Death of the stethoscope?

By Font Awesome by Dave Gandy - http://fortawesome.github.com/Font-Awesome, CC BY-SA 3.0, LinkIt’s not just zombies that rise from the dead—science news stories can also come back to haunt the reader.

Take “Death of the stethoscope,” which surfaced in my RSS feed in the middle of 2015. As a former stethoscope user, the clickbait headline immediately intrigued me.

No stethoscope? How would clinicians survive?

Historical

First off: a little history. According to his Wikipedia summary, a French doctor called René Laennec invented a hollow hearing tube in 1816 to assist doctors in listening to a patient’s heart and lungs. Around 1852, the single tube morphed into the standard model that you see plugged into physicians’ ears from Grey’s Anatomy to House to ER. Apart from making them look hot professional, a stethoscope also helps with auscultation, the examination procedure whereby a doctor eavesdrops on your internal whooshes, pings and lub-dups. Noises from heart rhythms, gut movements and respiration all help with making a diagnosis since a lot of this internal chatter is very specific.

Contemporary

According to the headline(s), the humble “manual” stethoscope is on the edge of obsolescence in the medical world, facing a high-tech upgrade to or even replacement by hand-held devices that apparently do the job better.

The Motherboard post on vice.com adopts its title from Adel Birbari’s article of the same name, published in the Lebanese Medical Journal in 1999. It suggests that clinicians favour high-tech USB-powered digital over rubber tubing, echoing a point in a press release from the World Heart Federation released the previous year. An article in the Washington Post from January 2016 repeats the call for replacement with something more appropriate to the digital age.

The number one contender to replace the stethoscope is a portable, hand-held ultrasound device, but this is closely followed by digital adaptations ranging from electronic versions to the Eko CORE, a digital add-on that works with the traditional stethoscope to amplify and record sounds.

https://commons.wikimedia.org/wiki/File%3AThoracic_landmarks_anterior_view_heart_ausc.svg https://upload.wikimedia.org/wikipedia/commons/d/df/Thoracic_landmarks_anterior_view_heart_ausc.svg By Põnn [CC BY 2.5], via Wikimedia Commons Practicalities

While it is refreshing to learn that technology has not passed over such a basic piece of diagnostic kit, I do have some concerns about encouraging clinicians to dump the familiar neckwear or even to abandon the professional skill of auscultation.

As a former practising veterinary surgeon, some of these reservations do have a practical component.

  • Distance: Number one for me is that being at the earpiece end of a stethoscope removes my face somewhat from the immediate danger zone, whether fanged or hoofed. Apparently, this also is why Laennec came up with his idea, though he was more interested in staying away from the heaving bosoms of well-padded female patients than avoiding bites. Medical doctors celebrate the contact stethoscope auscultation brings with the patient; most vets prefer to maintain a safe zone.
  • Expense: Veterinary patients are notorious for not respecting boundaries. Electronic stethoscopes and their digital alternatives cost a lot more than a standard manual model. Would I want to brandish hundreds of dollars’ worth of hearing tube wannabe in a muddy farmyard cattle crush, or dangle it over the open ocean? No; nor would my boss be happy with me for risking the practice profits. As a side note, how many clinicians in marginal communities or developing countries can afford more than the perfectly functional basics?
  • Convenience: The alternatives might be hand-held, but they all need power. Where’s the electrical outlet in a remote cow byre? And how many battery changes are required to complete a herd health visit? Just my luck that the battery would fade just as I homed in on a crucial diagnostic squeak in the consulting room. My ears don’t wear out unless they are enjoying a Pet Shop Boys concert.

Resistance

But am I just being a luddite?

I checked with some of my peers through Facebook. Most of them are still in practice and therefore see life at the sharp end. Would they lose the stethoscope and swap the traditional for digital, I wondered?

https://commons.wikimedia.org/wiki/File%3AVet_Students_Cattle_RVC_2006-08.jpg https://upload.wikimedia.org/wikipedia/commons/6/68/Vet_Students_Cattle_RVC_2006-08.jpg By Tim1965 [Public domain], via Wikimedia Commons Of the seven who replied, three mentioned that electronic stethoscopes received as gifts remained unopened, unused and unloved. One reason given is that veterinary use is a very small market, and stethoscopes designed for human use, even with pediatric sizing, are often not refined enough for diagnostic work in cats, for example. Three large-animal vets mentioned problems with cost for both maintaining the equipment and dealing with damage or loss in the field.

Q: Just wondering if any large-animal vets would carry around a $350 stethoscope out in the field.

N:  No. We have 45 vets who regularly lose things! And out in the field there is seldom a power source. We power our scanners with good rechargeable batteries, but they are $500 to $800 each.

J: Just the basic stethoscope. Although they will sometimes use their rectal scanner on the chest wall if they think there is a pericardial effusion. All cows.

C: And have left/lost/damaged plenty of kit on farms. … So prob would avoid if expensive.

Only one vet regularly uses the electronic version, commenting that it lasts for ages on a single AA battery. He also mentioned it was a great boost for mild hearing loss, this last point echoed by an internal-medicine teacher at a vet school.

Three vets commented on using scanners as alternatives, with one describing the hand-held option as useful for cage-side assessments but lacking the detail of larger machines. Another mentioned that cattle vets often reach for the rectal scanner when suspicious of pericardial effusion (fluid build-up around the heart)—hand-held yes, but probably not what was envisaged in the articles!

So maybe not such a dinosaur then.

Evergreen

The topic resurfaced again in the last year, with a news story on the CBC/Radio-Canada website and an interview with Dr. Raj Bhardwaj on the Calgary Eyeopener radio program. Dr. Bhardwaj mentions the same high-tech replacements and benefits but does bring up the subject of cost—around $200 will buy you a stethoscope, but you need $8,000 or so for an ultrasound device—and fragility.

Stethoscopes bounce…

…as does the story, which, like the instrument itself, refuses to die.

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