rapid death.
Several issues make this scenario highly improbable. Formidable force would be required to shove a thin blade through the thick, binding fabric of the belt, the thick regimental jacket, and the undergarments. The victim would notice and experience pain. Even if the force was disguised by a shove or heavy pat on the back, the victim would feel the piercing of the skin. Anyone who has ever pricked themselves with a sewing needle knows how painful that can be. Inserting an epidural needle in the back requires that the skin be anesthetized first. Even micro-thin acupuncture needles are often felt. The blade would need to be thick and strong enough not to bend. It would have to travel sufficient distance to pierce a blood vessel that could cause significant bleeding. Anatomical variations from person to person mean that the location of the target can’t be certain. If a significant blood vessel were torn and bled and pressure from the belt prevented the expulsion of blood through the entry wound, internal bleeding would not be likewise restricted. The victim would hemorrhage inside and show rapid symptoms of decline. Furthermore, if the belt’s pressure prevented external bleeding, it would also enable the wound to clot and be sealed. Removing the belt simply couldn’t create a source of sudden, massive bleeding hours later and only along the track from the piercing as portrayed in the practice victim. For an “unnoticed” murder, this method just doesn’t really work.
A worse situation occurs in “His Last Vow.” Watson’s fiancée, Mary, shoots Sherlock in the chest a couple of inches below the nipple and slightly to the right of the midline (sternum). The ensuing stages of falling, shock, and pain are portrayed correctly. Sherlock becomes clinically dead for some minutes. The sequence where Sherlock restarts his own heart by merely commanding it is a fantasy sequence; this cannot happen in real life. The surgical suite is lacking in equipment and personnel (where are the nurses?), but again, this could be attributed to fantasy or the limits of a BBC budget. Where the show gets it flagrantly wrong is Sherlock’s conclusion that Mary shot him with surgical precision because she only wanted to knock him out, not kill him. It is a ridiculous justification to excuse a terrible action by someone Sherlock knows and loves.
Bullet wounds to the chest are very serious. Major blood vessels can be torn to cause massive hemorrhage, and a lung can be collapsed and by itself lead to death. Looking carefully at the anatomy of the chest, the site of this bullet entry is not a safe area. There are major vessels lying along the midline, extremely close to the point of entry. The right border of the heart is an inch or so to the left. Depending upon whether Sherlock is breathing in or out at the time he is hit, the right lung or liver is most likely to be pierced. Both can cause major blood loss, the lung can collapse, and the lung can overinflate (tension pneumothorax) to squeeze the heart and stop all blood flow. Ribs and vertebrae can deflect and alter a bullet’s path, and Mary couldn’t see Sherlock’s ribs through his suit. The heart or vena cava may be hit. The firing of a bullet cannot be so precise as to be called “surgery” in the way Sherlock defends it. Shooting him directly in the heart would be the more absolute way of killing him; conversely, the location of the shot slightly to the right of the heart was definitely not one that the shooter could be reassured would be nonfatal.
A chest shot is certainly more dramatic than a leg shot (although even shooting someone in the leg can be fatal), and drama was the key ingredient of this episode. However Sherlock’s deduction isn’t medically plausible and adds uncertainty to future episodes. Sherlock seems deluded and overly trusting, and the shooter may or may not try again. Delicious stuff.
Unethical clinical research
In “Walking Gear” by Sean Monaghan (Asimov’s, March 2014), the protagonist works for a biotechnology company that has used alien technology to develop a prototype for biologically engineered limb replacements. The efficacy of the limbs is being tested in a controlled clinical study that is mandatory before the FDA can approve them for routine use in patients. He searches for his sister, a “low rent hooker” who lost a leg years ago in an accident. He feels guilty about her injury and plans to convince her to have this experimental procedure done. She doesn’t qualify for the study for a number of reasons, including her serious multidrug addictions and the effects that these have had on her liver and other body systems. He coerces her to enroll and covertly brings her in the back door of the research center during the night. The study protocol and regulations are violated in order to enroll her: necessary preparatory blood tests and investigations are not done. Data are faked in order to make it appear that she qualifies and to hide the evidence of her drug addiction. A research colleague adds other experimental treatments for the drug addiction that aren’t part of the experimental protocol and does so without the patient being aware or consenting to it. The entire sequence of events is rushed in order to examine the aftermath of the limb replacement on the patient and her interpersonal relationships with her brother, estranged father, and new girlfriend.
The plot ludicrously violates crucial aspects of how clinical testing of medical treatments and technologies are regulated and perpetuates myths that biotech companies, pharmaceutical companies, and doctors willfully experiment on patients without their knowledge. Human experimentation was supposed to have been eliminated with the Geneva Convention in 1949, and numerous international and national regulations and practices have been developed and enforced to ensure that clinical studies are ethically done and carried out according to a rigorous protocol. Study protocols have to be approved by the FDA in the USA before they can begin, and detailed records must be kept of study procedures and results. Study participants must give voluntary, informed consent, meet all entry criteria and none of the exclusion criteria, and comply with the study procedures. The researchers must collect the data accurately and in a manner that prevents fabrication of results. The records of every study participant are periodically inspected during the trial to ensure that everything is being done appropriately, while the FDA and other monitoring agencies perform additional random audits. Importantly, a researcher cannot simply hurry someone into a clinical trial and bypass all the entry criteria and enrollment procedures, which the author refers to as “FDA bull” in this story. It wasn’t necessary to the plot for the author to perpetuate this offensive myth about how medical research is conducted.
A major error in blood types
Blood can be typed in a number of ways to ensure that a patient doesn’t receive an incompatible variety that causes a widespread and life-threatening transfusion reaction. The basic blood types O, A, B, and AB are determined by the presence or absence of A and B antigens (proteins) on red blood cells. Type O individuals lack both antigens and may produce antibodies to A and B. Type AB expresses both antigens and will have no antibodies to either A or B. Types A and B express one antigen and may have antibodies to the other antigen. Type O is usually the most common blood type while AB is the least common. Type O is termed the “universal donor” because it lacks both antigens; therefore, anyone can receive that blood type safely. Conversely, type AB is called the “universal recipient” because that person will lack antibodies to A or B and can receive any of these blood types.
If someone receives an incompatible blood type, a transfusion reaction occurs. This most often happens if a type O person receives any of the other three blood types. This will cause fever, chills, blood oozing from puncture sites, and hemoglobin appearing in the urine. It is a life-threatening condition that can also cause irreversible kidney damage. The affected person’s blood may appear pink rather than red due to rapid destruction of red blood cells. The transfusion reaction also causes the clotting factors to be rapidly consumed; consequently, blood cannot clot and this leads to it oozing out of the body.
There are other ways that blood can be further subtyped, including the presence or absence of Rh, Lewis, Kell, Kidd, and Duffy antigens (Kleinman). Most of these are detected by testing a sample of the recipient’s blood against potential donor blood (“cross-matching”). The Duffy antigen is of particular interest to what follows in the story we will cite. It is a receptor or channel that enables the parasite Plasmodium vivax to invade red blood cells and cause malaria. Conversely, people who lack the Duffy antigen are relatively resistant to P. vivax. This protective effect of the absence of Duffy antigen has led to the Duffy null blood type having very high prevalence in black populations where P. vivax is endemic; it is in about 70 percent of blacks globally regardless of where they reside. Conversely, the Duffy null phenotype is extremely rare in Caucasians and other ethnicities (Dean; Kleinman).
“Dolores, Big and Strong” by Joe M. McDermott (Asimov’s, April/May 2014) features June, a young woman who is described as having the very rare Duffy blood type. She frequently has to access a plastic shunt in her arm to transfuse her blood into Dolores, who is her mother’s stepmother. Dolores has the same rare Duffy blood type. Through these blood transfusions, June helps maintain a protective effect against the development and progression of Parkinson’s and Alzheimer’s diseases in Dolores. In the story’s climax, June deliberately kills a drug dealer by infusing a pint of her blood into his circulation through an intravenous line, thereby prompting a rapidly fatal transfusion reaction in him.
There are major problems that completely invalidate the scenario described by the author and derail the plot. The errors begin with the author’s confusion over the difference between arteries and veins. Arteries transport blood under high pressure from the heart, whereas veins carry blood back to the heart slowly, passively, and under lower pressure. Connecting two veins together would not result in substantial blood flow from one person to another; instead, an artery in one person needs to be connected to a vein in the recipient for this scenario to work. A shunt in a dialysis patient connects an artery to a vein so that there is high pressure. But the author describes the shunt as a plastic tube placed into a vein and which has “an in and an out” to connect it to another person.
The genetics are wrong because the Duffy null blood type is a recessive condition and extremely rare in Caucasians and non-African ethnicities. It cannot be expected to occur in June and her step-grandmother unless they are closely related by inbreeding. But June is brown-skinned from mixed ethnicity (“Hispanic and Asian and Indian”) and definitely unrelated to Dolores who is “as Caucasian-looking as anyone of such old New York bloodlines.” For these two non-African and genetically unrelated family members to share this blood type has odds approaching that of winning a lottery.
A transfusion reaction doesn’t look like what the author described: “his body was turning purple like a bruise from where the blood was clotting along his arm.” When there is incompatibility due to Duffy blood types, any reaction is more likely to be a delayed and mild to moderate, rather than the depicted immediate reaction that kills the drug pusher within a few minutes.
Most importantly, a fatal error in the plot is that the rare Duffy null blood type cannot cause transfusion reactions at all, because it does not contain any Duffy antigens. Duffy null blood is similar to the type O “universal donor” blood type, because it can be given to people regardless of their Duffy blood types. Instead, it is a person with the rare Duffy null phenotype who is at risk of developing a transfusion reaction when receiving blood that contains the common Duffy antigens. This means that June could have a transfusion reaction by receiving the pusher’s blood, but she cannot induce a transfusion reaction in him.
Furthermore, and relevant to a key aspect of the plot, the Duffy antigen is not known to have anything to do with the pathogenesis of Parkinson’s or Alzheimer’s diseases. These are not “diseases of the blood” as the author suggests. If the author is granted the “just suppose” science fictional proposition that the Duffy null blood type does somehow protect against these diseases, it remains unclear why June has to do these transfusions when Dolores produces the same Duffy null blood herself. How is June’s blood “stronger” than Dolores’s when the red blood cells in both individuals lack the same protein?
This story reads as if the author knew only that there was a Duffy blood type, but none of its features or implications beyond that it somehow protected against malaria and thereby might protect against other things. The author also confused the ABO blood typing with Duffy typing as if it’s an either-or situation: “My mom was a B. Her mom was a B. Dolores was a rare type called Duffy, and so was I.” But depending upon her father’s blood type, June could be O, A, B, or AB, and that has nothing to do with what her Duffy blood type is! The Duffy null blood type has the opposite and milder effects in a transfusion reaction from what the author proposed and cannot explain the events of the story.
We note with interest that in the July 2014 issue of Locus, Gardner Dozois independently reached a similar conclusion, declaring that the story was “thinly rationalized as sf by a medical device that I don’t think could work the way that the story says it does.” Since this medical issue was central to the plot and the motivations of the main character, it was mandatory for the author to adequately research the topic. However, the information that the author did provide was completely erroneous.
Self-impregnation of a hermaphrodite
Intersex disorders are an area that has long been shrouded in myth, mystery, and misunderstanding. Until recent years, if a baby was born with ambiguous genitalia—meaning that neither a penis nor a vagina was clearly distinguishable—the default decision was often made to raise the baby as female. This was done for two main reasons. First, it is a psychological and emotional emergency for new parents to be able to identify their baby as male or female both to themselves and to their relatives and friends who await the news. The ominous pause in answering the standard delivery room question—”Is it a boy or a girl?”—is distressing for everyone, and the longer the delay before a definitive answer is available, the more upsetting the situation becomes. A birth certificate cannot be completed until the sex of rearing has been determined; it is very difficult to change that information at a later date. Second, it has always been technically easier to surgically correct the genitalia to look female and construct a vagina at a later age than to construct a functional penis out of available tissues.
However, long-term follow-up of affected intersex children has revealed that these urgent and well-intentioned decisions can lead to substantial psychological stresses and gender identity difficulties, as in a child raised as female who later self-identifies to be male. This occurs in part because sexual identity is not simply determined by genetic sex (classically XX vs. XY) but also by such factors as relative exposure of the brain to estrogen or testosterone during embryonic and fetal development and the influence of the chosen sex of rearing. In view of these problems and advances in surgical techniques that make it more feasible to construct a functional penis, the approach to the baby with ambiguous genitalia has changed (Moshiri, et al.). Sex assignment is now based on a number of factors including genetic sex (genotype); the presence, location, and appearance of reproductive organs; fertility potential; and the wishes, beliefs, and cultural background of the parents and family (ibid.). The goal is to achieve the closest possible match between the assigned sex of rearing and the anticipated gender identity. In some cases, it may be acceptable to delay decisions about gender assignment until the child is older and capable of choosing.
Among the intersex conditions, a hermaphrodite is a rare condition in which someone possesses both male and female sexual organs. What happens in these instances is that there is a testicle on one side of the body and an ovary on the other. The testicle produces testosterone and inhibitory factors that cause the development of a penis while suppressing the development of the uterus and vagina on that side. The ovary produces estrogens that permit the possible development of a partial uterus and vagina on the other side. The result may be a penis with a single testicle in or near the scrotum and a small vagina with a rudimentary uterus above it. In other cases there may be a penis but no vagina, or ambiguous genitalia without a recognizable penis or vagina. Puberty causes rising levels of testosterone from the testicle that will in turn induce the physiological changes that normally occur in adult males (beard growth, deepened voice, increased muscle mass, increased libido, aggressive behavior, etc.). The testicle may produce sperm, and so the individual may be fertile as a male. Conversely, the high levels of testosterone produced by the testicle typically suppress the development and function of the ovary, and so egg development, ovulation, and menstruation are completely inhibited.
With this as background, the recent novel Annabel by Kathleen Winter featured a child, Wayne, who was recognized at birth to be a hermaphrodite. The author explores gender identity disorder in which Wayne is raised as male but later has feminine characteristics emerge during puberty and chooses to become Annabel. In a controversial scene, she self-impregnates. As mentioned above, this is an impossible situation because human hermaphrodites do not produce eggs or ovulate. The author admitted that she “heard of a child who was born intersex” or “born with both genders” in a remote Newfoundland town and had the female side “hidden from him.” Winter was fascinated by this scenario and thought to tell a story about a child raised as male but for whom the feminine side emerges at puberty. She evidently did not do sufficient background research into intersex disorders and did not appreciate the impossibility of self-impregnation or that hormonal changes of puberty would increase male characteristics rather than induce emergence of female characteristics.
Does this error matter? It happens that the book was selected in 2014 as one of a select few novels for a nationally broadcast competition called Canada Reads. Actress Sarah Gadon nominated the book, and when challenged she defended the controversial scene by declaring it to be a “science fiction aspect” that was merely “a technicality” and not meant to be a “literal reading” or “not just a physical truth.” Instead, Gadon felt that the self-conception was “a metaphor of the collision between man and woman.” (cf. the two “Canada Reads” articles in the bibliography). However, the other panelists declared that the book does a “huge disservice” because of its “fundamentally confused views of the bodies of intersex people—misconceptions perpetuated in this book.” They felt that the “author didn’t do due diligence” by researching what it meant to be born intersex and whether self-conception was possible. The term “hermaphrodite” was also considered disparaging, but it was acknowledged that use of the term was appropriate for 1968 in which this fictional child was born.
And so the error did matter. The book featured prominently in the national award program but lost out in the semi-finals because of what other panelists considered to be a glaring error that perpetuated misconceptions about intersex adults. However, the novel was shortlisted for several other awards and did receive an award for best novel by an author from the Atlantic provinces.
Urban myths come to life
We’ve emphasized the importance of avoiding common mistakes and myths, to realize what is medical fact and what is fantasy or error. But occasionally an outlandish urban legend can have a real-life counterpart. Is virgin birth possible? Can a woman become pregnant after performing oral sex on a man? The answer to both questions is “of course not”—except that both scenarios did happen to one 15-year-old girl (Verkuyl).
Shortly after the young woman performed fellatio on her new boyfriend, a jealous former lover attacked the couple. In the ensuing knife fight, the girl was stabbed in the abdomen. Her stomach was punctured in two places, and urgent surgery was needed to repair the lacerations. The surgeon noted that the stomach was empty and washed the abdominal cavity with saline as a precaution to remove possible spillage of stomach contents. But 278 days later, the woman presented with acute abdominal pain and was discovered to be in labor. Further inspection revealed the surprising fact that she did not have a vagina, and so the baby had to be delivered by C-section. This was a real-life virgin birth! She had been unable to have sexual intercourse but became adept at oral sex in order to satisfy her boyfriends. She hadn’t eaten in hours before the oral sex and subsequent stabbing, and so the lack of stomach acid enabled the swallowed sperm to survive. The puncturing of her stomach spilled the semen into the peritoneal cavity, from where the sperm would have swum to her open fallopian tubes. The washings with saline may have helped the sperm surf to their destination.
This pregnancy must have occurred after the woman’s first or near-first ovulation. Otherwise the uterus and fallopian tubes would have become filled with old, inspissated menstrual blood that could not drain out.
A paternity test wasn’t done, but the man who’d received oral sex believed that he was the father, and everyone was reassured that the child by 2.5 years of age looked very much like him.
And so with two apparent medical myths realized by a series of incidents in one 15-year-old girl, the challenge is out there for an imaginative author to turn other medical myths into plausible and possibly amusing realities.
Minimal medical information is more than sufficient
In these essays, we don’t mean to imply that authors must provide a medical infodump to the reader. A few words can be more than enough to provide sufficient verisimilitude and accurate medical information without being intrusive or distracting. A good example of this is Neil Gaiman’s The Ocean at the End of the Lane, in which the unnamed narrator recalls a childhood memory of discovering a body in the back of the family’s car. “It looked a little like the opal miner.... its skin was very red. It looked like a parody of health.... A length of green garden hose ran from the exhaust pipe to the driver’s window. There was thick brown mud all over the exhaust, holding the hosepipe in place.” The child narrator cannot fully comprehend what he is seeing, but the information is sufficient for the reader to understand that the lodger died a suicide. Moreover, “very red” skin is remarked upon by the child but, appropriate for his age, its significance is not appreciated.
An apparition of the opal miner later haunts the child. “His face was still an alarming cherry-red, as if he had just spent too long on the beach.” Some readers might misinterpret this to mean that the man was sunburned, and that he had died during the daytime before his discovery the following morning. However, “very red” and “cherry-red” skin are specific indications of the cause of his death, something the child still does not understand.
Near the end of the novel the narrator, an adult once more, recalls the opal miner as he appeared prior to the suicide. “His face and arms were tan, not the cherry-red of monoxide poisoning.” Those added few words serve two purposes. First, for readers who did not yet appreciate it, they make clear that very red skin is a specific consequence of carbon monoxide poisoning. Carbon monoxide binds more tightly than oxygen to the hemoglobin within red blood cells, and that causes the blood to appear bright red even though it contains fatally low levels of oxygen. Second, and more importantly, the description distinguishes the child narrator—who observed without understanding—from the adult narrator who later appreciated what cherry-red skin signified. It is a reminder about how much the narrator’s perspective, knowledge, and understanding have changed from when these events were originally viewed through a child’s eyes. And this was all conveyed by the short but medically correct description of bright red skin.
Getting the needed amount of advice
The amount of medical advice that an author may require can be broad or limited depending upon how central the medical issue is to the character and the work.
If the main character is living with a chronic medical condition that significantly impacts daily activities (e.g., type 1 diabetes, post-traumatic stress disorder, blindness), then it may be illuminating to have a health care professional and an affected individual read a draft of the entire work. This not only enables errors to be corrected, but the advisors are likely to provide suggestions about how the medical disorder affects the person in ways that the author may not have considered. By adding additional but possibly subtle details, the affected character will become more realistic and convincing.
If there’s a short but important scene such as in a hospital emergency room or ambulance, it may be sufficient for a physician, nurse, or paramedic to read only that passage. Or sometimes the help needed from a medical specialist may be simple answers to specific questions, without the advisor needing to read any drafts. For his novel V-S Day, Allen Steele wanted an astronaut to die in a centrifuge during training. He emailed one of us to ask for advice about how that might realistically occur. A quick reply gave him a half-dozen plausible scenarios, from which he chose one that he liked.
Many health care professionals are likely to be flattered and happy to answer a writer’s medical questions, and if a short passage of material needs to be read, it is not likely to be considered a burden. Conversely, if an expert needs to read an entire novel-length manuscript, that’s a substantially greater time commitment that some may do in return for a simple acknowledgement in the book, while others may be expect to be paid for their efforts. And so it’s important for the inquiring author to determine in advance what the expert would want to receive in return.
In the end, our advice is not “write what you know” but instead to “know what you write.” Don’t be afraid to ask questions of people who are likely to have the answers, and don’t assume that what was depicted onscreen or written in another story is necessarily correct. Perpetuating medical myths and errors can throw the reader out of a story in the same way that historical, technological, and other factual errors will.
Christopher S. Kovacs, MD, and Susan M. MacDonald, MD, live in Paradise, Newfoundland.
Canada Reads 2014 with Jian Gomeshi. “Canada Reads Day 2 and Day 3.” Canada Reads 2014 with Jian Gomeshi. 2014. Accessed June 16, 2014.
—-. “Sarah Gordon Defends Annabel by Kathleen Winter.” Canada Reads 2014 with Jian Gomeshi. 2014. <www.cbc.ca/books/canadareads/sarah-gadon-defends-annabel-by-kathleen-winter.html>. Accessed June 16, 2014.
Dean, L. “Chapter 9, The Duffy Blood Group.” Blood Groups and Red Cell Antigens. Bethesda, Maryland: National Center for Biotechnology Information, 2005. Available from: <www.ncbi.nlm.nih.gov/books/NBK2271/>.
Engel, G., S. J. Burnham, and M. F. Carter. “Penile Blood Pressure in the Evaluation of Erectile Impotence.” Fertil Steril 30. 6 (1978).
Kleinman, S. “A Primer of Red Blood Cell Antigens and Antibodies.” UpToDate. Ed. Silvergleid, A. J. Waltham, Massachusetts: UpToDate, 2014. Accessed June 15, 2014.
Moshiri, M., et al. “Evaluation and Management of Disorders of Sex Development: Multidisciplinary Approach to a Complex Diagnosis.” Radiographics 32. 6 (2012).
Verkuyl, D. A. “Oral Conception. Impregnation via the Proximal Gastrointestinal Tract in a Patient with an Aplastic Distal Vagina. Case report.” Br J Obstet Gynaecol 95. 9 (1988).
Xue-Rui, T., et al. “Changes of Blood Pressure and Heart Rate During Sexual Activity in Healthy Adults.” Blood Press Monit 13. 4 (2008).