The (Flat)Line Between Life and Death

Disclaimer: All characters depicted dead or alive are fictional. Any resemblance is purely due to your own imagination.

One of the first thing you learn as a medical student is that in Medicine, 1 + 1 is not always equal to 2. To put it simply, if the ah pek (whom I often abuse in my many stories) take two Viagra, he is not going to enjoy himself twice as much. This was not an easy concept to grasp for someone like me who liked hard concrete numbers and predictability. 

Eyes Wide Shut!

The fact is that things are never straightforward in Medicine. They are never black and white but shades of grey. Unfortunately these shades of grey applies to Death as well. How do we really know if someone has died? Is it after that last breath he took like in the movies? But what if his heart is still beating? What if his brain is still thinking? And what if his eyes are still looking?

Flatline - Asystole

To verify and pronounce death, the attending doctor has to first make sure that all resuscitative efforts have failed or the criteria of not resuscitating are met. There should be no pulse, no breathing, the pupillary reponse to light and corneal reflex are absent and there is no response to painful stimuli. In the hospital, an echocardiogram (ECG) has to be performed to show a flatline.

On call one day, I was asked to attend to an elderly patient who had collapsed. He had the DNR (Do Not Resuscitate) status and there was really nothing much I needed to do. By the time I was there, there were no pulse or breathing on auscultation, no constriction of the pupils when the torch light was shone on his eyes and no response on sternal rub or supraorbital pressure. I hooked up the ECG lead from the defibrillator but there were still wriggly lines and waveforms on the monitor. I needed that flatline and a printout to demonstrate asystole (complete stoppage of the heart) before I can pronounce death. The time indicated on the printout is also used as the time of death.

After waiting for a few minutes, the ECG did not looked like it was going flat any time soon. I instructed the nurses to keep the monitor on and to call me when there is a flatline as I had another emergency to attend to. In the middle of the night in the hospital, you are IT and I had no time to waste.

15 minutes later, I was back up in the ward. When I got to the bed, I was shocked to find the bed empty! I ran frantically to the nursing counter and one of the staff nurse told me that the patient had been pushed to another room to be with the family for mourning. I went, "What the fxxk! What about my ECG strip!"

The staff nurse reassured me that she had already printed the strip and proudly passed it to me. I took a look and went, "What the fxxk! This is not a flat ECG!"

My heart literally sank as this was not a flatline ECG and was STILL full of wriggly waveforms. The patient has technically not be pronounced dead and I needed to retrieve the patient / the body to get the proper ECG! I had no choice but to sheepishly enter the room where the patient /body was with an ECG machine. About 8 relatives were by the patient /body wailing loudly. I was a junior doctor then but I knew that approaching emotional relatives often resulted in catastrophic outcomes. I apologised to them for interrupting and asked if the relatives could excuse themselves for five minutes. Miraculously (yes in Singapore, nice relatives are miracles!),  they were kind enough to comply. I managed to get my ECG strip and quickly returned the room and the body to the relatives.

As I stared at the flatline on the ECG strip, I wondered if there WAS a distinct line between life and death.

Perhaps we will find out for ourselves one day...

or perhaps we won't...