Tuesday, September 7, 2010

Heart Sounds

I'm just going to put it out there. I probably wouldn't pick up a murmur in the clinical setting if it got off the bed and slapped me in the face.

Today we had a 2h clinical lab to 'go over' (read: learn for the first time, really) heart sounds and murmurs.

Yeah, the highlights included the one clinical instructor actually saying

"just learn some buzz words so that in the OCASE when you are thinking CH&*ST F*&K I can't remember ANYTHING you will be able to rattle off some key terms at least"

and another instructor saying

"well shore you'll say what it is then get an echo and find out it's somehting completely different so fock it".

Sigh. Ireland. You really do amuse me.

The lowlights included:

feeling like I don't know anything
feeling like my medical knowledge and cardiac knowledge is ZERO
feeling slightly deaf
not understanding what everyone else seemed to be grasping (awesome feeling)
being POSITIVE it was a systolic murmur when in fact it was not that at all
wishing I'd listened to heart sounds on every patient that ever stepped into the ED over the past, oh 6 years


The lowlights were punctuated by the fact that I was demonstrating my incompetent medical student persona in front of one of my favorite clinical instructors who is a totally badass ED doc. Pretty serious and intense guy and just someone you generally want to be on-the-ball around.

I was so not on the ball.

It is one of the things I love about medicine though, just when you think you understand something...you realise you have no bloody clue.

15 comments:

Grumpy, M.D. said...

1. Hell, I still don't know a huge amount in my own specialty.

2. When you feel like you're the only one who doesn't understand something THEN EVERYONE ELSE IN THE ROOM IS THINKING THE SAME THING!!! Anyone who tells you differently is lying to hide their own fears.

3. I remember some instructor at my school talking about pediatric murmurs actually said "this type of murmur sounds like a snowflake landing on carpet." Thanks. Like WTF does that sound like?

Old MD Girl said...

Your classmates were lying -- they couldn't hear either.

Just focus on hearing aortic stenosis and you'll be fine.

Old MD Girl said...

PS -- If you become an ortho, you won't even have to remember what side the heart is on.

Grumpy, M.D. said...

That's true.

Hey, what side is the heart on, anyway?

EMT GFP said...

If I was anywhere near Ireland, I would donate my heart for practice of murmur sounds. Unfortunately, I am stuck in the US. :(

I am supporting Dr. Grumpy's point 2 also!

NP Odyssey said...

Curious to hear some of those good Buzz words when you learn them.

Keet said...

I remember studying for your ACLS with you, you didn't think you could learn that either.

What the ears don't tell you, the ECG and echo will. Unless you're going to be a GP with a special interest in cardiology, there is usually an expert on the other end of a phone, right?

Keep up the good work EBSCO. I got an app for iphone that identifies heart sounds and you can email the spectrogram, I've just sent you my 8 seconds of glory. Enjoy!

Nurse J said...

i've lent my stethoscope to a coupla nurses and even to our cardiologist hospitalist (an internist) and every time, when they give it back, they comment on how nice my stethoscope is, or how mine is better than thiers (the cardio hospitalist). and i also could not find a murmur if it snuck up on me and hit me with a MI. so, yeah....i though the heart was the beaty thing in the MIDDLE of the chest......

ertwro said...

Hey, I can help you on this one. Recently I started with heart sounds and I'm amazingly good thanks to this page: http://blaufuss.org/

It has a quiz and free tutorials, if you do know the cardiac cycle you will be alright.

I did also bought the book by doctor proctor harvey with the audio dvd's it will arrive in 3 weeks (it's expensive on me but free on my future patients) I decided to invest on auscultation since I read in an article of the NEJM how someone in his 3rd year killed a patient by not knowing how to appropriately take the vital signs... and how poor are auscultation skills even in between cardiologists.

Those are the articles in case you are interested (and have any free time)
The Demise of the Physical Exam
http://www.nejm.org/doi/full/10.1056/NEJMp068013

Cardiac Auscultatory Skills of Internal Medicine and Family Practice Trainees
http://jama.ama-assn.org/cgi/content/abstract/278/9/717?ijkey=c55553a2c676d368e3e258305ce300a8f38e8b34&keytype2=tf_ipsecsha

Good luck.

Cartoon Characters said...

I have heard and recognize one in a newborn.....but all greek to me in bigger bodies. Love the Irish...I am a half Irish... ;)

medrninja said...

Ahhh ABB don't be so hard on yourself :). Just listen in the 4 areas (Aortic, Pulmonic, Tricuspid and Mitral aka All Physicians Take Money), figure out what normal sounds like (use your new roomie!) and after that you can recognize an abnormality pretty easily.

My (crazy smart) IM attending told me the only ones you'll really ever have to ID clinically anyway are Aortic Stenosis, Mitral Regurg, and maybe an ASD in a kiddo. Easy enough to narrow those down just by where you hear them and a good Hx.

Aneesa said...

We're covering heart sounds now as well, which actually means watching the Harvey computer assignment and straining your ears to hear the mid-systolic click. "Say it with me, lub dub lub dub!" Good luck!

Albinoblackbear said...

Grump--That is reassuring.

The annoying thing about this program (because it is self directed and in PBL format) is that you never know if you've covered enough or to the depth required for our level. So it's not like we get lectures and notes and know "ok, this is what I have to study" plus not having boards or USMLE to guide is frustrating as well.

I guess it teaches us to get comfortable in always feeling there is more to learn.

And, that is the most hilarious way I have ever heard a murmur described.

OMDG--They pretty much said "learn aortic/mitral regurg and stenosis" the rest is just showing off.

And TRUE the only sound I'll have to get used to is the sound of my drill! (and of someone knocking on my door with divorce papers!! hahaha)

EMT--Aw too bad! Yeah I am concerned that in the real patient the "click" and the "rush" are not going to be quite so loud, and in stereo!

NP--I will make a post dedicated to only buzz words, once I gather more than one. :)

Keet--I know about this iphone app. I posted an article about it on FB. I will be living in the stone age with my garage sale NOKIA until approx 2018. It can hardly find a phone number let alone heart sounds.

NurseJ--Ok good, that makes me feel slightly reassured, because I know that you ICU nurses are like the smarty-pants-keener-nerds of the nursing profession... :) P.S Is your stetho one of those sweet ones with the button amplification? I am getting myself one as a graduation present.

ERTWRO--Thanks a mil!! That site is AMAZING!!! Tobie was reading his book in the study and commented "um, you've been listening to the same sound for 45 mins.." I got a little autistic in the aortic stenosis part of the tutorial. I sent the link to my study group as well.

Cartoon--I would think it'd be harder to hear in babes because of the rate--yikes. I always hated that part of the antenatal screen when babies came back to the communities up North. I would get EVERY nurse in the building to come and listen to make sure I wasn't missing anything. One place you don't want a missed congenital defect is in the high Arctic! hahah

Ninja--I like the mnemonic! Dropped it on study buddies as well. It'e true, I know I just need to really get the horses dialed and leave the zebras to cardios, IM's, anesthetists...shit. :p

Aneesa--My boyfriend (violist) started using it as a metronome while I was studying!! hahahah

Cartoon Characters said...

Did you see this article by the way?
http://www.canadianmedicinenews.com/2010/09/stethoscope-app.html
free app ....

Bostonian in NY said...

You'll get it down eventually...it took me a while (about a year) to figure out what I was listening to and to develop my system to walk through the diagnosis. If you do hear a murmur figure out systolic vs. diastolic (palpate the radial pulse...if it occurs with the pulse it's systolic). If it's systolic, listen to the carotids (because then you know it's Aortic Stenosis instantly). Then try to figure out where it's loudest. Clinically, that's usually enough to get me out of trouble.

And then I memorized a mneumonic for the maneuvers for the USMLEs and promptly forgot it upon taking the exam...there are several floating around the interwebs/study resources.