The Soundtrack of a Clinic Day

Martina Ann Kelly; Gerard Gormley

doi:10.1370/afm.240253

Abstract

There is a hum and drum to the clinical day, sounds and rhythms that pervade physician and patient’s soundscape. We hear but we do not listen. The soundtrack of the daily grind is experienced as an audio blanket of white noise. Often taken for granted, we suggest the sounds of practice form an important role in our daily lives as family doctors. Masked in these sounds are tacit skills and auditory expertise that speak louder than words. In this essay, as 2 family doctors, we reflect on the sounds of a single day in the clinic.

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I sit still, close my eyes, and inhale the silence of the empty clinic at 7:30 AM, on a dark wintery morning. A click of the large ON computer button and it whirls into life, accompanied by 2 short beeps, startling the stillness, yet vanishing into the background within moments. Computer searching, saving, and spewing sets the pace of my day, synchronizing with my pulse. In the corridor, I hear the clip-clop, traipse, and trudge of staff coming in. My nurse gives a loud sigh, and a colleague responds with light laughter; their morning routine, a bantering singsong as they set up their stations. Further beeping as computers flicker into action, telephone lines changed with a click, fax checked with a distinct screech. The fluorescent light clinks on, blinks and invades my quiet darkness. The clinic has started.

A sick child has been fitted in as an extra; I sigh, a busy day ahead. Outside the room, before I enter, I pause. I hear the wheels of the office stool, squeaking on the linoleum, as the child swivels on it. The snap of drawers being opened and closed repeatedly to hushed admonishments—“stop that!” The lid of the garbage bin pops, up-down, up-down, as the child plays with the foot pedal. And, “Oh!”—the childish gasp of delight; discovery of the buttons that elevate the examination table in many fascinating ways, hiss, swish. “Hmm,” I mutter to myself, “not that sick.” I enter the room, the squeeky-twinky voices of cartoons on an iPad playing in the background. But I am mistaken. The lively explorer is not my patient, but their sibling. The infant whimpers in their parent’s arms, eyes wide, breath rapid, wheezing or the heart-rendering sound of misery, the quiet “ah-ah-ah.” The sounds of examining an ill child are muted, clothing whispers as it is gently removed, soundless effort of moving limbs, punctuated by muffled texting as parents exchange anxious messages. I hear the asynchrony of parent and child’s breathing, unconsciously calculating the breath rate of both.

Later, the computer pings, notifying me my urgent patient has arrived. It’s her first pregnancy; a miracle after multiple failed cycles of IVF. It’s her second semester and her anxiousness hasn’t abated. Reduced movements. Just holding it together, the patient inhales deeply as she lies gingerly on the couch. The silence is broken as a squelch of cold ultrasound gel is expressed and massaged on to the gravid abdomen. The coldness evokes an ectopic breath in the patient; mine deepens. The ambient noise of the clinic fades and is filled with the erratic squawks of the amplified noises from the sonic aid. The rhythm fills the room. Her breath is held, eyes peering at me for confirmation. But my gaze remains focused on the porcelain abdomen, my breath hastens. The rhythm of an anxious maternal tachycardia. The hunt for rhythm of new life continues … the stillness is oppressing. Then, just then, life vibrates the room, from an initial quiver to a steady oscillation. My eyes look at hers, the suppressed smile of relief is matched by a nervous grimace and a sharp exhalation of relief. The ambient sound of the clinic enters the room again.

My next patient is booked for a “check-up.” Sounds become more orderly. Tick, click, tick, click, goes the keyboard, as we review symptoms, recent investigations, preventative care. I exit the room, pulling the drape behind me, it rattles indistinctly as I tuck it into the door, indicating a patient is changing. I return and listen to the sounds of routine physical examination—the stretch of the blood pressure cuff as it grips the patient’s arm, the poof as it deflates—is that the machine or the patient? The slick slither of the measuring tape as abdominal girth is appraised. Saying “ahh” seems so old-fashioned but a good look in someone’s mouth can tell a lot. Deep breath in and out, I steadily move the stethoscope across the lung fields. Next the clichéd hub-dub, hub-dub, hub-dub, heart sounds 1 and 2; I like to hear at least a few seconds, sometimes—a whoosh or click, if I’m sufficiently skilled to hear a murmur. Throughout, creaks of the examination table as the patient moves hesitantly, vulnerably. The twang of the rubber glove—intimacy invaded. For women, one more dreaded sound—the opening and closing snap of a speculum. A sigh when it’s over, nervous laughter or just relief.

The last patient of the day is well known to me, and it is the visit I have been dreading—now I hear my own pulse hammer in my ears, my heart pounding. Slow breathing to steady myself. Chairs are moved as the wheelchair ambulates clumsily into the room, the room just about adequate to accommodate its bulk which dwarfs the slight figure sitting hunched over in it. His robust sister accompanies him, taking the seat beside the desk. Expectantly he asks for the test results. A pause, a slight hesitation, just enough to signal what is coming. Outside the room, the cheery voice of my nurse as she rooms another patient, and a child skipping in to “see the doctor.” A telephone in the next room is ringing persistently. The piercing sound of the sister’s cell phone shatters the silence in this room, as she scrambles in her handbag to mute it. The moment is broken, the prognosis terminal. I heard in that instant a resigned sigh; my patient was already aware. But he seems to shrivel, shrinking almost as the air leaves the room. His sister fiddles with her hair, tucking and untucking it behind her ear, her eyes roving back and forth between me and her brother. She clears her throat, opens her mouth, and closes it again. The silence has said what needs to be said. The wheelchair rotates once more colliding with the furniture and the patient departs.

My day ends. It is no longer punctuated by the tread of feet or careful skipping of children, the plod of the underserved, impatient stride of the healthy, and the tactful pace of my nurse as she ushers us along. Now my feet echo in the still corridor. The ding of the elevator as I descend to meet my husband. As we drive home, I listen to the white noise of the radio and exhale.