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Medical Writing Advice

Flatlines don’t get shocked #MedicalWritingAdvice

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I was recently reading a Science Fiction novel and was slightly appalled at one of the scenes. The novel was fairly well written with some scientific and medical jargon thrown in, accurately I might add, showing that the writer either had previous knowledge of these subjects and/or researched them for her story. So what was appalling?

In one scene (no spoilers here), a patient is on the operating table and as the doctor’s back is turned, the heart monitor alarms and the nurse says, “Flat line!” The doctor then grabs the paddles and defibrillates the patient. What?! No-no-no, we do not do that!

As the hashtag advertises, this is an article on medical writing advice so let me explain when you should and should not defibrillate your characters.

First, let’s talk about the basic concept of why patients are defibrillated or cardioverted in the first place. If your heart is in a non-productive or injurious rhythm, we shock it to stop it for a second or two. Once the heart is stopped, we hope it will start up again in a proper and productive rhythm. Think of it as doing a ctrl-alt-delete for your heart.

If you are in asystole, aka flat line, your heart is completely stopped and not doing a darned thing. We DO NOT shock this rhythm as it would do absolutely no good. Remember, the purpose of shocking is to stop the heart. If it’s already stopped, what would be the point of defibrillation?

Do not shock this rhythm!

Do not shock this rhythm!

There are plenty of other times we do shock our patients. If a patient is in ventricular tachycardia (with or without a pulse) or ventricular fibrillation, they get to ride the lightning. These rhythms are also called V-Tach and V-Fib.

V-Tach, ride the lightning!

V-Tach, ride the lightning!

V-Fib, CLEAR!

V-Fib, CLEAR!

If you really want to show your medical prowess, make your character patient go into either unstable atrial fibrillation or atrial flutter (A-Fib or A-Flutter). These patients however don’t get defibrillation, they get synchronized cardioversion. Sync Cardioversion uses less energy (joules) than defibrillation does and the shock is delivered at a specific synchronized time with the rhythm of the heart. In sync mode, the monitor is constantly analyzing the rhythm and waiting for the exact correct millisecond to deliver the shock. After you press the shock button, there might be a second or two delay before the monitor determines that it is the correct time to deliver the shock. The desired effect is the same, a restarting of the correct electrical conduction through the pathways.

Delivering a shock, in either mode, can cause a flat line that the heart doesn’t restart from. If this happens, no more electricity will be delivered, CPR and medication administration will be the only treatments that remain.

On a side note, when you do shock a patient, they don’t jump on the gurney like they always show on TV or in movies. Their trunk, especially the area in between the paddles, does become rigid as the electricity causes involuntary contractions of the chest and back muscles. And we almost never use paddles anymore. They do exist on the older equipment but most healthcare providers, prehospital and in-hospital alike, use hands-free pads that stick on the patient’s chest wall and plug into the monitor.

To sum up, never ever shock a flat line or asystolic character. It’s really that simple. Most patients don’t become asystolic immediately, (cardiac arrest is the exception rather than the rule) it’s a rhythm they end up in after going through one or more of the above listed rhythms or others that weren’t discussed in this article. And while we’re at it, stop making characters put medication injections directly into their hearts, this is not done anymore and hasn’t been done in decades (to be discussed in a later article).

Questions or comments are always welcome 🙂

 

Jay started his medical training in the Navy in 1992 when he became a Hospital Corpsman. He is now a nationally registered Paramedic and has been training and involved in medicine for the last 22 years. He is also a medic on a Regional SWAT team and teaches paramedicine at a college in his hometown.

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