Columns, Patient Care

Listening to Our Patients

Issue 8 and Volume 42.

When was the last time any of us used a stethoscope and felt it made a difference either to clinch a diagnosis or to change the management of a sick patient?

Diagnostic Tool or Neckwear?

How many of us have had a patient with a history of hypertension, diabetes or myocardial infarction (MI), who presented with complaints of chest pain and shortness of breath?

On exam, he might have been anxious and diaphoretic, with a heart rate of 130, respirations of 24, blood pressure of 190/110, bilateral pedal edema, oxygen saturation (SpO2) of 89% and 12-lead ECGs showing ST-elevation.

Then you put your scope on his chest and said, “Wow, this guy has crackles two-thirds of the way up. Good thing I checked, otherwise I never would’ve guessed he was in pulmonary edema.”

Or, “Gosh, that three pack-a-day smoker with a productive cough, green sputum, a temperature of 103, an SpO2 of 92% and respiratory rate of 32 has crackles in her right lung. She must have pneumonia!”

When you got these patients to the hospital, things might not have gotten much better.

With the use of increasingly sophisticated technology and imaging modalities, some of the tools of our trade, like the stethoscope, have been relegated to near museum status.

Several years ago, the chairman of radiology at a teaching hospital asked what I thought about their emergency medicine residency. I said I thought it was good but also bemoaned the fact that their residents would often throw the patient’s entire differential diagnosis up against the wall, and then use a CT scan to sort it out.

The radiology chair looked at me and said, “Differential diagnosis? Hell, they use the CT to do the physical exam!” Why would busy residents screw around with stethoscopes, or even have to interpret their own chest X-rays, when highly skilled radiologists could give them quick CT readings in a matter of minutes?

Opportunity to Listen

In EMS, we have few sophisticated tools to rely on. Instead, we have to depend on our eyes, ears, hands and even our sense of smell. That’s not a bad thing because, like clinicians of old, we’re forced to develop and use highly tuned senses.

Instead of sending patients to radiology, we examine them more closely, seeing if a couple doses of nitro actually improve their shortness of breath, thereby narrowing our differential diagnosis in the act of treating them.

For those of us who have the interest and time, there may be other less obvious advantages as well. Since we have the opportunity to interact with our patients, not just their lab results and scans, we may take better histories and not order unnecessary workups based on two lines (or two words) written by the triage nurse.

At the risk of sounding like a country preacher, there’s also the untold benefit of “laying on of hands.” Touching sick or worried patients may even have its own
therapeutic benefits.

They may also be more willing to tell us what’s going on, instead of getting whisked off to the scanner before anyone comes in to take a history.

Gaining the Edge

A fair amount has been written about the sensitivity and specificity of the physical exam. How likely are we to miss something when it’s actually there, and how likely are we to identify something when it really isn’t? The results of some of these studies aren’t pretty. The physical exam, whether performed by EMTs, paramedics or physicians, may be no better than the flip of a coin.

What if an elderly female patient presents in pulmonary edema because of a blown papillary muscle, and you happen to put your stethoscope on her chest and pick up the loud systolic murmur of acute
mitral regurgitation?

Not only might you correctly identify a surgical emergency (that all the nitro in the world may not fix), but you might also recognize that intubating her could potentially kill her. A sudden increase in intrathoracic pressure, and therefore afterload, after placing the tube might not only increase retrograde blood flow through the leaking valve into her lungs, but it could also lead to a precipitous drop in her cardiac output and blood pressure.

Relaying all this to hospital staff at triage might also lead to an early echocardiogram (cardiac ultrasound) in the ED and lifesaving surgery in the operating room.

It’s noisy out there, but if you don’t at least try and listen, you might miss an excellent opportunity. The next time you take that stethoscope out it may not make a difference, but it might give your patient that little extra edge.