“The music is not in the notes, but in the silence between them.”
– Achilles Charles Debussy

Silence is an important part of our everyday lives. Yet, we often don’t consider its critical importance in helping us to reflect on what we’re doing. This is especially important in medicine where we’re so busy sometimes that we forget that what we say and do actually has huge implications on people’s lives.

This is even more so in the emergency room. It’s not really set up as a place to reflect. It’s overcapacity and over-busy; my workday is so frequently on the go-go-go that I often feel guilty for stopping to eat or run to the bathroom. I shouldn’t. But that’s the system we’re currently in.

At work, I’m often multitasking many patients, learners, and nurses requiring my attention at the same time. It’s often hard to even really focus on what I’m actually doing in the moment. In the moment I’m often sitting with a patient (or, more simply, a worried person in pain and distress asking for my help) but thinking about that CT head that’s pending, what to do about the lady in bed B, or why it’s taking my medical student so long to see that patient with “ankle pain.”

I leave work sometimes after many long hours on the go, and so many things have happened that I hardly have any time to process it at all. And I’m often too tired to give it an opportunity when I get home.

There are times when I get home, and someone asks me how my day went. In my own head, I barely remember anything and just want to get on with my day. Move on to something else. But when prompted, I’ll often remember.

Today I told someone a thing that changed their entire life. They came in with fairly benign-sounding symptoms, and I looked them in the eye and told them they had metastatic cancer. Before this moment, they were one thing, and after it, their lives were something else. Boom. But as they look at me for solace, I’m already three steps out of the door, moving on to the next thing I have to do.

I’m really sorry ma’am, but the lady in bed B needs a blood transfusion, and I have three patients to reassess, and there’s a guy yelling the hallway that he’s already been waiting for “two and a half hours!” and the nurses are looking at me to do something about it. I wish I had more time. I do. But I’ve got to go.

And then there was the guy with the brain bleed, and the kid who broke his arm, and the lady who miscarried for the third time. How did I forget about all of that?

We’re often too busy to process what happens in our days. But that doesn’t mean it doesn’t get processed. We’re not immune to the things we see. I know I’m not. Somewhere, way down there, emotional processing is happening at some level. We might not realize it, but it affects us in subtle ways.

For some, it turns us cold. Or numb. We’ve all seen those people who’ve been in the game for too long and are clearly burnt out. They’re bitter, sarcastic, and clearly jaded with what they do. It’s the people in my world that think that every patient is a waste of their time. Everything sucks, and this place is a joke. You’ve seen them around.

For others, they escape. Some into unhealthy behaviors. The alcoholics. The drug users. Others cope by spending. Fancy cars, big houses, and swanky lifestyles. Certainly, this justifies all of the difficulties we have to face at work. Right?

Many people plod away quietly. But they’re drained. The things that drew them to their line of work are no longer so interesting. They’re just trying to get through their days, weeks, and years, looking forward to retirement when things will be better.

What’s the antidote to this? Well, given our environments, and how we need to work to keep things afloat, I’m not entirely sure. But I think we need to take a few moments in our days, to pause, gather ourselves, and reflect, just for a few seconds on what we’re about to do, or just did. We just can’t keep pushing things down inside, hoping that they’ll resolve themselves. We need a safe and open environment to freely talk about the things we see in our days.

“The pause.”

Have you heard of the pause? It’s a method that started out of the University of Virginia and has been used frequently throughout the continent.

In essence, it’s about instituting a moment of reflection after the death of a patient. At the time of death, no one leaves the room. And there is a brief 30-60 second pause to reflect on the events that have occurred. That the patient on the bed is a human being whose life has just come to an end. Someone’s child. Someone’s lover. Friend. Co-worker. Someone who you could have just walked by on the street yesterday. Perhaps something is said to the group. Perhaps not.

By taking a second to pause, we allow ourselves to acknowledge what is happening in the present moment. We take a moment, silently, to make sense of this scene, our feelings. The sacredness of what we are trying to do.

It’s a great practice and something I’ve been adding to my work. In my experience, it relieves some of the tension that’s built up over the course of a resuscitation. A little space for it to breathe. Closure. Co-workers have mentioned that they appreciate having that moment of reflection.

I’ve found other times to pause throughout the course of my day. Usually, for me, about one minute before my shift begins. Just noting what sensations I’m feeling, or just watching my breath. A minute mid-way, and a minute at the end of my shift. So three extra minutes over the course of my workday. But I find that I’m much calmer and patient, and I’m not carrying the same tension throughout my days.

It’s not like we’re bad or heartless people. Over the course of a single shift, there are so many varying emotions. Anger, frustration, joy, anguish, sadness. We’re so busy that we don’t have time to really pay attention to any of it. One thing ends, and it’s hurry up and get to the next thing. Instituting a little space, just a little one now and again, just brings us back to where we actually are. In the moment. Just trying our best to help someone out.

Navpreet Sahsi is an emergency physician who blogs at Physician, Heal Thyself.

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