Littman: The best Stethescopes

Your Question: What is the best stethescope to use as an RT?

My humble answer: Good question. I'd go with a Littman. Here is a link to one site that sells them, yet I just chose this one because it has some good pictures with prices. I have a Littman cardiology III which costs about $120 and has a five year warranty. I purchased this one because it has both an adult and a pediatric head that I need because I take care of both populations.

However, any one that fits your budget will work fine. I've used them all at some point.

You have to keep in mind here that your specialty is lung sounds, and therefore you will want to have a stethescope that will allow you to hear all lungsounds. You certainly don't want to have a cheap $10 stethescope that someone else purchased at a dime or dollar store, or your local pharmacy (like the light blue one pictured below).

Another neat things about lung sounds is they help you to pre-diagnose. If you miss those fine crackles in the bases, you might get the wrong initial impression of the patient. Plus picking up on certain lung sounds with a good stethescope will allow you to be proactive.

As you start working in a hospital you'll see many nurses carrying around a cheap stethescope like the one in the picture to the right. If you see one of those, you're seeing a nurse or an RT who doesn't value hearing all lung sounds, because you won't be able to.

What I find funny is when I'm watching a show like Becker or ER and seeing well paid doctors with cheap stethoscopes. Any astute physician can easily afford a good stethoscope.  So the fact the cheap ones are often seen on TV doctors shows the naivety of Hollywood.

That's why they should hire me and pay me a million to watch movies and TV shows to make sure all the medical stuff is right.

Anyway, I know college itself can get kind of expensive, but it's especially important you get a good stethoscope before you go to your first clinical. I'll give you two more good reasons.

1. Your preceptor will probably want to show you how to listen to lung sounds. When this happens, you'll want to make sure you're hearing what your preceptor is hearing. A good stethescope will allow you to do just that.
2. A cheap stethescope makes you look like a cheap RT or RN, as opposed to the elite one that you are. Don't sell your self short, be the best, and have good ears.

And no this is not an advertisement for Littman.  There are probably other good stethoscopes out there, but Littman seems to have a good grasp on the market and have me brainwashed.

This post was originally published on August 7, 2010, right here on RT Cave.  It has since been edited. 

Further reading:

• Lungsound lexicon
• How to listen to lungsounds
• How to hear bronchospasm

This RT not a fan of the labcoat

The Anonymous RT over at Respiratory Therapy 101 posed a great question recently regarding lab coats. Do you wear one?

Okay, so it's a boring question, but I'm sure there's one or two RTs out there that care what RTs at other hospitals do or don't do.

Most students are required to wear one. And, actually, our hospital policy says that we have to wear one. But I never do. I hate wearing a lab coat. All it is is a big bulky thing that makes you hotter in an already hot place. You know, old people like it H-O-T.

So usually I walk around in scrubs only. I have to add something else to this. I hate wearing my stethescope around my neck, so I carry it in one of my pockets -- 99% of the time the left pocket.

My meds go in the right pocket. That's my system. Now, some of my scrubs don't have pockets. If I have a lot of patients, I try to avoid wearing these scrubs. But, when I'm on a lazy streak and have not done my laundry, then I have no choice but to wear these pocketless crubs.

So on these days I have no choice but to wear the stethescope on my neck, or carry it over my clipboard, and store my drugs at randoms spots around the hospital. You know, I just stash a stack at a few random spots. Unless, that is, I have a chest pocket, then I plop some amps in there -- one of each (obviously I can't do this when it's busy. On those days I might be forced to wear the lab coat.)

The anonymous RT says he quit wearing a lab coat because he kept getting confused for a dr. While that has happened to me on occasion, at this small hospital there aren't enough random doctors for people to get THAT confused.

But, on those nights when I have few patients and the workload is low, and my metabolism slows way down, it can get quite cold. So, I tend to keep in nearby.

Still, when I do wear it I travel light. I keep as few drugs on me as possible. Usually I stock up on Duonebs because that seems to be the drug of choice by Dr. Q1, of whom I usually get stuck working with, and then a few of the other bronchodilators (depending on what the floor patients require).

I also might stock of few other RT essentials, like nipple adaptors and o2 connector tubing.

I honestly HATE wearing my stethescope over my shoulders. I got out of this habit the first time
the tubing on my Littman got hard and snapped in half. The company explained to me the oil in my skin dries out the tubing. I had to pay to get it fixed, and from then on it stays on my pocket.

Of course I could pay for a stethescope cover (one of my coworkers makes them), but I hate wearing on my neck anyway. (So, how did I get from lab coats to stethescopes. What a lame post this turned out to be.)

It's funny how each RT has his or her own system. One of my coworkers carries her meds around in a ziplock bag. Another wears a shirt and tie and dress clothes under his lab coat.

There's no such thing as coarse lung sounds

The rest of this week I thought I would discuss some of the basic lungsounds. I know this might sound hilarious, but there are some people who have listened to lungs for 20 years and still have no clue how to describe them.

To be fair, however, different books can describe the same sounds differently. Lets take crackles for instance. Some books say that a crackle is either fine, medium or coarse, while others say it's rhonchi, rhales and fine crackles.

On a side note, someone in my RT department (we won't name names) keeps charting "Coarse" under lungsounds. Allow me to share this information with you: there is no such lung sound as coarse.

What is coarse? Is it a coarse wheeze? Is is rhonchi? Actually, it could be both. It could be a coarse wheeze or coarse rhonchi. But, so, where is it? RUL? RML? RLL? LUL? LLL?

So we need to be more specific.

The majority of the time, however, a coarse wheeze is actually rhonchi. if you can isolate it to one particular lobe, its more likely a wheeze. But if it's continuous throught all the lungfields, it is probably not a wheeze.

Why do I say this? Because rhonchi is usually heard over a wheeze and is usually hard throughout the lungs. The low pitched coarseness of rhonchi is usually in the upper, larger airways where sound travels better, and it produces a noise that is more easily heard.

A wheeze, for definition purposes, is not a low pitched coarse sound but high pitched whistling sound. And because it comes from the small bronchial tubes in the lungs, it is NEVER heard audibly. I will discuss wheezes at a later date.

Today I want to discuss rhonchi and coarse.

There was a practice NBRC test that asked this question: You are listening to lung sounds and you hear a coarse sound throughout on inspiration and expiration. How do you best describe this sound? a) a wheeze b) rhonchi c) crackles d) a and c.

Do you want to know what the answer was? It was (drum roll please) "b" rhonchi.

If you are charting coarse, you should actually be charting rhonchi. In a lot of patients you have that loud sound on inspiratory and expiratory. It may even sound like snoring. This is not a wheeze, it is rhonchi. What you are hearing is secretions rumbling on inspiratoin and expiration.

This is probably the toughest lung sound to pick out because it's not taught very well in school. Even many doctors chart this is coarse or as a wheeze and assume it is bronchospasm.

Yet, as soon as the RT does the STAT breathing treatment, the patient feels no better and the peek flow is the same before and after. Yet, three weeks later and after the insurance company is out $10,000 because of useless breathing treatments, the patient still has those treatments ordered.

And all of that because the doctor heard rhonchi and had no idea it was not a wheeze.

Rhonchi can also produce a bubbly sound over the throat and upper airway, which almost sounds like fluid is in there. You have the patient cough and usually this goes away. However, sometimes those secretions are further embedded in the upper airway, and this causes the COARSE sound you hear.

Sometimes these secretions are embedded by the vocal cords, and produce an audible sound. As I wrote in my last post, any lung sound that is audible is not a wheeze: it is rhonchi. Either that, or it is stridor.

Stridor is usually an audible inspiratory high-pitched sound. It is usually caused because of swelling near the vocal cords. It can be the result of croup or post extubation. It can be caused due to laryngospasms. And, despite contrary belief, it is a common lung sound in adults too. Only, it usually gets charted as a wheeze, so no one ever talks about it.

However, some RT books describe stridor as any noise inspiratory and expiratory that is heard in the throat. (Dana Oakes, "Clinical Practitioner's Pocket Guide to Respiratory Therapy," describes it this way).

To hear this noise, all you have to do is take your stethoscope and set it over the throat. If you hear it loud and clear their, then the noise you heard in the lower airways was this same sound.

Yet, it is true, many times doctors only listen to the posterior lungs and hear this high pitched sound and call it a wheeze, when it is actually upper airway stridor or rhonchi. A lot of older patients get secretions stuck right up behind the vocals, and they produce this high pitched sound. This happens sometimes for no reason on healthy adults, or it can happen on those with NGs, or simply OTL (Out To Lunch) patients or SGD (She's gonna die) patients.

I'm to the point now that I get so irritated when a doctor orders a treatment because a patient has upper airway swelling or secretions and no otherwise signs of shortness of breath, that if the doctor is still standing there, I will listen to the throat and say, "What you hear isn't a wheeze, it's stridor."

"Don't you know a wheeze by now," a doctor said to me once.

"Yes, and that's a stridor."

Of course I don't do that very often, only when I'm extremely busy and don't have time for such nonsensical treatments, very tired, or simply irritated. Unfortunately that doesn't happen enough around here, so our doctors continue to go uneducated.

Now I say doctors, I know there are some nurses and even a few RTs who have no clue what lung sounds are actually bronchospasm and which are secretions. I suppose this will be a continual battle.

However, there are some really smart doctors and RNs that I work with who know the difference, and don't call me every time they hear "COARSE" lung sounds.

Tomorrow I will expound a little about crackles and then maybe wheezes.

How to listen to lung sounds

As he places the stethoscope on your back, the doctor says, "Take a deep breath."

As an RT who has listened to the lung sounds of over 10,000 patients, I will tell you that having a patient take in a deep breath is not the ideal way to listen to lung sounds.

Ideally, you want the patient to breath normal. The reason is you want to hear what a patent's lungs sound like when he is breathing normal.

When a patient is taking in a deep breath, you will have more turbulence in the lungs, and you will hear a lot of extra noises, particularly upper airway noises, and secretions sitting in the throat. Throat noises are often mistaken for wheezes caused by bronchospasm.

So, here is an RT 101 coarse on how to listen to lung sounds. If I disagree with what you learned in RT, RN or DR school I apologize. But this is how you hear lung sounds.

First, you listen to the apices while the patient is breathing normal. Many times, though, the patient could have the worse lung sounds and still sound clear in the front, so this should never be the only place you listen.

Second, while the patient is still breathing normal, you'll want to listen to the right upper lobe and then left upper lobe, and then right lower lobe and left lower lobe. You do this because you want to make sure the lung sounds are equal on both sides.

If lung sounds are not equal, this may be indicative of whatever illness is ailing the patient. For example, crackles in one part of lung may be indicative of pneumonia. Diminished in one lobe may be indicative of pneumonia or pleural effusion or pneumo.

If a patient has fine crackles in the bases, you sometimes will not hear them unless the patient takes a deep breath. So, third, you have the patient take a deep breath while you listen to the bases for those fine crackles. This is how you hear your fine crackles.

Many times these crackles get missed by nurses, doctors and probably even some RTs. But never me.

Many times, if the crackles are equal in both bases, this may be a normal sound, particularly in COPD and CHF patients. However, fine crackles in the bases can be an early sign that the lungs are getting wet, and you should check the patients urinary output to see if he is retaining fluid.

See, by your proper lung assessment, you can easily prevent a patient from ever getting short-of-breath due to wet lung. And the Dr. and RN might even be impressed with you (or their faces might be red because they failed to listen at all).

Okay, by now you have heard all your lung sounds right? Wrong. When you listened you heard a loud wheeze throughout the lungfields. This "wheeze" may also even be audible.

Here is something I learned by experience and not through school: If the wheeze is audible it is not bronchospasm: it is a throat wheeze. Many times when a patient is wet he has a throat
wheeze, so when I hear this I assess for wet lungs while auscultating.

So, we have to add a fourth step that most doctors miss.

Fourth, listen to the patient's throat. If you hear the wheeze loud in the throat, there is a high likelihood that it is not a bronchospasm wheeze. It is probably a wheeze caused by phlegm in throat, or a dry throat, or snoring, or maybe even stridor.

Many times, doctors order breathing treatments just because a patient has throat wheezes that are RADIATING throughout the lungfields mimicking a bronchospasm wheeze. Many times this throat wheeze is laryngospasm, such as you might hear after a bronchoscopy or extubation.

If you follow these four simple steps you will always get accurate lung sounds. Then you go look at the chart to see what the doctor charted: "wheezes." Then the order says, "Albuterol Nebs Q4 ATC."

As a smart RT or smart RT student or smart RN you question the doctor: "What kind of wheezes? Where are the wheezes?"

You know that they are not bronchospasm wheezes, but the doctor doesn't. While you once thought a doctor could do no wrong, you now know better. You may even snicker.

RTs need a quality, reasonably priced stethescope

Since we RTs are the lung experts, it's important that we have a good stethoscope. And that's why I arm myself with a Litman.

I remember when I was a student I had a cheap one I bought at Walgreens, and it worked fine while I was a student. But one day I decided to splurge and buy a Litman, and the first time I went to use it I could really tell the difference.

With a Litman (or any quality stethoscope), you can hear things that you simply cannot hear with a cheap stethoscope. And, being the lung experts, it's important that we RTs are armed with the best stethoscope possible.

I can't remember what I paid, but I think it was something like $120 or less. If I were recommending a stethoscope to a student, I'd recommend a Litman that is of a reasonable price. I don't think there is much of a difference between the $60 version and the $300 version.

Also, you must realize that a stethoscope doesn't last forever, especially since you will be using it often. And the warranty only lasts so long.

I think the bell broke on my first one, and I sent it to the Litman company a week before the warranty ran out, and they gave me another 2 year warranty. So, if your warranty is ending soon, you might want to consider getting it fixed if you were thinking about it.

A few years later I noticed the casing of the stethoscope was really hard. Then it cracked. Then I learned this happens because you wear it around your neck. The oils in your neck get into the material of the scope, and it hardens.

So I got this fixed and got another 2 year extension on my warranty.

When I got it back I decided to carry it in my pocket instead. I actually liked this method of carrying it better than wearing it around my neck, because I hate wearing things over my neck.

But then the ears of the stethoscope got snagged on a door handle, and my lab coat ripped. This has happened many times.

Then, one day, after the warranty finally ran out, I got it snagged on a door handle and the metal part snapped. So, then I used a warped stethoscope because I'm too cheap to buy a new one.

Finally my wife splurged and bought me a new one for my birthday a few years ago, and now the new one is wearing out and in need of repair.

So, the moral of my story here is this: you need a good stethoscope, but don't spend to much on it because you may need to replace it eventually.