# a rhetorical question



## Veneficus (Dec 9, 2011)

When I was in EMT class, many years back, we were taught how to listen to heart tones.

The last few years, I noticed this skill has been dropped.

Most recently I am engaged in a debate in another thread over the appropriateness of this being performed by EMTs.

But I have a question.

If you listen to lung sounds, what is so different about heart sounds that makes them so intimidating?


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## akflightmedic (Dec 9, 2011)

I would answer but a rhetorical question by definition needs no answer.


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## Veneficus (Dec 9, 2011)

That was my point...


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## mycrofft (Dec 9, 2011)

*Rhetorically answering*

Heart sounds are more subtle and thus more of an "art", while ling sounds useful to basic level field folks (paramedics and EMT-B's) are easier, to a certain point, and thus more of a science. It is harder to teach art than science and more talent is involved.


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## JPINFV (Dec 9, 2011)

Isn't lung sounds now watered down to the point of being "normal" or "abnormal?"


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## Veneficus (Dec 9, 2011)

JPINFV said:


> Isn't lung sounds now watered down to the point of being "normal" or "abnormal?"



Are you trying to piss me off?


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## usafmedic45 (Dec 9, 2011)

Veneficus said:


> Are you trying to piss me off?



Yes, but what else is new?


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## STXmedic (Dec 9, 2011)

Veneficus said:


> Are you trying to piss me off?



LOL!!!

And I really hope you're joking, JP...


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## JPINFV (Dec 9, 2011)

Veneficus said:


> Are you trying to piss me off?




If I really wanted to piss you off I would have mentioned that I got into an argument about a month ago with a professor who didn't believe that "rales" and "crackles" were the same thing.


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## abckidsmom (Dec 9, 2011)

Veneficus said:


> Are you trying to piss me off?



It's a true.  I am precepting a new EMT-B right now, and she absolutely did not have the vocabulary to describe the lung sounds she heard.


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## Veneficus (Dec 9, 2011)

abckidsmom said:


> It's a true.  I am precepting a new EMT-B right now, and she absolutely did not have the vocabulary to describe the lung sounds she heard.



la la la la not listening


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## usafmedic45 (Dec 9, 2011)

abckidsmom said:


> It's a true.  I am precepting a new EMT-B right now, and she absolutely did not have the vocabulary to describe the lung sounds she heard.


http://www.youtube.com/watch?v=5JA6D1Mguh0
http://www.youtube.com/watch?v=h7BtrWATfg8&feature=related
http://www.youtube.com/watch?v=WjP1fDjbE_s&feature=related


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## abckidsmom (Dec 9, 2011)

usafmedic45 said:


> http://www.youtube.com/watch?v=5JA6D1Mguh0
> http://www.youtube.com/watch?v=h7BtrWATfg8&feature=related
> http://www.youtube.com/watch?v=WjP1fDjbE_s&feature=related



That's exactly what I did with her.  I don't think we watched those exact videos, but youtube is such a valuable tool.  I can't believe it.


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## firetender (Dec 9, 2011)

We are, in U.S. medicine anyway, consistently moving away from the human art and depending more and more on machines to do our work.

I don't think that lessens the mistakes. It just gives us something else to blame while minimizing the healing effects of human interaction.


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## Brandon O (Dec 9, 2011)

Lung sounds are also more likely to be relevant to the type of field treatment and decision-making we usually make in the field, especially for BLS.


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## Dwindlin (Dec 9, 2011)

Brandon Oto said:


> Lung sounds are also more likely to be relevant to the type of field treatment and decision-making we usually make in the field, especially for BLS.



Agree.


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## Veneficus (Dec 9, 2011)

Brandon Oto said:


> Lung sounds are also more likely to be relevant to the type of field treatment and decision-making we usually make in the field, especially for BLS.



you don't think an apical pulse is?


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## Brandon O (Dec 9, 2011)

I love me a good apical, but I wouldn't exactly call it advanced heart sounds.


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## Veneficus (Dec 9, 2011)

Brandon Oto said:


> I love me a good apical, but I wouldn't exactly call it advanced heart sounds.



I didn't suggest advanced heart sounds, 

but I don't think: "That sounds abnormal" is requiring too much.

For lungs I expect better. 

But if you could skillfully listen to heart sounds, wouldn't that make you a very skilled (and therefore respected and valuable) EMT?


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## Brandon O (Dec 9, 2011)

Hey, you'll never hear me say that EMT's shouldn't be improving their clinical assessments.  But on the balance of things it's a difficult skill with limited opportunity to use it (really need a quiet space and some time), with not a great deal of probabilty to influence our care. There are other things I'd want someone working on first.

Edit: also somewhat hard to find educational resources on this.


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## abckidsmom (Dec 9, 2011)

Veneficus said:


> I didn't suggest advanced heart sounds,
> 
> but I don't think: "That sounds abnormal" is requiring too much.
> 
> ...



Not necessarily.  A skilled EMT is one who can control a scene, make a few decisions, and work with people to bridge them into the health care system.  If they can hear mitral regurg, great, but it's not going to really effect things that dramatically, beyond being very cool and improving the image of the EMT in the eyes of the ED staff.

An EMT can have all the exam skills in the universe, but if they can't manage the people, they're useless in their role.


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## JPINFV (Dec 9, 2011)

abckidsmom said:


> An EMT can have all the exam skills in the universe, but if they can't manage the people, they're useless in their role.



Knowledge without power is impotent.
Power without knowledge is dangerous. 

Besides, who wants to go into neurology?


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## mycrofft (Dec 9, 2011)

*Knowledge without power is the path to doing something regretful.*

...because we never know as much as we think we do.

That said, what actual pragmatic value to an EMT-B would knowing heart sounds and the different between a rale and a rhoncus be? (Wheeze versus stridor I know can be important and of use, but they hardly even need a steth for those).  I'm ignorant, but are there devices or meds they can use, the selection of which is affected by those findings?

I'm in favor of inquiring individuals learning all they can, and of services to train their folks all they can, but EMT is still predicated on getting shoals of trained people out quick, so the left side of the bell curve (not as adept) will still get more certificates than maybe it ought to.


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## Veneficus (Dec 9, 2011)

mycrofft said:


> ...because we never know as much as we think we do.
> 
> That said, what actual pragmatic value to an EMT-B would knowing heart sounds and the different between a rale and a rhoncus be? (Wheeze versus stridor I know can be important and of use, but they hardly even need a steth for those).  I'm ignorant, but are there devices or meds they can use, the selection of which is affected by those findings?
> 
> I'm in favor of inquiring individuals learning all they can, and of services to train their folks all they can, but EMT is still predicated on getting shoals of trained people out quick, so the left side of the bell curve (not as adept) will still get more certificates than maybe it ought to.



I was thinking that knowledge, competence, and skill lead to respect, which is the first step towards becomming a true profession.

But as of late I have seen a lot of protocol nazis (common EMS term in no way associated with godwins law) posting. If the the direction EMS providers want to take is mindless laborer, why should I expend anymore effort trying to convince them otherwise? It has no effect on me.

Let them receive all that they wish for in abundance.


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## mycrofft (Dec 10, 2011)

*Robert Townsend had it right (Up The Organization)*





To condense and paraphrase, don't rave and brag about making things better, dig in and make your corner of it better. 

When you wheel into the ED with the patient appropriately treated and alive, the report and hand off smooth and without showboating, all without swagger and lifting a few hemostats on the way out, in time they will notice the excellence.

To the employer, you will be in need of less supervision and thus will suffer less of their attentions, good or bad.

Since the system is predicated upon mass training and matriculation, you will be thought of subconsciously as a good cotton picker, not just a cotton picker.

Personally, train and go past technician slots, into the professional aspects of health care and admin, then help those behind you.


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## Brandon O (Dec 10, 2011)

mycrofft said:


> ...because we never know as much as we think we do.
> 
> That said, what actual pragmatic value to an EMT-B would knowing heart sounds and the different between a rale and a rhoncus be? (Wheeze versus stridor I know can be important and of use, but they hardly even need a steth for those).  I'm ignorant, but are there devices or meds they can use, the selection of which is affected by those findings?



We give nebulized albuterol here. But in most areas EMTs can assist with inhalers.

CPAP is becoming BLS in a few places.

Lung sounds can help distinguish between cardiac and respiratory etiologies, which can affect a number of decisions.

Noting ronchi could affect a diagnosis -- for instance, in the context of apparent fever, tachycardia, and borderline hypotension, it might support a suspicion for sepsis, causing you to escalate your care.

Rales could affect how you choose to position the patient.

Just some thoughts.


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## mycrofft (Dec 10, 2011)

*Brandon Oto, thanks for your answer.*

Rhetorically speaking of course.


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## Handsome Robb (Dec 10, 2011)

lub dub, lub dub, lub dub. I wont stand here and say that I know a whole boatload about heart tones but I can sure as hell tell you "normal vs. abnormal". It is one of my things on my list to do some more reading on when I have time, right now between studying for school and working 48hrs/week I truly don't have time.


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