To the Editor
Bravo to Dr. Terring W. Herionimus, III, MD, FACA, FCCP, for his excellent letter published in the Spring 2005 APSF Newsletter. In his discussion of the tragic cases described in Dr. Lofsky’s article, he noted his admonition to residents and students to not break contact with the patient.
I have made the observation that newly trained anesthesiologists routinely forego the use of precordial and esophageal stethoscopes. I believe they have been trained to rely on the other monitoring devices in use. While I applaud the ongoing development of sophisticated monitoring technology, I have great difficulty understanding how anyone can have a secure feeling without this direct patient contact. I have been in practice for 18 years and find these tools indispensable. Not only do they help avert disaster, but they are so important in the practical management of patients. Some of the scenarios in which I feel they are critical are as follows: immediate detection of partial or complete airway obstruction; assessment of proper placement and seating of LMAs; migration of endotracheal tube into the right mainstem bronchus, especially in pediatric cases during which I place the precordial on the left chest; diagnosis of wheezing; need for suctioning; disconnection; and light anesthesia with swallowing and borborygmi.
No doubt, some or maybe all of these conditions may be noted with other monitors. But how much more rapidly does one hear a wheeze as opposed to noticing a change in the end-tidal carbon dioxide curve? Or what about noticing an increased airway inflation pressure: isn’t it much more instantaneous to just hear secretions clogging the endotracheal tube?
These are just a few examples that come to mind. I have been so troubled by this that I consulted my mentor from UCLA who told me that he thinks the problem is starting in medical schools with less emphasis on auscultation. He feels that many residents are uncomfortable with auscultation, and that even if they use an earpiece, they don’t know what they are listening to.
I have also acted as a reviewer for malpractice cases in which these issues have been critical to patient outcome, although sometimes this is hard to prove in retrospect.
What can we do to improve this situation? Do we need to tighten the ASA standards? Or do others feel I am completely off base? I look forward to some answers.
Danielle M. Reicher, MD