Crozet Annals of Medicine: The Pause

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By Dr. Robert C. Reiser

I see a lot of people die. Over the years it has worn on me. Not only do I have to tell the families and bear their grief, I also have to face my staff’s reactions and support my residents and students.

But who is really supporting whom? As usual in the ER, we face these things together and support each other. I am honored to work with so many remarkable caring people.

One of my RN colleagues pioneered at U.Va—and now nationally—a foundational change in how we navigate the enormity of a loss of human life in the ER.

Below is his account of this change.

The Pause

Jonathan B. Bartels, RN BSN

Nineteen-year-old Brad was driving his old 1970 flatbed ford down Route 64. Just past the 29 South exit, he reached down to the floorboard to pick up a cigarette he dropped. When he looked up and over the steering wheel he was slammed by an 80,000-pound semi-truck driving directly at him. Glass shattered, his truck flipped backwards end over end and he was launched 50 feet from the back window of the cab. He shot into the air like a bullet and landed head first on the pavement. To bystanders he looked like a rag doll that was tossed to the ground. He wasn’t moving. Despite the nature of this accident, he appeared intact, like a guy just lying there on the ground resting. No bleeding, no protruding bones.

An off-duty EMS provider arrived at his side first. He checked for a pulse and it was present. He saw the rise and fall of his chest, so he knew the airway was intact. He moved into his next role and stabilized his spine. EMS arrived and called for helicopter and paramedic support.

The helicopter was there within five minutes and the team opted to protect his breathing by placing an airway assistance device (intubated the patient). He was loaded onto the helicopter and the bird took off toward the Level I Trauma center. While en route the patient lost a pulse and cardiac resuscitation was started. The team was dedicated to bringing him back using every skillful means possible. They worked in the small space of that helicopter with precision. They worked using all techniques available; compressions, blood, meds and IV fluids. This was all done in the seven-minute flight.

The helicopter arrived at the hospital and an ER nurse met them at the helipad. The nurse jumped up onto the stretcher to continue compressions and rode into the trauma bay like a cowboy, thus ensuring a smooth transition of care without any break in the lifesaving compressions. Once the patient arrived, the trauma team began their work. They knew the numbers and understood the odds of survival. You see, a trauma patient who goes into cardiac arrest has less than five percent chance of survival. This had no bearing on their work; they were in it to win it. This guy was only 19, and he needed every chance possible. They worked on him for over 60 minutes. Compressions, ventilation and blood products. A controlled dance dedicated to the preservation of life. You could almost taste the tension, yet each member acted according to their allotted role. To untrained eyes the room looks like it’s in chaos, but to those in the thick of it, this is lifesaving at its best.

“Don’t give up. Keep pushing. He is only a kid!” This echoed in everyone’s mind.

No one wanted to stop. His grandmother stood by the curtain watching and praying. She had raised him as a child and just could not believe this surreal play of events.

After 50 minutes, the lead ER physician asked for another pulse check. Fingers placed on his neck, groin and wrists. Each team member looked up and indicated with a shake of the head: no pulse. Compressions were resumed. The lead physician handed over the reins to his chief resident. He took the boy’s grandmother to a quiet space along with a chaplain and social worker.

They sat and held hands, the physician described the situation as dire. He compassionately let her know that it was not recommended to continue down this road. Her adopted son/grandson was, in fact, dead, and we were not going to be able to revive him. It is a conversation that is not easy to say and not easy to receive. It was the ugly truth.

The physician returned to the room where an exhausted team continued to push on without skipping a beat. A pulse check was called, and the results were the same. No pulse. As is always the case, the lead physician quickly recapped the last hour and asked for any suggestions regarding interventions missed. No one on the team had any suggestions. It was decided that they stop the futile interventions. The room was quiet and you could sense the feeling of failure.

Normally in hospitals across the country, the team walks out dejected and drained. They step away from the body on the table and turn their backs on it. Gloves thrown off in disgust, they step back out into the chaos of the Emergency Department.

This is not how we roll. Often a member of the team will call out. “Before we leave this room, could we stop and PAUSE just for a moment in silence. Let us recognize this person in the bed. He was someone who was alive earlier today and now is gone. He was someone’s brother, son, and child.  He loved and was loved. Let us stop and in our own way and in silence honor both this person and the valiant efforts his whole care team gave.”

Then the room remains silent and each person takes a moment to honor the life that has passed. It may last a minute, maybe two, but it has become standard practice in our hospital and many others across the country.

I initiated this action because I was willing to take a chance. I wanted to add a voice to the speechless. In standing in this space we pause and time stands still. This is a time to acknowledge the sacredness of a life that has passed and the sacredness of our own fallibility. This act allows us to embrace our own vulnerability and acknowledge our humanness. This has become THE PAUSE. This Pause allows people in this multi-cultural and poly-religious environment to stand as one and speak in silence.

This practice has spread from our emergency department throughout the hospital. It has spread beyond our hospital to other facilities across the country. It has even spread internationally. We Pause because we care.

2 COMMENTS

  1. As a 1976 graduate of the University of Virginia School of Medicine, I am proud of Dr. Robert Reiser and Jonathan Bartels for initiating The Pause and am pleased to see it is expanding across the hospital and to other facilities. As a board certified internist & geriatrician since I completed my training, I learned that caring for the dying and their families is the ultimate in professionalism. I am also a mother, a grandmother, and served as the caregiver for my mother during the last 15 months of her life in our home.

    Currently, I lead efforts to improve quality of life near the end of life for individuals and their families, honor individual preferences and achieve the triple aim, including New York’s Medical Orders for Life-Sustaining Treatment (MOLST) & eMOLST. NY’s MOLST is one of the 4 original states endorsed by the National POLST Paradigm Program. Our work is housed on CompassionAndSupport.org. I will share THE PAUSE in my work.

    We all die some day and PAUSING to honor the human life is important. Equally important is identifying those near the end of life who are not appropriate for resuscitative efforts, as CPR was never designed to stop death. For those who might die in the next year, resuscitation does not work because of the underlying disease – not because of failure of our efforts. Thus, Virginia’s POST program is equally important to integrate and implement on a statewide basis.

    • As the one who was the impetus for this movement and now a Palliative Care Liaison I can not agree more with Dr Bomba. We will all face end of life (EOL) and it is imperative that we become the people who (when possible) choreograph how that will unfold. Every day I assist others in this process. The Pause is not meant to address this issue.
      The Pause is a way for me to offer support to those who do the caring. This is done so that we do not stop caring, despite the hardships we face. It is a practice that helps the practitioner to find closure with their peers.
      Thank you
      Jonathan B Bartels
      HPCN Palliative Care Liaison

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