Listen up! Auscultation tips for EMTs, paramedics and students
Gain confidence in the difference between normal and abnormal by auscultating lung sounds on every patient
Auscultation, which is to listen, with a stethoscope is part of every patient assessment. At a minimum, EMTs and paramedics are expected to auscultate a patient’s blood pressure and listen to lung sounds as part of a respiratory illness physical exam. [At the end of this article, download an auscultation tip sheet for easy reference]
In some situations, paramedics might auscultate a patient’s heart sounds or a long bone to assess for a fracture. But hearing through a stethoscope in the chaotic prehospital environment is a constant challenge. Bystanders and partners talking, dogs barking, idling vehicle engines and more can make it difficult to hear the transmission of audio waves from the patient’s lungs, heart, bowels or arteries through the stethoscope tubing and into your ears.
If you are having a hard time hearing through your stethoscope, here are a few things to try. I have also added additional tips from other EMS educators, so read all the way to the end of the article and submit your own tips to be added to the list.
Protect your hearing. When you are not using your stethoscope, take good care of your hearing by keeping the volume down on music, videos and games, especially while using AirPods or headphones. While riding in the ambulance or fire apparatus, keep the windows up when running with the siren (and lights) and use employer-provided hearing protection. In general, use hearing protection anytime you are operating light- or heavy machinery, including your lawnmower, leaf blower and chainsaw.
Quality matters. When buying a stethoscope, like anything, you’ll get what you pay for. The beginner stethoscope you bought at the start of EMT class might be great for the relative calm and quiet of the classroom, but you’ll probably be better served by a higher-quality stethoscope in the ambulance, on the street or in a patient’s bedroom. But don’t spend so much on a stethoscope that you’ll be financially and emotionally crushed if you leave it behind on scene or forget to take it out of the ambulance at shift change.
Place on bare skin. Clothing, even light layers, can dampen the sounds you are attempting to hear. You'll hear best if you place the stethoscope diaphragm directly against the patient’s bare skin.
Visualize anatomical locations. The lungs are underneath and protected by the ribs. If you are too low or below the posterior rib cage, you are more likely to hear bowel sounds than the whoosh of air moving in and out of the lungs. Start high and listen to lung sounds as you work your way down the patient's back.
Hold firmly in place. The diaphragm of the stethoscope, placed on the patient's bare skin, needs to be held firmly in place, but not pressed deeply into the patient’s tissue. Apply just enough pressure that the diaphragm doesn’t slide and stays in place as the patient’s chest wall expands and contracts with breathing. If you hold the diaphragm too loosely, you’ll hear the sound of the diaphragm moving on the patient’s skin and hair.
Wear the stethoscope correctly. The most common mistake I have seen EMT students make is inserting the stethoscope ear tips in the wrong direction. The ear tubes and ear tips are generally angled and should be inserted pointed or angled towards the user’s nose. Double-check the direction the ear tips are facing if you are having a hard time hearing.
Reduce ambient noise. Use verbal direction and body language, like a focused glance or head nod, to quiet your partner, the patient and bystanders as you attempt to listen. Ask your partner to pause with an assessment or intervention or the patient to stop moving while you are listening. Some scenes, especially outdoors, as just too loud with ambient noise. You may need to move the patient to the ambulance or an exam room before you are going to be able to hear well with your stethoscope.
Listen to lots of normal lung sounds. A critical step in identifying abnormal lung sounds is having listened to lots and lots of normal lung sounds. Use every patient contact as an opportunity to hear the gentle whoosh of air during exhalation and inhalation. As you listen, consider how what you are hearing matches the patient’s current and chronic medical conditions, age and chest wall thickness.
Quiet your mind and body. Auscultation requires your attention and mindfulness. You are both attempting to hear the existence of something – a pulse or movement of air – while also assessing the quality or type of sound you are hearing. Be patient, continue your own breathing and tune out mental distractions as you attempt to differentiate between rales, wheezes or rhonchi.
Try again. After deflating the blood pressure cuff and not hearing the patient’s heartbeat indicating systolic blood pressure, give yourself permission to try again. Make sure you’ve already palpated the patient’s radial pulse, so you have a sense of the rate. Consider taking a blood pressure by palpation before your next auscultation attempt. Also, palpate the patient’s brachial pulse so you are placing the stethoscope diaphragm as close as possible to the brachial artery. Instead of guessing, be persistent, fine-tune your technique, and politely tell the patient, “I am going to try again.”
Bonus tips from EMS educators
I asked some of my favorite EMS educators, including Ginger Locke, Rob Theriault and Rom Duckworth, for their stethoscope tips for EMT and paramedic students. Here is what they and several others had to say. If you have a tip for new EMS professionals, submit your tip in the form below and we’ll add it to the article.
“Some manufacturers use what is called 'tunable technology.' Using this technology, the chest piece can be used like a bell or a diaphragm depending on how much pressure is applied to the chest piece,” Ginger Locke, paramedic and Medic Mindset podcast creator, said. “The benefit of this is that once a sound is heard, the clinician doesn't have to lift the stethoscope from the chest and risk losing the location where the sound was heard. Many new clinicians are walking around with this technology, but are unaware of the functionality.”
“The stethoscope is one of the most important and underutilized tools in the paramedic’s diagnostic toolbox,” Rob Theriault, paramedic, educator and author, said. “At a bare minimum, it should be used on every single patient with a respiratory or a cardiac complaint to assess lung and heart sounds.”
“Whether you are using an acoustic or electronic stethoscope, be very mindful of the pressure you are applying,” Rom Duckworth, paramedic, educator, and presenter, said. “Fine adjustments of pressure will make a world of difference to what frequencies you hear, or if you hear anything at all.”
“Hold the stethoscope lightly between your index and middle finger with the tube draped over your thumb to minimize artifact,” Brittany Prater, paramedic and EMS educator, said.
“Clean your stethoscope with an alcohol swab in front of your patient,” Kevin Collopy, paramedic and EMS educator, said. “To allow it to dry before use (air drying helps the alcohol kill bacteria) clean it while talking to your patient and let it dry while counting a pulse or respirations, once it is dry you can use it on your patient. This helps prevent the spread of diseases and helps us slow and work methodically.”
“Use the bell of your stethoscope, not the diaphragm,” writes Kelly Grayson in an article on blood pressure reading tips and tricks. “The bell of your stethoscope works better on those low-frequency sounds. Try for yourself and you'll see.”
“Start on the back and move to the front,” Steve Whitehead teaches when assessing lung sounds. “The best lung sounds you are going to hear are on the patient’s back.”
Learn more about auscultation
Even though the stethoscope has been around since the early 1800s, it is an essential piece of assessment equipment, that you can always learn to use more effectively. Check out these additional articles to learn more.