I can remember, with distinct clarity, the first few calls that I was involved with during my paramedic internship. Specifically, I can recall hearing the phrase “now you get to see how we really treat patients”. I remember being confused and not quite sure what to do. On one hand I had just completed one of the most intense training courses in pre-hospital care; and yet, what did that education matter, if we don’t actually use it?
One case in particular that stands out was an elderly woman complaining of chest pain and shortness of breath. I remember being taught that a cardio-respiratory assessment included the auscultation of both heart and lung sounds. I clearly remember my preceptor telling me that, “doing that (auscultation) is useless in the back of the rig”; and that “we’re not freakin’ cardiologists – why do we have to do that anyway – it’s not like it’s going to change our treatment”. Closing my eyes, I can see the familiar script running through my head…“are you serious”; of course, we’re not cardiologists or pulmonologists- we ARE paramedics, and YES, we should be including auscultation in our assessments; and YES – it does (or it better) make a difference in our patient care!
Ok; Ok; Ok; – everybody just hold on; take a deep breath – let’s explore what the evidence says. The Journal of the Society for Simulation in Healthcare offers some great information – and frankly, I’m in their corner on this one – all the way. Not only have they debunked the theory that auscultation plays an important role during the “in-transit” phase of patient care, but they also made some exciting and evidence-based discoveries that are sure to bring attention, focus and resolution to this issue. In April of 2014 they (the Journal of the Society for Simulation in Healthcare) published an article titled “A Simulator-Based Study of In-Flight Auscultation”. A comparative clinical study, using two different types of stethoscopes (conventional and electronic) as a McNemar test, concluded that “flight practitioners involved in aeromedical evacuation [were] better able to [correctly perform] lung auscultation on a mannequin with an amplified stethoscope than with the traditional one” (1). Specifically, the data regarding lung sounds demonstrated that conventional stethoscopes were accurate about 10/20 times, versus the electronic stethoscope which yielded 18/20 correct diagnoses.
Despite the study’s barriers, there are a few things to consider. One, the study does not discuss how ground transport affects auscultation, but there is certainly a high likelihood that the data would be similar. Second, auscultation should never be used as a single diagnostic tool. It should be paired with the patient’s clinical presentation along with other medical monitoring devices such as skin color, pulse oximetry and end-tidal carbon dioxide measurements. Third, it is important to note that there was no suggestive evidence that heart sounds were better heard with either stethoscope. For those that love statistics – the P value for heart sound testing was 0.13, versus lung sound examinations at 0.013. Fourth, the study was conducted in a C-135 fixed wing aircraft using a mannequin-based SimMan who had everything from crackles, wheezes, pneumothoraxes as well as several different variants of cardiac murmurs. Five different practitioners were evaluated in a sequential and scientific manner.
From a professional standpoint, a few of us critical care practitioners here at FlightBridgeED, started out (and continue to use) the Master Cardiology (bell) stethoscope. This particular flavor of scopes is useful for initial learning as well as ground transport. This is especially true with the assessment of bowel sounds. Eric Bauer, CEO of FlightBridgeED, in reference to auscultation during transport, says that “I think it takes time to block out some of the noise”; especially on the ground. He also reminds us that if you suspect that you are not going to be able to hear anything during transport, that you should do a thorough assessment prior to moving the patient. Even though the conventional scope seems to be the go-to-choice, this article certainly bring a challenging perspective to traditional practice.
Soooo – here is the “who cares” moment; “what does any of this have anything to do with me?”, you might ask. Well, its simple. The message is clear – the inability to provide proper medical treatment is severely handicapped in a high ambient noise environment. At the cost of a moderate price, the solution lies in the purchase of an electronic stethoscope, not a conventional one. We may never know that outcome or impact it may have, until we start regularly collecting data and information on these scenarios. Think about it; do some of your own research and most importantly; let’s start gathering, mining and analyzing some of this readily available data!!
Stay safe and be well…