Just learned a cool hack with a reflex hammer, wondering if you guys had some more?

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z3roto60

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Posted on reddit, thought I'd try SDN out for the first time

I'll try and keep the background short: Second year med student here, was watching a final year do an examination for a patient with an abdominal mass. When it came to percussing to find the borders, she took out a reflex hammer and (from 4 feet away) I heard the clearest percussion I've ever heard. Later, I tried this on a few friends checking the notes all around the chest/abdomen and on my next abdominal mass patient - better results than I've ever gotten with just my fingers. Apparently, though, our profs aren't too keen on this "reflex hammer percussion" (see below)

Do you guys have any other hacks? Have there been any issues with you using them in the hospital?

More on my reflex hammer usage: So on asking one of the surgical residents why professors don't accept the reflex hammer percussion (the final years told me this), he said that this use isn't mentioned in standard clinical text books. He did say that if, during an exam, I did an "off-label" use of a device, I'll probably have to justify myself and back it with a solid reference. So, he said to go find that reference.

Did some reading on the history of a reflex hammer, and it ends up that it was used for percussion initially (see links below). I still haven't found a reason for why the reflex hammer should not be used for percussion, though. Any thoughts (besides needing to have a reflex hammer on you)?

http://www.ncbi.nlm.nih.gov/books/NBK458/
http://pn.bmjjournals.com/content/3/6/366.full.pdf
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My clinical preceptor, who is an old school IM guy, always uses a reflex hammer and taught me to do the same. I've never been able to hear much using my fingers and I know 99% of my classmates are bull****ting when they say they can hear things when they do hand percussion. My SP's have also noticed the difference, and I've been told it's the only time they've been able to hear anything on the percussion parts of the exam. That being said, there are definitely docs who will think you are a b**** and just have bad technique if you use a reflex hammer, and there are docs whose hand percussion is at least as good as what I can do with a reflex hammer (pulmonologists are wizards in this regard...). Ultimately I don't think anyone is going to care much as long as you do a good physical exam.
 
Most of the physical exam is low yield and a complete waste of time. Percussion especially.

IMO of course.
 
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atomi said:
Most of the physical exam is low yield and a complete waste of time. Percussion especially.

IMO of course.
Click to expand...

Because most people suck balls at physical exam.

My med hack contribution: want to see a ventral hernia really pop out? Ask the patient to flex his neck (or help him/her do it). It will jump right out at you.
 
anbuitachi said:
wait do you use the reflex hammer and smack your hand with it, or do you just smack the patient directly
Click to expand...

The hammer is acting only as the plexor. You still use your left hand's middle finger as a pleximeter
 
I don't understand why people have such a hard time with percussing. All you do is make sure your DIP is firmly pressed against what you're trying to percuss(this is the part that the average M1/M2 doesn't understand for some reason), then you whack it, one time solidly. I see people try to hit it like 4 times and it's like wtf are you doing, you're not having the patient do anything so why would the sound change?
 
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I don't see why a reflex hammer would make you have a clearer sound unless you're hitting your finger harder with it. The only two components are really just a good seal with your DIP and hitting it hard enough to get the loudness you want. The only difference I've seen between attendings and students w/ percussion is that they actually press with their DIP and they don't sit there and hit their finger 4 times for every spot
 
PL198 said:
I don't understand why people have such a hard time with percussing. All you do is make sure your DIP is firmly pressed against what you're trying to percuss(this is the part that the average M1/M2 doesn't understand for some reason), then you whack it, one time solidly. I see people try to hit it like 4 times and it's like wtf are you doing, you're not having the patient do anything so why would the sound change?
Click to expand...

+1. Same opinion. Somebody told me he trained weeks in order to improve his percussion skills 😵
My opinion on physical examination as it is taught in med school: half of it is useful, the rest is myth and makes you look like a wizard.

For instance: percussion of the liver. Can somebody prove me this is not a f****** joke?
 
I recognize that it's probably not high yield, however I don't have the credentials to yet determine how I actually want to practice so it's necessary for me to learn the skills while training. Once I become board certified I'll have the ability to determine what exactly I want to use, but until then I don't think it's a students place to pull the whole " I've never seen an attending actually percuss a liver or stuff like that." In driver's training we had to fully stop at every stop sign so I don't really know why medical training would be any different.
 
southernIM said:
I mean...it's one of the easiest physical exam maneuvers. Are you saying you don't think it's possible, or don't think it's useful?
Click to expand...

you cannot draw any conclusion from it: it's almost random ( http://europepmc.org/abstract/med/15598999 ). The fact that three attendings told us a different story ("scratch it", "percute it because scratching isn't reliable", "skip it because every method is mediocre") also made me suspicious.
 
TraumaLlamaMD said:
For patients who are hard of hearing and do not have their hearing aids: put a stethoscope in their ears and talk near the diaphragm. Worked wonders on my elderly patient in post-op who magically stopped being delirious and combative as soon as she could hear what was going on.
Click to expand...

see stuff like this is gold, or like I heard with kids being fussy about having their ears looked in, it often helps if they have a stuffed animal with them, either pretend to look in it's ears or the parents first and that usually calms them down. This is stuff that should be taught, it's like how in drivers ed you learn stuff that isn't important, but none of the rules of the highway or actual driving are ever discussed
 
PL198 said:
I don't understand why people have such a hard time with percussing. All you do is make sure your DIP is firmly pressed against what you're trying to percuss(this is the part that the average M1/M2 doesn't understand for some reason), then you whack it, one time solidly. I see people try to hit it like 4 times and it's like wtf are you doing, you're not having the patient do anything so why would the sound change?
Click to expand...
Really? Maybe you're an expert percussionist but the rest of us have to practice, and at least in front of the attending the first time pretend we hear **** (newsflash - we don't).
 
PL198 said:
I don't understand why people have such a hard time with percussing. All you do is make sure your DIP is firmly pressed against what you're trying to percuss(this is the part that the average M1/M2 doesn't understand for some reason), then you whack it, one time solidly. I see people try to hit it like 4 times and it's like wtf are you doing, you're not having the patient do anything so why would the sound change?
Click to expand...

Because they don't even lift.
 
DermViser said:
Really? Maybe you're an expert percussionist but the rest of us have to practice, and at least in front of the attending the first time pretend we hear **** (newsflash - we don't).
Click to expand...

I know I don't have this down. Saw a FP with 30+ years experience do it, and the sound is completely different than anything I've made.
So far as I can tell, none of my classmates do it right either.

Maybe we're all idiots though.
 
z3roto60 said:
Posted on reddit, thought I'd try SDN out for the first time

I'll try and keep the background short: Second year med student here, was watching a final year do an examination for a patient with an abdominal mass. When it came to percussing to find the borders, she took out a reflex hammer and (from 4 feet away) I heard the clearest percussion I've ever heard. Later, I tried this on a few friends checking the notes all around the chest/abdomen and on my next abdominal mass patient - better results than I've ever gotten with just my fingers. Apparently, though, our profs aren't too keen on this "reflex hammer percussion" (see below)

Do you guys have any other hacks? Have there been any issues with you using them in the hospital?

More on my reflex hammer usage: So on asking one of the surgical residents why professors don't accept the reflex hammer percussion (the final years told me this), he said that this use isn't mentioned in standard clinical text books. He did say that if, during an exam, I did an "off-label" use of a device, I'll probably have to justify myself and back it with a solid reference. So, he said to go find that reference.

Did some reading on the history of a reflex hammer, and it ends up that it was used for percussion initially (see links below). I still haven't found a reason for why the reflex hammer should not be used for percussion, though. Any thoughts (besides needing to have a reflex hammer on you)?

http://www.ncbi.nlm.nih.gov/books/NBK458/
http://pn.bmjjournals.com/content/3/6/366.full.pdf
Click to expand...


My preceptor taught me both, but he himself uses the reflex hammer. My PCP, who isn't old school (graduated med school in 2001), uses the reflex hammer for percussion. I always thought this was standard use of a reflex hammer.
 
Meh.meh said:
I know I don't have this down. Saw a FP with 30+ years experience do it, and the sound is completely different than anything I've made.
So far as I can tell, none of my classmates do it right either.

Maybe we're all idiots though.
Click to expand...

It's not like it's a complex technique, like I said it's literally just good DIP seal and a decent quick hit on your DIP, obviously a 30 yr attending is going to be better at it than me but I think their superiority would more deal with understanding findings and that technique wouldn't be a huge difference relatively speaking
 
PL198 said:
It's not like it's a complex technique, like I said it's literally just good DIP seal and a decent quick hit on your DIP, obviously a 30 yr attending is going to be better at it than me but I think their superiority would more deal with understanding findings and that technique wouldn't be a huge difference relatively speaking
Click to expand...

Maybe it's the way we were taught. I see a lot of people press really hard and just tap, but that's not the issue.

The way he showed us, you hit the finger pressing at the DIP with the DIP of the other hand, and let it bounce. I don't have the motion down. If you don't do it right, the sound is distorted. If you're not precise, you'll hear differences in the sounds of hitting your own finger.

I don't think it's something most people get down immediately. I'm not too worried, I think we'll get plenty of practice.
 
Meh.meh said:
Maybe it's the way we were taught. I see a lot of people press really hard and just tap, but that's not the issue.

The way he showed us, you hit the finger pressing at the DIP with the DIP of the other hand, and let it bounce. I don't have the motion down. If you don't do it right, the sound is distorted. If you're not precise, you'll hear differences in the sounds of hitting your own finger.

I don't think it's something most people get down immediately. I'm not too worried, I think we'll get plenty of practice.
Click to expand...

We were told to go home and practice on our SOs or on the walls of our apartments. Obviously walls are not the same but for musically challenged people such as myself I found it to be decent practice when my fiancée wasn't home. Fortunately she has been on board with me practicing physical exam stuff on her and for that I'm very grateful.
 
evilbooyaa said:
A cool hack? What is this, buzzfeed (or some other clickbait website)?

Damnit, guess I clicked on it. Damn me.
Click to expand...

New use of a reflex hammer that made him 500$/hr.
Doctors HATE him!
Insurance companies tried to have it BANNED!
You WON'T BELIEVE what happens next!
 
Last edited:
TraumaLlamaMD said:
For patients who are hard of hearing and do not have their hearing aids: put a stethoscope in their ears and talk near the diaphragm. Worked wonders on my elderly patient in post-op who magically stopped being delirious and combative as soon as she could hear what was going on.
Click to expand...

This is cool, thank you for sharing!
 
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