r/anesthesiology • u/Zombies71199 CA-1 • 2d ago
Do you still use a stethoscope?
If so how often? Do you carry it with u to the OR or during pre operative assessment?
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u/RemiFlurane 2d ago
Wear mine every day. Use it incredibly rarely.
We have ‘emergency’ stethoscopes on every anaesthetic machine, but I think they’re made by Fisher-Price and I can’t hear a thing with them.
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u/Cautious-Extreme2839 Anaesthetist 1d ago
Fisher-Price: cheap piece of shit
Fisher-Paykel: Insanely expensive nasal cannula machine.
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u/dogmaahm 1d ago
I loved my Fisher Price stethoscope as a child, and swear it picked up better heart/lung sounds than half of the "real" stethoscopes I use now.
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u/infineonblue 2d ago
Everyday; we have no capnographs 🥲
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u/Apollo2068 Anesthesiologist 2d ago
What country is this?
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u/infineonblue 2d ago
Syria. Not some podunk backwater either. I’m in Damascus at the largest public hospital in the country.
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u/St_Beuve 2d ago
Good luck bro, I hope things will get better for you and Siria and you can one day offer the best safety standards to your patients. Not that I doubt you already doing the best, but capno relieve a bit of pressure off your shoulders!
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u/stupid-canada Flight Paramedic 2d ago
Not that you should ever have to get your own equipment but have you heard of the EMMA capnograph? Extremely small and portable. No idea of import costs but its about $1200
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u/HOCM101 Cardiac Anesthesiologist 2d ago
No. Any respiratory distress that effect your anesthesia, you can diagnose from the door.
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2d ago
[deleted]
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u/pinkfreude 1d ago
Finally, someone who understands the system
We need a new department chair. You looking for work?
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u/lambchops111 2d ago
Yeah. If they’re intubated, end tidal gives me 10x the info that a stethoscope does
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u/pinkfreude 1d ago edited 1d ago
You still get end tidal if you’re ventilating the bronchus intermedius
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u/Square_Opinion7935 1d ago
But you check the number after it passes through the cords and you can palpate the cuff at the trachea
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u/69Reddit_sucks69 2d ago
I really don’t get how some people unironically don’t use a stethoscope.
- pre op evaluation of heart and lung sounds
- check for one-sided intubation after securing the airway/prone positioning etc.
- fastest way for me to DDX bronchospasm
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u/Halfmacgas Critical Care Anesthesiologist 2d ago
I’m anesthesia / critical care. I probably use it 3 times a year
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u/PatientsMoving 2d ago
And on those 3 times I’m like “yup I have no idea wtf I’m hearing, what a worthless POS”
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u/Halfmacgas Critical Care Anesthesiologist 5h ago
Haha I went to my First PCP appt last year. I think he was a little intimidated that I’m an anesthesiologist. He was doing my “annual physical” and straight up asked me if I wanted him to “pretend to use his stethoscope, since he doesn’t really hear anything with it anyway and just gets an echo if he’s worried” 😂😂
In the ICU I’ve found it occasionally helpful to assess for bronchospasm
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u/BRB_MD 2d ago
I mean, there's one hanging in the OR for that. I don't wear it around my neck all day like i'm on an episode of Grey's..
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u/PaulaNancyMillstoneJ 1d ago
Do you trust it to be there when you need it? Because I guarantee no one else has one around their neck either
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u/Cautious-Extreme2839 Anaesthetist 1d ago
...yes? It's literally part of the kit check along with shit like the self inflating bag and spare O2 cylinder.
If you can't rely on it to be there then you should reconsider even starting a case in that facility.
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u/BRB_MD 1d ago
I have to trust that all the needed equipment is stocked in the OR when I need it--but it's part of my quick check in the morning. Machine check, drugs, airway equipment, etc. I eyeball it all to make sure it's been stocked because I know I can't rely on the nurses to always make sure everything is perfect. But I do keep a stethoscope in my locker, so I could go get it or send someone for it if needed.
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u/cockNballs222 2d ago
I am a cardiac anesthesiologist and deal with basically nothing but ASA 4s and haven’t had a stethoscope for at least a decade.
I’m diagnosing acute HF, SOA, increased work of breathing visually. If I ever need it in the OR (double lumen tubes) one will be around.
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u/IntensiveCareCub CA-2 2d ago
If I ever need it in the OR (double lumen tubes) one will be around.
You use a stethoscope for DLTs? Use do all ours under fiberoptic.
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u/Longjumping_Bell5171 1d ago
An appropriate increase in airway pressures before dropping your Vt can also help confirm isolation.
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u/cockNballs222 2d ago
Of course but once in a blue moon with tough anatomy, I’ve reached for it for confirmation.
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u/Cautious-Extreme2839 Anaesthetist 1d ago
That's on oneway to waste £300 for little reason.
Left sided DLT with straightforward insertion doesn't need a bronch 9 times out of 10. Save a lot of kit and cash with some basic clinical skill.
Right sided or it's difficult? Sure, open up the scope.
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u/bupivacaine 2d ago
- patients these days universally have had a PCP/cardiology appt prior to surgery, not to mention stress tests, echo, etc. Even if you auscultate a murmur, as long as they are over 4 METs, are you really going to cancel the case?
- airway pressures, SpO2 should give you this information, plus a disposable bronch at most facilities is moments away
- I guess, but if I know my ETT is in the right place and I am struggling to move air, the ddx list is exceedingly small and you're probably getting B2 agonist and epi anyhow
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u/cockNballs222 1d ago
Exactly! Suddenly elevated pressures with no real volumes being moved? Check the circuit and give 10 mcg of epi and watch. Virtually no use in the or.
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u/Freakindon Anesthesiologist 1d ago
I’m frankly disgusted by the raw ego and disregard for quality patient care here. We are advocates for our patients well-being and we aren’t willing to take 30 seconds for a quick listen to heart/lungs?
It’s not about you being a badass and thinking you can deal with any complication. Yeah, you can see if a patient is decompensated from the door. But maybe they are in a subclinical asthma exacerbation and have some obvious wheezing on exam. Take care of that now and that’s one less problem to deal with back there. The best time to deal with a bronchospasm is before it happens. Appropriate management of intraop bronchospasm can potentially cause a pneumo, which may not have needed to happen if you have them a quick treatment in preop.
Or maybe you find some undiagnosed AS or afib. They claim their exercise tolerance is good but when you press a little harder after hearing this “oh well now that you mention it I do get a little lightheaded and have to sit down at the store”.
Even if you proceed with the case (which you probably shouldn’t if it’s elective but that’s up to you), you now are better equipped to prevent some bad outcomes.
Even if you feel comfortable that you can rescue this patient from an MI from an undiagnosed heart condition, their life will have a quality impact from them having had it in the first place.
And you could have potentially prevented that altogether. But nah man, you can save them in the moment because you’re a badass. And that’s what matters right?
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u/Is_This_How_Its_Done Anaesthetist 14h ago
I don't think insullts is the way to go if you want to convert people to your way of practicing. The reason we stopped is that the exam doesn't add any information of value. We already see the things you mentioned.
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u/Hismadnessty 2d ago
Every day, but I do peds.
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u/ForeverSteel1020 Cardiac Anesthesiologist 2d ago
What task in peds anes requires the stethoscope?
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u/Hismadnessty 1d ago
I work with residents/CRNAs and a stethoscope helps confirm that they put the breathe-y tube in the breathe-y hole
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u/ForeverSteel1020 Cardiac Anesthesiologist 1d ago
Isn't end tidal CO2 a more specific and sensitive measure of this??
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u/Cautious-Extreme2839 Anaesthetist 1d ago
If they're real small kids with a bit of bronchospasm you might not get much back I guess.
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u/ForeverSteel1020 Cardiac Anesthesiologist 1d ago
If the bronchospasms is so bad you can't get CO2 return, you can still hear the air with stethoscope?
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u/Cautious-Extreme2839 Anaesthetist 1d ago
If you're just moving small volumes, yeah. There's quite a bit of volume for a paed in a tube + catheter mount + filter + anatomical deadspace.
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u/Hismadnessty 1d ago
Advantages of a stethoscope:
1. If my trainee has a grade 1 view and I trust them, I can immediately auscultate breath sounds without excessively bagging them and waiting for ETCO2.
2. If my trainee loses their view, or if I don’t trust them, I can auscultate the stomach and remove the tube after 1 breath rather than excessively bagging them and waiting for ETCO2.
3. Neonates have shorter tracheas than adults and I prefer to utilize both of their lungs during surgery.
4. Kids are often sick and the decision to proceed with surgery is often based on auscultatory findings.
5. Post-extubation respiratory difficulty is quickly and conveniently assessable with a stethoscope. Children deteriorate quickly and while there are other tools available, the stethoscope is an excellent diagnostic tool.I could go on and on and on, but those are a few examples.
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u/Sunny-skies-8675 2d ago
Yes, I listen to 99% of my patients in preop and carry it everywhere I go.
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u/PatientsMoving 2d ago
You listen to someone’s heart before a colonoscopy?
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u/elantra6MT Anesthesiologist 1d ago
I wonder how often it’s changed management (assuming you read the chart, look at their home meds, and ask about recent respiratory illness)
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u/BaltimorePropofol Anaesthetist 2d ago
It’s good to have. We have one in every OR.
But I truly think those stethoscopes were forgotten and eventually ended with one in every room .
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u/Existing-Big-7002 2d ago
30 year anesthesia here. I cannot believe people dont listen to patients chest preop. If anything, it reassures the patient that you care. Basic part of evaluation.
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u/staffnsnake 2d ago
Bingo. Also, if anaesthesiologists don’t want to be treated like technicians whose work can be replaced by a NP, then not acting like one would be a good start.
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u/Cautious-Extreme2839 Anaesthetist 1d ago
Performing a low yield exam that doesn't change management just because the tick box says to is literally NP behaviour....
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u/Cautious-Extreme2839 Anaesthetist 1d ago
Do not think a single person in my entire department routinely auscultates ever, and plenty of them been around longer than 30yrs, and plenty are fresh faces.
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u/Grateful77Grateful 4h ago
That's what I was going to say. Patients feel seen and reassured. It's like going to a PC and they don't listen or look at your throat.
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u/Grateful77Grateful 4h ago
That's what I was going to say. Patients feel seen and reassured. It's like going to a PC and they don't listen or look at your throat.
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u/TheGrimSleeperZzZ 1d ago
Any get this, you actually touch the patient… which is super important (diagnostically and sympathetically).
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u/Mud_Status 2d ago
I just put my ear to the patients chest if needed
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u/nonsepticemicsepsis 1d ago
That's gross. Just fold their paperwork into a cone and put it to your ear. It's cleaner and louder than the bare ear.
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u/ImaginationWrong6770 2d ago
Every day. After every intubation no matter if I’m supervising or doing my own case.
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u/Square_Opinion7935 1d ago
Why I don’t see the need Have the cuff pass the vocal cords then look at the number at the lips before removing the laryngoscope
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u/ImaginationWrong6770 1d ago
I’ve gotten surprised a few times by how short the right main takeoff is. Takes 2 seconds to listen. And with supervision, gotta CYA.
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u/lamedadz 2d ago
My pre-op note very clearly states "CTAB" so obviously I listen to everyone. Where's my stethoscope? Oh shoot I must have forgoten it when I came back from lunch ... Hold on I'ma go get it.
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u/Longjumping_Bell5171 2d ago
I’ve changed my pre-op exam macro to read things like “appears well perfused” and “respirations non-labored” for heart and lungs.
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u/PatientsMoving 2d ago
I’m not disagreeing with what you do (I mean what kind of nerd is using a stethoscope in pre-op), but I could see an attorney picking at the phrase “appears well perfused”. I feel like it’s less legally risky to just say CTAB like every other chart in the USA and move on.
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u/Longjumping_Bell5171 2d ago
Im not sure why you think lying is somehow better? If you didn’t actually listen to the heart/lungs, but say you did, you’re opening yourself up to significantly more liability. Appropriate mentation and pink lips are both objective physical exam findings that support perfusion and can be assessed without a stethascope.
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u/PatientsMoving 1d ago
I think it would be very difficult to produce evidence that I didn’t listen and I don’t think a malpractice attorney is ever going to give a second glance to CTAB. I see your point that this is, in essence, a lie, but it’s just hard to imagine going down this line of questioning.
I think you run a greater risk of attracting undue attention to charting this is objectively outside the norm.
I honestly respect your perspective and this stuff runs through my head every chart I complete. I do some “outside the norm” stuff too, in all honesty.
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u/Longjumping_Bell5171 1d ago
I’ve spoken to attorneys and folks who work in risk management and their response is unanimous. Regardless of norms surrounding documenting physical exams you didn’t do, it’s a very bad idea to document physical exams that’s you didn’t do. I’ve also spoken to the coders. There’s nothing that says we specifically need to listen to heart/lungs, just that we need to perform “evaluation of the heart and lungs”. There are many ways to evaluate these systems, of which auscultation is one.
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u/PatientsMoving 1d ago
I hear what you’re saying, but I’ve literally never read a chart that didn’t say some version of RRR/CTAB
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u/tinymeow13 Anesthesiologist 2d ago
I have a door exam template for my preops. Resp: Breathing comfortably on room air.
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u/PatientsMoving 2d ago
I think you have to have some awareness that this sticks out from 99% of other pre-ops that all claim they auscultated. If for no other reason than being outside the norm (ie. Standard of care), I personally do not chart this way.
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u/startingphresh Anesthesiologist 1d ago
If my homie here goes down for not lying in our b/s worthless templated pre op notes bring me down with him 🫡
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u/tinymeow13 Anesthesiologist 1d ago
We actually had 3 different lectures with MedMal experts between my med school and my residency. All 3 made the common point of "Don't Lie in your documentation." Documenting results of an exam you didn't do--on an awake patient with probably a family/friend for that patient present--is a really really easy catch for a plaintiff's attorney to start nailing you to the wall. Even if breath sounds have no bearing on the case, it ruins the credibility of the rest of your documentation.
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u/PatientsMoving 1d ago
I read a fair amount of MedMal case review and I have never once seen this issue being litigated. It’s easy to get lost in “what-ifs” and play out fantasy scenarios, and I’m definitely guilty of it myself. Do you have an example where an MD was questioned if his documented physical exam was falsified?
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u/Cautious-Extreme2839 Anaesthetist 1d ago
Equating the norm with being standard of care is just complete wrongthink in the first place.
That's not what standard of care means at all.
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u/LearningNumbers Cardiac and Critical Care Anesthesiologist 2d ago
Everyday, on my hip. I can't imagine practicing without it honestly (and yes I have had colleagues poke light hearted fun at me for it)...in pre-op, at minimum I listen to heart and lungs (I have caught many murmurs this way, some of which led to me doing a POCUS and finding valvulopathies that should otherwise be addressed before an elective case). I also listen to every carotid in people older than about 50ish (depending on how healthy they look) and I have heard undocumented bruits.
During cases I listen after intubation, before coming off bypass for heart cases to make sure the tube hasn't migrated / main stemmed, it's also helpful during more troublesome extubations or hypoxia to help rule in/out lingering bronchospasms, listening for cuff leaks after 10+ hour cases in Trendelenburg with fluid resuscitation.
I don't practice much peds, just the occasional appy or something while I'm on call for a relatively healthy kiddo, but I would imagine it's very useful for peds too.
I also practice in an ICU where it's helpful as well. Not to sound elitist or rude in any way because technology has come a long way, but I really think a stethoscope is one of the most underrated tools in modern medicine and it's art / use is being lost on younger grads.
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u/Extension-Gap1817 2d ago
You listen to the lungs before coming off bypass? Just look at the lungs over the field lol
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u/LearningNumbers Cardiac and Critical Care Anesthesiologist 1d ago
Not every surgeon acesses both pleural spaces well enough to visualize them in a busy field, making it a bit harder to see. Also after the chest is shut, I have had instances where the tube is main stemmed from bringing the thoracic cage back together. It's happened seldomly but enough to warrant the 20 seconds to listen before coming off and after chest closure. I'm not saying everyone should do that, I'm just saying that's what I have gotten used to doing is all 🤷🏼
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u/BigWoodsCatNappin 1d ago
Im just a nurse, but I listen to my patients at least every shift, even if they aren't in for a respiratory complaint. A hundred years ago in my EMT basic course the medic teaching it said "if you feel 99 healthy bellies, when you feel that 100th one, and its sick, you'll KNOW". Extend that assessment skill to LS. Not that I am probably helping change my patients management based on crusty, dusty LS, but it gives the next nurse something to be aware of. (Lol no, Im not paging at 0300 because someone developed trace fine crackles in one base and is WNL WOB and 98% on RA...I'm extra but not that extra)
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u/FranciscanDoc Pain Anesthesiologist 2d ago
Carry? Yes. Use? Rarely.
When you need it, you NEED it.
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u/PharmD-2-MD Critical Care Anesthesiologist 2d ago
I heard a story at this place where I do some prn work. Basically, some anesthesiologist was reporting heart and lung exams on their preops, clearly not auscultating anything. No bad outcome or anything, but somehow this was reported to leadership, anesthesiologist was shit canned. I don’t think auscultation adds much of anything to an adult pre op exam, with few exceptions for some inpatients or people with heart failure. However, you could argue that if they are on room air, is this changing anything? Probably not. But I still do it, because most systems require that I do it and document it. The only other benefit is that patients seem to like it- it’s a little symbolic gesture of giving a shit and makes a little bit of a personal connection.
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u/Kaesix 2d ago
Everyone is a hot shot until they get sued (successfully or not). If your pre-op assessment states “lungs CTAB” (as it has to), you better have fuckin listened to those lungs, and all your patients’ lungs, or the lawyers are going to eat you alive. Food for thought.
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u/yagermeister2024 Anesthesiologist 2d ago
Nah, just non-labored or “normal”
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u/Kaesix 2d ago
More than fair if they let you. Our EMR’s all have the “Lungs: CTAB” check box or you have to check a sign (wheeze, rhonci, etc). It sucks but EMR’s are only billing programs these days.
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u/cockNballs222 2d ago
You think people are getting sued left and right for not performing a full lung exam with a stethoscope in preop?? This is purely a figment of your imagination, never happened. I’m based in the US.
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u/Freakindon Anesthesiologist 2d ago
What you get sued for is documenting things that didn’t happen. So saying lung sounds are CTAB or heart is RRR no MRG when you never auscultated. People have been sued for that. Usually only happens if the chart is being reviewed due to a bad outcome and everything is under a fine tooth comb. If it’s lung or heart related especially. Then they ask if you auscultated. And they’ll bring in a witness who said you didn’t even though you documented that you did. Then you’re done.
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u/Square_Opinion7935 1d ago
How would anyone know four years later
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u/Freakindon Anesthesiologist 1d ago
“Oh Dr. Square? Yeah he/she never has a stethoscope and I’ve never seen them listen.” Not enough for perjury or fraud but enough for the family to also pile on that you didn’t listen.
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u/farawayhollow CA-2 1d ago
I mean you could have very well done that and they’ll still lie and say you didn’t. Your defense is what’s in the chart lol
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u/Kaesix 1d ago
Exactly, wish I could upvote you twice. Once there’s $ millions on the line, they’ll come from all angles to attack your character. “Dr. Square never has a stethoscope” “Our expert witness says a physical cardiopulmonary exam is the standard of care” “You documented you did a physical exam but our witness(es) said you never even touch patients” etc etc.
Like I said, everyone’s a hot shot until they’re in court.
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u/TrichomesNTerpenes 1d ago edited 1d ago
Also, imagine your template states no mrg no wrr and the patient had obviously auscultated ILD or valvulopathy already documented.
Imo, that kind of trouble is not worth skipping out on the 30 seconds for a cardiopulmonary exam (not anesthesiologist but as a GI fellow, I listen to heart and lung before our moderate sedation cases).
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u/Kaesix 1d ago edited 1d ago
I read the edit*
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u/TrichomesNTerpenes 1d ago
Sorry? I think you agree with me but misinterpreted my comment on initial glance. Perhaps my phrasing was poor and I've edited the comment to reflect that.
No - I will continue to listen to my patients, bc the ask is minimal and the possible consequences are huge
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u/Kaesix 1d ago
Gotcha, I see now, I 100% agree.
It’s a minimal effort thing that a) sometimes saves the day because patients can worsen, studies can be wrong or miss things, other doctors’ work can be shoddy etc. and b) is a physician’s duty to his or her patients.
The medicolegal thing is just the high risk/zero reward culmination of not spending an extra 10 seconds with a patient, and many times are too arrogant or short sighted to see how it can unfold until it does. Like I said, working as a side gig in that realm has really opened up my eyes more than I could have imagined.
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u/cockNballs222 1d ago
How about just putting “appears to not be in any resp distress”? It’s pretty simple.
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u/Freakindon Anesthesiologist 1d ago
Asa guidelines for documentation of preop evaluation has:
> Appropriate physical examination, including vital signs, height and weight and documentation of airway assessment and cardiopulmonary exam.
When this happened, my group mandated a true cardiopulmonary exam. Some tried to game it by saying “oh well how about unlabored breathing and good perfusion” and that got shut down. It’s clearly not in the spirit of what was being recommended.
So to answer your question, you wouldn’t be lying by saying that. But you’re also not following the standard of care for preop evaluation. And an expert witness would act like you were the most incompetent person to ever exist (thats how it always goes) for not doing it. Esp if the reason for the bad outcome was even tangentially related to heart/lungs.
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u/throwawayabay 1d ago
Not trying to argue, but curious if the ASA guidelines specify who performs this pre-op eval (or at least, each element of the outlined eval).
I've never personally checked a patients pre-op H/W, the RNs do that. So could the RNs also be the ones auscultating to check cardiopulmonary status?
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u/cockNballs222 1d ago
Reasonable minds can disagree on what an appropriate cardiopulmonary exam means. I can easily defend my point of view, I’m good.
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u/Freakindon Anesthesiologist 1d ago
I think that’s a lot of ego and it’s going to get you one day. I hope I’m wrong but I wish you luck for your patient’s sake.
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u/cockNballs222 1d ago
I’m cardiac and I have an echo/PFTs/carotids on basically everyone I take care of, don’t worry about me or my patients.
Plus, I have a set of eyes!
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u/Kaesix 1d ago
I’d love to see you say “I have a set of eyes!” on the bench when a million dollar verdict is read against you, great defense. I hope for your own sake and your patients’ you smarten up one day.
Either way, you are what you eat cockNballs
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u/cockNballs222 1d ago
I already told you, dr cock n balls to you (and only you). If you’re routinely getting sued for not listening to lungs in preop with a stethoscope, you’re not very good at this.
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u/OneOfUsOneOfUsGooble Pediatric Anesthesiologist 1d ago
When they comb over your medical documentation, lying looks really bad. And they will view an incongruent physical exam as lying.
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u/cockNballs222 1d ago
No word of a lie, there was no obvious resp distress, my documentation matches reality.
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u/OneOfUsOneOfUsGooble Pediatric Anesthesiologist 1d ago
Was more hitching into the top comment, not saying you are. The top commenter is saying "lungs CTAB" = we better have listened.
You can chart "no obvi respiratory distress" = no lie there, I agree.
I agree with you that people aren't getting sued just for not doing an exam. However, once sued over a complication, the lack of an exam will look sloppy at minimum. Charting an exam that didn't happen is the ultimate sin—sounds like that's not your practice.
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u/smshah Anesthesiologist 2d ago
"As it has to" - what are the bare minimum requirements for the preop physical exam? An airway exam is a physical exam, isn't that enough? Not talking medicolegally, just for billing.
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u/Kaesix 2d ago
It’s the ASA standards of practice recommendations: https://www.asahq.org/standards-and-practice-parameters/statement-on-documentation-of-anesthesia-care Billing gets more complicated because then you’re going into insurers and more specifics.
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u/Cautious-Extreme2839 Anaesthetist 1d ago
lungs CTAB” (as it has to)
*Citation Needed
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u/Kaesix 1d ago
It’s listed down below as well, keep reading.
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u/Cautious-Extreme2839 Anaesthetist 1d ago edited 1d ago
Ew. American.
Also "appropriate exam"? I decide an EOB exam is appropriate for 99% of patients.
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u/Murky_Coyote_7737 Anesthesiologist 2d ago
The main reason to use it is so people see you using it.
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u/medicinemonger Anesthesiologist 2d ago
Before my Eko? 5 times a year. With my Eko, 5 times a month.
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u/samsonthehedgehog Anesthesiologist Assistant 2d ago
Carry mine around my neck every day and use it after every intubation, especially after positioning lateral or prone.
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u/OneOfUsOneOfUsGooble Pediatric Anesthesiologist 1d ago
I auscultate every patient I document a physical exam on . . . and I document an exam on every patient. I catch murmurs and wheezing in the adults often enough. Murmurs, I refer them to PCP; wheezing I treat preoperatively.
The lawyers and juries will eat you alive if you lie about a physical exam.
I also agree that an exam is one more connection with the patient to show how much you care. I understand that the clinical utility is low when I already have an echo, normal vitals, a well-appearing patient, etc.
I hear the CRNAs all the time say "the doc is taking care of my pre-ops while I'm in the OR." It's so much more. We're conducting a pre-operative evaluation, a history and a physical exam, to assure appropriateness for anesthesiology services.
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u/TheGrimSleeperZzZ 1d ago
If they’re saying that, it makes me sad. I’m an SRNA, and there’s a lot of critical thinking that goes into preoperative evaluation and planning. It can make or break a good anesthetic and… morbidity.
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u/justaphaze04 23h ago
For those that do not I (cardiologist) would like to make a case.
The most important cardiac pathology to diagnose prior to surgery is aortic stenosis. Severe AS is a big potential risk with anesthesia. It’s the only cardiac condition that has a class I indication for intervention prior to surgery to improve outcomes. (Meanwhile stress tests for CAD are a usually a waste of time/resources) There is good justification in the TAVR era to intervene, even if asymptomatic.
So I argue that everyone with a murmur should be getting an echo prior to elective surgery. Ideally this would be done by the PCP in preop clinic but they are unfortunately missed.
I’ve had 2 cases in the past year where the anesthesiologist picked up a murmur that was missed by the PCP and critical AS was found. We spared the patient a potential terrible outcome by an astute anesthesiologist carrying a stethoscope.
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u/borgborygmi 14h ago
I know I wandered off the beaten track coming here as an ER doc but I just came here to say that arguably the most useful application of the stethoscope now is to put it in the ears of someone who left their hearing aids at home and talk into it.
(ofc we use it, can't find bronchospasm with an ultrasound...just thought you'd like a laugh)
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u/Stealthy_Wealthy57 2d ago
I listen to breath sounds for every single intubated patient. Bar none.
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u/smshah Anesthesiologist 2d ago
Why, when you have EtCO2, SpO2, ventilator mechanics, and cuff palpation at the SSN available?
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u/Stealthy_Wealthy57 2d ago
Because it's easy, and quick, and reliable. We are doctors, not technicians. Just my bias. I teach residents to not assume that technology will always be available.
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u/PatientsMoving 2d ago
Do you also take manual blood pressure every 5 min bc who knows when an automatic cuff won’t be around? Do you not use a pulse ox and just assess their color? This Luddite logic never makes any sense to me.
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u/librabaddie 1d ago
Ausculating once as part of your exam is different than doing q5 min vital checks lmao
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u/Stealthy_Wealthy57 1d ago
I frankly don't care if it makes sense to you. Using technology as an excuse not to perform certain very easy and very informative tasks sounds like laziness to me. But do as you wish. Technology was never meant to replace actual examination, it was meant to compliment it. If technology can truly replace human actions, then this specialty will soon be in trouble.
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u/Cautious-Extreme2839 Anaesthetist 1d ago
It's not very informative though is it?
There is extremely little you will learn through auscultation about a patient with normal pressures, volumes, capnography and saturations.
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u/Stealthy_Wealthy57 1d ago
I suspect you are someone that makes surgeons laugh and diminish anesthesiologists.
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u/Cautious-Extreme2839 Anaesthetist 6h ago
Yeah, that's why they have me look after their critically ill patients for them. Because I'm shit and they love when their patients die within 30 days of surgery.
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u/janliebe 2d ago
No, don’t know where I left it at.
Seriously, I do 90% regional and Land, hardly any intubation, mostly video assisted. I see no need, got one in a drawer in every theater if the need arises (it never does). Switzerland
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u/staffnsnake 2d ago
Yes. It isn’t so much use in the anaesthetic except for confirming tracheal tube placement or bronchospasm. But preoperatively it is part of the “laying on of hands” that most patients expect from a doctor of any type. It enhances the patient’s sense that you are taking a keen interest in them and will monitor them closely. It can function a positive hypnotic (placebo) effect for a feeling of wellbeing in general.
Also, uncommonly I detect murmurs for the first time. Earlier this year a patient came back for another procedure, having seen me 18 months before when I picked up a murmur and recommend she ask her FMP/GP for a cardiology referral. She ended up having an aortic valve repair.
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u/maddash2thebuffet 2d ago
Truelearn told me you don’t actually have to listen to heart or lung sounds.
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u/takeoutnstudy Anesthesiologist 2d ago
Used it yesterday- as an additional check for DLT and then in my second case to ddx bronchospasm
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u/giovariot 2d ago
Yes, use it every day multiple times a day. I do love capnography but no better way to check proper tube depth positioning than a fast check with the stethoscope
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u/Aggravating_Fly2978 1d ago
Yes. Went a few months without using it and got burned with an untreated unknown asthmatic. Back on the neck it went the next day.
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u/assmanx2x2 Anesthesiologist 1d ago
I have one that sits in the preop drawer....I get it out occasionally
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u/Icomeheretoreaduntil 1d ago
I bring it everyday, use it almost never. Afraid to leave it thinking i might need it.
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u/mrb13676 Anesthesiologist 1d ago
While the majority of the time I’m not hearing anything unexpected, just occasionally I’ll pick up something that wasn’t and that changed my management plan - many of our patients haven’t been examined by anyone before. I think we do the patient a disservice by not at least having a good listen.
Also when the s&it is hitting the fan in theatre I know where MY stethoscope is and that I’ll be able to hear what I need to.
We spend so much time trying to convince people of our medical bonafides- why dump one of the tools?
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u/Ok-Leadership-8144 1d ago
I use for evaluate kids, Asthma patients and selective intubation, fibroscopy is not so avaliable in my region
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u/TommyMac 1d ago
I do a lot of geriatric patients and our pre-op nurses are shit - reliably documenting HS normal when there’s no steth in the room.
Hell yes I listen to HS in older folks. Picked up more than a few AS
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u/Aggravating_Sir_6857 4h ago
As a nurse i always carry one in my pocket, but rarely use it. But it’s better safe than sorry
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u/Grateful77Grateful 1d ago
Are you an attending? Do you do pre-ops? My go-to for anesthesia, and life generally is- Could it hurt to do it? - if answer is no, then follow-up - Could it hurt not to do it? It never hurts to take a listen, but it could definitely hurt not to listen to the lungs and heart.
Also, in the OR or PACU- the time I forget it, is always the time I need it.
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u/Cautious-Extreme2839 Anaesthetist 1d ago
You just ordering a non-con head to toe MRI and US on every patient then? Can't forget the posterior and right sided 12 lead ECGs either. There's no harm afterall.
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u/Grateful77Grateful 23h ago
There's lots of harm in your comparison, in terms of cost and wasted resources.
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u/TypicalMission119 Pediatric Anesthesiologist 2d ago
Everyday. On my hip. Can't imagine practicing peds without it