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'127 Hours' earns high marks from doctors

The Unreal World

The self-amputation depicted in Danny Boyle's '127 Hours' is mostly accurate, experts say. But drinking urine is not recommended in survival situations.

January 17, 2011|Marc Siegel | The Unreal World
  • James Franco portrays trapped canyoneer Aron Ralston in the film "127 Hours."
James Franco portrays trapped canyoneer Aron Ralston in the film "127… (Chuck Zlotnick, Fox Searchlight )

The premise

Twenty-seven-year-old Aron Ralston ( James Franco) is a mechanical engineer and thrill-seeker. He is in Utah's Blue John Canyon when he falls down a narrow canyon, and his arm is pinned by a large chalkstone boulder. He watches as his fingers turn blue and gray from insufficient blood flow (ischemia). Though he doesn't appear to be in pain, he is unable to free himself. He has very little food and water, and finally, as he grows dehydrated, he drinks his own urine. After 51/2 days and facing certain death, he manages to free himself by breaking his bones at the forearm and amputating his lower arm by sawing through it with a blunt pocket knife.

Medical questions

How could a man stay alive for 127 hours with his arm wedged by a rock with only a liter of water and urine to drink? How could he then cut off his own arm with a pocket knife without fainting, going crazy with the pain or bleeding to death?

The reality

When faced with certain death, primordial instincts take over, says Dr. Leon Pachter, chief of surgery at New York University Langone Medical Center. "Man is often able to achieve the unachievable, taking on an almost Superman persona," Pachter adds. Physiologically, a person experiences an acute stress reaction with an outpouring of hormones. Adrenaline and noradrenaline keep the heart pumping strongly and direct blood flow to the vital organs, including the brain, liver and kidneys. Glucagon stimulates glucose release, so that a person has more energy. Cortisol keeps the metabolism in overdrive, and endorphins (the body's natural opiates) are released in the brain to decrease pain and allow the victim to function.

With massive willpower combined with the hormonal surge, such a person could survive in some pain with only small amounts of water — no more than three days, however. The body's daily water requirement is approximately 2.5 liters, so surviving more than five days on one liter is extraordinary.

Drinking urine would probably worsen dehydration because of the salts it contains (called urates). Several sources, including the U.S. Army Field Manual, advise against drinking urine in survival situations. The effect is similar to that of drinking seawater, in which more fluids must be excreted than taken in to get rid of the excess salt introduced.

In the operating room, amputations are done using a modified saw. "Sawing away without benefit of a saw," Pachter said, would take many passes before the arm would be severed, and the marked pain of breaking one's own bones would certainly cause a person to black out, at least temporarily. This is, in fact, how Ralston described the actual event in Outside magazine in 2004 and WorldWide magazine in 2009, though the film did not show this.

The film shows Ralston applying a tourniquet before removing the arm, although in his real-life account he reveals that he forgot to apply the tourniquet. Dr. Nader Paksima, hand surgeon and chief of orthopaedic surgery at Jamaica Hospital Medical Center in New York, believes that the blood vessels would be mostly clotted from the initial injury and there would be little bleeding — and that therefore the tourniquet might not be completely necessary. Dr. Mark Adelman, chief of vascular surgery at NYU Langone Medical Center, agrees and says that — as the film shows — some bleeding would occur during the cutting because the arteries would not yet have gone into spasm. But once the limb is off, he adds, almost all the bleeding would stop as the arteries spasm and contract. So the film's rendering of the self-amputation appears mostly accurate.

Amputating the forearm would involve breaking the radius and ulnar bones. This, Paksima says, is the hardest part — because they are very strong at the middle of the shaft. The film shows Ralston using his body weight as leverage, which is believable. The radial, ulnar and median nerves would then be cut, along with the muscles and tendons of the forearm, as well as the radial and ulnar arteries and their branches.

Ralston said in his accounts that he had developed a " compartment syndrome" from the trapped limb — a condition in which the muscles, nerves and blood vessels are crushed together in a closed space. Pachter says that this is hard to believe, however, because it would make it far less likely that Ralston could survive 127 hours. If there were enough muscle damage from a compartment syndrome, a patient could develop rhabdomyolysis, a release of muscle fibers into the blood, which can cause kidney failure and death. After several hours, as the tissue began to die, there would be reduced feeling — which, on the plus side, might have made it less excruciatingly painful for Ralston to cut off his own arm, but it would also have made it far more likely that he would die before he had the opportunity to do so.

Siegel is an associate professor of medicine and medical director of Doctor Radio at NYU Langone Medical Center.

marc@doctorsiegel.com

"127 Hours"

A Danny Boyle film based on a true story

2010, Everest Entertainment

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