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
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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