The Stethoscope is Now Obsolete

[fahimaz7]

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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.

I think you need to spend more time with the ultrasound machine. Just b/c someone can successfully find the aorta while in the simulation lab doesn't mean they are the equivalent of an u/s tech or someone credentialed in US. I used to think it was going to be fast and easy as well, until I started doing a lot of scans on our ultrasound rotation, and saw how variable and challenging it can be to get quality looks at all 3 segments in a general patient population.

Now optic nerve sheath diameter, FAST, DVT scan, abscess evaluation, line access, etc are all fairly easy scans to do. If you get bored try to do appendicitis evaluations with u/s. lol

 

[The White Coat Investor]

The sensitivity and specificity of nearly every physical exam finding I've ever seen listed is ridiculously poor and would be thrown away if it were a lab test or radiology study. Take one that's pretty good, like RLQ tenderness for appy. 96% sensitivity. Use that to rule it out (SNOUT remember) and you'll miss one out of 25. What do you suppose the specificity of that is?

Percussion? Really? What's the sensitivity and specificity of that? SBO? Look, you're telling me if the patient is vomiting, feels distended, hasn't passed gas in two days, and the belly looks and feels distended that percussion (or auscultation for that matter) is somehow going to change your next step (order an x-ray, CT, or call a surgeon)? No, it isn't. Give me a break.

A AAA study is a 30 second study. Sure, it's tough to see a normal aorta behind the fat and gas. But it isn't tough to see a AAA that matters.

To be a good emergency doc you've got to figure out which corners you can cut and which things really matter. Otherwise, there's no way to safely care for 2-3 patients an hour. Faking it so patients think you care just makes them think a more efficient doctor isn't giving them good care the next time. Spend your time thinking about their differential diagnosis instead of doing unhelpful physical exam maneuvers. If you want to do that thinking with your stethoscope on their belly, fine. I do it better in front of the computer outside the room.

 

[GeneralVeers]

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)

A BNP and LFTs are much quicker. Just check a few boxes in the computer and move on to the next patient.

 

[FSU2013]

Who cares about the liver margin?

I saw a guy a couple months back on a medicine rotation. He went to an outside ED with an appearantly benign GI complaint. Clearly documented no hepatomegaly. He came to our ED a couple weeks later completely unresponsive with cancer everywhere. His liver edge was around the umbilicus.

I know that guy would have still died anyway, but he could have had the chance to say goodbye if the first doc (could have been an NP or PA) at the other ED had paid attention on his or her physical exam (assuming he or she did what they documented).

Edit: I don't want you to think I'm some high and mighty med student. Im not saying the physical exam is the be-all, end-all. It was just upsetting to see that documented when anyone who touched this guys belly would have immediately said "something's really wrong here."

 

[Mudpile MD]

I saw a guy a couple months back on a medicine rotation. He went to an outside ED with an appearantly benign GI complaint. Clearly documented no hepatomegaly. He came to our ED a couple weeks later completely unresponsive with cancer everywhere. His liver edge was around the umbilicus.

I know that guy would have still died anyway, but he could have had the chance to say goodbye if the first doc (could have been an NP or PA) at the other ED had paid attention on his or her physical exam (assuming he or she did what they documented).

Edit: I don't want you to think I'm some high and mighty med student. Im not saying the physical exam is the be-all, end-all. It was just upsetting to see that documented when anyone who touched this guys belly would have immediately said "something's really wrong here."

Hindsight is 20/20. This is a lot easier said on your med student medicine rotation where you have 2 hours to do an H&P on all your new admits, after getting the work up/story from your ED, then when you're in the pit seeing 2-3 undifferentiated pph. Everyone will miss something working at that pace.

 

[joeDO2]

Hindsight is 20/20. This is a lot easier said on your med student medicine rotation where you have 2 hours to do an H&P on all your new admits, after getting the work up/story from your ED, then when you're in the pit seeing 2-3 undifferentiated pph. Everyone will miss something working at that pace.

Its one thing to cut a corner here and there and not do something. Its quite another to say you did something that you didn't.

 

[Rendar5]

A BNP and LFTs are much quicker. Just check a few boxes in the computer and move on to the next patient.

umm what? you're telling me not to listen to heart and lung sounds cause they take too long?

 

[45408]

Hindsight is 20/20. This is a lot easier said on your med student medicine rotation where you have 2 hours to do an H&P on all your new admits, after getting the work up/story from your ED, then when you're in the pit seeing 2-3 undifferentiated pph. Everyone will miss something working at that pace.

That's understandable. It's not excusable to miss something egregious and document that it was normal.

 

[Arcan57]

That's understandable. It's not excusable to miss something egregious and document that it was normal.

The rise of EMR (combined with the de-emphasis of physical exam) is going to make this common place. I don't document physical exam items I didn't do, but the majority of the scribes I work with will document a complete physical exam and I then have to go back and unmark the things (ears, reflexes, etc) I didn't exam on that patient. I'm almost certain that not all of my colleagues do the same. And on the in-patient side, the document physical is either scant (cardiologist not commenting on heart sounds) or clearly templated (equal pulses in patient with BKA documented on same H&P).

 

[joeDO2]

The rise of EMR (combined with the de-emphasis of physical exam) is going to make this common place. I don't document physical exam items I didn't do, but the majority of the scribes I work with will document a complete physical exam and I then have to go back and unmark the things (ears, reflexes, etc) I didn't exam on that patient. I'm almost certain that not all of my colleagues do the same. And on the in-patient side, the document physical is either scant (cardiologist not commenting on heart sounds) or clearly templated (equal pulses in patient with BKA documented on same H&P).

Yes, I have seen this with many docs. I hear them say things like "use my headache template" to the scribe. When you actually look at what it says, most of the physical findings were not actually checked. Even without scribes I'm sure its tempting just to check off boxes on the EMR without thinking.

 

[e30ftw]

The trick with EMR is to make your base template off of the PE you always do for that complaint. You can technically bill a level 5 physical by reviewing VS, walking in the room, looking at the patient's head, face, extremities, talking to them, and shaking their hand. If you always listen to heart/lungs and press on the belly of every pt w/ an ESI <4 (probably worth it with any pt w/ a chance of pathology) it's very easy to make a template to which you can add pertinent positives or negatives after meeting the patient.

I use templates mostly for fast track patients. Always write the HPI from blank but use templates for ROS and PE that are very basic (ie, normocephalic, atraumatic, skin dry, affect normal, trachea midline, resting comfortably, etc). I end up spending a fair amount of time editing templates when I use them but in the end for certain circumstances it saves time imo.