xkcd.WTF!?

Explanation ➲

IBM's Watson is a natural language system designed to answer questions posed by humans. Recently, IBM has extended Watson to act as a clinical decision support system, using image analytics to aid physicians in medical decision making. In this comic, Randall uses a flowchart (as he often does) to represent a guide to the algorithm used by Watson, including bizarre and horrifying techniques including surgical alteration of a patient to match a height and weight chart or squeezing the patient to make sure fluids come out of them. Like 416: Zealous Autoconfig, this comic pokes fun at a rigid, poorly-designed setup that ends up potentially doing more harm than good.

Modern medicine involves both standard processes and clinical judgment based around years of advanced training. An algorithm like this would have to be incredibly complicated in order to simulate the clinical judgment of a good doctor. However, some procedures are not normally used, and some would obviously cause damage.^{[citation needed]} Below is a detailed description of each step, but here is a list of some of the more strange steps:

• The algorithm depicted treats a patient as more of a machine or mechanical system than a living being, especially through decisions such as:
  • Injecting oxygen into patients with low oxygen saturation, rather than administering an oxygen mask or treating the root cause.
  • Removing and inspecting a skeleton, then diagnosing the patient's condition with a bone count. This is likely a reference to A Serious Case Of Spookiness from the Buttersafe web-comic, a comic Randall links to from below the comics on xkcd .
    • In the book Thing Explainer there is an explanation Colors of light for the electromagnetic spectrum, where Ponytail as a doctor looks at a full body x-ray of Cueball and exclaims that ... It looks like your body is full of bones to which Cueball replies Oh no! Is there any cure? Well if he meets Watson he might have them all removed... This comic came out about a month after the book so it may be viewed as a kind of reference to the problem with too many bones.
  • Dissecting a doctor "for parts" after consulting them for advice.
  • Removing extra limbs from a patient if the count is 100 or more (This might be a reference to different number systems used in computers, as 100 is read in binary as four.)
  • Determining whether the "build environment" of the patient is sane. This is most probably a reference to the configure script used in the GNU build system, which emits "checking whether build environment is sane" as one of its status messages. This is also referenced in 371: Compiler Complaint.
  • Rinsing the whole patient with a saline solution.
  • Removing organs from a patient regardless of response to an organ donation request.
• Other decisions appear to be entirely unrelated to the conditions upon which they are predicated:
  • If the patient doesn't rate their pain on a scale from 0-10, sequence their genome, apply a tourniquet, and perform an autopsy
  • If the patient's phone's battery is low, defibrillate until the battery is charged, sync photos, then administer general anesthesia
  • If the patient is successfully comforted after an oxygen injection, check their medical history and apply skin grafts
  • If green fluid is released from the patient, begin to cauterize
  • If the patient has less than 100 limbs, check their Vitamin D level

Although there are two options where the patient is discharged the patient should be very lucky to make it to one alive. The only survivable route requires the patient to be injecting with oxygen, which is typically lethal. The patient would also experience multiple unnecessary operations, which hopefully do not last long enough for their vitamin D levels or their phone battery to decrease significantly. The option at the bottom left is only reached after your skeleton is removed (and nothing is mentioned about putting it back, even if that would help).

The other discharge option is to the right, three boxes down, and can only be reached if you survive having an oxygen saturation of less than 50 % (less than 80-90 % can be a serious problem, see table below), and a very dangerous oxygen injection. Then you have to have a skin graft and a good D vitamin level. It is also best that you have a fully charged phone else you will be subject to defibrillation (which may very likely kill you, if it will continue until your phone is charged to above "low" level - which is probably not even possible). You can also reach this discharge option another way, but that would only be after your organs were removed... But if you get through this you could reach the discharged option alive. Sadly there is a little glitch mentioned in the title text:

The title text implies that, if the patient is so lucky to ever reach one of the two places with the option "discharge patient", a minor glitch will cause the program to go back to the hunt down and capture patient option which thus force the patient and the program to repeat the process again in an infinite cycle, that will only end once the patient give another rating than 0-10 of their pain level on the 0-10 scale. Then the program will start to sequence their genome, then apply a tourniquet and finally perform an autopsy on what will, in the end, for certain be a deceased patient; but maybe the patient was still alive when the autopsy began. This will finally cause the patient to leave the cycle as a corpse. If the patient dies before giving a different option, the machine could get stuck, as it will never receive any answer to the pain level question. It could also get stuck trying to charge the patients phone battery by defibrillation.

One potential way to survive is to keep answering “nine” on the pain level question. Another possible exit would be spitting, drooling or sweating enough to register in the "fluid coming out of patient" stage while not bleeding or having snot fall out, causing the algorithm to freeze due to not having a response for clear liquids. This is the second comic in a row about health issues with the last comic being 1618: Cold Medicine.

Explanation of steps

Step	Medically valid?	Conditions and following step
Draw Blood	Phlebotomy is a normal early step in the diagnostic process, but not as first and unconditional step	Record patient’s name
Record patient’s name	Ideally done before a robot is involved, but not an abnormal step	Measure Patient’s height and Weight
Measure Patient’s height and Weight	OK	Consult Standard height/weight chart
Consult Standard height/weight chart	OK	Surgically adjust patient to match
Surgically adjust patient to match	May be considered ethically dubious unless there are sound medical reasons for doing so. Could be an allusion to Procrustes.	Is patient coughing up blood?
Is patient coughing up blood?	OK, coughing up blood is generally a sign that there is something wrong. Typical causes are respiratory tract infections (e.g. tuberculosis), lung trauma or pulmonary embolism.	Yes: Gather blood and return it to body
		No: Is patient still here?
Is patient still here?	Not usually considered a step, but missing patients are a problem in some fields, psychiatry or intensive care for example.	Yes: Record pulse rate
		No: Hunt down and capture patient
Hunt down and capture patient	Valid if patient should not have left the bed/unit, but the wording is possibly dubious.	Is patient still here?
Gather blood and return it to body	Dangerous idea in this case due to likelihood of contamination, although if safely done autotransfusion is an accepted medical technique to ensure a matching blood supply prior to a major operation, or to enhance stamina (blood doping)	Record pulse rate
Record pulse rate	OK, but maybe a little late.	Is patient screaming?
Is patient screaming?	Very important question, indicating patient is conscious, in pain, and aware pain is bad. First attenders can use it in classifying priorities (quiet patients may be more severely injured). Generally useful in assessing nerve damage, pain relief, etc.	Yes: Ignore
		No: Check blood O2 saturation
Ignore	Ignoring that a patient is screaming might not be a good idea, as it indicates that the patient is in severe pain, but could be indicated in mass casualty situations or other dire emergency.	Check blood O2 saturation
Check blood O2 saturation	Only really indicated if the patient is in danger of hypoxia. Generally normal people should have a SpO2 of 98-100%, but in chronic lung disease this can fall as low to 80%, and in premature babies a SpO2 of 90% is usually targeted to avoid problems with retinopathy. If the SpO2 were to fall as low as 50%, the patient would definitely be dead or unconscious.	>50%: Remove and inspect skeleton
		<50%: Inject oxygen
Remove and inspect skeleton	Fatal if patient is still alive when beginning. Also not a valid medical procedure in any way as it is impossible to remove most of the long bones of the body without destroying all surrounding tissue.	Too many bones: Is fluid coming out of patient?
		Too few bones: Request consult with human doctor
Request consult with human doctor	Medically valid in the context of obtaining an opinion from a doctor in a different speciality who is better suited to treating the patient.	Dissect doctor for parts
Dissect doctor for parts	This may be considered ethically dubious.[citation needed] Possible reference to the Doctor Who episode “The Girl in the Fireplace”	Discharge patient (left)
Discharge patient (left)	Acceptable, but patient would generally be dead by then.	END STATE (before you read the title text)
Is fluid coming out of patient	Unintended fluid release is always a problem. How significant a problem depends on where the fluid came from and if it is supposed to be coming from there. Red generally is due to blood, yellow is due to pus/tissue fluid/lymph and green signifies bacterial infection or bile salts (biliverdin). Could also relate to normal fluids being lost (e.g. urine, saliva, sweat)	No: Squeeze patient
		Yes: What color?
Squeeze patient	Could be in the medical context, as in providing external ventilation (see iron lung) or some means of removing fluid (e.g. squeezing pus from a boil).	Is fluid coming out of patient
What color?	Never underestimate the number of different types of fluid the body can produce. This may also be a refence to 1148: Nothing to Offer.	Yellow: Squeeze Patient
		Black: Activate Sprinklers
		Red: Ask patient to rate pain level
		Green: Cauterize
Activate sprinklers	Not medically valid. Presumably a reference to how much cleaning up will be required by this stage. Or, since this occurs when fluids are black, the black fluids might indicate that there are ashes or charred tissue, indicate that the patient has caught on fire and sprinklers are needed to extinguish the fire.	Subdue patient
Subdue patient	Potentially very important if patient is behaving dangerously to themselves and others around them (due to mental health issues e.g. psychosis or drugs) and/or is moving too much to be given treatment. This would be likely due to what happened earlier.	Apply cream
Apply cream	Medically valid as a form of barrier dressing to improve wound healing.	Ask patient to rate pain level
Ask patient to rate pain level	Useful in the sense that it provides the doctor with the means to ensure that the patient is receiving adequate analgesia during conditions of chronic and acute pain.	0-8: Massage scalp
		9: Admit for observation
		10: Laser eye removal
		Other response: Sequence genome
Massage scalp	This would belong more to the domain of palliative care and reflexology rather than being an accepted medical treatment.	Patient is healthy
Patient is healthy	A subjective assessment of the health patient is often helpful in ruling out certain diagnoses. For example, one is less likely to suspect cancer in a fit, healthy 30 year old than a thin, lethargic 50 year old.	Admit for observation
Admit for observation	Useful in the context of 'watchful waiting', in which the doctor may be unsure if the patient actually has a condition that they suspect that the patient has. By keeping the patient on the ward for a few days, the clinician can monitor the progression of symptoms and rapidly initiate adequate treatment if medically warranted.	Ask patient to rate pain level
Laser eye removal	This is not a standard medical procedure, and not a good idea. This is a reference to 1681: Laser Products. At least in animal surgery, however, laser eye removal does exist.	Admit for observation
Sequence genome	Useful in the association of extremely rare point mutations with an organic illness. See for instance the Genome 10K Project or the Cancer Genome Atlas. Or in diagnosing extremely rare mutations that are not picked up by most commercial DNA screening tests (e.g. kidney failure due to INF2 mutation).	Apply tourniquet
Apply tourniquet	Useful to stop acute bleeding from an injured extremity, but if it is drawn too tightly it can cause neuromuscular damage.	Perform autopsy
Perform autopsy	The patient has died, and Watson is being ordered to determine the cause of death. Note that the only way to reach this state is from "apply tourniquet", implying the cause of death is strangulation via tourniquet.	END STATE (taking the title text into account, the only possible one)
Cauterize	Cauterizing is done with a heated instrument or a chemical to burn the skin or flesh of (a wound), typically to stop bleeding or prevent the wound from becoming infected. This could be useful if there is an open wound, but can cause tissue damage and other complications.	Ask patient to rate pain level
Inject oxygen	May be fatal as injecting gases directly to the blood vessels can cause a serious embolism if it blocks blood flow to the brain or coronary arteries. However, if the oxygen is injected slowly into the venous circulation, it may be survivable as the bubbles may simply collect in the lungs where the oxygen is then slowly reabsorbed into the blood.	Comfort patient
Comfort patient	Psychological support to the patient and relatives is often useful after breaking news of a poor prognosis. It may also be useful in subduing the agitated or psychotic patient.	Comforting successful: Review medical history
		Comforting unsuccessful: Subdue patient
Review medical history	Important early step, rather too late and conditional.	Skin grafts
Skin grafts	Only indicated if massive areas of the skin are damaged (typically due to burns)	Count number of limbs
Count number of limbs	Not really relevant in medicine, but may be of use to know the reason behind any missing or extra limbs on seeing the patient though a through review of the medical history will render this point moot. Probably a little late to be noticing this now.	Fewer than 100: Measure Vitamin D
		100+: Remove extra limbs
Remove extra limbs	Medically indicated in cases of polymelia either due to cosmetic purposes or because the extra limbs pose a direct threat to the health of the baby.	Subdue patient
Measure vitamin D	Valid in diagnosis of bone related issues, for example if multiple or comminuted fractures were being counted as additional limbs/bones.	Good: Check whether build environment is sane
		Bad: Blood loss?
Check whether build environment is sane	Could be technical reference to the installation of the algorithm in the robot, or could relate to the sanity of: The robot doctor The patient undergoing this procedure (before or after reaching this part of the process) The person who programmed the robot to perform this flowchart The person who allowed this state of affairs to occur This could also be a reference to the title text for 371: Compiler Complaint. NB: Whether the build environment is sane is irrelevant to the flowchart.	Rinse patient with saline solution
Rinse patient with saline solution	Tepid sponging may be indicated if the patient has a high fever. Could also refer to internally rinsing patient with saline solution i.e. providing intravenous sodium chloride to boost circulating volume or to perform peritoneal dialysis.	Is patient phone battery low?
Is patient phone battery low?	Invalid in medical terminology, could be a technological metaphor for the patient's consciousness or stamina. "Your life-force is running out"	Yes: Defibrillate
		No: Sync photos from camera
Defibrillate	Indicated in cases where there is ventricular fibrillation, and to a lesser extent in other heart rhythm disorders, but would not help with a phone.	Is patient phone battery low?
Sync photos from camera	Definitely invalid. Could refer to the robot attempting to backup photos from a camera before attempting to repair it/attempting to back-up patient's consciousness.	Administer general anesthesia
Administer general anesthesia	Valid, but not at this stage. Only used when the procedure will invoke unnecessary distress or pain to the patient if they were to be awake beforehand. This also has the implication that no anesthesia has been applied beforehand. This implication means the patient has likely been subject to unnecessary pain which is ethically dubious.	Discharge patient (right)
Discharge patient (right)	Acceptable in general, but the patient would most likely be dead in both cases as life is not possible without organs, and general anesthesia often requires mechanical ventilation to support breathing.	END STATE (before you read the title text)
Blood loss?	Useful. Patient may die if this clinical sign is missed. However, it should be noted that there is no option for "No blood loss".	Minor: Patient address changed?
		Substantial: Apply cream
Patient address changed?	Useful to ensure that the organization has current contact details for the patient in the event that they may need to contact the patient (e.g. to arrange further appointments)	Yes: Request organ donation
		No: Patient is healthy
Request organ donation	Generally done prior to registering an individual for a driving license or to a medical practice, or to the relatives of the deceased if consent had not been acquired beforehand.	Remove organs
Remove organs	The only organs which can be safely removed from a living person without resulting in serious, chronic medical issues are the kidneys/lungs (only one can be removed), spleen, gonads (ovaries/testes), thyroid gland, part of the liver (as long as one lobe is left it can regrow to its original size) and colon (usually consisting of the appendix only). With some serious lifestyle modifications, the pancreas, pituitary gland, frontal lobe of brain, half of the brain, second kidney, adrenal glands, bladder, and most of the gut can be removed. The heart can be removed from the body and replaced with an artificial pump for a few months at the most. However, such organ removals are only indicated if there is a genuine clinical need to do so due to the non-negligible risk of death associated with these operations.	Discharge patient (right)
Title text	The glitch in the algorithm causes it to continue in spite of having just discharged the patient	Hunt down and capture patient.