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 9^th 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: http://www.livefromtheor.com/themusic.html