# Heart sounds



## daedalus (Feb 13, 2008)

This question is posed to the medic/RN/RT members as well as EMTs.

I am currently in college and hopefully going into PA school within two years.
My mother is a nurse and my grandfather retired from primary practice a few years ago, he is an MD. I also used to do a lot of volunteer work at a local clinic where a doctor took me under his wing and I would assess patients with him and he would teach me the medical model and go over each patient with me. 

Anyways, I had a call to a psych facility last week because a resident was complaining of SOB. I was driving that day and would not attend so I decided to get a quick history and lung sounds myself before my partner got him the rest of the ride. Anyways his sat was good, 97, his pressure was a little low 110/66 with hx of hypertension. Lung sounds where mostly clear. I decided to listen to his  heart sounds for a gallop, s3, s4 extra sound. I didnt hear any. But never the less, this is technically not something I was taught as a basic, but I have been taught before and very much practised in. Would this be out of my scope of practise? Would I be better off letting the nurse know of my suspicion of heart failure and leave the advanced assessment up to the doc?
Is it unethical for me to be doing this?


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## Grady_emt (Feb 13, 2008)

Ethically: No I don't think thats the issue, I would think that the issue would be a nurse thinking "what a cocky EMT, thinking he knows everything".  Keep in mind it is also most likely well beyond your scope of practice and standard of care in your state.

As for is B/P, its not really that low depending on what his baseline pressure is. If he is medicated, it entirely possible that 110/66 is his baseline medicated pressure.


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## daedalus (Feb 13, 2008)

your right, however I would only listen for my own learning purposes and not to report to the nurse.

BTW:
just to add
pt was around 55.


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## VentMedic (Feb 13, 2008)

If given the opportunity I would approach the doctor with the "I've been advancing my education in other ways and would like you to confirm what I am hearing or offer some pointers".    Approach the ED  RN only if you know they are expert at heart sounds.

The ED RN may or may not be well skilled in heart sounds.  Asking him/her to confirm heart sounds may embarrass them and your intent may not be clear if asking was a show of cockiness for that purpose.

CCU RNs usually have more expertise with heart sounds in progressive CCUs and are very secure in their postion and knowledge.   Many of them love to teach and share epertise.   

The RNs you have heard discussing heart sounds approach them from an educational standpoint and let them "take the lead" to expand your knowledge further.  You might just change your working relationship into a different perspective regardless of the patch on your shoulder.  

Of course, for documentation you would have to stay within your scope but you already know that.


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## Ridryder911 (Feb 13, 2008)

Ditto to what Vent described. I hate to admit that 99% of the Paramedics I have met could not distinguish the difference of an S3 gallop from a hollow systolic murmur. It is a shame we do not cover basic assessments and consider listening to the heart an advanced technique. Unfortunately nursing does but does not emphasize and require it unless like Vent describes inside a progressive unit, where it is expected to know. 

R/r 911


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## skyemt (Feb 13, 2008)

question:

is it not true, that if the airways become narrowed, and stale air gets trapped in the lower airways and alveoli, that the O2 sats would read high, due to the oxygenated air being trapped?

i continually read posts citing respiratory distress, only to quote that their "O2 
sats" are good...

it proves to me that this piece of equipment is overemphasized, and it's limitations not well enough understood.


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## VentMedic (Feb 13, 2008)

skyemt said:


> question:
> 
> is it not true, that if the airways become narrowed, and stale air gets trapped in the lower airways and alveoli, that the O2 sats would read high, due to the oxygenated air being trapped?.



Absolutely! 

Trapped air and resistance in the airways create a "PEEP" effect that will increase or maintain oxygenation for a period of time dependent on the individual patient. 




skyemt said:


> i continually read posts citing respiratory distress, only to quote that their "O2
> sats" are good...
> 
> it proves to me that this piece of equipment is overemphasized, and it's limitations not well enough understood.



Correct!

The pulse oximeter should only be used as an adjunct and its numbers must correlate with what the patient is saying and presenting.  It doesn't mean crap to say "but its correlating with the HR" if the patient is saying they cannot breathe.  

If the SpO2 starts to drop on an asthmatic/COPD patient:
1. You may have opened some airways but there is still an underlying pathology causing a V/Q mismatch or shunting.

2. The patient has now decompensated while you were paying more attention to the pulse ox than other signs and symptoms the patient was giving you.

This can hold true for almost any assessment situation for any disease process. The body's compensating methods will try to maintain homeostasis for as long as it can.  Once the compensating mechanisms are exhausted, rapid decompensation will occur.   The patient may be a more reliable tool to identify these situations than a piece of machinery.

This is especially true in the face of an MI.  I do not want to see the SpO2 start to drop.


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## JPINFV (Feb 13, 2008)

Pulse Oximetry tells you the percent of hemoglobin bound. Because of that, there are numerous conditions that can give you false highs [e.g. carbon monoxide] or make the number useless [e.g. cyanide poisoning, anemia]. Of course there are other dissolved gasses [CO2] that are, for the most part, not carried by hemoglobin that needs to be off loaded in the lungs. SpO2 is not the end or be all measurement of ventilation.


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## Topher38 (Feb 13, 2008)

Heart sounds in the BLS section. :wacko: Im confused guys.


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## VentMedic (Feb 13, 2008)

Topher38 said:


> Heart sounds in the BLS section. :wacko: Im confused guys.



Why not?

Even if you can not differentiate the various heart tones it is a great way to check the heart rate and assess regularity.   In infants, the apical pulse is the best way to assess the HR.   I always do a quick check of the apical heart rate when I'm listening to breath sounds even if I don't always assess the heart sounds.  If you do this often enough you will start to notice the different sounds.


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## Ridryder911 (Feb 13, 2008)

This is why it is confusing among EMS providers and their peers. When one studies the human body and assessing it, one is taught basic concepts of assessment. We do not exclude assessing vital organs except in EMS. Even the LPN level is taught such, maybe not in detail but at least it is covered because of the importance. 

The same as I wonder why the Paramedic is not taught about hair growth, nail thickness, clubbing, skin disruptions, etc. There are so many tell tale signs of patient conditions or underlying medical problems that the body can tell you from a good assessment. For example clubbing occurs in patients that have chronic cardiac conditions, thick nails can represent diabetes, and poor oxygenation. Differential between venous and arterial skin ulcerations. All important factors in determining the patients history. So many additional assessment skills should be added on all levels. 

We really need to review assessment knowledge and skills in our curriculum of EMT's. 

R/r 911


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## Topher38 (Feb 13, 2008)

VentMedic said:


> Why not?
> 
> Even if you can not differentiate the various heart tones it is a great way to check the heart rate and assess regularity.   In infants, the apical pulse is the best way to assess the HR.   I always do a quick check of the apical heart rate when I'm listening to breath sounds even if I don't always assess the heart sounds.  If you do this often enough you will start to notice the different sounds.



I just learned something ^_^ 

Ill give it a try. Never heard of someone taking heart sounds before so this whole thread is like totally out of my leage. Very interesting conversation though. I always look forward to ridryder911's comments


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## VentMedic (Feb 13, 2008)

For your viewing and listening pleasure.

Illustrated heart sounds

http://www.blaufuss.org/


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## JPINFV (Feb 13, 2008)

Why would, neccessarily, heart sounds be out of a providers scope of practice? I've always worked under the idea that scope covered what I could use for assessment, not neccessarily what I could do. Now a lot of things aren't taught, as Rid alluded to, that could be very helpful, but if something like heart sounds are considered out of a basic's scope of practice, then shouldn't things like clubbing be out of the picture as well [until incorperated under NHTSA/state guidelines]?


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## Ridryder911 (Feb 13, 2008)

The reason is out of scope (not literally) is because of the time allotment. In other words, they have only so much time before "cram" so many things into a class. That is why it is most programs are given as minimal required, not maximum allowed (if there were such). 

Personally, I would like to see assessment be given per body systems, and be about at the least 16 weeks in length. For example integumentary, renal, pulmonary, cardiac, and so on. Can one imagine after having completed a thorough anatomy and physiology class a detailed assessment course would produce? 

R/r 911


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## skyemt (Feb 14, 2008)

i think it is also important to understand that what we learn in class is the ABSOLUTE MINIMUM necessary to function as an EMT...

for example, there are many good assessment questions that were not covered in class... are we supposed to not ask them because we didn't learn it in class? we all know how ridiculous that sounds, until we see a post where someone says we're not supposed to do that because it wasn't covered in class...

we are supposed to be thinking dynamic individuals, always learning and applying what we learn to our practice.


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## daedalus (Feb 15, 2008)

VentMedic said:


> Absolutely!
> 
> Trapped air and resistance in the airways create a "PEEP" effect that will increase or maintain oxygenation for a period of time dependent on the individual patient.
> 
> ...


If, during my assessment, I noticed cyanosis or ALOC and/or other signs of hypoxia I would have documented it as such and probably stated it here in my post. The SpO2 measure here was a wonderful indicator of my patient's condition because he was not in acute distress and in no danger of sudden decompensation, so it gave me a picture of his sat as it would stand in five minutes from now and five minutes ago, however I placed this pt. on 3 LPM o2 anyways. I understand a pulse oximeter is not the only thing I should rely on, and therefor I dont.

And your "trapped air" would likely continue to exchange if it had oxygen in it, rapidly becoming CO2, unless it was in dead spaces, which would not affect O2 levels anyways.

My patient was not having severe/acute difficulty getting air. Using a oximeter does not make me a bad EMT. Witholding treatment because of it's reading would make me a bad EMT.


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## daedalus (Feb 15, 2008)

my post above is directed at skyemt not ventmedic.


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## skyemt (Feb 15, 2008)

daedalus said:


> If, during my assessment, I noticed cyanosis or ALOC and/or other signs of hypoxia I would have documented it as such and probably stated it here in my post. The SpO2 measure here was a wonderful indicator of my patient's condition because he was not in acute distress and in no danger of sudden decompensation, so it gave me a picture of his sat as it would stand in five minutes from now and five minutes ago, however I placed this pt. on 3 LPM o2 anyways. I understand a pulse oximeter is not the only thing I should rely on, and therefor I dont.
> 
> And your "trapped air" would likely continue to exchange if it had oxygen in it, rapidly becoming CO2, unless it was in dead spaces, which would not affect O2 levels anyways.
> 
> My patient was not having severe/acute difficulty getting air. Using a oximeter does not make me a bad EMT. Witholding treatment because of it's reading would make me a bad EMT.



who said anything about being a  "bad emt"?
i use it as well... the point is that it is overused and often misunderstood, and if you dispute that fact, you don't really know what you are talking about.

if you use it properly (which means not relying on it at all), good for you.
many emt's DO NOT.  if you notice a pt in respiratory distress, you don't even need it at all.  treat the patient. 

if you have a pt in distress, but the pulse-ox says 97%, are you still going to treat the distress? of course you are.  if you have a pt with NO distress, no s/s of distress, but the pulse-ox says 75%, are you going to start bagging them? i doubt it.  so basically, it will confirm what you already know.

the real value of the pulse-ox, which rarely gets mentioned (and wasn't by you) is for trending.  do you get a room air reading? do you compare it to a reading on high flow O2? do you use the baseline number, and trend it to the hospital?

well, pardon me, but i never hear those things mentioned. i see, "pt was in resp distress, sats at 96%".  to me, that is a relatively meaningless statement.

again, if you use it properly, then good for you.  many do not.


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## daedalus (Feb 16, 2008)

Im sorry skyemt, i didnt mean to lash out. It wasnt a attack at your post and you are completely correct. 

I lost a patient the other day because of slow response time. Family called us instead of 911 and our dispatch gave the family a 10 minute ETA when we where jammed in traffic. Dispatch should have refered to 911 in the area and shouldnt have dispatched our unit. The mistake cost the mans life.


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## Keith (Feb 16, 2008)

I love pulse ox as a guide, but I agree with the people in here that stated that its not a "sure fire" thing. For the most part, its awsome, and with my previous training I used to live by it, but I was taught otherwise by a medic that I highly reguard, as well as a few other well educated clinicians. Granted I am still just an ambulance driver (he he). I have been taught the wonderful word of capnography, and I will tell you... holy crap, it makes life some much easier (and more accurate).

BUT... the "unnamed" company that I work for doesn't believe that basics need access to pulse oximeters, so I purchased my own.

And as for the reference to a "bad emt" previously, thats a load of crap, think if your in this field, your in it for a reason. Your pretty much gonna have to go out of your way to be a bad emt, or else you just need to be educated in a different way. It takes a lot to be a "bad emt".

...cause everyone knows we're all in it for the money, right? hahaha


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## BruceD (Feb 17, 2008)

daedalus said:


> .. his pressure was a little low 110/66 with hx of hypertension. Lung sounds where mostly clear. I decided to listen to his  heart sounds for a gallop, s3, s4 extra sound. I didnt hear any. But never the less, this is technically not something I was taught as a basic, but I have been taught before and very much practised in. Would this be out of my scope of practise? Would I be better off letting the nurse know of my suspicion of heart failure and leave the advanced assessment up to the doc?
> Is it unethical for me to be doing this?



I know that Grady_emt already covered this, but just a little further information on this:

Over the longer term (please don't use this to treat an acute patient!) patients in heart failure (or DM or renal failure) are often treated to lower BPs than what an otherwise healthy person with hypertension would be treated to. 

This reduces cardiac workload (oxygen demand), increase coronary blood flow, and help prevent cardiac remodeling and (sometimes, hopefully) reverse some of the damage already done. (ref. below)

It does not seem to me to be unethical to practice non-invasive, patient monitoring skills as long as that person is in no immediate danger, the practice is not uncomfortable, does not cause harm, does not prevent you from monitoring their condition(s), the patient doesn't mind it, and all your other required checks have been completed.

Good luck
-B

Ref: Mayo Clinic: http://www.mayoclinic.com/health/high-blood-pressure/DS00100/DSECTION=8
Ref: WebMD: http://www.webmd.com/hypertension-h...lood-pressure-hypertension-treatment-overview
Ref: Lippincott's Pharmacology 3rd edition, chapter 19 pp213-225


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## BossyCow (Feb 19, 2008)

I'm a firm believer that what other people think of me is none of my business.  So, I would not allow a potential reaction from someone else to determine what I'm going to learn from a call. 

A lot of that is going to be in the presentation though. Often I will ask the nurse, medic or doc.. "Hey.. I saw this, which to me looked like this..... is that right?" I generally get more of an education than I bargained for and the accompanying evil stare and rolling eyes from my partner on the rig who really wants to get back home.


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## paramedix (Mar 18, 2008)

If you know what you are listening to and listening for... go ahead. You can never learn too much. 

It is not an invasive procedure and you cannot harm the patient by listening to the heart sounds. I was in a similar position before and fully understand that people would rather think you are arrogant than turning around and thinking, wow this medic's got potential... let's help him!

Fortunately we have a lot of medics that are very eager to teach you or share knowledge.


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## Ops Paramedic (Mar 18, 2008)

With regards to your original post, you were not unethical.  There is distinct difference between being unethical and ignorance (You weren't).  It would be unwise to  not raise the alarm, should you think to do so.  The worst that can happen is that someone can help you along or say that it not the case, either way no harm done.  

Abnormal heart sounds is easy to learn but could be hard to ausciltate.  As mentioned in other posts, you will only what is wrong if you know what is right.  Thus by you ausciltating for heart sounds (the different types and there locations) will not be to the detrement of the patient (Provided it does not interfere with the emergency care of the patient), it will only increase your database for future reference. 

As for the scope of practice:  " does it mention any where that you are not allowed to ausciltate heart sounds??"  I don't know your scope, but i will bet it doesn't.  But be carefull of falling into the the trap, of "someone once told me about a this or that".  Ensure thet you know what you are talking about and that you can back it up, even to the cardiologist.

Some posts refered to their training and that it may not have been included.  Alot of times I get "I was not taught that".  Your training and knowledge does NOT depend on your lectures, it depends only on YOU.


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## FFMedic1911 (Mar 29, 2008)

Rid, do you know of some good sites for info on pt assessment.Such as things to look for and what they are telling us.


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## skyemt (Mar 29, 2008)

I in no way want to answer for Rid...

i do think Clinical Clues, by Paul Werfel is an excellent book...


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## Ridryder911 (Mar 29, 2008)

Here is a site that is written by a Paramedic with examples, you listen to with a stethoscope on you computer speakers ( be sure to turn it down first :wacko 

http://www.co.gaston.nc.us/gemshp/training/HeartTones.htm

R/r 911


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## rhan101277 (Oct 8, 2009)

Went over heart sounds today, just at a fundamental level for detailed cardiac exam on physical assessment.  We won't hit cardiology until next month.  I learned S1 and S2 are normal and that S3 or S4 or not.  However S3 or S4 may be normal in babies.  There is much more to learn.


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