Monday, March 8, 2010

The Sound of Surgery

When Australia’s top surgeons emerged after the mammoth 32-hour surgery to separate conjoined twins Trishna and Krishna late last year, they revealed that listening to music had helped the team get through the marathon procedure. The steady beeps of monitors, the sound of suction, the stirring strains of Beethoven’s 9th Symphony - It seems, as elsewhere in modern life, surgery has acquired a soundtrack.
Surgeons are just as receptive to the calming benefits of music as anyone else, perhaps even more so, as several studies have demonstrated improved task performance among staff in the operating theatre when a CD or radio is playing in the background.
Ask most surgeons about their operating theatres, and they will describe them as havens from the stresses and pressures of a busy clinical practice. Most theatre personnel would gladly accommodate any means that might diminish the stress or enhance the smooth running of an operation. Techniques such as dimming the lights, decreasing human traffic, and playing a selection of tunes from the surgeon’s iPod are increasingly common in theatre. Music reduces stress. It lifts moods, making the operating room a more pleasant work environment.
But this is by no means a recent revelation. The beneficial effects of music during surgery have been lauded in medical journals going back 50 years. In fact, the magazine ‘Popular Mechanics’ wrote in a 1924 edition, “music has been found of value in surgical operations to ease patients during and after the administration of ether. Melodies are supplied by a phonograph or instrumental selections are rendered by an artist. Several demonstrations have been made at a Brooklyn, New York, hospital.”
A generation ago, music in operating rooms was rare, partially because the surgeons who ran them didn’t want it but also because it was impractical: radio reception was often poor and tinny. Boom boxes that first played cassettes and then compact discs were an improvement, and today’s MP3 players can hold thousands of songs, so now surgeons can carry their entire music library around in their pockets.
A growing body of research in recent years shows mild benefits for the patient going under the knife as well as for the surgeon holding it. A landmark study that observed the effects of music on 50 male surgeons (aged 31–61 years) who regularly used music in the operating room was published in the Journal of the American Medical Association (JAMA) in September 1994.
Skin conductance, systolic blood pressure, and pulse rate were measured during the performance of two mental arithmetic problems separated by a five-minute rest period. The researchers found that the beneficial autonomic effects of the music were due primarily to reduced cardiovascular reactivity, and that the beneficial behavioural effects were derived primarily from improved task performance.
Furthermore, investigators writing in the journal Surgery reported on an objective evaluation of the effect of noise on the performance of a complex laparoscopic task in 2004. They concluded that music did not interfere with or impede the performance of the surgeons in any way.
Scope contacted a number of Irish surgeons and asked whether they felt music had an important de-stressing role to play in the sterile environment of their operating theatres. And Scope can reveal that indeed the sound of music and the occasional hummed melody is a frequent companion to surgery, with most of the doctors surveyed agreeing that listening to music while they worked had a relaxing effect, helping to focus their attention.
But, naturally, there are rules and restrictions. As one surgeon pointed out, they work in an operating theatre, not a concert venue. The volume usually doesn’t go above background level, the music often doesn’t start until after the patient is asleep and surgery is in progress, and if a case is especially difficult or if problems rise during the procedure, the music is switched off.
Nevertheless, music has become a regular component to life in the operating theatre, as illustrated in two separate studies. In a survey of 200 Anaesthetists published in 1997 in the British journal Anaesthesia, 72 percent of respondents said music was played regularly in their operating rooms. Also, a 2008 study in the journal Injury found that almost two thirds of more than 170 doctors and nurses in three hospitals listened to music on a regular basis in the operating theatre. Classical music was the most requested (58 per cent), and about eight in ten of the participants claimed that music in the OR made them calmer and more efficient. The authors concurred, “Music has a positive effect on the staff working in the operating rooms”.
Mr Javaid Butt, a Consultant General/Breast Surgeon in St James's Hospital, Dublin, says that he ‘always’ listens to music during elective surgery. When Scope caught up with him, Abba was playing softly in the background as he left the theatre, having just finished a procedure.
“I like to listen to music in the background while I’m in surgery. We have a CD player in the theatre and the music selection is open to requests. The nurses bring a selection of music, usually classical but sometimes the latest chart hits, once it’s not too intrusive. And sometimes we listen to the radio, so it’s a mixture,” he explains.
Mr Butt’s personal favourite melodic accompaniment is classical music: “I find it helps with concentration when the procedure is complex.”
“Sometimes the type of music depends on the procedure, or which stage we’re at during the procedure. The music may get a little livelier when I’m closing, for example. Today it was Abba.”
He adds that he usually listens to music in theatre at a medium volume and he finds it does not interfere with his performance at all. However, if he is dealing with an emergency case, there is no music.
“When we are doing emergencies, we don’t listen to music. When it’s elective surgery, we start the music after the first skin incision, and the music usually stops by the time we finish stitching up. But if there are any complications during the procedure we tend to stop the music.”
Mr Sean Carroll, a Plastic, Cosmetic and Hand Surgery in Saint Vincent's University Hospital Dublin and the Beacon Clinic, also listens to a CD player while he works in Theatre. He says the volume is usually low – “nice background noise” – and his preferred selection of tracks vary from rock to classical, depending on the procedure and the mood of his surgical team. And who gets to select the play list for the time in theatre? “Democracy rules,” Mr Carroll quips.
“I believe music can have both beneficial and perhaps adverse affects when played during an operation. That is why I can switch it off whenever things were not going well,” he says.
However, there are some surgeons, including those who love music in other parts of their lives, who find it too distracting while they’re operating. Music can also prove intrusive while teaching, according to Prof Michael Kerin, Professor of Surgery at NUI Galway, who says he doesn’t usually listen to music when he has medical students and NCHDs with him in theatre.
“There is usually silence or discussion during elective lists and music in emergency theatre. It depends on what Anaesthetist likes,” he tells Scope. Prof Kerin, who is a Consultant in Breast, Endocrine & General Surgery in University College Hospital Galway, also remarks that the positive or negative effects of listening to music during theatre may be down to personal preference. He says it’s “like listening to music during study:  Some people like it and some don’t.”
His deference to the anaesthetist, who works alongside him in theatre, raises a valid issue concerning the addition of music to this work environment. Auditory input is important to anaesthetists for monitoring the patient and for communication between the anaesthetist, surgeon and nursing staff.  Some doctors think that music can be a distraction that could undermine communication and the crucial teamwork necessary to pull off a difficult operation.
More than a quarter of the 200 Anaesthetists surveyed for the 1997 study in Anaesthesia felt that music potentially “reduced their vigilance" and impaired communication with other theatre staff, whereas 11.5 percent of them felt music might distract them from alarms. Just over half of respondents felt that music was distracting when a problem was encountered during the anaesthetic.
However, a subsequent study by the same research group on 12 trainee anaesthetists using a computer-based psychomotor performance assessment failed to show any adverse effects of self-chosen music, silence, white noise or classical music on their performance in these tests (Anaesthesia 1998).
The same cannot be said for the effect of music on patients. A 2005 study by the Yale School of Medicine confirmed previous work showing that surgery patients listening to music require much less sedation. Previous studies left open the question of whether it was music that did the trick, or just the act of blocking out the sound of dropped surgical instruments and other operating room noise.
However, Prof Zeev Kain, a Yale professor in the Department of Anaesthesiology, writing in the journal Anesthesia & Analgesia, remarked: "Doctors and patients should both note that music can be used to supplement sedation in the operating room.” He arrived at this conclusion after testing 90 surgery patients at two facilities. Some wore headphones and listened to the music of their choice. Others heard white noise designed to drown out noises in the operating room. Others had no headphones. Prof Kain and his team reported that blocking sounds with white noise did not decrease sedative requirements, but music did.
His results confirmed a 1999 study in Pain, which found that music after abdominal surgery reduced patients' post-operative pain. And other studies have shown that music before and during surgery can reduce blood pressure and nervousness.
These beneficial effects are being witnessed first-hand by Mr Arthur Cummings, a consultant ophthalmic surgeon in the Beacon Hospital in Sandyford and the Wellington Eye Clinic in on the Beacon medical campus, Dublin.
“I feel music is beneficial for patient, surgeon and the rest of the staff in theatre. I find it calms everyone down including the patient. Almost all my surgery is under topical anaesthesia,” he explains.
Ninety percent of the time the music playing in his operating room is from the radio, the rest of the time a CD player provides some ambient tunes.
“During surgery we simply avoid anything too loud and anything that may startle the patient or anyone of the staff, such as music with loud drum solos or very high pitched singing. The music is quite soft so that it’s still very easy for the patient and I to communicate. We’re never ‘fighting to be heard’ against the music.”
Mr Cummings says that all of his staff in theatre gets to pick the music and put whatever they like on. “It’s mostly laid-back, easy listening type of music so there are not too many surprises at all in terms of song choices or CD choices,” he adds.
But the last word is always left with the patient. If they would prefer silence in the room, then the music is turned off.
Mr Butt in St James’s is convinced of the benefits of listening to relaxing music in the operating room. “Definitely, it has a very calming effect,” he asserts. “Obviously it all depends on the individual person but I feel very calm and relaxed and my concentration is in fact enhanced while listening to classical music in theatre. It brings with it a happy background factor and you tend to concentrate more during surgery,” he says, however he is aware that not all of his surgical colleagues share his fervour. “Many of my colleagues listen to music in theatre. They would have different music selections, whatever works for them and their team at the time, but some of my colleagues of course don’t listen to music at all while they work. That is their choice, this is how they work best, and in the end that is what is best for the patient.”
The overall feedback from Irish surgeons is that music can bring a welcome vibe to their operating theatre. It can help put them in the right frame of mind, relax the other members of the surgical team, and contribute to the feeling that the theatre is a refuge from their busy lives, a place where they can focus solely on the patient, the surgery and their skills. Musical tastes vary, from Sinatra to Debussy to Coldplay, but they are all united on one point: if at any stage the music interferes with the procedure at hand, the ‘off’ button is pressed.

Live from the OR

Combining music with surgery is what Dr Jorge Camara does best. As an internationally renowned ophthalmologist and classically trained pianist, Camara has infused what he says are clinically proven relaxing properties of classical music with medicine to produce a recently released album, Live from the Operating Room.
The CD was recorded in the operating theatre of then St Francis Medical Center in Honolulu (now Hawaii Medical Center East) when he played live classical piano music for 115 patients before operating on their eyes.
He believes it's the first study in which a surgeon performed on a piano in an operating room for patients before surgery.
The patients, aged 49 to 79 years old, were having surgery for the first time. Camara’s study reports average decreases of 21 per cent in their blood pressure, 8 per cent in heart rate and 21 per cent in breathing rate.
The music had "profound" physical benefits, lowered the patients' blood pressure and heart and respiratory rates before any sedation or pain medication, according to a paper in the Medscape Journal of Medicine (Medscape J Med. 2008;10(6):149).
“My co-researchers and I found that playing live classical music for patients significantly brought down their blood pressure, heart rate and breathing rate. We published the study to share the information with other physicians, and I decided to release the music from the study so that other people could benefit from the music without necessarily having to undergo surgery,” explains Dr Camara, who is Clinical Assistant Professor of Ophthalmology at the University of Hawaii’s John A Burns School of Medicine.
The album includes many recognisable pieces, including Chopin’s Nocturne In E Flat, Etude in E Major and Beethoven’s Moonlight Sonata. More information about Dr Camara, his work and music is available on his website:

Medical Myth Busters

You know you’ve struck a sensitive cord with the medical profession when you’re forced to take out a restraining order against an abusive and threatening doctor. Such is the price for debunking myths, half-truths and outright lies about our health.
When American paediatricians Aaron Carroll and Rachel Vreeman published their book ‘Don't Swallow Your Gum!’ last year, which tackles commonly held medical beliefs, laying out the science that proves or disproves them, they were somewhat prepared for the negative backlash that ensued. Apparently, their earlier British Medical Journal article in 2007, which set the record straight on the top ten medical myths, triggered a bombardment of criticism from doctors who simply refused to let go of their long-held beliefs.
"We were shocked at how many people had strong reactions to the beliefs we debunked in the BMJ studies. These myths may be things people have heard since childhood, like 'you lose most of your body heat through your head.' Some people have a hard time letting these beliefs go," offers Dr Rachel Vreeman, Assistant Professor of Paediatrics at the Indiana University School of Medicine (IUSM) in Indianapolis.
Dr Aaron Carroll, who is Associate Professor of Paediatrics at IUSM, told Scope: “People believe these things incredibly strongly. We were just hit hard. There were a lot of complaints. On the BMJ website, for the first paper, they allowed people to post comments and some of them were really very angry, you know, personally attacking us. We were not expecting that,” he laughs. “We had one gentleman here in the United States, who was so angry about our conclusions about the recommended eight glasses of water a day that he phoned repeatedly and was so abusive to our staff they had to get a police restraining order against him to get him to stop calling back!”
The fact is there is no scientific proof stating that you need to drink anywhere near eight glasses of water. One doctor who made this his research focus, Dr Heinz Valtin, searched through many electronic databases and also consulted nutritionists and colleagues who specialise in water balance in the body. In all of his research, and in all of the research Drs Carroll and Vreeman conducted to double check his work, no scientific evidence could be found to back up the daily requirement of eight glasses of water.
“The water in coffee is water, and the water in fruits and vegetables is water. The body doesn’t know the molecule difference, water is water and it’s all good. Actually people should be careful not to drink too much water,” Aaron cautions, referring to a recent and much publicised death of a young woman who participated in a water drinking contest hosted by her local radio station in the US. Too much water dilutes the normal level of sodium in the blood, causing hyponatremia, in which the brain cells can swell and die.
In their book, ‘Don't Swallow Your Gum! And Other Medical Myths Debunked”, Drs Carroll and Vreeman take on all those weird and worrisome things we think about our body and expose them for what they are. The authors blend authoritative research with a breezy sense of humour, providing the ultimate myth-busting collection of more than eighty enlightening, practical, and quirky facts about health and wellbeing.
Aaron, who is Director of the Center for Health Policy and Professionalism Research at IUSM, admits that he had assumed most doctors, armed with their medical training, might have been less inclined to entertain some of the commonly held myths about health.
“I don’t think you can generalise too much but doctors are just as guilty, we are all human beings and most of these myths are things you’ve heard from your parents back in the day so you just believe it’s true.
“And you’d be shocked at how much in medicine is ‘best guess’. As doctors, we are use to taking what we’ve been told or taught or using experience to decide how to actually practice medicine, and unfortunately some of the stuff we’ve been told is not correct. Doctors are often the most difficult to change minds because they are just so convinced that not only are they correct personally but professionally as well. It is very difficult to change their minds,’ he observes.
Aaron readily confesses that he was just as misguided in some of his long-held beliefs as the next person.
“The really fun part of writing this book was that we had believed so many of these myths - but upon reflection, we weren't sure whether they were true or not. As health services researchers, we couldn't resist the temptation to be myth busters.
“I’m a paediatrician and I can tell you that I spend hours talking about the myths that concern kids, such as teething doesn’t cause a fever – lots of paediatricians believe that – the truth is teething doesn’t cause a fever but I hear doctors say it does all the time. And I still hear people who really believe that sugar makes kids hyper and that is absolutely not true. In fact that was one myth I firmly and absolutely believed. It blows my mind to this day! I have three kids and I was convinced that giving them sugar made them hyper but it simply isn’t true.
“Another one is that Turkey makes you sleepy, I mean, I just believed that. Everybody knows it’s the tryptophan. The sleep-inducing effects of tryptophan in turkey are common currency in America, I just absolutely knew that was true, but then to find out that, first of all, Turkey isn’t high in tryptophan, and then that tryptophan needs to be taken on an empty stomach - the worst way to get it is a big meal - that was just mind blowing.
“But I can rattle off others too. I thought a dog’s mouth was cleaner than a human’s. I thought you needed eight glasses of water - I assumed that was proven science. There were just lots and lots of them. I absolutely believed as many of these as anyone else who’s reading them. Like eating at night, I totally believed that eating at night made you fat. Every weight loss programme in the United States says that, so I assumed it was true. If you eat and go straight to bed it turn right to fat but that is totally not true.
“My favourite two are probably sugar makes kids hyper and turkey makes you sleepy, those are probably the two that I believed the most strongly and they have the most unbelievable solid evidence showing that they’re just not true,”
Their book, which was published by Penguin in Europe in November 2009, is divided into six sections:
"Look at the size of his feet!" Myths about your body
"Do you want to catch pneumonia out there?" Myths about how we contract and treat diseases
"But I was on the pill!" Myths about sex and pregnancy
"He won't get into Harvard without Baby Einstein" Myths about babies and children
"Don't swallow your gum!" Myths about what we eat and drink
"Shots made my baby autistic" Myths that spark controversy and debate.
Already on its fourth reprint in the USA – an impressive result for a paperback – the concept for this quirky book of endlessly fascinating and occasionally disgusting facts (aren’t they the best?) actually began as a conference paper. Aaron and his then Fellow, Rachel, delivered a hugely popular talk exposing the top ten medical myths to a meeting of paediatricians in the US several years ago. Their paper was later published in the BMJ and ever since both doctors have been contacted by email, text and casual conversation about a myriad of health-related myths.
Ranging from the curious to the seriously bizarre, they began compiling a list of myths that would provide the bones of a book for which they would fill in the flesh through a fact-finding trawl of medical and scientific research.
Although co-authoring a book can be notoriously problematical, the two colleagues fell easily into pace not only with each other’s writing styles but also with proportioning the workload.
“It was pretty easy for us. Perhaps that’s because, in writing medical research, you’re a little more use to collaboration. Papers have multiple authors almost every single time and so you get use to one person taking the lead and another person doing serious editing.
“For this book, we would divide up chapters and divide up responsibilities. Sometimes I’d be responsible for doing the research and then hand it off to Rachel to write up that chapter, and sometimes we’d do the opposite. In fact, we got so use to working and writing together that we will have arguments to this day over who wrote which chapter so I guess that speaks well of the fact that our writing merges well. 
“We’re from the same division in the same department in the same hospital (Riley Hospital for Children). We’ve been colleagues and worked together for such a long that it wasn’t that big a deal. There wasn’t any competition between us either, we were both doing this for fun and it was exciting. Neither one of us expected it to go this far,” Aaron admits happily.
Their extensive research has secured a large fan-base, along with the inevitable detractors of course, and their work has been featured in The New York Times, USA Today, The Los Angeles Times, Scientific American, Newsweek, and many other publications. They have also appeared on Good Morning America, CBS Evening News, and ABC News NOW, as well as attracting a host of the international media.
When Aaron reveals that he and his myth-busting partner are now talking to their agent and editor about writing a sequel to their runaway success, it requires a true feat of will power not to blurt out some myths of my own.
Eventually, I relent – joining the many before me proffering their myths - and I suggest that they research whether ‘sea air’ is the appetite stimulating, sleep inducing constituent my mother has long claimed it to be.
Aaron graciously appears interested, almost fascinated. He has never heard that one, and will certainly look it up. If the scientific research is available on the miracles of ‘sea air’, he assures me it will make the cut for their next book. I tell him my mum would be delighted “But you realise,” I hasten to add. “You’re going to have to prove her right.”

How Bizarre!

During his daily clinic, paediatrician Aaron Carroll hears many myths from mothers concerning their baby’s health and wellbeing. “There are some that come into play that are just really strange,” he confides.
“Like there’s a group of mothers who believe that breast milk can be used for everything, including curing ear infections. They think if you put it into someone’s ear it’ll cure their ear infection. They also recommend breast milk in the eye for eye infections or pink eye. Some of their other suggestions for any spare breast milk you might have around the house include clearing up a stuffed-nose or easing a sore throat, removing make-up and healing mosquito bites. It’s crazy.
“I remember I met one set of parents who believed that if they blew tobacco smoke into a child’s ear it would prevent ear infections. Oh my God! Why would you ever want to blow tobacco smoke at a child’s face? But people believe crazy things all the time.”
In this book “Don’t Swallow Your Gum”, Aaron and his co-author Dr Rachel Vreeman select several other bizarre myths and the peculiar individuals who believe them.
In exposing the myth that you can beat a breathalyser test by, for example, sucking on cough drops, onions, peanuts and pennies; they recount the true story of one intoxicated man who even thought that a mouthful of his own faeces would stump the breathalyser. His blood alcohol level was found to be twice the legal limit.
“We think that most people would have to be more drunk than that to lean over, poo in their own hand and then stuff it in their mouth,” the writers remark.

The truth is hard to swallow

The next time you are at a party and considering a plunge into the dip bowl, perhaps you should take a look at the people around you. Would you kiss them or lick the insides of their mouths, ask the two medical scribes of “Don’t Swallow Your Gum”.
Apparently, one intrepid group of microbiologists, led by Dr Paul Dawson, studied whether or not bacteria were really transferred from mouth to chip to dip (the double-dipping scenario). Their findings revealed that on average three to six double dips transferred about 10,000 bacteria from the eater’s mouth to the dip.
And another group of food scientists and microbiologists decided to put the ‘five second’ rule to the test to find out what happens when this myth comes up against Salmonella typhimurium, a fairy common but nasty bacterium.
They found that bacteria were still alive after four weeks on a variety of floor surfaces, although the rate of transfer varied. The worst offender of the five-second rule was tile, from which over 99 percent of the bacteria cells transferred to the dropped food after just five seconds.
As for the book’s title myth of swallowing chewing gum, does it actually stay in your stomach for seven years? The reality is, even though gum is sticky, it is no match for your gut and like all indigestible foods will eventually be “pooed out by the power of peristalsis”.