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SPEAKER_03: And ever since people moved into cities, we have 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. 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. And 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. The operating room is an interesting space because we think of it, it's like my cockpit, if you will.
SPEAKER_00: And anesthesiology is related a lot to aviation. We are a culture of safety. We have safety checklists 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. Landing the plane takes focus, but Joe doesn't work in silence.
SPEAKER_03: It might come as a surprise, but in the OR, there's music playing all the time. 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.
SPEAKER_00: And if you're working long hours doing difficult cases in the operating room, if you can improve mood, certainly there's benefit. But who chooses the music is usually the surgeon. And if the surgeon's excited, the surgery's 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. Joe remembers one surgery where music was playing, and then all of a sudden, the patient's vital signs started to crash.
SPEAKER_03: And so now my alarms are going off, the music volume is high,
SPEAKER_00: 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. So Joe and his researchers are trying to figure out how to get the benefits of music in the OR
SPEAKER_03: without the risk of hearing, we built this thing up, we built this thing on rock and roll while someone is having a heart attack. I'm working with another anesthesiologist on a device which is called the Canary Box.
SPEAKER_00: The Canary Box has two levels of alarm, a warning zone and a danger zone.
SPEAKER_03: When the alarm is in the warning zone, it halves the music volume.
SPEAKER_00: And when the alarm is in the danger zone, it turns the music off. Fixing how sounds work together in the operating room is a step in the right direction,
SPEAKER_03: 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, hospitals are horrible places to get better. That's sound designer Joel Beckerman, and he's right,
SPEAKER_03: hospitals can be bad for your health because hospitals sound terrible. I think of when I walk into the neuro ICU and I hear the automatic door
SPEAKER_00: which opens and closes as people walk by it opens and closes without anyone going in or out. And 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. Yoko Sen is an electronic musician researching sound in hospitals.
SPEAKER_03: When it's quiet, it's about 40 to 50 decibels,
SPEAKER_01: but when it's pretty loud, it goes up to easily 60, 70 decibels. Sometimes it hits 80 to 90 decibels as well. To give you some perspective, 60 decibels is the volume of an average office,
SPEAKER_03: 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. I hear alarms coming from multiple patient rooms,
SPEAKER_00: 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. And even when he knows what he's listening for, Joe has a hard time figuring out what to do with the alarms.
SPEAKER_03: He has a hard time figuring out what device is making noise. It could be the IV infusion pump, the epidural pump, the intra-aortic balloon pump,
SPEAKER_00: the dialysis machine, the ventilator.
SPEAKER_03: Joel Beckerman has experienced the same thing in hospitals he's worked in.
SPEAKER_02: There's a heart monitor that makes 86 different alarms. There's no way that that can be meaningful to anybody.
SPEAKER_03: 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.
SPEAKER_00: I go home at night, and I still hear the beeping of alarms and the beeping of pulse oximetry in my head.
SPEAKER_01: Clinicians are annoyed by lots of alarms, but there are a number of physicians and nurses that, you know, I love those alarms. Like, I have my adrenaline up, and I get excited.
SPEAKER_03: But the high from alarms is not sustainable. It's actually pretty exhausting. The result is something called alarm fatigue.
SPEAKER_02: The problem with alarm fatigue is that din of sound, which caregivers 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.
SPEAKER_01: 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 off for, you know, their babies, the first thing that young parents would think is, oh no, is my baby going to die? It's very scary. It can lead to neuropsychological side effects such as ICU delirium.
SPEAKER_00: ICU delirium is when patients get confused and paranoid
SPEAKER_03: 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. I interviewed one person.
SPEAKER_01: He had his daughter, you know, more than 10 years ago in NICU. That's the NICU, intensive care for infants.
SPEAKER_03: And there was this particular alarm sound that kept going off.
SPEAKER_01: So even after 10 years, if he hears the sound that's similar to the alarm on television or other places, he still gets this sort of a traumatized reaction.
SPEAKER_03: 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.
SPEAKER_01: 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 as an 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.
SPEAKER_00: 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. We'll talk about how we can make the sound design of hospital alarms
SPEAKER_03: as sophisticated and precise as the medical devices that are blaring them out after this. Learn more at rwjf.org
SPEAKER_01: We have to use 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?
SPEAKER_03: 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.
SPEAKER_00: I've been playing the piano since I was five years old, so music and medicine was part of my life together for a long time.
SPEAKER_03: 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.
SPEAKER_00: Imagine that somebody down the hall were to 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. We have an acoustic feature called roughness, which has enhanced sensitivity in the amygdala. So we have this reflexive response.
SPEAKER_03: This has a surprising implication for our alarm tones.
SPEAKER_00: 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, that's a flat amplitude envelope, and that's an unnatural sound in our environment. The unnatural sound is effective at grabbing our attention.
SPEAKER_03: 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. Compare that with what's called a percussive amplitude envelope,
SPEAKER_00: which has an exponential decay. So think about if you're clinking two wine glasses together. That's a sharp upstroke with an exponential decay, and that's a sound we have in nature. By changing the amplitude envelope to something more natural,
SPEAKER_03: you can go from this to this. But even this sound doesn't tell you a lot. The alarms need to be more informative.
SPEAKER_00: What we are particularly working on is how to contain information and 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.
SPEAKER_03: The result is something that can tell you exactly what's wrong before you enter the room. And that's just the beginning.
SPEAKER_00: 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 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. And we can use the hospital soundscape to do even more.
SPEAKER_03: Researchers are finding ways to give a voice to people who have lost theirs.
SPEAKER_00: 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 non-traditional sense, for example through their autonomic nervous system. Patients who can't speak or communicate their feelings are still expressing themselves
SPEAKER_03: through their heart rate or their body temperature.
SPEAKER_00: So 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?
SPEAKER_03: The result is something called bio-music, 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. The result is actually kind of beautiful. Bio-music is being looked at as a way for non-verbal autistic children to express themselves. Here's a calm state of mind. And here's an anxious one. You don't have to be a medical specialist to hear the difference.
SPEAKER_00: 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.
SPEAKER_03: Joel Beckerman believes our hospital soundscapes can be improved, from an unhealthy and dangerous cacophony to something more useful and healthy.
SPEAKER_02: Imagine you could walk into a room and be able to sift through enormous data sets 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. Basically, I think he's in good shape. Maybe in a week we can look at the chart again and make sure.
SPEAKER_02: Sounds good. 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. In a very, very short period of time, we can help people understand those differences of all the different key healthcare data points to understand what a patient needs or whether that patient is okay and they can turn their attention elsewhere.
SPEAKER_00: Music When I was in music school, 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. And so the reason why we need to do this is because this adds colors to our palette. And I think it's important from a patient care perspective that we make the most beautiful painting that we can create.
SPEAKER_03: This special episode of 99% Invisible was produced by Leila Batterson and Dallas Taylor with help from Sam Sneempley. Edited by Chris Berube. Sound design and mix by Colin Devarnie. Music by Sean Rial. Thanks also to our guests, Yoko Sen and Joe Schlesinger. Special thanks to the Robert Wood Johnson Foundation and Man Made Music, who contributed as executive producers and providing the soundscapes in the show. Joel Beckman has written a book, it's called The Sonic Boom, How Sound Transforms the Way We Think, Feel and Buy. Go check it out. You can learn more about these stories and other topics related to sonic humanism and sound's effects on our health by visiting info.sonichumanism.com. Thanks again to the Robert Wood Johnson Foundation for their underwriting support of this special series. Learn more about their efforts to help create a culture of health at rwjf.org. Great sleep can be hard to come by these days, and finding the right mattress feels totally overwhelming. Serta's new and improved Perfect Sleeper is a simple solution designed to support all sleep positions. With zoned comfort, memory foam and a cool-to-the-touch cover, the Serta Perfect Sleeper means more restful nights and more rested days. Find your comfort at serta.com.
