THE STETHOSCOPE OBSOLETE? REALLY!

THE STETHOSCOPE OBSOLETE? REALLY!

You may have seen the same video I just saw. It’s the one where a doctor dressed in scrubs talks about a device he thinks has already replaced the stethoscope in its diagnostic capability. He uses it when he examines the heart, the blood vessels, the abdomen, and the joints, and he may be right in claiming it can give a doctor more information about a patient than any stethoscope. The device is called a hand-held, ultra-portable, point-of-care ultrasound, commercially called the “Butterfly-IQ.” It is one of five such products manufactured by technology companies Butterfly Network, Philips, SonoQue, and TENS Pro. 

Ultrasound technology has been used since the 1960’s, initially to evaluate the heart (echocardiography). In fact, I.U. Medical School cardiologists were some of the earliest investigators of that technology. Now, it’s use has advanced to everything from the brain to the feet. An ultrasound of an infant’s head looking for bleeding inside the skull, checking blood flow through the carotid arteries, determining the cause of a heart murmur, evaluating the pumping function of the heart, examining the abdomen for gallstones or an aortic aneurysm, examining the status of a fetus, examining the reproductive organs for cysts or masses, and examining the bottom of the foot for torn plantar fascia are just some of the many uses of ultrasound. Image quality has improved over the decades, as has reliability of interpretation. The diagnostic value of ultrasound is exceeded only by CT and MRI.

The stethoscope has long been a device symbolic of the medical profession. Doctors, nurses, and EMT’s are recognized by wearing their stethoscopes around their neck or in their coat pocket. In recent years, though, the stethoscope has become a symbol rather than a tool as the breadth of ultrasound technology has advanced. With the arrival of a hand-held ultrasound no bigger than a barber’s electric razor, the stethoscope is gathering dust on many doctor’s desks. 

In the video, the doctor explains how the Butterfly-IQ connects to his iPhone or computer and displays the the organ he is scanning. By scanning the heart, he not only can hear the heart but also observe the movement of the valves, measure the pumping force of the heart, and watch blood flow through the chambers. If the doctor hears a heart murmur, he can instantly determine the cause and assess the effect on heart function.

Moving to the abdomen, the hand-held ultrasound can do things the stethoscope cannot, such as diagnose gallstones and measure the diameter of the aorta for an aneurysm. The stethoscope can find suspected blockages in the Carotid artery blood flow by detecting a bruit (the sound blood makes flowing over a plaque), but ultrasound goes one step further by actually confirming a blockage and determining if it is affecting blood flow. The same is true for lower extremity arteries and veins. Arterial plaques and venous blood clots are detectable with ultrasound if symptoms suggest such a problem. The doctor in the video even assessed a knee injury and could see a torn meniscus when he scanned the joint.

In the ICU, “point-of-care ultrasound” (POCUS) is “routinely used….for rapid hemodynamic and respiratory assessment.” The accuracy of this device is operator dependent and proper training  is very important. The operator not only needs proficiency in the function of the device, but also expertise in interpreting the images produced. 

I think comparing a hand-held ultrasound device to a stethoscope, though, is like comparing a Titan missile to a bottle rocket. The stethoscope has limited utility while the Hand-held ultrasound has multiple uses. However, the device does have limitations such as cost (upwards of $8000-$10,000), short battery life, and image quality. The images are adequate for screening purposes only, but for “focused care” they fit the bill. 

When I think about this device, it’s potential is limitless. It can be used in so many ways that it takes the guesswork out of making a diagnosis. In the ER, in the ICU, in the office, at the bedside—this device can be used to help diagnose just about anything. Fluid around the lungs, around the heart, and in the abdomen, heart murmurs, circulation problems, abdominal pain and masses, lumps and bumps under the skin, swelling of the testicles or extremities, and breast lumps, are some of the problems amenable to diagnosis with portable ultrasound. Why this technology hasn’t caught on more than it has lends credence to the slow-to-change-and- accept new technology mindset of physicians. Many doctors are “cutting-edge”-oriented while  others are “dinosaurs” and accept change only after it’s become the standard of care. But this device has so much potential and makes so much sense that to ignore its benefits is short-sighted. 

I was asked, “If you were still in practice would you use it?” The answer is a resounding “yes!” Once I got over the cost of the device (using the instrument would not generate higher payment), I could see that it gives me instant answers to the patient’s symptoms. If I heard a heart murmur, I could assess its significance. If I found right upper abdominal tenderness, I could look for gallstones. It would save the patient time and money because the need for additional, expensive tests would be eliminated; not in all cases, of course, but certainly in many.  

Doctors barely use their stethoscopes anymore so possibly hand-held ultrasounds are a way to get them interested in examining patients. It seems to be a lost art. There is genuine value in using this device so the next time you see the doctor, if he examines you with a strange, probing instrument, you can know he’s open to new technology. And you will be better cared for because of it.  

References: Baribeau Y, Sharkey A, et al. Handheld Point-of-care Ultrasound Probes: The New Generation of POCUS J Cardiothoracic Vascular Anesth 2020 Nov; 34(11):3139-3145.

Nilsson G, et al. Hand-held cardiac ultrasound examinations performed in primary care patients by non-experts to identify reduced ejection fractions. BMC Med Educ 2019 Jul 25;19(1):282.

Khanji MY, et al. The Role of hand-held ultrasound for cardiopulmonary assessment during a pandemic. Prog Cardiovasc Dis 2020 Sep-Oct;63(5):690-695.

Breithardt OA. Hand-Held Ultrasound—the real stethoscope. Eur Heart J-CV Imaging 2015;16:471-472.