A sign that I’m too deep into studying anesthesia and training in the operating room: I see it everywhere. Even in superhero movies. As an MCU fan and an anesthetist in-training, I couldn’t help noticing enough medical-related scenes in Black Widow to make a fun post about them. So if you’re a sucker for science-in-fiction info, and want to know how surgery and anesthesia ties into Black Widow, this is the thread for you!

That masks looks familiar…

The oxygen transport mask Melina got looks a lot like the one my hospital uses, right down to the green drawstrings. The movie shows its use on the field (think paramedics and EMS). In a hospital setting, these masks are used when a patient is in transition between the OR and PACU (post-anesthesia recovery unit, or more commonly known as the recovery room). The mask hooks up to an oxygen tank on the bed and usually I set the oxygen flow to 6 liters per minute, although I’ve gone as high up as 10 L/min. And still on the topic of masks…

On a scale of 1 to Alexei, how hard are you to bag mask?

As soon as I saw present-day Alexei, first thing I thought was “that guy would be hard af to bag mask.” Bag mask ventilation/BMV involves putting a mask on the patient and helping them breathe with the anesthesia machine that connects to the mask. BMV is an important skill for anesthesia providers. It saves lives. Several factors would make a patient hard to bag mask, like Alexei’s ginormous beard. All that hair in the way would make it hard to get a good seal of the mask on the face. You don’t want leaks through the mask.

There’s a very particular way to BMV. With one hand, you make the “C-E grip:” make a C with the first two fingers on the mask, and the E with three fingers along the jawline. The other hand is squeezing the reservoir bag to give breaths to the patient. Double-handed BMV is also possible, though you’ll need someone else to squeeze the bag for you.

Yelena dramatically explains hysterectomy!

Like everyone else, I cracked up when Yelena got “all clinical and nasty” with describing hysterectomy. But in reality, it’s not as painful and awful as she makes it sound. Hysterectomy is removal of the uterus. It’s a very common gyn procedure with low mortality rate and little complications. I’ve helped provide anesthesia for plenty of these cases. Most of them are done laparoscopically, which means that surgeons use long rods with cameras at the end instead of large incisions. Contrary to Yelena’s hand motions from below and saying how “they go in and rip it out,” laparoscopy is through the abdomen, and as a minimally invasive surgery, it leaves much smaller scars than open incision. Hysterectomy is usually accompanied with salpingo-oophorectomy (removal of fallopian tubes and ovaries). This operation, as with most, is permanent and has long-lasting effects. Which leads me to patient consent: anesthesia and surgery can’t go forward without it. Part of my future job involves getting consent while interviewing the patient in pre-op. We want to be extremely sure that patients are sound of mind and aware of the risks and impact that comes with the procedure. Which is why the idea of forced sterilization, the Widows having no autonomy or choice in the matter, is particularly awful.

Time for EKG interpretation!

On the top left corner of Melina’s tablet, you can see an EKG reading for the pig Alexei. EKG/ECG stands for electrocardiogram. (The K is a byproduct of the German word for it, and for whatever reason, English speaking medical professionals usually go by EKG rather than ECG.) An EKG monitors the heart’s electrical activity. In the OR, the anesthesia provider closely watches this throughout surgery. I can detect abnormalities of a patient’s heart function if the rhythm looks whack. I have to go through entire classes on how to read EKGs. Human hearts normally beat at 60-100 beats per minute. Under 60 bpm is called “bradycardia” (heart beats too slow), over 100 bpm is called “tachycardia” (heart beats too fast). Going by human heart measurements, Alexei’s bpm is within what’s called “normal sinus rhythm” because it reads as 69 on Melina’s tablet. As for the rhythm line itself: those upward spikes are called QRS complexes. That represents ventricular depolarization, when the lower chambers of the heart squeeze to pump oxygenated blood to the rest of the body. The spikes seem evenly spaced out for the most part except for QRS complex #6 and #8. You see that they spike earlier than the rest? The image isn’t the clearest so I can’t be 100% sure, but those early spikes resemble what is called a “premature atrial contraction” or PAC. That means that the atria, the top chambers of the heart, are squeezing too soon. Not a life-threatening condition, but it’s not normal either.

The infamous “Melina makes the pig stop breathing” scene!

Ah yes, of course I have to discuss that one part in the movie. This is what happens in anesthesia, actually. A combination of drugs makes this possible: an induction agent like propofol plus a paralytic agent like rocuronium (roc) or succinylcholine (sux). These work together to impair airway reflexes and paralyze muscles. That way it’s easier to place an advanced airway down the patient’s windpipe, and it’s easier for the surgeon to muck around in the insides. (They don’t like it when the patient is moving and not fully relaxed.) I’m sure plenty of you already know propofol as the culprit that led to Michael Jackson’s death. Propofol is not supposed to leave the OR, let alone a hospital. It’s definitely not supposed to be used at home! Only certified anesthesia providers are allowed to handle this drug. (How it got into the hands of MJ’s doctor, a cardiologist with no training whatsoever to give it, is absolutely ridiculous. But I digress.) Propofol, roc, and sux are very powerful drugs that kick in almost immediately. We’re talking seconds, under a minute. What anesthesia accomplishes with drugs, Melina did with Hollywood handwavy mind control. (Don’t get me wrong, Melina is my favorite BW character. I love how intelligent and badass she is. I bet she has some medical training.)

I don’t have mind control tech like she does, but below is a pic I took of induction drugs I use daily, for almost every procedure. I lined them up in order of use. Fentanyl and lidocaine go in first to mitigate the burning pain of propofol going in the IV. Once the patient goes to sleep from the propofol, last to go in is the paralytic. The patient should always be induced BEFORE being paralyzed, so prop before sux or roc!

The clinical term for cessation of breathing is “apnea.” Melina made the pig “go apneic.” You may have also heard of it by obstructive sleep apnea (OSA), a condition that impacts the anesthetic plan in many ways (which I won’t delve into here). As Melina demonstrated, there’s a short period of time that the brain can survive on no oxygen without permanent damage. Anesthesia providers can prolong that time with pre-oxygenation: once the patient is wheeled into the OR, they’re put on 100% inspired oxygen through a mask and on high gas flow of ~10 L/min. We use that time to later place an advanced airway like an endotracheal tube. Once the airway is secured, the ventilator is turned on so it can take over breathing for the patient until the end of surgery.

Yelena is scheduled for a Red Room-style awake craniotomy!

A craniotomy involves removing a bone flap in the skull to access the brain. In the movie, the doctor mentions keeping her awake for cranial incision. So yes, this operation can be done when the patient is awake. Sounds scary, but the patient will be very sedated to keep them calm and pain-free. Awake surgery lets the surgeon communicate with the patient, so they know they’re working on the correct area of the brain. And yeah, as Yelena said, having a craniotomy would be a much less cool way to die. (Seeing a patient crash mid-operation is one of my worst fears.)

In the movie, Yelena is seen positioned almost flat on her back (called “supine” in medical lingo), although in real life, the patient would most likely be moved to the sitting position for head and neck surgeries like craniotomy. Positioning depends on the type of surgery and where the surgeon needs best access to the working site. Surgeon calls the shots for what position they want the patient to be in, but anesthesia handles actually moving the patient to that position on the OR table. Anesthesia’s in control at the head of the bed, as you can see below.

Surgery and anesthesia are a team! Patients come to get surgery, but there can be no surgery without anesthesia. It’s important that we work well together.

Bonus: so many things wrong with this lol

No good anesthesia provider would abide by this. Where do I start? (sucks in a deep breath)

-Why wasn’t she changed into a gown?
-Where’s her IV line? How is she going to get meds and fluids to stay asleep, stable, and hydrated?
-Where are the chest stickers/leads for EKG?
-Where’s the finger clamp for pulse ox?
-Where’s the probe for temperature?
-Where’s the cuff for blood pressure?

In reality, she’d be hooked up to at least 4 lines before surgery even starts. Then again, these Red Room docs are probably super sketch and sus/not board-certified. (To be fair, for movie purposes I get that Yelena doesn’t have anything on so she can jump off the table to kick ass right away. Otherwise she’d have to waste time pulling all the lines off.)

There you have it, a future anesthetist’s perspective on Black Widow. I hope you found this thread both interesting and informative. Maybe this even got you interested in a career in anesthesia! There’s a lot more involved than just “putting people to sleep.” It’s a pretty cool field.

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