Tag Archives: music

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The Unheard Problem with Noise

Life in the city can be noisy. That’s not where I live, so I find my occasionally unavoidable forays into its bowels almost unbearable.

“How can you live like this?” I asked a friend as we sat on the patio of a coffee shop on a downtown street as an ambulance screamed by.

“What do you mean?” she answered, looking at me with puzzled eyes, her coffee on it’s way to her mouth undisturbed.

The noise had been so obviously intrusive and irritating, that words failed me for a moment. I raised my arm and pointed along the busy, cacophonous street.

“All the people, you mean?” She smiled innocently and shrugged. “It’s near lunch time, I guess,” she said, and picked up her coffee for another sip.

I rested my hands on the table to steady them before I made an attempt to lift my own cup. “Don’t you find it rather…” I paused as I searched for the proper word to describe my angst. “… turbulent?” It was probably not the best description, but I still felt agitated.

The smile wavered for a moment as she tried to decipher my question. Then she sighed –or at least seemed to sigh –I couldn’t hear her soft intake of air in the din that vibrated and careened around us as if we were sitting in the middle of a traffic jam at rush hour. “You’ve been away too long, my friend,” she said, shaking her head sadly.

I attempted to return her smile, but I think my lips were quivering too much for it to become the answer she expected. “Doesn’t all the noise bother you Janet?”

She blinked her eyes slowly in reply. It might have been seductive in another setting, but here it only seemed like a rebuke. “You learn to block it out. It’s an urban adaptation…” Her face softened at my obvious discomfort. “To tell you the truth, I don’t think I even hear it anymore unless it’s so loud it scares me…”

That seemed counterproductive to me, but I didn’t say so at the time. Warning signals are surely just that: alarms that are meant to alert those in the vicinity to potential risks. They’re supposed to provoke a reaction. In my case it probably heightened my awareness of the risks of signal fatigue. Of crying wolf too often. Perhaps it also sensitized me to research that recognized this and attempted novel technological solutions: http://www.bbc.com/future/story/20170714-the-brain-hacking-sound-thats-impossible-to-ignore

The alerting signal the article discussed ‘was inspired by neuroscience research on sounds that affect the emotion-processing centres of the brain.’ It was originally used in Malawi, Africa, ‘To alert Malawi locals to HIV tests and health checks from a mobile clinic […].’

The problem there, as here, was the brain’s tendency to adapt to frequently discordant and unpleasant ambient noise –blocking it from conscious awareness, in effect. It ‘was inspired by the neuroscience research of Luc Arnal at the University of Geneva. Arnal had investigated what neural connections are activated when humans hear a sound that is particularly difficult to ignore: screaming. Scans revealed that, when we hear the characteristically rough, distressing sound of a scream, the amygdala – which processes fear reactions – is activated in our brains. “What I found is that this roughness doesn’t go through the same neural pathways used by speech,” he says.

It means that screams don’t just get our attention, they immediately prompt us to react in some way. We’re stimulated to actually do something. […] Arnal had previously suggested that this insight could be used to design better alarms and sirens that don’t just make us freeze when we hear them, but actually invoke a more constructive reaction.’

An American artist, Jake Harper, had previously recorded  the music of a local band in Malawi and edited it into a form that ‘sounds like nothing you’d recognise from a street elsewhere in the world. Strangely unlike a conventional emergency services siren, instead it is a discordant mashup of musical fragments and intermittent white noise.’

‘Harper spent months experimenting with audio software to try and come up with a noise that sounded man-made enough to distinguish it from human or animal voices in the bush, but which was also not overly harsh or distressing. Getting the balance right – appealing to the emotion-processing parts of the brain without inducing fear or shock – was tough. The results were encouraging. Harper says that on average, a mobile clinic would test 40 people per day for HIV. “During the trial we had 160 people come to get tested,” he says.’

For Arnal, ‘that succeeds in meeting the three key goals here: produce a sound that grabs people’s attention; avoid distressing them; make sure it is distinguishable from non-manmade sounds in the environment.’

‘Our understanding of how audio influences human psychology has evolved greatly in recent years, according to Annett Schirmer at the Chinese University of Hong Kong. For example, studies have shown that people’s neural activity can be co-ordinated with the help of external rhythms. This is exactly the sort of effect you would expect from, say, factory or farm labourers working in time to a song – or the effect of cohesion observed in musicians performing together.

“Music stimulation entrains certain mental processes and aligns them between individuals […]” However, she warns there is also a dark side to using music to alter behaviour.

“Shops use music to make customers stay longer or increase the likelihood that they purchase things,” she notes.’

This is exciting stuff for sure. As Arnal observes, ‘In the future, sound that provokes responses deep in our brains could be more thoughtfully designed into the built environment.’ But we humans are an adaptive lot. We quickly learn to ignore sounds that might have been initially distressing when we first heard them. Apart from the morbid curiosity aroused by it, an ambulance wailing past soon loses its relevance if there is no one nearby who needs it. And if it becomes a too frequent and unwelcome guest, surely the doors to our ears would quickly become unwilling to allow it entrance. I’m not advocating for the Luddites, though, just for an appreciation of Darwin.

Or, perhaps, for the sentiment of Oliver Wendell Holmes as he observed in one of his poems: And silence, like a poultice, comes to heal the blows of sound.

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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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FHR: Fetal Heart Rap

When I was a child, I was fascinated with noise. Well, perhaps sounds would better describe what interested me. What were they –I mean really? And what happened to them after I heard them? When I was finished listening and if there was nobody else around to use them, what occurred then? Sounds told us stuff –information- and I didn’t think Nature would just throw them away. So were they like the wind and simply moved on after touching my ears, or did the data get stored somewhere? Collected and saved –someplace chock-a-block with noise bouncing off every wall, or stacked neatly in little, labelled piles? Maybe there was a sound library somewhere. And when I discovered echoes, I thought I was getting close: recycled sound. It was like taking a book out of that library.

As I grew older –I was going to say matured, but that never really happens, does it?- the riddle of the information contained in sound only intensified for me. I mean, where is it? I even wrote a novel to explore my fascination with it (Sound Bites) that’s published somewhere Googleable online, but that didn’t quell the itch… I began to wonder if I was haunted by something –an idée fixe.

When we are enchanted by something, does that make it more likely we will find it? Or just more likely that we will look for it..? Seek, and ye shall find. But even more mysteriously, does it find us?

 

FHR. Every obstetrician –every nascent parent- knows what that stands for: Fetal Heart Rate. Along with uterine contractions, it’s what we measure on our monitors in delivery rooms around the world. More importantly, it’s the sound that connects us to that inner intrauterine environment. The hidden world. It’s the baby talking to us, giving us a weather report directly from that moist, warm space where we all once lived.

And it’s not a one-off either. Midwives, doctors -and increasingly, parents- are regularly tapping into it for news. Information. Meaning. It’s a sound fraught with emotion and expectation –the unopened present.

But I recently got to unwrap the present in an unexpected venue, in an unforeseen medium: music.

 

“Would it be okay if my uncle came to one of my appointments?” Cynthia was a tiny little woman from the Caribbean that was seeing me for her first pregnancy. She spoke with a delightful accent and every sentence was embedded in an almost musical rhythm. It was as if she was singing to me… She was certainly one of my favourite patients and I looked forward to her visits.

With the notable exception of her husband –another small person who usually sat quietly at her side with an embarrassed smile on his face- I hadn’t met any of her family. “Of course he can come with you, Cynthia,” I said. “Your aunt, too, if you want…”

She shook her head, and ringlets of rich, shiny hair escaped from her headband like children at recess. “No, my aunt is no longer with us…” She blinked and then a huge smile invaded her face and her eyes twinkled like crumpled foil in the overhead lights. “Uncle Ed raised me pretty well by himself…” She seemed to hesitate for a moment before continuing. “But now he says he’s curious.”

“Curious?” Now I was curious.

She nodded her head, and her hair came out to play again. “About the sound.”

“The sound? I don’t…”

“You know, doctor. The sound!”

My face must have galvanized her husband because he realized he finally had a role to play: the interpreter. “She means the sound you play from the baby each time we come, doctor.”

“The baby’s heart rate?” I tried not to make it sound like a question. More like an acknowledgment of a point made. They both nodded their heads in a sort of random unity, and smiled. The doctor had understood.

“Well, I’ll try to put on a good show for him, then.”

Cynthia glanced at her husband and a surprised expression flitted briefly over her face; she suppressed it as she turned back to look at me. “Do you know my uncle?” she said, this time unable to disguise her curiosity at my seeming prescience.

I shrugged politely and smiled. “I don’t think so… Should I?”

They exchanged looks again; secrets crept from eye to eye. “Well…” –her husband started to say something, but Cythia reached out and squeezed his hand.

“It’ll be a surpise… Okay?” she said, the last word asking for my permission.

“Okay. I’ll look forward to meeting him.” I really was looking forward to it.

She was fairly far along in her pregnancy so I saw her again in a couple of weeks. It was, however, just long enough for me to forget the surprise. An office is busy, even chaotic at times. There are many surprises…

Cynthia was already in the examination room when I walked in and I noticed the uncle immediately. A tall, thin man with a patchy white beard, sat comfortably beside her –lounged might describe it more accurately. He looked entirely at ease in his rumpled brown fedora and clean but wrinkled blue suit, and his face lit up and immediately cracked into a thousand crevices when he noticed me and smiled. He stood up and extended his hand. “Thanks for letting me come,” he said, his voice sonorous with a hint of gravel. “Cynthia’s been bragging about you for some time now,” he added, and his eyes locked on me like talons from under the brim of his hat.

He glanced at an expensive looking recording device he’d placed on the table by the sink and his smile widened. “Thought I’d record the baby –if that’s okay with you…” He was asking permission, but his eyes knew my answer and relaxed their grip, caressing my face briefly as they returned to the recorder.

“Of course, of course,” I found myself repeating, strangely nervous that my performance might not be up to the machine –or the uncle’s- standards. Cynthia got onto the table and I proceeded to take her blood pressure and assess the size of the baby in her abdomen with my measuring tape. It was an old tape, the numbers worn thin by the years of use, and for some reason I felt embarrassed with it. Like I should have used the new one I had in another room…

And then came the time to listen to the heart. I positioned the doptone over the region of her abdomen I hoped would give the best sound and turned it on. Nervously again. With stage fright, almost. I got the area right and the sounds pounded out in their usual steady cadence –fast at first (I had disturbed the baby by measuring the abdomen) and then settled down into a steady, industrial rhythm. A horse galloping. One hundred and forty hooves per minute -I almost said that, I was so anxious.

Uncle Ed, for his part was entranced, and his eyes were focussed elsewhere –inside his head, if I had to guess. Then he closed them -closed the private door- and his whole body began to sway in sync with the beating heart. Even his feet began to tap. I almost thought he was going to get up and dance…

Finally he raised his head and opened his eyes, sated. Exhilarated. Then, like an orchestral conductor he nodded for me to stop the sounds as he reached for the machine to turn it off in tandem. The performance was over; I almost expected applause, but except for the delight, bordering on exaltation I could feel around me, that was it.

He shook my hand warmly, gathered up his instrument, and sidled out of the room as relaxed and in control as ever. He left Cynthia beaming and her husband wide-eyed. But she winked at me as she left –a show of silent appreciation of the concert.

The whole episode left me puzzled however. Why had I felt so nervous? It was like I’d been onstage the whole visit. I walked down the short corridor that led to the reception desk and discovered both my secretaries huddled together and whispering loudly. They both looked up in unison when I turned the corner, their eyes sparkling, their expressions, well, rapt I suppose. Another puzzle.

“Interesting chap that uncle, eh?” I said, to break the spell.

“Interesting?” one of them managed to gasp as they saw my entirely benign expression.

I felt naïve, for some reason. “Yeah, he was really into the fetal heart stuff. He even recorded it,” I said, trying not to expose how strangely anxious his taping of it had made me, but I must have said it too loudly.

A patient I didn’t recognize was sitting nearby in the waiting room and she rolled her eyes when she heard me. “Well, I guess so, eh?” she said, and exchanged glances with one of my secretaries. They both laughed.

“Do you even know who that was?” the patient said.

I shook my head slowly. But just then, my colleague, the other doctor in the office, called for the patient, and she disappeared through a door after winking at my secretaries with an enigmatic smile on her face.

“Well,” I said to the now empty waiting room, trying to pretend I wasn’t as curious as I must have looked. “Who was the uncle..?”

Another set of eye-rolls –this time from behind the counter. “Come on,” one of them said when she finally found the strength to close her mouth. “Don’t you ever listen to rap?” She pronounced it like an accusation, but I know she didn’t mean it like that.

I am appreciated in the office –admired, maybe- but not for my musical insight. I am loved for other things… I hope.