I have retired my stethoscope for good

[NewYorkDoctors]

*DISCLAIMER* I am not here to sell any product.

I have used the same stethoscope (Littman Cardiology III) from my MS1 year all to way through to my current PGY6 year right now. It has served me well but it has been receiving declining use over the last few years.

This is not because of a lack of respect or practice for auscultation or physical exam.

I can percuss for Castell's sign, identify stertor from a stridor, and identify heart failure via auscultating for the square wave blood pressure response on Valsalva as well as any other seasoned physician forty to fifty years my senior.

But the fact of the matter is that we all know our physical examination is severely and sorely limited in both the in and outpatient domains for anything beyond a simple "textbook" case.

Though I have been carrying my portable tablet ultrasound for a few years ago and it has been an amazing tool in the specialties I practice and am training in, I still carried the stethoscope. Not out of tradition or anything like that. Rather I cannot "see" wheezing or peristalsis (outside of a very thin person or someone with ascites) and hence I kept it.

However, now that I have picked up an iPhone stethoscope which I connect to my AirPods for supreme portability (and much less neck strain or gripe with the stethoscope falling off of a belt clip), I have thoroughly retired the Littman's.

The combination of instant access to point of care ultrasound, electronic stethoscope with phonocardiography and ability to record breath sounds, bowel sounds, and Korotkoff sounds, has thoroughly rendered the stethoscope (which should be called a stethophone anyway) thoroughly obsolete.

Feel free to share your thoughts. Though I think technological advancements have put an end to any excuses for the stethophone to remain a mainstay other than during a power outage.

The three probes weigh about the same as the Littman's.

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[chessknt]

And how about the cost difference?

 

[aafisahar]

In the words of the immortal wu tang clan, cash rules everything around me, CREAM, get the money, dolla dolla bill y'all.


Meaning, can you get level 5 encounters with a POCUS and no stethoscope and can you bill for POCUS studies

 

[NewYorkDoctors]

And how about the cost difference?

Strictly luxury items .. but not so expensive that a physician cannot afford it on a physicians salary .

 

[NewYorkDoctors]

In the words of the immortal wu tang clan, cash rules everything around me, CREAM, get the money, dolla dolla bill y'all.


Meaning, can you get level 5 encounters with a POCUS and no stethoscope and can you bill for POCUS studies

Nah more like properly triage the PE as ESC intermediate high/low when the echo department is gone , find the gallstones and the CBC yourself , get a feel for the ICP yourself , find that clot in transit , hear and then see that new regurgitant murmur in a sepsis workup ...

In other ways keep hospital and ICU length stay down ... from .. the point of care .

None of that pan consult shotgun approach wishy washy medicine .

 

[bobsmith]

ability to record breath sounds, bowel sounds, and Korotkoff sounds, has thoroughly rendered the stethoscope (which should be called a stethophone anyway) thoroughly obsolete.

I am genuinely curious to know what utility there is to being able to record bowel sounds.

 

[gutonc]

I am genuinely curious to know what utility there is to being able to record bowel sounds.

Practical jokes? Otherwise useless.

 

[NewYorkDoctors]

Practical jokes? Otherwise useless.

Borbyrigmi as a ringtone ?

Anyway the peristalsis sono images (with ascites as an acoustic window of course) are strangely hypnotic .

 

[ReviewOfSystems]

Who cares about the utility of the stethoscope...it makes the patients think you did something, and above all, its a sexy instrument IMHO

 

[IMreshopeful]

Nah more like properly triage the PE as ESC intermediate high/low when the echo department is gone , find the gallstones and the CBC yourself , get a feel for the ICP yourself , find that clot in transit , hear and then see that new regurgitant murmur in a sepsis workup ...

In other ways keep hospital and ICU length stay down ... from .. the point of care .

None of that pan consult shotgun approach wishy washy medicine .

Point. It’s reasonable to use POC echo to screen for murmurs and such. If you’re actually worried about endocarditis, you’re best served with a formal study utilizing hemodynamics, Doppler echocardiography, 3D echo, TEE if needed etc. I wouldn’t hang my hat on this alone

 

[NewYorkDoctors]

Point. It’s reasonable to use POC echo to screen for murmurs and such. If you’re actually worried about endocarditis, you’re best served with a formal study utilizing hemodynamics, Doppler echocardiography, 3D echo, TEE if needed etc. I wouldn’t hang my hat on this alone

Agreed good point. Outside of lung sonography, anything I find positive I bring to the attention of others and recognize that I will still need the formal test. (Even for the BLUE Protocol PEs with McConnell's Sign and positive DVT on exam, my attendings have stated our hospital still wants a diagnostic CTPA ordered, though we could start A/C far ahead of time and not cause any delays)

I openly admit I am not the 100% NPV guy. Nevertheless, one of my attendings has described a situation in which CCM POCUS found wide open MR in a patient in pulmonary edema and fever with positive BCx for staph and then it was Friday and we brought this to the attention of CTSx who then mobilized the OR in a short period of time. So as long as the support is there, it is an extra tool, if used wisely and responsibly.


However, this sure beats wringing my thumbs thinking "dunno order everything" and waiting for results and praying nothing bad happens.

 

[IMreshopeful]

Agreed good point. Outside of lung sonography, anything I find positive I bring to the attention of others and recognize that I will still need the formal test. (Even for the BLUE Protocol PEs with McConnell's Sign and positive DVT on exam, my attendings have stated our hospital still wants a diagnostic CTPA ordered, though we could start A/C far ahead of time and not cause any delays)

I openly admit I am not the 100% NPV guy. Nevertheless, one of my attendings has described a situation in which CCM POCUS found wide open MR in a patient in pulmonary edema and fever with positive BCx for staph and then it was Friday and we brought this to the attention of CTSx who then mobilized the OR in a short period of time. So as long as the support is there, it is an extra tool, if used wisely and responsibly.


However, this sure beats wringing my thumbs thinking "dunno order everything" and waiting for results and praying nothing bad happens.

I would argue that even if you see a McConnell’s most surgeons will still need the CTPE protocol if they want to take it out. If they’re crashing then you thrombolyse anyway. For the submassive ones you have time to think.

For echocardiography it depends a LOT on not just skill level with acquiring images but recognizing the limitations. That acute MR or AR might not be seen because of eccentricity. That flail P2 might not be immediately visible. You can miss regional wall motion abnormalities or overread them if you are off axis. Without M mode or Doppler all you can say is that there’s a big effusion and maybe not enough to recognize tamponade. Etc etc etc. so as long as this stuff is understood it can all be a very good tool otherwise

 

[chessknt]

I can't imagine these mobile tools are any better than the 20k portable machines which already have a hard time getting usable windows in my average bmi 45 or 70% Emphysema patient. Limitations indeed.

 

[Instatewaiter]

Yeah these are like $3500 per year with a warranty. Per year ...

Any ICU worth it's salt will have an echo machine and multiprobe ultrasound machine which will get you better pictures than this stuff.

In the hands of someone who has no idea what they are doing and without REAL formal training, this can be dangerous technology. Better to leave it to the imagers.

 

[NewYorkDoctors]

Yeah these are like $3500 per year with a warranty. Per year ...

Any ICU worth it's salt will have an echo machine and multiprobe ultrasound machine which will get you better pictures than this stuff.

In the hands of someone who has no idea what they are doing and without REAL formal training, this can be dangerous technology. Better to leave it to the imagers.

2019 Examination of Special Competence in Critical Care Echocardiography (CCEeXAM)

Real training like this?

Again, no crit care physician can replace the echocardiography technician and the echo boarded cardiologist, but can definitely not have to rely on a 9-5 service for emergencies.

Tell me, when are you in line for the critical care boards?

 

[rokshana]

2019 Examination of Special Competence in Critical Care Echocardiography (CCEeXAM)

Real training like this?

Again, no crit care physician can replace the echocardiography technician and the echo boarded cardiologist, but can definitely not have to rely on a 9-5 service for emergencies.

Tell me, when are you in line for the critical care boards?

why do you feel that when someone has an opinion contrary to your own, its somehow personal?

 

[bobsmith]

...CCM POCUS found wide open MR in a patient in pulmonary edema and fever with positive BCx for staph and then it was Friday and we brought this to the attention of CTSx who then mobilized the OR in a short period of time.

...if only there was some sort of medical tool that would have allowed you to auscultate this heart sound. Maybe you hung this tool up somewhere while you were sitting around "wringing your thumbs"?

 

[Instatewaiter]

2019 Examination of Special Competence in Critical Care Echocardiography (CCEeXAM)

Real training like this?

Again, no crit care physician can replace the echocardiography technician and the echo boarded cardiologist, but can definitely not have to rely on a 9-5 service for emergencies.

Tell me, when are you in line for the critical care boards?

I'm not sure why you made this personal about me sitting for the critical care boards as my comments weren'ta necessarily directed at you, but you went there . I have seen many providers of critical care and ER who think they see something on their echo that just isn't there. And all of these guys have supposed ultrasound training. Real and formal training with someone who knows what they are doing is important if you are to use bedside us

There is a reason basically all hospitals offer stat echos, even in the middle of the night.

As to the link you posted, that appears to have no requirements to sit for the boards other than have a pulse and $1000. That sounds a bit like a ripoff and a racket. Note that this is in direct contrast to the real echo boards (comprehensive) which do actually have training and number of examination requirements.

As to me sitting for the critical care boards, yeah I'm a board certified cardiologist so I have no need or desire to get in line for critical care boards. But, I am boarded in the comprehensive cardiovascular echo boards not just the basic critical care ones.

I don't see the utility in people carrying around an ultrasound machine that costs like 3500 bucks per year. It is a ripoff and sets yourself up to liability if you don't have the proper training.

 

[Instatewaiter]

...if only there was some sort of medical tool that would have allowed you to auscultate this heart sound. Maybe you hung this tool up somewhere while you were sitting around "wringing your thumbs"?

To come to the guys aid, the murmurmof acute severe MR often cannot be heard because the left atrial and left ventricular pressure equilibrate almost immediately

 

[NotAProgDirector]

I've replaced my stethoscope with a fully electronic one, it definitely takes some getting used to. But it makes me look cool.

As far as bedside U/S, I want one of these: Butterfly iQ - Personal ultrasound - Butterfly Network

Not on the market yet, but I've had a chance to play with one. They are amazing, One probe, fully tunable so that it can work at any frequency and in curvilinear, phased array, or linear imaging modes. The probe has 100x more sensors than a standard U/S probe. It's all chip based (not crystal based), so much cheaper. List price is $2K, you plug it into a screen (iPhone / iPad / etc), and away you go. Amazeballs. The image quality is amazing.

Full disclosure: I have no relationship to the company that is making this, other than wanting one.

 

[IMreshopeful]

2019 Examination of Special Competence in Critical Care Echocardiography (CCEeXAM)

Real training like this?

Again, no crit care physician can replace the echocardiography technician and the echo boarded cardiologist, but can definitely not have to rely on a 9-5 service for emergencies.

Tell me, when are you in line for the critical care boards?

The crit care board echo is nowhere near as comprehensive as the real echo boards/ASCeXAM. I recently had to bend over and take the abuse of that exam.

 

[IMreshopeful]

I'm not sure why you made this personal about me sitting for the critical care boards as my comments weren'ta necessarily directed at you, but you went there . I have seen many providers of critical care and ER who think they see something on their echo that just isn't there. And all of these guys have supposed ultrasound training. Real and formal training with someone who knows what they are doing is important if you are to use bedside us

There is a reason basically all hospitals offer stat echos, even in the middle of the night.

As to the link you posted, that appears to have no requirements to sit for the boards other than have a pulse and $1000. That sounds a bit like a ripoff and a racket. Note that this is in direct contrast to the real echo boards (comprehensive) which do actually have training and number of examination requirements.

As to me sitting for the critical care boards, yeah I'm a board certified cardiologist so I have no need or desire to get in line for critical care boards. But, I am boarded in the comprehensive cardiovascular echo boards not just the basic critical care ones.

I don't see the utility in people carrying around an ultrasound machine that costs like 3500 bucks per year. It is a ripoff and sets yourself up to liability if you don't have the proper training.

Lol if I had a dime for every time I got called in for a stat echo because some bro with an ultrasound machine “saw an effusion” or “thought the squeeze was low” (use real freaking medical words idiot) or “sees a wall motion” and it turned out to be nothing - I would be a rich rich man

 

[Psai]

Any of you progressive thinkers willing to send me their useless stethoscopes? I'll throw in shipping.

 

[CCM-MD]

As to the link you posted, that appears to have no requirements to sit for the boards other than have a pulse and $1000. That sounds a bit like a ripoff and a racket. Note that this is in direct contrast to the real echo boards (comprehensive) which do actually have training and number of examination requirements.

As to me sitting for the critical care boards, yeah I'm a board certified cardiologist so I have no need or desire to get in line for critical care boards. But, I am boarded in the comprehensive cardiovascular echo boards not just the basic critical care ones.

I don't see the utility in people carrying around an ultrasound machine that costs like 3500 bucks per year. It is a ripoff and sets yourself up to liability if you don't have the proper training.

There are no real requirements to take the NBE comprehensive echo exam either - just a state medical license is sufficient. Several intensivists I know have taken the exam and have "testamur" status. To be "certified" requires a cardiology fellowship. Many of these physicians contributed to the development of the critical care echo boards

Similarly, anyone with a medical license will be able to take this exam to attain "testamur" status but becoming "certified" will probably require a fellowship in CCM.

May sound like a "ripoff and a racket" but the NBE is the same board that administers echo exams to cardiologists and anesthesiologists... and now intensivists.

I'll never be as good at echocardiography as a cardiologist but echo for intensivists has its role - particularly in relation to resuscitation.

 

[Trogghunter]

I'll never be as good at echocardiography as a cardiologist but echo for intensivists has its role - particularly in relation to resuscitation.

Dream big my friend. I'm a hospitalist but I admitted a patient last week for SOB/chf/pna, did a bedside echo in the ER because they had some cardiomegaly on the xray that was new and found a pericardial effusion that looked tamponad-y. Ordered a stat TTE, cardiology wasn't impressed initially, when another guy looked at it, they confirmed tamponade, they got a window next day, 500cc of blood had developed acutely. I've been doing them for years since intern year, always find it helpful.

 

[IMreshopeful]

Dream big my friend. I'm a hospitalist but I admitted a patient last week for SOB/chf/pna, did a bedside echo in the ER because they had some cardiomegaly on the xray that was new and found a pericardial effusion that looked tamponad-y. Ordered a stat TTE, cardiology wasn't impressed initially, when another guy looked at it, they confirmed tamponade, they got a window next day, 500cc of blood had developed acutely. I've been doing them for years since intern year, always find it helpful.

Tamponade is a clinical diagnosis - for every one real tamponade case I’ve been called about overnight, I’ve had about 30 effusions which were big but not in tamponade. Echo signs of tamponade do not mean always that a needle has to be stuck in there in the middle of the night

It’s good to build skills, but echo is a tool. Whether it’s resuscitation or tamponade assessment or whatever, it’s important to recognize limitations

 

[Bobblehead]

I've found ultrasound resources are best purchased with OPM (other people's money). Whether that's a handheld US or a cart-based US you're better off having the practice or hospital buy it. That way they're responsible for servicing, repairs and replacement. It could even be assigned to you or your role whatever that may be. I always get the formal study if I see something I want further clarification on, but then again I'm not credentialed to bill for POCUS beyond critical care time.

I'm likely going to ask them to buy one of the Butterfly IQ ultrasound probes when they're released and assuming they don't turn out to be vaporware.

Stethoscopes don't break easily and with direct skin contact a cheaper $100 stethoscope is good enough to decide whether you want to go follow that up with an US.

 

[deleted547339]

I would argue that even if you see a McConnell’s most surgeons will still need the CTPE protocol if they want to take it out. If they’re crashing then you thrombolyse anyway. For the submassive ones you have time to think.

For echocardiography it depends a LOT on not just skill level with acquiring images but recognizing the limitations. That acute MR or AR might not be seen because of eccentricity. That flail P2 might not be immediately visible. You can miss regional wall motion abnormalities or overread them if you are off axis. Without M mode or Doppler all you can say is that there’s a big effusion and maybe not enough to recognize tamponade. Etc etc etc. so as long as this stuff is understood it can all be a very good tool otherwise

Your surgeons are taking out PEs!?!

 

[deleted547339]

Who cares about the utility of the stethoscope...it makes the patients think you did something, and above all, its a sexy instrument IMHO

I find it ironic that someone who’s name is ROS is discussing the lack of utility of something.

 

[Psai]

Your surgeons are taking out PEs!?!

ours do

 

[ReviewOfSystems]

I find it ironic that someone who’s name is ROS is discussing the lack of utility of something.

My name is ROS not PEx

 

[deleted547339]

My name is ROS not PEx

I get infinitely more out of my physical exam than asking patients if they get chills (hint: they all “stay cold”)

 

[ReviewOfSystems]

I get infinitely more out of my physical exam than asking patients if they get chills (hint: they all “stay cold”)

I usually have what I need before I get to the PEx inclusive of the ROS

 

[IMreshopeful]

Your surgeons are taking out PEs!?!

Our surgeons can do submassives and chronic. IR and vascular also have some stake in it as well. Depends on who gets called and what is most appropriate based on clinical situation

 

[deleted547339]

Our surgeons can do submassives and chronic. IR and vascular also have some stake in it as well. Depends on who gets called and what is most appropriate based on clinical situation

I know they can....the question whether or not they should.

 

[mimelim]

Your surgeons are taking out PEs!?!

I took out two this weekend.

 

[IMreshopeful]

I know they can....the question whether or not they should.

There’s some trial data to support submassive PE removal to prevent RV failure but studies ongoing

Massive PE absolutely should be intervened on in some form - whether catheter based or systemic tPA, surgical thrombectomy, etc.

Various specialists do this. Having a multidisciplinary team deciding who is most appropriate or whether an invasive approach is appropriate at all is the best way to do this.

 

[deleted547339]

I took out two this weekend.

Based on what data? I’m not being confrontational, I’m really asking. I call my surgeons for PEs with some frequency, but it’s never for embolectomy, it’s for ecmo. The only time I’ve seen embolectomy performed was for chronic emboli. I’ve never even had them mention they thought it was a good idea to take them out. And this is at two different well-respected institutions.

My understanding was that there’s nothing more than a couple case series and that the mortality rate is quite high (primarily because of the disease burden) - is this not the case? Thanks.

 

[CCM-MD]

There isn’t great data for endovascular embolectomy or surgical thrombectomy for acute PEs but there are definitely patients out there that can benefit from it. I can think of several cases that I encountered or heard of through colleagues - usually patients with massive/submissive PE that cannot be anticoagulated or recieve thrombolysis (systemic or catheter) due to various reasons. One memorable case recently - platelets of 5 due to HIT and concomitant massive PE. It’s nice to have a bold interventionalist/surgeon in these situations.

Surgical Embolectomy for Acute Pulmonary Thromboembolism

 

[mimelim]

Based on what data? I’m not being confrontational, I’m really asking. I call my surgeons for PEs with some frequency, but it’s never for embolectomy, it’s for ecmo. The only time I’ve seen embolectomy performed was for chronic emboli. I’ve never even had them mention they thought it was a good idea to take them out. And this is at two different well-respected institutions.

My understanding was that there’s nothing more than a couple case series and that the mortality rate is quite high (primarily because of the disease burden) - is this not the case? Thanks.

We are a major referral center for CTEPH patients and do quite a few pulmonary thromboendarterectomies for chronic clot. I don't do those operations as I am not a cardiac surgeon, but it was a part of my training as I trained at a 'CV surgeon' mentality program.

On a day to day basis we as vascular surgeons see all massive and submassive PEs. I don't think that there is much question that massive PEs need treatment. In general for us that means systemic thrombolysis, but on occasion it does mean open embolectomy. It is a relatively straight forward operation and given that the selected patients tend to be on the younger side, people bounce back pretty quickly all things considered.

The area that is under active change is 'sub-massive' which in reality is ultrasound or CT signs of right heart strain along with imaging of large clot burden. The data is mixed, but I don't think that anyone who isn't completely and totally set in their ways thinks that intervention doesn't have a role to play. Our primary goal is reduction of RV dysfunction, acute reduction of symptoms. I'd say the bulk of what I do is CDT (I have two patients right now getting lytics infused, will get repeat echos in the morning). I'm involved in a couple of clinical trials for different devices for endovascular mechanical thrombectomy, which is of major interest, but still a long ways from being really ready ready. At the end of the day, it comes down to patient selection. I do know that from my review of the available data and evidence, as someone in my 30s, if I came in with an acute submassive PE, I want to clot out as soon as is possible.

 

[deleted547339]

We are a major referral center for CTEPH patients and do quite a few pulmonary thromboendarterectomies for chronic clot. I don't do those operations as I am not a cardiac surgeon, but it was a part of my training as I trained at a 'CV surgeon' mentality program.

On a day to day basis we as vascular surgeons see all massive and submassive PEs. I don't think that there is much question that massive PEs need treatment. In general for us that means systemic thrombolysis, but on occasion it does mean open embolectomy. It is a relatively straight forward operation and given that the selected patients tend to be on the younger side, people bounce back pretty quickly all things considered.

The area that is under active change is 'sub-massive' which in reality is ultrasound or CT signs of right heart strain along with imaging of large clot burden. The data is mixed, but I don't think that anyone who isn't completely and totally set in their ways thinks that intervention doesn't have a role to play. Our primary goal is reduction of RV dysfunction, acute reduction of symptoms. I'd say the bulk of what I do is CDT (I have two patients right now getting lytics infused, will get repeat echos in the morning). I'm involved in a couple of clinical trials for different devices for endovascular mechanical thrombectomy, which is of major interest, but still a long ways from being really ready ready. At the end of the day, it comes down to patient selection. I do know that from my review of the available data and evidence, as someone in my 30s, if I came in with an acute submassive PE, I want to clot out as soon as is possible.

Ahh. I think that was my disconnect. None of the surgeons at either of my institutions have provided catheter based interventions. The interventional cardiologists and radiologists would do CRL and sometimes clot retrievals.

I kind of compartmentalize CTEPH into a separate box. Maybe I’m wrong for doing that.

Agree, if I threw a massive clot, I’d want it addressed immediately. I have a hard time lysing submissive PEs, but I think that, if it were me, I’d want them.

So I’m correct in understanding that there is little to no good data for surgical embolectomy? Not saying it couldn’t be helpful, but there’s not good data for it, right?

 

[mimelim]

Ahh. I think that was my disconnect. None of the surgeons at either of my institutions have provided catheter based interventions. The interventional cardiologists and radiologists would do CRL and sometimes clot retrievals.

I kind of compartmentalize CTEPH into a separate box. Maybe I’m wrong for doing that.

Agree, if I threw a massive clot, I’d want it addressed immediately. I have a hard time lysing submissive PEs, but I think that, if it were me, I’d want them.

So I’m correct in understanding that there is little to no good data for surgical embolectomy? Not saying it couldn’t be helpful, but there’s not good data for it, right?

There is 'no good data' in the same way that there is no good data on virtually any relatively rare surgery. There are good series published in the literature that reflect that some centers can/do have good outcomes. These obviously reflect publication bias. You are never going to have a trial demonstrate that open surgical embolectomy is superior to other options. Like most everything in our fields of this ilk, it will remain 'expert opinion'.