9 July 2020

The Devil’s Chord or a Tap on the Shoulder?

Recomposing the soundscape of the intensive care unit

Sally O’Reilly

A replica of Sputnik 1 on display at the National Air and Space Museum, Washington, DC.

Official Soviet press releases announcing the launch of the Sputnik satellite on 4 October 1957 pointedly publicized its radio signal frequency of 20–40 MHz—well within the range of amateur radio enthusiasts. Newspapers published timetables of its passage, and TV and radio stations and hams around the world lay in wait for Sputnik’s crackly beep, produced by a spherical body weighing 83.5 kilograms and flinging through near-space at 18,000 miles per hour.[1]

With no precedence for an electronic beep broadcast internationally, there was a lot of scope for interpretation. Life magazine described it as “an eerie, intermittent croak” that “sounded like a cricket with a cold.”[2] Very much an other. Douglas Edwards declared on CBS television news: “Until two days ago, that sound had never been heard on this earth. Suddenly, it has become as much a part of twentieth-century life as the whirr from your vacuum cleaner.”[3] And even with historical hindsight in a context of cultural commentary, Sputnik’s ambiguous tone might still divide a room. Is it joyous, whooping through its laps of honor, the first leg of the space race won? Or is it frail and panicked, the sound of a finite soul staring into infinity? Compare this to the electronic sounds routinely heard now: the encouraging click of activated virtual “buttons,” the approving bleep of a computing task achieved, the blooping displeasure of a device mishandled or inopportunely activated. They relay their messages succinctly. Since that first tentative transmission, electronic signals have become confident managers of their milieu.

Computing hinges on the use of physical objects to represent abstract objects, most rudimentarily with fingers standing for integers, but the principle carries for the laptop I am writing on.[4] A virtual function is instantiated by an internal physical movement (of electrons), readable in translated form on a digital display. Many computer-driven devices are designed to give further executional feedback that is illusorily physical. The “click” of a touch-screen button, the “scrunch” of emptying trash, and the vibration of the video game controller are all tangible, but extraneous, renderings of the mysterious, but vital, internal movements that perform the user’s intended action. (Some of this feedback, thankfully, can be deactivated, because we don’t all need all of our virtual actions reflected back to us, right?)

These responses are skeuomorphisms, remnants of the physical referent on which a design has been based. By “retaining” these faked details, the transition from actual to virtual is smoothed, sometimes out of concern for user safety and comfort, sometimes to capitalize on old appetites. (Think of online gambling sites that preserve the sound and image of the spinning roulette wheel, despite producing random integers via algorithms.) In the case of beeps, the definition of skeuomorphism must be stretched to include such referents as utterances and gestures of supplanted humans. The design reference model is not just the thing, but the thing in its working situation. And so a beep might stand in for a co-pilot or banksman and must be appropriately articulate. Warning sounds for the drivers of commercial vehicles, for instance, are composed to approximate effects that range from a “tap on the shoulder” to a shout: “Act now!”[5]

I am not entrusted with any especially dangerous equipment. And I seldom find myself in situations where I must act precipitously. The machine feedback that chivies, encourages, assures, and warns me is more associable with friendly, non-urgent utterances. The “ping” of the college’s communal microwave is a “hey you” that prevents me inadvertently hogging it in the precious lunch hour; the beepette of our television turning on a tiny “hoorah” to mark the commencement of entertainments. These ersatz exclamations ease the passage through or mark the difference between routine activities of a multitasking brain and body. They are minor contributions to the comfort and convenience of the comparatively rich. But recently I have, unsurprisingly, been thinking about hospitals, about life-saving beeps. I have been imagining the sound of overloaded intensive care units and their equipment alarms. And I have been worrying about their unequal distribution, and about what it means that the BBC hospital drama series Holby City owns more working ventilators than some entire countries.[6] And I have been remembering how, on first entering an intensive care unit, the beeps and hums are literally alarming. While the hospital soundscape does not shatter with the yelps and screams of security systems or reversing lorries, anything that stands in for the (comparatively) silent running of a body is disquieting.

In the days before the pandemic, you could visit intensive care units (ICUs) and observe their composition of intersecting forms and movements, the medical team tending your loved one like an ecosystem, nudging drug levels here, reducing mechanical dependency there. The nurses, doctors, housekeeping staff, porters, and consultants rotate in shift patterns that phase with one another. Friends and relatives appear and reappear in erratic emotional states, like motifs and variations. Critical turning points—an organ failing, an operation succeeding—provide large-scale dramatic structure. And all the while these alarms, their rhythms and pitches layering experimentally. There is no single continuous “blip” of a monitored heartbeat threatening to end in the stereotypical screaming flat line. It is more a continual fidgeting of sound, a representation of the chaotic systems of a body responding to clinical adjustments in a recursive, non-linear dance toward wellness or death.

After a week of sitting beside an intubated loved one, it becomes like birdsong, a fact of nature in this strange, still, pale glade.

Give it longer than a week, and ask questions with as much objectivity as you can muster, and meanings emerge from these cryptic, busted melodies. Note the fluxing functionality of organs or the passing of a limit—of pulse rate or oxygen levels in the blood. Know that drug X has run out again. An infection has taken hold. If your sibling is also a nurse, and understands the relationship between beep and medical staff action (and hasn’t misread the appropriateness of visitor intervention in that relationship), then you might start to relay certain alerts via improvised sign language to the staff member at the workstation visible through the window. You can become part of the conversation.

Painting by Robert Priseman, 2004. Courtesy Robert Priseman and Wellcome Collection. Used under Creative Commons Attribution 4.0 International.

A year on, I found recorded snippets of the ICU soundscape among my phone’s voice memos, collected to remind me of a month that had seemed to be both dissociated from the rest of life and the cold slate that lay beneath everything. Listening back, it struck me how soft the timbre was, how my pictorial interpretation would be curve-cornered and feather-edged, not hard and spiked like the classic digital alarm that punctures sleep. Hospital beeps are burred and protrude from an undergrowth of buzzes, whirrs, and clicks. They gather into short melodies, some more archly “contemporary” than others. I asked composer Matt Rogers to perform a deliberately conventional Western musical reading of my four snippets:

  1. A pattern of three pitches on a regular pulse, followed by a gap of one pulse unit and then two more pitches, all a G quarter-tone sharp, concluding with a pause, with the whole phrase then repeated once. If we assume that the rhythm of the pitches represents an even subdivision of the whole phrase, including the pause, then time signature-wise the phrase sounds like it thinks it’s in a 4, except in strict time it’s more like 17/16 than 16/16. That is, the repeat of the phrase begins a fraction late.
  1. A single, short, E quarter-tone sharp, repeated at a rate that describes a pulse of about 40 beats per minute. This overlaps with the end of a phrase from clip no. 1. The interval between the two pitches is a major sixth.
  1. A pattern of three pitches on a regular pulse across a tritone pitch interval: F three-quarters sharp to C quarter-sharp back to F three-quarters sharp. The phrase occurs twice in the recording with a gap of about ten seconds between the end of the first instance and the beginning of the second. It could be considered that each instance of the phrase is independent of the other or that the gap is part of the phrase. Assuming the latter, and that the pulse of the pitches represents an even subdivision of the whole phrase, including the pause, then the phrase is about fifteen beats long at a tempo of 86 beats per minute. The tritone interval can be considered the sum of two minor thirds, implying a diminished chord, which in the Western tonal system often functions as instability, ambiguity, and transition. It’s unsettled. It also features a lot in heavy metal. Historically, the tritone was dubbed diabolus in musica, controversial in church music, hard to sing, and generally considered distasteful.
  1. A pitch dyad, or pair of simultaneous pitches, iterated twice on a fast, regular pulse. The pitches of the dyad are A and G; a major second which has a more “open” feel than the pitch content of clips 1–3, lacking any major or minor component and implying the open intervals of fourths and fifths. Inferring meter from the pulse of the dyads, we arrive at a phrase of seven beats at a tempo of about 158 beats per minute, with the dyad pulse representing the even subdivision of a single beat, the other beats being rests.

    On the issue of tuning, while clip 4 is in equal temperament (where A4 = 440 Hz), clips 1, 2 and 3 are all closer to a temperament of A4 = 446 Hz. They are micro-tonally sharper. This difference of temperament in the whole soundscape could be a source of tensions for some (or indeed, stimulating for others). It might be torturous for anyone with perfect pitch.

    Interestingly, taking together the pitches that are of the same temperament—G, E, F#, C—you have a lot of the characteristics of the scale referred to as the acoustic scale, Lydian dominant, or Lydian flat seven scale. These are also to be found in the opening phrase of the theme tune to the cartoon The Jetsons. (Add the pitch of the fourth clip, in the same temperament, and you end up with the opening phrase of the theme tune of The Simpsons.)

Despite the soft edges, then, there is much here to unsettle ears habituated to Western music norms: a “distasteful” chord, different tuning between machines, irregular temporal patterning.[7] This is not easy listening. What’s more, ICU alarms are copious. Nurses must process hundreds in a single shift.[8] Often there are too many to remember or identify or differentiate between. And one alarm can potentially mask another. Then there are the huge number of “false” alarms that don’t require clinical intervention, but which are difficult to adjust, and so are often disabled entirely, which presents fresh issues. Add to this the lack of standardization between device manufacturers, and poor mapping between the urgency of a situation and the perceived urgency of its corresponding alarm, and the result is, hermeneutically speaking, a horrid garble.[9]

This is not a novel state of affairs in sectors that have developed over time through the efforts of many people with disparate outlooks, capacities, experiences, and expectations. Take the railway in the UK. In 1865, after three decades of laissez-faire free-market pioneering, there were 366 authorized railway companies in Great Britain, each operating with their own agendas, procedures, and even rail gauges.[10] It wasn’t until statutory amalgamation in 1923 that the railway was consolidated from 120 companies into four. Add to this nationalization in 1948, the notorious “reshaping” of the railway—with vast cuts to stations, lines, and services—in 1963, and reprivatization in stages between 1985 and 1997, and you have a network today that is noticeably more unwieldy than that of, say, Belgium, which was government-built and -owned, and designed coherently, from the off. The ICU finds itself in a state analogous to the British railways. Infusion pump, feeding pump, warm air generator, suction pump, heart-rate monitor, electronic patient record, oxygen supply, ventilator, normothermia system—potentially all made by different manufacturers without consultation on coherent overall design or even regulatory standardization on such things as pitch tuning. And this latter point is not merely an aesthetic concern. Research suggests that in the absence of consciousness, many patients process sound automatically and implicitly and can distinguish between the sounds of human, animal, tool, and musical instruments in the environment.[11] What anguish, then, if one such patient were a musician with perfect pitch?

This is not to suggest that the biomedical machine industry is negligent or incompetent. Thought has certainly gone into the timbre of individual ICU alarms, and there are sound design companies out there who have been hired by a handful of biomedical machine brands. But in the industry more generally, the effects of sound tend to be considered as just one element within the issue of “human factors” in the working environment.[12] To compare across industry boundaries, for the last ten years the Swedish truck and bus manufacturer Scania has employed an in-house sound designer, Stefan Larsson, to develop driver-vehicle interaction sounds using synths and music-industry software, and to evaluate them, in consultation with users, in driving simulators. The company is currently working on a system by which these sounds can self-adapt in response to ambient noise. This is understood as part of the brand, certainly, but also of vehicle functionality. To be fair to the biomedical machinery industry, though, they compare favorably to the many machines and devices that seem to have had their beeps plonked in them without much thought at all. There are some that are unpleasant to the point of unusability. But on the upside, it is within these contingent electronic soundscapes that strange serendipities can occur. My composer companion has encountered supermarket barcode scanners playing “O Fortuna” from Carl Orff’s Carmina Burana, a reversing truck issuing a phrase from Mendelsohn’s A Midsummer Night’s Dream Overture, and a fragment of Beethoven’s Für Elise performed by the closing doors of a London Underground train. And while on the subject of supermarket checkouts with differently pitched beeps, he asks: If these checkouts were made by the same manufacturer, how are their beeps different in tone? We agree that some beeps drop in pitch when the device’s batteries are running out, but these supermarket tills are powered by mains electricity. I can only surmise that factory-made sound chips are programmed and manufactured in such a way that they fall somewhere between digital cookie-cutter duplication and the infinite variability of a hand-thrown pot.

Sonic branding is big business. Should you be interested, you could commission the composition of a long-form anthem, a sonic logo, or the sounds your product emits during user operation. Computer and video game companies lavish much time, effort, and money on the second and third of these. For a canonic commission, there is the Windows 95 start-up sound designed by Brian Eno. A more guerilla affair was Jim Reekes’s Apple computer start-up chime, which he snuck onto a new Mac model without permission circa 1992.[13] Interestingly, the sound he was so driven to replace was “absolutely the most inharmonic dissonant sound you could make”—a tritone. There are many other, less substantiated stories out there: that one-eighth of the bits of the original Sonic the Hedgehog game were taken up by the SEGA sonic logo; that the first note in the Intel logo comprises twenty sounds, one of which is an anvil being hit; that the first Facebook messenger “ding” was an F major seventh, which comprises the pitches F, A, C, and E.[14] But what becomes clear is that an increasing amount of thought and resources is channeled into the electronic soundscape. As interfaces disappear into the “internet of things,” sound will become an increasingly vital means of activation and affirmation.

These sounds will be lavishly fashioned. And before this they will have been explained to the corporate client. Reekes describes wanting to reassociate the computer booting up with a “palate cleanser,” a “refreshing” sound: “a big fat C major chord with a lot of thick rich sonic textures” comprising “a bunch of strings” and a “chiffy sound, like you get with a bamboo flute.” Other sounds suggest tension resolution or a waking up, a gentle rub on the back, a breath, excitement, a sense of community. The description of sound is a craft in itself. (I am reminded of the pronouncements of wine tasters. “Tarpaulin edged in lace” is an old favorite.) There is shorthand for most things, and in the sonic design sector less artful stereotypical sounds participate in circular hermeneutic hardening processes: the brass sound selected to signify “success” because the heroic is represented by trumpeting. (I am all for the communalizing effect of clichés, but it should always be remembered that a trumpet can also be played comically, schmaltzily, or pathetically.) But a discussion of ICU alarms would be less straightforward, since their emotional association and informational content is complexly ambivalent. I would love to attend a meeting between a UX designer and a healthcare technologist intent on squaring the circle of alarm fatigue.

I would host this meeting in a transdisciplinary research institute called the International Network of Practitioners for the Relief of Alarm Fatigue (INPRAF), where sound designers, musicians, composers, nursing staff, anesthetists, hospital managers, product designers, machine manufacturers, electronic engineers, app designers, psychologists, linguists, and semioticians collaborate on the problem.[15] INPRAF would house an archive of recordings of every ICU in the world and crosscheck them against mortality and recovery rates. And, as the institute’s pragmatic text analyst, I would ask sound engineers and electronic music makers to contribute to a directory of descriptions of sounds, so we all know precisely which beep, click or hum we are talking about should it need to be invoked in its absence, or before its existence.

INPRAF will also lobby for standardization within the biomedical equipment industry, insisting that every machine’s pitched beeps are tuned to the same temperament. And we would proffer a development plan whereby different timbres of alarm are consistently mapped onto specific types of machines and different urgencies of response required. This standardization would be rolled out across all hospitals in all countries so that staff moving between appointments would no longer have to relearn a whole new set of sounds and their meanings.

When we meet with senior management about redesigning their hospital’s soundscape, we will heed artist and sound designer Yuri Suzuki’s warning that any new sonic design appeals, at most, to just 40 percent of any given client group.[16] And so, finding it easier to smuggle change in through the backdoor, we would not propose a whole new palette of sounds, but make subtle adjustments to what already exists. For our research, we will visit Brian Eno’s “healing soundscape” in Montefiore Hospital in Hove in the UK, and study his remodeling of the acoustics of Chelsea and Westminster Hospital, London. We will note how Eno and Suzuki agree that it is the harsh blankness of the clinical setting that induces fear, and so we will turn our attention to what lies between and beneath the beeps. We will fill this dead space with the soothing sound of the sea, although one of our team will find this embarrassingly close to piped whale song, and so we will press on for a more admirable solution.

Like so many sound and video makers, we will absorb the beeps into a cozy, amniotic digital layering of buzzes, hums, and drones. And we will have the brilliant idea of tailoring this for each patient. We will explore the possibilities of scraping home environments for calming, familiar sounds: of strip lights, vacuum cleaners, washing machines, traffic. We will build up a library of ambient samples, from which the patient selects a personal mix (or a loved one will choose, if the patient is already unconscious on entering the ICU). This montage will be incrementally altered by a recursive monitoring and compositional system that responds to the patient’s fluxing biophysical state. But eventually a patient will be found for whom all mixes send them into a downward trajectory. Someone will point out that not everyone has a home life they can associate with calm, or even with safety. And not everyone has a home.

We then will turn our attention to the epochal charge of this sonic space around the beeps. Since it is the stark atmosphere of frontier medicine that alienates, might we cloud it with noise that appeals to the deep and ancient amygdala? And which relic should we revive? We could look to the buzz of gases in glass vacuums, the breath of bellows, the hiss of burning damp wood. We could visit Francis Bacon’s Sound-Houses, circa 1624, “wher wee practise and demonstrate all Sounds, and their Generation.” We might admire his “diverse Tremblings and Warblings of Sounds, which in their Originall are Entire” and marvel at tech that runs on no amperage we can discern, yet produces “Strange and Artificiall Eccho’s, Reflecting the Voice many times, and as it were Tossing it,” or returns the voice “Lowder then it came, some Shriller, and some Deeper,” all conveyable “in Trunks and Pipes, in strange Lines, and Distances.”[17]

Though gorgeous and apparently magical, we would decide that an unconscious mind might mistake this for the contemporary technologies it anticipates, and which we are trying to mask. We will continue our journey back in time, seeking other, somatic ambient sounds. Some bright spark will remember the hum of Philoctetes. But on investigation this will turn out to be, unhelpfully, a wound so ‘noisome’ that his company could not be tolerated.[18] We will audition the ancient healing sounds of the yidaki, or didgeridoo, and the lyre, and the harmonic resonance of throat singing. But all these fiddling fingers and aspirating lungs will be cluttering. We will turn to air moved by innate forces, creating a diplomatic incident through our joint appeal to Shu—Egyptian god of wind and air, who wears a feather in his hair, and whose bones are the clouds—and Amun, Egyptian god of air and fertility, who bears two plumes on his head and is rumored to have masturbated the world into being. To drown out this clash of personalities, we will widen our appeal, and become inundated with deities who control or embody one particular wind, or all the winds; who take the form of a fawn or a moose or a panther or an old woman, or who ride on the back of a tiger; who couple their weather duties with those of forgiveness or safe journeys, or who oversee endings or beginnings, or start fires. But when we interview every one of these winds, we will again find too much humanity, too much meaning, too much to disturb the patients.

And so, working ever backwards through time, we will eventually find ourselves at the birth of the universe. We will hear the Planck telescope’s recording (made audible by a fifty-octave compression) of primordial soundwaves that “shook this infant universe, triggered by minute, or ‘quantum,’ fluctuations happening just moments after the big bang.”[19] We will know this is perfect. We will carpet the ICU ward and line its walls with the hissy hum. And through these natal sighs of the heavens, the alarms will surge like satellites.

  1. For Sputnik’s full technical specifications, see Anatoly Zak, “Design of the First Artificial Satellite of the Earth,” RussianSpaceWeb.com (blog). Available at russianspaceweb.com/sputnik_design.html.
  2. “Soviet Satellite Sends U.S. into a Tizzy,” Life, 14 October 1957, pp. 34–37.
  3. “Special Report on Sputnik 1,” CBS News, 6 October 1957. Available at youtube.com/watch?v=qdQHuiV_9AI.
  4. Thanks to David Deutsch for this elegant definition of computing. See “Why Is the Quantum So Strange,?” Closer to Truth, 1 September 2014. Available at youtube.com/watch?v=MckuBQC6gKU.
  5. Intermediary referents are “Here’s some information that might be handy” and “You need to review this information and take action pretty soon.” These were related to me by Stefan Larsson, Scania’s in-house sound designer.
  6. This came to light when the BBC loaned two machines to the National Health Service’s Nightingale Hospital. Many frothed at the expense of a television program having procured working medical machines for its set. Unnecessary, surely, when all is pretense? But in the real world of props and sets, a fake machine would be difficult and costly to make. Another option would have been to track down a faulty one that was not so out-of-date that the general viewer would sense the anachronism. But, unlike household electrical goods, there is a culture of maintenance, repair, and second-hand procurement in biomedical equipment. A ventilator would not be discarded unless it was entirely irreparable or obsolete. And if an art director did resort to fake or broken equipment, what of the dearth of sound and movement? The set would need puppeteering and ventriloquizing. The hospital’s recognizable menagerie of beeps and whirrs would need manufacturing in post-production; creating the sounds using Foley (if they could have afforded it), library sound effects, and field recordings, and then syncing them to machinery animated by LED lights, fluxing data monitors, and numerical displays. See “Coronavirus: Holby City Donates Ventilators to London Nightingale Hospital,” BBC News, 11 April 2020. Available at bbc.co.uk/news/uk-52250706. See also Ruth Maclean and Simon Marks, “10 African Countries Have No Ventilators. That’s Only Part of the Problem,” The New York Times, 18 April 2020. Available at nytimes.com/2020/04/18/world/africa/africa-coronavirus-ventilators.html.
  7. It is entirely possible to notate this within conventions, however. The slight delay might be marked by a comma for breath or a tenuto—a pause to be leant on—before the second iteration of a phrase. Or the whole passage could be marked “rubato,” calling for an expressive freedom with phrasing, the pushing and pulling of time in performance.
  8. A twelve-day alarm system analysis at the Johns Hopkins Hospital logged an average of 350 alerts per bed per day. In one intensive care unit, the average was 771. See Kierra Jones, “Alarm Fatigue a Top Patient Safety Hazard,” Canadian Medical Association Journal, 18 February 2014, vol. 186, no. 3, p. 178. Available at ncbi.nlm.nih.gov/pmc/articles/PMC3928208.
  9. See Julie Darbyshire, “Noise in the Intensive Care Unit: Where Does It Come from and What Can You Do about It?,” ICU Management & Practice, vol. 19, no. 2 (Summer 2019). Available at healthmanagement.org/c/icu/issuearticle/noise-in-the-intensive-care-unit-where-does-it-come-from-and-what-can-you-do-about-it. See also Christina Meredith and Judy Edworthy, “Are There Too Many Alarms in the Intensive Care Unit? An Overview of the Problems,” Journal of Advanced Nursing, vol. 21, no. 1 (January 1995).
  10. Jack Simmons and Gordon Biddle, The Oxford Companion to British Railway History (Oxford: Oxford University Press, 1997).
  11. Natacha Cossy et al., “Robust Discrimination between EEG Responses to Categories of Environmental Sounds in Early Coma,” Frontiers in Psychology, vol. 5 (25 February 2014). Available at ncbi.nlm.nih.gov/pmc/articles/PMC3933775.
  12. See William A. Hyman and Valory Wangler, ‘Human Factors: Environment,” ed. Joseph F. Dryo, Clinical Engineering Handbook (St. Louis: Elsevier Science, 2004), pp. 353–355.
  13. See “Interview Jim Reekes: Creator Mac Startup Sound.” Available at youtube.com/watch?time_continue=996&v=QkTwNerh1G8.
  14. “Audio Experts Break Down the Most Common Tech Sounds,” Wired (YouTube channel), 10 November 2016. Available at youtube.com/watch?v=S_gBMJe9A6Q.
  15. I have settled for an initialism rather than an acronym, because with the latter one can often end up compromising the accuracy of the name for the sake of a neatly redolent outcome. There are exceptions to this, of course, and some institutions perform a sleight of hand to achieve both precision and soul. See, for example, the Nuffield Department of Clinical Neurosciences at the University of Oxford’s research program Sleep in the Intensive Care Unit: Lowering Elements of Noise in the Critical Care Environment (SILENCE).
  16. This statistic emerged in a conversation with Suzuki on 27 May 2020 about the practicalities of redesigning the sonic environment of the ICU. See documentation of his projects at yurisuzuki.com.
  17. Francis Bacon, New Atlantis, written in 1624, published posthumously in 1627, reproduced in Daphne Oram, An Individual Note: Of Music, Sound and Electronics (Wakefield, UK: Anomie, 2016), p. 128.
  18. In Robert Graves’s account, this wound is from a water-snake bite on the foot. In all accounts, Philoctotes is abandoned on the deserted island of Lemnos because the “hum” of the wound is intolerable. See The Greek Myths (London: Penguin, 1992), pp. 654–655.
  19. “Sounds of the Ancient Universe,” Jet Propulsion Laboratory, NASA & California Institute of Technology, 21 March 2013. Available at jpl.nasa.gov/spaceimages/details.php?id=PIA16881.

Sally O’Reilly writes and makes for page, screen, and performance.