Episode 7: The Medicine of the Empire Strikes Back

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In Episode 7, we take you to a galaxy far, far away to explore the medicine of the best Star Wars film, the Empire Strikes Back. How close are we to replicating their medical interventions? And what can Star Wars tell us about medicine back here on Earth? This is the first in (hopefully) a series of “Medicine in Science Fiction” podcasts.

So I think it goes without saying that I’m something of a nerd. Strike one — I’m a doctor, which I’ve got to believe is at least a nerdier than average profession. Strike two — I’m an internal medicine doctor, or the nerds of the nerds. Sit in a morning rounds about the differential diagnosis of hyponatremia, or the likelihood ratio of an elevated jugular veins for heart failure, and you will see what I’m talking about. Strike three — I love science fiction. And I know there aren’t four strikes in baseball, but bear with me  — what I especially love in science fiction is the portrayal of medicine. Pretty bad, right? That’s probably not what most people get out of scifi, and sure, I also enjoy space battles, shapeshifters,  and human cloning projects. But what I love about medicine in science fiction is the prediction that it makes of how our medicine might change and adapt to different technology and ethics, how our relationship with medicine and science is always evolving, and of course, how it turns the looking glass back on medicine in the 21st century.I’m excited about this because I get to rewatch awesome science fiction movies, and discuss medical interventions and maybe even the greater health care delivery system. Oh, I know you’re excited to take about health care delivery in Star Trek’s post-scarcity world. So with that, this will be the inaugural episode of my Medicine in Science Fiction series.

For this inaugural episode I’m going to be talking about the medicine in one of my all-time favorite movies, the unrivaled best of the series, Star Wars Episode V: The Empire Strike Backs. There are three particular interventions that come to mind, which  I’ll be rating  in terms of plausibility, effectiveness, and downright coolness on the Bedside Rounds patented Ewok rating scale — the teddy bear warriors from the third Star Wars film —  where four Ewoks is an exciting therapy that has a cool real-world parallel, or just plain awesome, like, say, lightsabers, and one Ewok is, I don’t know, the Star Wars equivalent of homeopathy.

Okay, so our first foray into a galaxy far, far away will be decidedly low tech. Let me pique your memory. Luke Skywalker is horribly injured and wandering around delirious on the ice planet Hoth after escaping and shishkebabing the Wampa, essentially an abominable snow-man. Fortunately, Han Solo, riding a snow-camel creature called a Tauntaun,  quickly finds him tumbling through the snow. But Luke is injured, the sun is setting, and to add insult to injury, the poor tauntaun up and dies. Instead of some sort of magical warming technology, the ever-industrious Han takes Luke’s lightsaber and cuts open the Tauntaun’s belly, then pushes the poor jedi inside the animals steaming entrails.

So three issues here – is this a medical intervention? Would it work? And what experience do we have in the real world with freezing injuries like Luke’s?

Shockingly, crawling inside animals to survive the cold is a thing. And no, I didn’t learn about this in medical school — they conveniently left that out of Harrisons and Up-to-Date – but instead from the wonder that is the internet. Via the blog – and I’m not making this up – crawlinginsidenaimalstosurvive.blogspot.com, we have the story of the Reverend Jospeh Goiffon, a French priest in the Dakotas, who, much like Luke, set out on a fateful journey in August of 1860. I quote here:

 “the winter cold was also beginning to set in. But Father Goiffon was anxious to reach his parish and went ahead by himself on the horse which he had purchased while in St. Paul. The rain turned to snow and quickly both horse and man became hopelessly lost. The horse died in the bad storm, and TO SAVE HIS OWN LIFE THE PRIEST CUT OPEN THE CARCASS AND CRAWLED INSIDE. When Father Goiffon was found he was still alive but one leg was badly frozen.”

I should say that the author of the blog capitalized the part about cutting open the animal. So there’s at least a case report about crawling inside an animal carcass to escape the cold – not the highest level of medical evidence, but doctors have certainly operated on less.

Determining the effectiveness of this intervention is trickier business, though. I can’t imagine an IRB agreeing to randomize animal entrails versus placebo. Fortunately, Keith Veronese, a writer on the science fiction blog io9, has done science a great favor by using some simple math (along with assumptions about the body temperature of a tauntaun and the overnight temperatures near the Equitorial zone on Hoth), and he’s come up 47 minutes and 26 seconds  that Luke would have inside the belly of a tauntaun until severe hypothermia  — a body temperature of 20 to 28 degrees C — set in.  And once severe hypothermia sets in – well that’s bad. But is it survivable?

Besides ischemic tissue damage (what destroyed the French priest’s leg), much of the organ damage can be undone. It turns out, what is commonly fatal in freezing patients is cardiac arrhythmias, which start to appear at body temps below 30 – below 25 and we get asystole (or cardiac arrest).  For these most severe patients – which Luke would be rapidly approaching on frigid Hoth– the choice therapy would be extracorporeal rewarming through a cardiopulmonary bypass. In other wards, cracking the chest and surgically bypassing the heart with a blood warming machine. Does it work? A Finnish review  of 23 patients (of course in Finland, since hypothermia is an occupational hazard of living in Finland) found a 61% survival. And referenced in Atul Gawande’s Checklist Manifesto, there’s a fascinating case report of a 3-year old girl who drowned in a lake – her body temperature was 18.4 C when she arrived to the emergency room. A cardiopulmonary bypass was performed, then extracorporeal membrane oxygenation – essentially lungs outside the body – was started. She survived, and most miraculously, she survived with absolutely no neurologic deficits at 20 months.

So where does hiding inside an animal for warmth rate on our completely arbitrary rating scale? Surprisingly, I’m going to give in a completely arbitrary 3 out of 4 Ewoks. It’s plausible – tested out by French priests! It would give some time for Han to get help. And even at incredible levels of hypothermia, it’s potentially survivable with a cardiopulmonary bypass – assuming they have a cardiothoracic surgeon on hand at Hoth, and maybe an ECMO machine.

Which brings us to our second medical intervention in the Empire Strikes Back – the Bacta Tank. So after Luke is brought back to base, he’s suspended in a vat of blue fluid while a robot doctor looks on and presses some buttons. A short while later, he is hoisted out, wet, gooey, and definitely not looking like he had a cardiac arrest from severe hypothermia, and definitely not a sternotomy. So what’s going on here? Well, according to Dr. Wookiepedia, the Star Wars version of Dr. Wikipedia, bacta is some sort of healing bacteria slushy that magically fixes everything – or at least speeds up the healing process. Now, as far as I know, we have yet to develop tubes of goop that are cure-alls for everything under the sun. The closest equivalent that I can think of would be the hyperbaric oxygen chambers – essentially giant metal coffins full of pressurized oxygen that are traditionally used to treat decompression sickness in deep sea divers, and for severe carbon monoxide poisoning.  There’s some evidence that they might help in a variety of conditions like nonhealing ulcers, prior radiation therapy, actinomycotic brain abscesses – which sounds absolutely horrible – and severe anemia. It’s been proposed as therapy for a litany of other medical conditions.  So basically, we’re nowhere close to a Bacta Tank. Is it plausible? Unlike warm animal entrails, I have no idea what the proposed mechanism would be, besides magic. Of course in the Star Wars universe you can shoot lightning out of your hands, so I guess super healing bacteria is within the realm of possibility. But until I see some Force powers down here on earth, the Bacta Tank will have to get the unfortunate rating of only one Ewok.

Now for the coolest medical intervention in the Empire Strikes Back. After Luke Skywalker loses his hand in a duel with — hashtag 30 year-old spoiler alert– his father, he is whisked away to a rebel starship where the same bacta tank robot doctor installs an artificial hand on him. The hand is truly a marvel — Luke clearly has tactile sensation, good grip strength, fine motor skills, and he can wield a lightsaber better than ever. Absolute science fiction right?

Hopefully for not much longer. A case report was published earlier this year in Science Translational Medicine describing the Life Hand 2. I’ll just read a quote from the report, because this is remarkable:

We show that by stimulating the median and ulnar nerve fascicles … physiologically appropriate (near-natural) sensory information can be provided to an amputee during the real-time decoding of different grasping tasks to control a dexterous hand prosthesis. This feedback enabled the participant to effectively modulate the grasping force of the prosthesis with no visual or auditory feedback. Three different force levels were distinguished and consistently used by the subject. The results also demonstrate that a high complexity of perception can be obtained, allowing the subject to identify the stiffness and shape of three different objects by exploiting different characteristics of the elicited sensations

In other words — he controlled the hand with his BRAIN, via what was left of his median and ulnar nerves. And the hand sent messages back to his brain. The subject of the study, who lost his hand in a fireworks accident — can feel shape, consistency, and size of an object in real time, and adjust his grip strength. There’s a video on Youtube, which I’ll place on the website, which is remarkable. The project clearly has a long way to go before amputees will be able to wield lightsabers, but this is a good first step towards jedi domination. By the way, the research project working on these prostheses is called the Neurocontrolled Mechatronic Hand Prosthesis, or for short — and I’m not making this up — NEMESIS. That’s right, the NEMESIS Project, which seems like it’s right out of Star Wars, except working for the Dark Side. So robotic hands I’m going to have to give the highest honor, four Ewoks.

So those are three pretty cool medical interventions in Star Wars, ranging from, let’s call it generally “field medicine” to high tech orthotics. But now I want to take my nerding out to another level — if that’s even possible — I want to talk about the greater health care delivery system in the Star Wars Universe. I know, oh god. But medical technology plays a large part in science fiction — think about your favorite movie or television show, and a character is probably a doctor. Think Dr. McCoy in Star Trek — or really, any doctor from any Star Trek, Jack in LOST, Scully in the X-Files.. and the list goes on. Which is why it’s so interesting that there are no doctors in Star Wars. Not a single one, as far as I could tell. There’s certainly a need for them. Someone suffers a trauma every couple of minutes. Arms cut off, hypothermia, decompression, smoke inhalation, endless blaster wounds. The Star Wars Universe is a dangerous place. The medicine practiced in the Empire Strikes back is not done by a human — or alien — doctor, but rather a robot. A very scary looking robot who has attached scalpels, and apparently does not talk.  Which makes me wonder, does this same robot also see Luke for preventative medicine? Did check his lipids and A1C and make sure his immunizations were up to date? Or his midichlorians at least? Do people in the Star Wars universe even take medications, or just Bacta baths? Was this George Lucas’s commentary on medical decision making tools and IBM’s Watson?

Okay, I don’t think so. I’m making a lot of ado about a movie series that features warrior teddy bears and muppets. Star Wars has always been less about the “science” and more about the “fiction”. And despite that — or because of that — it’s awesome.

Okay, that’s it for the show. As always, thanks so much for listening. This was an experiment in trying something different. Was it a dud like Episode I? Do you desperately want another episode about biostatistics? Let me know on Twitter @AdamRodmanMD. And just kidding, you’re getting another episode on biostatistics whether you want it or not. Want more bedside Rounds? You can check us out on our website www.bedside-rounds.org, or on iTunes by searching for Bedside Rounds. And please subscribe! Oh, and of course, may the Force be with you…

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