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An all-black cardiology stethoscope hangs around my neck on the ward round in intensive care.
‘We should really ban those from intensive care,’ states the consultant. I interject that the cheap, toy-like stethoscopes that hang at each bedside are laughable pieces of plastic. That I might as well put my ear to somebody’s chest, because really, I would hear more in that instance.
‘If you’re reviewing on the wards,’ the consultant adds, ‘fine, but here in intensive care that stethoscope contributes nothing to patient care’.
‘What if I listen and hear a severe aortic stenosis we didn’t know about or a quiet base, which induces me to look at the patient’s most recent chest x-ray and white cell count and treat them for pneumonia?’
‘You should look at those things anyway.’
They are right and the truth is I continue to possess this stethoscope mostly for when I go to the wards, but I do love a good debate. So, I pull out another reason, and one that actually I am not sure we can do anything about.
‘What if I never listen to anybody’s chest on the ICU ward round and then something bad happens and they say you should have listened, if they say a reasonable doctor would have done that as part of a basic clinical examination.’
And I am answered that a reasonable doctor witness wouldn’t attest to that, in the setting of intensive care, because they’d be wrong.
‘Ah,’ I reply, ‘but what if my fate is not dependent on the opinion of a reasonable doctor or expert, but primarily on a jury of lay people who decide that doctors use stethoscopes?’
But at this point, the F1 approaches. He has been examining the patient on front of us, as I had asked him to, and he wanted to tell me that he wasn’t really sure if the patient had ‘crackles’ or ‘wheeze’.
So, I smile, take the stethoscope from around my neck, give it a rub with the disinfectant wipes at the bedside and say, ‘that’s not a problem, why don’t we have another listen together’.
And it is impossible for me not to look at the consultant and smirk, but knowingly, she smiles back and says: ‘That is teaching, which I am sure you know is something different entirely.’
‘Did you do that on purpose?,’ I ask the F1 when we reach the bedside and he says ‘no, I really just don’t know which it is’.
‘She’s probably right you know’ I tell the F1 as we listen ‘but I do love my stethoscope’.
They were crackles.
By the Secret Doctor
Read the blog and follow @TheSecretDr on Twitter and on Facebook
I agree - if I am ever without a stethescope and need to find one, all I need say to the family as I disappear is 'how can I be a proper doctor without a stethescope?' - and of course they agree and of course they are happy to wait while I find one.
I was initially surprised in cardiothoracic surgery that stethoscopes were so rarely routinely used - they had been replaced with chest X-rays (could easily be up to 5 per day per patient) and echocardiography, Similarly in anaesthetics it seems that the more senior one becomes, the less likely one is to have brought your stethoscope.
However when an intubated patient in theatre (or ICU) suddenly becomes difficult to ventilate/acutely desaturates, there is currently no substitute for a stethoscope (even with full monitoring including capnography, and a nearby suitable ultrasound that works). I have lost count of the number of times I have been called to those situations, where the consultants are taking immediate actions (100% O2, check capnography, pressures, cuff, circuit), but are then unable to tell what is actually going on. The first response after checking the basics is then to auscultate, which reveals the problem and completely alters management in many of the cases. CXR is a laughable first response (too slow), and echo (when it boots up and you have magically achieved an echo window, perhaps through the surgical drapes) will not see the bronchospasm, plugging, coarse creps etc that have acutely developed (plus many of the consultants using echo are not actually accredited to do so, and should not be changing patient management based on their informal attempts at imaging). The £1.50 stethoscopes provided at ICU bedsides and on anaesthetic machines (if you're lucky) are better than nothing, but are likely to be frustratingly useless for anything other than a grossly displaced tube (yes. you are probably better off putting your ear to their chest - I have done so)!
If your consultant is so anti-auscultation, why don't you check if they're an accredited echocardiography mentor (e.g. focused intensive care echo, FICE), and ask them to help you become a competent basic ultrasonographer? With basic echo skills AND a stethoscope, you'll be finding all kinds of critical diagnoses that are hidden to those without those skills - doctors who have to wait until their booked echo or CXR results return (if the patient hasn't died first)!
I presume your consultant was joking about banning stethoscopes from ICU (and is presumably also an ultrasonography guru); if not, perhaps they should discuss banning all stethoscopes (including the £1.50 ones) with the other ICU consultants and their anaesthetic/crash team cover, and see what response that engenders. If they're serious, as a tip, I'd call for (expert) help early when the next patient has an acute life-threatening deterioration while they're nearby!
it is good to practice as much as possible. Sometimes doctors need extensive working to get going . and most importantly working charity is always the best. I am a family physician and usually i give free consultation and medication advises to the homeless people. It is good to do that. At this easter, i am going to distribute clothes from www.reecoupons.com/.../choies choies promo codes to the people in need.
As a surgical trainee my colleagues often tell me that I look more like an anaesthetist wearing my scrubs with my stethoscope around my neck.
The other registrars seemingly have no need to hear the high pitched tinkling bowel sounds indicative of an obstruction or alert themselves that the upper abdo pain is possibly coming from a lower lobe consolidation or confirm that a patient with difficult abdominal signs does in fact not appear to have any bowel sounds and hence inform their urgency of investigation for possible perforation.
It is interesting how the more senior you go, there is often a distain for using this simple yet very informative piece of equipment.
I am proud that you think it is never beneath a doctor - even an ITU reg with access to all manner of expensive equipment / invasive monitoring / readily agreed scans to put your hands (or stethoscope) to the patient and listen for some crackles.
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The doctors are being paid great attention because more and more sick people need good doctors
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If there is a stethoscope or not, it is always supported by the doctors working for humanitarian hearts.
Great article! I am looking into this issue! Thank you for your helpful information!
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