Guessing Tubes

I broke my stethoscope this week. I was listening to a chest, on a ward round, as you do, and the ear-pieces just went all wonky. The metal spring hidden in the rubber tubing had snapped.

My stethoscope is like Trigger’s broom – I’ve had the same stethoscope since 4th year of medical school; I’ve only replaced the diaphragm twice, the bell rubber three times, and the tubing once. The metal bit – the business end – is the original, shonkily engraved with my name.

I borrowed my registrar’s guessing tubes for the rest of the ward round. I think I used them once.

I’ve found a place that will sell me a replacement tube/earpiece thing. Last time it broke, in 2001, I think, I went to a medical supply store, and picked out the replacements. This time it’s the internet to the rescue, of course.

I was very excited about getting my first stethoscope. 1997, 4th year of medical school, and the Littmann reps came to the students’ mess with a range of excitingly coloured stethoscopes, and boxes of complimentary fish and chips, I recall. The decision of colour was simple – hunter green, obviously – but the mode of transport was perhaps more important: over the shoulders, round the neck, in a pocket?

Fast forward 5 years and I was using (mostly) the same stethoscope sitting my PACES exams. No longer guessing with my tubes, I was dedicated to the fine art of differentiating a murmur of aortic stenosis from that of mitral regurgitation. Fortunately the murmur in my exam was aortic regurgitation, and I didn’t have too much trouble.

I was regaling my registrar with this tale of exam pressure in 2002, when she asked me “But what’s the point, though? You’re going to get an echo regardless, aren’t you?” Yes, that’s as maybe, but they’re really important for listening to lungs, say I. “But aren’t you going to get a CT?” Sigh.

She makes an interesting point though.

10 years ago, when I started my respiratory registrar post, we had access to an ultrasound machine. It was the size of a top-loading washing machine (remember those?), and weight about 20 metric tons. We didn’t use it very much. Now we have a number of portable USS machines, all the size of a chunky laptops, and every chest SpR has to be trained to ‘level 1’ before they can get their CCT. Is there a pleural effusion, is it consolidation, is it an elevated diaphragm? We don’t listen, we don’t percuss any more, we get the ultrasound machine out and we know.

Should we be training up all our doctors to use the same ultrasound machines to look for valve abnormalities? I’m no cardiologist, so I have no idea how long it must take to train up to be able to look at valves, but the cardiology trainees manage.

In days of yore the fine details of murmur analysis were critically important. When to refer for an aortic valve replacement? When the second heart sound disappears, of course. Who would refer for an AVR without a valve area, or pressure gradient? W don’t put in a chest drain without doing an ultrasound of the thorax immediately beforehand, would we?

So should I get those replacement parts for my stethoscope? It’s going to cost me over £100 after all. Or would I be better off putting that money towards an echo course?

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