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...

Sometimes They Don't Survive

Statistics is very much part of our training in medicine. The graph above is known as a survival curve and every step signifies a death. Whilst a million death is a statistic, each death is to a doctor a powerful if not sometimes painful reflection.

For we may try our utmost and do whatever we can but sometimes, some will slip through our hands. With each death and with the bias of hindsight, there is always that nudging, albeit transient, feeling of guilt. The feeling that I could have perhaps done things better or that I could have done more, if I can do it all over again.

Or perhaps it is with the knowledge that with each death, we are ourselves one step closer, that is the origin for this wishful thinking of saving our patient's life, such that ours may one day be saved.

But alas, sometimes, and oftentimes, they don't survive.

Death: The High Cost of Living

I am an avid fan of Neil Gaiman and in his best work to date, Sandman, Death is the sister of Dream. She is protrayed as a perky goth girl.... how nice.

In reality, death is lurking around us all the time. Especially for those of us in the medical profession. Perharps so much so that sometimes we forget the tragic side of death and become numb to it.

There was a time when I was still young and nothing in life seemed impossible. I believed that we should spare no cost in saving every life. It was only after becoming a doctor that I realised my believe was just magical thinking of an immature child.

My first professional encounter with Death was with a lady in her fifties. She suffered diabetes and consequently her heart was failing. Her husband had admitted her for a severe infection of her right leg. The only way to save her life was to cut off the leg but there was no chance of her surviving such an operation given her heart condition.

I had seen her briefly during the morning round and she was pretty alert despite the high fever. As I made my way around the wards in the afternoon, I noticed her chatting with other patients, smiling to the nurses. I was paged in the night and the nurse in charge told me she had stopped breathing.

When I arrived at the scene, the MO was already there. I was panting from the 100 metre dash looking all flustered and unsure. The MO gave me a reassuring smile and told me that nothing needed to be done. Just to certify that the patient is dead.....

Pupils fixed and dilated
No heart beat
No breathing
No response to pain
No reflexes

This is Death. She is not a perky goth girl. She was cold and distant.

Night Calls II...

The last post was for the minor things that happen.

Major things happen just like in the movies. A patient might be found not breathing or without heart beat. Code Blue is announced over the PA system and the team doctors rush to resuscitate the patient.

All sorts of wires will be connected to the patient monitoring his heart rate, oxygen levels, ECG rhythms etc. CPR will be started with the most junior doctor jumping on top of the patient and pumping the chest. To give the uninitiated a better idea, CPR is actually more tiring than sex. The danger of the resuscitator collapsing himself is a real possiblity.

The second most junior doctor will see if there is a need to stick a tube down the patient's throat to help the patient breathe. By this time, the senior doctor would have arrived and will be looking through the patient's record to determine the cause. Although from the outside this whole senario looks like what army terms as operation cluster f**k, it is actually very well orchestrated and organised. There is hierarchy to be maintained. No one oversteps his boundaries. Sometimes we manage to get a heartbeat back. Often we don't. And when we don't, there isn't that dramatic "Let's call it. Time of death 0400hrs". (Duh! that's in the movies).

It is a quiet affair, certifying death......