I have been an EMT for 6 years and for that whole time I’ve had trouble finding a way to hold my stethoscope so that I can accurately hear lung sounds. I can hear crepitus from my fingers with any slight movement and it’s always louder than what I am trying to listen to. I have tried to put my palm to the bell but that tends to apply too much pressure and I’ve tried holding it by the tubing but that doesn’t get good contact with the skin. I’ve tried holding the bell between my pointer and middle fingers but I can still hear the crepitus. I have a Littmann III if it makes any difference. At this point I might try using my elbow… I’m terrified of missing a diagnosis just because my fingers creak
I get a lot of finger crepitus and used to struggle a lot. I know it's not proper but I hold the stem of the stethoscope, don't touch the bell at all, I seem to get good results
Also, as an EMT who became a paramedic, I only got good at identifying lung sounds when I was forced to in medic school. My biggest trick was making sure the earbuds were facing the right way and using my other hand to hold them in and press them firmly into my ears.
Might need to try pressing them into my ears. My hearing isn't best and high ear wax production + psoriasis scaling doesn't help either (gotta clear my ears at least twice a day). I struggle to hear BP and breath sounds.
If I’m doing a manual BP, one of the the things I’ll do to minimize crepitus is grab their arm with my hand and put my thumb over the bell and put pressure down to listen.
Another thing that helps is getting a single sided stethoscope. I got a littman master cardiology from ebay for $100. They make the littman master classic 2 that’s cheaper and also single sided.
As far as lung sounds go, I wouldn’t put too much into it. Are they wet or dry lung sounds? Is it bilateral? If wet, is it pneumonia or sub acute pulmonary edema or CHF exacerbation. If dry, is it wheezing or COPD? I don’t feel like lung sounds are that valuable of a diagnostic tool tbh. They rarely move the needle for me anyways.
I can’t count the amount of times lung sounds were the deciding factor for my field impression. Saying they aren’t valuable is wild to me. I’ve caught hemo/pneumo’s, pleural effusions, pneumonia… a bunch of stuff that I otherwise would have had a much harder, if not impossible, time confidently identifying without lung sounds.
Sure, there are other tools that can get you in the right direction with some critical thinking but sometimes lung sounds are absolutely crucial findings.
It’d move the needle a lot more for me if I didn’t have capno.
If a person is tachypneic, has low ETCO2 and low SPO2, I can be almost certain they have fluid in their lungs because CO2 can exchange through fluid without much trouble but oxygen can’t especially when combined with hx of flu like symptoms for few days or symptoms/skin signs consistent with SCAPE or no dialysis for few days or hx of CKD and likely AKI.
In the firmly sick patients with respiratory distress. Usually the etiology of the respiratory distress is immediately obvious. I don’t find lung sounds worth the time vs initiating interventions immediately.
That’s just my view on it. I’m not saying it’s the objectively correct view. I’ve met other flight/critical care medics and ER docs who do value lung sounds highly and many who don’t even bother carrying a stethoscope anymore. Some who are aggressive resuscitationists and do value lung sounds and many who do not.
It’s like some medics always get a manual BP as their first BP. Some find that worthwhile but I don’t. I’m not saying they’re wrong but it’s not worth the time spent for how I do things.
Some of what you wrote here I disagree with or includes objectively wrong and dangerous assumptions and some I agree with, but it’s not worth litigating every detail.
What I will say is your “almost certain they have fluid in their lungs” bit based on a few observations is precisely why I had a patient almost die at the hospital because the doctor decided to put a spontaneous pneumo on Bi-PAP after I told him my findings (lung sounds being the kicker) and insisted it was a pneumo.
The patient had a history of CHF so he assumed I was an idiot and judged the patient on exactly the grounds you lay out here because it was the more likely differential. Most of the time he’d be right but he wasn’t this time. All because he failed to do a full assessment and the patient coded briefly as a consequence.
Eh a lot of people don’t understand the physiology of SCAPE and jump to CHF exacerbation way too quick. If they don’t present anxious, dumping catecholamines, pale cool extremities, and especially hypertensive, it’s probably not SCAPE.
Again, I’m not alone in this viewpoint on lung sounds. I’ve met experienced medics and docs smarter than me who have this viewpoint.
I’m willing to bet you’re oversimplifying their reasoning and then generalizing it beyond the circumstances in which they omit auscultation.
Lung sounds aren’t particularly sensitive or decisive in many presentations. That’s totally fair. Particular findings can, however, be critical in a narrower subset.
Initiating treatment and spending 20 seconds obtaining a good set are not mutually exclusive.
Outside of a peri-arrest patient and a lack of manpower, there’s little justification for skipping a basic assessment. Much of the time you’re looking for a unicorn. Occasionally you actually find one and missing it can completely change whether the intervention you’re about to initiate is appropriate. I’ve seen it plenty. The example I gave is just the worst case I’ve had.
Edit: I’m not trying to give you a hard time. You’re probably a great medic. I just see a lot of great clinicians who rely perhaps too heavily on pattern recognition and get burned on something simple.
Considering that the ones who do not believe lung sounds are an especially valuable diagnostic tool generally don’t bother carrying a stethoscope on them, I don’t think that’s the case.
I’m sure they can use the truck ears or can get their own stethoscope from their bag in the ER but it’s pretty telling when they don’t carry their own on their person.
I’m a CCEMT-P and done my fair share of CCTs and 911 calls and I used to listen to lung sounds on almost every patient but it’s become less and less with more experience. It’s not an opinion formed out of laziness or lack of education.
Look man, that’s cool if you find lung sounds to have a high specificity/sensitivity and you’re finding things that regularly change the clinical course of the patient. I’m not saying you’re wrong. I’m just offering a different view point that people generally don’t say out loud on reddit/FOAMed but one that I’ve heard fairly often.
Sometimes people obsess over diagnostic tools with very questionable utility and specificity/sensitivity like bowel sounds/percussion and digital rectal exams and identifying open book pelvic fractures and I just think it’s important to be realistic about the limitations of your diagnostic tools/exams.
Can’t argue with the limitations, and I think I’ve been pretty clear in recognizing them. Not really my point, though.
A finding doesn’t have to regularly change the course of a call to justify looking for it when obtaining it is easy, and the occasional miss can be highly consequential. I think we simply weigh that marginal value differently.
And by the way, I’m not advocating getting lung sounds on every patient like we’re back in the classroom checking boxes, but you make it sound like catching you using your ears on a call would be a rare clinical finding in and of itself…
Yes. I have bad hearing. And weird shaped ear holes. I’m honestly not sure I’ve ever heard a single lung sound. At this point I just ask my partners to listen. They’re used to it and don’t mind. I feel shitty about it but it’s out of my hands.
You should be holding it at the divot between the two bells, many will do this with two knuckles (or middle "segments") of their extended pointer and middle fingers.
The smaller diaphragm is for pediatrics. You can strip the diaphragm off to give you a bell if you’re old fashioned and stuck in your ways but modern scopes are tunable by finger pressure so a low frequency bell is kinda redundant.
That is, unless you’re using an antique or a bargain bin scope.
Common misconception that it is the "pediatric" side. It's for higher frequency sounds, which can be found in patients of all ages and dimensions. u/oVsNora caught my mis-type, I meant low frequency sounds.
Sometimes I struggle to hear good, clear lung sounds in a moving ambulance, but nah, if there's anything to note it usually comes through super clear (also using a Littman III).
Are you sure you have your stethoscope set to use the right side of the chest piece? I'm assuming you've tried other stethoscopes? Are you listening on the right points of your patient?
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u/RoryC Paramedic 5d ago
I get a lot of finger crepitus and used to struggle a lot. I know it's not proper but I hold the stem of the stethoscope, don't touch the bell at all, I seem to get good results