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.

Advertisements

The Goddess of Small Things

Every office needs a goddess. Every doctor needs to see one now and then to keep things in perspective. Separate the two Magisteria.

I have a goddess –not self-professed to be sure, but in a pinch, self-acknowledged. She comes to see me once a year or so, for reasons that are not at all transparent.

It began about fifteen or more years ago. It was a surprise; the referrral letter from her doctor said nothing about a goddess. It didn’t even mention her powers, as I recall. It merely said “Infection!!”  and although the writing seemed laboured, reluctant –scrawled perhaps describes it best- the exclamation marks were clear enough. In fact, they were several times the size of the writing, and burrowed deep into the page, breaking through the paper in one particularly enthusiastic area as if to justify their mission.

Judith did not come across as your average goddess at all. In fact that first time she seemed rather shy and dressed as background; I didn’t even noticed her sitting in the already crowded waiting room until she stood up when I mis-called her name. A short woman with matching short dark hair, she was wearing a dress that seemed at once plain, and at the same time almost camouflaged against the other dresses in the room. Quite a trick, really. She only stood out when she moved across the room to correct my shortening of the Judith part of her name to Judy.

She spoke, or rather commanded my attention, as soon as I closed the door. I couldn’t place her accent, but it seemed an unusual one. “I require only one thing of you, doctor, so we can dispense with the usual history taking.”

I hate it when they do that. I’m a specialist; I’m supposed to take a careful history and solve their otherwise intractable problems with the benefit of my esoteric knowledge base.

She studied my face for a reaction and, obviously satisfied with the engendered confusion, proceeded to enlighten me. “I’ve been to several specialists already, but they all seem unwilling –or perhaps unable- to help me.” I don’t know why, but I felt like a PhD candidate about to defend an assertion in his thesis. I was being examined.

“I have a recalcitrant case of Mobiluncus mulieris in my parts.”

I have to confess that I blinked involuntarily at the words. Was she a nurse? A doctor in disguise, sent by the provincial medical association to check on my competance? I had to think fast –she had just named one of the several microorganisms thought to be responsible for a rather malodorous vaginal problem. “Bacterial Vaginosis can be very difficult to treat…”

She was silent for a moment and then sat down in a chair across from my desk, a smile incipient, hiding in full view. “Very good, doctor.”

“Did I pass?”

The smile blossomed on her face like a rose opening in the morning sun; her eyes twinkled with mischief. She sat back in the chair, finally relaxed. “I had to know…”

I didn’t ask.

But from that moment, she seemed to bond –with me, with the room, with the Gestalt… And, no doubt it was my imagination, but she suddenly surfaced from the background, like a picture focussing. She shook her head like a fairy might and blinked back at me from somewhere deep inside her head. “You will be my doctor,” she said simply and then stood up.

The interview was obviously over, the threshold attained and crossed, but she stopped at the door and turned to me. “I will not come with problems I cannot solve, merely with problems I wish to discuss.” The now-famous blink again. “Is that all right?” she said, already knowing it was as she turned and left.

She would appear from time to time and tell me of her trips to places I had never heard of. Sometimes it was cloaked in the pretense of needing a pap smear, or a culture for some totally esoteric sexual disease, but we both understood that these were excuses. Dissimulations to cloak her need to connect. It was as if, when she disappeared each time through the door, she ceased to exist –much like Brigadoon –the famous musical about a town that exists for only one day every hundred years.

I told her the story of Brigadoon on a visit when she suddenly appeared in the waiting room, after not seeing her for what seemed like several years. She disappeared behind her eyes for a moment in surprise and when she surfaced again, she was a pixie. She shrugged mischievously, as if caught with a hand in the cookie jar. “I travel a lot,” she said, but not convincingly.

I realized how little I actually knew about her and when she sat down, I decided to find out more. But I suppose she could read my expression and shook her head almost imperceptively. “Magic lies not in what you can see, but in what you can’t quite make out, don’t you think?” she said innocently enough.

I smiled to conceal my embarrassment at being caught about to probe a past which, by some unwritten, unspoken understanding we had agreed should remain hidden. “My secretaries think you are a…” –I hesitated to continue, fearing she would take even the substitute word that I had decided to use the wrong way. An unintended, pejorative way. One secretary –the younger one- had actually said ‘witch’, but the other, the older worldly-wise one, a more sexually-innuendoed word.

But she merely smiled; her eyes told me she already knew what I wanted to say. “You were going to disguise their guess, weren’t you?”

“I…”

“Or change it into something more… polite?” her face twinkled playfully. I have to confess I blushed at her seeming prescience. She leaned towards me over my desk. “Some have called me fey…” She thought about the word for what seemed an eternity. As if she wasn’t sure how much to disclose. “There are many words they use,” she whispered and then sat back. “Witch, enchantresss, goddess… Weird things like that, because, like you, they don’t know much about me.” She stared at me for a full minute and then at something over my head –or so it seemed. “Because I only appear long enough to influence some part of their everyday lives and then vanish, there is a touch of mystery to me, I suppose.”

The skin on her face relaxed and she suddenly seemed older. Wiser. Ancient.

She got up slowly and walked to the door. “But it’s not like that, you know. Not really…” Even from the door I could see her sigh. “No matter what they think, I don’t do very much for them.” A final blink before she turned. “I am the Goddess of small things,” she said over her shoulder as if to the wall. As if, as it turned out, I would never see her again.