Defying The Flat Line

By Avelyn Miraal

I had been in operating theatres before, but mostly on the edges—an intern wistfully passing instruments, scribbling notes, or quietly holding retractors until my arms ached. That night was different. That night I stood close enough to see not just the science of medicine, but its soul—raw, desperate, fragile.

She had been wheeled in just after dusk, her pregnancy barely into its thirty-second week. She was only twenty-five, young, very impressionable and breakable. She was pale, her face wet with sweat, her breaths shallow, and with pain that was sharper than the usual discomfort of late pregnancy. Her hand clutched her abdomen with a desperation that spoke louder than words.

The monitors confirmed what her anguish had already told us—that the baby inside was in distress. The fetal heart tracing, those rhythmic waves we were taught to read like a second language, began to dip and falter, the baseline sliding lower until everyone in the room knew something was terribly wrong. The obstetrician’s decision came swiftly. “Emergency Caesarean.”

Everything moved at once—residents, nurses, scrubs, instruments flashing under bright lights. I had seen caesareans before, but tonight felt different, heavier, as if the theatre itself sensed what was coming. The consent form was signed, and the mother wheeled in, her body trembling, her lips murmuring words I couldn’t hear, perhaps prayers, perhaps fragments of hope.

The lights in the OT were bright, unforgiving, illuminating every fear etched on her face before the mask of anaesthesia softened it. The obstetrician’s incision was quick, practiced, a ballet of urgency performed under the hum of machines. There was no pause, no hesitation. And then the baby was lifted out, impossibly small, its skin tinged blue, its limbs limp, its body still.

The room held its breath.

I had been told countless times in classrooms what it meant when a baby didn’t cry, when the silence lingered longer than it should, but nothing prepares you for the real thing—for the way that silence feels like an intruder, filling the space where life’s first sound should be.

That silence—it was the loudest sound I have ever heard.

The paediatrician moved instantly, his hands steady though his jaw was tight. The baby was placed on the warmer, and I felt my breath stop as he bent over the tiny body, stethoscope pressed against the chest. He listened. Nothing. Not a heartbeat, not the faintest flicker of rhythm. He looked up briefly and shook his head once, and the room grew colder.

At one minute of life, the Apgar Score was less than three.

I felt a chill run through me. We had studied Apgar as a neat table, numbers tied to signs—respiration, tone, reflexes, colour, pulse—but seeing it applied to a silent body made the numbers feel merciless, like a verdict passed down too soon.

Resuscitation began at once. The airway was cleared with suction, but there was no obstruction. The laryngoscope glinted under the surgical light as the paediatrician guided the endotracheal tube into place, breaths delivered carefully, measured puffs into lungs that refused to rise. The chest stayed still.

Then came the efforts to stir neural response. He rubbed the sternum, hard enough to provoke reaction but gentle enough not to injure. He tapped the soles of the feet sharply, an age-old attempt to shock the nervous system into life. He flicked the skin, hoping for even the smallest twitch, the faintest grimace, the slightest protest that would signal the brain was still willing to fight. But nothing came. The baby’s body was slack, unyielding, as though suspended between worlds.

Chest compressions began. Two fingers pressing rhythmically on a sternum smaller than a coin, over and over, a cadence of desperation. Electrodes were placed, the ECG tracing spilling across the monitor—a cruel, unwavering flat line. It seemed impossible that life, which we are taught to believe is so fierce, so unstoppable, could be erased into such stillness.

Five minutes passed. The Apgar Score was called again—still devastating. Ten minutes. Still no heartbeat. Still no breath. Still no response to stimulation.

The mother lay awake on the table, anaesthetised but conscious, her lips moving in silent prayers and eyes darting face to face.

At fifteen minutes, the silence of the monitor remained. The guidelines I had memorised during my training echoed in my head: resuscitation may be ceased after fifteen minutes of asystole with no signs of life. The textbooks had told us that after this point, survival was unlikely, and even if a heartbeat returned, the damage of prolonged hypoxia would shadow the rest of the child’s life. We all knew that this was the point at which medicine was permitted to let go.

The obstetrician glanced at the clock, then at the paediatrician, then at the mother. The nurses shifted uneasily, their hands slowing, their eyes heavy with resignation. The silence thickened. Death was already in the room, patient, certain, waiting for us to step aside.

But he didn’t step aside.

The paediatrician’s hands never left the baby’s chest, his breaths never ceased, his eyes locked in fierce defiance. I could see the exhaustion in him—his forehead wet under the lights, his jaw clenched, his shoulders rigid. And yet his movements stayed steady, relentless. In his eyes I saw something raw, something I had not yet learned in books or lectures—the refusal to yield to Death’s certainty. It wasn’t blind hope; it wasn’t denial of reality. It was something deeper, something that could only come from years of fighting on this frontline, something that whispered: not yet, not this one, not tonight.

He pressed, breathed, pressed, breathed, refusing the surrender that guidelines allowed. It was faith that medicine, at its best, could still wrest something back from inevitability. I could see it in his eyes, a silent prayer, a hope that threaded through every motion, every tap, every compressive push.

Sixteen minutes passed. Seventeen. The silence pressed harder, the flat line mocked every effort. I felt tears sting the back of my eyes, but I did not blink. I could not. I thought then that I was witnessing a man fight not against illness, not against chance, but against inevitability itself.

And then, at seventeen minutes and forty seconds, it happened.

At first it was so small that I doubted myself. A twitch in the chest. A shallow gasp, like a whisper. Then the monitor crackled to life—a blip. Another. A rhythm, fragile, weak but real, began to carve itself across the screen.

For a moment, the whole theatre froze, as though we dared not believe it. And then chaos returned—nurses rushed forward, securing IV lines, wrapping the tiny body in warmth, adjusting the ventilator to support this fragile miracle. The obstetrician exhaled sharply, her hand resting briefly on the mother’s shoulder as tears welled in her patient’s eyes. And the mother—God, I will never forget that sound—the mother’s sobs filled the room, jagged, trembling, but alive with joy, alive with disbelief that her prayer had been answered when the world had already told her to let go.

And the paediatrician—after nearly eighteen minutes of unrelenting effort—finally let his hands fall still. He leaned back, closed his eyes for just a second, his lips moving in a whisper I could not hear. His chest rose and fell, heavy, as though seventeen minutes of holding off Death had drained him completely. For the first time that night, his face softened, and in his silence I saw not triumph, but something closer to grace.

The baby was not safe, not yet. It would go to the NICU, tethered to machines, watched with relentless vigilance. The future was uncertain, but that night, in that theatre, the heart was beating, and that was enough. The baby was alive. Fragile, tenuous, dependent on every machine in reach, but alive. And in that theatre, for the first time, I understood what it meant for medicine to defy.

I stood there, an intern, my throat tight, my hands trembling with the enormity of what I had just witnessed. It was a night I could never forget. Not because I had seen a miracle, though perhaps it was one, but because I had seen the truth of what medicine really was. It was not always triumph, it was not always clean, it was not always hopeful. It was messy and desperate and full of moments where Death stood close enough to touch. And yet, medicine insisted on standing in the way, on refusing to let Death pass unchallenged, even when the rules permitted surrender. It was the stubbornness of human hands standing against inevitability. It was prayers, hope, and a desperation that reached the heavens and moved God Himself.

And that was the night I found the words I had never had before.

Medicine had always fascinated me. I never understood why. But at that moment in life, I knew—I could finally give that fascination words. Medicine both awed me and broke me. The only profession where you look Death in the eye. You see it—laughing, gloating, watching with hunger, waiting to devour. But you realize it isn’t looking at you.

Death was looking at the stillborn lying under the surgical light, anatomically intact but void of function.

Death was looking at the monitor as the heart rate slowed, then fell into a flat, unbroken line.

Death was looking at the ICU chart, where blood pressures plummeted despite escalating doses of inotropes.

Death was looking at the trauma bay, where haemorrhage exceeded the capacity of transfusion and compression.

In medicine, you stare into the depths of Life’s patheticity—its pitiful frailty.

And in each of those moments, you see something else: Death was never ours to carry, impose, deny, or stop. It only waited. And Medicine—fragile, desperate, relentless—was the act of standing in its way. Medicine was the stubborn act of refusing to let it pass unchallenged. It was our fragile rebellion against its certainty.

By Avelyn Miraal