Diminished Breath Sounds: Story From the Trenches

The Leap.  It's what makes the difference between student and practitioner.  The Leap is when you see the theory in real life and recognize it, and apply the theory in practice, because you recognize it. I know I said "recognize it" twice in that last sentence, but seriously it's kind of the whole point of, well, everything.

Every student wants to make the leap.  And I totally, absolutely missed it.  Face planted like there was no tomorrow.  In front of two ex-paramedics turned into triage nurses in the ER--and thank God there were two ex-paramedic triage nurses to catch my absolute face plant because what I missed was pretty damn big.

The part that gets me is that I had just learned about it four days ago in lecture.  I learned about it, and every time my professor said it (and she said it at least once per lecture for 8 weeks) I could feel myself wanting to slam my own face into the table from the tedious repetition of it.  My professor was obsessed over airway.  Every day she would say: "If you have two patients--one, a man passing a kidney stone and screaming his lungs out with 10/10 pain, and the other a child in with exacerbated asthma and wheezing but now no longer wheezing, you better run in there and make sure that kid is breathing.  The guy next door has got very healthy lungs.  The kid is suffocating."

How many times did she say that?  And yet!

This was my very first, and only time, in the ER.  I didn't have an actual preceptor so I was just being bounced from one nurse to the next, from one case to the next--which isn't an excuse, I know.  Assessment is assessment, and it's the same no matter where you go, no matter which patient you're on.

I just didn't make the leap.  I don't know why.  I've been going over it again and again in my head.   Why didn't I see it?  Why didn't I stop and question when I heard what I heard?  What if I had been alone and triaged this man down?

This is what happened:

He was the third patient to come in.  I had just come back from delivering another patient to her bed, and the two triage nurses had already finished assessing, but they handed me a pair of stethoscopes and asked me to assess breath sounds.  The man was sitting with one hand braced on the table and one hand on his knee.  They had also already taken the pulse ox and bp cuff off so I had no vitals.  I know because I looked to see if his pulse ox would give me a hint.  And I had missed the intake so I didn't know what his complaint was.

http://e-safe-anaesthesia.org/sessions/06_03/gif/tripod.gif

"Okay, sir, sit up for me," I said, anticipating that if I was being instructed to auscultate lung sounds on a 25 year old male, the patient probably had asthma.  I expected to hear wretched crackling like the crumpling of a paper bag.

I chirped, "Deep breath please."

I didn't hear any wheezing or crackles on the back.  Nothing at all.  I had heard it in the front but not the back.  Puzzled, I stayed in the same spot.

"Breathe deep.  Please.  Deep."  (I mean, really, L.  SO OBVIOUS.)

I didn't hear anything, in fact, but I had a 15 dollar stethoscope, and I was listening through two layers of clothes and in a loud ER bay,  so I assumed I probably wasn't going to hear the most detailed of sounds.  Plus the man wasn't gasping for breath.  He didn't appear in distress as he was calm, and quiet.  Not just quiet.  Silent.  He didn't say a word.  (Which I didn't know was a big deal, but it seems so obvious to me now--the man was silent because he could barely supply himself with enough oxygen to keep from gasping like a fish out of water.)  And I did hear breath sounds in the front.  I also had no idea tripod was so subtle. It's subtle because the man can't breathe.  He's not exactly going to be making a lot of movement if he can barely breathe. Honestly, when I first saw the patient I thought to myself: "He's hunched over.  He looks tired."
So, like an excited, nervous puppy, I followed the pattern bilateral listening pattern, on his chest then on his back, and then took off the stethoscope and said, "Clear."

This is essentially what I heard: http://www.youtube.com/watch?v=O8OC7EiqBKQ&t=0m47s.  And, no, there wasn't even the faintest of crackles.  I didn't hear much, but there was some in and out, and there weren't crackles.  I've been kicking myself for over a week about missing this, because I swore there weren't crackled but dammit, L, that's the point!  You weren't thinking!

I didn't make the leap.

I just checked each part of his lungs like they were checkboxes, like they were tasks to overcome, not pieces of evidence to be examined and critically analyzed.

I was wrong.

I was so, so wrong.

"Clear," I said.
"Clear?" the first nurse asked, with the tiniest note of doubt.  Or maybe it was incredulity that I was as dumb as a brick.

Basically, the look he gave me.

"I don't hear crackles," I affirmed, a little less certain.
He gave me this look, then gestured to the other nurse.  "Take a listen," he said.  "Diminished?"
"Yeah," the other nurse said, nodding his head.  "Diminished."
The first nurse nodded and finished the paperwork, essentially dismissing me, and I, embarrassed but not really sure what had happened backed up against the supply table.  Silent.
The second nurse turned to me and said, "When people have really bad asthma, the bronchioles close up.  Wheezing means sound, just like when you blow through pursed lips you get a whistle.  When you open your mouth wide, there's still sound, it's loud and hollow.  When you close your lips.  There's no sound.  No sound is bad.  No sound is always bad."
"I'm sorry," I said after we had delivered the patient to the back for treatment.  "I messed up."
"No, you didn't mess up.  You're just new.  Next time, before you have the patient sit up, just step back and look.  He was tripoding, using accessory muscles--that's textbook respiratory distress--which you would have seen if you physically stepped back instead of standing right next to him.  It's not an emergency emergency, so, if the man isn't passed out or clutching his throat and turning blue, or hemorrhaging, you have time to look him over.  We'll just give him a neb treatment and refill his Albuterol, but, now you know.  Don't get sucked into just one part of the assessment.  Step back and look.  And if you don't hear anything it's not 'clear' it's 'diminished.'"