An Emergency Department Musician
When Martin and I first began playing in Alder Hey’s Emergency Department a few years ago, we initially played only in the public waiting area. It quickly became apparent that we could be of even more benefit on the clinical side whilst patients are being assessed and treated, so we began ‘accompanying’ patients during their A&E journeys.
In the ED we discovered an area that was frequently busy, noisy and stressful; a place that felt quite alien to children and families. As musicians we can provide a friendly, non-clinical presence, bringing familiar and comforting sounds. Children in the ED have to cope with pain, distress and fear. A distraction and change of focus at the right moment can make a dramatic difference to a child’s perception of their experience, and can make them more compliant and easier to treat.
At Alder Hey’s ED we have developed a unique and novel practice, working as part of a team with its wonderful clinicians. We aim to enhance the general atmosphere of the space with calming music, as well as working in a responsive, personalised way with individual patients.
Our repertoire ranges widely from Vivaldi to ‘Baby Shark’, with improvising, folk and pop music along the way – whatever seems appropriate on the day! We regularly take requests from staff too, who join in with us, singing and dancing.
Case Study – Patient ‘H’
We wander into the ED with Martin gently playing some simple atmospheric music to make our presence known. The nurses at the nurses’ station glance up, grin at us and exclaim ‘hurrah, it’s Wednesday!’!
We immediately hear the sound of a distressed child crying so head straight for their room. A two year old is being examined and is clearly terrified. She is sitting on her mother’s knee but is trying to struggle away from the doctor, which is making the assessment challenging and stressful for everyone. We shift our music to a familiar nursery rhyme, ‘Twinkle Twinkle’, and begin singing in an assured yet gentle manner near the door.
The little girl (H) looks up at us with surprise and her crying subsides a fraction as her curiosity is sparked. We reassure her with smiles that we are friendly, and give her a moment to get used to us. The doctor gives us a thumbs’ up and beckons us in, introducing us to H as ‘his friends’. H returns my eye contact warily so we slowly go into her room, being ready to back away again if she seems overwhelmed. There are still a few tears but she is not wriggling any more and instead leans around her Mum to look at us.
We kneel at H’s side to draw her eyes towards us rather than to what the doctor is doing. Both the doctor and her mother have joined in singing with us, and there is quite a cheerful sense of teamwork now, with stress levels settling. H now sits still on her mother’s knee, and the assessment can continue with greater ease. We move on to ‘Wind the Bobbin Up’, which her mum has told us is her favourite song and we all encourage H to join in with us. Martin and I maintain her interest by shifting the music continually to respond to her, adding our voices, dropping in or out with instruments (my clarinet and Martin’s guitar), whilst the doctor continues his examination, almost unnoticed now by H.
We produce a couple of simple percussion shakers and offer H a shaky egg, which she grabs enthusiastically. She now has her own part to play in the music, and we begin a version of ‘If You’re Happy and You Know It Shake Your Egg’ which occupies both her thoughts and her hands. She gives us a little grin and leads the speed of the music with her shaking. We know that H will need to have her throat examined and may get upset again, but we do some silly ‘Ahhhhhhh’ singing to join in with her and make her giggle, and the check is quickly completed.
H’s examination is now finished and we allow both the volume and the energy of our music to decrease a little. The doctor is able to have a quiet conversation with her parents whilst we settle H with a peaceful version of ‘You Are My Sunshine’, still singing at her knee. She cuddles into her mum, egg shaker still in hand, and looks quite contented.
The doctor mouths a ‘thank you’ to us and leaves the treatment room, still singing along with our music as he goes. We stay with H for a few more minutes to ensure that her final memory of the experience is a positive, cheerful one. We say goodbye and back out of her room whilst still playing, and are pleased to hear her still shaking her egg shaker as we move off to visit the next patient.
Though patient H was not in pain, she was having an intensely scary experience. This can have huge implications for future visits to hospitals or doctors, with lasting fear associations. This makes a clinician’s task more stressful and time-consuming. By improving the child’s experience and creating positive memories with them we hope to take away some of this fear, and make assessment and treatment less of a battle.
We have overheard children say to their parents several times ‘but I don’t want to go home yet!’ at the end of a ‘musical treatment’ which is about the most pleasing response we can hope for!
Feedback from the ED
Alder Hey ED Consultant responses to Cascade Music:
‘I truly believe the positive impact you have on children, their families and staff in the department is enormous.
I have watched many times as crying or screaming children have calmed immediately on seeing and hearing you outside their cubicle door. Children have loved hearing your familiar songs, and I think most had never seen music performed live before.
I could cite many instances where you have made a very positive difference, but let me just recall one:
A little boy came to the department with and ear problem. He had several previous surgeries on his ears and was terrified of having them examined. Mum also reported to us that the little boy was on the autistic spectrum. I had introduced myself and assessed the situation, realized that he needed a rather unpleasant procedure on one of his ears in our department. I explained this to you, and both of you came to the little boy, gave him a little shaker, and completely involved him in music whilst I carried out the procedure. I’m not sure he really knew what I had done.
For me this episode was one of very best practice – Mum was delighted, the little boy not traumatized in the slightest and enormous relief for the nurses and me.
Even when it is noisy and busy, the calm that emanates from you, and your choice of music is a wonderful anti stress factor for us all.’
‘I’m a consultant in paediatric emergency medicine at Alder Hey Children’s Hospital. I’ve been working in paediatrics for 18 years, and I’ve never known the effect of live music on patient care until I came across the work Cascade music do. The only way I can describe it is ‘magic’, and I can only explain this by using a case example:
A three year old boy was brought into our department as an emergency. He was struggling to breathe. His airways were reacting to a severe virus. They were full of inflammatory mucous, and were closing down on him. The longer he went without medication, the worse he was becoming as oxygen was being deprived from his body. The main medication was to be a nebuliser. This is a noisy device which goes over the nose and mouth and the steamed medication blows in the face. Imagine being a scared toddler who can’t breathe, in a new environment with strangers trying to hold a mask of steaming medication over your face, the machines are beeping that oxygen saturations are low, and your parents are crying. Imagine now trying to get that toddler to cooperate. Despite the treating teams years of collective experience in minimising distress, the only way we were able to stop him thrashing at the mask and us, was to hold him. This is distressing to the child, the parents and us as clinicians. Cascade Music had just arrived on in the department and I asked them to help us as we were really struggling. Their approach was tailored to the child. Within a minute of listening to the live music, the child was calm, accepting the medication and we no longer had to hold him. I have never in my years of experience seen a calming effect like this without the use of medication. The mum remarked that this was amazing care.
This is only one example. But collectively as a team, we notice that the patients, their carers and the staff are immediately calmer when hearing live music. I believe they are a vital part of holistic care, and provide a quality that is above what standard medicine can provide.’
‘It has been a pleasure working with Cascade Music in the Paediatric Emergency Department (PED). The musicians have become key members of the PED team providing calming music to children who may be upset or in pain. Both parents, staff and children have commented on how the music has a positive impact on their experience of the PED and often seek the musicians out if they hear them elsewhere in the department! On a personal level in a busy and often stressful environment the music helps to calm and help me to focus on my job.’
‘I just wanted to tell you I thought your work in the ED was phenomenal. The musical intervention whilst children were undergoing painful procedures, for example, having their blood taken, had a profound calming effect on both them and our staff. The overall ED environment was made more pleasant and hearing you both play quite simply promoted a positive work ethos.’