If you shock a flatline, I swear I will come to your home and beat you with a wet chicken.

Beep…… Beep…… Beep…… Beep…… Beep…… Beeeeeeeeeeeeeeeeeeeeeeeeeeeee..………………Clear!………………… KA-CHUNK!!!!!!!…… Beep…… Beep…… Beep…… Beep…… Beep…………………

You know what this sounds like. You know exactly what this sounds like. You’ve heard it on practically every hospital TV show, every movie in which someone is rescued near death in a spaceship with a sickbay…over, and over, and over.

And it’s WRONG!!!

I’d like to take some time and explain why, how to not be THAT WRITER, and what you can do instead.

When a person’s heart stops in a hospital, it’s known as a code.
Codes are nuts. Doctors really do run through the halls of the hospital, and it turns into an absolute madhouse. There’s a lot to do during a code.

There’s actually too much to talk about. So let’s focus on the heart monitor, for now. One of the first things that happens during a code is that you place monitors on the patient so you can keep track of what’s going on inside their body.

The beeps you hear on a heart monitor are an audible notation of the electrical activity that is going on in the heart. The electrical activity of the heart is the signal that says when the heart muscle is contracting to pump the blood to where the blood needs to go.

That long, extended beep is a flatline. It means that there is no electrical activity going on in the heart that the heart monitor can pick up. That means the heart is not beating correctly.

So what does shocking do for a person who’s having heart problems?

Contrary to popular usage, the heart doesn’t work like a car, where you can just jump a dead battery. The purpose of a shock to the heart is to DISRUPT an electrical pattern that does not result in an adequate heartbeat. The shock stuns the heart, hopefully so it will reset itself into a normal rhythm.

This is why you don’t shock a flatline, no matter how easily-recognized it might be to an audience of uneducated viewers. The flatline means that there’s no electrical pattern to disrupt, organized OR disorganized. The heart is pretty well stunned as it is, and re-stunning it won’t help you a bit.

According to usual medical practice, here are the shockable heart patterns, and what they look like on a heart monitor:

Ventricular Fibrillation: This is when the ventricles of the heart are fluttering, which doesn’t result in a sufficient squeeze to get the blood where it needs to go. It looks like this:

Pulseless Ventricular Tachycardia: Basically, a heartbeat where the ventricles squeeze so fast that the pumping chambers of the heart don’t have time to fill…and the blood doesn’t get where it needs to go. It looks like this:

So, what DO you do with a flatline? (Also known as “asystole”)

Well, it’s a little less dramatic than what the TV would have you believe. First, you make sure that the blood is still going where it needs to go. This is accomplished with chest compression, which is the technique of pushing on the chest in a way that squeezes the heart from the outside.

(By the way, chest compressions are EXHAUSTING. In a hospital setting, there are a bunch of people who volunteer during the code for chest compressions, and they rotate in and out every few minutes. You just can’t keep it up for more than a few minutes, even if you’re in fantastic condition.)

Beyond that, you push drugs into the patient’s circulation that act in ways that encourage the electrical activity of the heart to start up again. Meanwhile, you try to figure out what caused the heart to stop beating, and try to get that problem solved.

Here’s a list of usual causes of asystole: pulmonary embolism, tension pneumothorax, very low blood pressure, very low body temperature, cardiac tamponade, heart attack, acidosis, very high potassium, very low potassium, low oxygen, drugs (medications or illicit drug use), poisons.

So, if you really, really want a flatline on your monitor, the dramatic tension of the story shouldn’t be action-adventure oriented. Yeah, there are people running everywhere and doing everything during a code, but a flatline wouldn’t have anyone diving for the paddles. The tension from a flatline would come from the dialogue between the doctors, as they discuss what could be the cause of the patient’s asystole.

And there’s a time limit, which gives you the tension that comes from a ticking clock. If doctors can’t get the heart to restart in a reasonable amount of time, the patient will likely suffer so much brain damage that it’s more reasonable to stop efforts and let them go.

So, if you have a patient with a flatline: go for relatively quiet, dramatic tension. Have a doctor with a personal stake in saving this patient’s life, watching the clock tick as she desperately tries to figure out why the patient’s heart stopped. The family, standing by, waiting anxiously and praying. The nurses and students rotating through compressions, giving nervous glances to each other as the seconds and minutes pass. The pharmacists, at the ready with the next combination of drugs to try. It’s an atmosphere that’s so thick with real tension, you don’t need to add any electrical shocks to it.

But if you do want to dive for the paddles, and yell “CLEAR!” and have the patient twitch on the table…yes, that all does happen. But for the love of all that’s good and medically accurate, put one of the shockable rhythms on your monitor!

Sources:

http://www.acls.net/aclsalg.htm

http://content.onlinejacc.org/cgi/content-nw/full/43/10/1765/FIG1

http://www.12leads.com/asystole.htm

The contents of this site, such as text, graphics, images, and other material contained on the Site (“Content”) are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this Site!

If you think you may have a medical emergency, call your doctor or 911 immediately. This blog does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the Site. Reliance on any information provided by this blog, or other visitors to the Site is solely at your own risk.

The Site may contain health- or medical-related materials that are sexually explicit. If you find these materials offensive, you may not want to use our Site. The Site and the Content are provided on an “as is” basis.

If you do use this as if it were real medical information, I will come to your home and beat you with a wet chicken. Even if you don’t shock a flatline.

About these ads
Published in: on January 23, 2010 at 12:22 am  Comments (60)  
Tags: , , , ,

The URI to TrackBack this entry is: http://doctorgrasshopper.wordpress.com/2010/01/23/if-you-shock-a-flatline-i-swear-i-will-come-to-your-home-and-beat-you-with-a-wet-chicken/trackback/

RSS feed for comments on this post.

60 CommentsLeave a comment

  1. Great post, Doc!

  2. WTG, from a fellow doctor-writer.

    I will add that people used to say “Is it fine Vfib?” and shock asystole, but it is not acls protocol.

    Good luck with internal med!

    Melissa (melissayuaninnes.net)

  3. Very cool. I’ll be making good use of this. You’re already my go-to consultant for the terrible things I do to my characters, and you’re more interactive than http://www.amazon.com/Body-Trauma-Writers-Wounds-Injuries/dp/1933016418/ref=sr_1_1?ie=UTF8&s=books&qid=1264390491&sr=1-1

  4. Wow, this is phenomenal, D; and I especially love this post. Looking forward to seeing what other TV medical fallacies you debunk!

  5. This is so useful. I honestly had no idea that was bunk. I am currently relieved never to have written a flatlining scene.

    Thanks!

  6. I love this blog already and wish to have its little flatlining babies! Thank you so much for this helpful information. :D

  7. Thank you. Thank you SO much for this. It drives me nuts when I see doctors on TV shocking asystole. I just watched a show the other day where they were doing CPR with a ratio of five compressions to one breath. FIVE! I wanted to throw my shoe through the TV.

  8. Thanks, guys! I’m so glad you like it! Please let me know if there’s anything you want to see covered in the future; I’ll try to get to it.

    • had just seen the movie AWAKE, and it had a scene where a surgeon used a defibrillator during a asystole… lol. and being a nurse student I already knew something was wrong and that procedure is not necessary… but thats what makes fictional movies more thrilling! but good post! thanks!

  9. Great post! I could feel my ignorance abating slightly (and there being so much to know about medicine and the human body, there’s a lot of ignorance involved for me!). Please to keep doing this sort of thing.

  10. Good fill someone in on and this enter helped me alot in my college assignement. Gratefulness you on your information.

  11. [...] blog posts titled, “If you shock a flatline, I swear I will come to your home and beat you with a wet chicken,&#8… how can you not check this guy out? Leave a Comment No Comments Yet so far Leave a comment [...]

  12. I have just come out of hospital and I Flatlined twice. It was what my family and docter that told me. I cant get it out of my mind that I could be dead. do many people live through Flatelining.

    Your commet may help me understand more.

    Thank you.

    • Hi, ronald regan

      I want to emphasize that I am not yet licensed to practice medicine; I won’t graduate from medical school until May. This site is also focused on using illness accurately in fiction, not talking about real-life scenarios. Your doctor is really the best person to answer any questions you may have.

      That said, I can answer your general question about how many people live through flatlining, or asystole. According to UpToDate Online, 2% of people with asystole survive to hospital discharge. 11% of people with pulseless electrical activity survive to hospital discharge. (Podrid, Phillip et al. “Outcome of Sudden Cardiac Arrest”. UpToDate Online, September 2009. http://www.uptodate.com/online/content/topic.do?topicKey=carrhyth/33730&selectedTitle=2~118&source=search_result )

      I’m very happy that you made it; it sounds like you and your family have been through a very difficult experience. I wish you all the best!

      Dr. G

  13. really interesting I cant wait to watch a movie with my girl friend and show off my new knowledge when someone flat lines.

  14. [...] I’m studying ACLS this week! (That’s “Advanced Cardiac Life Support”.) Basically, what to do when someone’s heart stops. In a hospital, that’s called a “code”. I believe I will use the following [...]

  15. [...] points for NOT attempting defibrillation when the heart monitor flatlines, but instead doing what doctors actually do, ie CPR. Sure, there was nothing earth-shatteringly out of this world as regards the science, but [...]

  16. [...] комментария. Первый, главный – я пересказал то, что пишет автор doctorgrasshopper.wordpress.com, а не сам “совершил научное [...]

  17. i have heard about this all the time in ems do not shock asystole but when i was in iraq i had a conversation with a doc we started thinking,(DANGER),when you defib a pt an electric current passes across the mediastinum causing the heart to contract an disrupt electrical activity. Well what harm does it do to shock a dead person kill them twice. We were just thinkin that the shock would cause the sa node to fire again in a traumatic arrest. would you please research this and see what you come up with, I have heard that some docs have toyed with the idea thank you for the article it was very good though

  18. [...] “If you shock a flatline, I swear I will come to your home and beat you with a wet chicken.&#8… [...]

  19. My wife is going through EMT training and told me the same thing. Frankly I was skeptical and decided to look it up. I just want to say, the two of you have ruined Hollywood for me…

  20. Thank god for this post, my soon to be novel would be in tatters without this!

    • me too

  21. I’m learning about dysrhythmias at the moment for my LPN. None of my teachers are cardiac experts and don’t want us to go too in depth, but I love the CV stuff! So here’s my question: if we’re not supposed to shock asystole, then why is temporary pacing allowed? Isn’t it essentially shocking the heart?

    Love your wet chicken threat. Pretty original :D

    • Hi, Bonnie! Welcome to my blog; it’s nice to have you here!

      As far as I know, temporary pacing is used for symptomatic bradycardia, not asystole. With asystole, there’s usually some sort of chemical problem that’s interfering with the heart’s ability to contract (that’s why you have the “T and H” list:

      * Hypovolemia
      * Hypoxia
      * Hydrogen ions (acidosis)
      * Hypothermia
      * Hyperkalemia or hypokalemia
      * Hypoglycemia
      * Tablets or toxins (drug overdose)
      * Cardiac Tamponade
      * Tension pneumothorax
      * Thrombosis (myocardial infarction)
      * Thrombosis (pulmonary embolism)
      * Trauma (hypovolemia from blood loss)

      So basically, even if the heart got a signal to contract, it wouldn’t be able to until the problem is fixed.

      With symptomatic bradycardia, the problem is that the heart’s primary intrinsic pacemaker has failed for some reason, leaving only the backup pacemakers that tend to beat slower than the other ones. The heart can still beat if it gets the signal to; the signal is just coming at a slower rate than is healthy. The “shock” that temporary pacing gives is a signal to the heart to contract; it’s different than the strong “shock” that is given to stun the heart out of an inappropriate rhythm.

      Does that make sense?

      And I’m glad you like the chicken threat! It seems to have served me well! (Although there certainly are many writers out there who seem to think I’m not serious about it….see the latest episode of a show called Doctor Who…..)

      Thanks for reading, and thanks for writing!

      Dr. G

  22. Thanx, im writing a story with a flatline and this was helpful, thank you so much

  23. Thank you, from a fellow doctor! This drives me mad all the time in fics and on TV.
    Also, when you see a character on TV have some sort of traumatic accident, and the other characters check the pulse and shake their heads sadly. CPR, people! It works! (sometimes….)

  24. I think this is one of the most vital info for me. And i’m glad reading your article. But should remark on few general things, The website style is great, the articles is really nice : D. Good job, cheers

  25. [...] STAT! Without anaesthesia!!!!! FLASH! BANG! BLOOD! MEDICAL DERRING-DO! SEIZURE! SNARKINESS! SHOCKING OF FLATLINES! MORE [...]

  26. So helpful for the fic I’m writing! Some of my writing is in magical realism, but I want the MEDICAL aspects to be totally accurate!

  27. Good post, but the first picture (under heading of VF) isnt VF, Its a type of VT called torsades de pointes.

    The difference being that torsades can have an output (like Uncomprimised VT, but unlike VF) and would be treated differently with magnesium if it was reoccuring….. Even though the treatment is the same in an arrest- still grabbing the paddles.

    • Oooh, good catch! I haven’t looked at this post since I wrote it; I should find another picture for it! Thanks for the feedback! :D

  28. An interesting post. Nice to see someone paying attention to detail.

    I have a question: What would be the correct response if someone suffered a heart attack (or the heart simply stopped) due to a very large explosion, such as in a war zone? Would it simply be to give them CPR asap?

    Could you please be as specific as possible, for example, how many pressures are suitable per second, and why?

    Many thanks,

    Steve.

    • It’s very rare for the heart to stop from a concussion such as from an explosion, but I think it has been known to happen. If the heart isn’t beating, you’d give them CPR (100 beats per minute is the current fashion; it’s the same beat as “Staying Alive” or “Another One Bites The Dust”), but CPR isn’t a cure…it’s just a way to keep the blood circulating until you can get the heart beating again.

  29. Hi! I am writing a story based on an experience i had when i volunteered at a hospital, and I was just wondering, if someone does chest compressions does anything show up on the monitor? I saw a man flat line, but i was too focused on the fact that he turned blue to notice the monitor. Unfortunately in omniscient narrator fiction that one detail is not enough!

    thaaaanks. you are awesome!

    • Yes, actually! Chest compressions do show up on the monitor, and they actually look a lot like an uneven ventricular tachycardia. You’ll get an upward deflection with every compression (I think. Next time I’m in a code I’m not running, I’ll try to pay attention to the relationship between the compressions and the monitor.) Docs stop compressions about every two minutes to analyze the heart’s own electrical rhythm on the monitor, and also to feel for pulses.

      Thanks for the great question!

      Dr. G

  30. So I’m curious. If v-tach is >100 bpm, why do chest compressions at that rate in CPR? Is it because the compressions are less effective in moving blood than the functioning heart?

    • This is because you want to try and build up enough pressure through compressions to get blood moving through the body and (specially) to the brain. Even the best CPR only produces a small fraction of pressure and vascular travel compared to the actual beating of the patient’s heart.

  31. Thanks for the advice…I write a lot of medical fanfiction stories and this was very helpful.

    • Rock on with your bad self. I’m glad this could help!
      :D

      • It’s amazing how many people think you can shock a flatline…

  32. Deleted for uneducated trolling

    • Deleted because I should know better than to feed trolls

  33. I came upon this blog because I just flatlined 2 weeks ago. My pacemaker is in all is well but I still want to understand what happened. The first time I past out driving, without incident, had a friend with me, the next time I was in the hospital and hooked up to monitor so the docs seen it in black and white.

  34. Good Read. I have to ask what about those patients who have pacemakers implanted on them? would they still reveal flatline on ecg after they have arrested?

  35. Thank you! Just shared this on my Facebook wall after watching yet ONE MORE show who included this fallacy. My most disappointing to date was an episode of NCIS – it was a horribly run code from start to finish, involving one shock…no compressions…no meds…no asking if anyone wanted to try anything else…just dead. But the worst part was that the one shock was delivered while the “patient” was in asystole. Sigh. So, thank you! I have wiled away a bit of time this afternoon – when I should be sleeping as I work the overnight shift – reading your blog after stumbling upon this gem. Congrats on finishing residency! Seriously.

    • Hi Denise! Glad you liked it! Thanks for the kind words; I’m very much enjoying life after indentured servitu….I mean residency! Hang in there!
      :D

  36. I know this article is old but in case someone reads this comment I have a question. I’ve read in a few places that if you shock someone in asystole that actually makes it less likely for resuscitation to be successful. Why is that?

  37. Hiya very cool website!! Man .. Beautiful .. Wonderful ..
    I will bookmark your blog and taake the feeds additionally?
    I am satisfied to fiknd a lot of helpful info hee in the post, we’d like work out more strategies on this regard, thank
    you forr sharing. . . . . .

  38. I flat lined twice roughly 9 hrs after breaking my neck when I was 14.5. I was VERY lucky. To have such an awesome team of drs and nurses that night.

  39. Greetings! Very helpful adviuce within this post!
    It’s the little changes which will make the largest changes.
    Thanks for sharing!

  40. Hello, i believe that i noticed you visited my website
    so i got here to return the favor?.I am trying to to find issues
    to enhance my website!I guess its ok to make use of
    some of your ideas!!

  41. It’s truly very complex in this full of activity life to listen news on TV,
    so I just use internet for that reason, and obtain the hottest information.

  42. I know someone who said she suffered a heart attack about 7-8 years ago. She said the doctors used the paddles on her 18 times. Is this medically possible for a human being to endure this and would their skin have been burned by this? Also, how long a wait is there between each time shock treatment is used? Would a doctor try 18 times? Would the patient sustain any additional damage to the heart, body and or brain from this?

  43. Hey, i just wanted to let the doc know, i used this info for something i wrote and even used the phrase ‘It wasn’t like in the movies, only a gentle twitch, like waking from a dream of falling’… and it came out wonderfully well! Thank you, doc!!!!

  44. Help! Okay, I’ve written myself into a corner and I need some advice here. I am writing a sci-fi adventure story, and my character has a tracking device implanted in her. Another character uses an automated external defibrillator to deliver an electric shock to her body to disable the device. Now I am stuck because 1) AEDs aren’t supposed to shock a heart that is beating correctly and 2) If I have my other character pull a Fonzie and bang on the machine until it does what I want it to do, will it kill my character? What sort of damage will it do and what would it feel like? I don’t want to take the easy way out of “she’s actually a robot so none of this matters anyway.”

  45. Be like hollywood. Problem solved. I beg most of you reader wouldn’t even notice this.

    • bet*


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Follow

Get every new post delivered to your Inbox.

Join 132 other followers

%d bloggers like this: