Ebola: Using a stethoscope in now an issue - CVIEW NEWS

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Sunday, 8 February 2015

Ebola: Using a stethoscope in now an issue

Wearing “the full spacesuit”,  protective gear,  a  doctors treating  ebola  patients are struggling with a clinician’s dilemma: what to do if they can’t use one of the oldest, most basic tools in medicine like a 

stethoscope.
It’s not safe to cut holes in the hood, and nothing that might be contaminated should touch bare skin or the delicate ear canals.
Also, nothing that touches an infected patient should touch another or leave the ward.As a result, said Dr. Robert A. Fowler, a Canadian critical care specialist who helped write the World Health Organization treatment guidelines, “it’s quite uncommon that you see a stethoscope on an Ebola ward in Africa.”
Although cases are dropping rapidly in Africa, experts said stethoscopes could become more important as the remaining patients receive lifesaving intravenous hydration. A stethoscope can detect the “wet, crackling” sound of pneumonia — fluid in the lungs — that indicates a patient has been on the IV drip too long.
In American hospitals treating Ebola patients, doctors have used expensive electronic stethoscopes.
A $500 version from Thinklabs, a Colorado-based company, was used on Ebola patients at New York’s Bellevue Hospital Center and at University of Nebraska Medical Center. The hollow tubes are replaced by disposable earbuds that fit under the waterproof hood. The wire runs out the sleeve and plugs into a rechargeable, diaphragm-equipped microphone that acts as the bell. That microphone stays in the patient’s room, and the earbuds are thrown out. The microphone can also be plugged into speakers or into a cellphone for transmission.
“It’s a cool gadget,” said Dr. Laura Evans, the lead doctor in the care of Dr. Craig Spencer at Bellevue in the fall. “It looks like a hockey puck, but you get a nice, loud sound quality — much better than the disposable stethoscopes we tried.”
Before cases in Africa began dropping, Dr. Armand Sprecher, an Ebola expert for Doctors Without Borders, said his agency was considering field-testing a $400 3M electronic stethoscope and would be willing to consider the Thinklabs model.
Kyle Hall, the telehealth coordinator for Nebraska Medicine, which oversees the hospital that successfully treated two Ebola patients, said doctors there had tried both and preferred the Thinklabs model because it used no hollow tubes and directed the sound via wire, rather than Bluetooth, which can be blocked.
Several doctors working in Africa described stethoscopes as helpful but not indispensable there. Heart and lung ailments are not among the typical initial Ebola symptoms, which usually include fever, aches, vomiting and diarrhea. However, later symptoms can include heart failure from potassium loss and bleeding into the lungs.
Also, in the absence of electronic monitors, a stethoscope can help indicate when a patient is dead.
Doctors Without Borders once used light surgical head covers. “With those,” Dr. Sprecher said, “you could sort of cram the earpieces in your ears and use them — in an unsatisfactory way.”
The agency uses other “workarounds” that “hard-core clinicians who fetishize the bedside exam” would reject, Dr. Sprecher said, but were useful under crisis conditions.
For example, they used only half of a blood-pressure reading, the systolic pressure — the 120 in a 120/80 reading, for example. That can be taken by inflating a blood pressure cuff on an arm and feeling with a finger at what pressure the pulse below it restarts. (Getting the diastolic pressure requires a stethoscope to hear the thumping of the blood disappear as the cuff’s pressure ends completely.)
The top number “isn’t a complete picture, but it’s pretty good,” he said. “If it starts dropping, you start to worry.”
The agency is testing battery-powered cuffs that obtain both numbers, but it is still unclear if they can survive chlorine spray.
Another workaround involves the body’s reaction to the loss of fluids and electrolytes. Patients’ hearts may speed up and become irregular, and patients may hyperventilate, unconsciously trying to blow off carbon dioxide as their bodies become more acidic. A stethoscope makes diagnosis easier, but it can be done by taking pulses and counting breaths.
“If they are huffing and puffing, they’re very sick,” Dr. Sprecher said.
A stethoscope is also useful for hearing bowel sounds, he added, “but when diarrhea is pouring out, you don’t need a stethoscope to know the patient’s bowel is working overtime.”
Dr. Pranav Shetty, emergency health coordinator for the International Medical Corps, said his doctors avoided stethoscopes for safety and used similar workarounds, along with measures like urine output. But with more patients on IV drips, stethoscopes could help detect those being hydrated too much.
Also, Dr. Fowler of the W.H.O. noted, many Africans have had untreated infections, such as ear infections, that scar their heart valves. Leaky valves also cause fluid backup in the lungs, and stethoscopes can distinguish between the two causes.
Portable X-ray machines and ultrasound scanners could also do it, he said, but they are rare in Ebola wards and difficult to sterilize.

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