Symphony Orchestras, Heart Sounds, and Creepiness…

Music and language in medicine.

The Washington Monument in Autumn by David Rogawski

As we kicked off our second Clinical Foundations of Medicine module this week, we were given a strange assignment. We were asked to listen to a symphony orchestra and try to pick out various individual instruments. This would prepare us to listen to the heart and lungs, the main focus of the week. Learning to pick out the soloist from the ensemble is the auditory challenge of the physician in physical examination. I liked the musical connection. Aside from the main heartbeat, the heart apparently also “murmurs” and “gallops.” You recognize one type of “gallop” by a sequence of beats that sound like the stressed and unstressed syllables of the word “Kentucky” and the other which sounds like “Tennessee.” I thought, having lived in both states, that this would be especially helpful to me. But I found I could pronounce both words in such a way that stress patterns were ambiguous at best! Would northern states have worked better? Hard to say. When I simply reduced each gallop to a nice, funky rhythm it was fine. So, the next time you see me, ask for an S3 or S4 gallop and I’ll tap out a rhythm that will dazzle your senses!

As for the the lungs they can produce “rales” or “crackles.” The language of heart and lung examination is actually quite animated and enjoyable. The process of feeling a patient’s chest to note abnormalities is known as “palpation.”  You can, for example, palpate for “thrills” which I’m sure is a lot more serious than simply palpating for “kicks.” Murmurs can crescendo or decrescendo. You can also tap on the patient’s body in a process known as “percussion.” When learning modern dance, I heard of the concept of “the body as orchestra” from modern dance pioneer Jose Limon, who spoke of paying attention to “counter-energies and movements.” It’s the little “instruments” that I found tricky. At first, I could really only detect a heartbeat; yes, I single-handedly concluded from my physical examination that the patient was indeed alive. Of course, the fact he was talking to me was helpful in drawing that conclusion as well. But after time, the subtle voices, the embedded “instruments” began to make themselves heard. There is, for example, a lung sound known as the “whispered pectoriloquy” not to be confused with the “exclaimed soliloquy” which is more likely to be found in Hamlet.

With all this touching, feeling, vibrations, and whispering, there was bound to be someone who turned onto Creepy Avenue. And there was. At one point, one of my classmates wanted to let my other classmate know that he was going to percuss his back. He put it this way: “And now, I’m going to put my hands all over you.” He was advised to rephrase.

So this week was an example of what  I love about medicine. Medicine tests your senses, intellect, and sense of language. Of course, at the end of the week when we saw real patients with heart and lung conditions, we were reminded once again that each heart or lung sound spoke not just to a diagnosis but a story: a man who lost his lung in a car accident, a woman who finally gave up smoking to live to see her grandchildren and a 29 year-old who was only alive because of advances in care for cystic fibrosis. Their sounds were battle-cries, from their very center, an insistence on taking another breath.



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