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The Surgery of "His Last Vow": Agra’s killing shot

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Anatomy of heart and liver

A human heart is located in the middle of a chest, diagonally from right to left.

The liver is under the heart on the right. The heart is covered slightly by the lungs (pink).
Male nipples are at the level of the fifth rib, sometimes, slightly above or slightly below it. If we draw a line between the nipples, we cross the heart at its widest part.

When we breath, the diaphragm moves up (exhalation) and down (inhalation), and the position of the heart changes slightly.
A heart is covered by a special sac called pericardium. The pericardial sac has two layers. It encloses the pericardial cavity, which contains about 25 mL of pericardial fluid.

Similarly, lungs are placed in a double-walled sac called pleura.

Vena cava inferior lies behind the liver.

Anatomy of Sherlock’s wound

Wellingtongoose considered this picture:

This picture was imagined by Sherlock in his Mind Palace. It is not a reality. Wellingtongoose concluded that the bullet had hit the liver and vena cava inferior. However, to reconstruct what had happened, one should consider not only the picture, but also anatomy of the wound, physiology, clinical symptoms, and actions of the doctors.

I have found an X-ray of a young male. What can we see on this X-ray? The white areas are the heart, liver, and bones. The dark areas are lungs.

Let us put this X-ray on Benedict’s chest.

Fits rather well.
Now, let us put it onto the body in the mortuary.

The bullet hit between the heart and the liver. The wound is very serious, taking into account concussion and necrosis of the tissues. In this case, the bullet could pass through the liver and injury the vena cava inferior.
Such is indeed the case in Sherlock’s Mind Palace.

What has really happened?
In the movie, we can see two real situations. First, in the ambulance:

Second, in the intensive care unit (ICU):

Let us superimpose the ambulance photo onto the ICU picture.
We can see that the wounds coincide very well! There is the same wound in the ambulance and ICU!

Let us put the photo in the ambulance onto the picture in the mortuary:

We see that the real wound is located higher than the imagined one.

Look at the X-ray, superimposed onto the ICU photo. This is the key point of my investigation!

The wound entry hole is in the area of the HEART! Agra shot in the heart. Do we need any other evidence of her false "surgery"?
However, Sherlock did not die. This fact can be explained as follows. The bullet hit the edge of the sternum and slightly deflected to the right, brushing the edge of the heart (see the picture).

In this case, the right lung was injured, but the liver and vena cava inferior were intact.

Therefore, the diagnosis is as follows:

The penetrating gunshot wound of the thorax, injury of the pericardium and the right lung, bleeding in the pleural sac (hemothorax) and pericardial sac (hemopericardium).

It is a very impressive "surgical safety", isn't it?

What has happened to Sherlock?

Therefore, Sherlock lost consciousness after a minute or two, and after 15–20 minutes, there occured a cardiac arrest.
In case of injury of vena cava inferior, Sherlock is assumed to die because of an acute massive blood loss (500–1000 mL).

It means that:
1) The heart had stopped, because it had nothing to pump. The law of physiology says: a "dry" heart cannot work. An electrocardiograph would register asystole.
2) It is necessary to refill the blood vessels by massive infusion into 3–4 large veins (central and/or peripheral).
Look at the picture in the intensive care unit:

We can see only two infusion systems in the cubital veins. Perhaps, the doctors did not see the massive blood loss?

3. The hole in vena cava inferior makes impossible the reanimation without surgical operation and sewing up the wound.
That’s why vena cava inferior is beyond the scope.

See the final ECG:

It's not asystole. There are four variants of cardiac arrest, namely, pulseless ventricular tachycardia, electromechanical dissociation, fibrillation, and asystole. Asystole is a straight or wavy line at the ECG.

Sherlock had no asystole; he had small-wave atonic fibrillation. His heart was not really dead, but it could not beat. A defibrillator, by the way, is not effective in this situation.

What reason can be for cardiac arrest?
I think, because of blood in the pericardial sac (hemopericardium).

Between two layers of pericardium, there is 25 mL of fluid. Let’s suppose that the bullet had partially plugged the hole, and blood from damaged vessels of the pericardium began to flow inside the sac. When the blood volume achieved 150 mL, the cardiac tamponade occurred. The heart became trapped in the swollen sac and stopped.
So, the cause of death is cardiac tamponade.

In case of cardiac tamponade, cardiopulmonary resuscitation is ineffective without removing blood from the pericardial sac.

Is it possible for Sherlock to come to life by himself? Perhaps, when the doctors “pumped” the chest, the bullet shifted and opened the hole in the pericardium. Blood started to flow out, at some point, the living heart (it was not dead) could beat.

Other versions may be concerned with heart trauma.

The right lung was wounded, no doubt, hence, Sherlock had hemothorax (blood in the pleural space).
Treatment of hemothorax suggests the surgical operation via minimally traumatic access — right anterolateral thoracotomy:

If there was a gunshot abdominal wound (liver and vena cava inferior), the doctors had to cut off the abdomen in order to treat the damaged tissues without no exceptions! In this case, we could see laparotomic cut.
Sherlock in the intensive care unit: there are no laparothomic stiches.

However, we can see the bandage under the right rib. Quod erat demonstrandum.
There is the thoracic wound treated via right anterolateral thoracotomy.
A patient should suffer from strong pain (morphine is needed), but after the adequate surgical treatment, our Sherlock could stand and walk with strong painkillers.

Dead or not dead?

Sherlock had cardiac arrest; it was not a clinical death, taking into account that CPR (cardiopulmonary resuscitation) was provided at once.
CPR performed by skilled doctors provides the brain blood flow at about 35% of norm, the coronary blood flow at 25% of norm.
It is generally believed that successful CPR “starts" the heart within the first 5 - 10 minutes, after that period the possibility of irreversible brain damage increases sharply. However, there were cases, when after 30 minutes of resuscitation, the patient recovered without apparent consequences for the brain.

Since modern technologies allow to maintain the circulation almost without end, doctors in ICU have the specific set of rules, concerning the ascertaining of death. There are two cases, in which resuscitation should be stopped and a person is considered to be dead:
1) Brain death;
2) When CPR is ineffective within 30 minutes.

"Sherlock" presents the second variant, because Sherlock’s brain is not injured. Therefore, the doctors performed CPR for at least 30 minutes + the time in the ambulance.
Michael Jackson was resuscitated for an hour, before they ascertained the death.

In “Sherlock”, all the doctors took an official decision that the patient was dead.

Agra is a skilled assassin

From the interview with Amanda, we know that she had James Bond’s Walther PPK, 7.65.

This is a special police pistol for effective fire at short distances.
A cartridge for this pistol:

Blunt bullets are very effective to "get stuck" inside the target, transferring all the huge kinetic energy and damaging seriously the tissues. Sherlock was thrown back, and the bullet remained in his body.

Agra had the gun with a silencer. However, the silencer does not reduce completely the sound of the shot. In order to shoot silently, Agra was to reduce the amount of gunpowder. This explains the fact that a) the bullet ricocheted off the sternum, and b) Sherlock was not pushed to the wall, and he just fell on his back.

She was taking aim with a straight arm. Unlike Sherlock, who was aiming, bending the elbow and holding it by the other hand. Such a pose says that he was ready to stand a while and talk.

The pose of Agra suggests that she had no time to talk. This is a very threatening gesture that Sherlock had to recognize.
A bullet from her pistol punched a hole in the coin.

Therefore, Agra is a skilled shooter with a dangerous gun, she knows how to shoot and kill.
Targets for training of policemen and military men are made schematically, to avoid the feeling that you're shooting at a human being.
Here is an example of a training target:

The shot in heart (red "apple") gets "five plus", exactly in the center of the target. By the way, the zone around the red "apple” gets also "five", that shows the seriousness of the wounds of chest and abdomen.
So, Agra was taught to shoot at the center of the chest.

Where is the actual surgery?

In the "empty house", Sherlock offered the idea of “surgery” to protect himself and John. John, who saw the medical documents in the hospital, did not believe, but accepted “the game”. An interesting fact: during the scene in the "empty house", the music track "Lie in Leinster Gardens” is playing.
At 221b, Sherlock did not suffer from bleeding. Morphine has ended, and Sherlock lost consciousness from the pain with a dramatic performance. Not fatal, he would come to himself immediately after intravenous morphine. I think, John guessed about it, so did not rush to help in the first few seconds.

Where is the actual surgery?
Just before the shot, Sherlock started to make a step to the left. He began to get up and move to the left. The “target”, therefore, shifted slightly to the right and down. At the distance of 1,5 – 2 meters, the shift could be up to 1,5-2 cm. See above — only 0,5-1,0 cm separated him from the death. Here was the actual surgery!

In the movie, we can see that the bullet from the silencer went down a bit, it is a real thing.
Remember that Sherlock is a very skilled professional. In "Belgravia", Sherlock is a master of the technique of knocking the gun from the killer. When Agra raised her hand, I think, Sherlock had no doubt about her intentions. He tried to persuade her, but without success. Agra came to Magnussen to kill Sherlock. Sherlock saved himself by this little movement.

Assassination or not assassination?

The shot in the heart, thoracic wound, heart injury, lung injury, cardiac arrest. The conclusion of the forensic examination is formulated as "severe bodily injury". I think, Agra should be arrested for attempted homicide.

Possible motivation for the assassination

Agra was the missing sniper from Estonia or Dyachenko. She was hired by Moriarty to keep Sherlock at gunpoint on the roof and kill him if Sherlock would not jump. Sherlock staged the performance not for John, but for his personal sniper. The jump of Sherlock saved him from Agra's shot.

After Sherlock's "death", Agra stayed close to his friend. All these years, Sherlock did not hide from John, but from a spy near him (from Agra).
At the beginning of the "His Last Vow", the “employer” (Moriarty? Moran?) demanded to fulfill the order. Sherlock took the case of Lady Smallwood. Agra found out about it from Janine and used it as a trap for Sherlock. She came to Magnussen, pretending that she was going to take her documents from the blackmailer. She knocked Janine and the security guard to delay John. She used the perfume to lure Sherlock upstairs. She dressed like shinobi, who were skilled assassins. She shot in Sherlock's heart and left. However, Sherlock succeeded to survive, though severely injured.
In "empty house", Agra went to complete the assassination, because Sherlock had become her enemy, and the order remained unfulfilled. In order to protect himself, Sherlock came up with the idea of "surgery"and took John with him.
John, being a very good military doctor, did not believe in “surgery”, but agreed.

Perhaps, the information on the flash drive, which was to break John, was this: the contract with the employer about the assassination of Sherlock.
Why didn't she shoot in the head? She could be ordered to "burn the heart out", or the employer may want Sherlock's head or his skull (Sherlock Holmes had Billy skull, and Sherlock's name is Billy, Moriarty would want to have such a "friend").

Interesting, when Sherlock and Moriarty were talking on the roof, there was a heptagonal glare on Sherlock's head (like the heptagonal coin): This is a brilliant discovery of my friend, Vega-216

All other glares elsewhere are octagonal.


The case of Agra has completed. As a doctor, I has offered the diagnosis. As a spectator, I have no doubts that Agra had committed a crime. Was she really forgiven by Sherlock and John? Maybe, we'll see it in the fourth season.

Thanks to everyone who has read it to the end!