EMS DOCS’ PERSPEC TIVES ON STREET MEDICINE
SCOPING IT OUT
The art of listening
By Neal J. Richmond, MD, FACEP
When was the last time any of us used a stethoscope and felt it made a difference either to clinch
a diagnosis or to change the management of
a sick patient?
DIAGNOSTIC TOOL OR NECK WEAR?
How many of us have had a patient with a
history of hypertension, diabetes or myocardial infarction (MI), who presented with complaints of chest pain and shortness
On exam, he might have been
anxious and diaphoretic, with a
heart rate of 130, respirations of 24,
blood pressure of 190/110, bilateral pedal edema, oxygen saturation
(SpO2) of 89% and 12-lead ECGs
Then you put your scope on his
chest and said, “Wow, this guy has
crackles two-thirds of the way up.
Good thing I checked, otherwise I
never would’ve guessed he was in
Or, “Gosh, that three pack-a-day smoker
with a productive cough, green sputum, a tem-
perature of 103, an SpO2 of 92% and respira-
tory rate of 32 has crackles in her right lung.
She must have pneumonia!”
When you got these patients to the hospi-
tal, things might not have gotten much better.
With the use of increasingly sophisticated
technology and imaging modalities, some of
the tools of our trade, like the stethoscope, have
been relegated to near museum status.
Several years ago, the chairman of radiology
at a teaching hospital asked what I thought
about their emergency medicine residency. I said
I thought it was good but also bemoaned the
fact that their residents would often throw the
patient’s entire differential diagnosis up against
the wall, and then use a CT scan to sort it out.
The radiology chair looked at me and said,
“Differential diagnosis? Hell, they use the CT
CT readings in a matter of minutes?
OPPORTUNIT Y TO LISTEN
In EMS, we have few sophisticated tools to rely
on. Instead, we have to depend on our eyes, ears,
hands and even our sense of smell. That’s not
a bad thing because, like clinicians of old, we’re
forced to develop and use highly tuned senses.
Instead of sending patients to radiology, we
examine them more closely, seeing if a couple
doses of nitro actually improve their shortness
of breath, thereby narrowing our differential
diagnosis in the act of treating them.
For those of us who have the interest and
time, there may be other less obvious advantages as well. Since we have the opportunity
to interact with our patients, not just their lab
results and scans, we may take better histories
and not order unnecessary workups based on two
lines (or two words) written by the triage nurse.
At the risk of sounding like a country preacher, there’s also the untold benefit of “laying on of hands.” Touching sick
or worried patients may even have its own
They may also be more willing to tell us
what’s going on, instead of getting whisked
off to the scanner before anyone comes in to
take a history.
GAINING THE EDGE
A fair amount has been written about the sensitivity and specificity of the physical exam. How
likely are we to miss something when it’s actually
there, and how likely are we to identify something when it really isn’t? The results of some
of these studies aren’t pretty. The physical exam,
What if an elderly female patient
presents in pulmonary edema
because of a blown papillary muscle, and you happen to put your
stethoscope on her chest and pick
up the loud systolic murmur of acute
Not only might you correctly
identify a surgical emergency (that
all the nitro in the world may not
fix), but you might also recognize
that intubating her could potentially kill her.
A sudden increase in intrathoracic pressure,
and therefore afterload, after placing the tube
might not only increase retrograde blood flow
through the leaking valve into her lungs, but it
could also lead to a precipitous drop in her cardiac output and blood pressure.
Relaying all this to hospital staff at triage
might also lead to an early echocardiogram (
cardiac ultrasound) in the ED and lifesaving surgery in the operating room.
It’s noisy out there, but if you don’t at least try
and listen, you might miss an excellent opportunity. The next time you take that stethoscope out
it may not make a difference, but it might give
your patient that little extra edge. JEMS
Neal J. Richmond, MD, FACEP, is board certified in emergency medicine and medical
director for the MedStar Mobile Healthcare
System in Fort Worth, Texas.
In EMS, we have few
sophisticated tools to rely on.
Instead, we have to depend
on our eyes, ears, hands &
even our sense of smell.