The music lesson

Patey, Paul

I complete the death certificate and sign it. Then to the medical student, Lori, I say, "Let's go back to the room. There's something I want you to listen to." We return to the dead man.

"Put your stethoscope on his chest over his heart and listen."

As she listens I think about the information in the dead man's thick chart. He rapidly accumulated a big collection of inter-tangled burdensome illnesses. Today they led to his death. At home he felt weak, became unconscious, and a few minutes later ceased to breathe just as the ambulance arrived at his home. The attendants started cardiopulmonary resuscitation and hurried him to the rural health care centre where I work as a family physician, including shifts in the emergency department.

Lori had helped in the resuscitation efforts after he arrived. As expected, our endotracheal tube, adrenaline and atropine had been to no avail. The cardiac monitor said asystole. Now she listens to the silent heart again. Lori pauses and looks at me.

I say, "Listen again: listen until you hear the fluorescent lights humming and the ventilation fan turning. Listen until you start to feel or hear your own heart beating, and compare it with your own pulse by putting your fingers on your pulse at your wrist."

She listens again, after which I say, "The sound of a silent heart; it's the biggest sound in medicine. Not the loudest, but the biggest."

Neither Lori nor I know that this silent drum is but chapter one of today's music lesson.

In the afternoon I am assessing an old lady whose heart has started to weaken in the past few months. I get Lori.

"This is Mrs. Barns. I want you to listen to her heart. She's 99 years old. Don't try and understand what the heart is doing. Just listen to its music. Listen to the drum. There will be time enough later for understanding the science of hearts." Lori listens to the heart; a heart that has been beating for more than 100 years. A heart that has beat more than 3.6 billion times!

What magnificence endurance living human tissue can possess. What an array of experience 99 years of living has given this lady. Lori observes both the patient and the pump. She also observes the caring daughter, herself well along on her life's journey. Chapter Two.

A few minutes later another opportunity arrives - an infant in her mother's arms. To Lori I say, "She's nine weeks old. Listen to her heart. Notice how crisp and clear the sounds are. Notice that they seem to be right under your stethoscope. They sound near. Again, listen to the music; the science will come later." Lori listens to the drumming of the enthusiastic normal little heart that started beating as it was being formed less than a year ago. She hears the sound, but she also sees the happy mother and contented child. Chapter Three.

I suppose Chapter Four of today's music lesson would have been a fetal heart, but serendipity did not provide the opportunity that day.

These three hearts have allowed Lori to see the magnificence, the beauty and the mystery of human biology. Our atoms come together and for a few decades dance the dance of life and then disperse. It affirms for Lori what King David said 3,500 years ago about the human being: "How wonderfully I am made." She is also aware of the person within and for whom the heart pumps; she is aware of those who love the patient, including those who today commenced to grieve. Surely these experiences can provoke in the medical student a continuing wondering about the human condition.

A few days later, having discovered a murmur while listening to a man's heart, Lori has opportunity to show me what she already knows about examining hearts and comprehending in a scientific way the meaning of the sounds and other findings, including the patient's medical history.

It is an opportunity for her knowledge and skills to grow; opportunity to enhance her ability to assess the timing of the cardiac cycle and the position of the murmur within that cycle; time to learn how to seek out changes in the sounds and murmur as heard from different positions on the chest and to understand the reasons for the differences; time to search for other murmurs; time to see how the murmur is affected by position, respiration and exercise; and time to see how the chest X-ray and electrocardiogram augment, but do not replace, careful clinical history and examination. This encounter strengthens her science, her skill, and her competence; last week's "music lesson" provided nurtured her wonder, her motivation, and her compassion.

Theme: Patients | Patients
Theme: Teaching and Learning
Theme: Teaching and Learning | Enseignement et apprentissage

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.




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