More Crackles

More Crackles

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 Quoting the NEJM's Resident e-Bulletin 2/20/2014 Teaching Topic Lung Auscultation

"Q. What are the differences between fine and course crackles?

A. Two categories of crackles have been described: fine crackles and coarse crackles. On auscultation, fine crackles are usually heard during mid-to-late inspiration, are well perceived in dependent lung regions, and are not transmitted to the mouth. Uninfluenced by cough, fine crackles are altered by gravity, changing or disappearing with changes in body position (e.g., bending forward). Coarse crackles tend to appear early during inspiration and throughout expiration and have a “popping” quality. They may be heard over any lung region, are usually transmitted to the mouth, can change or disappear with coughing, and are not influenced by changes in body position. Typically, fine crackles are prominent in idiopathic pulmonary fibrosis, appearing first in the basal areas of the lungs and progressing to the upper zones with disease progression. However, fine crackles are not pathognomonic of idiopathic pulmonary fibrosis; they are also found in other interstitial diseases. Coarse crackles are commonly heard in patients with obstructive lung diseases, including COPD, bronchiectasis, and asthma, usually in association with wheezes. They are also often heard in patients with pneumonia and congestive heart failure."

Who is to argue with the NEJM, documented with modern auditory recordings and referenced with a pear reviewed lead article, Fundamentals of Lung Auscultation: Abraham Bohadana, M.D., Gabriel Izbicki, M.D., and Steve S. Kraman, M.D. N Engl J Med 2014; 370:744-751February 20, 2014DOI: 10.1056/NEJMra1302901, "Computer-assisted techniques allow detailed analysis of the acoustic and physiological aspects of lung sounds." 

From a teaching viewpoint there probably is no higher authority than that quoted above, yet some of the computer-assisted observations run contrary to my clinical experience and the teachings from the pre-crackles era. In my experience, fine rales at the left base are the hallmark of left lower lobe pneumonia. They are a fine low pitched sound similar to the sound of rubbing your hair together just above your ear. They do not go away with change in position and they occur in early to mid inspiration. I am not so interested in the computer findings as I am concerned by the missed or misdiagnosed early pneumonia and the sound in my own stethoscope. Pneumonia in the early stages, coincides with the patient's complaint of chills fever and a productive cough. X-Rays are not yet positive but a gram stain confirms the diagnosis. Unfortunately, this is the stage of pneumonia that is often misdiagnosed as a virus and sent home without adequate consideration. The above description of course crackles with pneumonia might come at a later stage of pneumonia's progress when a school teacher can make the diagnosis.

The problem may be that all the pre-crackles physicians are gone now or retired. I read that crackles live only in America. I doubt that with the distribution of today's journals, but I rather imagine that Europe, especially France, would be less willing to give up Rene' Laennec's terminology or diagnostic acumen. I do wonder about the digital rendition of rales, however. Harmonics plays a significant role in the low frequencies and digital may not be able to capture these low frequency analog harmonics. Furthermore, as one of my students commented speakers cannot reproduce the low frequencies. This is evident in the class room when attempting to broadcast heart and lung sounds over the speaker system. When I was in medical school, we had tubes from the examining table in the front of the amphitheater to the back of the chair in front of us with a lure-lock fitting. Our stethoscopes had a lure-lock fitting on a detachable head. We were thus able to attach our stethoscope to the closed system and hear the sounds from the examiner's stethoscope in real time without electronic distortion.

One cannot argue with the NEJM, but medicine is not immune to mistakes and bad ideas. Once they are in print it takes a long time to change them.

Syphilis

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University of Kansas Hospital Dana Hawkinson, head of infectious disease sounded the alarm -- on Valentine's Day -- for a 100% increase in the incidence of Syphilis appearing in all age groups from teenagers to seniors. What is more alarming, Hawkinson claims that these cases are antibiotic resistant.

Nothing that I know of could be more frightening. The world including the medical profession has forgotten the world wide epidemic of syphilis, the mortality and the  suffering it caused, nor do we remember the high degree of infectiousness of that little spirochete. It did not jump off the drinking fountain to infect you, but putting your mouth on the faucet got you. Syphilis was the reason for those thin paper toilet seat protectors you always wondered about.

Naples 1494 French and Spanish alternately occupied Naples. Some Spanish sailers who sailed with Columbus had picked up a strange disease in the Indies. With irresistible tales to tell of their voyage, they quickly passed it on to the ladies of Naples, who in fair turn passed it along to the French. The French called it the Spanish disease and the Spanish, the French disease.

Often confused with leprosy, Syphilis had no effective treatment. All sorts of things were tried. They used Guaiacum, mercury and later heavy metals.  Hieronymus Fracastorius (1483-1553) a physician and a poet wrote– Syphilis sive Morbus Gallicus – the shepherd-sufferer gave the disease its name. (Translated shepherd or swineherd)

Treponema pallidum Because of the extreme effectiveness of penicillin against syphilis, the disease is all but forgotten. Long ago the first laboratory test with every hospital admission was a VDRL or Wasserman. The health department enforced isolation and close follow up with all family and contacts. If we had done that with the AIDS epidemic, it would not have become the killer that it did. The health department today, however, is impotent. Bothe diagnosis and treatment are dictated by politics. The Health Department of old hardly exists. The laissez-faire political solutions favor individual liberties over the common good and motivate treatment for which there is a profit rather than public health for which there is not. Young doctors may not recognize the disease. A microscope is required for the positive identification of a chancer, and microscopy is becoming a lost art among physicians.

2,465 years ago Hippocrates stemmed the tide of the plague in Athens by burning the homes and the bodies of the victims with fires all over the city. A tribal chief in Africa contained Ebola by the same technique and locking down the village. Isolation is the only way to contain an epidemic with the infectivity of syphilis, isolation until the successful completion of treatment. Given a high degree of antibiotic resistance, that isolation might require a tertiary hospital's isolation ward.    

Meanwhile the U of Washington has developed a new condom that is thin, adherent, strongly antiseptic and dissolves after use. I doubt that it will stop the spread of syphilis, however. Mealy kissing, can transmit the disease, and already the distribution throughout all ages including seniors, suggests a complementary non-sexual transmission of the drug resistant spirochete.|

Crackles, an End to Civility and the timely diagnosis of pneumonia

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Rene Laënnec in 1816 fashioned a role of paper in order to listen to the heart sounds in an older obese woman in cardiac distress. Laennec later described the sounds of peripneumonia as rales at the left base of the lungs. Rales translate appropriately as rattles in English, and the term rales prevailed as the ausculatory sound of pneumonia. In referring to rales in front of a French patient, however, there was a problem. The French term for death rattle, `rales d mort,` was common knowledge, and known as a sign of imminent death. Thus, Laënnec substituted the word rhonchi when referencing rales in front of a patient. Both terms remained in common use in medicine and with some confusion between the two. 

I learned rales as the subtle rustling or faint bubbling sound of wet alveoli engorged with purulence during inspiration.  Rhonchi were a coarser sound emanating from more proximal bronchioli – not at all the interchangeable meaning of rales and ronchi as used by Laennec. The continuing confusion over these two terms lead the American Thoracic  Society and the American College of Chest Physicians in 1977 to change the name rales to crackles.

Crackles carry the suggestion of an onomatopoeia; Crackles implies the sound of Rice-Crispi’s. Crackles may mimic the sound of advanced pneumonia, but the sound of rales at the left base at the critically early onset of left lower lobe pneumonia sounds more like rubbing your hair above your ear. It is a subtle sound accompanied by respiratory lag and splinting of the diaphragm –to often missed.

Changes in curriculum, standardized patients, recorded sounds from a manikin, shorter clinical hours, the concern for overuse of antibiotics, the change in name of d-pneumococcus to streptococcus, the protocols for immunizations, cholesterol checks, colonoscopies, conspire to reduce the sensitivity for the seriousness of a patient’s early illness. Early onset pneumonia presents with a patient who is a whole lot sicker than he or she looks. Often the temperature is not so high and the protocols seem to suggest that anything that coughs is a virus. There is even a score called the Risk-Rating-Index that tries to quantify the risk of the patient actually having pneumonia. Without long hours in the middle of the night seeing such patients, the pattern recognition of early pneumonia is lost or never learned.

The treatment is wrong when the diagnosis is wrong. If we diagnose pneumonia only with the second Emergency Room visit after the treatment for the virus that is going around fails, and the patient becomes indeed critical, an easy early treatment with oral agents becomes a hospital admission treating a critical illness all for a failure to diagnose.

 So, crackles it is, but define them as fine, coarse, wet or dry and when in inspiration. Percuss the mobility of the diaphragm. Do a Gram stain and view it yourself. Recognize a critical diagnosis when it sneaks up on you.  They may forgive you for using the more civilized `rales` in the French tradition when your take the extra steps and correctly diagnosis a case of early pneumonia.

FREE INFORMATION

Share |Hippocrates said that sacred knowledge should not be given to the uninitiated. He also said we should share information freely among ourselves. Copyright locks up the best of medical thought behind monetary walls. When I first went into practice, I could not afford journals. I was too busy paying off debt. In family practice, I needed many journals to stay current, but the family doctor who needs them most can afford them the least. The specialist who can afford all of them wants only one or none at all.

Now we have the Internet and Google. People can access anything, but not physicians. The hospital, medical school or medical society library is the only access without a high priced subscription. Now that I am semi retired, I have none of those things available, but it is the older physician who needs current information the most. Restricted access to medical knowledge is a good thing on the one hand; there is too much mischief to be made in sharing critical knowledge with those who would misuse it. Price, however, is not the way to channel medical knowledge. Better that we make all knowledge free and take our chances.

The medical schools do us a disservice by not providing total online access to all publications through their medical library. Without access to free medical information, we are left with best evidence determined by someone else, of an unknown source, unknown date and unknown validity. The guideline stifles progress. The guideline provided by someone else ends clinical medicine as a science and clinical doctors who rely entirely on those guidelines as scientists. 

Standardized medicine has some merit, however, in shoring up clinical weaknesses, excesses and greed. Such standardization may be the only way forward from our broken profession, but by the same argument, published research and clinical information needs to be freely distributed within the profession. Neither copyright nor patent should interfere.We need free access to all medical  information. No wonder an office visit costs so much.

Citation Impact

Share The US scientific community as ranked by the number of citations for our scientific articles falls behind Italy for 1012.

Our global ranking in the burden of disease studies(GBD) -- ranking us near the bottom -- may be only the tip of the iceberg. As for widely cited scientific papers, we were once far ahead of all other countries, but Switzerland surpassed us in the relative citation impact sometime prior to 2002. The UK followed suit in 2006 and now Italy in 2012. SciVal Analytics of Elsevier did the calculations. We do, however, remain ahead in the share in the top 1% of publications according to a notation in Nature News[1]

Can you doubt that our academic standing has slipped as a result of the exorbitant cost of higher education, or is there something more? Has medical education slipped as well; do physician extenders now practicing on their own, or does alternative medicine have an impact? Osteopathic schools are a growth industry. Hopkins advises medical student applicants seeking family practice to apply to schools of osteopathy. Many schools are back to a curriculum before Flexner paying for community preceptors and in a new wrinkle, standardized patients and semi robotic manikins.

Absent the academic rigorous of scientific education and of the ethical discipline of professional societies, entropy prevails. Has science given way to humanity, or has it given way to expedience?

 [1] |Nature 12 Dec 2013, 504, p192

Protocol-Based Treatment of Hypertension

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Protocol-Based Treatment of Hypertension: A Critical Step on the Pathway to Progress 
Thomas R. Frieden, MD, MPH, Sallyann M. Coleman King, MD, MSc, Janet S. Wright, MD.
JAMA. 2014;311(1):21 doi:10.1001/jama.2013.282615

The undiagnosed and untreated incidence of Diabetes in this country far exceeds that of the rest of the modern World. If the article is to be believed half of us are walking around with BP in excess of 140/90. Are treatment protocols the solution to correcting this burden?

I think not. The problem is not treatment protocols or any treatment, but diagnosis of the hypertension in the first place. Judging by my experience with students, hospitals clinics and offices, the BP cuff is the most neglected and misused instrument in the clinic. The best you can hope for is a very expensive automated BP machine that may or may not be reliable, never mind calibrated. The operator of the auto BP machine likely has minimal training in its use and little or none in the anatomy, physiology and principal of BP readings.

The only reliable BPs readings come from the physician him or herself, the least likely person to waste time on such a mundane thing as vital signs, and even then a cavalier attitude can negate abnormal findings. A good RN will get you good BPs if you give her a good cuff and a mercury manometer, but there too, administrators do not want to waste RN time taking vital signs when it can be done at the lowest cost denominator by an assistant. If a number gets duly recorded. that satisfies the administrator and any auditor that might review the chart.

Can you say why, for instance, you might want to take the BP in both arms or at least in the right arm? Was the patient standing, sitting or recumbent when the reading was taken? Was the cuff the right size; was the stethoscope turned the right way, or was one earpiece of the stethoscope behind the ear of the assistant, or did she bother to take the patient's sweater off?

If any of us, psychiatrists included, profess to practice by the Hippocratic method -- by that I mean total focus on the patient observing every detail -- then the physician must surely examine the pulse, the appearance and the blood pressure. I submit that if half of us are running around with undiagnosed hypertension or pre-hypertension, then half or more of the BP recordings in the patient record are wrong. How long does it take to take a BP and note the patient's pulse? How often do you suppose the assistant fails to note an arrhythmia? There are BP machines outside almost every pharmacy. I have yet to try one that I found believable. The point is that diagnosis of HT will emerge as epidemic if we bother to sit down with our patient, look them in the eye -- not the computer -- and take the pulse and BP ourselves. (Left arm BP may be normal in Coarctation while the Right arm and cerebral circulation reaches high levels.) Protocols are worthless in the absence of the right diagnosis.|

Informed debate over free-market ideas for health reform.

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Academicians and planners often miss the simple fact that health care by any measure is not a free market. Arguably, there is room for debate. There are no winners or losers in this debate except the American people. They are losing. The Global Burden of Disease shows the US some 26^th out of 33 industrialized countries, close to the bottom in nearly every category.

The concept of competition has merit, but a blank check from insurance companies promotes only competition for the dollar return and not for patient care. The intentions are great, but the planners do not see the forest for the trees. Nearly everything they have done has made matters worse. There is no competition between insurance companies, either now or back before the ACA. There is no competition between providers or between institutions either. With insurance company blank checks each provider and each institution is free to charge whatever they like promoting the most profitable services as would any corporate business. There is no incentive for insurance companies to restrict charges because increased charges result in approved increases in policy pricing and thus revenue. All of these players in health care: insurance, institutions, providers and drug companies are, in effect, monopolies. I submit that efforts to enlist the magic of free enterprise merely codify the monopoly and greed from all players including patients.

Competition with cooperation between states is good. There are vast regional differences in health risk and disease. Competition with cooperation between universities is good; it leads to academic excellence and progress. Open competition with cooperation between providers is good because medicine is a science and diversity of effort, inductive reasoning and sharing of data are the scientific method.

Competition for the dollar in a vital public infrastructure is not helpful. Public health is practically dead on the vine in the US due to the favoring of personal liberties over the intrinsic mandate for the public good – health.

The best competition of all would be between the private sector and traditional insurance company medicine. Competing public systems, run state by state, would increase the diversity, the science and the advancement of medicine -- with patient outcome the reward. Medical schools and city or county hospitals once fulfilled some of that role but not now given the Siren call of pre paid insurance and deregulation. These two competing systems are vastly different. Let free enterprise work for the two systems and let the market determine which system dominates. Let both sides give it their best.

This dichotomy is the real debate in Washington. Let the debate play out in the real world as a competition between belief systems with cooperation between both.

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