The past two weeks have been hard, hence the absence. We’ve been chest-deep in cardiology – everything from normal functioning of the heart to congenital defects to arrhythmias to drug treatments. And we still have a week to go. One could say the amount of material is, uh, disheartening, but that would be a bad pun.
(No worse than the chest-deep one in the first sentence, but you didn’t catch that one, did you?)
As you’ve noticed, I tend to write about our physical diagnosis course a lot, because it’s where all of the fun happens. Try writing about days when you have four straight hours of class in a lecture hall built during the Cold War whose thermostat is set daily by Stalin. It’s, uh, heartbreaking. PDX is more fun.
This past week, our course director told us we’d be conducting heart exams on standardized patients with cardiac abnormalities. The lecture that Friday was a firehose of abnormal things: scary topics like “mitral valve regurgitation” and “pathological S3.” (I don’t know what either of those are, but they sound bad, right?)
On our appointed day, we traveled in groups of ten to our simulation center. Once there, we jammed into an exam room where a Real Live Patient wearing a ridiculous hospital gown patterned with what I think were puppies sat with someone who looked important and doctor-y. This was the cardiology attending physician, who had graciously volunteered his time in order to demonstrate exactly how little we know.
Dr. Attending stood in front of us as we nervously fingered our stethoscopes that we don’t know how to use and informed us that we future-doctors were now Medical Detectives: our job was to figure out the diagnosis of this patient. According to our classes and our textbooks, it is possible to determine the exact diagnosis of a patient simply by performing the cardiac exam. That was, I guess, our task today.
Dr. Attending had us perform the exam in pairs while the rest of us stood silently as instructed – watching awkwardly, maybe judging awkwardly, and whispering awkwardly.
The cardiac exam consists of three parts: inspection, palpation, and auscultation. What that means:
Inspection: you look at the patient. Is the patient about to die? No? Good. Wait, yes, he is? Run and go get your attending. Second, is there a geyser of fluid coming out of his body? No? Good, you can proceed.
Palpation: In medical terms, “palpation” means “feel things.” You’re supposed to put your hand on the patient’s chest. Like, right in the middle. And you’re supposed to feel for something. What, I have no idea. My best guess: this test is diagnostic for if the patient was attacked by a larvae from Alien and is about to hatch a mini ferocious killing machine that can only be killed by Sigourney Weaver.
Anyway. Next, you have to find the “PMI.” PMI stands for “Point of Maximal Impulse.” Supposedly you should be able to feel the point where the tip of the heart (the apex) is closest to the chest wall, because you can feel it beating against your fingers. This is, in my evaluation, not a real thing. It is the unicorn of the cardiac exam.
If I haven’t had ice cream in a couple of weeks and went to the gym that morning and hold my breath until my heart pounds, I can maybe convince myself that I can feel my own PMI. Finding it on a mildly overweight patient?
Nope. I’ll take the unicorn.
Auscultation: After the PMI, you auscultate. Why medicine insists on referring to the practice of using your ears as “auscultation” I will never understand. But you get to look all doctory, putting on that stethoscope you bought off Amazon from the lowest possible bidder, and listen to a heartbeat.
You can, in fact, hear things with a stethoscope. Sometimes you can even tell when something is wrong; the problem is in explaining and interpreting what you hear. After we listened to the patient’s heart, Dr. Attending asked us to describe his heartbeat.
I had to resist an urge to say “Well, Doctor, a normal heartbeat sounds like ‘lub-dub, lub-dub, lub-dub.’ This man’s heart sounds like WHUP WHUP WHUP WHUP HURRRRGLLLRRR, which one would assume is a potentially pathological finding.”
Instead, the doctor teased the components of presenting results out of us. “Is this murmur systolic or diastolic?” I love these questions, because there is a 50% chance of being correct. This is infinitely better than an open-ended question, where my odds approach 0.
“Is the murmur early systolic, mid-systolic, late systolic, or holosystolic?” said the attending.
Silence in the room. I had no idea. The man’s heart sounded like someone trying to start a lawnmower missing a sparkplug. I didn’t know if that qualified as mid-systolic or if that was technically “really messed up.” The guy was smiling, though, so it was probably the former.
The cardiologist zeroed in me. “Nathan” – I go by Nate UGH – “Nathan, you were the only one to listen to the carotid.” [I wasn’t.] “Why did you do that?”
OH GOD I HAVE NO IDEA. I remembered seeing something about that being important so I put my stethoscope on the guy’s neck and pretended to look thoughtful.
“Uh… it was another data point?” I replied, turning the color of my heart.
He laughed. Heartily. (anyone keeping track of the pun count?) “Yes, it is another data point. What did you hear when you listened to the carotid?”
I heard noises, that’s what I heard.
“Uh… it sounded like this flowy, rushing sound.” I was skating on thin ice in June. “They were… bruits?”
I don’t know what a “bruit” is. But I do know they, whatever they are, are in the carotid artery. To the best of my knowledge (1 hour of lecture), it is the only bad thing you can hear in the carotid artery, so I threw it out there.
“Yes! You heard bruits. Very good.” Relief. “What are bruits?”
S**t. PLEASE STOP ASKING ME QUESTIONS I DON’T KNOW.
A classmate rescued me and supplied the answer – narrowed arteries make the blood flow turbulent, so you can hear it. So that’s, apparently, a thing.
It was actually a tremendously helpful afternoon. Interpreting heart sounds is almost exclusively an exercise in pattern recognition – and the only way to learn it is to listen to a million hearts.
At the end of our time, the doctor asked us, “Okay, so you’ve described the murmur.” [Poorly.] What is this patient’s diagnosis?
We all chorused, “AORTIC STENOSIS.” Aortic stenosis is a narrowing of the largest blood vessel in your body, and can cause all sorts of problems, including heart failure. We know this because our first case of the block was about aortic stenosis. So we’re well-versed.
As it turns out, we were also suffering from availability bias. “No,” the cardiologist replied, clearly unimpressed. He coldheartedly (!) informed us that instead the patient had mitral valve prolapse, which is also, apparently, a thing.
Eh. You win some, you lose some.
And now, back to halfheartedly (!!!) studying cardiology.