Anesthesia Flix Fix: Episode Two!


Welcome to the second installment of Anesthesia Flix Fix, a place where I examine the relative merits of  movies that sport some kind of anesthesia-related thematic element.  In Episode One, we examined the movie Coma and how a lot of the plot structure revolved around several anesthesia concepts, such as the fail-safe mechanism that now exists ubiquitously to prevent the delivery of hypoxic mixtures of anesthetic gases.  That movie really gave me a lot of my inspiration to become an anesthesia clinician, as ridiculous as that might sound.

In case you missed it: Anesthesia Flix Fix: Episode One

Today, I’ll examine another Hollywood blockbuster with plenty of anesthesia references:  Flatliners.  I saw this movie just as I was graduating high school in 1990, and it really provided me with a very dramatic and over-romanticized version of medical school and anesthesia in particular.  The movie itself was largely panned, if not for the lack of dramatic depth in the acting, then for its uncomfortable straddling of reality and ridiculous fantasy.  As the New York Times reviewer put it:

“…when taken on its own stylish terms, ‘Flatliners’ is greatly entertaining. Viewers are likely to go along with this film instantly or else ridicule it to death. Its atmospheric approach doesn’t admit much middle ground.”

Of course as a soon-to-be medical student, I found the movie highly entertaining and compelling.  Now, I’m an anesthesiologist, so it wasn’t until I rewatched the movie recently that I appreciated the anesthesia references contained within and also recognized some of its finer elements of ridiculousness.  The movie follows five medical students who put each other to sleep and then into asystole and then resuscitated them in order to find out what lies beyond death.  Of course, their “afterlife” experiences result in post-resuscitation hallucinatory events which mirror the demons that have haunted each of their individual lives, and each must find redemption in some way in this new reality.

Despite the fanciful forays into the religious and moral ramifications of the afterlife, I found Flatliners to be a perfectly enjoyable movie.  The characters were well cast with quite a starry lineup, promising something for everyone.  I’ve listed the actors here, along with what I consider to be their more memorable and significant movie (and TV) roles.

Anesthetic Implications

The premise of this movie centers around the “induction of death” which is equated with asystole or “flatline”.  The method put forth in the movie is an induction of sleep by inhalation of nitrous oxide and induced hypothermia, immediately followed by defibrillating into asystole.  All of us anesthesia folks recognize that induction of sleep with nitrous oxide alone would be impossible since the MAC of nitrous is over 100%.  But progressively severe hypothermia decreases MAC requirements in a rectilinear fashion, so I suppose the combination would theoretically lead to sleep.  This isn’t too unlike a cardiac anesthetic where a predominantly nitrous-narcotic technique is employed for anesthesia and core body temperature is lowered not only for cardioprotection but also to decrease cerebral metabolic rate for neuroprotection.  The part that doesn’t really fit is defibrillating the heart to achieve asystole, although we all would agree that a cardiac rhythm degenerating into asystole is always a risk of defibrillation.  But I agree with the movie director here…shocking a person with those paddles is always entertaining on the big screen!

Once the person went asystolic, the dream sequences from the afterlife are cued, and each person’s personal demons are revealed one after another in this “life after death”.  Meanwhile, the students who have just helped their classmate into the afterlife are busily prepping to bring him or her back to life by providing woefully inadequate CPR (think: ONE-one-thousand, TWO-one-thousand…) and positive pressure ventilation with a pediatric-looking nasal mask.  Hollywood can be excused for this because surely no one can look attractive doing adequately forceful chest compressions.

At this point, I’m just going to interject that ACLS used to be a mess with all the different algorithms for different things and lots of different medications to choose from…it was overly complex.  The joke used to be that to simplify your learning, you should just get every patient into asystole no matter what rhythm they started with…That way you would only need to memorize one algorithm…the one for asystole.

This is the final failing of Flatliners.  At the point where they wanted to bring their asystolic colleague back from the afterlife, they would warm the person back up and then defibrillate the person back into a normal sinus rhythm.  Two immediate takeaways that you should get from this:

  1. It takes way longer to warm a person up than to cool them down under anesthesia. Better to keep someone warm than to let someone cool off and then try to warm them back up.  Use those warming blankets on your patients!
  2. Defibrillation is not part of the asystole algorithm…never has been and never will be. Defibrillation is the use of an electrical current to reset the electrical activity of the heart.  And asystole is the ultimate reset.  Asystole is the lack of all electrical activity. There is nothing to reset in asystole.  Unfortunately, defibrillation will not bring someone out of asystole.

Looking Forward

Flatliners is still a tremendously entertaining movie with all its flaws.  I watched it again just the other night and was again struck by the romanticized version of the prototypical medical student persona.  And I’m guessing that all of you would enjoy the movie too, especially through your “anesthesia-eyes”.  Despite the lackluster reviews, Hollywood is currently filming a remake of or sequel to Flatliners.  It will star Ellen Page and Kiefer Sutherland, among others, and be released in October 2017.  If nothing else, I think they will need to figure out an alternate method of resuscitating their asystolic characters.  For the ultimate in drama, I would suggest and welcome a return to stabbing someone in the heart with a giant needle and syringeful of epinephrine a la Pulp Fiction:

At least this would be in better keeping with current ACLS guidelines for non-shockable rhythms (ie. PEA and asystole).  And now that automatic external defibrillators (AEDs) are commonplace (unlike in 1990 when Flatliners was shot), they could even slap one on the asystolic victim in the sequel and let us all hear the AED announce loud and clear in its robotic cadence:

“No. Shockable. Rhythm.”

Would you ever have guessed that one movie would contain so much anesthesia food for thought?  Would you like to see future installments of Anesthesia Flix Fix?  Do you know of any other movies that would have special significance to us anesthesia folks?  Let me know in the comments below!  I’ll watch the movie and give you a special shout-out when I review it for anesthesia implications.  Until then…thanks for reading and keep on passing gas!

Anesthesia Flix Fix: Episode Three has been published!

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