Medical Review: That One Scene from “Casino Royale”
Filed under: Medicine
While our home lay blanketed in ice and powerless this weekend, the wife and I decided that it would be a good idea to travel someplace with a working heater, so we decided to see a movie. And not just any movie, but we decided to catch Casino Royale, the latest James Bond movie and the first to star Craig Daniels Daniel Craig as Bond.
It was a wise decision. Not only did we avoid hypothermia and frostbite, but Casino Royale is one of the best — if not the best — of the Bond films. Daniels played a phenomenal James Bond, and it was great to a Bond closer in spirit to the James Bond of the books than the outrageous movie bond of late. I agree with Tom that the movie was about thirty minutes too long, but the chase scene at the beginning more than makes up for it.
Cynical physician that I am, there was scene that caught my eye about two-thirds of the way through the film:
While playing a high stakes game of poker at the Casino Royale, James Bond drinks some poison that was slipped into his martini. Once he notices its effects (rapid heart rate, diaphoresis), he rushes to the bathroom where he makes an emetic of salt-water in an attempt to purge any remaining poison from his stomach. He rushes to his car where an AED (automatic external defibrillator) is waiting, along with a connection to the team at MI6 back in England. He jams a fancy needle in his arm which allows the chaps at HQ to determine that he has been poisoned with Digitalis. They have him slap defibrillator pads on his chest and then inject a medication into his neck. As the medicine takes effect, he tries to set off the defibrillator, but can’t manage it. As he collapses and his heart stops beating, Vesper arrives and sets off the AED, reviving Bond.
Digitalis is a potent cardiac medicine. Originally refined from the foxglove plant, digitalis is still used today in conditions such as heart failure and atrial fibrillation. A digitalis overdose has a surprisingly high morbidity and mortality.
It takes 6 hours for digitalis toxicity to kick in after a large dose, so it wouldn’t have taken affect until well after the poker game.
Toxic levels of digitalis can cause a wide variety of abnormal cardiac rhythms. The most common in acute toxicity is a bradyarrythmia, or an abnormally slow heart rhythm. Tachyarrythmias (abnormally fast rhythms) can also occur in acute toxicity and are a worrisome sign. Bond had a racing heart rate — though I have to admit that while he had fairly fast rate of around 135, it looked like a normal conduction pattern to me and not a dangerous rhythm.
Defibrillation is not recommended routinely for digitalis toxicity because it can cause very nasty heart rhythms (such as ventricular fibrillation) or it can cause the heart to stop beating entirely (asystole) — neither of which are good things.
I did not catch the name of the drug he injected into his jugular vein, so I I’m not going to speculate on how it would work. However, if someone more observant than me did catch the name…
You’ll note that Bond was defibrillated while in asystole. This is not a good idea, and one of the Most Common Comic Book Medical Errors (and movies too).
A final thought on the defibrillator. Many modern AEDs can set off the shock themselves once they are turned on, so there’s no need to manually trigger the shock. Additionally, nearly every model has a fault detector to make sure the circuit to the pads is working. It’s a shame MI6 spent all that money on his car and skimped on the AED.
[Don’t let this medical nit-picking make you think I didn’t enjoy the movie. I did. Go see it, and on the big screen too. That intial chase scene just won’t be the same on a small screen.]
December 5th, 2006 at 12:13 am
I believe you mean “Daniel Craig”.
December 5th, 2006 at 1:09 am
Does the bad guy weep blood because he is using his psychic powers?
December 5th, 2006 at 6:19 am
Official Comment
Conor,
You’re right. I realized it after I finished posting, but was too lazy to fix it.
December 5th, 2006 at 2:49 pm
The fact that he rushes to the AED and pretty much goes straight for shocks isn’t surprising. I was a cryptologist for the military, and they taught us that if there’s an AED around you should use it and pretty much ignore basic CPR. It seemed counter-productive to me, but you can’t fight the military. Besides, the thought of giving someone CPR scares me enough in the first place.
December 6th, 2006 at 6:51 pm
I thought I knew what they said the injection was, but now you have me questioning my memory. I seem to recall they said it was epinephrine (a “House, M.D.” favorite!)
December 7th, 2006 at 11:53 am
In Spanish I think it says “lidocaine”. I’m not physician but searching on the internet I found that lidocaine can be used
in cases of digital intoxication when the patient suffers from tachyarrythmia, like in the movie. Please, correct me if I’m mistaken.
December 7th, 2006 at 12:04 pm
Official Comment
Lidocaine makes sense. It is the best studied drug for tachyarrythmias due to digitalis toxicity. Of course, the trouble with lidocaine is that once the initial loading dose is given, the patient needs to be on a lidocaine drip (an IV slowly giving the drug) until the digitalis is completely out of the system — several hours, at the very least.
December 9th, 2006 at 9:26 am
Scott, saw the movie again last night and I swear it sounded like “comadine”??
December 9th, 2006 at 9:29 am
[…] By the way, if you’ve seen the movie I highly recommend this spoilerific and interesting discussion of the medical facts surrounding a particular scene in Casino Royale. Filed under: James Bond, Movies & TV — deblipp @ 10:29 am […]
December 29th, 2006 at 3:18 am
It really is the best Bond film, ever, medical mistakes and all! I wonder if special agents like Bond take issue with unbelievable “spy facts” in the film? :)
January 22nd, 2007 at 7:58 am
Does anyone knows what is that AED? type, production, any other information?
January 28th, 2007 at 7:02 pm
Actually, none of the characters in the original English-language version of the film specify what’s in the injection. Deborah, when you thought that the MI6 tech said “comadine” he actually said “(blue) ComboPen”. The ComboPen is an autoinjector (similar to an EpiPen) usually pre-loaded with drugs known to counteract the typical toxins that a soldier (or agent) will encounter. For example, the popular US military ATOX ComboPen contains atropine and obidoxime, and is used as an antidote for many kinds of nerve agents. These types of autoinjectors are in widespread use by military forces around the world. The term “ComboPen” is actually trademarked by Meridian Medical Technologies, but has passed into use as a generic term for any type of autoinjector, whether or not actually manufactured by Meridian.
I would also be interested to know the make and model of the AED used in the film, or whether it’s a fictional prop.
March 6th, 2007 at 10:03 am
Just for clarification, could you maybe tell us when defibrillation *is* used? So many shows seem to get it wrong nowadays that nobody seems to know anymore…
;)
March 15th, 2007 at 2:43 am
correct me if i’m wrong, but they taught us that you use defibrillation in ventricular fibrillation, so if you have to trigger yourself, you have to have an ecg strip you can base your strategy on. with persistent ventricular tachyarrhythmia, you wanna use cardioversion, which is a kind of defibrillation triggered some milliseconds after the R wave in the ecg, thus overstimulating and ending the tachyarrhythmia.
i agree with scott though, with digitalis intoxication, you shouldn’t just wildly defibrillate, especially not in asystole - totally useless. and yeah, aeds and ecgs here in switzerland sound an alarm if not properly connected ;-)
April 8th, 2007 at 2:45 am
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May 5th, 2007 at 10:46 pm
I always laugh at how AEDs are used in the movies, and this is just another case of it. However, as an EMT, I would really love to get my hands on one of those AEDs - anyone know if it’s real? It certainly looked good, as you could even see the diagrams on the electrodes showing where to put them.
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