Pacemaker

Electrocardiogram is the most common, but not the only, way for doctors and medical students to study the human heart. Those squiggly lines are the graphical display of each heartbeat's electrical activity. Instead of listening to the heart, we can tell its tempo and rhythm by taking a look at those waves, like what most musicians respond to musical notes without listening to the songs.

Not all musical notes are pleasant to recount. And electrocardiogram tracing can sometimes narrate a sad story. Many a time we declare patients dead after examining them, followed by the ritual of printing a flat line of their electrocardiograms. Signed and dated. More or less a picture proof that their hearts stop beating. But then it does not always have to be the case. We can't really come up with a completely flat line when a patient has a pacemaker. I mean, the battery of the pacemaker outlives its owner, firing discharge even after the heart isn't beating. The other day an intern of mine told me he dared not certify a patient dead without a line as flat as a pancake. I stared for a moment in shock. "So, what did you do in the end?" I finally said.

"I cut open the skin and pulled out the pacemaker," he answered. "Then I confirmed my patient's death by a flat electrocardiogram printout."

He really meant it.

I believe that I have heard, for the first time in my years in practice, how a doctor took away a life-sustaining device in order to declare the end of his patient's life.

A week later, I read the book Knocking on Heaven's Door by the American journalist Katy Bulter. That's an achingly beautiful story giving me a new perspective on that life-saving electric device hidden below the collarbone of a patient (when the natural electrical conduction system of the heart has worn out with age). Katy Bulter's dad had one. After his heart had worked for eighty years, the electrical fibres had thinned out and slowed down. The new pacemaker was supposed to save his life. The problem is the law of diminishing returns. With each year over the age of eighty and each downhill step from repeated stroke, Katy's father was never able to complete a full sentence, to put on a shirt without help, or to control his poos.

One day Katy's mother made a bold statement, "Please help me get your father's pacemaker turned off." The family's difficult conversations with the modern medicine never made way to a compromise. Doctors refused to disable the pacemaker, and Katy's dad lived in agony with that life-saving electronic device. For five years. Katy's father died with his lungs slowly filling with fluid, when his pacemaker was still quietly pulsing inside his chest.