By Kelly Grayson

Too many years of shooting without adequate ear protection, coupled with a few childhood traumas, have cursed me with a measurable hearing deficit through all frequency ranges, particularly the higher ones. At noisy gatherings, I've found that much of my conversational style consists of smiling politely and saying "What?" a lot.

I also found that, without the very highest quality stethoscopes, all my patients' auscultatory sounds strongly resembled a Powerstroke diesel engine. So, I became one of those elitist medics who carries a $300 pair of ears everywhere he goes.

I've tried them all — Littman, DRG Puretone, Welch Allyn, ADC, even the acrylic jobbies you see in EMS supply catalogs that are supposedly capable of detecting a gnat fart through two down comforters and a foot of cellulite. Heck, even amplified scopes proved unsuitable; I'd try one out in a conference exhibit hall, and the Korotkoff sounds and S3 gallop I wanted to hear were no louder than Ken Bouvier in the next booth explaining how to make an adjustable C-collar sound like a pump-action shotgun.

Even now, with my absurdly expensive stethoscope plugged into my ears, and my eyes screwed shut like a mystic summoning a spirit, I am still occasionally unable to hear Grandma's late inspiratory crackles over the sound of her granddaughter with tachylawdia ten feet away.

So for those occasions when the ambient noise level proves too much, I use my field expedient stethoscope: my hands.

The next time you're unable to hear breath sounds, try assessing for tactile vocal fremitus instead. Wrap your hands around the patient's chest and note the vibrations elicited as they say the words, "Ninety nine."

Since sound waves travel faster through solids than liquids and gases, vocal fremitus is usually more intense over areas of lung consolidation. Conversely, you'll notice it diminished over pleural effusions, and often absent altogether over a significant pneumothorax.

Read up on it, and give it a try some time. With a little practice, you'll find that you can learn quite a bit through tactile sensation.