Hiding in Plain Sight

The field of medicine evolved, principally, as a field of observation. Hippocrates (the first, and perhaps most famous physician, for whom the oath is named) would press his ear up against his patients to listen to their innards, a precursor to the common modern technique of auscultation. People used to dig up skeletons in graveyards and drew them for a better understanding of anatomy.  The french realized that you can tap on wine casks to see how full they are, and then realized you can basically do the same thing to people. Our attempts to understand (and ultimately fix) the human body have relied on thousands of years of looking and listening.

Describing a patient well has, and will always be, useful in medicine. A concise, accurate description of a patient’s history and physical examination remains one of the most elusive and difficult skills to master as a medical student and resident. This skill has proved especially useful in modern medicine, where patients are handed off between colleagues more and more as duty hour restrictions have hardened.

An interesting consequence of medicine’s collision with modernity has been the devaluation of physical exam findings. Ultrasound, CT,  and MRI imaging techniques have all brought the insides of our patient’s bodies into crystal clear focus. What used to be either inferred, missed, or seen retrospectively on dead patients, is now rapidly available, usually in under an hour. Modern imaging is something like a miracle. I dare you to even try to understand the science behind an MRI,  for which the nobel prize in medicine was awarded in 2003. A friend of mine is a medical physicist, which is an entire scientific field devoted solely to understanding the physics of medical imaging modalities like MRI and operating them. He once described the science of MRI’s to me as “basically indistinguishable from magic.”

Modern imaging has collided head on with the physical exam. Because imaging can catch so much that the physical exam misses, the physical often feels somehow fake. Forced. Like the opening ceremonies at the Olympics, it’s glitzy, it’s expected, it’s analyzed (albeit by fashion blogs), but in the end it ends up being a lot of arm waving before the actual games are played.

Recently on the wards, I saw a patient who had obvious signs of congestive heart failure. Edematous, swollen legs. Fatigue. Trouble laying flat. His blood, unable to be pumped fully throughout his body, was backing up into his lungs and his extremities, collecting in places it wasn’t meant to collect. He, indeed, had heart failure. This was proven to the team by echocardiography (sound wave imaging) only hours after he was admitted to the hospital.

He had a special kind of heart failure stemming from aortic insufficiency – blood was flowing back through his aortic valve, causing a buildup of fluid in his lungs. Aortic insufficiency has a characteristic murmur on auscultation: an out-of-place whoosh that trails off in a decrescendo where there should be only silence.

I imagine that in the days before transthoracic echocardiograms, this murmur would have been the crux of the case. The physician that found the murmur would have solved the riddle. I can picture several physicians, stooped over the man’s chest, ruminating for minutes on the exact degree and characteristic of the murmur, comparing it to others they had heard, debating the acoustics and dynamics.

Today, things are different. The murmur was heard, but it wasn’t heard. It was noticed, and promptly forgotten. The echocardiogram was ordered, and it did the heavy lifting. “Severe aortic insufficiency seen. Left Ventricular Ejection fraction 20%. Recommend CT for full characterization of aorta; concern for aortic root dilation.” Pressures, gradients, valve areas, and outflow jets velocities given in neat tables.

After receiving this information, we went back to the patient’s bedside the next day to find the murmur. There it was, waiting for us the whole time.

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