The Most Unkindest Cut of All


It was the best of times, it was the worst of times

I’m a surgeon, so for me, the operating room has always been a haven of sorts. It’s one of the few places where I feel safe from interference from out there. Where, for a brief but immeasurable time, there is no outside –no politics, no traffic jams, no rainy days- just the task at hand. It is a magic place where we all work as a team –all interdependent, all focussed on our mission, all oblivious to anything else. A world unto itself, it exists briefly -like Brigadoon- then vanishes as suddenly leaving only remnants glimpsed through a door: soiled sheets being secreted away into plastic bags, or paper drapes being crumpled into even noisier containers by relative strangers -a different team- busy with wiping and washing… And then the room is empty, barren of meaning –its sacred purpose subdued by the evanescently profane. A sanctuary no more.

I say ‘no more’, but that is hyperbole because it always begins again: samsara. It is an organism that cannot be fully assessed from outside the doors. In the room it is measured in the steady pulse of a beating heart, the razor thin stroke of a piece of steel, the strength and tightness of a length of string.

There are, of course, distractions inside, but they are like traffic noises in the night and soon forgotten, hidden in blood or quickly acclimatized as more urgent problems –often unexpected- surface in the morass of organs vying for attention. It is a stormy sea, the opened body, and to navigate requires immersion in the troubled waters.

But absorption, however deep, demands surfacing from time to time to take stock, to breathe deeply –to assess and plan. And it is then, when the spirit needs whatever succour it can find, when distractions finally disturb -bewilder. It is then when the team finds solace in music.

Ay, and there’s the rub. http://www.bbc.com/news/health-33771022

There are as many tastes in music and what soothes, as there are people in the room -as there are people in the world, probably. So what knits up the raveled sleave of care for one, is definitely not the nourisher of life’s feast for another (Sorry, Macbeth). The article I’ve linked is from the BBC News and suggests that music in the operating room may be counterproductive.

But it is more of a ‘Just right, baby bear’ story I think -obvious stuff that seems almost too obvious to study: if the music is too loud, people can’t communicate with each other; dance music with drums or whatever, definitely distract, although they didn’t elaborate. But the BBC report partially retracted the condemnation towards the end of the article and suggested a compromise approach that fits more closely with my own Confirmation Bias: a link to a 2011 study reported in The Journal of Anaesthesiology and Clinical Pharmacology: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3161461/ This was a prospective, questionnaire-based cross-sectional study -a survey- that tried to pin down elements of music that might be acceptable both to those who were standing or sitting in the operating room as well as the silent one who wasn’t.

For example, ‘…62% thought that music helped in reducing anxiety of patients before anesthesia’ – or to completely obfuscate the observation and clothe it in scientific attire: ‘According to the gate control theory which is based on the fact that pain is an integrated sensory, affective, motivational system that modulates noxious input and attenuates the perception of nociceptive inputs, it has been suggested that pain and auditory pathways inhibit each other. Perhaps the activation of auditory pathway by music during surgery inhibited the central transmission of nociceptive stimuli.’

And also: ‘Our study revealed that 59% of the respondents thought that music helped in reducing their autonomic reactivity in stressful surgeries thus calming them down and allowing them to approach their surgeries in a more thoughtful and relaxed manner.’

It goes on to suggest (with references) that: ‘Music has been used to achieve a wide range of outcomes not only in the hospital, but also in the community and residential care settings. It minimised anxiety levels of patients during hospitalisation and during unpleasant or invasive procedures. It helped people relax. Its effect has been measured in terms of its impact on the person’s heart rate, blood pressure and respiratory rate. It reduced the severity of pain and the need for analgesia in people with acute or chronic pain. It was found to improve cognitive function in terms of behavior, eating and minimised the need for physical restraint for people with dementia. The effect of noisy environment produced by medical equipments in OTs [Operating Theatres- or ORs] and critical care units on patients was also found to be minimal, when music was played in such settings. Patients and hospital visitors were more satisfied with the care provided. It improved mood and feeling of well being for a range of different patient groups. It enhances tolerance level of people to unpleasant or invasive procedures, such as insertion of intravascular lines, surgical interventions, burns dressings and chemotherapy.’

Then there was an attempt to prescribe tempo: ‘Tempo of music around 60-80 beats per minute was found to be the best for creating relaxation. A higher tempo acted like a “driving input”, which resulted in increased heart rate, blood pressure and respiratory rate.’ So, since I prefer the classical music I usually bring to be played in the OR, this meets with my approval, and as long as the team doesn’t nod off during the more lugubrious passages I think I satisfy those criteria.

But of course, volume is the elephant in the room. As the authors of the study put it: ‘The volume of the music played also had a tremendous effect on the mood of the OT staff. Of the total study population 59% of the respondents preferred medium volume while 41% preferred low volume of music in the OT. It was evident that the staff would not let music compromise or interfere with the technical aspects of patient care or competence.’

Although I think it’s hard to turn a symphony up too loud in an OR, I’ve found that violin or even -dare I admit it- piano passages tend to elicit angry, but accidental, elbows in my ribs if played other than sotto voce. I tried out opera once as well, only to discover that the musical device I used was missing for the next case… So I hesitate to draw any firm conclusions… Except that it kept the team awake, I guess -I mean you have to be alert to plan where to hide an iPod.

But I will leave the final words to Shakespeare again –this time from Henry IV: ‘Let there be no noise made, my gentle friends; Unless some dull and favourable hand Will whisper music to my weary spirit.’ A simple request -but this time from a king. They outrank even surgeons.

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