We meet again, Harvey

On Friday we reviewed diastolic murmurs using Harvey.  Harvey is a life-sized cardiopulmonary simulator, developed in 1968 at the University of Miami, that can mimic a number of patient scenarios.  For each scenario, there are a number of findings in the precordial examination that can clue trainees into the diagnosis.

With our preceptor on Friday, we focused on aortic regurgitation and its salient features.  Our preceptor developed a simulated case of a man with a history of infective endocarditis presenting with shortness of breath.  The first step was reviewing the vital signs and his blood pressure was said to be “159/60” – we noted a wide pulse pressure and spoke about our differential for this.  The other vital signs were unremarkable.  After this, we discussed that for the physical examination we would inspect and palpate moving from peripheral to central.  We altered the scenario for a moment to consider other causes of aortic regurgitation, such as Marfan’s syndrome, so that we could discuss the manifestations we would see on exam such as pectus excavatum.  Throughout our scenario, we took a few minutes to review the characteristics of the JVP; this is a key component of any cardiovascular assessment even though it is not significantly affected in aortic regurgitation.  Although we cannot perform all of them on Harvey, we practiced other physical examination maneuvers that may be relevant to aortic regurgitation such as Quincke’s sign.  Before auscultation, much of the assessment was made from the information we had already gathered.  Interestingly, we also heard the Austin-Flint murmur that occurs in aortic regurgitation and this helped us to think about mitral stenosis as the Austin-Flint murmur occurs because of a functional mitral stenosis.

The richness in the discussion came from the synthesis of all of the information and putting together how the pieces of the puzzle would lead to a diagnosis.  Often times we are coloured by the more common “bread and butter” reasons for presentations but reviewing our cardiovascular examination emphasized the importance of thoroughness in order to not only identify the pathology but also to determine its etiology.

There was a meta-analysis done in 2013 by McKinney et al. of simulation-based medical education for health care professionals for the cardiac physical examination.  The authors suggested that hands-on practice with simulators increases the acquisition of cardiac skills because it lends itself to repetitive and deliberate practice.  The idea of repetition is important.  We have a Harvey simulator at a number of our teaching hospitals and I was introduced to this tool in my Art and Science of Clinical Medicine (ASCM) course in first year of medical school when we first learned about heart sounds and murmurs.  Throughout clerkship, we have re-visited Harvey with our attending physicians and a small group of students to enact various mock cases and discuss our approach and differential diagnosis for each.  As we move forward in our training, Harvey sessions have become an opportunity to consolidate knowledge from lectures and clinical experiences.  We are also able to continually improve and refine our technique for the same physical examination while tailoring it each time to the suspected diagnoses.

Until next time, Harv!

SH

Resources:

McKinney, J. et al. (2013). Simulation-Based Training for Cardiac Auscultation Skills: Systematic Review and Meta-Analysis. J Gen Intern Med, 28(2): 283 – 291.