WEBVTT - Ep 151 Stethoscope: Lub dub 0:00:05.080 --> 0:00:07.880 The patient's age and sex did not permit me to 0:00:07.960 --> 0:00:10.959 resort to the kind of examination I have just described, 0:00:11.119 --> 0:00:14.040 I e. Direct application of the ear to the chest. 0:00:14.760 --> 0:00:18.840 I recalled a well known acoustic phenomenon. If you place 0:00:18.920 --> 0:00:22.040 your ear against one end of a wood beam, the 0:00:22.079 --> 0:00:26.040 scratch of a pin at the other end is distinctly audible. 0:00:26.480 --> 0:00:29.360 It occurred to me that this physical property might serve 0:00:29.440 --> 0:00:32.000 a useful purpose in the case I was dealing with. 0:00:32.600 --> 0:00:35.640 I then tightly rolled a sheet of paper, one end 0:00:35.680 --> 0:00:38.400 of which I placed over the precordium and my ear 0:00:38.440 --> 0:00:41.519 to the other. I was surprised and elated to be 0:00:41.600 --> 0:00:44.560 able to hear the beating of her heart with far 0:00:44.800 --> 0:00:48.800 greater clearness than I ever had with direct application of 0:00:48.840 --> 0:00:53.000 my ear. I immediately saw that this might become an 0:00:53.120 --> 0:00:57.160 indispensable method for studying not only the beating of the heart, 0:00:57.280 --> 0:01:37.400 but all movements able of producing sound in the chest cavity. 0:01:51.120 --> 0:01:52.520 I was so excited for this episode. 0:01:52.520 --> 0:02:00.480 Are me too? Me too? I have listened to more hearts, 0:02:00.600 --> 0:02:02.680 I think, than I ever have in lung sounds. We 0:02:02.680 --> 0:02:06.040 were just listening to them, and it has created a 0:02:06.080 --> 0:02:10.640 weird sense of anxiety. Further, do you. 0:02:10.600 --> 0:02:13.160 Remember that Radio Lab episode about the person who could 0:02:13.240 --> 0:02:15.440 hear their own heartbeat, and then yeah. 0:02:15.320 --> 0:02:17.760 Yeah, I think that that's I think that might be 0:02:17.800 --> 0:02:19.680 what's going on. And I don't know why that is. 0:02:19.960 --> 0:02:21.000 I don't have an answer to that. 0:02:21.320 --> 0:02:25.720 Yeah, I don't know. I mean anyway, but that quote 0:02:25.800 --> 0:02:31.240 that paragraph was from of course Lenek, whom you'll hear 0:02:31.280 --> 0:02:33.720 a lot more about later in the episode. Who basically 0:02:33.760 --> 0:02:35.120 invented the stethoscope. 0:02:35.840 --> 0:02:37.400 Yep, spoiler sure did. 0:02:37.760 --> 0:02:41.800 Yeah. And Hi, I'm Aaron. 0:02:41.560 --> 0:02:44.040 Welsh and I'm Erin omn Updike. 0:02:44.000 --> 0:02:46.680 And this is this podcast will kill you today. 0:02:46.720 --> 0:02:48.880 We're talking all about the stethoscope. 0:02:48.480 --> 0:02:52.960 All about it. Yeah, you know, we put this down 0:02:53.120 --> 0:02:55.720 in like our let's do this as a topic, put 0:02:55.720 --> 0:02:58.080 it on the list, and then when it came time 0:02:58.200 --> 0:03:01.640 to do it, we're like, wait, what are we? What 0:03:01.680 --> 0:03:03.120 do we What is the goal here? 0:03:03.400 --> 0:03:05.800 I still don't quite know what my goal is, So 0:03:05.880 --> 0:03:07.800 hopefully some we'll get something out of it. 0:03:08.240 --> 0:03:11.359 You know, I'm really excited because I was like, Okay, 0:03:11.360 --> 0:03:14.079 for me, it's clear cut, right, like who had the stethoscope? 0:03:14.120 --> 0:03:16.200 How did it change things? Blah blah blah, all that 0:03:16.560 --> 0:03:17.640 usual stuff. 0:03:17.720 --> 0:03:20.480 I feel like that's the story. I'm really excited about because, 0:03:20.520 --> 0:03:23.400 like I know very little pieces of it, but the 0:03:23.560 --> 0:03:26.840 like what the stethoscope has become I think is so 0:03:27.160 --> 0:03:30.000 interesting to then think back to when we didn't have 0:03:30.080 --> 0:03:32.160 them and like what it was like. Then. I'm really 0:03:32.160 --> 0:03:33.560 excited about it totally. 0:03:33.600 --> 0:03:36.080 Well, and of course I am excited because, like I 0:03:36.520 --> 0:03:38.560 want to hear these sounds, even though they give me 0:03:38.960 --> 0:03:42.520 anxiety or like some some weird creeping sense of unease. 0:03:43.000 --> 0:03:45.600 I want to understand how you can tell the difference, 0:03:45.720 --> 0:03:49.000 because I feel like there's when someone listens to your 0:03:49.320 --> 0:03:52.640 your body and they're like, what are they listening to? Right? 0:03:52.840 --> 0:03:54.800 That's what I'm going to talk about. I'm really excited 0:03:54.800 --> 0:03:57.240 about it. It should be fun, Like I figured, that's the 0:03:57.320 --> 0:03:59.560 question I want to answer, is like when you go 0:03:59.720 --> 0:04:02.320 to your doctor and they stick this metal thing on 0:04:02.360 --> 0:04:04.640 your chest, Like why, what are they what are they 0:04:04.680 --> 0:04:06.120 doing and what are they actually hearing? 0:04:06.360 --> 0:04:09.880 Yeah, Yeah, I'm really excited about this episode. I feel 0:04:09.880 --> 0:04:11.880 like we're I mean, we always say this, but I 0:04:12.760 --> 0:04:16.560 like sometimes feeling surprised by the things that we learned, 0:04:16.600 --> 0:04:18.400 Like there are some topics where we're like we know 0:04:19.480 --> 0:04:22.919 more the outline of the story. Yeah, and this is 0:04:23.320 --> 0:04:23.839 brand new. 0:04:26.839 --> 0:04:29.640 But what's not brand new is that we start every 0:04:29.680 --> 0:04:31.479 episode with quarantine ey time. 0:04:33.440 --> 0:04:34.960 What are we drinking this week? 0:04:35.320 --> 0:04:38.839 We're drinking Music to My Ears because it's kind of 0:04:38.880 --> 0:04:41.520 like there's some musical murmurs and wheezes. 0:04:41.920 --> 0:04:46.040 Yeah, yeah, and Music to My Ears is a tasty 0:04:46.120 --> 0:04:47.000 little concoction. 0:04:47.680 --> 0:04:47.840 You know. 0:04:47.960 --> 0:04:50.920 We're we're bringing out the mescal for this one. It's 0:04:50.960 --> 0:04:55.320 been a while, and maybe some campari in there, some 0:04:55.360 --> 0:04:58.960 little bitterness, some blood orange juice, a little tart acidic, 0:04:59.320 --> 0:05:02.279 and then some agave syrup just to help round it out. 0:05:02.360 --> 0:05:05.160 Suiteen it up, make it delicious and tasty. 0:05:05.880 --> 0:05:08.000 I love it. We'll post the full recipe for that 0:05:08.080 --> 0:05:11.200 quarantini as well as our non alcoholic plussey burrita on 0:05:11.279 --> 0:05:13.719 our website This podcast will Kill You dot Com and 0:05:14.040 --> 0:05:16.039 on our social media channels. Do you follow us on 0:05:16.080 --> 0:05:17.480 social media because we're there. 0:05:18.040 --> 0:05:20.680 We are there, and we are also on our website 0:05:20.800 --> 0:05:23.400 This podcast will Kill You dot Com. It's great. It's 0:05:23.440 --> 0:05:26.840 got some good resources like sources which we put on 0:05:27.360 --> 0:05:29.600 our website for each and every one of our episodes. 0:05:29.640 --> 0:05:32.839 We've got links to merch. We've got some cool merch. 0:05:33.400 --> 0:05:36.440 Check it out. We've got links to bookshop dot Org, 0:05:36.480 --> 0:05:41.000 affiliate account, our Goodreads list, links to music by Bloodmobile 0:05:42.000 --> 0:05:45.600 contact us form a submit your first hand account form 0:05:46.040 --> 0:05:51.120 transcripts transvention that we have those probably more things outdated 0:05:51.200 --> 0:05:53.440 pictures of us that we really need to update. 0:05:53.680 --> 0:05:56.320 We will maybe by the time this episode comes out, 0:05:56.320 --> 0:05:58.520 they'll be updated. So check it out and see see 0:05:58.880 --> 0:06:02.040 how old the picture. Sorry, this podcast will kill you 0:06:02.080 --> 0:06:04.400 dot com. 0:06:05.400 --> 0:06:07.880 Wow. Okay, before we go to off the rail, should 0:06:07.920 --> 0:06:10.359 we get into the content? All right? I think we should. 0:06:10.360 --> 0:06:11.239 I think we really should. 0:06:12.040 --> 0:06:14.000 Let's take a quick break and then begin. 0:06:52.160 --> 0:06:55.200 What the heck is the stethoscope? I feel like everyone 0:06:55.279 --> 0:06:58.159 knows what a stethoscope looks like, but I'm gonna describe 0:06:58.160 --> 0:07:04.080 it anyway, just in case. A stethoscope is a metal 0:07:04.320 --> 0:07:07.360 piece at one end, and this metal piece usually has 0:07:07.400 --> 0:07:11.120 two different sides. One of the sides is more open 0:07:11.280 --> 0:07:14.960 and curvy, and it's called the bell side. It usually 0:07:15.080 --> 0:07:18.160 has just like a rubber ring around it. And then 0:07:18.200 --> 0:07:21.679 the other side is more funnel shaped and it's covered 0:07:21.720 --> 0:07:28.200 with this thin, usually plastic diaphragm. And then this metal 0:07:28.320 --> 0:07:32.120 piece is connected to tubing that then splits into a 0:07:32.280 --> 0:07:34.760 y shape. And then is connected to ear pieces that 0:07:34.800 --> 0:07:38.160 we stick in our ears. And at its core, a 0:07:38.200 --> 0:07:43.800 stethoscope is just a tool to help amplify sound, and 0:07:43.920 --> 0:07:48.440 we use it to amplify the sounds in your chest 0:07:48.640 --> 0:07:50.960 for the most part. And Aaron, I know you're going 0:07:51.040 --> 0:07:52.520 to talk about like how it came to be and 0:07:52.560 --> 0:07:54.520 how it's changed because it didn't noise used to look 0:07:54.560 --> 0:07:58.560 like this, and later we'll talk about like does anyone 0:07:58.640 --> 0:08:01.760 still use the stethiside and what are they using instead 0:08:01.880 --> 0:08:05.800 and what's going to replace the stethoscope. But for this part, 0:08:05.880 --> 0:08:08.000 what I wanted to kind of focus on is like 0:08:08.800 --> 0:08:14.320 what are people listening to and listening for when they're 0:08:14.480 --> 0:08:18.040 using a stethoscope. It's funny, I feel like I take 0:08:18.080 --> 0:08:21.040 it a little bit for granted that like we get 0:08:21.160 --> 0:08:22.880 a decent amount of training and how to use the 0:08:22.880 --> 0:08:24.920 stethoscope in med school and so it's like, oh, of 0:08:24.920 --> 0:08:27.400 course you're listening to heart and lungs. Everyone knows that. 0:08:28.520 --> 0:08:30.360 But it's kind of been fun to go back and 0:08:30.400 --> 0:08:33.920 be like, oh, what for someone who has never put 0:08:33.960 --> 0:08:36.640 their ears to a stethoscope, Like what are you hearing 0:08:36.640 --> 0:08:39.920 and what are you listening for? Right? So the two 0:08:40.080 --> 0:08:43.240 main things that we're listening to are your lungs and 0:08:43.280 --> 0:08:46.200 your heart. To a lesser degree, you can also use 0:08:46.240 --> 0:08:48.560 a stethoscope to listen to bowel sounds if you stick 0:08:48.600 --> 0:08:51.600 it on the abdomen, but like I don't, I'm just 0:08:51.679 --> 0:08:53.520 personally not a huge fan of bowels sounds. 0:08:55.240 --> 0:08:56.920 Can you Can you say more. 0:08:59.080 --> 0:09:04.520 Bowel sounds like present or not present, or like hyperactive 0:09:04.880 --> 0:09:09.280 or not hyperactive. So they're just like not that interesting 0:09:10.040 --> 0:09:12.400 when you think about like the different pathologies, Like you 0:09:12.440 --> 0:09:16.560 can't get that specific with the stethoscope on a belly. Okay, 0:09:16.679 --> 0:09:19.680 In any case, we're mostly using a stethoscope to listen 0:09:19.720 --> 0:09:22.840 to what's going on in the chest cavity, and so 0:09:22.920 --> 0:09:25.520 I want to focus first on the lungs and then 0:09:25.840 --> 0:09:28.840 on the heart, and we'll talk about like what is 0:09:28.880 --> 0:09:32.680 a quote unquote normal sound and what are the abnormal 0:09:32.880 --> 0:09:36.000 sounds that we're listening for to try and diagnose if 0:09:36.080 --> 0:09:39.320 something is a miss. And to do this we will 0:09:39.520 --> 0:09:43.640 use some recorded lung sounds and heart sounds. So thank 0:09:43.679 --> 0:09:46.040 you so much to the open source databases that exists 0:09:46.120 --> 0:09:47.439 for us to get this, and they will all be 0:09:47.520 --> 0:09:51.440 linked in our sources as well. All Right, So the 0:09:51.480 --> 0:09:55.840 first thing is lung sounds. The sound that you hear 0:09:56.480 --> 0:09:59.480 when you are listening to a lung is literally the 0:09:59.520 --> 0:10:03.440 sound of air moving through the lung tubes, right through 0:10:03.480 --> 0:10:04.960 your bronchi and through your bronchioles. 0:10:05.760 --> 0:10:06.520 The name for. 0:10:06.520 --> 0:10:10.680 These lung sounds is vesticular breath sounds. That's the technical 0:10:10.800 --> 0:10:14.680 term for it, okay. And you hear these vesticular sounds 0:10:14.840 --> 0:10:17.800 mostly on inspiration, so when you take a breath in 0:10:18.200 --> 0:10:21.080 and then the first part of expiration, and then they 0:10:21.200 --> 0:10:25.599 kind of fade out after that. So I'll play a 0:10:25.679 --> 0:10:41.640 quick clip for you to be able to listen. So 0:10:41.920 --> 0:10:44.680 that click click clicking that you hear is actually the heartbeat, 0:10:44.840 --> 0:10:46.680 and we'll talk more about the heart in a second. 0:10:46.720 --> 0:10:49.760 And that kind of does predominate in that particular clip. 0:10:50.200 --> 0:10:53.680 But what you hear in the background is that very gentle, 0:10:53.840 --> 0:10:55.679 very even whooshing right. 0:10:55.800 --> 0:10:59.280 It's like rhythm, very wave sounds. 0:10:59.640 --> 0:11:04.320 Waves sounds, that is lung sounds. Those are vesticular breath sounds. 0:11:04.440 --> 0:11:08.959 Nice healthy inspiration, expiration. The deeper that you breathe in, 0:11:09.000 --> 0:11:12.080 the longer that you'll hear it. What's always amusing is 0:11:12.080 --> 0:11:14.040 when you ask people to take a deep breath, they'll 0:11:14.120 --> 0:11:19.040 usually go for a really long time and then for 0:11:19.080 --> 0:11:21.120 a really long time, and like half of that expiration 0:11:21.200 --> 0:11:24.840 you're not hearing anything. But that's a bit of an aside. 0:11:25.120 --> 0:11:27.360 I always feel like stressed because I'm like, am I 0:11:27.440 --> 0:11:29.679 doing this fast enough? Am I breathing deeply enough? Are 0:11:29.720 --> 0:11:32.840 they going to miss something? Because I'm like and then 0:11:32.880 --> 0:11:34.960 they're like, I'll breathe in, and then they're like, okay, 0:11:34.960 --> 0:11:37.240 breathe out, breathe in, and I'm like, that's too fast, 0:11:37.360 --> 0:11:37.880 I read. 0:11:37.800 --> 0:11:40.400 Do it's because we're only you only hear that first 0:11:40.400 --> 0:11:43.760 part of expiration, so the expiration is is less important 0:11:43.840 --> 0:11:47.440 except when there's pathology. So we'll get there. But the 0:11:47.520 --> 0:11:49.800 first thing that you might notice if you're listening for 0:11:49.880 --> 0:11:52.880 lung sounds is if you don't hear them at all, 0:11:53.240 --> 0:11:55.880 because if you don't hear lung sounds when you put 0:11:55.880 --> 0:11:59.240 your stethoscope over someone's lungs, then that means that something 0:11:59.280 --> 0:12:02.040 is going on, right, you should hear air moving in 0:12:02.080 --> 0:12:05.160 and out. If you don't, it might mean that there's 0:12:05.160 --> 0:12:07.920 a blockage. So that could mean a mass, it could 0:12:07.920 --> 0:12:11.559 mean so much fluid that there's just like a chunk 0:12:11.720 --> 0:12:14.040 that you're not moving air. It could mean that a 0:12:14.080 --> 0:12:17.200 lung has been collapsed, so there is literally no lung 0:12:17.240 --> 0:12:20.199 there for you to hear. Or it could mean that 0:12:20.240 --> 0:12:24.520 you have such massive obstruction, even from something like asthma, 0:12:24.840 --> 0:12:27.880 that there's just not air moving in and out enough 0:12:27.920 --> 0:12:29.760 that you can hear it with a stethoscope. 0:12:30.120 --> 0:12:32.560 And so this would be like on one side you 0:12:32.600 --> 0:12:35.040 would hear breath sounds because someone would have to still 0:12:35.080 --> 0:12:37.000 be breathing, and on the other side you would hear 0:12:37.040 --> 0:12:40.280 no breath sounds, and that would indicate pathology potentially. 0:12:40.440 --> 0:12:44.439 Yeah, okay, yeah, so that's just breath sounds present, breath 0:12:44.440 --> 0:12:48.280 sounds absent. Then there are a couple of different abnormal 0:12:48.320 --> 0:12:52.960 lung sounds that we will focus on, and neither of 0:12:53.000 --> 0:12:56.520 these are specific in and of themselves to any like 0:12:56.640 --> 0:13:00.439 one particular diagnosis. None of the exam that you get 0:13:00.440 --> 0:13:04.160 with a stethoscope is like an absolute clincher. Necessarily, they're 0:13:04.200 --> 0:13:08.800 all part of an overall exam and findings that are 0:13:08.800 --> 0:13:10.760 going to help you try and figure out what's going on. 0:13:11.720 --> 0:13:13.760 And the types of lung sounds have a lot of 0:13:13.800 --> 0:13:17.000 different names in older literature and newer literature and across 0:13:17.000 --> 0:13:19.080 the globe, but I'm going to use the names that 0:13:19.120 --> 0:13:22.400 the American Thoracic Society tends to use, and so that 0:13:22.640 --> 0:13:27.360 is wheezes, and ronki and ronchi are just lower pitched 0:13:27.400 --> 0:13:31.319 wheezes and then crackles. And with crackles you have both 0:13:31.360 --> 0:13:34.960 fine crackles and coarse crackles. Now this is not all 0:13:35.000 --> 0:13:37.840 of the things that you would hear, but this is 0:13:38.040 --> 0:13:44.240 the majority of the abnormal or also called adventitious breath 0:13:44.320 --> 0:13:47.200 sounds that you would hear. So let me play a 0:13:47.200 --> 0:14:05.240 clip for you of crackles. Do you hear that? 0:14:06.160 --> 0:14:06.600 M hmm. 0:14:07.200 --> 0:14:10.120 They're kind of I feel like crackles is a really 0:14:10.160 --> 0:14:14.199 good word in all honesty, because they sound crackly, like 0:14:14.720 --> 0:14:17.320 you're mixing up a piece of paper or something like that. 0:14:18.720 --> 0:14:22.480 There's other descriptions that I really love. There's a description 0:14:22.720 --> 0:14:26.920 for fine crackles, specifically that they sound kind of like 0:14:26.960 --> 0:14:31.200 if you join velcro together and then separate it. That's 0:14:31.240 --> 0:14:34.360 another way to describe the fine crackles. And that clip 0:14:34.360 --> 0:14:36.840 that I played is a little more coarse crackles than 0:14:36.880 --> 0:14:44.080 fine crackles. What's causing these crackles? Fine crackles happen when 0:14:44.120 --> 0:14:49.200 you have inspiration that's opening these really small airways that 0:14:49.240 --> 0:14:52.840 have been collapsed, and that kind of collapse can happen 0:14:52.880 --> 0:14:56.600 for a number of different reasons. So you might have crackles, 0:14:56.640 --> 0:15:00.400 fine crackles, or course crackles in something like pneumonia. Yeah, 0:15:01.000 --> 0:15:04.680 you might have crackles with something like heart failure because 0:15:04.720 --> 0:15:08.120 you have fluid in the lungs. Or you might have 0:15:08.200 --> 0:15:11.960 coarse crackles with something like chronic obstructive pulmonary disease or 0:15:12.000 --> 0:15:16.000 COPD or bronchitis. There's a lot of different types of 0:15:16.040 --> 0:15:22.360 pathology that can cause crackles. Then there are wheezes. Wheezes 0:15:22.400 --> 0:15:25.560 are one of my favorite sounds when in the lung, 0:15:25.640 --> 0:15:27.960 even though they're not like, no one wants to be wheezy, 0:15:27.960 --> 0:15:29.960 it's not good. But let me tell you this clip. 0:15:30.320 --> 0:15:31.880 Why are they your favorite? 0:15:33.040 --> 0:15:36.360 I think that they're my favorite because a lot of 0:15:36.360 --> 0:15:41.680 the times with wheezing, you can really diagnose something with 0:15:41.720 --> 0:15:45.640 wheezes and then treat it a little bit more specifically. 0:15:45.720 --> 0:15:49.880 So with wheezes we're usually thinking about asthma or COPD. 0:15:50.360 --> 0:15:51.880 Are those the only things in the world that can 0:15:51.960 --> 0:15:54.680 cause weezes? Definitely not. If you have like a foreign 0:15:54.720 --> 0:15:58.440 body ingestion, you might have a focal wheeze, and the 0:15:58.480 --> 0:16:01.800 wheeze is happening because there's that's trying to squeeze through 0:16:01.880 --> 0:16:06.080 a really small constricted tube. So let me play the 0:16:06.120 --> 0:16:25.680 clip so you can hear that. 0:16:25.680 --> 0:16:29.640 That sounded really horrible. That makes me feel like I 0:16:29.680 --> 0:16:30.320 can't breathe. 0:16:30.880 --> 0:16:37.520 Yeah, so in that clip, there's more inspiratory than expiratory wheezes. 0:16:37.640 --> 0:16:41.200 You can get both. It's not a good sound. You 0:16:41.280 --> 0:16:43.920 definitely know that, like there is something very much wrong 0:16:44.000 --> 0:16:46.680 going on here. But a lot of times with wheezing, 0:16:46.760 --> 0:16:49.440 it's something that we can then say, oh, based on 0:16:49.600 --> 0:16:52.200 the other things that I know about this person who's 0:16:52.240 --> 0:16:55.480 coming in here and this lung exam, I know what 0:16:55.520 --> 0:16:58.280 the next treatment is going to be. Does that make sense? 0:16:58.680 --> 0:17:00.760 I think that's why I like this. It's not like 0:17:00.800 --> 0:17:01.640 they're good. 0:17:02.320 --> 0:17:07.560 So if there are more inspiratory wheezing than expiratory, then 0:17:07.600 --> 0:17:08.840 what what does that indicate? 0:17:09.760 --> 0:17:14.000 That there's probably like a very detailed answer to that 0:17:14.119 --> 0:17:17.720 question that I don't specifically have. You can hear both 0:17:17.800 --> 0:17:21.439 inspiratory and expiatory whezing, but classically something like asthma is 0:17:21.480 --> 0:17:24.840 described as expiratory wheezes, but you can certainly get both 0:17:24.840 --> 0:17:29.840 inspiratory and expiatory wheezing in something like asthma, COPD, et cetera. Okay, 0:17:30.640 --> 0:17:33.560 so that's like the main types of lung sounds that 0:17:33.640 --> 0:17:37.399 you might hear. There's nuances there, there's other types of 0:17:37.440 --> 0:17:40.639 sounds that you might hear too, but these all just 0:17:40.840 --> 0:17:43.440 give the listener a bit of an idea about what 0:17:43.560 --> 0:17:46.080 is going on in the lung and then maybe what 0:17:46.160 --> 0:17:46.920 to do about it. 0:17:48.400 --> 0:17:53.200 I have some questions, okay, okay, so when you're listening 0:17:53.240 --> 0:17:55.760 to first of all, where are you listening to the lungs? 0:17:55.800 --> 0:17:58.479 What is the best place to put that little end 0:17:58.480 --> 0:17:59.320 of the stethoscope. 0:17:59.680 --> 0:18:02.399 Yeah, it's not about one place. It's about listening in 0:18:02.480 --> 0:18:06.920 multiple places and comparing them. So people are always going 0:18:06.960 --> 0:18:10.840 to listen minimum in like four different areas because the 0:18:10.920 --> 0:18:14.560 two lungs and the top and the bottom. But then 0:18:14.600 --> 0:18:16.919 there's also places that can stay kind of hidden, and 0:18:16.960 --> 0:18:19.159 so sometimes you have to listen around like towards the 0:18:19.240 --> 0:18:22.679 front side to get like the right middle lobe. And 0:18:22.760 --> 0:18:26.119 really the more places that you listen across the back, 0:18:26.640 --> 0:18:29.440 the more information that you're going to gather. But it's 0:18:29.480 --> 0:18:32.440 really about comparing one side to the other, and comparing 0:18:32.480 --> 0:18:36.120 the top to the bottom to listen to the whole lung, okay, 0:18:36.400 --> 0:18:38.880 And it's not just so, it's a really good question 0:18:38.920 --> 0:18:40.800 of where do you listen, because it's not just the 0:18:40.920 --> 0:18:44.479 sounds that you're hearing, it's also where you're hearing the sounds. 0:18:44.680 --> 0:18:47.840 Are you hearing crackles everywhere or do you only hear 0:18:47.880 --> 0:18:51.480 them in one specific spot? Are you hearing wheezing everywhere 0:18:51.680 --> 0:18:55.320 or just in one particular spot? And so that information 0:18:55.440 --> 0:18:58.080 is also really important as part of this whole exam. 0:18:58.600 --> 0:19:16.720 Okay, when it comes to something like crackles and wheezing 0:19:16.840 --> 0:19:18.720 and stuff like that, you know, like you said, the 0:19:18.840 --> 0:19:22.200 location of the you know, the origin of that or 0:19:22.240 --> 0:19:25.639 how pervasive it is or whatever, that's important. But what 0:19:25.800 --> 0:19:29.320 about the degree, Like, if you're hearing fine crackles versus 0:19:29.440 --> 0:19:32.919 coarse crackles, what does that tell you if any or 0:19:32.960 --> 0:19:34.119 is it just like a descriptive? 0:19:34.840 --> 0:19:37.600 Yeah, so it might give you ideas about what the 0:19:37.680 --> 0:19:41.840 underlying pathology is. If it's more course versus more fine, 0:19:42.600 --> 0:19:46.440 you think of slightly different pathology. And if it's like runcous, 0:19:46.520 --> 0:19:50.520 like those low pitched wheezes versus those high pitched wheezes, 0:19:50.960 --> 0:19:55.640 it's gonna clue people into different types of disease that's 0:19:55.680 --> 0:19:59.160 going on. If that makes sense, Okay, there's like too 0:19:59.200 --> 0:20:02.399 many different lungs to get into, like all those specifics. 0:20:03.040 --> 0:20:05.159 Well, and then that kind of brings me to another question, 0:20:05.200 --> 0:20:08.359 which is, like we use the stethoscope. It's a tool. 0:20:08.760 --> 0:20:12.520 How often is it the last line? Like, how often 0:20:12.600 --> 0:20:16.520 is it the diagnostic tool, rather than like, oh I 0:20:16.520 --> 0:20:18.600 hear some wheezing, Oh I hear some crackles, We better 0:20:18.600 --> 0:20:21.119 get you an X ray to see just how bad 0:20:21.160 --> 0:20:22.240 it is or whatever. 0:20:22.800 --> 0:20:27.280 Yeah, it so depends on the situation that you're in. 0:20:27.760 --> 0:20:27.960 Right. 0:20:28.440 --> 0:20:31.480 If if somebody is in an emergency room and they 0:20:31.480 --> 0:20:34.439 look super sick, no one's going to end with the stethoscope, right, 0:20:34.480 --> 0:20:36.359 You're going to be getting imaging, You're going to be 0:20:36.400 --> 0:20:40.840 doing more things, and you might be treating something. Even 0:20:40.920 --> 0:20:44.040 if you think that your lung exam sounded totally normal. Right, 0:20:44.040 --> 0:20:47.560 It all just depends on the situation. There are definitely 0:20:47.600 --> 0:20:52.439 situations that this stethoscope might be the last part of 0:20:52.480 --> 0:20:56.000 your diagnosis. For example, a kid who has a known 0:20:56.160 --> 0:20:59.480 history of asthma who comes in having trouble breathing, You 0:20:59.480 --> 0:21:02.160 put a stuff the scope on their chest and they're wheezing, 0:21:02.680 --> 0:21:05.520 then you'd say, okay, let's treat this as an asthma exacerbation, 0:21:05.760 --> 0:21:07.520 and so then you treat it and then see if 0:21:07.520 --> 0:21:10.320 they get better by listening to their lungs again. So 0:21:10.359 --> 0:21:14.000 there are situations where it's still something that you very 0:21:14.040 --> 0:21:18.280 much use and would not then need to do further 0:21:18.359 --> 0:21:21.119 imaging or even like further imaging might not tell you 0:21:21.160 --> 0:21:24.359 all that much. But as we'll talk more about like 0:21:24.480 --> 0:21:29.600 throughout this episode, there are a lot of things about 0:21:29.600 --> 0:21:33.400 the stethoscope that are limitations, I guess of the stethoscope, 0:21:33.440 --> 0:21:35.959 and so there are a lot of new modalities that 0:21:36.080 --> 0:21:40.760 are much better for making diagnosis compared to the stethoscope. 0:21:40.640 --> 0:21:43.440 Right, because there are presumably a lot of lung pathologies 0:21:43.480 --> 0:21:46.040 that you wouldn't be able to hear through a stethoscope, 0:21:46.040 --> 0:21:50.040 but you would be able to see in imaging. 0:21:50.480 --> 0:21:52.960 Yeah, lung and heart especially and heart. 0:21:53.000 --> 0:21:55.359 Yeah. Okay, so then that's sort of another question, and 0:21:55.400 --> 0:22:00.000 this applies to both. This is just like stethoscope broadly. Yeah, 0:22:00.119 --> 0:22:04.000 how subjective is it? Like obviously you can take these 0:22:04.040 --> 0:22:06.359 classes or like in med school, you're trained. Okay, this 0:22:06.560 --> 0:22:08.600 is a wheeze, this is a crackle, this is fine. 0:22:08.600 --> 0:22:11.119 Crackle course, crackle. Yeah, a lot of the heart stuff 0:22:11.119 --> 0:22:13.640 that we haven't touched on yet and then be tested 0:22:13.680 --> 0:22:18.440 on that. But how subjective is it? 0:22:18.880 --> 0:22:22.680 Yeah, that's I think one of the biggest, the biggest questions. 0:22:22.880 --> 0:22:26.960 There's huge inter user variability in stethoscopes. That's one of 0:22:27.000 --> 0:22:30.119 the biggest downsides of them. What one person hears and 0:22:30.160 --> 0:22:33.280 what another person hears, they might describe totally differently. They 0:22:33.359 --> 0:22:36.520 might hear things totally differently, and especially when it comes 0:22:36.560 --> 0:22:40.040 to a lung exam, the lungs change over time, and 0:22:40.080 --> 0:22:42.680 so what one person hears at one moment, another person 0:22:42.760 --> 0:22:45.040 might never be able to hear again because that sound 0:22:45.080 --> 0:22:49.200 might disappear or move or something like that. So there 0:22:49.240 --> 0:22:52.439 is definitely a lot of variability. There was a paper 0:22:52.480 --> 0:22:56.080 that I read that was like lamenting how medical students 0:22:56.119 --> 0:22:58.679 are just no longer trained in the stethoscope, and I 0:22:58.720 --> 0:22:59.040 was like. 0:22:59.119 --> 0:23:01.840 Come on, like, I think I read this was a 0:23:01.880 --> 0:23:06.040 little much. Yeah, well, it's like all of these papers 0:23:06.080 --> 0:23:09.760 seemed so dramatic. They're like so drum already holding like 0:23:09.840 --> 0:23:12.200 a funeral for the stethoscope, and I'm like, I've never 0:23:12.240 --> 0:23:15.119 seen a doctor without one, even if they don't use them, like, 0:23:15.200 --> 0:23:17.680 come on, now. 0:23:16.920 --> 0:23:19.800 I do. I think that it's it's such an interesting 0:23:19.880 --> 0:23:22.439 Medicine has this tendency this is sorry, this is I 0:23:22.480 --> 0:23:25.080 wasn't gonna riff like this until way later in the episode, but. 0:23:26.200 --> 0:23:27.239 Riff away, I love it. 0:23:28.320 --> 0:23:33.919 Medicine has this tendency to like really dramatize new technologies 0:23:34.080 --> 0:23:37.560 as being like the end of the practice of medicine. 0:23:37.600 --> 0:23:41.360 And I think the stethoscope has absolutely gotten caught up 0:23:41.400 --> 0:23:44.439 in that right where it's like, well, if students can't 0:23:44.560 --> 0:23:51.359 use the stethoscope, then where has medicine gone? When it's like, sorry, 0:23:51.440 --> 0:23:55.800 ultrasound is great, you know, right, But at the same time, 0:23:56.000 --> 0:23:58.239 like I I can say, and this is just like 0:23:58.520 --> 0:24:02.080 me as an individual and of one, I use my 0:24:02.119 --> 0:24:07.320 stethoscope very frequently, almost every day as a primary care provider, 0:24:07.480 --> 0:24:10.800 especially one who sees kids. And so I don't think 0:24:10.840 --> 0:24:13.000 that we are at this day and age in twenty 0:24:13.040 --> 0:24:16.000 twenty four at the point where anyone's throwing their stethoscope 0:24:16.040 --> 0:24:19.440 out the window. And I do think that it still 0:24:19.560 --> 0:24:23.320