Tuesday, 12 May 2020

Heroic post-mortem: Boromir

Deaths in film can often be badly portrayed, with people often falling and dying to wounds that should have done nothing. Other people seem to live when there is every assumption they would not have made it.

The part most difficult to do is for actors to portray their injuries. This is understandable, since for health and safety purposes, actors are not usually shot and stabbed, but have to pretend instead. Unfortunately, most actors probably do not see people in real life having been hit by bullets, arrows, or blast injuries. So far as I am aware, this is not compulsory reading at drama-school. 

In addition, actors are usually direct to pass away "heroically", or "beautifully". Completely understandable as films are a form of art, but there should be a way to combine both.

I am going to take a look at the representation of Boromir's death, which is one that I was actually quite impressed with. 



Arms and armour question: Would the arrows have penetrated to the depth that they did?

The first question is a historical/practical one - would the arrows have penetrated into Boromir in the way that they did?

So…what is Boromir decked out in? It seems to be a light and practical affair – a  suit of chainmail (presumed, since we only see he sleeves), under a leather overcoat and what seem to be fairly normal clothes. Elegant and flashy, managing to maintain Sean Bean’s figure while also looking all war-like.

Unfortunately, this is not great arrow protection. Historically a large thick padded coat (a gambeson) would have been worn below any metal armour. This padding is the real protection with any metal delaying the penetration of sharpened edges. Video demonstrations can show how vulnerable unpadded chain is, while how much more effective it is with several layers behind it. Proper protection at the time would be from plated armour, which generally has a nice slope to deflect the arrow.

The type of arrow used is also important. The broader the arrow head, the harder to penetrate metal armour (more video evidence here). Lurtz, the uruk-hai who fires the arrow seems to be using quite thin arrows, although it is hard to see on-screen.

Summary
So, Boromir opted for flashy clothing and fairly impractical armour, while Lurtz was properly geared as part of a scouting force to hunt the fellowship down. Conclusion: there is every reason to believe the arrows would pierce to the depth that they did.


Blood and bones question

Would Boromir have kept fighting with all the injuries?

Three arrows. Three injuries. Can someone keep going? Let us analyse them in turn.



First arrow: Lungs and muscle

Number 1 seems to hit Boromir in the top of the chest, and I want to know exactly where it hit. So…


So this is Boromir. More precisely, Boromir with an additional arrow. 






Now lets work out on a chest x-ray what this corresponds to.

First though, for anyone that wants to know more about how to interpret a chest x-ray, I heartily recommend this website

In medical terms we might say just level of the third rib, mid-clavicular line. In less medical terms, the arrow is mostly just hitting lung, and not much else. We can also make out where it hits by looking from the side (what we call the sagital view).



As a further note, the arrow pierces the pectoralis muscle. This is a main controller of the arm. If it had a stick of wood coming out of it, then any movement with this arm would be exceedingly painful, and very restricted. From this point on, Boromir mostly (with one exception), fights one-handed, where before he typically used both hands.




      Second arrow: abdominal content
      Enters much lower down the body, but more or less in line with the first arrow. It lands slightly above the belt, so entering into the abdomen.


  
 
      Checking the scans, all we can really see down here is intestines, so not that important and while painful, Boromir could fight on. It goes far enough to the left that it probably misses any important things like blood vessels.

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      Third arrow: important thoracic content
      Difficult to see from the movie exactly where it landed, however it is between the first two, and more closer to the centre of the body. Big problem here is that it looks like about a 50% chance that it should have hit the heart. 


    

      Yet, as the documented evidence shows; Boromir does not instantly die. Maybe went below. Nonetheless, the depth that the arrow could have gone means that it would get a massive vessel at the back called the aorta. 


In actuality, I think it likely that the arrow probably did hit the aorta, and this is for a couple of reasons. 


First off, Boromir seems to loose the use of his legs, and as he collapses defeated, he does so in the kneeling position. If the arrow did hit the aorta at this level, it would disrupt the blood flow to the legs, stopping him from moving them. 


Furthermore, when Boromir eventually passes away, it is fairly slow and peaceful. Despite the arrow to the lungs, he does not die of breathlessness and lack of oxygen, but seems to drift away. A simple  explanation for this is internal bleeding and as he says farewell to Aragorn, he is noticeably pale - a good sign of massive blood loss.


The only issue here is that penetrating trauma to the aorta would lead to a very rapid loss of blood, and death can occur in seconds. It is almost four minutes from injury to death (2 minutes for Aragorn to leap in and kill Lurtz, and then a further minute and a half of chit-chat). Nonetheless, there are plenty of ways to explain this; the arrow just nicked the aorta, or the rupture was somehow contained, or it hit the vena cava (the main vein, just next to the aorta) instead.




Other points
So far, I have tried mainly to offer clinical justification for what you see on screen. Medicine in films has to strike a balance between art and realism, and I can respect this. However, there are a few bits and pieces that you might expect if this were real life.

Breathing, pain, coughing
When you get a penetrating wound into the chest, you would expect to have some difficulty breathing. This comes about for a few reasons. Number one is pain, number two is the likelyhood that some of the ribs were fractured, and number three is the strong likelihood of causing a pneumothorax.

It is difficult to say exactly how breathless Boromir should be. He does not last all that long from arrow to collapse, and it is quite possible to survive with just one lung.

Really it comes down more to pain. There is some difficulty talking with Aragorn at the end, but not as much as you might expect - imagine having a conversation with you, and every time you speak or breath, someone jabs you in the chest. The difficulty breathing looks more like what you would expect from exertion (like fighting a battle), than from pain and injury.

Probably more than breathlessness though, I would have expected some coughing. There are many reflexes in the lungs to try and clear out foreign objects. Blood, fluid and arrows all fit into this category. It is a stimulus that you have to work quite hard to suppress.

Conclusion
Overall, I am generally impressed by how Boromir's death was portrayed. It matches the books, which is a good start, and the order of the wounds follows a natural progression that matches the symptoms that he displays.

Do you agree? Any further points you want to add?

Or have you got a film death that you want analysing? Post in the comments if you do.



Appendix - autopsy report

Patient: Boromir, Captain of the White Tower

Age: 41, born Third age, 2978.

Date of death: Unclear, but from state of the body, likely late February 3019

Next of kin: Denethor (Father), Faramir (brother). Finduilas (Mother, deceased). No descendants.

Cause of death: 3 x penetrating injuries, death by exsanguination from aortic rupture. 


Case history:

Body initially recovered from the sea. Signs inconsistent with life, pronounced dead at the scene. Body was easily identifiable due to clothing, and a recent “prophetic death alert” put out by brother Faramir.


Clothing (copied from admission notes)

Black leather surcoat, burgundy and gold under-tunic, dark under-shirt, chainmail, dark green cloak with leaf shaped clasp, dark trousers, black boots, dark socks.


No note made of any vambracers on the arms, or recovered with the body, however old skin impressions consistent with these having been worn at time of death.


External examination

Caucasian male, neck-length length brown hair, 


Generalised bloating, consistent with several days bring submerged in water.


Two x penetrating wounds to the thorax (1 x left upper, 1 x central), 1 x penetrating wound to abdomen (Left upper quadrant).


Recent bruising but no obvious recent lacerations. Multiple old scars, now well healed.


Internal examination

Examination limited due to time spent submerged in water.


Upper left penetrating injury to the Left chest

  • Associated fracture to third rib with localised damage to the chest wall. Corresponding lung injury with evidence of haemothorax 
  • Arrow tip in place inside of chest, no external part of arrow retained. 


Central penetrating injury to chest

  • Wound is directly below xiphisternum, with scarring to the bone. Small tear of the aorta. No retained foreign bodies, however consistent with an arrow as per first chest injury.

Penetrating injury to the abdomen 

  • Left upper quadrant. 
  • Underlying damage to the small intestines. 
  • No retained foreign bodies, but consistent with an arrow injury.


Stomach has no discernable content - either starved prior to injury, or making use of travellers food such as the elven “lembas bread”.


Otherwise, the colon, spleen, liver, kidneys, bladder and brain are unremarkable. 











5 crazy circumflex arteries you never heard of



1) The anterior circumflex humeral artery
Our first candidate, arising from the very trendy axillary artery (famous for its role during the Lincoln assassination by supplying the shooter's arm with a good blood supply)



2) Circumflex scapular artery
Another one from the arm, and probably the most interesting one, because it can actually provide extra circulation to the arm if the axillary artery gets blocked.



3) Circumflex femoral artery
A most important addition to the circumflex ranks. It provides most of the blood supply to the head of the humerous - a fracture at the neck of the femur can stop this supply.


4) Circumflex coronary artery
If you have heard of any circumflex arteries, you have probably heard of this one. It supplies much of the left side of the heart. 

Awesomely good clinical nugget: When it is damaged, the areas of an ECG that typically show changes are in leads V5, V6 and leads I and aVL.



5) The posterior circumflex humeral artery
Arguably the same category as case number 1, but I wanted to try and make five cases in this blog so here it is:

In case you wanted a good way to remember how to differentiate it from the circumflex femoral artery, remember that it comes off the arm, not the leg.

Know of any other circumflex arteries? Let me know in the comments





Thursday, 24 November 2016

Medical teaching: simulation vs on the ward

Much happy, I have just helped as part of a team of 6 (plus several supporters) to win the London Simulation competition. It was fantastic to be working with the others, and actualyl the whole thing was everything I had hoped medical school would be, from the adrenaline rush of being in the simulation to the hours of preparation and rehearsing scenarios.

I have long felt there should be more simulation, and fewer of the traditional methods i.e. didactic lectures (see here for a beat poem expressing how silly this is for mainstream school) . Having now experienced 2 and a bit years of ward placements, I am also firmly of the belief that being on the ward is of limited use as well.

There are advantages, and to its credit as a methodology it can work. However, it takes almost as long to settle into a new firm as the actual length of the placement. Furthermore

Being on the ward to learn medicine was great for a certain era, when books were experensive and the internet a century or two off






Saturday, 25 June 2016

Third penultimate year mock OSCE

So last Wednesday I ran the third of the mock OSCEs for the year.

It built on the feedback of the first and second (sadly I did not blog the second), and in terms of smoothness I'm happy, with a few points.

Organising
Firstly the organising changed - In the first OSCE I wrote all nine stations, in the second I wrote five and this time around only wrote one.

Advantages:
- Less time on my part
- More variation in approaches

Disadvantages
- They should all have been proof-read, but
- The mark schemes were variable in how readable they were and this was noted by participants. Readability is key as there is a quick turnaround.

Stations
Previously stations were randomly allocated and people got random stations depending on what I had written, this time I allocated topics to different people and so it was easier (as far as dictation goes) to get certain stations ready.

Overall
It ran well, finished almost on time and there were many thank yous at the end. I gained from it and the format seems to work.

Thursday, 14 April 2016

Phew, just organised my first practice OSCE station (Where you are put in a clinical situation with actors and need to work accordingly) for my year (4th year currently) - it was rather harder work than I thought it would be at the start, and I'll probably still wake up sweating for a few days.

Nonetheless I am really grateful to everyone's participation, including those in my year who treated it well (and adapted to a few of my lapses), two thyroid clinicians (Paul Dent and Dominic Pritchard), and Josephine Saramunda (a 3rd year), who all volunteered at very short notice to fill in when some of the patient-actors and examiners who could not make it.

Several points for me:
- I need a little more assistance next time, there were a few snags on the day which I didn't quite adapt to so well.
- The sheets need more proof-reading, as there were a few inconsistencies that became apparent.
- The actors felt they needed a little more time to prepare.
- A few people suggested a little more feed-back time, as it was an informal event.
- Some of the stations, particularly in neurology were a little too specific and maybe beyond 4th year level.

Nonetheless, of the three rounds I did, the last one ran pretty smoothly, and in the feedback the participants graded it positively 4.5 out of 5, so with a little more organisation the next one (eeep) should be even better.

The scenarios were:


Round 1
Upper limb exam Syringomyelia
Acute neurology hx Delerium tremens
Msk hx + exam Hand arthritis

Round 2
Cranial nerve exam Parietal stroke
GUM history Sexual history
Endocrine hx + viva Medication review

Round 3
Thyroid exam Thyroid exam
Acute neurology Seizure + DVLA
Hearing hx + exam Drug induce Hearing loss

Thursday, 29 May 2014

Further ideas for leapmotion

So, following the excitement of the NHS hackathon I was at recently, it has been difficult to resume the normal medical pattern of studying 7am - 9 pm. Fortunately Monday was a bank holiday, so nothing was "officially" expected of me. It is also fortunate that we are currently in the neuro modules, which is something I semi-understand a bit of already.

A number of people have expressed excitement at the project - both clinicians and researchers as well as students. Most recently today at a placement with the INS I spoke to one of the Occupational Therapists who was interested in the potential. So far my ideas had focused on the potential for detecting severity and types of tremor in a patient, with maybe the development of games for physiotherapy.

On the way back from the INS placement I was discussing it with a fellow student, and between his feedback and what we had seen during the day, an idea crept in regarding people with Parkinsons.

The disease presents with a severe tremor, such that eating and drinking or dressing and going to the toilet are made very difficult. They also find it difficult to write, a sign that medication is working is regaining the ability to sign your name. Yet it is often still difficult to hold a pen dexterously and typing is similarly difficult.

Now, the app. If it were possible to map out a Parkinsonian tremor and tell the computer what to expect, then someone could trace out the letters they want in the air and, even if their tremors made the writing illegible, by allowing for this the computer could discern where the hand "intended" to go and react accordingly.

Possibly a simpler method (no complicated algorithms) - a virtual keyboard that moved itself relative to the finger position. Since the Leapmotion software isolates each finger, it knows which one has moved to where and can move the virtual keyboard accordingly. Even if ten-fingered typing were still impossible and it only worked with one finger, it could still improve communication.

Of course, this requires a library of different tremor types first which as far as I'm aware does not yet exist - but that is my summer plan. It may also require a more in depth knowledge of how tremors present, but I'll be at the weekly neurology grand round at the hospital tomorrow so I will pick the brains of the learnèd faculty.

Monday, 26 May 2014

NHS Hackathon

I've just had an awesome weekend of awesome. Honourable mention in the NHS hackday, won a t-shirt and surgical book, and was a far cooler bank holiday weekend than...for instance...playing in the sun. I met lots of awesome people, and if anyone wants to see the presentation it is here over at google docs

And a video of it (skip to 11:45)


We were an honourable mention (the first honourable mention, which I count as runner up ;) and I have a team photo (as well as other photos of the day) here.
 
(Edit - I'm putting in here a better discription of what we did - apologies, I've spent too long staring at medical textbooks and not long enough writing creatively)

Hackathons are a day where all manner of people (programmers, business managers, mathematicians etc) get together to discuss problems and find solutions. In this case, I got attached to a group of programmers who were looking for possible uses of a Leap Motion device  (https://www.leapmotion.com/). The device uses infra red to detect the position of the palm of the hand and all five fingers and records the position.

Working with the team over the weekend, we discovered how it could be used to measure tremors in the hand. Amongst the possibilities this opens, it can be used to objectively record a patient's progression over time, whether it is monitoring a disease such as Parkinsons, assessing the effect of medication or rehabilitative physiotherapy. So far as I am aware, there is no clinical objective measure on the severity of tremor, there only seems to be approximations based on quality of life measures.

The possibilities of what we created seem colossal, and I was excitedly talking to other clinicians about how neurological diseases could be monitored, and how GPs, on seeing a new patient can exactly track the extent of a disease, or when transferring patients around a hospital, a doctor can look at a graph and see instantly the extent of a patient's tremor.

It opens possibilities for further subdividing tremors which currently consist of "does it interfere with a patient's life or not", and (excitingly) it may uncover new types of tremor to subdivide existing disease classifications, discover new syndromes, and find ways to assess the early onset of conditions.