Sound and Health: Hospitals

Roman Mars:
This is 99% Invisible. I’m Roman Mars.

Roman Mars:
Sound can have serious impacts on our health and wellbeing. Ever since people moved into cities, we had been exposed to an unhealthy amount of noise – cars, power lines, and the constant ding of our devices. We live in a very noisy world and most of the noises we hear aren’t designed to work together.

Roman Mars:
This is the second part of our special series on sound and health supported by the Robert Wood Johnson Foundation. We’re taking a look at how a more intentional approach to sound can help us live better, healthier lives. There’s no better place to think about health than hospitals. Joe Schlesinger is an anesthesiologist at Vanderbilt Medical Center. He spends a lot of his time in the operating room.

Joe Schlesinger:
The operating room is an interesting space because we think of it, it’s like my cockpit, if you will, and anesthesiology is related a lot to aviation. We are a culture of safety. We have safety checklist just like pilots do. We think of takeoff and landing, just like putting a patient to sleep and waking them up. In fact, when we wake someone up from anesthesia, we call it landing the plane.

Roman Mars:
Landing the plane takes focus, but Joe doesn’t work in silence. It might come as a surprise, but in the OR, there’s music playing all the time.

Joe Schlesinger:
There’s great data that shows that music improves surgical efficiency, which can translate to an economic benefit, and music subjectively makes us feel good. If you’re working long hours during difficult cases in the operating room, if you can improve mood, certainly there’s benefit. But who chooses the music is usually the surgeon. If the surgeon is excited the surgery is over and the music volume gets cranked up, it’s really hard for us to be delicate, and intentional, and artful, and elegant about our anesthetic.

Roman Mars:
Joe Remembers one surgery where music was playing and then all of a sudden the patient’s vital signs started to crash.

Joe Schlesinger:
Now, my alarms are going off, the music volume is high. The surgeon and I are having to raise our voices and almost yell at each other to communicate, not because we’re mad at each other, but just to understand each other.

Roman Mars:
Joe and his researchers are trying to figure out how to get the benefits of music in the OR without the risk of hearing “We Built This City on Rock and Roll” while someone is having a heart attack.

Joe Schlesinger:
I’m working with another anesthesiologist on a device which is called the CanaryBox.

Roman Mars:
The CanaryBox has two levels of alarm – a warning zone and a danger zone.

Joe Schlesinger:
When the alarm is in the warning zone, it halves the music volume. When the alarm is in the danger zone, it turns the music off.

Roman Mars:
Fixing how sounds work together in the operating room is a step in the right direction, but it’s part of a bigger problem. Doctors know more about the human body than ever and are better equipped to save your life, but still …

Joel Beckerman:
Hospitals are horrible places to get better.

Roman Mars:
That’s sound designer Joel Beckerman, and he’s right. Hospitals can be bad for your health because hospitals sound terrible.

Joe Schlesinger:
I think of when I walk into the neuro ICU and I hear the automatic door, which opens and closes as people walk by, it opens and closes without anyone going in or out. As I walk in, there’s the hubbub of people talking and it might be clinicians, it might be patients’ families. I hear the rolling of the big metal cart that houses all the meals for the patients and it’s the wheels rolling on the hardwood floor.

Roman Mars:
Yoko Sen is an electronic musician researching sound in hospitals.

Yoko Sen:
When it’s quiet, it’s about 40 to 50 decibels, but when it’s pretty loud, it goes up to easily 60, 70 decibels. Sometimes it hits 80 to 90 decibels as well.

Roman Mars:
To give you some perspective, 60 decibels is the volume of an average office. 70 decibels is about as loud as a vacuum cleaner. 80 decibels is as loud as a garbage disposal. And 90 decibels is as loud as a motorcycle passing by. All this in your so-called “healing environment”. Hospitals can be really loud, but volume isn’t the only problem.

Joe Schlesinger:
I hear the alarms coming from multiple patient rooms and I don’t know what’s wrong with the patients. The alarms are difficult to localize, so I’m not sure which rooms they’re coming from.

Roman Mars:
Even when he knows what he’s listening for. Joe has a hard time figuring out what device is making noise.

Joe Schlesinger:
It could be the IV infusion pump, the epidural pump, the intraaortic balloon pump, the dialysis machine, the ventilator.

Roman Mars:
Joel Beckerman has experienced the same thing in hospitals he’s worked in.

Joel Beckerman:
There is a heart monitor that makes 86 different alarms. There’s no way that, that can be meaningful to anybody.

Roman Mars:
The scary thing is most of these alarms are false alarms. It could be due to a loose connection or a temporary blip in the patient’s vital signs, but most of these alarms don’t tell you anything useful. Still, they saturate the hospital soundscape.

Joe Schlesinger:
I go home at night and I still hear the beeping of alarms and the beeping of pulse oximetry in my head.

Yoko Sen:
Clinicians are annoyed by lots of alarms, but there are a number of physicians and nurses that, “I love those alarms.” Like, “I have my adrenaline now, but I get excited.”

Roman Mars:
But the high from alarms is not sustainable. It’s actually pretty exhausting. The result is something called alarm fatigue.

Joel Beckerman:
The problem with alarm fatigue is that din of sound, which caregivers then learn to ignore, means that they also ignore critical alarms and patients die. This is a very, very serious problem that needs to be addressed.

Yoko Sen:
When things are loud, people complain that it’s difficult to sleep at night. It disturbs their sleep. It disturbs their rest. Noisy environment could cause more anxiety, sense of fear and stress for patients and visitors as well. I often hear from those parents that when alarms go for their babies, the first thing that young parents would think is, “Oh no, it’s my baby going to die.” It’s very scary.

Joel Beckerman:
It can lead to neuropsychological side effects such as ICU delirium.

Roman Mars:
ICU delirium is when patients get confused and paranoid because of the exhaustion of staying in a hospital. Sometimes this can lead to hallucinations. Up to 80% of patients in an ICU are thought to experience some form of delirium during their hospital stay. It’s the sort of thing that can leave hospital patients with PTSD.

Yoko Sen:
I interviewed one person. He had his daughter, more than 10 years ago, in NICU.

Roman Mars:
That’s the NICU, intensive care for infants.

Yoko Sen:
And there was this particular alarm sound that kept going off. Even after 10 years, if he hears the sound that’s similar to that alarm – on television or other places – he still gets this sort of a traumatized reaction.

Roman Mars:
There are long lasting effects on the body as well as the mind. Noise leads to stress and stress hormones in the body stiffen our blood vessels which can increase the risk of heart attack.

Yoko Sen:
I often quote this phrase from Florence Nightingale who said unnecessary noise is the cruelest absence of care. She wrote that more than 100 years ago, but I’m guessing 100 years ago there was no alarm fatigue issue. Most things in medicine progressed in 100 years, but I feel like when it comes to the quality of our sound environment, it’s like a side effect of our technological advancement. So I bet things got louder.

Joe Schlesinger:
Right now, you can’t turn alarms softer. You can silence them, but the FDA maintained a database which found that nearly 600 patients had adverse outcomes, mostly death from alarm mismanagement.

Roman Mars:
We’ll talk about how we can make the sound design of hospital alarms as sophisticated and precise as the medical devices that are blaring them out, after this.

Roman Mars:
Support for this special two part series, exploring the power of sound to influence our health, comes from the Robert Wood Johnson Foundation. The Robert Wood Johnson Foundation is working to build a culture of health that ensures that everyone in America has a fair and just opportunity for health and wellbeing, which includes exploring how our current or future environments will impact daily life. Learn more at www.rwjf.org.

Joe Schlesinger:
When you think of the design of a patient monitor or any device, you think of the visual complexity of the device and the expense of the device. But why is the sound that’s generated by this highly engineered, visually attractive expensive device so poor? It usually comes out of a very cheap speaker attached to the device.

Yoko Sen:
I love all the medical device alarm tones to be at least not dissonant, at least in harmony with each other, and that’s not that difficult. As a musician, it’s like, “Can I just tune them at least?”

Roman Mars:
But Yoko isn’t the only one taking a musical approach to alarm fatigue. Joe may be an anesthesiologist, but he’s also a professional jazz musician. It’s infuriating, isn’t it? This is him playing the piano right now.

Joe Schlesinger:
I had been playing the piano since I was five years old, so music and medicine was part of my life together for a long time.

Roman Mars:
Right now, alarms are loud and annoying, but they don’t have to be, they just have to be different from all the other sounds in the hospital.

Joe Schlesinger:
Imagine that somebody down the hall were to scream (sound clip of a scream) and it’s not loud, but you can perceive it. We have our attention diverted not because of the volume, but because of the acoustic features of the human scream. There’s an acoustic feature called roughness, which has enhanced sensitivity in the amygdala, so we have this reflexive response.

Roman Mars:
This has a surprising implication for our alarm tones.

Joe Schlesinger:
Alarms can be softer than background noise and you can still perceive them. A lot of the alarms have what’s called a flat amplitude envelope, and so if you imagine the emergency broadcast signal that you hear on TV (sound clip of the emergency broadcasting signal) that’s a flat amplitude envelope, and that’s an unnatural sound in our environment.

Roman Mars:
The unnatural sound is effective at grabbing our attention, but in a hospital, these unnatural sounds layer on top of each other creating a wall of sound that we tune out. They also create a stress response that’s harming our minds and bodies.

Joe Schlesinger:
Compare that with what’s called a percussive amplitude envelope, which has an exponential decay. Think about if you’re clinking two wine glasses together (sound clip of wine glassing clinking), that’s a sharp upstroke with an exponential decay and that’s a sound we have in nature.

Roman Mars:
By changing the amplitude envelope to something more natural, you can go from this (sound clip of flat amplitude envelope alarm) to this (sound clip of percussive amplitude envelope alarm), but even this sound doesn’t tell you a lot. The alarms need to be more informative.

Joe Schlesinger:
What we are particularly working on is how to contain information in sound and that is what we call auditory icons. For example, having a lub-dub heartbeat type of sound in an alarm that is indicative of a cardiovascular problem (sound clip of lub-dub heart beat).

Roman Mars:
The result is something that can tell you exactly what’s wrong before you enter the room and that’s just the beginning.

Joe Schlesinger:
I don’t want to know just when something is bad. I want to know when something is trending towards being bad. I want visual signals that are always in my receptive field versus a monitor that right now I have to be staring at it. I want vibrotactile information that is wearable and comfortable and I want it to provide signals that are not so strong that I get fatigued or habituated to it, and I want auditory information that is directed to me. When I get auditory information, it’s information that can mean something in that I need to act upon it.

Roman Mars:
We can use the hospital soundscape to do even more. Researchers are finding ways to give a voice to people who have lost theirs.

Joe Schlesinger:
You think of a patient in the ICU when they’re non-communicative or in long-term acute care, those patients often get neglected, but they have ways to communicate in a nontraditional sense. For example, through their autonomic nervous system.

Roman Mars:
Patients who can’t speak or communicate their feelings are still expressing themselves through their heart rate or their body temperature.

Joe Schlesinger:
They’re communicating but not in a traditional verbal sense. How can we take those physiologic signals, turn them into sound in a way that we can start to ascertain what these patients, what these people are saying?

Roman Mars:
The result is something called biomusic, pioneered by a colleague of Joe’s at McGill University in Montreal. Sensors on the patient’s body detect vital signs, and that makes the data into sound. Heart rate controls the tempo. Temperature determines the notes and skin sweat drives the melody.

Roman Mars:
The result is actually kind of beautiful. Biomusic is being looked at as a way for nonverbal autistic children to express themselves. Here’s a calm state of mind (calm music plays) and here’s an anxious one (anxious music plays). You don’t have to be a medical specialist to hear the difference.

Joe Schlesinger:
Our hope is that we can make it easy to implement throughout the world where you don’t have to be at a high powered academic institution with fancy EEG equipment to make this a reality.

Roman Mars:
Joel Beckerman believes our hospital soundscapes can be improved from an unhealthy and dangerous cacophony to something more useful and healthy.

Joel Beckerman:
Imagine you could walk into a room and be able to sift through enormous datasets by sound alone. We actually create an idealized soundscape for what a sonification of data idea might be in a hospital room of the future.

Doctor:
Basically, I think he’s in good shape. Maybe in a week, we can look at the chart again and make sure …

Doctor:
Sounds good.

Joel Beckerman:
You don’t need to be a musician. You don’t need to be really intensely trained for this. You can determine whether a pitch is higher than another or lower than another if they’re pretty far apart. You can determine whether a sound is rising or a sound is falling.

Joel Beckerman:
In a very, very short period of time, we can help people understand those differences of all the different key health care data points to understand what a patient needs or whether that patient is okay and they can turn their attention elsewhere.

Joe Schlesinger:
When I was in music score, my piano teacher told me, “The more you actively listen to jazz and you practice, you’re adding colors to your palette.” The more I study, the more I practice, the more I listen, I have more colors on my palette. I can create a beautiful painting. So the reason why we need to do this is because this adds colors to our palette. I think it’s important from a patient care perspective that we make the most beautiful painting that we can create.

Comments (1)

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  1. Chris Kantarjiev

    I really enjoyed these episodes. I can’t find it, but I thought you guys also did an episode about overlapping and confusing alarms/alerts in airliner cockpits, and this seems to fit right with that theme… at least, it’s a similar problem space, though the idea of using the alert sound to convey information is a new one.

    I’ve worked for the past 10-15 years to shape my personal alert soundscape. It’s a chore to carry my sound files from phone to phone and adjust the notification settings every time I upgrade, but totally worth it to have it fine tuned in a way that conveys adequate information without derailing my attention.

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