The Last of Us finale on Sunday night sparked a broad discourse: How could Joel make this choice, between one girl and the fate of humanity? Spoiler: The gruff protagonist, who many viewers slowly but surely grew to love over season 1 of the video game adaptation, went on a killing spree, shooting a dozen rebels (Fireflies) and medical personnel on an enraged quest to save Ellie from a potentially lethal procedure.
But another, more specific, debate also took off—this time, between medical residents online.
“After watching the Last of Us finale did anyone else do the math that the doctor performing the surgery was probably a resident when cordyceps took over? Like he’s not more than 50 so he was no more than 30,” posted one user on the r/Residency subreddit.
“Also is it ethical to perform a nonsurvival surgery on a minor to save mankind from cordyceps?” the self-proclaimed anesthesia resident continued. “And why not a spinal tap and see if it grows cordyceps and use that for your vaccine?”
It was the post that launched a thousand ships. Or at least a hundred replies. Reddit users—presumably medical residents, given the subreddit—began a spirited discussion over the accuracy and plausibility of the events of episode 9. Ellie was supposed to save the world, but now it seems, humanity may be doomed.
“This was the last subreddit I would have guessed to see spoilers for this,” wrote one user.
Where The Last of Us went wrong, medically speaking
Most of the comments on the original post pointed out the glaringly obvious medical malpractice in the finale. Common concerns included: the lack of evidence in the show that Firefly scientists could successfully cultivate Cordyceps from a sample, the absence of any medical imaging, like a CT scan, to confirm their theory, and the failure to biopsy Ellie first, before attempting a highly risky procedure that would likely end her life.
Multiple users lamented that the Firefly doctors hadn’t tried a spinal tap to collect cerebrospinal fluid (CSF) from Ellie, from which they could try to grow Cordyceps, and make a vaccine from there. One user has a “PGY3” flair on their profile, seemingly meaning that they are a year-three post-grad, or medical resident.
“I think the most important step is to identify the compound and receptor that cordyceps uses to tell self from non-self,” they wrote. “I would be surprised if the compound isn’t in her CSF (it may even be in her blood, given how quickly the infection was stopped when she got bitten.)”
Several people worried about the handling of Ellie’s anesthesia and her subsequent lack of ventilation once Joel picked her up.
“My wife told me to shut up when I said where’s the tube,” wrote the original poster.
“I actually yelled ‘I HAVE CONCERNS ABOUT HER AIRWAY,’” wrote another.
Plenty of comments were tongue-in-cheek, acknowledging the absurdity of the situation. “Clearly the smartest thing to do is to immediately kill the test subject without any tests :)” wrote one exasperated user.
Someone else pointed out that, at least in the game, there was medical imaging. Using this technology, the Fireflies found a lesion in Ellie’s brain that they wanted to sample—with the caveat that the sampling would be non-survivable. A user who hadn’t played the game was incredulous to learn this. Marlene, the leader of the Fireflies played by (Merle Dandridge), deserved to die, they wrote. Joel kills Marlene in a later, tense scene.
“She gave him zero real info just said ‘yeah we decided to harvest her brain to save humanity.’ Like girl. Lie. Say she’s just undergoing a biopsy or that she hit her head and they’re saving her,” the user wrote. “Or at least explain why you feel so confident this random theory will work that you sacrifice a child.”
Members of the subreddit also had strong opinions on medical specialties and who, exactly, that doctor was. “Was he even a neurosurgeon?” someone asked. “Definitely giving me Ortho vibes for some reason. Maybe Cardiothoracic.”
“The guy operating had big surgeon energy as well,” someone with a “PGY2” flair (presumably post-grad, year two) wrote. “Just started giving orders to the unhinged man barging into the OR with a gun.”
A user with a “PGY4” flair said that they didn’t recall seeing any other doctors this season.
“But of all medical professions left in the world, there’d just happen to be a pediatric neurosurgeon around. Literally the rarest Pokémon.” This, unfortunately, soon becomes apparent: Joel may have killed one of the only people left with this specific skillset.
“And he’s gonna do the procedure on Ellie without a head CT and MRI prior to?” they continued. “Ours would want coags and reversal of any anticoagulants before even taking the consult.”
How the game handles it
One subredditor wondered why the Fireflies did not, at least, attempt to do blood work or try some nonlethal technique with Ellie first. The Last of Us video game touches on this: “The irony is that in the game they actually do collect blood samples and specifically mention they can grow the fungus from the samples… so yeah,” clarified a user with a “PGY4” flair. Per the game’s implication, Ellie—and thus a dozen Fireflies—didn’t have to die.
In the show, there is no evidence or implication that anyone else like Ellie exists. She seems to be the only one immune to the Cordyceps infection—and thus humanity’s last chance at long term survival?.
“The game does imply that Ellie isn’t exactly unique and the Fireflies have done this before,” wrote one user with an “attending” flair.
“It hits different when it’s someone you spent the last 20 hours with getting through hell to get to your goal,” they continued. “If this was a text game or simbuilder, Ellie would have [been] sacrificed in a heartbeat because it’s easier to make that decision when it’s a dispassionate block of text.”
One user wrote that the hardest thing about watching TV was suspending disbelief about the medicine portrayed on screen: “The number of monitors with perfect vital signs and a mystery arterial waveform drive me crazy.” Someone else said they had actually answered an ad to be a physician advisor on a TV show, but never heard back, “sadly (for me and maybe the show!)”
“Lol I played the game and believe me the questionable ethics of this have been around for a while,” wrote someone with an “MS2” flair (meaning, perhaps, a medical student in their second year.)
“What TLOU story wants you to do is a great deal of suspension of disbelief for quite a lot of your medical/ethical knowledge,” they continued. “This is simply because it wasn’t written for people like us who have a great deal of this knowledge.”
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