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THE ANESTHESIA CONSULTANT

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

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I love the movies, but it can be painful to watch scenes where the facts are distorted, sometimes so much that the storyline is implausible. Let’s take a look at medical inaccuracies in movie scenes from 12 famous Hollywood films:

1. Million Dollar Baby (2004). This film is my Hollywood medical pet peeve, and the movie that motivated me to write this column. Million Dollar Baby won the Academy Award for Best Picture in 2004, yet the concluding scenes vital to the movie’s plot are both medically impossible and unrealistic. The female lead, Maggie Fitzgerald (Hilary Swank) is seriously injured in a $1 million World Boxing Association welterweight title match. Maggie is paralyzed from the neck down— a ventilator-dependent quadriplegic—and is hospitalized in a private room. Her coach and trainer, Frankie Dunn (Clint Eastwood) visits her. He sits next to her bedside and they discuss her fallen health. She tells Clint she doesn’t want to go on living like this, a paralyzed invalid. What’s the problem with this scene? It’s impossible for Maggie to talk if she’s on a ventilator. Maggie has a tracheotomy, with the breathing tube inserted in the front of her neck, below the level of the vocal cords. A patient cannot speak with a tracheotomy tube in place because all ventilation takes place below the vocal cords. If Maggie can’t speak, she can’t utter her lines, and she can’t partake in the dialogue with Clint. Somehow the movie’s medical consultants let the movie be filmed with this medical impossibility.                   But wait—there’s another medical impossibility. In a later scene, Clint returns to the same room and kills Maggie. First he turns off the ventilator and disconnects Maggie’s breathing hose at the tracheotomy site. Then he injects her IV with a syringe of adrenaline, and leaves the vital signs monitor on. The vital signs monitor shows her heart rate suddenly change to zero as she dies. That’s not how adrenaline works—it’s not a euthanizing drug. Adrenaline causes the heart rate and blood pressure to rise higher and higher—think heart rates in the range of 200 beats per minute and a blood pressure of 250/180. This may or may not kill someone over time, but it will not kill them in seconds. An injection of potassium chloride could kill Maggie in seconds, but where would Frankie obtain potassium chloride? He could not. As this scene ends, Frankie walks out of the room leaving Maggie to die behind him. The vital signs monitor continues to emit a soft high-pitched tone, but there’s no one else around to hear it. In reality the vital signs monitor would be emitting a loud alarm, signaling to everyone that the vital signs are gone and the patient is trying to die. These alarms would bring a fleet of nurses and/or doctors into the room to try to save the patient. But if they saved Maggie, Million Dollar Baby would’ve had a different ending, and Clint Eastwood wouldn’t have had his bold moment of stopping Maggie’s suffering—the bogus version of Million Dollar Baby that won Best Picture.

2. Pulp Fiction (1994). In a famous scene Mia Wallace (Uma Thurman) snorts a large dose of heroin and collapses in either a cardiac arrest or a sudden coma. Vincent Vega (John Travolta) brings the unconscious Mia to his dealer’s house. The dealer hands Travolta a syringe of adrenaline connected to a 6-inch-long needle. Travola plunges the needle into the front of Mia’s chest with a prodigious swing of his arm. He doesn’t even have time to push the plunger and inject the adrenaline before Mia immediately screams and wakes up. This scene, as entertaining as it is, could never occur. No layperson would understand where in the body to inject intra-cardiac adrenaline. The chance of puncturing a lung or lacerating the heart or great vessels of the chest would be high. In a cardiac arrest the preferred route of epinephrine injection is into an arm vein, concurrent with chest compressions which move the drug through the circulatory system and into the heart. I’ve practiced acute care medicine for over three decades, and I’ve never found a need to inject epinephrine into a patient’s heart directly.                                                                                             And it’s unlikely Mia Wallace would wake up instantly. If her diagnosis was stupor from the combination of alcohol and heroin, then perhaps the pain of the injection would wake her. If she was suffering from a heroin/narcotic overdose, the specific antidote would be Narcan, not adrenaline, and it should be injected into one of her arm veins. If her diagnosis was a cardiac rhythm disorder such as ventricular fibrillation or ventricular fibrillation which caused sudden death, the only therapy likely to immediately revive her would be cardiac defibrillation, e.g. by an ACD (automatic cardiac defibrillator) similar to the machines found in public areas like airports or arenas. But if she had ventricular fibrillation or tachycardia for the entire duration it took to transport her across town to Travolta’s dealer’s house, then Mia would be dead after that prolonged time and she could never recover. Director/writer Quentin Tarantino scored bigger points by having his two biggest stars connect via a 6-inch needle to the chest. The result was memorable, laughable, and outrageous entertainment, but without plausibility.

3. Casino Royale. (2006). James Bond realizes he’s consumed a poison drink while at a baccarat table in a casino. He knows he’s about to die, and stumbles to his car in the parking lot outside. He removes some sort of cell phone device from the glove compartment and contacts M’s headquarters in London. Bond instantly inserts a needle into his radial pulse at his wrist, and miraculously his vital signs are revealed to London. The doctor in London assesses that Bond is in ventricular tachycardia, a dangerous heart rhythm, and tells Bond to take the defibrillator out of the glove compartment and connect it to his chest. Within another minute, the electronic device inserted into Bond’s pulse miraculously transmits to London the diagnosis: the poison is digitalis. The doctor tells Bond to inject the blue syringe from the glove compartment to “counteract the digitalis.” (There is zero chance any spy would be carrying this rare antidote in his glove compartment) Bond blindly stabs himself in the neck with the syringe at a 90 degree angle, and then passes out before he can activate the defibrillator. Bond’s lady friend arrives on the scene in the nick of time and pushes the red button on the defibrillator to shock Bond, and he wakes up . . . all cured! None of this could happen.
   Let’s look at the series of medical impossibilities in this scene:
   It’s nearly impossible that in his stuporous state, Bond was able to insert a needle into a blood vessel. (No one inserts a needle into an arm vein without a tourniquet, so the vessel can’t be a vein. The blood vessel must be the radial artery. Also, no one inserts a needle into an arm vein at such an acute angle, so this argues for the vessel being an artery as well. In medicine, we do place catheters in the radial artery, but this takes significant skill as the vessel has an interior diameter of about 1 millimeter. We do send blood samples from a radial artery to a lab to diagnose blood levels, but the lab results take time to be processed. This is science fiction  that the touch of a needle into an artery would give an instant analysis of all blood levels, including diagnosis of a digitalis overdose.
   The continued impossibility is that the antidote for a digitalis overdose (A digitalis overdose antidote does exist, but the diagnosis is rare and so is this treatment) just happens to be one of the few syringes in the glove compartment in Bond’s car. The impossibilities continues in that Bond stabs the needle at 90 degrees into his right neck, magically finding a blood vessel there. The two blood vessels in the neck are the jugular vein and the carotid artery, and even the most experienced surgeon or anesthesiologists could not stab a needle into either of them in his own neck at a 90 degree angle without even aiming.
   That’s my analysis. An impossible scene, not medically researched, but it made for a James-Bond-level of entertainment.

   Somehow you had a feeling all along that Bond wouldn’t die, didn’t you? An academic medical paper examined the phenomenon of cardiac arrest survival rate in the movies. The article studied thirty-five cardiac arrest scenes in 32 movies from 2003 to 2012 (including Casino Royale, Mission Impossible 3, Inception, and Spider Man 3) for accuracy and credibility. (Ofole UM et al, Defibrillation in the movies: a missed opportunity for public health education, Resuscitation. 2014 Dec; 85(12): 1795–1798.) This medical study concluded that in the movies, defibrillation and cardiac arrest survival outcomes were often portrayed inaccurately. In 8 scenes of in-hospital cardiac arrest, 7 of the 8, or 88% of the patients survived, compared to survival rates of 23.9% reported in the medical literature. In 12 movie scenes involving out-of-hospital cardiac arrest, 8 of 12, or 67% of the patients survived, compared to survival rates of 7.9-9.5% reported in the medical literature. In summary, too many patients survived in the movies. I presume that’s because writers, directors, producers, and audiences all prefer to see their movie stars wake up and live. See #4 below for another example of the same in a blockbuster Hollywood movie.

4. Jurassic Park (1993). Tim Murphy, the middle-school-aged grandson of the park’s inventor, is electrocuted on the perimeter fence of a dinosaur pen. He collapses to the ground and Dr. Alan Grant (Sam Neill) says, “He’s not breathing.” Dr. Grant proceeds to give Tim mouth-to-mouth resuscitation and chest compressions, and in exactly 26 seconds Tim coughs several times and wakes up. Remarkable! Per the medical publication in Resuscitation above, this sort of recovery from out-of-hospital cardiac arrest . . . only happens in the movies.

5. Coma (1978). The 1977 novel Coma by Robin Cook, MD from Harvard was the first outstanding medical thriller, and one of the books that inspired me to become a writer. A successful movie version of Coma followed the book. The premise of Coma was that healthy young patients were developing brain death after general anesthesia, for no apparent reason. The protagonist Dr. Susan Wheeler (Genevieve Bujold) uncovers the root cause of the evil scheme: patients are breathing carbon monoxide instead of oxygen during general anesthesia, because some diabolical doctors have spliced a pipeline of carbon monoxide into the oxygen pipeline. The brain-dead patients are then harvested to a secret room and suspended by wires from the ceiling in a supine posture until their bodies can be sold and transported off as organ donors.                                                                                                                   In the 1970’s when the screenplay was written this plot may have seemed plausible, but in the 21^st century it’s impossible. The anesthetic gases you breathe are now monitored on a second-to-second basis, and if the mixture does not contain adequate oxygen, multiple alarms sound off instantly. In addition, you wear a pulse oximeter on your fingertip. If the blood in your finger does not contain adequate oxygen, the oximeter reads a low result and alarms instantly so the anesthesiologist can remedy the situation. As well, extra oxygen tanks are present in every operating room as a safety back up, in the rare instance that the piped-in wall oxygen source is stopped or is inadequate. You can relax. Coma could not happen in this manner in the 21^st

6. Split (2016). The villain in this film suffers from multiple personality disorder, or dissociative identity disorder (DID). In more than one scene, the villain Kevin Wendell Crumb (James McAvoy) sprays an aerosol into the face of his victims. Within seconds these individuals collapse in unconsciousness. Crumb lives and works at a zoo, where the audience is led to believe such a spray tranquilizer is used as needed to tranquilize the animals. As an anesthesiologist who induces unconsciousness in my patients every day, I can tell you that no such immediate coma-inducing spray gas exists. The potent inhaled anesthetics we anesthesiologists use are sevoflurane, desflurane, and isoflurane. Veterinarians these same anesthetic vapors for their surgical anesthetics as well. Each of these drugs is a liquid, which is then vaporized by special equipment to deliver inhaled anesthesia gas. These vaporizers are metal cylinders about the size of half-gallon milk carton. The fastest and most pleasant smelling of these vapors is sevoflurane. Inhaled sevoflurane can induce anesthesia in ten to thirty seconds if a high concentration of the drug is inhaled deeply into the lungs, but there is no drug that works in one second, like the aerosol that the villain used in Split.

7. Old School (2003). This movie portrays another version of the instant sedative. In a scene at a youth birthday party, Frank Ricard (Will Farrell) picks up a tranquilizer gun which is designed to inject “the most powerful animal tranquilizer in the world” into any of the ponies or farm animals on display at the party. Frank accidentaly shoots himself in the neck, and the dart remains sticking out of the left side of his neck at a perpendicular angle. The owner of the gun, an animal tamer, comments that Frank has injected himself “in the jugular.” Within the next 30 seconds, Frank becomes increasingly wobbly and stuporous, and eventually falls face first into the swimming pool. Could this happen? Almost certainly not.                 Ketamine is the quickest injectable drug anesthesiologists have in their arsenal to anesthetize a patient by a non-intravenous injection. Ketamine is an injectable general anesthetic which is effective in inducing general anesthesia within 30-120 seconds after an intramuscular injection. If injected directly into a vein, e.g. an arm vein, ketamine can induce general anesthesia in 10-15 seconds. But the stab to Frank’s neck at the 90-degree perpendicular angle is unlikely to hit the exact location of the internal jugular vein, which is only about 1/2 an inch in diameter. And Will Farrell’s dart didn’t land in any big muscle like the buttock or the deltoid muscle at the shoulder, either. Powerful injectable animal tranquilizers such as etorphine or xylazine or tiletamine exist which can subdue a beast in a short time after intramuscular injection, but none of them will work as fast as the drug does in this scene. Movies are about entertainment, and it’s not entertaining to watch an actor spend five slow minutes becoming sedated enough to pass out so the plot can move onward.

8. Awake (2007). Young billionaire Clay Beresford (Hayden Christensen, or Anakin Skywalker from the Star Wars movies) needs a heart transplant, and it turns out that he is awake and aware during the general anesthetic for his heart surgery. While he is awake he overhears the surgeon’s plan to murder him. Producer Joana Vicente told Variety that Awake “will do to surgery what Jaws did to swimming in the ocean.” The movie trailer aired a statement that states, “Every year 21 million people are put under anesthesia. One out of 700 remain awake.” Awake was not much of a commercial success, with a total box office of only $32 million, but the film did publicize the issue of intraoperative awareness under general anesthesia, a topic worth reviewing.                                                                                                              If you have a general anesthetic, do you have a 1 in 700 chance of being awake? If you’re a healthy patient undergoing routine surgery, the answer is no.  If you’re extremely sick and you’re having a high-risk procedure, the answer is yes. A key publication on this topic was the Sebel study. (The incidence of awareness during anesthesia: a multicenter United States study, Sebel, PS et al, Anest. Anal.  2004 Sep;99(3):833-9, Department of Anesthesiology, Emory University School of Medicine.) The Sebel study was a prospective, nonrandomized study, conducted on 20,000 patients at seven academic medical centers in the United States. Patients were scheduled for surgery under general anesthesia, and then interviewed in the postoperative recovery room and at least one week after anesthesia. A total of 25 awareness cases were identified, a 0.13% incidence, which approximates the 1 in 700 incidence quoted in the Awake movie trailer. Awareness was associated with increased American Society of Anesthesiologists (ASA) physical status, i.e. sicker patients.  Assuming that approximately 20 million anesthetics are administered in the United States annually, the authors postulated that approximately 26,000 cases of intraoperative awareness occur each year.                                                                         Healthy patients are at minimal risk for intraoperative awareness. Patients at higher risk for intraoperative awareness include: 1) patients with a history of substance abuse or chronic pain, 2) ASA Class 4 patients (patients with a severe systemic disease that is a constant threat to their life) and others with limited cardiovascular reserve, 3) patients with previous history of intraoperative awareness, 4) patients requiring the use neuromuscular paralyzing drugs during the anesthetic, and 5) patients undergoing certain surgical procedures which are higher risk for intraoperative awareness, including cardiac surgery, Cesarean sections under general anesthesia, trauma cases, or emergency cases.

9. Vertigo (1958). Vertigo has no surgical/anesthetic/critical care gaffes, but I’ll comment on the film because the leading lady (Kim Novak) and I have the same last name (alas, we’re not related) and because it’s always been one of my favorite movies. The physical symptom known as vertigo is defined as, “a medical condition where a person feels as if they or the objects around them are moving when they are not. It often it feels like a spinning or swaying movement. This may be associated with nausea, vomiting, sweating, or difficulties walking. It is typically worsened when the head is moved. Vertigo is the most common type of dizziness.^” In key scenes from Vertigo, Scottie Ferguson (Jimmie Stewart) suffers from attacks of acrophobia. His symptoms are presented as a whirling sensation when he looks downward from a height.                                                                                                           The symptom complex Jimmie Stewart suffers from in this movie would more accurately be described as acrophobia than vertigo. Acrophobia is “an extreme or irrational fear or phobia of heights, Acrophobia sufferers can experience a panic attack in high places and become too agitated to get themselves down safely.” Jimmie’s character is incapable of functioning at heights, and contributes to his inability to save Kim Novak from falling to her death in the film’s final minute. Vertigo is a catchy title—no doubt a more nuanced and debatable title than Acrophobia. In 2012 Sight & Sound granted Vertigo first place in their poll of the greatest films of all time. Imagine if the number one movie of all time had been correctly named Acrophobia after it’s medically accurate diagnosis.

10. The Doctor (1991). In the movie’s opening scene, surgeon Jack MacKee (William Hurt) is shown in the operating room completing a heart surgery. As the final crucial stage of the operation is completed successfully, he asks for his “closing music.” The Jimmy Buffett song “Why Don’t We Get Drunk (And Screw)” begins to play, and the three male surgeons and the male anesthesiologist all sing the chorus together. William Hurt says to his scrub nurse, “Nancy, I want to hear you sing for me.” The photo above is the scene just before the singing begins. William Hurt is the surgeon, second from the right, and Nancy is on the far right. The anesthesiologist is in the center, in the immediate background. Why is this scene inaccurate? One answer is that the singing anesthesiologist is not separated from the sterile surgical field by the usual vertical barrier of sterile drapes known as the “ether screen.” Anesthesiologists don’t stand inches from the surgical field next to the surgeons. But how about singing the sexual song in the operating room? Many surgeons have their favorite closing music, and an occasional surgeon will sing along with their closing music. Could this scene of sexual harassment occur in 1991 when this movie was made? It could—back in the 1980s and 1990s I saw actions as bold as portrayed by William Hurt’s character, and worse. But this wouldn’t occur in 2017. There’s no tolerance for sexual harassment in the medical workplace nowadays.

11. Get Out (2017). An excellent thriller with absurd characters and shocking scenes, Get Out faltered badly regarding surgical and medical science. (Spoiler Alert) The plot hinges on brain transplantation, a far-fetched fiction in itself. To make the movie’s depiction even worse, the brain transplantations are performed in the basement of the neurosurgeon’s house, with the two patients side-by-side, and there is no anesthesia equipment or anesthesiologist. The first patient seems to be dozing, without any breathing tube or ventilator, while the surgeon (above) slices off the top of his skull. There are also no nurses or scrub techs, the only assistant being the neurosurgeon’s son, who is a medical student. An entertaining movie, right up until this scene, which is so absurd that no one could possibly believe it. Get Out received a Rotten Tomatoes score of 99%, so the critics (none of whom are doctors) still loved the movie.

12. The Outsiders (1983.) Francis Ford Coppola’s fine coming of age movie is marred by the improbable and impossible next-to-last scene where Johnny (Ralph Macchio) dies in his non-ICU hospital bed while his two friends Ponyboy (C. Thomas Howell) and Dally (Matt Dillon) watch him breath his last, and no one calls for a doctor or a nurse to help. In reality, a witnessed cardiac arrest in a hospitalized patient would lead to a Code Blue, with multiple doctors and nurses rushing into the room to treat the patient with a breathing tube, CPR, and intravenous Acute Cardiac Life Support medications.

There they are: my 12 favorite examples of medical inaccuracies from major film studios. Will there be more in the future? Don’t doubt it. Hollywood directors and writers aren’t likely to let mere medical science stand in the way of entertainment. 🙂

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan: