Strayerism - The Pause

The Pause

Reuben Strayer MD

Take Home Points

• Utilization of a pause and moment of silence to recognize a patient after pronouncement of death can help with closure for ED staff.

• Strayer recently read an essay by an emergency physician, Jay Baruch MD, which described a young patient who was killed in a motor vehicle accident (https://www.statnews.com/2017/08/02/emergency-medicine-trauma-doctors/). After the unsuccessful thoracotomy, the team carried on with business as usual. It isn’t business as usual, even if it is what we do. These “crushing experiences deserve to be recognized and not blindly endured”.
• This reminded Strayer of a ritual he incorporated into his practice years ago; the pause. He decides it is the appropriate time to terminate resuscitative efforts and pronounce the patient. He asks everyone in the room, “Does anyone have further suggestions for resuscitation?” It is unusual for anyone to offer any suggestions at this point. A few moments later, he says, “I pronounce Ms. X deceased. The time is 1145. We can stop compressions and turn off the monitors.” He then says, “Could we please take a silent moment to honor the deceased.” He looks down at the patient and stands there in silence for up to 30 seconds. He thanks everyone and allows the team to dissemble.
• Strayer started doing the pause after a brutal series of shifts where it felt like every patient he cared for died. He realized later that he couldn’t picture any of them and it bothered him.
  • His old roommate was into Buddhism. When Strayer asked him why he was meditating, he replied, “Every day I was brushing my teeth before bed and I would try to remember what happened that day. The only thing I could recall was first thing in the morning, sitting in my car in the driveway waiting for the engine to warm up.”
  • This resonated with Strayer and he decided he had to do something to mark the death of a patient under his care. A moment of silence seemed obvious.
• It started out as a selfish project. He wanted to do something to make himself feel better about being witness to death. He was nervous that the rest of the resuscitation team would be annoyed or uncomfortable. This didn’t happen. Every time he took a moment of silence, someone approached him later and thanked him for doing it.
• He makes an effort to use the patient’s name in pronouncement. Using the patient’s name is so humanizing. If he doesn’t have the name, he says this man or this woman.
• Occasionally someone walks away during the pause or says a prayer. This makes some uncomfortable. This is ok too. We don’t need to pretend to be comfortable with death, even if it sometimes it feels like death is our job.