Conversations in Cardiology: Music in the Cath Lab?

Morton Kern, MD, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in cardiology.

Conversations in Cardiology: Music in the Cath Lab?

Morton KernMorton Kern, MD, of VA Long Beach Healthcare System and University of California, Irvine, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in interventional cardiology. With permission from the participants, TCTMD presents their conversations for the benefit of the cardiology community. Your feedback is welcome—feel free to comment at the bottom of the page.



Kirk Garratt, MD, MSc (ChristianaCare, Newark, DE), asks:

I took radios out of the lab 5 years ago and the natives are restless. What's up in your lab and why?


Kern replies:

While not a Nobel-ponderable issue, we just had such a discussion recently. The nurses/techs are free to bring their music pods to play with the permission of the patient and his approval of the tunes during the setup period.

Once the case starts, I ask the crew to turn the sound level down so we can communicate clearly and easily. If at any time the music is distracting, we turn it off.

This might make for an interesting discussion. Let's see.


Samuel Butman, MD (Heart & Vascular Center of Northern Arizona, Cottonwood), replies:

Hmmm.....

Had not considered the procedural “zones.” Do we need to break it down as to whether this is permissible during 1) preop period, 2) setup period, 3) during case, and/or 4) postop period?

Well then, music during periods 1 and 4 may disturb other patients unless ear buds are available. Music in periods 2 and 3 may interfere in procedural communication and, of course, all is good until someone in the loop misses a task, an order, or a deviation during “WE will WE will ROCK you!”

Surgeons play music all the time, I think, unless the Joint Commission has killed it in the OR?

To the point, we do not play music any longer. Not sure why, but we do not. Perhaps occasionally during the setup and in between cases. Maybe we will bring it back. Good thing to discuss.


Farouc Jaffer, MD, PhD (Massachusetts General Hospital, Boston), replies:

Please let me know if I’ve been doing something wrong to mandate alternative 80s music or the soundtrack to Guardians of the Galaxy during all cath lab cases.


Charanjit Rihal, MD (Mayo Clinic, Rochester, MN), replies:

In our lab we have operators playing a variety of music from smooth jazz and Spanish guitar to rock. Same in the ORs. No rap as far as I know. It should not be distracting and can be relaxing. Play this to see why.


Neal Kleiman, MD (Houston Methodist Hospital, TX), replies:

Interesting. In most cases, if you do it right, patients seem to like it. However, I have banned Zep and Pink Floyd from our lab.


Mitchell W. Krucoff, MD (Duke University Medical Center, Durham, NC), replies:

There is a whole literature on healing music—every one of our cath labs has been constructed with built-in sound systems, and for patients receiving conscious sedation background music can be “tuned” to have a consistently soothing effect. 

We employ common sense as our disc jockey. Patient preferences are accommodated within reason. Defaults are vocalists, male and female, pop and jazz, quiet and melodic music, instrumental jazz (used to include classical, but popularity has waned over the decades). Volume allows for communication without shouting or repeating, but for music to still be audible during the many quiet moments of a procedure. Recently in our VA cath labs single-ear headsets for all staff allow us to communicate with a whisper that is clearly heard by all on the team, while the built in overhead speakers play the ambient sound that the patient hears.

Especially for a radial interventional lab, soothing music is worth a world of antispasm vasodilators and sedation.

My 2 cents.


Jennifer Ann Tremmel, MD (Stanford University Medical Center, Stanford, CA), replies:

I have a quiet lab (ie, no music), because it takes great will for me to keep from singing, lip-syncing, or dancing if there’s music on. Even classical music will demand some sort of dramatic hand-waving.


Pranav Patel, MD (UCI Health, Orange, CA), replies:

I have just found that music (especially before a case starts) puts both the patient and staff in a better mood and helps everyone to relax. We usually bring the volume down or stop once the case starts (attending dependent). I’ve also seen research where music makes the workplace more efficient and productive, although I am not sure whether you can use the same analogy with the cath lab environment.


J. Jeffrey Marshall, MD (Northside Hospital, Atlanta, GA), replies:

I ask the patient what kind of music they like, and we make the patient’s choice the transient favorite genre. It is not played so loudly that old guys/gals can readily hear it without concentrating on the music. This serves to distract/sooth the patient and serves only as background noise to us with rapidly diminishing hearing acuity.


Theodore Bass, MD (UF Health, Jacksonville, FL), replies:

We play exclusively Led Zeppelin’s “Stairway to Heaven.” Enjoy.


Sunil Rao, MD (Duke University Medical Center), replies:

We listen to music in the cath lab. I don’t see a reason why we wouldn’t. At the very least, it allows me to quiz the fellows on one-hit wonders from the 1980s.


Larry S. Dean, MD (UW Medicine, Seattle, WA), replies:

I approach it the same way as Jeff: patient choice but draw the line on heavy metal at 9 AM!

Once had a patient's wife play her violin in the labs. Both played professionally. She played the music from Ken Burns’ Civil War series. Spectacular case/event. 

If we took music out of the labs, we'd have a patient and staff revolt!


Bonnie Weiner, MD (Saint Vincent Hospital, Worcester, MA), replies:

Music calms the soul and is so much better than the extraneous conversations that can occur.


Spencer King III, MD (Emory University, Atlanta, GA), replies:

If I were the patient with a choice of Larry’s Civil War carnage and Ted’s “Stairway to Heaven,” I would take my chances with crickets.


Kenneth Rosenfield, MD (Massachusetts General Hospital, Boston), replies:

It’s Allman Brothers or bust!


Rajiv Gulati, MD, PhD (Mayo Clinic), replies:

Party pooper here. Headphones for patient—awesome. For the rest of lab—an unnecessary distraction. By the time the volume is dialed down to enable clear communication, music just sounds like radio interference to me. Sorry just my 2 cents and years of Zeppelin abuse!


Peter Block, MD (Emory University), replies:

Hmmm. I used to ask the patients their preference as the setup was done. After that, once the procedure began no more music. For acute MIs, no music. I felt I needed all hands on deck.


Aaron Kaplan, MD (Dartmouth-Hitchcock Medical Center, Lebanon, NH), replies:

For me it’s something soothing, without words in English (This rule was imposed after a patient without musical background starting singing). I usually prefer chamber music.


Gurpreet S. Sandhu, MD, PhD (Mayo Clinic), replies:

No music in my room either. Don’t want any team members getting distracted and missing critical communication.


Andrew Doorey, MD (University of North Carolina at Chapel Hill), replies:

Personally, I am in favor of music. I think the patients like it, and I find most music relaxing. So when that ogre—er, I mean patient safety advocate—Kirk Garratt banned music at Christiana, I was not in support. But we have now completed a 5-year cath lab communication project there, aiming to assess and improve read back and communications and to reduce therapeutic errors. In short, the more noise/distractions, the more errors in staff communication were noted. Most were not noted by the cardiologist, but some were serious (wrong meds, wrong doses, wrong equipment delivered to the sterile field and occasionally used). So while most of us music lovers think there is little downside to the noise/distraction of music, that is not true.

At UNC we have been measuring the noise levels in the cath labs and control rooms using calibrated, sensitive decibel meters, and the levels are surprisingly high, especially during the critical parts of interventions/structural cases when accuracy is most important. We’re fortunate to have noise and hearing specialists on the university staff to assist us in evaluating the functional effects of the “noise,” and in some labs even the baseline decibel levels exceed levels felt to impair team communication (65 dB BTW). Hard to imagine this does not impact patient safety.

Any airline pilot playing music on the flight deck during critical phases of flight would certainly be fired immediately. One of the many reasons commercial aviation is so safe.


Arnold Seto, MD (Long Beach VA Medical Center, CA), replies:

In our lab, we ask our patients what music they would like to have played on the Bluetooth speaker, and the patients and staff really appreciate it.

There is extensive nursing literature on the benefits of reduced patient anxiety with music. I believe that tension overall in the cath lab is reduced with music, as well, which is always a benefit when working in a team.

That being said there are times when the music should be off and all hands should be on deck. This would certainly include the time-out and critical moments of the procedure (valve deployment). But if I did a 3-hour CTO and there was no music on, my staff would shoot themselves (and me!)

Here's a quick slide from a patient safety lecture I have given. The slide immediately before was about distracted pilots, who were arguing about politics and used cars, caused a deadly airplane crash. (Eastern Air Lines flight 212). It is debatable whether music is a distraction or benefit—it probably is both depending when/where you use it!


Peter N. Ver Lee, MD (Northern Light Cardiology, Bangor, ME), replies:

I follow Arnold’s approach. Patient’s choice as long as it’s reasonable. I once was doing a pericardial tap on an 18-year-old gal who wanted to hear the most shocking hard-core rap music. After a few f-bombs, we said, “OK, that’s enough, how about something a little more mellow.”

Also agree that with cardiogenic shock, STEMI, and cardiac arrest, no music.

We also have a list of songs that CANNOT be played in the lab.

  • “Stairway to Heaven”
  • “Spirit in the Sky”
  • “Knockin’ on Heaven’s Door”
  • “Final Countdown”

On the other hand, if “This Heart Needs a Second Chance” comes on, that’s perfectly fine.


Michael Ragosta, MD (UVA Health, Charlottesville, VA), replies:

How about Janis Joplin’s “Take Another Little Piece of My Heart” during endomyocardial biopsies?


Carl Tommaso, MD (NorthShore University HealthSystem, Skokie, IL), replies:

Geoffrey Hartzler and I had a debate on whether there should be music in the cath lab in some throwaway many years ago. He was absolutely against music or any distractions in the lab. I countered with some data I found that said music in the lab relaxed the patient and as a result there were fewer vasovagal episodes. In addition, the patient’s satisfaction seemed better. I continued to play music in the lab but at low volume so that orders and discussions were clearly heard, and with constant background everyone knew to speak over the background.

Anecdote: recently we did a procedure on a patient from the local county jail and during the procedure “Folsom Prison Blues” came on.


Stephen Ramee, MD (Ochsner Medical Center, New Orleans, LA), replies:

I listen to music . . . beep, beep, beep


E. Magnus Ohman, MD (Duke University Medical Center), replies:

I have enjoyed this “debate.”

We have five cath labs, all with SiriusXM. Most attendings play some music during the procedures. We typically let the patient decide what they would like to listen to in a patient-centric manner. Hardest is to do complex PCI with rap music playing. Few patients ask for that.

We have some fun moments where patients sing to the songs under conscious sedation—can be very entertaining.

Scientific studies carried out over the years suggest that right-sided (creativity) brain is more active when you perform procedures while music plays, as longs as it is not a distraction. Personally I like “The Bridge” channel, as it is a smooth mixture of good music over the years.

So if there was no music in the cath lab, I would bring my own music source.

Kirk—let them have it! Things will go smoother.


Duane Pinto, MD, MPH (Beth Israel Deaconess Medical Center, Boston, MA), replies:

I’m usually done with the case before the Sammy Hagar vs David Lee Roth and Angus vs Jimmy (P or H) are done. 


Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), replies:

Like everything, there are multiple sides to this. We typically do not play music in our labs, but do accommodate patient requests for music when they come up. Some of the staff have occasionally played music via Bluetooth speakers. Maybe it’s because I’m a “music person” that, every time this happens, I think to myself how it would be great if we did this systematically or if there were studies on it. Thanks to you all, I may now have the impetus to pursue this further, but of course after we finish our JCAHO visit…


Frederic S. Resnic, MD (Lahey Hospital & Medical Center, Burlington, MA),

We tend to play music in almost every case. For endomyocardial biopsies in posttransplant patients, we often play Joplin's “Take Another Little Piece of My Heart”—but only for posttransplant patients. Native EMB patients can be sensitive to that song. For some reason, for any particularly complex PCI, our cath lab teams have learned that classic (pre-“The Wall”) Pink Floyd tends to help me get the best results....


Malcolm R. Bell, MD (Mayo Clinic), replies:

I have followed the same approach as Guri on this one. The teams I work with know that once the case has started, including the preprocedural briefing, all focus is on safely completing the procedure. Music can be distracting, and I have heard staff chatting about the music when they should be focused on the procedure. Side conversations are also potentially dangerous—taking a leaf out of pilots’ protocols seems appropriate (and many tragic examples of when they did not follow protocol). My approach was instilled in me a long time ago by Ron Vlietstra, and I have never forgotten or regretted it. Real joviality comes between cases.

If the patient really wants to listen to music, put headphones on them and we focus on doing the procedure as safely and as well as we can.

Great debate, and enjoyed the appropriated creative music titles from many of you 😊


Michael A. Kutcher, MD (Wake Forest Baptist Medical Center, Winston-Salem, NC), replies:

Mort and all, I agree with Malcolm and Guri’s approach.

Just want to add that we must also remember the patient is under conscious sedation and sometimes their perceptions of what is happening may significantly be altered. We once had a patient who a few hours after the procedure reported us to Patient Relations, accusing my staff and I of having a “beach dance party” during the procedure. After that I curtailed playing music during the intervention
 


The Bottom Line

Kern: As I sum it up, the choice to play music during a procedure is an individual and institutional decision. And of course, foremost, we should always make these decisions with patient safety first.

Thanks to all our experts for contributing to the dialogue.

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