Clinical Case of the Month: A 56-year-old internist colleague of yours is scheduled for cholecystectomy. He has stable hypertension, asthma, and hyperlipidemia. During your pre-op evaluation, he asks if you will be listening to his breathing and heartbeat continuously during the anesthetic. What do you say? How do you defend your answer?
Discussion: What’s more symbolic of the medical profession than a white coat and a stethoscope? As anesthesiologists strive to become recognized as perioperative physicians in a changing medical world, some of us actually carry stethoscopes around our necks, like those actors on Grey’s Anatomy.
On the first day of my Stanford Anesthesia residency in July 1984, each incoming resident had foam injected in their ears for molds to supply us with custom-made individually-fitted earpieces for our mono-aural stethoscopes. In 1984, continuous stethoscope monitoring via a precordial or an esophageal stethoscope was a standard of care practiced by residents and attendings alike. In July 1984, the Santa Clara Valley Medical Center operating rooms had exactly two (2) pulse oximeters. Anesthesiologists would negotiate with each other daily to determine who had the sickest patients, and therefore most needed to use one of the oximeters that day. The Stanford University operating rooms had exactly one (1) end-tidal-CO2 monitor, used exclusively by ENT anesthesiologist Dr. Chuck Whitcher.
Pulse oximetry and capnography became widespread in the late 1980’s, anesthesia safety statistics improved, and unexpected cardiac arrests due to undiagnosed esophageal intubations became rare. The 1999 National Academy of Sciences publication To Err is Human: Building a Safer Health System reported, “Anesthesia is an area in which very impressive improvements in safety have been made. . . . today, anesthesia mortality rates are about one death per 200,000 to 300,000 anesthetics administered, compared with two deaths per 10,000 anesthetics in the early 1980’s.”
Once OR’s were equipped with oximeters and capnography, most anesthesiologists abandoned routine use of mono-aural stethoscopes.
A prospective single-blind study of 520 consecutive patients in 1995 (Prielipp RC, Use of esophageal or precordial stethoscopes by anesthesia providers: are we listening to our patients? J Clin Anesth. 1995 Aug;7(5):367-72.) found 68% of patients had an esophageal stethoscope placed, 16% had a precordial stethoscope, and 165 of the 520 patients had no stethoscope. This study documented that many stethoscopes that were placed were not used — overall, providers listened continuously via an anesthetic stethoscope in only 28% of the anesthetics.
In 2001, a study from London utilized questionnaires to document that 35.2% of anaesthetists never used an oesophageal or precordial stethoscope, and the majority of the remaining 64.8% used the devices in less than one-third of their practice. (Watson A, Survey of the use of oesophageal and precordial stethoscopes in current paediatric anaesthetic practice. Paediatric Anaesth. 2001 Jul;11(4):437-42.)
Regarding auscultation, the 2005 American Society of Anesthesiologists Standards for Basic Anesthesia Monitoring says: 1) “every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated. Qualitative clinical signs such as chest excursion, observation of the reservoir bag and auscultation of breath sounds are useful.” 2) “every patient receiving general anesthesia shall have, in addition to (ECG and blood pressure monitors) circulatory function continually evaluated by at least one of the following: palpation of a pulse, auscultation of heart sounds, monitoring of a tracing of intra-arterial pressure, ultrasound peripheral pulse monitoring, or pulse plethysmography or oximetry.” 3) “when an endotracheal tube or LMA is inserted, its correct positioning must be verified by clinical assessment and by the identification of carbon dioxide in the expired gas.”
Are anesthesiologists in private practice in Palo Alto using esophageal or precordial stethoscopes in 2007? An e-mail survey of the twenty-five private practice attendings on the Stanford anesthesia Adjunct Clinical Faculty revealed: 1) continuous stethoscope monitoring for adult anesthetics is almost extinct, 2) use of precordial stethoscope monitoring during inhalational induction in pediatric anesthesia is standard for most practitioners, 3) in pre-op, stethoscopes are used during cardiac and pulmonary assessment only as indicated by the patient’s history and the planned surgical procedure, and 4) most practitioners, but not all, use a stethoscope to document bilateral breath sounds after every endotracheal intubation.
Dr. Terri Homer is a former cardiac anesthesiologist who has transitioned into a busy private practice of intravenous sedation general anesthetics in dental offices, where no ETCO2 monitoring is available. Terri discussed the gulf in precordial stethoscope use between herself and the current Stanford residents in her e-mail reply. Terri wrote, “I use a precordial stethoscope on all of my I.V. sedation cases in dental and oral surgery offices for both my pediatric and adult patients. In my opinion, there is no better monitor to assess the quality of the airway under sedation. On my GA cases in the O.R., I use a precordial on every pediatric case on induction and during maintenance. On my adult GA cases I use an esophageal stethoscope on all prone cases but not anymore on other intubated adult patients. I do not check for bilateral breath sounds on my LMA cases but I definitely still do on intubated patients of any age. When I work with a resident on my Adjunct Clinical Faculty days I am astonished that more than 95% of them have never even seen a precordial stethoscope. That’s when I start feeling like a dinosaur. When I explain the value of this monitor, I don’t think they are at all convinced.”
How should we answer our patient in the Clinical Case of the Month question above? You tell your colleague the truth: In light of his history of stable asthma, you will listen to his lungs in the pre-operative room and immediately after endotracheal intubation. You do not plan to continuously listen to his breath sounds during the cholecystectomy, but you tell him that if any change or adverse trend occurs in the vital signs, oxygenation, ETCO2 tracing, or airway pressures, you’ll have a stethoscope on his chest in a heartbeat.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: