Sounding disease

Sounding disease Anna Harris This essay appeared on the Sociology of Diagnosis website on the 1 st April 2015. You can access it via this link: https://www.facebook.com/SociologyOfDiagnosis/posts/799049830181091 There are some sounds that clinicians never forget hearing for the first time: the laboured erratic breathing of someone dying; their own heartbeat amplified by a stethoscope; the silence of a patient absorbing bad news; a beeping pager in the middle of the night. Listening to sounds has long been an important part of clinical practice, yet is a sensory skill that is argued to be increasingly shadowed by clinicians' focus on visual information through the abundance of images shared across screens, printouts and scans lit up on lightboxes. Image 1: William Osler listening at the bedside. From Wellcome Images (http://commons.wikimedia.org/wiki/File:William_Osler_at_bedside_of_patients._Wellcome_L00049 00.jpg) Centuries old techniques of medical diagnosis such as auscultation are reportedly disappearing from the clinic, the stethoscope predicted to barely survive its 200th birthday next year. Some despair the loss of practices such as percussion, the 1 findings of which are difficult to examine on standardised patients (Verghese 2007). Has listening to sounds really disappeared from clinical diagnosis? In 2013 I set out to examine this question ethnographically, delving into the sonic world of hospitals and medical schools in Australia and The Netherlands. My focus was on sounds of the body and sounds of machines [insert research website]. While patients' silences and stories are incredibly important, and in many cases fundamental to diagnosis, the focus of my research tied into that of a larger sound studies project based at Maastricht University, The Netherlands, which set out to investigate the contested role of sounds and listening in science, medicine and technology. Entitled Sonic Skills: Sound and Listening in the Development of Science, Technology and Medicine (1920 - now) [insert project website] and led by the historian Karin Bijsterveld, the project entailed creative collaborations between historians, sociologists and anthropologists. The team worked together to research how different professions learned to listen, and engaged in listening, to sounds in their work. This included car mechanics, ornithologists, scientists and doctors. Image 2: Alarms. My own. Stepping into the hospital on the first day of fieldwork was a strange experience. Was the hospital really this noisy when I worked as a doctor? The project sensitised me to all kinds of sounds: elevator dings; flutes and violin music threading through the hallways; intermittent overhead announcements; code blue emergency calls; constant intravenous line and access swipe beeps. Soon my head was throbbing with a raging ethnographic headache. I needed to plow on however, and find out how the staff waded through and made sense of this cacophony. 2 Over the months I found, like my colleagues studying the other professions, sound to be indespensible to the work that went on around me. In the intensive care unit for example, alarms are an integral part of monitoring very sick patients, where nurses ears are constantly alert to the many machines standing guard at the bedside, while other tasks are performed. Setting alarms (i.e. indicating which abnormal figures will set off the alarm) is a skill in itself. Nursing students are taught to set their alarms "wide", so that they are alerted to even the slightest deviance in heart rate or blood pressure. More experienced nurses may set "tighter" alarms, as they have the expertise which enables them to monitor a patient without the continual sounding of alarms. In the operating theatres, anaesthetists, and other staff in the room, use alarms to help monitor patients during surgery. These alarms work against a background of the surgeons music on the operating room stereo system, and often coincide with other sounds such as that of the diathermy machine, which emits a long dull tone when being used, indicating that a blood vessel is being sealed off. These sounds all help the operating theatre staff keep a check on the patients and on the progress of the operations. On the wards a barrage of alarms beep throughout the day, with undulating rhythms: a loud chorus of alarms often sounding in the morning, while being quieter in the evenings. One nurse could tell what kind of shift she would have, how sick the patients were, by the soundscape she entered. Other sounds alerted staff to ward activities: the sound of the approaching lunch trolley indicating that lunchtime medications needed to be administered for example; a pager beep meaning a doctor might be nearby. The sounds of coughing were used not only to diagnose possible infections but also as a healthy sign that bed-ridden patients were clearing their lungs. For these patients, the lack of cough was concerning. Based on some of my conversations and interviews with doctors, there were spaces where I expected listening to be completely replaced by looking at the visual image. Such as the echocardiogram suite for example, where cardiologists told me heart murmurs were now diagnosed, rather than with the stethoscope. While the echo ay e ore tra sporta le tha the sou ds of aus ultatio though how the digital stethoscope may change this is yet to be seen), sounds were nonetheless an important part of the testing procedure. I watched echocardiograph technicians as they turned up the volume on their machines to hear the pulsing of vessels, to ensure that they had their probe in the correct location. One technician told me she would not start recording an image until the sound was right. The technicians would 3 often then turn the sounds down as patients had reported the loud pulsing as disturbing, sounding like they were a human washing machine. Image 3: Training stethoscopes. My own image. While I had my ears out for the ways in which sounds were used by hospital staff in their work to diagnose problems and monitor patients, I was also interested in how medical students learned to listen to sounds, in particular the role of listening when they learned the skills of physical examination. I was especially interested in how students learned lung sounds, through techniques such as auscultation (listening with the stethoscope) and percussion (tapping out organs with fingers). Teaching and learning not only happened on the wards with patients, but also in tutorial rooms, libraries and lecture theatres, as well as in students' own bedrooms, where lungs and bowels were percussed while they lay on their beds. In these teaching and learning situations sounding for disease was still considered an important skill to be learned by novices, both in Australia and the Netherlands. Learning how to use a stethoscope to find heart murmurs or how to percuss the borders of the liver were seen by educators and tutors as skills which helped initiate students into their profession. 4 While these techniques of sounding the patient through auscultation and percussion were in fact to be little used during everyday work in the hospital (with exceptions such as respiratory physicians), learning these skills provoked a sensory awareness in the novice doctors, teaching the students how to observe their patients closely, through listening attentively. Image 4: Percussing hands. Drawing my own. Auscultation and percussion were often difficult for the students to learn, their fingers at first clumsy and the sounds amplified through the stethoscope indistinct. Gradually however, many students learned to listen, with the help of their teachers who demonstrated techniques, used analogies and drawings and hand gestures to introduce the sounds and share their meaning (Harris and van Drie forthcoming). The students practiced their skills on the wards, learning how to listen to patients' sounds amidst the orchestral background of coughs and alarms. Through learning to listen to diagnose disease, the students learned some of the more general skills of being observant and attentive doctors. My work on sound in medicine has been informed by and contributes to, a wider body of sociological and anthropological literature on the use of sound in medical diagnosis. The anthropologist Tom Rice (2013) for example, has done exemplary work on how medical students in London learned to listen to heart sounds. Researchers have also investigated how the sounds mothers make during labour help guide midwives in their work (McKay and Roberts 1990), how doctors use fetal heart sounds to help materialise fetuses for their patients in Mexico (Howes-Mischel 2015) as well as the use of ultrasound (Draper 2002, albeit from a visual 5 perspective). New avenues for research are also opening up in regards to studying the use of soundwaves to diagnose tumours and other diseases. While medical sociology has largely embraced studying the visual and the role of images such as X-Rays and CT scans in diagnosis, there still remains however much to learn about diagnostic practices involving other forms of sensory information, not only sound but also smell for example. Methodologically such work remains challenging for researchers. There has been a significant body of work now on visual methods in health research, but less attending to other sensory methods (Harris and Guillemin 2012). Studying sounds and how people listen was difficult for me, and for other researchers, and the creative ways that researchers use to sharing sonic experiences helps to think through the challenges that our research participants also have in sharing sounds in their own work (Harris and van Drie forthcoming). The difficulty of documenting sensory experiences such as listening, and sharing sounds, does not render such research questions and topics obsolete however, but rather, on the other hand, makes it an ever more crucial topic of sociological study. Anna Harris’ research concerns the social study of medicine. She approaches this field from the productive and lively ground where science and technology studies intersects with anthropology, through ethnographic investigations and experiments exploring relations between bodies, healthcare technologies, practices and medical places. This article is based on research conducted while Anna was a postdoctoral researcher at the Faculty of Arts and Social Sciences, Maastricht University, The Netherlands, on a project funded through the NWO Vici Scheme. Links Personal website: www.annaroseharris.wordpress.com Research website: http://fasos-research.nl/sonic-skills/about/hospital/ Project website: http://fasos-research.nl/sonic-skills/about/ 6 References Draper, J. . It was a real good show : the ultrasou d s a , fathers a d the power of visual knowledge. Sociology of Health and Illness, 24(6): 771–795. Harris, A. and M. van Drie (forthcoming) Sharing sound: Teaching, learning and researching sonic skills. Sound Studies: An Interdisciplinary Journal. Harris, A. and M. Guillemin (2012) Developing sensory awareness in qualitative interviewing: A portal into the otherwise unexplored. Qualitative Health Research 22: 689 - 699. Howes-Mischel, ‘ 5 With this you a eet your a y : Fetal perso hood a d audible heartbeats in Oaxacan public health. Medical Anthropology Quarterly (Early Online View doi: 10.1111/maq.12181) McKay, S. and J. Roberts J (1990) Obstetrics by ear: Maternal and caregiver perceptions of the meaning of maternal sounds during second stage labour. Journal of Nurse-Midwifery 35: 266 - 273. Rice, T. (2013) Hearing and the Hospital: Sound, Listening, Knowledge and Experience. Canon Pyon: Sean Kingston Publishing. Verghese, A. (2007) Bedside manners. Texas Monthly: 70 - 76. 7