Thirty five years ago, my cardiovascular auscultative powers were at their peak. In other words, my hearing was perfect and I had just finished a job in cardiothoracic surgery. Many of my patients had abnormal heart sounds and I became a dab hand at interpreting thrills, opening snaps, murmurs and clicks. Once you have mastered the mysteries of the murmur, you never lose that skill. It’s like learning to ride a bike. Or so I thought.
Earlier this week, a nurse asked for my opinion. A young man had been complaining of increasing difficulty in breathing over the past week. He had fainted while working, and recently had started vomiting. The nurse had examined him and couldn’t find a cause for his breathlessness.
When I saw him, he looked distressed and anxious, exerting a lot of effort to get air in his lungs. Listening to his breathing, it all sounded perfectly normal. But his heart was making strange noises – murmurs. This just means that the blood flow is turbulent, making an additional sound. For example, if the blood is passing through a tight or leaking valve, you can hear (and sometimes feel) the distorted flow.
Without boring you with details, I diagnosed mixed valve disease probably caused by rheumatic fever, a disease now rare in UK but still common in developing countries. I asked another doctor for her opinion. She wasn’t as sure as I was, and thought there might be another reason for the murmurs, such as a hole in the heart. Our visiting obstetrician offered to scan his heart even though this wasn’t her normal territory, as the patient would not be able to afford investigation at a Thai hospital. We gathered around the oscilloscope in the scanning room and watched mysterious white shapes fluttering on the screen. She wasn’t sure, but it looked as though at least one valve was abnormal.
I haven’t a clue about ultrasonography. It happened after I left medical school. Even when I did obstetrics, only one of the three specialists in the hospital had been trained to scan. Although I’ve always had a hankering to learn to scan, I’ve never been trained.
The patient was looking more and more worried. He had seen three different doctors, all of whom were interested in his abnormal heart. He knew that the more attention he got, the more serious his condition was likely to be. He had a young family to support. He should be out in the fields tending to his crops. He had a panic attack and we had to get him to rebreathe from a paper bag.
Another day, another specialist. This time a trainee cardiologist visited the clinic. He examined the patient and did another ultrasound scan. One view showed a tiny jet of blood flowing from the left to the right ventricle. He couldn’t confirm it, but the same valve that looked dodgy to me yesterday, he thought was fine.
A large hole in the wall between the ventricles doesn’t sound very loud because the flow through it isn’t very turbulent. Vice versa, a smaller hole causes a louder sound because the flow is more tempestuous. Holes just don’t suddenly appear. He had probably had the problem since birth and it had not sealed itself off. It is possible that over exertion had caused his recent symptoms, but it was more likely to be related to the stress and worry about not being able to provide for his family. Now his main problem was anxiety and panic because four doctors were fussing over his heart.
The trainee cardiologist calmed him down. Afterwards, he told me that private cardiologists spend a lot of their time dealing with patients who have nothing wrong with their hearts but who are suffering from “cardiac neurosis”.
I was wrong here on two counts. Firstly, I misdiagnosed the murmur. I should have considered other possibilities before jumping to conclusions. Secondly, instead of making a triple diagnosis (taking into account biological, psychological and social factors), I’d been blinkered by what I was hearing through my stethoscope. I did not assess the murmur in a holistic context.
Even though we’d like to, we can’t get it right all the time. Read the previous blog about the anxious mother. What is important is that we keep an open, enquiring mind, correct our mistakes and learn from them.