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Michael J. Green, MD, MS; and Ray Rieck
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Author and Illustrator Information:

Michael J. Green, MD, MS, is a Professor of Medicine and Humanities at Penn State College of Medicine, where he cares for patients, teaches medical students, and conducts research on informed medical decision making. He is a founding organizer of several international conferences on Comics and Medicine (www.graphicmedicine.org/comics-and-medicine-conferences) and is a member of the editorial collective of a forthcoming book series on graphic medicine from Penn State University Press. He teaches a course on comics and medicine to fourth-year medical students (whose comics can be viewed online at www2.med.psu.edu/humanities/for-medical-students/research-opportunities/graphic-storytelling-medical-narratives). The author wishes to acknowledge the Physicians Writers Group at Penn State Hershey who provided support and critical feedback on the story that inspired this comic.

Ray Rieck is a freelance illustrator and graphic designer with over 14 years of experience creating comics, storyboards, print and product design, children's activity books, and curricula. He teaches at Pennsylvania College of Art and Design in Lancaster, Pennsylvania, and can be found online at www.rayrieck.com.

Ann Intern Med. 2013;158(5_Part_1):357-361. doi:10.7326/0003-4819-158-5-201303050-00013
© 2013 American College of Physicians
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I loved this
Posted on March 10, 2013
Jim Bane
Portland VA Medical Center Portland OR
Conflict of Interest: None Declared
I much appreciate the venture into the graphic arts. This well established form captures substance and emotion in a unique and accessible way. Very moving topic nicely written and beautifully illustrated. More please
Posted on March 13, 2013
Jessica Ryff, MD
Conflict of Interest: None Declared

I just wanted to leave my feedback about the graphic novel section of the 5 March edition of the Annals. I really liked it and thought it was a welcome change of pace for the journal. I think that the topic was serious and thought provoking and the accompanying images helped to bring back shared memories about my own time in residency and similar patient experiences. I hope you will add more of these new formats in the future.

Thank you,

Jessica Ryff, DO

A Great Addition
Posted on March 28, 2013
Michael Dowling
Conflict of Interest: None Declared
I loved this comic book article.. thought it was a great addition to the 'ways to learn and remember'.... would love to see more different visual approaches...
Effective and Powerful
Posted on April 8, 2013
Paul R. Skolnik, MD, FACP
University of Connecticut School of Medicine
Conflict of Interest: None Declared
I thought the pictorial description of the missed diagnosis and subsequent patient death was very effective and powerful. In this era of imagery and "sound bite" messages, even the older and more conservative among us respond to this type of pictorial "messaging". And yes, regarding full disclosure, I did read Superman and Batman comics during my youth, along with Classic Comics (but never for school!), if I remember the latter name correctly (maybe Cliff notes once in a while though)!
Missed It - Teaching Points
Posted on May 16, 2013
Gregory Bismack MD, Jaya Bussa MD, Khurram Ahmad MD
Internal Medicine Resident St. Mary Mercy Hospital, Internal Medicine Resident St. Mary Mercy Hospital, Cardiology Faculty Oakwood Hospital
Conflict of Interest: None Declared

We commend Dr. Green for his special illustration highlighting the importance of a good physical exam. However we would hate to miss this opportunity to highlight some important aspects of acute decompensation in aortic stenosis.Aortic stenosis is a progressive disease with a prolonged latent period. Patients with severe aortic stenosis have a fixed obstruction and are preload dependent .The progressive worsening of the left ventricular outflow leads to left ventricular hypertrophy. The hypertrophy of the left ventricle leads to an elevation of the left ventricular end diastolic pressure. Eventually left ventricular function declines leading to Heart failure.1, 2Acute decompensation of aortic stenosis typically occurs in a patient with severe aortic stenosis, which is defined as having a mean gradient greater then 40 mm Hg, an aortic valve area less then 1.0 cm2, an aortic valve area index of less than 0.6 cm2 per m2, or an aortic jet velocity greater than 4.0 m per sec.3 Possible causes of acute decompensation include:• Atrial systole contributes less than 20% of stroke volume in normal heart. This contribution becomes significantly important in patients with severe aortic stenosis.Sudden onset of atrial fibrillation and atrial flutter may significantly decrease cardiac output by losing this contribution.4 • Hypovolemia may lead to a reduction in preload. Patients with Severe aortic stenosis are dependent on adequate preload to maintain cardiac output . • Hypotension causes reduction in coronary blood flow which may lead to myocardial ischemia and worsening of ventricular function and cardiac output. • Afterload reducing agents can worsen the gradient across the aortic valve.They are relatively contraindicated in this condition. • Tachycardia decreases the time available for ventricular filling by decreasing the diastolic filling period which also effects coronary perfusion. • Cardiopulmonary resuscitation is not very effective in patients with severe aortic stenosis as it is not possible to generate adequate stroke volume across a severely stenotic aortic valve by chest compressions. The critical step in treatment of acute decompensation of aortic stenosis remains identification of the precipitating event. Atrial arrhythmias require electrical cardioversion. Hypotension is initially treated with fluid resuscitation, followed by ionotropic agents for those not responsive to fluid therapy. In the current case illustrated the patient received breathing treatments for suspected COPD which may have lead to tachycardia . Moreover the shortness of breath could be related to pulmonary edema which indicates decompensated condition .Finally this is a mechanical obstructive condition and the treatment is surgical or invasive relief of obstruction.5

1. Sawaya F, Liff D, Stewart J, Lerakis S, Babaliaros V. Aortic Stenosis: A Contemporary Review. The American Journal of the Medical Sciences. June 2012; 343 (6): 490-496

2. Grimard B, Larson J. Aortic Stenosis: Diagnosis and Treatment. American Family Physician. 2008; 78 (6): 717-725

3. Bonow R, Carabello B, Chatterjee K, et al. ACC - AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology - American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration with the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Journal of American College of Cardiology. 2006; 48: e1-148

4. Stott D, Marpole D, Bristow J, Kloster F, Griswold H. The Role of Left Atrial Transport in Aortic and Mitral Stenosis. Circulation. 1970; 41: 1031-1041

 5. Janz T. Valvular Heart Disease: Clinical Approach to Acute Decompensation of Left-Sided Lesions. Annals of Emergency Medicine. March 1988; 17: 201-208

Posted on May 1, 2015
Conflict of Interest: None Declared
This case reminded me of my previous committed follies. Someone rightly said that 'wise men should learn from their mistakes'. So when dealing with human lives, one should not feel shy to search all possible resources & seek guidance from seniors as well as juniors.
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