“What’s a bruit?”

I’ve posed the question to Joan, a first-year medical student with her shiny new stethoscope, gracious manner, and quiet enthusiasm.

Hesitantly Joan replies: “A bruit? ... It’s a noise..... A noise made by blood flowing?”

“How’s that different from a murmur?”

“Well... both are noises made by blood flowing...but murmurs come from the heart, bruits come from flow in blood vessels.”

“Have you ever heard one?”

“No, not yet.”

“Put your stethoscope here.” I say, as I place my finger near where the patient’s right leg and belly meet.

Carefully Joan positions the stethoscope ear pieces to her head. Gently she places the other end of the stethoscope on the place I’ve indicated. Joan listens.

Our patient, Fred Barnes, smiles. He knows what’s coming. Fred has taught this before. He enjoys our teaching sessions which -- like today -- are frequently combined with his visits to clinic. Fred knows his conversation with us this visit has already taught Joan something more about diseases: hypertension, chronic obstructive lung disease, atherosclerosis, and arthritis. Joan has also learned something about the person, Fred, now retired from logging and fishing, and still living happily with his wife of many years. I’ve already briefly examined him this visit. Fred lies quietly on the examining table as Joan continues to listen through her stethoscope.

Joan raises her head and looks at me.

“I heard a ‘whoosh...whoosh’ sound,” she says.

“Listen again. But this time put your fingers on his pulse at his wrist at the same time.”

With her left hand Joan finds Fred’s pulse at his right wrist, and once again puts the stethoscope over Fred’s right femoral artery and listens. I know she will notice that the pulsation she feels with her left hand is keeping time with the sound she hears. I see her smile. Joan looks up.

“I notice it better that way.”

“Yes. Your fingers help your ears. Now try and feel the pulse there.”

Joan puts the index and middle fingers of her right hand over the femoral artery where she had just held the stethoscope. After a pause, she says “It’s there, but it’s very difficult to feel.”

“Is it your own?”

“I don’t know.”

“Put the fingers of your left hand on your temporal artery.”

Joan puts her left hand just in front of her left ear where she knows the temporal artery is located, and pauses, with her right fingers still on Fred’s right femoral artery.

“My pulse has a different rate.... so the one I’m feeling there must be his.”

“Listen once more. This is a very special bruit. It’s the first one you’ve ever heard. Remember it. You’ll never hear it again; not your first one.”

Again, Fred smiles to himself. He really enjoys teaching.

Joan listens once more to the noise in Fred’s right femoral artery, caused by advanced atherosclerosis which has narrowed, hardened and bent the artery, and changed its inner lining from smooth and slippery to rough and lumpy. Normally blood flows so smoothly through arteries that no audible noise is made, but Fred’s cruddy vessels growl.

“Now,” I say, “Try the left femoral artery.”

Joan tries to feel the pulse but cannot find it. I tell her to look for a bruit. She listens with her stethoscope.

“I hear another bruit,” she says, with surprise and satisfaction.

“Listen a while longer.” She does.

“Your second bruit.”

“Yes, and less than five minutes after the first one.”

Fred knows me well. We have developed considerable mutual respect: he for me as his family doctor, and me for him as a unique human being, still full of the joy of life, despite his accumulated illnesses. I say, “May we listen to your neck, Fred?”

“Sure, Doc.”

I put my stethoscope on the right side of Fred’s neck, between the collar bone and jaw bone. Briefly I listen. With my index finger I mark the spot over the carotid artery. To Joan I say: “Listen here.”

Looking at Fred’s face, Joan says: “May I, Mr. Barnes?”

“Sure, Miss. I’m glad to help you learn.”

Joan listens. Then she looks at me.

“I hear breathing sounds.”

“Did you hear a bruit amongst the breath sounds?”

“No.”

“Put your finger on his pulse at the wrist, and listen again.”

Carefully Joan finds the pulse, repositions her stethoscope and listens. After awhile she pauses saying, “Yes, there is a whoosh sound with each pulse, I can hear it now but it’s hard because of the breathing noises.”

“While you are listening, ask Mr. Barnes to hold his breath. But hold your own also to remind yourself to tell him to breathe again.”

Joan listens again, and while she continues to listen says, “Can you hold your breath now sir?” Fred does. Then a few seconds later Joan says, “Ok, you can breathe now.” A few moments later Joan stops listening and says to me, “I heard it much clearer when the breathing was stopped.”

“Yes. And you only had him stop breathing a short while, and you remembered to ask him to recommence breathing. That’s a good habit. You didn't wait until you needed to breathe. You remembered his illnesses make it hard for him to hold his breath for more than a few seconds. Some patients have so much trouble breathing they can’t hold their breath at all for us.”

To Fred I say, “Thanks Fred. How about one more?”

Fred grins and nods contentedly.

“You’ve found three bruits in Mr. Barnes. That’s rare. Let’s listen to his abdomen. Try here,” I say as I place my fingers gently on Fred’s thin abdomen, just above his umbilicus. “Start by putting your fingers on his pulse at his right wrist.”

Joan finds the pulse, and whole holding her right fingers at Fred’s wrist, positions the diaphragm of the stethoscope on Fred’s abdomen. After a long silent listening interval, Joan says, “I think I hear it, but the bowel sounds make it hard to be sure.”

“Feeling the pulse helps?”
“Yes.”
“Try tapping your toe to the rhythm of the pulse.”

Joan grins at this suggestion, and listens again, her fingers still on the pulse. I see the front of her right toe making small regular movements. As she continues to listen Joan smiles, then stops, stand back and says, “I heard it. Thank you, Mr. Barnes.”

“Ok, my dear,” says Fred.

Comments:

1. From now on whenever she thinks about bruits or atherosclerosis Joan will remember Fred -- a gracious, kind old man who helped her learn. That memory will empower her further learning.

2. Patients are our greatest teachers, and the most essential resource in medical education. It may be months before Joan hears four bruits again, much less four in the same patient. Most patients with bruits die before getting that many.

3. Contact with patients early in medical school can facilitate patient centered learning, nurture greater synergism between the art and science of medicine, and help other means of learning strengthen -- rather than erode -- the doctor/ patient relationship.

4. Every clinical encounter has more learning potential than can be utilized in any one clinical teaching session, otherwise patient, student and teacher would all become exhausted and overloaded.

5. Much extremely powerful clinical teaching at all levels can done in the family medicine clinic but the setting needs to be adapted to the added demands this places on patients, time, space, and staff .

6. Fred has taught both junior and senior medical students and family medicine residents. I help integrate the teaching into clinical care, focus the teaching on a subject and level appropriate to the specific learner, and nurture good clinical skills and patient care.

7. Patients must not be treated simply as containers for diseases. Before and after the time focused on bruits, the interaction between Fred and me during this clinic encounter dealt with his current health care needs and concerns. Thus Fred has the satisfaction of contributing to medical education for the next generation, while at the same time also being acknowledged as a unique individual, whose health care needs are being effectively addressed.

8. For me, clinical skills teaching has been fun for more than 30 years. Conducting an interview, performing a physical and mental examination, organizing and interpreting the information, and making a diagnosis of the patient’s health problems and their severity is the core of medicine. Helping students learn to do this well is a great joy.