Final Project

Stethoscopy for Dummies Session

Bob Page

EDAE 639

12-13-2014

Introduction:

This class is designed to be a supplemental course that current paramedics, EMT’s, and nurses can take for continuing education credit. Audience analysis polling revealed that most providers do not have the fundamental knowledge required to use a stethoscope properly. The basic assumption is that the learners have had some introduction in the use of the stethoscope. The overall objectives for the course is that the learner will be able to use their stethoscope in a clinical setting and can correctly identify various normal and abnormal breath sounds.

Audience analysis:

The purpose of this audience analysis is to determine the knowledge level and confidence level of prospective students to take a stethoscopy class. The first section is a self-assessment (a 5 point Likert scale) to determine a baseline of how they feel they grasp the skill. The second part is actual assessment of their knowledge. I do it this way because some students will say they know something but indeed they do not. By doing this I can gauge the level of interest and the genuine knowledge gap and needs of the student.

The questions will be anonymous using an audience response system and the students will have clickers to respond to the questions that appear on the screen. This will allow for quick and measurable feedback. The Likert scale will appear on the screen with each question to prevent confusion in answering.

The second set of questions featured a real breath sounds played aloud and the participants hear them and select the correct answer. Here is an example of the question that appeared on the screen.

Results

The audience was informed that the study was to determine their needs and interest in a class on stethoscopy. I asked the participants to be honest and open with their answers. I polled a total of 104 students in two separate venues: Gunnison, Colorado and Panama City, Florida. Overall I was surprised that there was a difference between their perceived knowledge and their actual knowledge of procedures and performance in identifying sounds; A big difference.

The perception questions were presented first before the learners were actually tested. I did this to gauge their perception of their own skills. When asked to respond to the statement: “I feel I am completely competent is my skills in using a stethoscope.” Only 20% disagreed with the statement meaning they did not feel competent at all. However 80% thought they were confident. When asked about their initial training on a stethoscope, 59% thought they didn’t receive sufficient initial training. This was intriguing because it did not correspond with their perception of their skill. They must have learned through experience.

I asked a pure clinical question that was used to gauge the perceived value of breath sounds. “I listen to breath sounds on every patient.” 92% disagreed, which tells me that the providers are only listening when they think the patient has a condition that the need to listen.

The questions about their perceived need for more training was very telling as most agreed they needed more training. That was also apparent because a large majority voiced they did not have a way to train on this themselves.

Then when put to the test to actually identify sounds that were played aloud, the results were very clear that more training in sound identification was needed. When all sounds that were played, less than 30% correctly identify any one sound.

The raw results from all of the questions are in appendix B.

Conclusions

Based on the data in this audience analysis, there is strong evidence that the class is not only needed but is also desired but the audiences polled. I also learned the students may not value the information gained by the stethoscope as they do not listen on every patient. This is not promising as experience is only gained by practice and valuable information is being lost. In developing this course, I will include several cases where routine breath sound assessment reveals unexpected results. I also think that the lack of doing lung sounds assessments may also be due to their not being at all confident on how to use a stethoscope. Although I did not poll the learners after they were assessed on their ability to identify the sounds. It was apparent to me that they struggled to identify the sounds. This class is going to be a real success and a much-needed offering that should fill in a learning gap that exists.

Appendix A: Question List

Section 1

Audience instructions. After carefully considering the following statements, please respond with your clicker with the number that corresponds with your answer.

  1. Strongly Agree
  2. Agree
  3. Neither agree or disagree
  4. Disagree
  5. Strongly disagree

Statements

  1. I feel I am completely competent is my skill in using a stethoscope.
  2. I received sufficient training in using a stethoscope in my primary EMS course.
  3. I listen to breath sounds on every patient.
  4. I can easily recognize normal breath sounds by location heard
  5. I can easily recognize and name adventitious breath sounds.
  6. I am aware of the proper procedure for auscultating breath sounds.
  7. I have access to a lab that I practice listening to breath sounds.
  8. I need more practice in using a stethoscope.
  9. I need more practice in identifying the various breath sounds.
  10. I would take a class on stethoscopy if one were offered.

Assessment:

  1. When auscultating breath sounds, which of the following statements are true?
  2. They are high pitched sounds heard with a bell
  3. They are high pitched sounds heard with a diaphragm
  4. They are low pitched sounds heard with a bell
  5. They are low pitched sounds heard with a diaphragm
  6. Blood pressures should be taken with
  7. The bell of the stethoscope
  8. The diaphragm of the stethoscope

Listen to the following sounds and select the correct answer to these questions

  1. Identify the following breath sound.
  2. Normal vesicular
  3. Normal broncho-vesicular
  4. Normal tracheal
  5. Normal bronchial
  6. Identify the following breath sound
  7. Monophonic wheeze
  8. Polyphonic wheezes
  9. Stridor
  10. Crackles
  11. Identify the following breath sound
  12. Normal vesicular
  13. Course crackles
  14. Fine crackles
  15. Rales
  16. In using a stethoscope with a tunable diaphragm, which of the following techniques will result in the user hearing low frequency sounds.
  17. Diaphragm lightly held
  18. Diaphragm firmly held
  19. Bell lightly held
  20. Bell firmly held

With this information in mind, I have developed the following course designed to address the needs and requests of EMS medical professionals

Course Proposal:

“Stethoscopy for Dummies”

Time Frame: 60-75 minutes or

2 hour hands on Skills Session

Audience: All, BLS, ALS

CEU category: Assessment

Web Page Link:

How much did you pay for your stethoscope? How much training did you get on how to use it? This will fill the gap. In this session, participants are provided down to earth “for dummies” information on various types of stethoscopes and how to use them to get the most out of patient assessment. In this “Ear Opening” session, new and improved methods and techniques are presented and you will get the chance to practice this on others. Breath sounds are also played aloud so all participants can hear the sounds rather than hear a “description” of the sound.

Stethoscopy with Skills Session: 2hours

In this session, participants must bring heir own stethoscopes with them. Bob brings simulators for all participants to use their own stethoscopes to hear the various sounds. There is even a test at the end of class to see who earns the right to wear the stethoscope!

Objectives

By the end of this session, the participant will be able to

  1. Describe the parts of the stethoscope and the proper way to wear it
  2. Describe the difference in the bell vs the diaphragm and the use for each
  3. Identify by sound, common normal and abnormal breath sounds
  4. Describe a technique for identifying consolidated lung tissue
  5. Value the use of a stethoscope as a primary assessment tool on every patient contact.

Sub-objectives:

  1. Given a stethoscope, correctly identify the bell, diaphragm, tubing, earpiece and yolk with 100% accuracy
  2. Describe the difference between the bell and the diaphragm.
  3. Demonstrate on another person or simulator, each of the proper locations for a 6 point breath sound assessment.
  4. Demonstrate the proper use of a tunable diaphragm stethoscope on another person for both high frequency and low frequency sounds.
  5. Correctly identify by sound all of the following: normal tracheal, bronchial, broncho-vesicular, and vesicular breath sounds.
  6. Correctly identify by sound all of the following adventitious breath sounds of narrowed airways such as wheezes and stridor.
  7. Describe the difference between polyphonic and monophonic wheezes.
  8. Correctly identify by sound all of the following adventitious breath sounds of mechanical obstruction: course and fine crackles and consolidated tissue.

Lesson Plan: Stethoscopy for Dummies

Materials needed: Stethoscope, sounder, handout/course syllabus, clicker, alcohol wipes

Time needed for lesson: 2 hours

Time Index / Objective / Content / Methods / Instructor
Prior to start / Baseline assessment / On screen poll
Sounds overhead / Clickers, Q and A / B. Page
0 -15 minutes / History and why use a stethoscope / Brief history
How a stethoscope works / Lecture
Powerpoints
Photos and old stethoscope tacticle / B. Page
15 – 30 minutes / Describe the parts of the stethoscope and the proper way to wear it
SO - 1 / The parts of the scope
Hands on wearing and seating the scope in your ears / Photos of proper ways to wear in a PowerPoint. In seat practice in small groups / B. Page
30 – 40 minutes / Describe the difference in the bell vs the diaphragm and the use for each
SO 2,4 / How to adjust the touch to hear different frequency sounds / Students pair up and practice. Show them quick, Show them slow, Let them practice,
Let them go! / B.Page
40-50 minutes / SO 3
Demonstrate on another person or simulator, each of the proper locations for a 6 point breathsound assessment. / How to do a methodical assessment of breath sounds using correct anatomical landmarks / Students pair up and practice. Show them quick, Show them slow, Let them practice,
Let them go! / B. Page
50-60 minutes / Respite / Respite / Respite
60-75 minutes / Ears on Lab, Normal Breath Sounds
OB - 3
SO - 5 / Normal Tracheal
Bronchial
Broncho-vescicular
Vesicular sounds / Live use of stethoscope on sounder. Play sounds three times for 15 seconds each / B. Page
75 – 90 minutes / Ears on Lab
Abnormal breath sounds-
OB 3
SO – 6 -7 / Abnormal Sounds
Stridor
Monophonic and polyphonic sounds / Live use of stethoscope on sounder. Play sounds three times for 15 seconds each / B. Page
90 -100 minutes / Ears on Lab
Abnormal Sounds
OB 3 SO 8 / Abnormal sounds
Crackles
Consolidation / Live use of stethoscope and sounder / B. Page
100-110 minutes / Review game show assessment / All sounds / Use stethoscopy final challenge game with clickers, scope and sounders / B. Page
110–120 minutes / Reflection and evaluations
OB 5 / Class discussion after a period of processing / Final evaluations with clickers and on screen questions / B. Page

When practicing the hands on skills with the stethoscopes, make sure participants wipe down their stethoscope before touching the volunteer. Emphasize the importance of direct skin contact to prevent extraneous sounds. Make gloves available for those that request it. Allow time for reflection after each task is done.

Rubric for Assessment of Stethoscopy Skills

This rubric is an assessment that can be used throughout a module by the instructor and the student for self-evaluation and for feedback on their progress towards skill mastery.

Scoring / Identifies parts of the stethoscope / Uses stethoscope properly / Correctly Identifies breath sounds
Mastery - 4 / Can easily identify all the parts of the stethoscope and can elaborate on the differences between scopes / Easily uses the stethoscope correctly and with confidence / Can correctly identify all breath sounds correctly on one breath every time
Competent - 3 / Can identify all the parts of the stethoscope without prompting / Wears and uses properly with some hesitation
and deliberate movements / Can correctly identify all breath sounds correctly after a few breaths
Progressing - 2 / Can identify some of the parts of the stethoscope with some prompting / Knows how to wear it properly, but need more practice to use properly / Can identify many but not all of the breath sounds correctly
Beginning - 1 / Cannot identify an of the parts of the stethoscope / Does not know how to wear a stethoscope or how to use it / Cannot correctly identify any breath sounds

I chose mastery at the top and beginning at the bottom. As a minimum, I want providers to achieve the competent level. To be considered competent, the student has to meet the objectives. Some will achieve the mastery level, the highest rating. Those that achieve mastery are expected to perform easily and with confidence, on their own without help. I tried to select the scoring based on a student’s progress towards mastery. The progressing phase is the students that has learned the skill but is in need of further practice. The beginning section is the student that has just started learning the skill as a baseline.

Sounder Skills Practice

When practicing the sounds with the sounder device, play the sounds for at least 15seconds each. Allow time for a self-description and reflection of the sounds. Mention the correct name of the sound played before, during and after the sound.

During the sounds practice, have the students assess each other using the rubric provided. The can get feedback from each other and help each other to obtain the minimum level of competency.

The review assessment will be done using the clickers, their stethoscopes, and the sounders. Sounds will be played, the students will have 15 seconds to correctly identify the sounds they hear.

Evaluation Plan:

Pre-course Evaluation

At the beginning of the class, I will use audience polling to determine the baseline attitude of my students towards their knowledge of stethoscopy skills and training in general. This will be done with clickers that each student will have. Questions will appear on the screen and students will answer with their devices.

This type of polling is anonymous to the students but I can see the results via a bar graph on my screen giving me instant knowledge and feedback as to their responses.

The questions will be general opinion questions based on the objectives I plan to cover in the course. The information gained from this polling will allow me to improve my delivery and content based on the feelings of the group. I will know what areas to emphasize and which do not need that much time spent it. Covering things the audience already knows well will not benefit the learner and will diminish the overall impact of the course. This also will help me to evaluate the success of the course design by spotting opinion changes in the pre and post course evaluation.

The purpose of this type of formative evaluation is to try to measure the learner’s pre and post course opinions on their understanding of the information presented. I will use the following questions to measure their opinions before the class begins as a baseline for a comparative evaluation

Audience instructions. After carefully considering the following statements, please respond with your clicker with the number that corresponds with your answer.

  1. Strongly Agree

2Agree

3Neither agree or disagree

4Disagree

5Strongly disagree

Statements

1I feel I am completely competent is my skill in using a stethoscope.

2I received sufficient training in using a stethoscope in my primary EMS course.

3I listen to breath sounds on every patient.

4I can easily recognize normal breath sounds by location heard

5I can easily recognize and name adventitious breath sounds.

6I am aware of the proper procedure for auscultating breath sounds.

7I have access to a lab that I practice listening to breath sounds.

8I need more practice in using a stethoscope.

9I need more practice in identifying the various breath sounds.

These questions are a baseline because I really want to see their response to the statements after having the opportunity for hands on and “ears” on learning sessions.

Overall Summative Post-Course Evaluation

The overall summative course evaluation will query anonymously the learner’s opinions of the instructor’s effectiveness and their thoughts on the learning techniques used and their desire to continue to learn. I really want to see how they will process the session and get to the “now what” phase. I will use the following questions in the post- course summative evaluation.

Audience instructions. After carefully considering the following statements, please respond with your clicker with the number that corresponds with your answer.

  1. Strongly Agree
  2. Agree
  3. Neither agree or disagree
  4. Disagree
  5. Strongly disagree
  1. The instructor covered the stated objectives adequately.
  2. The instructor encouraged questions
  3. The instructor provided adequate feedback
  4. The instructor used effective teaching techniques
  5. The hands on use of the stethoscope drill was helpful to me
  6. The ears on simulator experience was helpful to me
  7. I would like more practice listening to the breath sounds
  8. This class will change my practice using a stethoscope
  9. After the class, I feel more confident using a stethoscope

Using the Data from the Evaluation

I will use the data from this post course evaluation to alter the methodology and delivery style of the material until the learning objectives and the behavioral objectives are met. Since this is relatively new or infrequently assessed skills, Questions 1-4 are designed to evaluate the instructor’s ability to establish a great learning environment. One that is conducive to learner’s engagement in the course. Since a course like this may seem to make the learner feel like they are ill prepared or hesitant to divulge their own weaknesses to the material, an open and honest approach to feedback and questioning is essential. This part of the evaluation should help to improve this important part for future classes by exposing weakness or areas for improvement. It is equally important to provide feedback to instructors doing a great job as well.