Prehospital Heart Sounds

EMS providers are generally not educated to evaluate more than gross differences in heart sounds. In fact, heart sounds are rarely included in prehospital patient assessment guidelines. In addition, fire/EMS agencies supply inexpensive stethoscopes not suited for good heart sound interpretation. In spite of these issues, EMS providers can make a positive impact in patient outcome by taking time to acquire the skill of interpreting heart sounds.

Case Study

Medic Ambulance 310 is sent to a private residence for a sick person. You are directed to a 75-year-old male sitting in a chair. His daughter, who stopped by to visit, tells you he is weak, not eating well, and she is concerned that he is not bouncing back to baseline after suffering the flu for the past few days. You have been on more than 100 flu calls in the past couple of months and recognize the familiar story.

You approach the patient, who is alert and oriented. He adamantly tells you he doesn't want to go to the hospital, but his daughter won't leave him alone. He simply has the flu and is slow to recover. After all, he tells you, he's not 20 years old anymore. While he is weaker than normal, he says he is still able to get around, but he mentions one incident of near-syncope and some dyspnea on exertion. He now feels like he is improving and denies chest pain. Food and liquid intake are reported to be normal, with no nausea or vomiting. You see adequate food in plain view, and the apartment looks clean and orderly. The patient has a history of hypertension, with no medications and no known allergies. His last visit to a physician was over five years ago. He dislikes the whole concept of visiting doctors and avoids hospitals, particularly emergency departments, under all circumstances.

His BP is 150/92, PR 86, RR 16, PO2 97%, NSR in lead II, skin slightly pale, warm and dry. Pupils are PEARL, grips and speech are normal, with no JVD or peripheral edema.

Given the plethora of flu cases you have seen in the last two months, you agree that transport to the emergency department is not necessary, although follow-up with a physician would be a good idea considering his age and lack of recent medical care. You recommend transport to the ED and, as you expect, he still refuses transport for "a simple case of the flu." Except for that one case of near-syncope and dyspnea on exertion, which is not that typical for flu, you tend to agree with his analysis, although you are concerned about his lack of routine healthcare. Knowing he is going to wait at least six hours before getting past the triage nurse, you make one more attempt to get him to go, but he again refuses. As you are thinking "what now?" and your EMT partner is looking in your clipboard for your list of clinic referrals, you realize you were distracted by your initial conversation with the patient and his daughter and neglected to listen to his lung sounds. You listen and find them clear, with normal tidal volume. You then move to auscultate the heart and are surprised to hear a harsh crescendo systolic ejection murmur, with no radiation to the neck or axilla. You know this could be many things, but, considering his history, you begin to suspect aortic valve stenosis or hypertrophic cardiomyopathy, which would account for his symptoms beyond the simple flu. In the prehospital setting and this particular case, the exact diagnosis is not the issue. You now have evidence to convince him to go to the ED to diagnose a heart problem beyond your capability. He listens to your concern and, with the help of his daughter, your patient reluctantly consents to transport. His gait is more unsteady than he admitted as you assist him to your gurney. The patient is later diagnosed with left ventricular outflow tract obstruction and, after surgical resection of the subaortic membrane, recovery is uneventful.

The Medic's Role