The Device That Changed The Practice Of Medicine: The Stethoscope

Imagine for a moment the year 1800. A doctor is meeting with a patient – most likely in the patient’s home. The patient is complaining about shortness of breath. A cough, a fever. The doctor might check the patient’s pulse or feel their belly, but unlike today, what’s happening inside of the patient’s body is basically unknowable. There’s no MRI. No X-rays. The living body is like a black box that can’t be opened.

The only way for a doctor to figure out what was wrong with a patient was to ask them, and as a result patients’ accounts of their symptoms were seen as diseases in themselves. While today a fever is seen as a symptom of some underlying disease like the flu, back then the fever was essentially regarded as the disease itself.

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But in the early 1800s, an invention came along that changed everything. Suddenly the doctor could clearly hear what was happening inside the body. The heart, the lungs, the breath. This revolutionary device was the stethoscope.

The inventor of the stethoscope was a French doctor named René Laennec. In medical school, he had learned to practice percussion – a technique in which doctors tap their fingers against a patient’s chest and listen to the sound to try and hear what’s going on inside.

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One day, he tried percussing a patient but had trouble hearing. So he rolled up his notebook into a little cylinder and put one end on the patient’s chest and one end in his ear. He was so impressed by the quality of the sound that he decided to construct a device for listening to the internal sounds of the body.

The result was the original stethoscope. Laennec had invented a way to hear the inner workings of the human body. Now he needed to connect the sounds he was hearing with what was happening anatomically inside the patient’s body.

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To do this, Laennec listened to people right before they died, and then connected these sounds to discoveries made during the autopsy. Soon, Laennec made some key discoveries using his stethoscope. For example, he found that when a person has fluid beneath their lungs, they make a bleating sound, kind of like a goat. A sound he called egophony. He also discovered sounds that tracked with the different stages of tuberculosis.

Laennec published his results, and soon doctors were making other important discoveries that changed the way people thought about disease. Little by little our entire understanding of disease shifted from one centered around symptoms to one centered around objective observation of the body. Medical language completely changed, as doctors invented new anatomical words for diseases, like Bronchitis, which means the inflammation of the bronchial tubes.

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In parallel, the device evolved as well. In the 1840s, doctors began experimenting with flexible tubing and soon an Irish physician invented the binaural stethoscope design with two earpieces that we still use.

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This evolving device got doctors thinking about disease in new ways, changing their dynamic with patients and giving doctors a lot more power. Before the stethoscope, to be sick, the patient had to feel sick. After the stethoscope, it didn’t matter what patients thought was wrong with them, it mattered more what the doctor found.

René Laennec actually felt that patient’s accounts of their own disease were still important, but the quest for objective information about disease was underway, and the stethoscope was just the beginning. Now we have X-rays, CT scanners and MRI and PET scans. All of these devices are basically trading upon the same paradigm that the stethoscope created: that doctors should be able to detect abnormalities inside the body to reach a diagnosis, regardless of how the patient is feeling.

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These new technologies have led to so many important discoveries about the human body and disease. Today, we can spot tumors before they become life threatening and diagnose problems like high blood pressure before they causes heart disease. But this new way of thinking has also pushed doctors and patients farther apart. The doctor is no longer in your bedroom interviewing you about every detail of your experience.

René Laennec died in 1826 at the age of 45, mostly likely of tuberculosis, a disease he and his stethoscope helped us understand. It’s been 200 years since he first rolled up his note book and pressed it to that patient’s chest. Medicine looks completely different than it did back then, but somehow the stethoscope has endured.

It’s no longer a wooden cylinder, but to this day, when you walk into a doctor’s office for a routine exam, you can expect to feel the familiar stethoscope on your back.

But that could be changing. Powerful imaging technologies like ultrasound have made the stethoscope exam less critical to the diagnostic process. Medical students aren’t as good as using stethoscopes as they used to be, and across the board doctors today rely less on the stethoscope to make diagnoses. The rise of portable ultrasound has some doctors arguing that we don’t need the stethoscope anymore. They say that if you have that technology right at the bedside, why not use it right away? Ultrasound is an incredible tool, but it still isn’t widely available in many developing countries, and even in the United States it’s expensive. Right now the stethoscope functions as a screening tool so that patients don’t need to go get an expensive ultrasound unless they need one.

Dr. Andrew Bomback is a nephrologist and an assistant professor at Columbia. He still uses his stethoscope, but he says that in general doctors aren’t as good at listening to the body as they once were, and they rely on the stethoscope exam less and less to make a diagnosis. “It’s become almost a ritual more than an actual tool in terms of making diagnosis,” Bomback explains.

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Regardless of how it’s used, the stethoscope remains omnipresent in our culture. Do a Google image search for doctor, and you will see what a physician is supposed to look like. The plurality of the doctors pictured on the first page of results are white men in white coats. Some of them are peering inside patient’s ears, others are writing something down on a clipboard. But all of them have stethoscopes.

And they are wearing the stethoscope in the exact same way–which is like a shawl around the back of the neck. Andrew Bomback says this way of wearing the stethoscope is a relatively recent fashion trend, probably borrowed from TV shows like ER and Scrubs. Doctors used to wear their stethoscopes dangling down the front of the shirt like a tie, which was practical. If you needed to use it quickly you could just pop it into your ears. Bomback observes that “it’s almost like this new version of wearing it like a scarf or a shawl is almost a concession that it’s more a fashion accessory than actually a tool that we’re using.”

But even if it’s become a fashion accessory, Dr. Bomback isn’t ready to give up his stethoscope. He says it’s an important conduit to connecting with his patients. Physical contact between a doctor and a patient has become increasingly rare. Doctors visits are short and physicians often spend much of time staring at a computer screen. Bomback says the stethoscope provides an important opportunity for intimacy.

“The stethoscope is still a part of the exam” he says, “aligned with the laying on of hands” associated with healers. “When we go to do the physical exam, we move away from our desk, we move away from the computer, and we stand right next to the patient and it’s a much more intimate conversation.”

Bomback says he thinks the stethoscope lives on in part to keep doctors and patients from drifting too far apart. To make sure doctors keep close to their patients, and keep listening.


This article originally appeared on 99pi.org. 99 Percent Invisible is a podcast on the design of things we never stop to think twice about. If you enjoyed this article, head over to their website and listen to their playlists.



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  source: Larm Rmah  

  1. Paediatrics  
 2. History  
 3. Key differences  
 4. Ethics  
 5. Training  
 6. Job scope  
 7. Required skills  
 8. Common Cases  
 9. Career Opportunities  

 Paediatrics 

 Paediatrics is the branch of medicine that deals with the medical of infants, children, and adolescents. The American Academy of Paediatrics recommends people be under paediatric care up to the age of 21. A medical practitioner who specializes in this area is known as a paediatrician. 

 The word paediatrics can be spelled as either  paediatrics , as per British English, or  pediatrics , as per the American counterpart. Both spellings are acceptable. 

 The word paediatrics comes from two Greek words: “ pais “, meaning children, and “ iaitros “, meaning “doctor” or “healer”. Paediatric nurses usually work in hospitals, assisting physicians in specialized subfields like  neonatology . 

 History 

 Paediatrics is considered to be a new subset of medicine today. Ancient Greek physicians like Hippocrates, Aristotle, Celsus, Soranus, and Galen understood the differences in growing organisms like children; as compared to fully-mature adults. Soranus, a Greek physician and gynaecologist from Ephesus (located in modern-day Turkey) has published  records dealing with neonatal paediatrics . 

   

  source: EIT Mental Health  

 Paediatrics as a specialized field of medicine continued to develop in the mid-19th century. The first generally accepted paediatric hospital is the L’Hopital des Enfants Malades, which literally translates from French as “The Hospital for Ill Children.” It opened in Paris in the month of June, 1802. It accepted patients up to the age of 15 years, and still continues to operate today. 

 Key Differences Between Adult and Paediatric Medicine 

 Maturation of the human body is paralleled by differences in body size. In other words, the smaller the infant, the more different the physiology of the said patient. The smaller body of an infant or a neonate (a baby) provides a greater concern to physicians or nurses in the paediatric ward. Congenital defects, genetic variance, and developmental issues adversely affect children more than adults. 

 Children, therefore, must not be treated as “a smaller version of adults.” 

 Nurses and physicians in the paediatric specialty must take into account the immature physiology of the infant or child when considering symptoms, prescribing medications, and diagnosing illnesses. 

 Ethics 

 Another major difference between adult and paediatric medicine, is that  children cannot make decisions for themselves . This is important enough to warrant its own subsection in this article. 

 The issues of guardianship, privacy, legal responsibility and informed consent must  always  be considered in every procedure. 

 
 … children cannot make decisions for themselves. 
 

 Rather than just treating the child, those working in paediatrics often have to treat the parents and the family. Adolescents are in their own legal class, depending on the country, and they have rights to their own health care decisions in certain circumstances. 

 Not only will a paediatric nurse or doctor take into account the desires of a child when considering treatment options, he or she will conform to the wishes of many people. This becomes especially  important when dealing with conditions of poor prognosis, and complicated or painful procedures.  

 Training 

 Courses are available to registered nurses who have completed a minimum number of service years. The number of years differ according to country. The qualifications range from advanced diplomas, to PhD research focusing on paediatric care. Many academicians forgo clinical practice in order to pursue research that will improve the quality of healthcare or bring about favourable policies to the care of children and adolescents. 

   

  source: paediatricemergencies.podbean.com  

 It is very common for paediatric nursing training to be comprised of  didactic  and clinical components covering the management and treatment of acute and complex child patients. 

 In Malaysia, paediatric training also comprises of management of sophisticated technology, providing nurses with the capability to offer quality care in a variety of situations. Training for disease prevention and recuperative treatment are also common modules in a paediatric nursing course. 

 Core modules of training would include  interpersonal skills and counselling ,  values and ethics ,  paediatric principles and practice ,  nursing of children with special needs ,  paediatric oncology , and some clinical practice. 

 Job scope and responsibilities 

 Typical activites may vary according to the role and work setting of the paediatric nurse. Children with special needs often require a different level of care compared to others. With that said, responsibilities include: 

 
	 assessment and critical reporting of patients 
	 preparing patients for pre- or post-op 
	 setting up drips, transfusions 
	 administering drugs and injections 
	 explaining procedures, treatments, to patients or guardians to acquire their consent to treatment 
	 support, comfort, and advise the child and family 
 

 Required skills 

 Children are sensitive, therefore tread lightly when giving care. Paediatric nurses need to display: 

 
	 respect towards the patients and their family’s decisions 
	 excellent communication skills 
	 be able to communicate on a level that the child would understand (if required) 
	 ability to deal with a range of patients at one time 
	 emotional resilience, and mentally strong to handle patients under difficult conditions 
	 compassion to others’ suffering 
 

 Common cases 

 Flat feet 

   

  source: smartlivingnetwork.com  

 Usually happens when the bar ossifies, about 8-12 years old. The tarsal area coalesces and causes rigid and painful flat feet. Operative treatment is not usually needed, unless severe. Usually managed non-operatively. 

 SUFE (Slipped Upper Femoral Epiphysis - also known as SCFE) 

   

  source: Raymond Liu, MD  

 This is a disease that afflicts adolescents (13-18 years old). The growth plate widens during growth spurt and some factors then predispose to slip. Adolescents who suffer from obesity, femoral neck retroversion, endocrinopathies, and trauma are particularly likely to be diagnosed with this. 

 Bradycardia 

   

  source: cardiachealth.org  

 Bradycardia is defined by a heart rate less than the lower limit of normal for age. For infants below 3 years, it is 100 bpm. For children 3-9 years, it is 60 bpm. For 9-16 years, it is 50 bpm. Bradycardial abnormalities can be diagnosed using the 12-lead ECG or the 24-hour holter monitor. 

 Exercise stress testing is not needed in the diagnosis, but may be helpful to determine chronotropic competence. 

 Non-neonatal jaundice 

   

  source: patient.info  

 Jaundice is a yellowish discolouration of the skin, sclera, and mucous membranes due to high counts of bilirubin. It occurs as a result of abnormal bilirubin metabolism and/or secretion. Typically occuring in neonates, jaundice can occur in all age groups. 

 Treatment is done after classifying the jaundice as conjugated or unconjugated hyperbilirubinemia in the older child. Jaundice in older children may be the first clinical manifestation of unrecognized chronic liver disease. 

 Career opportunities 

 Paediatrics is one of those specialties that becomes deeper with more things to explore the more experience you have. Subspecialties in hospitals and community areas include: 

 
	  neonatal intensive care  
	 paediatric oncology 
	 child protection 
	 ambulatory care 
	 asthma 
	 diabetes 
	 counselling 
	 special needs 
 

 A more senior paediatric nurse is likely to have less and less clinical duties as a ward manager or ward sister. A future as a clinical unit manager is entirely within reach. 

 Outside clinical settings, opportunities to work in private healthcare, social services, NGOs, charities, or volunteer organizations are aplenty. 

 Search for high-paying nursing jobs on  MIMS Career . Browse, save, and apply for nursing jobs, all in one-click. Take the opportunity for higher pay and better work locations. Our pages are all mobile-responsive, allowing you to take that leap for a better job whenever, wherever you are. All our job postings are heavily screened to  prevent scams and mistrustful behavior.  
   

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 Recently there’s been talk about the Malaysian Nursing Board phasing out the Diploma in Nursing programme. As a result, soon all future nursing students that want to practice the profession in the country has to complete a four-year degree (Bachelor of Science in Nursing). 

 Many parties have been very vocal about this, citing that many nurses cannot afford the extra costs it takes to study for four years instead of the usual two for a diploma. Some students get into nursing for that reason; it offers a quick pathway to work in a respectable profession, without the added burden of a pre-university programme after completion of secondary school. 

 While I understand that some nurses have to support their families ASAP, I’m here to argue that there is a hidden benefit to all nurses being required to do their degree in order to be registered practitioners. 

 That benefit is the extra 2-4 years of age that nurses have upon graduation. 

 Older… Wiser? 

 A few days ago there was news of a 19-year old girl who will become the  youngest medical doctor in Malaysia  this year. The prodigy completed her secondary education at the age of 14, enrolling straight into an Australian pre-U programme, followed by medical school. 

 While I applaud her achievements (it is nothing to make light of), for the rest of us entering the healthcare workforce at 19 is not the best of ideas. 

 A doctor fresh out of medical school at the age of 25 is six years older than 19, and will have six years of extra life experiences that will make him or her relate better to patients. 

 The healthcare line, as we all know, is riddled with a lot of challenges and difficulties that are difficult to teach in training colleges. There are unexpected obstacles from patients, their relatives, and colleagues that are difficult to circumnavigate without emotional maturity. When these are not handled well they lead to burnouts and depression. 

 Forcing the degree programme for nurses rather than diploma grants student nurses extra time to prepare themselves. Most of the time, maturity comes with age. Being a nurse (or a doctor for that matter) is an arduous endeavor in itself. There will be times when you have to react to difficult situations requiring you to make a choice. Maturity grants the wisdom to make the right ones. 

 
 The healthcare line, as we all know, is riddled with a lot of challenges and difficulties that are difficult to teach in training colleges. 
 

 Being sure about oneself 

 As a patient, you would want nurses or doctors who are sure of themselves for your treatment. You want those who believe in what they do and believe in the importance of their work. Not the reluctant ones. 

 It is common for healthcare practitioners to leave the profession within the first 5 years of working. An extra few years of study provides the extra time to contemplate on whether this career path is really for them or not. This creates better rounded nurses and doctors. 

 Better clinicians 

 Better rounded nurses and doctors, who can find the balance between their personal growth and career, make for better clinicians. They are more likely to innovate and push medicine forward. This is why countries like the US and Sweden require prospective medical school students to have a Bachelor’s degree beforehand. These countries have the most number of medical innovations in history. 

 Removal of bad habits 

 
 Better rounded nurses and doctors make for better clinicians. 
 

 For nurses, making BSN degrees mandatory in order to be registered means an addition 4-5 years of study; 1-2 years for a pre-university course (like STPM) and another 4 years for the degree. Contrast this with immediately hopping on the diploma programme for two years after school. 

 The work involved to obtain a degree is very hard. It can only be done by being mentally sound, organized, and effective. These habits are not necessarily attained in school. 

 An older nursing graduate has more time to become a better, organized person; to know her strong points, faults, breaking points, things she cannot do, and learn how to deal with them knowing that a harder road lies ahead.

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 A common question asked to academic counselors by prospective nursing students is: “So how’s the life of a nurse? What kind of hours to they work?” 

 It depends. It really depends on your location, academic qualifications, experience, country of practice, working environment… Really, I could make a long list but then the article would be way too long. 

 So our team at MIMS Career has sifted through the working hours of a lot of different types of nurses, so you can have an idea of what kind of career choices you’d have to make to go towards that kind of life. We’ve categorized it in five parts: a little, a bit, normal, a bit more, and a lot. 



 A little (3-5 hours a day) 

 Part-time nurse practitioners 

 These nurses mostly work doing house calls, or are doing contract jobs with non-medical institutions like schools or companies. Their employers do not require their presence most of the time, so as little as 3-5 hours per work session is pretty common. Part-time nurse practitioners usually have another job other than their nursing one. 

  Find out how to become a part-time nurse practitioner in our in-depth nursing career advancement guide HERE.  

 A bit (5-8 hours a day) 

 Locum nurses 

 Locum nurses work part time shifts in clinics or hospitals or other medical-related institutions. They are not on the payroll of the institution they work with; as they are only meant to supplement the institution’s own workforce. On average a locum nurse’s shift is about 5-8 hours. 

 It is more common to see nurses doing locum jobs to supplant their monthly income, but nurses who exclusively do locum jobs exist, albeit rare.  

  Find out part-time locum jobs for nurses on our career portal HERE.  

 Normal (8-10 hours a day) 

 Nurse instructors, academicians, dialysis nurses 

 These nurses work office hours. This is as normal as it gets. Dialysis centers and nursing schools all have regular, fixed schedules that don’t demand anything more than the usual office workday. 

 Same goes for those who work in nursing schools as teachers, trainers, or professors.  You can find out what it takes to be an academician in the nursing world in our article about lifelong learning HERE.  

 These kinds of nurses don’t normally work weekends, and their schedules are mostly the same and predictable. 

 A bit more (10-14 hours a day) 

 Those involved in direct patient care, like emergency room nurses 

 Most of the time, when nurses at the ER say they work a 12-hour shift from 7am to 7pm, they almost always never get to get out on time. There’s always something to do, someone else to cover, or some loose ends to tie up. 

 This is made even worse by working in hospitals with a shortage of staff. Nurses would be brought in to do things that are not in their job scope, because they can do those tasks. But people who are not nurses do not do nursing tasks because they cannot do those tasks. How many times have you been to an ER, and see a nurse doing clerical work at the front desk because the hospital doesn’t have a secretary or clerk? 



 A lot (14-24 hours a day) 



 Paediatric intensive care, intensive care, surgical, labor and delivery. 

 It is very common to see nurses doing double shifts in these wards. Their shifts might be 12 hours, but are sometimes to do two of those shifts back-to-back to reduce shift handovers, staffing overlap, and reduce costs. 

 Moreover, the type of work that this category of nurses do are a bit on the lengthier side. Surgeries can go up to 24 hours, including perioperative care. Intensive care can be very demanding as patients hover around critical states. 

 There is a variety of workloads for nurses. Each type of work suits different people who prioritize different things. With MIMS Career you have the opportunity of applying with ease to the jobs that you want to go into. Signup and apply with our easy, 1-click application process. Browse for jobs in Malaysia, Singapore, Philippines and Indonesia. Save jobs for later if you’re still on the fence. Also, you can opt for job alerts if nothing fancies you. 

  Signup and apply today! It’s fast, secure, and free.

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  Photo cr: Unsplash  

 Mental Health 

 Mental health is a level of psychological well-being, or an absence of mental illness. It is the “ psychological state of someone who is functioning at a satisfactory level of emotional and behavioral adjustment” . From the perspective of positive psychology or holism, mental health may include an individual’s ability to enjoy life, and create a balance between life activities and efforts to achieve  psychological resilience . 

 According to the World Health Organization (WHO), mental health includes “ subjective well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence, and self-actualization of one’s intellectual and emotional potential, among others.”  Cultural differences, subjective assessments, and competing professional theories all affect how mental health is defined. 

 Mental health nurses play and important part in helping patients lead a positive life. It is not uncommon for physical disorders to arise from mental issues. It is a field that is growing in awareness. It is estimated that  40% of Malaysians will suffer from mental health issues in their lifetime . 

 Specialization tasks 

 Maintaining good mental health is crucial to living a long and healthy life. Mental health nurses are required to show a considerable amount of empathy towards their patients in assisting them to make a full recovery. Research has shown that there is stigma attached to mental illness. Therefore, it is extremely important that mental health nurses develop excellent observational skills in the treatment of the patient. 

 Activity therapies 

 Activity therapies, also called recreation therapy and occupational therapy, promote healing through active engagement. Making crafts can be a part of occupational therapy. It is very common for nurses to take patients on walks as part of this type of therapy. 

 Psychotherapy 

 Psychotherapy is the general term for scientific based treatment of mental health issues based on modern medicine. It includes a number of schools, such as  gestalt therapy ,  psychoanalysis ,  cognitive behavioral therapy  and  dialectical behavior therapy . 

 Legal requirements 

 Mental health nurses assist in the legal requirements for the patient. Requirements encompass the setting of the patient or a group of patients. 

 Progress monitoring 

 Mental health nurses may have roles that include visiting patients in their home to monitor their progress and carry out risk assessments. While carrying out this task, nurses assess the risks involved to the patients’ safety, health, and welfare. 

 Pathway 

 In order to specialize as a mental health nurse, you must be a registered nurse, practicing for a minimum of three years. A Bachelor’s of Science in Nursing is an advantage. You must take up a psychiatry-based training course with practical hands-on experience. For those courses, you may be able to get accreditation if you have a degree in psychology, or social work. 

 Required skills 

 You will need to display: 

 
	 
	 Exceptional observational skills. You will be required to assess patients and look out for signs of tension or anxiety, which sometimes are not that obvious. 
	 
	 
	 Physical fitness, especially when working in a hospital. Increased stamina and strength is an added bonus. 
	 
	 
	 Emotionally and spiritually resilient to work in a challenging environment. 
	 
 

 Job prospects 

 While a lot of work for mental health nurses is done in the hospital, the majority is community-based in a wide variety of settings. Some of them include community mental health centers, nursing homes for the elderly, rehab units, and private clinics. 

 Working conditions 

 Salaries for mental health nurses will depend on the level of education that they possess. Those with a BSN or MSN will earn more. The type of institution and experience that you have will also factor in your earnings. 

 It is important to have a calm demeanor and able to handle stress well as you will be working with many difficult patients with psychotic episodes. It can be rather jarring to those who are not used to it. However, when approaching these situations without judgement, many mental health nurses manage to overcome these issues and help the patients with their treatment. 

 Career opportunities 

 Search for high-paying mental health nursing jobs on  MIMS Career . Browse, save, and apply for nursing jobs, all in one-click. Take the opportunity for higher pay and better work locations. Our pages are all mobile-responsive, allowing you to take that leap for a better job whenever, wherever you are. All our job postings are heavily screened to  prevent scams and mistrustful behavior . 

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