Speaker 1: The patient's age and sex did not permit me to
Speaker 1: resort to the kind of examination I have just described,
Speaker 1: I e. Direct application of the ear to the chest.
Speaker 1: I recalled a well known acoustic phenomenon. If you place
Speaker 1: your ear against one end of a wood beam, the
Speaker 1: scratch of a pin at the other end is distinctly audible.
Speaker 1: It occurred to me that this physical property might serve
Speaker 1: a useful purpose in the case I was dealing with.
Speaker 1: I then tightly rolled a sheet of paper, one end
Speaker 1: of which I placed over the precordium and my ear
Speaker 1: to the other. I was surprised and elated to be
Speaker 1: able to hear the beating of her heart with far
Speaker 1: greater clearness than I ever had with direct application of
Speaker 1: my ear. I immediately saw that this might become an
Speaker 1: indispensable method for studying not only the beating of the heart,
Speaker 1: but all movements able of producing sound in the chest cavity.
Speaker 2: I was so excited for this episode.
Speaker 1: Are me too? Me too? I have listened to more hearts,
Speaker 1: I think, than I ever have in lung sounds. We
Speaker 1: were just listening to them, and it has created a
Speaker 1: weird sense of anxiety. Further, do you.
Speaker 2: Remember that Radio Lab episode about the person who could
Speaker 2: hear their own heartbeat, and then yeah.
Speaker 1: Yeah, I think that that's I think that might be
Speaker 1: what's going on. And I don't know why that is.
Speaker 2: I don't have an answer to that.
Speaker 1: Yeah, I don't know. I mean anyway, but that quote
Speaker 1: that paragraph was from of course Lenek, whom you'll hear
Speaker 1: a lot more about later in the episode. Who basically
Speaker 1: invented the stethoscope.
Speaker 2: Yep, spoiler sure did.
Speaker 1: Yeah. And Hi, I'm Aaron.
Speaker 2: Welsh and I'm Erin omn Updike.
Speaker 1: And this is this podcast will kill you today.
Speaker 2: We're talking all about the stethoscope.
Speaker 1: All about it. Yeah, you know, we put this down
Speaker 1: in like our let's do this as a topic, put
Speaker 1: it on the list, and then when it came time
Speaker 1: to do it, we're like, wait, what are we? What
Speaker 1: do we What is the goal here?
Speaker 2: I still don't quite know what my goal is, So
Speaker 2: hopefully some we'll get something out of it.
Speaker 1: You know, I'm really excited because I was like, Okay,
Speaker 1: for me, it's clear cut, right, like who had the stethoscope?
Speaker 1: How did it change things? Blah blah blah, all that
Speaker 1: usual stuff.
Speaker 2: I feel like that's the story. I'm really excited about because,
Speaker 2: like I know very little pieces of it, but the
Speaker 2: like what the stethoscope has become I think is so
Speaker 2: interesting to then think back to when we didn't have
Speaker 2: them and like what it was like. Then. I'm really
Speaker 2: excited about it totally.
Speaker 1: Well, and of course I am excited because, like I
Speaker 1: want to hear these sounds, even though they give me
Speaker 1: anxiety or like some some weird creeping sense of unease.
Speaker 1: I want to understand how you can tell the difference,
Speaker 1: because I feel like there's when someone listens to your
Speaker 1: your body and they're like, what are they listening to? Right?
Speaker 2: That's what I'm going to talk about. I'm really excited
Speaker 2: about it. It should be fun, Like I figured, that's the
Speaker 2: question I want to answer, is like when you go
Speaker 2: to your doctor and they stick this metal thing on
Speaker 2: your chest, Like why, what are they what are they
Speaker 2: doing and what are they actually hearing?
Speaker 1: Yeah, Yeah, I'm really excited about this episode. I feel
Speaker 1: like we're I mean, we always say this, but I
Speaker 1: like sometimes feeling surprised by the things that we learned,
Speaker 1: Like there are some topics where we're like we know
Speaker 1: more the outline of the story. Yeah, and this is
Speaker 1: brand new.
Speaker 2: But what's not brand new is that we start every
Speaker 2: episode with quarantine ey time.
Speaker 1: What are we drinking this week?
Speaker 2: We're drinking Music to My Ears because it's kind of
Speaker 2: like there's some musical murmurs and wheezes.
Speaker 1: Yeah, yeah, and Music to My Ears is a tasty
Speaker 1: little concoction.
Speaker 3: You know.
Speaker 1: We're we're bringing out the mescal for this one. It's
Speaker 1: been a while, and maybe some campari in there, some
Speaker 1: little bitterness, some blood orange juice, a little tart acidic,
Speaker 1: and then some agave syrup just to help round it out.
Speaker 1: Suiteen it up, make it delicious and tasty.
Speaker 2: I love it. We'll post the full recipe for that
Speaker 2: quarantini as well as our non alcoholic plussey burrita on
Speaker 2: our website This podcast will Kill You dot Com and
Speaker 2: on our social media channels. Do you follow us on
Speaker 2: social media because we're there.
Speaker 1: We are there, and we are also on our website
Speaker 1: This podcast will Kill You dot Com. It's great. It's
Speaker 1: got some good resources like sources which we put on
Speaker 1: our website for each and every one of our episodes.
Speaker 1: We've got links to merch. We've got some cool merch.
Speaker 1: Check it out. We've got links to bookshop dot Org,
Speaker 1: affiliate account, our Goodreads list, links to music by Bloodmobile
Speaker 1: contact us form a submit your first hand account form
Speaker 1: transcripts transvention that we have those probably more things outdated
Speaker 1: pictures of us that we really need to update.
Speaker 2: We will maybe by the time this episode comes out,
Speaker 2: they'll be updated. So check it out and see see
Speaker 2: how old the picture. Sorry, this podcast will kill you
Speaker 2: dot com.
Speaker 1: Wow. Okay, before we go to off the rail, should
Speaker 1: we get into the content? All right? I think we should.
Speaker 2: I think we really should.
Speaker 1: Let's take a quick break and then begin.
Speaker 2: What the heck is the stethoscope? I feel like everyone
Speaker 2: knows what a stethoscope looks like, but I'm gonna describe
Speaker 2: it anyway, just in case. A stethoscope is a metal
Speaker 2: piece at one end, and this metal piece usually has
Speaker 2: two different sides. One of the sides is more open
Speaker 2: and curvy, and it's called the bell side. It usually
Speaker 2: has just like a rubber ring around it. And then
Speaker 2: the other side is more funnel shaped and it's covered
Speaker 2: with this thin, usually plastic diaphragm. And then this metal
Speaker 2: piece is connected to tubing that then splits into a
Speaker 2: y shape. And then is connected to ear pieces that
Speaker 2: we stick in our ears. And at its core, a
Speaker 2: stethoscope is just a tool to help amplify sound, and
Speaker 2: we use it to amplify the sounds in your chest
Speaker 2: for the most part. And Aaron, I know you're going
Speaker 2: to talk about like how it came to be and
Speaker 2: how it's changed because it didn't noise used to look
Speaker 2: like this, and later we'll talk about like does anyone
Speaker 2: still use the stethiside and what are they using instead
Speaker 2: and what's going to replace the stethoscope. But for this part,
Speaker 2: what I wanted to kind of focus on is like
Speaker 2: what are people listening to and listening for when they're
Speaker 2: using a stethoscope. It's funny, I feel like I take
Speaker 2: it a little bit for granted that like we get
Speaker 2: a decent amount of training and how to use the
Speaker 2: stethoscope in med school and so it's like, oh, of
Speaker 2: course you're listening to heart and lungs. Everyone knows that.
Speaker 2: But it's kind of been fun to go back and
Speaker 2: be like, oh, what for someone who has never put
Speaker 2: their ears to a stethoscope, Like what are you hearing
Speaker 2: and what are you listening for? Right? So the two
Speaker 2: main things that we're listening to are your lungs and
Speaker 2: your heart. To a lesser degree, you can also use
Speaker 2: a stethoscope to listen to bowel sounds if you stick
Speaker 2: it on the abdomen, but like I don't, I'm just
Speaker 2: personally not a huge fan of bowels sounds.
Speaker 1: Can you Can you say more.
Speaker 2: Bowel sounds like present or not present, or like hyperactive
Speaker 2: or not hyperactive. So they're just like not that interesting
Speaker 2: when you think about like the different pathologies, Like you
Speaker 2: can't get that specific with the stethoscope on a belly. Okay,
Speaker 2: In any case, we're mostly using a stethoscope to listen
Speaker 2: to what's going on in the chest cavity, and so
Speaker 2: I want to focus first on the lungs and then
Speaker 2: on the heart, and we'll talk about like what is
Speaker 2: a quote unquote normal sound and what are the abnormal
Speaker 2: sounds that we're listening for to try and diagnose if
Speaker 2: something is a miss. And to do this we will
Speaker 2: use some recorded lung sounds and heart sounds. So thank
Speaker 2: you so much to the open source databases that exists
Speaker 2: for us to get this, and they will all be
Speaker 2: linked in our sources as well. All Right, So the
Speaker 2: first thing is lung sounds. The sound that you hear
Speaker 2: when you are listening to a lung is literally the
Speaker 2: sound of air moving through the lung tubes, right through
Speaker 2: your bronchi and through your bronchioles.
Speaker 1: The name for.
Speaker 2: These lung sounds is vesticular breath sounds. That's the technical
Speaker 2: term for it, okay. And you hear these vesticular sounds
Speaker 2: mostly on inspiration, so when you take a breath in
Speaker 2: and then the first part of expiration, and then they
Speaker 2: kind of fade out after that. So I'll play a
Speaker 2: quick clip for you to be able to listen. So
Speaker 2: that click click clicking that you hear is actually the heartbeat,
Speaker 2: and we'll talk more about the heart in a second.
Speaker 2: And that kind of does predominate in that particular clip.
Speaker 2: But what you hear in the background is that very gentle,
Speaker 2: very even whooshing right.
Speaker 1: It's like rhythm, very wave sounds.
Speaker 2: Waves sounds, that is lung sounds. Those are vesticular breath sounds.
Speaker 2: Nice healthy inspiration, expiration. The deeper that you breathe in,
Speaker 2: the longer that you'll hear it. What's always amusing is
Speaker 2: when you ask people to take a deep breath, they'll
Speaker 2: usually go for a really long time and then for
Speaker 2: a really long time, and like half of that expiration
Speaker 2: you're not hearing anything. But that's a bit of an aside.
Speaker 1: I always feel like stressed because I'm like, am I
Speaker 1: doing this fast enough? Am I breathing deeply enough? Are
Speaker 1: they going to miss something? Because I'm like and then
Speaker 1: they're like, I'll breathe in, and then they're like, okay,
Speaker 1: breathe out, breathe in, and I'm like, that's too fast,
Speaker 1: I read.
Speaker 2: Do it's because we're only you only hear that first
Speaker 2: part of expiration, so the expiration is is less important
Speaker 2: except when there's pathology. So we'll get there. But the
Speaker 2: first thing that you might notice if you're listening for
Speaker 2: lung sounds is if you don't hear them at all,
Speaker 2: because if you don't hear lung sounds when you put
Speaker 2: your stethoscope over someone's lungs, then that means that something
Speaker 2: is going on, right, you should hear air moving in
Speaker 2: and out. If you don't, it might mean that there's
Speaker 2: a blockage. So that could mean a mass, it could
Speaker 2: mean so much fluid that there's just like a chunk
Speaker 2: that you're not moving air. It could mean that a
Speaker 2: lung has been collapsed, so there is literally no lung
Speaker 2: there for you to hear. Or it could mean that
Speaker 2: you have such massive obstruction, even from something like asthma,
Speaker 2: that there's just not air moving in and out enough
Speaker 2: that you can hear it with a stethoscope.
Speaker 1: And so this would be like on one side you
Speaker 1: would hear breath sounds because someone would have to still
Speaker 1: be breathing, and on the other side you would hear
Speaker 1: no breath sounds, and that would indicate pathology potentially.
Speaker 2: Yeah, okay, yeah, so that's just breath sounds present, breath
Speaker 2: sounds absent. Then there are a couple of different abnormal
Speaker 2: lung sounds that we will focus on, and neither of
Speaker 2: these are specific in and of themselves to any like
Speaker 2: one particular diagnosis. None of the exam that you get
Speaker 2: with a stethoscope is like an absolute clincher. Necessarily, they're
Speaker 2: all part of an overall exam and findings that are
Speaker 2: going to help you try and figure out what's going on.
Speaker 2: And the types of lung sounds have a lot of
Speaker 2: different names in older literature and newer literature and across
Speaker 2: the globe, but I'm going to use the names that
Speaker 2: the American Thoracic Society tends to use, and so that
Speaker 2: is wheezes, and ronki and ronchi are just lower pitched
Speaker 2: wheezes and then crackles. And with crackles you have both
Speaker 2: fine crackles and coarse crackles. Now this is not all
Speaker 2: of the things that you would hear, but this is
Speaker 2: the majority of the abnormal or also called adventitious breath
Speaker 2: sounds that you would hear. So let me play a
Speaker 2: clip for you of crackles. Do you hear that?
Speaker 4: M hmm.
Speaker 2: They're kind of I feel like crackles is a really
Speaker 2: good word in all honesty, because they sound crackly, like
Speaker 2: you're mixing up a piece of paper or something like that.
Speaker 2: There's other descriptions that I really love. There's a description
Speaker 2: for fine crackles, specifically that they sound kind of like
Speaker 2: if you join velcro together and then separate it. That's
Speaker 2: another way to describe the fine crackles. And that clip
Speaker 2: that I played is a little more coarse crackles than
Speaker 2: fine crackles. What's causing these crackles? Fine crackles happen when
Speaker 2: you have inspiration that's opening these really small airways that
Speaker 2: have been collapsed, and that kind of collapse can happen
Speaker 2: for a number of different reasons. So you might have crackles,
Speaker 2: fine crackles, or course crackles in something like pneumonia. Yeah,
Speaker 2: you might have crackles with something like heart failure because
Speaker 2: you have fluid in the lungs. Or you might have
Speaker 2: coarse crackles with something like chronic obstructive pulmonary disease or
Speaker 2: COPD or bronchitis. There's a lot of different types of
Speaker 2: pathology that can cause crackles. Then there are wheezes. Wheezes
Speaker 2: are one of my favorite sounds when in the lung,
Speaker 2: even though they're not like, no one wants to be wheezy,
Speaker 2: it's not good. But let me tell you this clip.
Speaker 1: Why are they your favorite?
Speaker 2: I think that they're my favorite because a lot of
Speaker 2: the times with wheezing, you can really diagnose something with
Speaker 2: wheezes and then treat it a little bit more specifically.
Speaker 2: So with wheezes we're usually thinking about asthma or COPD.
Speaker 2: Are those the only things in the world that can
Speaker 2: cause weezes? Definitely not. If you have like a foreign
Speaker 2: body ingestion, you might have a focal wheeze, and the
Speaker 2: wheeze is happening because there's that's trying to squeeze through
Speaker 2: a really small constricted tube. So let me play the
Speaker 2: clip so you can hear that.
Speaker 1: That sounded really horrible. That makes me feel like I
Speaker 1: can't breathe.
Speaker 2: Yeah, so in that clip, there's more inspiratory than expiratory wheezes.
Speaker 2: You can get both. It's not a good sound. You
Speaker 2: definitely know that, like there is something very much wrong
Speaker 2: going on here. But a lot of times with wheezing,
Speaker 2: it's something that we can then say, oh, based on
Speaker 2: the other things that I know about this person who's
Speaker 2: coming in here and this lung exam, I know what
Speaker 2: the next treatment is going to be. Does that make sense?
Speaker 2: I think that's why I like this. It's not like
Speaker 2: they're good.
Speaker 1: So if there are more inspiratory wheezing than expiratory, then
Speaker 1: what what does that indicate?
Speaker 2: That there's probably like a very detailed answer to that
Speaker 2: question that I don't specifically have. You can hear both
Speaker 2: inspiratory and expiatory whezing, but classically something like asthma is
Speaker 2: described as expiratory wheezes, but you can certainly get both
Speaker 2: inspiratory and expiatory wheezing in something like asthma, COPD, et cetera. Okay,
Speaker 2: so that's like the main types of lung sounds that
Speaker 2: you might hear. There's nuances there, there's other types of
Speaker 2: sounds that you might hear too, but these all just
Speaker 2: give the listener a bit of an idea about what
Speaker 2: is going on in the lung and then maybe what
Speaker 2: to do about it.
Speaker 1: I have some questions, okay, okay, so when you're listening
Speaker 1: to first of all, where are you listening to the lungs?
Speaker 1: What is the best place to put that little end
Speaker 1: of the stethoscope.
Speaker 2: Yeah, it's not about one place. It's about listening in
Speaker 2: multiple places and comparing them. So people are always going
Speaker 2: to listen minimum in like four different areas because the
Speaker 2: two lungs and the top and the bottom. But then
Speaker 2: there's also places that can stay kind of hidden, and
Speaker 2: so sometimes you have to listen around like towards the
Speaker 2: front side to get like the right middle lobe. And
Speaker 2: really the more places that you listen across the back,
Speaker 2: the more information that you're going to gather. But it's
Speaker 2: really about comparing one side to the other, and comparing
Speaker 2: the top to the bottom to listen to the whole lung, okay,
Speaker 2: And it's not just so, it's a really good question
Speaker 2: of where do you listen, because it's not just the
Speaker 2: sounds that you're hearing, it's also where you're hearing the sounds.
Speaker 2: Are you hearing crackles everywhere or do you only hear
Speaker 2: them in one specific spot? Are you hearing wheezing everywhere
Speaker 2: or just in one particular spot? And so that information
Speaker 2: is also really important as part of this whole exam.
Speaker 1: Okay, when it comes to something like crackles and wheezing
Speaker 1: and stuff like that, you know, like you said, the
Speaker 1: location of the you know, the origin of that or
Speaker 1: how pervasive it is or whatever, that's important. But what
Speaker 1: about the degree, Like, if you're hearing fine crackles versus
Speaker 1: coarse crackles, what does that tell you if any or
Speaker 1: is it just like a descriptive?
Speaker 2: Yeah, so it might give you ideas about what the
Speaker 2: underlying pathology is. If it's more course versus more fine,
Speaker 2: you think of slightly different pathology. And if it's like runcous,
Speaker 2: like those low pitched wheezes versus those high pitched wheezes,
Speaker 2: it's gonna clue people into different types of disease that's
Speaker 2: going on. If that makes sense, Okay, there's like too
Speaker 2: many different lungs to get into, like all those specifics.
Speaker 1: Well, and then that kind of brings me to another question,
Speaker 1: which is, like we use the stethoscope. It's a tool.
Speaker 1: How often is it the last line? Like, how often
Speaker 1: is it the diagnostic tool, rather than like, oh I
Speaker 1: hear some wheezing, Oh I hear some crackles, We better
Speaker 1: get you an X ray to see just how bad
Speaker 1: it is or whatever.
Speaker 2: Yeah, it so depends on the situation that you're in.
Speaker 1: Right.
Speaker 2: If if somebody is in an emergency room and they
Speaker 2: look super sick, no one's going to end with the stethoscope, right,
Speaker 2: You're going to be getting imaging, You're going to be
Speaker 2: doing more things, and you might be treating something. Even
Speaker 2: if you think that your lung exam sounded totally normal. Right,
Speaker 2: It all just depends on the situation. There are definitely
Speaker 2: situations that this stethoscope might be the last part of
Speaker 2: your diagnosis. For example, a kid who has a known
Speaker 2: history of asthma who comes in having trouble breathing, You
Speaker 2: put a stuff the scope on their chest and they're wheezing,
Speaker 2: then you'd say, okay, let's treat this as an asthma exacerbation,
Speaker 2: and so then you treat it and then see if
Speaker 2: they get better by listening to their lungs again. So
Speaker 2: there are situations where it's still something that you very
Speaker 2: much use and would not then need to do further
Speaker 2: imaging or even like further imaging might not tell you
Speaker 2: all that much. But as we'll talk more about like
Speaker 2: throughout this episode, there are a lot of things about
Speaker 2: the stethoscope that are limitations, I guess of the stethoscope,
Speaker 2: and so there are a lot of new modalities that
Speaker 2: are much better for making diagnosis compared to the stethoscope.
Speaker 1: Right, because there are presumably a lot of lung pathologies
Speaker 1: that you wouldn't be able to hear through a stethoscope,
Speaker 1: but you would be able to see in imaging.
Speaker 2: Yeah, lung and heart especially and heart.
Speaker 1: Yeah. Okay, so then that's sort of another question, and
Speaker 1: this applies to both. This is just like stethoscope broadly. Yeah,
Speaker 1: how subjective is it? Like obviously you can take these
Speaker 1: classes or like in med school, you're trained. Okay, this
Speaker 1: is a wheeze, this is a crackle, this is fine.
Speaker 1: Crackle course, crackle. Yeah, a lot of the heart stuff
Speaker 1: that we haven't touched on yet and then be tested
Speaker 1: on that. But how subjective is it?
Speaker 2: Yeah, that's I think one of the biggest, the biggest questions.
Speaker 2: There's huge inter user variability in stethoscopes. That's one of
Speaker 2: the biggest downsides of them. What one person hears and
Speaker 2: what another person hears, they might describe totally differently. They
Speaker 2: might hear things totally differently, and especially when it comes
Speaker 2: to a lung exam, the lungs change over time, and
Speaker 2: so what one person hears at one moment, another person
Speaker 2: might never be able to hear again because that sound
Speaker 2: might disappear or move or something like that. So there
Speaker 2: is definitely a lot of variability. There was a paper
Speaker 2: that I read that was like lamenting how medical students
Speaker 2: are just no longer trained in the stethoscope, and I
Speaker 2: was like.
Speaker 1: Come on, like, I think I read this was a
Speaker 1: little much. Yeah, well, it's like all of these papers
Speaker 1: seemed so dramatic. They're like so drum already holding like
Speaker 1: a funeral for the stethoscope, and I'm like, I've never
Speaker 1: seen a doctor without one, even if they don't use them, like,
Speaker 1: come on, now.
Speaker 2: I do. I think that it's it's such an interesting
Speaker 2: Medicine has this tendency this is sorry, this is I
Speaker 2: wasn't gonna riff like this until way later in the episode, but.
Speaker 1: Riff away, I love it.
Speaker 2: Medicine has this tendency to like really dramatize new technologies
Speaker 2: as being like the end of the practice of medicine.
Speaker 2: And I think the stethoscope has absolutely gotten caught up
Speaker 2: in that right where it's like, well, if students can't
Speaker 2: use the stethoscope, then where has medicine gone? When it's like, sorry,
Speaker 2: ultrasound is great, you know, right, But at the same time,
Speaker 2: like I I can say, and this is just like
Speaker 2: me as an individual and of one, I use my
Speaker 2: stethoscope very frequently, almost every day as a primary care provider,
Speaker 2: especially one who sees kids. And so I don't think
Speaker 2: that we are at this day and age in twenty
Speaker 2: twenty four at the point where anyone's throwing their stethoscope
Speaker 2: out the window. And I do think that it still
Speaker 2: has clinical uses. And sure, maybe someday it won't and
Speaker 2: we'll be able to replace it, and that's okay, But
Speaker 2: right now, it definitely still has its place, and it
Speaker 2: also isn't the only thing, and it's not perfect for sure.
Speaker 1: Yeah, I mean, medicine has such a short memory where
Speaker 1: it's like, I know, we think that somehow we are
Speaker 1: here and this is how we've always been here.
Speaker 2: Well, that's why I'm so I'm so excited Aaron to
Speaker 2: hear about like when this came, because I know there
Speaker 2: was like controversy when the stethoscope came to be, and
Speaker 2: I just I love, I'm excited for it.
Speaker 1: But onto the heart. We're still on the heart organ
Speaker 1: to discuss.
Speaker 2: I feel like the heart is what probably people think
Speaker 2: about and focus on the most when you think of
Speaker 2: the stethoscope. I don't know, maybe it's a toss up
Speaker 2: heart and lungs, but the heart is a big thing
Speaker 2: that you're also listening to and probably what gets even
Speaker 2: more focus in med school training in terms of the
Speaker 2: specifics of what you're trying to listen for and the
Speaker 2: diagnosis that you're trying to make when it comes to
Speaker 2: heart sounds, because with a stethoscope, with a well trained ear,
Speaker 2: as they say, and a stethoscope, you really can make
Speaker 2: diagnoses of the heart function a little bit better than
Speaker 2: you can with the lungs. At least that's my interpretation
Speaker 2: as a not perfect provider. I don't know whatever. So
Speaker 2: what is someone listening to when they're sticking a stethoscope
Speaker 2: on your heart on the front side of your chest.
Speaker 2: The first thing, of course, is the heart sounds that
Speaker 2: you would expect to hear, and that is loub dub
Speaker 2: lob dub. Let's take a listen to a normal heart,
Speaker 2: shall we love dub love dub.
Speaker 1: Yeah, right, pretty much what I expected.
Speaker 2: Right, do you know what those sounds are?
Speaker 1: Your heart? Technically right erin, right erin.
Speaker 2: Oh, that was quite funny, So yes, it is your heart.
Speaker 2: The first lub, that first sound, also called s one,
Speaker 2: is the beginning of what's called sisterly and that is
Speaker 2: when your heart is contracted. So that sound that you
Speaker 2: hear lub is actually the sound of your valves. Specifically,
Speaker 2: the valves are that go between the top half and
Speaker 2: the bottom half of your heart, so your mitral and
Speaker 2: tricuspid valves snapping shut. That is the sound. It's a
Speaker 2: snapping shut of those two valves. That's that first sound
Speaker 2: that you're hearing, and then the second sound that you
Speaker 2: hear dub is the beginning of diastily, and that is
Speaker 2: when your heart is relaxing, it's filling back up. And
Speaker 2: the sound that you're hearing is the pulmonic and the
Speaker 2: aortic valves closing, so the valves that block off your
Speaker 2: heart from shunting the blood to your lungs and the
Speaker 2: rest of your body. Right, So those are the two
Speaker 2: sounds that we expect to hear S one s two.
Speaker 2: It's the closing of the first two valves and then
Speaker 2: the closing of the second two valves. And there's a
Speaker 2: lot like that sounds just like wow, there is so
Speaker 2: much pathology that you can hear in between those two sounds.
Speaker 2: If those two sounds are split in certain ways, and
Speaker 2: if like one sound is stronger or quieter, where you're
Speaker 2: hearing one sound as stronger than the other. So there
Speaker 2: is like quite a lot of pathology that you can
Speaker 2: actually distinguish within heart sounds. The biggest thing, like the
Speaker 2: most obvious thing that we're looking for in terms of
Speaker 2: like pathologic heart sounds are murmurs. So if the sound
Speaker 2: that you hear love dub are actually just the closing
Speaker 2: of valves, those are kind of discrete sounds right, Lub
Speaker 2: dub lub dub. Murmurs are when those sounds get blurred
Speaker 2: a little bit, and they get blurred because of turbulent flow.
Speaker 2: And so what a murmur sound tells you is that
Speaker 2: something is going on with the valves, which one depends
Speaker 2: on the murmur and depends on where on the chest
Speaker 2: you hear it. But it means that there's something going
Speaker 2: on with the valves so that the flow of blood
Speaker 2: across those valves is no longer a nice linear flow
Speaker 2: like it should be, and it's turbulent, and so it
Speaker 2: causes woushing type of sounds that you can hear. Let
Speaker 2: me play a couple examples of like the most classic
Speaker 2: kind of murmurs, because I think it'll give you a
Speaker 2: really good sense of how different it is from just
Speaker 2: a love dub love dub. WHOA right you hear how
Speaker 2: different that sounds?
Speaker 1: Yeah it's not? Yeah, yeah.
Speaker 2: So that one is a murmur called aortic stenosis. So
Speaker 2: your aorta, of course, is what connects the left ventricle,
Speaker 2: the left side of your heart to the rest of
Speaker 2: your whole body. And that valve is supposed to close
Speaker 2: at s two. It's supposed to be open during sisterly
Speaker 2: when your heart is contracted and blood is supposed to
Speaker 2: be able to flow to your whole body. But what
Speaker 2: can happen sometimes is that valve gets stenotic or hard,
Speaker 2: and so then it doesn't open all the way, so
Speaker 2: it's more narrow. And when that happens, when the blood
Speaker 2: tries to go across that valve, it gets forced. Think
Speaker 2: of like forcing, like sticking your finger on your hose
Speaker 2: or something. And the water that's previously just flowing quietly
Speaker 2: is like whoosh.
Speaker 1: Right.
Speaker 2: Yeah, So you hear this very specific kind of murmur
Speaker 2: that's like hu where it gets louder and then quieter.
Speaker 2: It's called a crescendo de crescendo, I'm telling you. Murmurs
Speaker 2: are like that's a whole language, a musical.
Speaker 1: Yeah.
Speaker 2: Yeah, And so if you hear that, especially at specific places,
Speaker 2: then that can tell you that murmur, that specific murmur
Speaker 2: means that someone has aortic stenosis. Without needing any additional imaging.
Speaker 2: You can say, well, you have an aortic stenosis, okay,
Speaker 2: if you hear that murmur.
Speaker 3: Yeah, there's lots of other kinds of murmurs, and depending
Speaker 3: on where and when you hear them and what they
Speaker 3: sound like, that can tell you is this murmur because
Speaker 3: someone's mitra valve isn't working correctly?
Speaker 2: Is it because someone's tricuspid valve so on the right
Speaker 2: side of their heart, Is that the one that's not working?
Speaker 2: Is the murmur in sistily, so when the heart is
Speaker 2: contracted or is it in diastily when those ventricles are
Speaker 2: trying to fill back up? Right, There's a lot of
Speaker 2: different things that you can get from when that murmur
Speaker 2: is and what it sounds like.
Speaker 1: Interesting, I know.
Speaker 2: So there there is definitely a lot of pathology that
Speaker 2: you can't hear with the stethoscope. Even that example that
Speaker 2: I gave of aortic stenosis, if it's really severe, you
Speaker 2: actually don't hear it at all because now it's just
Speaker 2: like such a tiny valve that you just can't you
Speaker 2: can't even hear the flow across that valve, okay, And
Speaker 2: there is varying degrees. For example, let me play a
Speaker 2: great This is a great classic med school murmur that
Speaker 2: happens with what's called mitral regurgitation. So when the valve
Speaker 2: on the left side of your heart is a little floppy,
Speaker 2: then sometimes you get backflow of blood during when your
Speaker 2: blood is supposed to be squeezing out to your aorda.
Speaker 2: So if you listen to this whoa, So that one
Speaker 2: sounded different, right than the previous murmur. Yes, so that
Speaker 2: one also had a fun little what's called an extra
Speaker 2: heart sound that you can get when you have other
Speaker 2: kinds of heart pathology, Like if your heart is very dilated,
Speaker 2: then you might get these like extra instead of love dub,
Speaker 2: it's like love da dub loub bub bub thing. So
Speaker 2: you might hear that murmur in someone if that pathology
Speaker 2: is severe, if you maybe have a crappy stethoscope or
Speaker 2: don't know what you're listening for, or if it's just
Speaker 2: not that severe you have like a little bit of regurgitation,
Speaker 2: then yeah, you might not hear that with a stethoscope.
Speaker 2: There are other modalities like ultrasound, Gonna keep saying it,
Speaker 2: where you would be able to see the blood flow
Speaker 2: because you're actually seeing the blood rather than just hearing
Speaker 2: the blood flow. So that's like the main and most
Speaker 2: obvious kinds of things that you'd be listening for in
Speaker 2: a heart and really it all comes down to trying
Speaker 2: to get a picture of how the valves are working
Speaker 2: and how the heart is squeezing a little bit of
Speaker 2: information about how it's squeezing. And you can get all
Speaker 2: of that information just by listening for these murmurs and
Speaker 2: listening at different places on your chest. So you asked
Speaker 2: when we were talking about the lungs where you listen.
Speaker 2: There's four main places that people listen to listen to
Speaker 2: the heart, and those are named after the four valves,
Speaker 2: so aortic, pulmonic, tricuspit, and mitrol. All physicians take money. Haha,
Speaker 2: that's rever.
Speaker 1: It took me a second.
Speaker 2: I was like, whoa, Okay, sorry, that's how we remembered
Speaker 2: it in med school. But so depending on what type
Speaker 2: of murmur you hear and where you hear it, it
Speaker 2: can give you clues as to what that pathology might be.
Speaker 2: And then there are degrees of like is it a
Speaker 2: really loud one or is it a really soft one?
Speaker 2: Does it start out loud and then get softer? Like
Speaker 2: there's so much that like people who are really really
Speaker 2: good at murmurs would be like the joke is like
Speaker 2: if a cardiologist can just like touch their stethoscope to
Speaker 2: someone's chest, they'll hear a murmur that a med student
Speaker 2: would have to like listen really closely with the best
Speaker 2: possible stethoscope to hear. There's like all these jokes about it.
Speaker 1: But that's a really good joke, isn't it.
Speaker 2: I'm just hilarious. I told it really well. But that's
Speaker 2: like how you rate the degree, Like is it a
Speaker 2: one out of six, a three out of six, blah
Speaker 2: blah blah.
Speaker 1: That's there is like a scale.
Speaker 2: Yeah, there's a scale out of six on how loud
Speaker 2: a murmur is?
Speaker 1: Okay, interesting, And then like presumably, I mean this is
Speaker 1: getting into like other things, not stethoscope, but like presumably
Speaker 1: then that is do we do surgery? Do like what
Speaker 1: are the steps that you take?
Speaker 2: Totally totally? What are the next steps? It all depends
Speaker 2: on what that murmur is, how long has it been there.
Speaker 2: Because there are lots of totally benign murmurs, especially in childhood,
Speaker 2: these tend to be often described as musical murmurs. The
Speaker 2: ones that we listen to we're all very pathologic murmurs.
Speaker 2: But there are lots of different flavors of murmur, and
Speaker 2: some of them, if someone hears would definitely choir follow
Speaker 2: up and some of them probably wouldn't. Okay, It all
Speaker 2: just depends on like how old is the person, is
Speaker 2: it the first time you're ever hearing it, et cetera,
Speaker 2: et cetera. Right, so that's what we do with the stethoscope.
Speaker 2: We'll talk a lot more about like how far we've come.
Speaker 2: But that's like when someone sticks a stethoscope on your chest.
Speaker 2: That's what they're trying to figure out is does it
Speaker 2: just sound like love dub and like or does it
Speaker 2: sound weird?
Speaker 1: Yeah?
Speaker 2: There you go, Aaron, I had this guy come up
Speaker 2: with it. How did we do anything before it?
Speaker 1: Oh? Those are great questions, and I can't wait to
Speaker 1: tell you what I can of the answers to them
Speaker 1: right after this break. We've kind of talked about this already, Aaron.
Speaker 1: But truly, is there anything that symbolizes doctor more than
Speaker 1: the stethoscope?
Speaker 2: I mean, the little uh what do you call it?
Speaker 2: The snake or whatever? Yeah? No, no, it's I mean.
Speaker 1: Like, okay, I thought maybe the white coat could also
Speaker 1: count shorter, but then like you could see a picture
Speaker 1: of someone in a white coat and think, oh, maybe
Speaker 1: they're a scientist who.
Speaker 2: Works in a lab. Yeah, it's a little more generalized.
Speaker 1: Yeah, but the stethoscope. That's the thing that acts as
Speaker 1: the visual cue for doctor.
Speaker 2: Yeah.
Speaker 1: It's included in every single doctor Halloween costume, any like kids,
Speaker 1: doctor play set, any toy figurine of a doctor. If
Speaker 1: you Google image search just the word doctor, which I did,
Speaker 1: nearly every single picture features a person in a white
Speaker 1: coat with a stethoscope. I will note that the first
Speaker 1: picture that did not include a physician with the stethoscope
Speaker 1: was Mic Dreamy from Anatomy. I can't remember the character's
Speaker 1: real name.
Speaker 2: Was it Jared m It does start with a G,
Speaker 2: I think Nope, anyway, dream Mick Dreamy is the gray
Speaker 2: hair guy, right.
Speaker 1: I don't think. I don't know if it started out gray.
Speaker 2: Oh.
Speaker 1: I never finished the show. I stopped when one of
Speaker 1: the characters turned into a ghost.
Speaker 2: And yeah, I remember that we had an elvad too,
Speaker 2: right anyways.
Speaker 1: Fifteen years ago. But studies have shown that doctors with
Speaker 1: stethoscopes are perceived as more trustworthy than those without, which
Speaker 1: I think is fascinating. Huh. The stethoscope is such an establishment,
Speaker 1: It is such an integral part of practicing medicine, even
Speaker 1: if it's not used that it seems impossible to imagine
Speaker 1: a time when it didn't exist, more a future without
Speaker 1: the minute, although as we'll discuss, that does seem to
Speaker 1: be the future that some people are envisioning. It's more
Speaker 1: controversial than I bargained for. I did not expect to
Speaker 1: see articles with headlines like bring back the stethoscope, save this,
Speaker 1: you know, relic of medicine, And I'm like, really, like.
Speaker 2: It's hilarious to me how much drama there can be
Speaker 2: in medicine sometimes about things like that.
Speaker 1: Right, I was like, we just talked to me, just
Speaker 1: mentioned Gray's anatomy. Of course there's drama in medicine. But
Speaker 1: as it turns out, the stethoscope is actually a lot
Speaker 1: younger than I expected it to be, and its development
Speaker 1: marked the beginning of a huge transition in medicine and
Speaker 1: in the relationship between patient and doctor. So let me
Speaker 1: take you back to the second half of the seventeen hundreds.
Speaker 1: Medicine during this period of time was still very much
Speaker 1: under the spell of Hippocrates and the humoral theory of disease,
Speaker 1: where illnesses, of course, were thought to be caused by
Speaker 1: an imbalance in the body's humor's blah, blah blah. Human
Speaker 1: anatomy was still in its early stages, since dissections had
Speaker 1: long been seen as sacrilegious and only recently were people
Speaker 1: beginning to develop an atlas of the entire human body.
Speaker 1: And as a result, this belief persisted that most illnesses
Speaker 1: were not localized but systemic, owing to this humoral imbalance.
Speaker 1: And I'm talking the origin was systemic, not the effects
Speaker 1: were systemic, right, right, And so things like heart disease,
Speaker 1: liver disease, illnesses associated with the lungs, they weren't really
Speaker 1: conceptualized the way that we think of them today. Diseases
Speaker 1: of the heart were known, but symptoms indicative of heart
Speaker 1: disease weren't really considered, if that makes sense. So like
Speaker 1: someone has a symptom of something and you think, oh,
Speaker 1: that symptom is in their heart, but it's a systemic disease.
Speaker 1: I think it's their entire bodies humors that are imbalanced,
Speaker 1: not the anatomy of their heart is actually not functioning
Speaker 1: the way that it should.
Speaker 2: It's like their heart isn't working because the rest of
Speaker 2: their body is off balance.
Speaker 1: Yes, okay, yeah. And part of what perpetuated this was
Speaker 1: that in the late eighteenth and into the nineteenth centuries,
Speaker 1: physicians were limited in what they could observe in a
Speaker 1: patient beyond what the patient themselves could tell them, which
Speaker 1: is important, as we know, and it sort of I
Speaker 1: think has over time. We've now the pendulum has swung
Speaker 1: in the other direction to some degree, but it doesn't
Speaker 1: always capture all of the elements, right Like, someone can
Speaker 1: feel completely not sick whatsoever, and there could be something
Speaker 1: that shows up there on whatever imaging, or shows up
Speaker 1: even with a stethoscope. And if you remember from our
Speaker 1: fever episode, watches with second hands weren't developed until the
Speaker 1: sixteen nineties, which only then allowed physicians to accurately measure
Speaker 1: pulse rate, and the mercury thermometer, invented in seventeen fourteen
Speaker 1: wasn't regularly employed by physicians until the early to mid
Speaker 1: eighteen hundreds, and the incorporation of these tools into medicine,
Speaker 1: especially for diagnostic purposes, was part of this larger trend
Speaker 1: in the scientific search for truth with a capital T,
Speaker 1: like objective truths that could be measured and standardized so
Speaker 1: that their meanings remained constant across individuals, across space and
Speaker 1: across time. In medicine. It seemed to be driven in
Speaker 1: part by a mistrust by the physician of the patient's
Speaker 1: account of things. The physician's like, well, I can't trust
Speaker 1: what you're telling me. I gotta see it for myself.
Speaker 1: I got to hear it for myself. I gotta smell
Speaker 1: it for myself. Whatever. It is not necessarily malicious, but
Speaker 1: a recognition that people's accounts can vary, sensations can feel
Speaker 1: differently to different people, and that there could be a
Speaker 1: disconnect between the way someone feels and what they're experiencing,
Speaker 1: like fever, for instance, where you might feel freezing cold,
Speaker 1: but actually your temperature is burning up low grade fever.
Speaker 1: One of these tools or methods to make objective measures
Speaker 1: in medicine was developed in seventeen sixty one by a
Speaker 1: physician from Vienna named Leopold Irenbruger. Essentially, percussion entailed tapping
Speaker 1: a person's body with their fingers and then listening to
Speaker 1: the sounds produced, which were supposed to tell you the
Speaker 1: quote vitality of the internal organs, especially the heart and lungs,
Speaker 1: so you would like thunk, yeah. And he wasn't the
Speaker 1: first to listen to the internal goings on of the organs,
Speaker 1: but he was among the first to write about it
Speaker 1: systematically and apply it to specific diagnoses. So like, maybe
Speaker 1: a dull funk meant that the lungs were full of fluid,
Speaker 1: or a hollow echo meant the spleen was doing just fine.
Speaker 1: I don't really know the guidelines I'm making. I made
Speaker 1: all of that up, but neither did the physicians who
Speaker 1: came across his treatise, which apparently included only the vaguest
Speaker 1: of descriptions.
Speaker 2: Gotta love that.
Speaker 1: Yeah, right, He's like, let me tell you about this method.
Speaker 1: It's really great, and you just tap your fingers on
Speaker 1: a person's body and then listen, and then what you
Speaker 1: hear will tell you everything about what the person has
Speaker 1: the end, and so this sort of lack of description
Speaker 1: probably had something to do with his method of percussion
Speaker 1: not catching on the way that he had hoped, but
Speaker 1: it was also because what he was proposing was very
Speaker 1: much outside of the norm for medicine at the time. Because,
Speaker 1: for one thing, this method of percussion required physicians to
Speaker 1: think of the body and disease in anatomical terms, which
Speaker 1: was still very much a new concept. Anatomy took a
Speaker 1: backseat in most explanations of the day of how disease
Speaker 1: began and how it developed. And secondly, to successfully employ
Speaker 1: the percussion technique, physicians really had to get in there,
Speaker 1: like up close and personal, had to touch their patients
Speaker 1: and then they would have to bring their head close
Speaker 1: to their chest or whatever part of their body to
Speaker 1: get a good listen. And this was something that would
Speaker 1: you know, called into question the physician's dignity, since manual
Speaker 1: labor was considered beneath the physician at the time. They
Speaker 1: were intellectuals, not common laborers. They used their minds, not
Speaker 1: their hands.
Speaker 2: I find that so interesting and not at all a
Speaker 2: part that you learn about medicine.
Speaker 1: Yeah. Yeah, well, and it's also okay, let me read
Speaker 1: you a quote that I think even brings a little
Speaker 1: bit more color into this picture. Quote. In particular, the
Speaker 1: physical intimacy required by percussion threatened to undermine the professional
Speaker 1: standing of the physician, even to place him in a
Speaker 1: class with the surgeon, over whom he affirmed both medical
Speaker 1: and social superiority. End quote.
Speaker 2: Wow it's a surgeon. Yeah, run deep.
Speaker 1: Yeah they told Wow, So I think it was. It
Speaker 1: was really interesting, Like the divide was so stark and
Speaker 1: the hierarchy was so well established where a physician was
Speaker 1: a thinking man. He was I mean, and I say
Speaker 1: man because pretty much yep what I mean and uh
Speaker 1: and yeah. So it was like, no, they make diagnoses
Speaker 1: with their books, with their minds, with the way that
Speaker 1: they take in all of the data. They don't cut,
Speaker 1: they don't touch. That's just fascinating to me. Oh, Aaron,
Speaker 1: this profession, I know, I know. And so Aaron Berger's
Speaker 1: percussion had a lot working against it and it largely
Speaker 1: faded into obscurity, but it did catch on in a
Speaker 1: handful of doctors who passed it down to their trainees.
Speaker 1: One of these trainees went by the name of Renee
Speaker 1: theotfully Hyacinth Lenek. I'm just gonna say Lenek from this
Speaker 1: point forward. Lenek was born in France on February seventeenth,
Speaker 1: seventeen eighty one. When he was just five, his mother
Speaker 1: died from tuberculosis, and his father sent him to live
Speaker 1: with a great uncle. His childhood and youth was filled
Speaker 1: with playing the flute, reciting and composing poetry, learning Latin
Speaker 1: and Greek, and going to the countryside for fresh air.
Speaker 1: When his asthma acted up and I just need your Okay.
Speaker 1: I found this paper from like the nineteen twenties that
Speaker 1: was celebrating the life of Linek. Like no one was
Speaker 1: higher in this person's esteem than Linek was. It was
Speaker 1: the most praise. Okay, let me just get to it. Quote. Okay,
Speaker 1: from this land of salt sea breeze, gray rocks and
Speaker 1: downs and druidical forests of mystery came the calm and
Speaker 1: prodigious intellect of one comparable only two Hippocrates, in his
Speaker 1: vast store of medical lore and almost superhuman accomplishments. End quote.
Speaker 2: Okay, I mean did someone's chest.
Speaker 1: I mean he did a lot, but like I know,
Speaker 1: I mean he also was the first to besides the sethoscope,
Speaker 1: he did other things too. I think he died lenex cirrhosis.
Speaker 1: He described that for the first time.
Speaker 2: I think there's rules named after him and stuff. Yeah,
Speaker 2: and he.
Speaker 1: He identified melanoma as not as being a cancer and
Speaker 1: separate from he like a lot of people thought at
Speaker 1: the time that was tuberculosis, like the black granules that
Speaker 1: came to the surface, and he's like, no, this is
Speaker 1: not that anyway. But when he was when Lenek was
Speaker 1: fourteen and a half. He started as a student in
Speaker 1: the School of Medicine of the Hotel due at Nance
Speaker 1: and quote. Soon after he was appointed military surgeon of
Speaker 1: the third class at a salary of something like nothing
Speaker 1: a year out, which, first of all, a few things
Speaker 1: to unpack. I love the description of something like nothing.
Speaker 1: And then soon after he was fourteen when he enrolled
Speaker 1: to imagine, like a fifteen year old.
Speaker 2: How soon are we talking couple years, five years, one year?
Speaker 1: I would think he was probably within a few years.
Speaker 2: Oh my god.
Speaker 1: Yeah, So in this in his stint, he did a
Speaker 1: bit of surgeoning with the troops, and then when that
Speaker 1: was over, he continued his medical education in Paris, which
Speaker 1: of course is where he invented the incredible device, for
Speaker 1: which he still receives just untold praise from like the
Speaker 1: author of that article. The story goes that as he
Speaker 1: was on his way to the hospital one morning in
Speaker 1: September eighteen sixteen, he saw some children playing with a
Speaker 1: wooden beam and a pin. One kid held the end
Speaker 1: of the piece of wood to his ear while his
Speaker 1: friend scratched the other end with a pin, sending little signals. Okay,
Speaker 1: did this actually happen? I probably shan't. I doubt it.
Speaker 1: I highly doubt it. I don't think he ever wrote
Speaker 1: about it personally. I think it only shows up in
Speaker 1: people who wrote about Lennek how funny.
Speaker 2: Yeah, that fateful day he remembered seeing those children, like
Speaker 2: come on.
Speaker 1: But maybe it did happen. Maybe, And he I think,
Speaker 1: you know, if it did happen, the incident would have
Speaker 1: probably been soon forgotten. If not, he had a particular patient,
Speaker 1: and like you heard about in the first hand account,
Speaker 1: he couldn't use his usual method of percussion or direct ouscultation,
Speaker 1: where he like put his ear directly on this person's
Speaker 1: chest because his patient was a young woman with suspected
Speaker 1: heart failure, which we didn't mention this at the top,
Speaker 1: but we included audio of a clip of someone who
Speaker 1: has heart failure.
Speaker 2: Yeah, in acount those crackles, the crackles, yeah yeah.
Speaker 1: And so yeah, he was like, well, I don't want
Speaker 1: to get up close and personal. This is really uncomfortable.
Speaker 1: And so then he the first hand account, he rolled
Speaker 1: up that piece of paper and was like, whoa, I
Speaker 1: can this is amazing. This has potential not only for
Speaker 1: this particular patient in this particular situation, but so many
Speaker 1: things like. He immediately saw potential, and over the next
Speaker 1: few years, Lenek put this new tool to work and
Speaker 1: he called it the tethoscope, meaning I look into the chest.
Speaker 1: He played around with different designs and materials, starting with
Speaker 1: a piece of paper tightly rolled like he described, and
Speaker 1: then he would like glue the ends to try to
Speaker 1: create more of a I don't know, capture the sound
Speaker 1: because it would come out and I don't know how
Speaker 1: anything about like audio engineering works, which is you know.
Speaker 2: Yeah, that was the thing I thought about looking into.
Speaker 2: And then I was like at physics and me don't
Speaker 2: get along, so I didn't.
Speaker 1: And then he tried different materials. He tried ivory, he
Speaker 1: tried gold beater's skin, which I looked it up. It's
Speaker 1: made from an animal's intestine, so like yep. Then he
Speaker 1: tried various woods, and ultimately he landed on soft woods
Speaker 1: with an opening at the end. So Aarin you described
Speaker 1: this modern stethoscope. Yeah, if you saw, if you just
Speaker 1: like saw in a random museum or antique store or something,
Speaker 1: one of Lenex's early stethoscopes, you would not recognize it
Speaker 1: as a stethoscope. You'd be like, what is this? Like
Speaker 1: long pin it's like a wooden cylinder.
Speaker 2: I would because I've seen pictures of them. But like,
Speaker 2: if you haven't seen pictures of them, you would not
Speaker 2: You would think it was like just a stick thing.
Speaker 1: Yeah, it looks like a stick. Maybe there's like a
Speaker 1: flaring out at the end. Maybe, yeah, maybe, which is
Speaker 1: funny because I think that, like now, our image of
Speaker 1: the stethoscope is of the modern stethoscope, which is not
Speaker 1: that that old, and so it's it's just funny, it's
Speaker 1: like anyway. Yeah. But so in eighteen nineteen, Lenek presented
Speaker 1: his stethoscope to the world with the publication of his
Speaker 1: two volume on media Ouscultation, available for the low price
Speaker 1: of thirteen francs or sixteen if you wanted a stethoscope
Speaker 1: included with it. He made a bunch of them, which
Speaker 1: is a complete stroke of genius, Right.
Speaker 2: That is really funny. Here's the book and here's the thing.
Speaker 1: Yeah, He's like, do you don't have to wonder what
Speaker 1: this is like? You don't have to wonder what these
Speaker 1: noises I'm describing. See for yourself, here for yourself.
Speaker 2: Love it.
Speaker 1: Yeah. His book and the Stethoscope took off in popularity,
Speaker 1: probably in part because the device was included with it,
Speaker 1: or you could you could buy it. But also because
Speaker 1: his descriptions of various chest sounds in association with certain
Speaker 1: diseases were so detailed and precise. Yeah, like let me
Speaker 1: read you a quote, Oh I love it. Quote when
Speaker 1: the patient coughed or spoke, and still more, during respiration,
Speaker 1: there was heard a tinkling like that of a small
Speaker 1: bell which has just stopped ringing, or of a gnat
Speaker 1: buzzing within a porcelain vase.
Speaker 2: Right, and like you really understand what you're hearing or
Speaker 2: what you're supposed to be hearing, or what he was hearing.
Speaker 1: Yes, what a way with words like I don't think
Speaker 1: I would be as creative or articulate.
Speaker 2: You heard me hearing I was like, you know, it's
Speaker 2: like whoosh.
Speaker 4: And.
Speaker 1: Now put that in writing and there you go. And
Speaker 1: so in these volumes he created new terminology entirely like stethoscope,
Speaker 1: but also rails fremidous, cracked pot sound, metallic tinkling, egoffany, bronchophony,
Speaker 1: cavernous breathing, puerile breathing, veiled puff, and brute. Yeah.
Speaker 2: Yeah, some of those words we still use.
Speaker 1: It's kind of amazing. I mean, like, okay, maybe I
Speaker 1: am back to thinking that he's like hypocrites level. But
Speaker 1: with this tool and his book, Lenek revolutionized medicine. The
Speaker 1: stethoscope has been called the first major diagnostic tool of
Speaker 1: modern medicine. Before the stethoscope, there was virtually no way
Speaker 1: to observe what was going on inside the body except
Speaker 1: for autopsy, which of course happened after death, or surgery,
Speaker 1: which at the time almost always led to death. With
Speaker 1: this device, Lenek was able to say, these sounds are
Speaker 1: linked to this disease or this illness, and then he
Speaker 1: could confirm the location and pathology in autopsy later on,
Speaker 1: something that again was in its early stages, like the
Speaker 1: concept of localized disorders. His book flew off the shelves
Speaker 1: as this tethoscope picked up speed, leading to more refined descriptions,
Speaker 1: applications outside of lung and heart sounds like in obstetrics
Speaker 1: and orthopedics, and then people started to make variations in
Speaker 1: the design of the device that allowed for better listening.
Speaker 1: So Lenek, who was only thirty five years old when
Speaker 1: he invented the stethoscope, would only live to see some
Speaker 1: of this excitement because, of course, having a diagnostic tool
Speaker 1: doesn't necessarily help prevent or treat or cure disease. Linek
Speaker 1: had never been the image of perfect health, even as
Speaker 1: a kid, But as the eighteen twenties rolled around, his asthma,
Speaker 1: his insomnia, and his chest pain got worse. In eighteen
Speaker 1: twenty six, he had a sense that things were coming
Speaker 1: to an end. He had a fever, productive cough, shortness
Speaker 1: of breath, and he'd been a doctor long enough to
Speaker 1: know the signs of tuberculosis when he saw them, but
Speaker 1: he had for years denied that he had the disease.
Speaker 1: A lot of people in his family had gotten sick
Speaker 1: and died of tuberculosis, and so maybe it was sort
Speaker 1: of a matter of just like, I don't this can't
Speaker 1: this can't happen to me? How can this happen to me?
Speaker 1: And so finally, in the summer of eighteen twenty six,
Speaker 1: while in the countryside, he had his physician nephew listen
Speaker 1: to his chest using the tool of his own invention,
Speaker 1: what he called, quote unquote, the best part of my
Speaker 1: legacy and the diagnosis. I don't know, I don't know
Speaker 1: why I feel so sad.
Speaker 2: This is more emotional than I expected.
Speaker 1: I know, I can feel tears. The diagnosis was I'm laughing,
Speaker 1: but I really do feel sad. Yeah, the diagnosis was
Speaker 1: tuberculosis and he died later that summer at the age
Speaker 1: of forty five.
Speaker 2: Wow.
Speaker 1: Yeah, but as we all know, the stethoscope didn't die
Speaker 1: with him at all. There was some resistance Aarin you
Speaker 1: kind of alluded to that earlier, like some patients were
Speaker 1: afraid of this new instrument. Some physicians felt like the
Speaker 1: physical labor aspect of it gave off too much of
Speaker 1: a surgeon vibe. But most of the energy was focused
Speaker 1: on better incorporating the tool into medicine, like how can
Speaker 1: we use this what are the max how can we
Speaker 1: maximize the use of this tool? And so the rest
Speaker 1: of the nineteenth century was filled with improvements on linex's
Speaker 1: simple design. In the eighteen fifties, doctor George Phillip Comans
Speaker 1: developed the first two ear stethoscope. Smaller stethoscopes were introduced
Speaker 1: so you could carry them more easily. People worked on
Speaker 1: flexible stethoscopes, and in the early nineteen hundreds, physicians realized
Speaker 1: that they could pick up sounds better if they stretched
Speaker 1: a diaphragm over the mouth. Of that little open cup
Speaker 1: at the end of the stethoscope. As the century came
Speaker 1: to a close, it seemed like the stethoscope was here,
Speaker 1: to say, a permanent fixture in medicine. But is there
Speaker 1: such a thing us? Yeah, I mean, if there is,
Speaker 1: the stethoscope is probably the closest thing to it, but
Speaker 1: its future seems uncertain. At least that's what we've been
Speaker 1: talking about based on some of these papers titled things
Speaker 1: like throw the Stethoscope Away, a historical essay and in
Speaker 1: defense of the Stethoscope and the bedside.
Speaker 2: I have some good ones too.
Speaker 1: And although these papers are from the last couple of decades,
Speaker 1: the sentiment of behind this is a lot older, as
Speaker 1: is the downward trend in the stethoscope's use. Why is
Speaker 1: that we've talked about this like other diagnostic more precise
Speaker 1: tools have come onto the scene that provide better and
Speaker 1: more accurate pictures of what might be going on, like
Speaker 1: the X ray machine, which is quite old, and when
Speaker 1: it was introduced and started to become widely used, it
Speaker 1: replaced the stethoscope as a major diagnostic tool of lung
Speaker 1: conditions or CT scans, MRIs, chest radiograph, ultrasounds, and so on.
Speaker 1: With these instruments, we move closer and closer to objectivity
Speaker 1: in medicine in terms of measuring tools, not in terms
Speaker 1: of bias. Medicine is not objective by any means. Percussion
Speaker 1: was developed and the stethoscope invented so that physicians could
Speaker 1: better observe for themselves what was going on inside their patient,
Speaker 1: to not have to rely on their patient's testimony entirely
Speaker 1: to make a diagnosis and decide on a course of treatment.
Speaker 1: But like we've talked about the noises that people hear,
Speaker 1: the sounds that you hear in a stethoscope, they are
Speaker 1: open to interpretation, to misdiagnosis, to simply not hearing them
Speaker 1: at all. And several studies have confirmed that stethoscopes harbor
Speaker 1: lots of germs like MRSA, although I don't know if
Speaker 1: they are significant vectors for transmission or if that's been measured.
Speaker 2: Oh, there is a paper that measures that it doesn't
Speaker 2: carry sea diff which is nice than most of the papers.
Speaker 1: That's great, yeah, right, yeah, But teaching these sounds can
Speaker 1: be difficult in that regard. You know, it's like in
Speaker 1: the ear of the beholder, I guess a squawk to
Speaker 1: one physician might sound like a bell clang or crackle
Speaker 1: to another. The ideal diagnostic test in medicine is one
Speaker 1: that produces results that look the same to every physician, right, Like,
Speaker 1: wouldn't we want them to be universally yes? No, binary, almost.
Speaker 2: We would?
Speaker 1: We would? I mean that's the ideal. Yeah.
Speaker 2: Is any diagnostic test capable of that at this point?
Speaker 1: No? I doubt it, but I mean maybe, but I
Speaker 1: think we can get closer, you know, And I think
Speaker 1: that's the whole thing behind it. And this isn't to say,
Speaker 1: of course, that noting that squawk or bell clang or
Speaker 1: whatever isn't important, because that might be what gets you
Speaker 1: to order additional tests to find out what's going on.
Speaker 1: And the stethoscope itself is I think, an opportunity to
Speaker 1: keep met present in the room, like grounded in humanity
Speaker 1: and physical diagnosis and dependent in part on bedside skills.
Speaker 1: And I want to hear you like your thoughts on
Speaker 1: all this, but first let me leave you. Yeah, let
Speaker 1: me leave you with this quote from a nineteen seventy
Speaker 1: nine article that I really liked. Quote today, the stethoscope
Speaker 1: is the old warrior of medicine. Although it cannot compete
Speaker 1: with the array of elaborate and expensive technologies for which
Speaker 1: it paved the way. It clings tenaciously resisting retirement. Its
Speaker 1: staying power in modern times is based in part on
Speaker 1: its giving both physicians and patients a sense of continuity
Speaker 1: with the past. Identified with dependable diagnosis, the familiar object
Speaker 1: evokes confidence. Most important, it provides those physicians who still
Speaker 1: know how to use it with good, immediate and low
Speaker 1: cost information that can eliminate the need for complicated diagnostic tests.
Speaker 1: End quote. So, Aaron, what do you think is the
Speaker 1: art of usuations something we should preserve or is that
Speaker 1: sentiment just a reflection of the natural resistance to change
Speaker 1: in fear of the new?
Speaker 2: Oh, I cannot wait to tell you Aaron's Opinion corner
Speaker 2: about this right after a quick break erin It's funny
Speaker 2: that you ended that section with a quote from a
Speaker 2: paper from nineteen seventy nine, because I actually I'm guessing
Speaker 2: it's the same paper.
Speaker 1: The one from by Riser from Scientific American.
Speaker 2: Yes, yes, I also have a quote from that paper,
Speaker 2: but it's a totally different quote, and it's like the
Speaker 2: opposite end of the coin. And I think what it
Speaker 2: highlights is what you mentioned, which is like, why does
Speaker 2: the stethoscope represent what it has come to represent in
Speaker 2: this like push and pull of like new technology and
Speaker 2: physical exam and all these things. So let me read
Speaker 2: to my quote from that same paper, yay okay.
Speaker 1: Quote.
Speaker 2: When the nineteenth century physician chose to make diagnosis less
Speaker 2: on patient's verbal accounts of their symptoms and more on
Speaker 2: the physical signs of illness that in many cases he
Speaker 2: alone detected, he was obliged to make up his own
Speaker 2: mind about illness. As a medical era, the twentieth century
Speaker 2: must be characterized as a time when physicians have come
Speaker 2: to rely less on themselves and more on specialists, tech
Speaker 2: tgnicians and machines to collect and evaluate the evidence of disease.
Speaker 2: End quote.
Speaker 1: Aaron I almost included that quote.
Speaker 2: It's just it's such a good one, because that really
Speaker 2: is what it feels like. It comes down to where
Speaker 2: there are people who say that the stethoscope is a mark,
Speaker 2: like the ability to use a stethoscope to make a diagnosis,
Speaker 2: to have that good ear like that's the mark of
Speaker 2: a good physician, and the fact that we are kind
Speaker 2: of doing away with it, or there are people who
Speaker 2: say we need to do away with it, like that
Speaker 2: is the problem with medicine and blah blah blah. Right,
Speaker 2: these new technologies are going to replace us as physicians.
Speaker 2: Like that is that is something that you hear and
Speaker 2: not just about the stethoscope. That's like a fear of medicine.
Speaker 2: Like what is the future of the physician in the
Speaker 2: face of all of these new technologies? Jeez. I think
Speaker 2: that the stethoscope and the problems with the stethoscope and
Speaker 2: the new technologies that exist really get at the heart
Speaker 2: of that fear that exists in the practice of medicine.
Speaker 2: My Okay, now for my opinion corner.
Speaker 1: Yeah, yeah, I want to hear your opinion corner.
Speaker 2: So, like I said, like I use a stethoscope pretty frequently.
Speaker 2: Do I use it every day? Definitely not. Do I
Speaker 2: use it on every patient? Definitely not. Do I always
Speaker 2: feel like I'm really confident in what I'm hearing? Nope,
Speaker 2: definitely not. I think that in terms of the like
Speaker 2: future of medicine question, Like the stethoscope is such a
Speaker 2: minor thing in that it's like it's a symbol. Errand yeah,
Speaker 2: it's one hundred dollars or one hundred and fifty dollars,
Speaker 2: which when I was in med school was super expensive
Speaker 2: and for a lot of people is very cost prohibitive.
Speaker 2: But like compared to an ultrasie, compared to an X ray,
Speaker 2: like it's really a drop in the bucket. Is it useful, Sure,
Speaker 2: it's still useful today. Is it the end all be all?
Speaker 3: No?
Speaker 1: Should it be.
Speaker 2: A substitute for these incredible technologies that are coming out?
Speaker 2: Absolutely not. And what I think is so interesting is that, like,
Speaker 2: there doesn't have to be a reality where these new
Speaker 2: technologies threaten medicine as a practice. Right, if we use
Speaker 2: the stethoscope as an example, Yes, there is wide user
Speaker 2: variability in the stethoscope, and it's an imperfect tool and
Speaker 2: there's areas for improvement, but it has its place, and
Speaker 2: so many other tools that we also use have inter
Speaker 2: user variability. Right, think about an X ray. Not every
Speaker 2: radiologist interprets an X ray the same way. And so
Speaker 2: I think that what this lets us get at is
Speaker 2: one of the ways that the stethoscope itself and the
Speaker 2: practice of ouscultation can act and has begun to be
Speaker 2: improved upon in the same way that X rays and
Speaker 2: radiology and things are being improved upon and that is data.
Speaker 2: So with the advent of digital stethoscopes, you are able
Speaker 2: to not only augment the sounds that you're hearing by
Speaker 2: doing things like noise canceling, like reducing ambient noise, and
Speaker 2: then amplifying the sounds that you hear, which makes it
Speaker 2: easier for the user to hear the sounds. It also
Speaker 2: allows for us to record sounds. Recording tons and tons
Speaker 2: of sounds of normal and abnormal hearts and lungs, allows
Speaker 2: for things like machine learning algorithms to compile all of
Speaker 2: this data. And what's really cool is that you said aran, like,
Speaker 2: what is a crackle to one person might sound like
Speaker 2: a squawk to another, And that is true in that
Speaker 2: someone might say one word or a different word, or
Speaker 2: interpret something. But if you look at wavefour, there are
Speaker 2: very distinct waveforms associated with these things that we call crackle,
Speaker 2: fine crackle, coarse crackle. Like if you can look at
Speaker 2: this on a computer screen instead of only relying on
Speaker 2: your ear to hear the differences, then you can actually
Speaker 2: pick up on things in a much more specific way
Speaker 2: by combining the digital stethoscope with imaging of that sound
Speaker 2: in terms of waveform.
Speaker 1: Which is awesome, it's so cool.
Speaker 2: But there's so much more than just digital stethoscopes. And
Speaker 2: if there is one single tool that may spell the
Speaker 2: downfall of the stethoscope, it's another pretty old one that
Speaker 2: has gotten upgrades in recent decades, and that is the ultrasound.
Speaker 2: So specifically, what is called point of care ultrasound. And
Speaker 2: I'm not going to get into details of ultrasound, because again,
Speaker 2: physics and me are not friends, but everyone can probably
Speaker 2: picture an ultrasound machine if you've ever seen, either in
Speaker 2: real life or in a movie, someone getting an ultrasound
Speaker 2: of their baby, right of their fetus. So ultrasound uses
Speaker 2: sound waves that bounce off of tissue and then are
Speaker 2: reflected back into a transducer and then interpreted as these
Speaker 2: magical black and white images. And while we all might
Speaker 2: think of an ultrasound machine as this giant, bulky thing
Speaker 2: that they wheel into the room and they squirt all
Speaker 2: this gel and it's a huge screen with all of
Speaker 2: these buttons, because of advances in technology, there are now
Speaker 2: ultrasounds that plug into your smartphone that are literally just
Speaker 2: the size of a transducer, or even ones that are
Speaker 2: an entire ultrasound that's the size of a tablet or
Speaker 2: a small laptop. They're really portable, they're much less expensive,
Speaker 2: and while a lot of these, at least today in
Speaker 2: twenty twenty four, don't have the resolution of the really big,
Speaker 2: fancy ultrasounds, they do a really amazing job even in
Speaker 2: relatively inexperienced hands, first year medical students who are learning
Speaker 2: how to use ultrasound at picking up pathology equal to
Speaker 2: or better than a stethoscope in very experienced hands, and
Speaker 2: that includes in the heart and lungs, but also a
Speaker 2: lot of other places in the body too. So I
Speaker 2: think that point of care. Ultrasound is one of the
Speaker 2: things that comes up time and time again as being
Speaker 2: the thing that's going to out seat or replace the stethoscope.
Speaker 2: And it's true that this is kind of the big
Speaker 2: thing right now in medical schools that people are really
Speaker 2: being trained in. And that's kind of like it's the
Speaker 2: new stethoscope. Is that a thing? It's like, ooh, this
Speaker 2: is the thing we all need to get trained in.
Speaker 2: And as we've talked about on this podcast before, one
Speaker 2: of the issues with incorporating anything new in medicine is
Speaker 2: the kind of time lag and turnover yea, and when
Speaker 2: it comes to ultrasound. One of the challenges is that
Speaker 2: while a lot of medical schools have really accelerated this training,
Speaker 2: not all of the attendings have, which means that maybe
Speaker 2: it's your new trainees who know what they're doing and
Speaker 2: the people who are supposed to be training them who
Speaker 2: have no idea how to do it. There's also issues
Speaker 2: with any new diagnostic tool, and especially the better diagnostic
Speaker 2: tools that we get if in inexperienced hands, especially, can
Speaker 2: have things like false positives, right, so you have this
Speaker 2: risk where you're going to see things that maybe you're
Speaker 2: not interpreting the correct way, or you're overcalling things as
Speaker 2: being abnormal, and really it's not a big deal, if
Speaker 2: that makes sense. Yeah, So there's downsides to every new
Speaker 2: piece of technology. There's ups and downs to every diagnostic
Speaker 2: and screening tool that we use in medicine. But they're
Speaker 2: all just a part of the story. And I think
Speaker 2: that that's what's missed in all of these you know,
Speaker 2: very heated emotional papers about defending the stethoscope or saying
Speaker 2: stop listening and look, that's the ones that are defending
Speaker 2: the ultrasound as being the end. I'll be all like,
Speaker 2: why does it?
Speaker 1: Why is it so binary? Like why can't it be
Speaker 1: that the stath is right? And it just seems like
Speaker 1: you're creating this. It's like a it's like an invented argument.
Speaker 1: And so it's like, who are you debating against? Just
Speaker 1: a ghost who's like, throw away the stethoscope entirely and
Speaker 1: get rid of all of them. Let's burn them all
Speaker 1: in a giant pile, like.
Speaker 2: Right, But then if we do that, and then we're
Speaker 2: relying on computers. Now computers have replaced the physician. Oh,
Speaker 2: if we do that then, And part of it is
Speaker 2: like there there is a lot to learn. So part
Speaker 2: of I think if I give them some grace. Part
Speaker 2: of the like drive in some of these arguments is
Speaker 2: like what should we be focusing on when we're teaching
Speaker 2: in medical school? Sure, because there is so much, so
Speaker 2: like how much do we need to focus on the
Speaker 2: stethoscope versus the ultrasound versus the whatever else? And that's
Speaker 2: a valid question, you know, like how much do you feel?
Speaker 2: But it also just like I don't know, it feels
Speaker 2: like it misses the point.
Speaker 1: It feels like it misses the point. It is sort
Speaker 1: of this like existential fear of yeah, are we going
Speaker 1: to no longer be needed? I think it does call
Speaker 1: into question what makes a good physician, which is like
Speaker 1: a whole separate episode that we could talk about.
Speaker 2: I have a lot of opinions on it.
Speaker 1: Yeah, I think it's What seems really important to me
Speaker 1: about the stethoscope someone who's not in medicine, who's that
Speaker 1: completely outside, is that it's low cost relative to like
Speaker 1: an ultrasound yep. And it seems like that would be
Speaker 1: helpful in terms of a decision tree if someone doesn't
Speaker 1: have insurance or if they don't have good insurance, things
Speaker 1: like an ultrasound can be really expensive. And so it's like,
Speaker 1: if you don't know that you need to get an ultrasound,
Speaker 1: it's like, is that part of the decision tree? I
Speaker 1: don't know, you know what I mean?
Speaker 2: Yeah? Well, and it gets so complicated too, because then
Speaker 2: that is, in all honesty and argument for point of
Speaker 2: care ultrasound over things, because you're able to diagnose better
Speaker 2: right in the clinic setting without having to send someone
Speaker 2: and bill for a separate but billing, Oh my god,
Speaker 2: don't get me started. So you know, and this is
Speaker 2: America specific because that's what I know. But Yeah, it's
Speaker 2: it's all really interesting, and I think that they're at
Speaker 2: this point in twenty twenty four, the stethoscope still exists,
Speaker 2: it still has a place, it's still being taught. Will
Speaker 2: it go away someday? Maybe it doesn't mean the demise
Speaker 2: of physicians. Yeah, but AI is Aaron Ai, so AIAI
Speaker 2: might be just kidding. It's also not Aaron hot take.
Speaker 2: I've got opinions, not worried about it. Bring it on anyways,
Speaker 2: want to know more. We've got sources.
Speaker 1: We got so many sources. So there's that paper that
Speaker 1: we both loved by Riser from nineteen seventy nine in
Speaker 1: Scientific American titled the Medical Influence of the Stethoscope. I
Speaker 1: loved it, and there's a bunch more, but honestly, that
Speaker 1: one was like, really really great.
Speaker 2: I have a lot of sources. Unsurprisingly, so the sounds
Speaker 2: that you heard, all of those recordings, the lung sounds
Speaker 2: came primarily from a database that came from a paper
Speaker 2: titled a Respiratory Sound Database for the Development of Automated Classification.
Speaker 2: And I wrote down specifically which clips we ended up using.
Speaker 2: So if anyone wants to find those clips, they also
Speaker 2: have like literally thousands more. It's phenomenal. There's another really
Speaker 2: great heart sound database that was an open access database
Speaker 2: for the evaluation of heart sound algorithms. But the ones
Speaker 2: that we primarily used for this so that they could
Speaker 2: be specific to types of murmurs was the incredible database
Speaker 2: from University of Michigan School of Medicine. We'll link to
Speaker 2: all of those. And then I had a bunch of
Speaker 2: really fun papers. Some of them were old, like the
Speaker 2: Clinical Methods, the History Physical and Laboratory Examinations from way
Speaker 2: back in nineteen ninety and then a lot of those
Speaker 2: drama papers that we talked about, like a paper from
Speaker 2: twenty twenty one titled the Future is More Than a
Speaker 2: Digital Stethoscope. Anyways, we'll post the full list of our
Speaker 2: sources from this episode and every single one of our
Speaker 2: episodes on our website, This podcast will Kill You dot Com.
Speaker 1: Thank you to Bloodmobile for providing the music for this
Speaker 1: episode and all of our episodes.
Speaker 2: Thank you to Tom Bryfogal and Leona Scolacci for the
Speaker 2: incredible audio mixing.
Speaker 1: Thank you too exactly right, and thank.
Speaker 2: You to you listeners. We hope that you had fun
Speaker 2: with this episode. I sure did.
Speaker 1: Yeah, I did too. And what are your thoughts on
Speaker 1: the stethoscope yay nay, yay nay, don't care.
Speaker 2: Do you like it? Wash it better? What do you think?
Speaker 1: Yeah? And a special thank you, of course, as always
Speaker 1: to our wonderful, generous patrons. We appreciate your support.
Speaker 2: So very much, so much. Thank you, thank you, thank you.
Speaker 1: Well. Until next time, wash your hands.
Speaker 2: You feel the animals.
Speaker 4: Buba, Buba, Buba, bumbo bu