it’s just noise

Monday, May 13, 2013

How hushed the world becomes at a golf tournament or tennis match. The extreme quiet is needed for the athlete to mesh concentration with physical dexterity to maximize the athletic performance and succeed on the playing field. The crowd can roar in approval once the ball is struck or the point over, but heaven help the poor spectator who has the audacity to snap a photo or cough at the critical moment of play. And how dare Tiger Woods rummage for a golf club while Sergio Garcia stood contemplating his next shot. Sergio was unhappy; his errant shot muct have been due to the interruption. How rude…and how silly.

It’s not often that I use to talk about my world in the ER, but just a little noise would be a wonderful environment, since a lot of noise is the norm. It’s not just the conversations of dozens of people that echo in my workspace, but it’s the monitors beeping, the IV pumps alarming, the ambulance radio going off and we can’t forget the crying children, the sobbing elderly and the extra loud alcoholics. Noise is the norm and we have to deal with it. Numerous studies, in many countries, confirm that the ER noise level can interfere with communication between nurses and doctors and can affect patient wellbeing.

Noise is measured in decibels and a 10dB increase in sound intensity subjectively doubles how loud the sound is perceived. A library averages 20dB and is a pretty quiet place. Normal conversation measures at about 50dB while at 10 yards, a large truck comes in at 90db. The sound levels in an ER wax and wane depending upon what’s going on but in one study averaged 63 dB and spiked higher than 70dB. And that’s just the background noise that inundates the workplace. It can get much noisier at the bedside.

Imagine the scene at a trauma center as a victim rolls in. Surrounding the gurney, there are two physicians, two nurses, a paramedic, a respiratory therapist, a lab and x-ray tech. Each has their role and every finding needs to be communicated loud enough to be documented by the scribe. Now, try to listen to the patient’s chest and decide if there is decrease air entry in one lung compared to the other. A chest x-ray can confirm a collapsed lung, but if the patient is in shock and crashing, clinical skills may be required to decide if a tube needs to be inserted through the chest wall to re-expand that lung collapse. Choose wisely, because putting the chest tube in on the wrong side might be deadly.

Perhaps the next patient has stopped breathing and requires intubation. A tube needs to be placed into the trachea and hooked up to a ventilator. For the emergency physician, this is a skill learned in residency training but there are a myriad of training courses available to teach intubation in the difficult airway patient. It’s a stressful time. The patient isn’t breathing and the potential for death is real. The other disaster complication is taking too long to establish the airway. Not returning oxygen to the body quickly will damage the brain. There are no Sergio Garcia moments when one can hear a pin drop.

As it turns out, noise isn’t the only distraction in the ER. Research has found that the ER doctor has to be able to cope with distraction and interruptions every few minutes. The ability to multi-task is a skill in the physician toolbox. In a busy emergency department, the physician will care for 3-4 patients an hour, will be interrupted to review tests, answer the ambulance radio or take a call regarding a patient, 10 times an hour and will have to break away from performing a task about 7 times an hour. It’s plenty of information for a brain to juggle and a noisy environment adds to the difficulty. By the way, the brain can keep about seven tasks in short term memory.

The calmest time for me is suturing. I have one-on-one time with the patient while I sew up a laceration.  While there are technical challenges and skills, the best results are achieved if one takes the time to be meticulous with cleaning to prevent infection and aligning the skin edges to give end up with the best looking scar. The time to sew is also the time to think about the other patients in the department, organizing what test to consider, what treatment to suggest and deciding who needs to get admitted to the hospital and who gets to go home.

The etiquette of golf and tennis are a world away from my reality in the ER. Noise is everywhere and interruptions are expected. The ability to concentrate and perform is independent of the environment. I can appreciate how Tiger Woods, Phil Mickelson, Raphael Nadal and Roger Federer need quiet to hit a ball. I can’t imagine it requires more than putting a needle into an artery or a tube into a chest. But if I had some quiet, perhaps my job would be easier.

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