Heart sounds

daedalus

daedalus

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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?
 
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.
 
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.
 
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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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
 
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.
 
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?.
Click to expand...

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.
Click to expand...

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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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.
 
Heart sounds in the BLS section. :wacko: Im confused guys.
 
Topher38 said:
Heart sounds in the BLS section. :wacko: Im confused guys.
Click to expand...

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.
 
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
 
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.
Click to expand...

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
 
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]?
 
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
 
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.
 
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.




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.
Click to expand...
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.
 
my post above is directed at skyemt not ventmedic.
 
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.
Click to expand...

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.
 
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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