The Stethoscope is Now Obsolete

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Yeah there are some things you just want to hear and not interpret on a snowy screen. Hearing bowel sounds is pretty easy and tells you a lot about the patient. I do agree that hand held US will become prevalent though. It's pretty cool technology.

Survivor DO
 
Oh, dont get me wrong, I want one - but really, what I really want is a sonosite with all the probes I can imagine in my department.

(I don't work in an academic center, and while I can get my hands on an ultrasound, I have to go to radiology and look for it).
 
joeDO2 said:
well, almost. My prediction: every doc will have a handheld u/s in their pocket rather than a stethoscope around their neck. After all, why listen when you can see.

http://www.internalmedicinenews.com...142297&cHash=a4a21f28db83db3ea6b8c69eed62deb8
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Maybe in certain specialties. Interestingly enough, there are still a lot of EM training sites that are not very strong in U/S and/or don't even offer rotations in the field. Neat thing for sure though. I wonder how many of these guys fall back on "official" u/s for anyone who they are actually worried about?
 
fahimaz7 said:
Maybe in certain specialties. Interestingly enough, there are still a lot of EM training sites that are not very strong in U/S and/or don't even offer rotations in the field. Neat thing for sure though. I wonder how many of these guys fall back on "official" u/s for anyone who they are actually worried about?
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[bold mine]

That's not necessarily a bad thing.

Bedside US in the ED should not routinely substitute for formal US; nor should the ability to order a formal US mean that the ED doc shouldn't be doing frequent bedside ultrasonography.
 
Many times you can do a quick bedside scan to check for pathology and then order an official scan to get a more in depth look (i.e. if you do a bedside u/s and find gallstones or pericholecystic fluid then you get an official u/s to get CBD diameter, look at the hepatic ducts, pancreas etc). It is also more reassuring depending on your surgical services to have an official u/s to confirm surgical pathology.
 
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The study was funded by GE Healthcare, which markets the VScan system.
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LOL... surely objective data. I think some of the US folks are like the political fringes.

I love US, im pretty good at it, but the push to make it the end all be all is extreme.
 
i go through the motions w/ the PE but it often goes like this:

pt comes in resp distress, intubated.. auscultate lungs carefully ---> completely clear exam.

cxr shows whopping focal consolidation/PNA.

US is great for certain things (confirm IUP, procedures, bedside AAA scan, bedside GB, eFAST, echo in cpr pt, IVC) but I agree there are a lot of people obsessed to the point of strangeness with it.
 
Considering exactly zero people in my hospital currently have pocket handheld US machines, we have a long way to go for the stethoscope to become obsolete.
 
Mudpile MD said:
I don't know of any faculty or residents who listen to bowel sounds. Incredibly insensitive and non-specific.
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Big mistake. I've picked up the 'high-pitched, tinkling' bowel sounds of an SBO and called what I've seen on plain films many a time. Frequent nonstop rushes in the setting of LGIB also has value.

Its the little things.
 
RustedFox said:
Big mistake. I've picked up the 'high-pitched, tinkling' bowel sounds of an SBO and called what I've seen on plain films many a time. Frequent nonstop rushes in the setting of LGIB also has value.

Its the little things.
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Interestingly enough, out of the GI docs that I've spent time with the majority of them don't listen to the abdomen during their exam. As mentioned above, some feel it is incredible variable with poor sensitivity and specificity. Add to that bad acting and you get an exam that is, for the most part, not very useful.

For the record, I still listen to bowel sounds if it's a bowel complaint, but that's probably more for a thorough physical exam for note writing purposes.
 
RustedFox said:
Big mistake. I've picked up the 'high-pitched, tinkling' bowel sounds of an SBO and called what I've seen on plain films many a time. Frequent nonstop rushes in the setting of LGIB also has value.

Its the little things.
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Of all the auscultation I do, I trust my GI exam far more than lungs and heart...at least for the subtle stuff.

Also, "palpation" with the stethoscope is a nice way to differentiate real abd pain from the 12/10 drama llamas.
 
fahimaz7 said:
Interestingly enough, out of the GI docs that I've spent time with the majority of them don't listen to the abdomen during their exam. As mentioned above, some feel it is incredible variable with poor sensitivity and specificity. Add to that bad acting and you get an exam that is, for the most part, not very useful.

For the record, I still listen to bowel sounds if it's a bowel complaint, but that's probably more for a thorough physical exam for note writing purposes.
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Glad to hear that you still listen. There is value, guaranteed. Its not as specific as say, hearing a "crescendo-decrescendo" SEM with radiation to the carotids, but its often "made" my diagnosis before imaging confirms it.
 
fahimaz7 said:
Interestingly enough, there are still a lot of EM training sites that are not very strong in U/S and/or don't even offer rotations in the field.
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Can you name a few? I had never heard of such a thing...
 
gutonc said:
Also, "palpation" with the stethoscope is a nice way to differentiate real abd pain from the 12/10 drama llamas.
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I have a pinball (yep, a real authentic pinball) that I carry with me as a good luck charm, but also helps me to ferret out the fakers. They see something shiny, I do a little manipulation trick with it, and then drop it on their abdomen. Often times they just look confused. If they wince or complain of pain, then I'll buy their story.
 
RustedFox said:
Big mistake. I've picked up the 'high-pitched, tinkling' bowel sounds of an SBO and called what I've seen on plain films many a time. Frequent nonstop rushes in the setting of LGIB also has value.

Its the little things.
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While I agree that the specificity of tinkling bowel sounds is probably greater than the approximately awful sensitivity of decreased bowel sounds, it is still very poor (there was a JAMA rationale clinical exam series discussion on this which I will attempt to find). I don't see how hearing tinkling bowel sounds is every going to change your management. With a good story and imaging evidence of obstruction, you are obviously going to treat even without high-pitched, tinkling' bowel sounds. In contrast, have you ever not gotten imaging with someone with a good story for obstruction that you heard the high-pitched, tinkling' bowel sounds? If so, good for you. At my shop neither the surgeons nor the medicine folk would go for that. I think a good story plus plain film evidence of obstruction is strong enough evidence, even without bowel sounds to back it up. I'm not saying you will never pick up on these things on auscultation. I just think it doesn't change management, so why waste the time, aside from putting on a show or for documentation.
 
It doesn't change management, but it does make you think about the differential and the likelihood of the items on the list. Its just good medicine to take 20 seconds and listen to the abdomen. I've heard the bruit of a AAA once or twice, too. Odd sound. Looking at the records let me know that this AAA was 'in there', and I didn't do anything about it, but hey, it was there.
 
RustedFox said:
I have a pinball (yep, a real authentic pinball) that I carry with me as a good luck charm, but also helps me to ferret out the fakers. They see something shiny, I do a little manipulation trick with it, and then drop it on their abdomen. Often times they just look confused. If they wince or complain of pain, then I'll buy their story.
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I usually ask them a question about their life that is completely unrelated to their reason for seeing me or their complaint of pain. Same basic idea of distraction and misdirection.
 
RustedFox said:
It doesn't change management, but it does make you think about the differential and the likelihood of the items on the list. Its just good medicine to take 20 seconds and listen to the abdomen. I've heard the bruit of a AAA once or twice, too. Odd sound. Looking at the records let me know that this AAA was 'in there', and I didn't do anything about it, but hey, it was there.
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I agree that taking 20 seconds to listen can't hurt. But, If you agree that it doesn't change managment and it mostly gets you to think about the differential (that from everything I've read of yours over the last couple of years, I would guess you're thinking about with or without auscultation), then might you agree that your statement that it is a "big mistake" to not auscultate might be a little strong?

Thanks for the discussion!
 
Mudpile MD said:
I agree that taking 20 seconds to listen can't hurt. But, If you agree that it doesn't change managment and it mostly gets you to think about the differential (that from everything I've read of yours over the last couple of years, I would guess you're thinking about with or without auscultation), then might you agree that your statement that it is a "big mistake" to not auscultate might be a little strong?

Thanks for the discussion!
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No idea what this means. Not trying to be a d!ck, but its just unclear to me what you want to say.

"Skipping" parts of a relevant exam is a mistake. Even if it just gets you to take a hot second to think - "what does this mean and why am I doing it?" and you get that "bazinga!" moment to think about what might actually be going on. I've been burned before by "not considering" things that I got clued in to in a millisecond later on.
 
Flopotomist said:
Can you name a few? I had never heard of such a thing...
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The PD at Resurrection said U/S is not an important part of residency and it's not encouraged in his program. That's for one. On the interview trail I saw lots of programs claim to be "strong" in ultrasound, but later found out they have 1 dinosaur machine and poor QA/QC/feedback at best.

Not all places have the faculty in place to give a quality ultrasound education to their residents, much less the funding to purchase the equipment and the directors to make it work.
 
Mudpile MD said:
I agree that taking 20 seconds to listen can't hurt. But, If you agree that it doesn't change managment and it mostly gets you to think about the differential (that from everything I've read of yours over the last couple of years, I would guess you're thinking about with or without auscultation), then might you agree that your statement that it is a "big mistake" to not auscultate might be a little strong?

Thanks for the discussion!
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It sounds like Rusted is using auscultation as a cognitive forcing strategy. I do the same thing with doing a GU exam on every peds abdominal pain. If I don't, I forget to think about torsion or hernia. It's low yield (I've never picked up either as a result of the exam), but if I don't do it I'm not going to remember to put it on my differential. And the differential we can rattle off on-line is a very different list from what we can come up with at 0300 seeing the 12th belly pain of the shift. That's also the theory behind the complaint specific t-sheets.

Also listening to bowel sounds is hella useful for differentiating anti-cholinergic from sympathomimetic toxidromes.
 
Arcan57 said:
It sounds like Rusted is using auscultation as a cognitive forcing strategy. I do the same thing with doing a GU exam on every peds abdominal pain. If I don't, I forget to think about torsion or hernia. It's low yield (I've never picked up either as a result of the exam), but if I don't do it I'm not going to remember to put it on my differential. And the differential we can rattle off on-line is a very different list from what we can come up with at 0300 seeing the 12th belly pain of the shift. That's also the theory behind the complaint specific t-sheets.

Also listening to bowel sounds is hella useful for differentiating anti-cholinergic from sympathomimetic toxidromes.
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Cognitive forcing strategy is exactly what it is - thanks for putting a name to it.

I just always thought "touch 'em all on the way around the bases - or else the run doesn't count."
 
RustedFox said:
Cognitive forcing strategy is exactly what it is - thanks for putting a name to it.

I just always thought "touch 'em all on the way around the bases - or else the run doesn't count."
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The traditional trauma 3-way, while being overkill for the majority of today's SUV driving, curtain air-bag deploying, crumple-zone having, seat-belt wearing MVCs, forced you to briefly consider some of the more easily missed causes of hypotension in a trauma patient. It's value as a screen is somewhat minimal (although I've missed a couple of pubic rami fxs on patients that weren't sick enough to need scanned because I don't routinely order pelvic x-rays), but it's a useful framework upon which to hang your thinking about the non-abdominal sources of injury.

So I guess what I'm trying to articulate is that there are plenty of things that aren't evidence based (or that have been discredited based on evidence) that are still useful because they anchor our thought process regarding a disease or process.
 
fahimaz7 said:
The PD at Resurrection said U/S is not an important part of residency and it's not encouraged in his program. That's for one. On the interview trail I saw lots of programs claim to be "strong" in ultrasound, but later found out they have 1 dinosaur machine and poor QA/QC/feedback at best.

Not all places have the faculty in place to give a quality ultrasound education to their residents, much less the funding to purchase the equipment and the directors to make it work.
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Really? Resurrection has a really well set-up ultrasound fellowship and solid fellowship director--I find this a little hard to believe.
 
Tiger26 said:
Really? Resurrection has a really well set-up ultrasound fellowship and solid fellowship director--I find this a little hard to believe.
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Yup. And they don't use U/S very much either (multiple classmates rotated through there and said they were very poor on this front). Nice place and people though. Not trying to chastise them, just saying that all places aren't equal in this training.
 
joeDO2 said:
well, almost. My prediction: every doc will have a handheld u/s in their pocket rather than a stethoscope around their neck. After all, why listen when you can see.
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At $7,900 per machine, there' s a lot more waiting to do until every doc carries one around. Also, as the article mentions, the average time for a cardiac exam is >8 minutes. With my stethoscope I'm usually done in <10 seconds, 20 if it's a critical case. Can I use this machine to check for carotid bruits? How about lung findings? Can I use this phased array probe to look for signs of fluid?

Vscan website
 
I like the sensitivity and specificity arguments. Sure, we have better ways of diagnosis. Look at the recent research on the Chvostek sign: "25% of healthy individuals (43% between the ages of 20 and 29 years) have a positive Chvostek sign, and 29% of patients with hypocalcemia do not (Neurology, 3/12/13, Vol. 80, no. 11, pg. 1067)" Emed Home. Many physical exam maneuvers don't change our management, especially in the ED.

But remember that part of what we do is offer compassion, how can you do that without fulfilling the physical exam? The average patient doen't know Jack about a physical exam, but they know when it's rushed... They know when you're not listening. I could give two craps about Press-Ganey, but I care about my patients. Part of what they're in my ED for is the relationship, the "Doctor show."

"Mission of medicine: to cure occasionally, treat mostly, and care always" Gregory Henry MD
 
I agree that the overall utility of the stethoscope has decreased as technology has advanced, but it's still among the easiest and least invasive diagnostic tools we have.

Those of you not in private practice don't realize the other important point. A stethoscope allows you to hit a lot of physical exam points so that you can bill for your physical exams. I like to call it my little billing tool.

When you first get out of residency, it's also useful for stalling briefly while you collect your thoughts and decide what to say to the patient next about the diagnostic plan. Take your time thinking when listening to their heart and lungs, and they'll think you're just being really thorough.
 
Interesting stuff guys, thanks for the good discussion. I agree with some of you that the stethoscope probably does still have a place in certain settings, however as you have pointed out it is becoming less and less useful.


RustedFox said:
It doesn't change management, but it does make you think about the differential and the likelihood of the items on the list. Its just good medicine to take 20 seconds and listen to the abdomen. I've heard the bruit of a AAA once or twice, too. Odd sound. Looking at the records let me know that this AAA was 'in there', and I didn't do anything about it, but hey, it was there.
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I can't see the value in listening to the abdomen in this case. Using the stethoscope, you *may* hear a bruit. There is not much data beyond that. If I use my handheld ultrasound on the same patient I can visualize the aorta and tell if there is aneurysm with close to 100% sensitivity. Further, I can measure it, take a picture, and document the findings. This can easily be done in <60 seconds.
This goes for listening to the heart as well. Instead of describing what I think I hear, I can simply take a quick look and even videotape the dysfunctional valve as I'm watching. I doubt the listening ability of most physicians can compare to the information obtained from directly observing the heart. I'm sure it takes practice to interpret the subtle findings, but I would like to see more training in that area over listening to heart sounds tapes for example.

As far as the $$ aspect, I'm sure the price will come down as it does with all new technology. I'm not sure how policies will develop with ultrasounds performed in the ED going into the future.
 
joeDO2 said:
Interesting stuff guys, thanks for the good discussion. I agree with some of you that the stethoscope probably does still have a place in certain settings, however as you have pointed out it is becoming less and less useful.




I can't see the value in listening to the abdomen in this case. Using the stethoscope, you *may* hear a bruit. There is not much data beyond that. If I use my handheld ultrasound on the same patient I can visualize the aorta and tell if there is aneurysm with close to 100% sensitivity. Further, I can measure it, take a picture, and document the findings. This can easily be done in <60 seconds.
This goes for listening to the heart as well. Instead of describing what I think I hear, I can simply take a quick look and even videotape the dysfunctional valve as I'm watching. I doubt the listening ability of most physicians can compare to the information obtained from directly observing the heart. I'm sure it takes practice to interpret the subtle findings, but I would like to see more training in that area over listening to heart sounds tapes for example.

As far as the $$ aspect, I'm sure the price will come down as it does with all new technology. I'm not sure how policies will develop with ultrasounds performed in the ED going into the future.
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Good news is that I doubt any 4th year medical student (unless they were a u/s tech before) can reliably find, measure, and analyze the aorta using ultrasound, much less do all of that in <60 seconds. If I lined up 20 >55 y/o male smokers and had you run down the line, I bet you would struggle with capturing at least 1 data point on more than half of the patients. I'd love to see you do it all in <60 seconds with a portable device, when it takes an u/s tech 5 minutes to get the 3 points found, measured, and recorded in most patients.

I've done ~150 scans towards getting credentialed and I get very frustrated with the AAA exam, as you have to constantly deal with bowel gas and poor penetration through the 50 inch waist that we have here at our center.
 
Sessamoid said:
When you first get out of residency, it's also useful for stalling briefly while you collect your thoughts and decide what to say to the patient next about the diagnostic plan. Take your time thinking when listening to their heart and lungs, and they'll think you're just being really thorough.
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We had a tough family situation recently with a really sick patient with advanced cardiopulmonary disease. We had a host of complex studies evaluating the patient's disease, but when one of our attendings went in to see the patient, he brought out his stethoscope and listened carefully and quietly to the pt's heart and lungs for probably a minute. It was honestly a nice touch that makes it looks like you care (because he did care), even though it's fairly pointless to listen to heart sounds a few hours after a formal TTE. The specialist who breezes in and says something succinct and leaves just looks like he doesn't care, even if he spent hours reviewing studies and discussing the case with other specialists and has come to the perfect plan.
 
I don't find bowel sounds useful in general honestly, I find percussion to be a lot more sensitive and accurate for picking up the borderline sbo's (ones I wouldn't CT because of a moderately weak story except for the fact that they were tympanitic). However, I do always pay extra attention in my tox patients. It has changed my diagnosis in cases before (like the sedative overdose that everyone thought was benadryl because of an empty benadryl bottle on the bed). Then again, the tox physical exam is focused differently than the regular one.

You know why I still listen to bowel sounds regularly though? billing 🙂 2 aspects of the GI physical exam for highest level coding.
 
Inspection, palpation and percussion don't count? Those are all very useful.
 
TheProwler said:
Inspection, palpation and percussion don't count? Those are all very useful.
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I don't percuss non-distended abdomens, and there isn't a convenient place on my emr nor on my t-sheets (which are no longer in use) to comment on inspection of abdomen. Usually stuff like that is written on skin exam. unless distension counts as inspection (which I don't feel it does)
 
fahimaz7 said:
Good news is that I doubt any 4th year medical student (unless they were a u/s tech before) can reliably find, measure, and analyze the aorta using ultrasound, much less do all of that in <60 seconds.
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I don't know about that. It seems like the aorta is one of the easier structures to identify. Maybe 60 seconds was an exaggeration though. I also haven't scanned a lot of 50 inch abdomens so I can imagine it could get difficult in a population like that.

Take a look at this... http://www.ncbi.nlm.nih.gov/pubmed/20491683

It was a relatively small study, but it showed that participants with no prior training were able to obtain quality images after a 6 hour training program.
 
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Rendar5 said:
I don't percuss non-distended abdomens, and there isn't a convenient place on my emr nor on my t-sheets (which are no longer in use) to comment on inspection of abdomen. Usually stuff like that is written on skin exam. unless distension counts as inspection (which I don't feel it does)
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I don't usually percuss non-distended abdomens either, but if you're trying to find the liver margin, it's perfectly reasonable. Distention is a cross between inspection and palpation, I guess. For inspection, I was mostly referring to scars, hernias, stigmata (periumbilical varices), ecchymosis, etc. Hopefully not mottling.
 
TheProwler said:
I don't usually percuss non-distended abdomens either, but if you're trying to find the liver margin, it's perfectly reasonable. Distention is a cross between inspection and palpation, I guess. For inspection, I was mostly referring to scars, hernias, stigmata (periumbilical varices), ecchymosis, etc. Hopefully not mottling.
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Who cares about the liver margin?
 
GeneralVeers said:
Who cares about the liver margin?
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GI, lol, because the new pitting edema could be from liver failure. Nevermind the fact that the guy's in florid CHF with rales up the whazoo and a 4/6 mitral regurg murmur from the endocarditis that he's being treated for. oh wait, made the diagnosis with a stethoscope on that one. (real case)
 
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