Do we really need a stethoscope in a rehabilitation ward? The Helicopter Sign
Abdelmugeet Hassan MRCP, DGM, SCE (Geriatric Medicine) is a physician practicing at West Park Rehabilitation Hospital, The Royal Wolverhampton NHS Trust.
I was late as usual and rushing … I forgot my stethoscope. My roommate, a Cardiology clinical fellow, joked: “a Geriatrician doesn’t need a stethoscope - probably only to listen for AS in a frail older faller!”
I replied: “I want to check for the helicopter sign today. Do you know what a helicopter sign is?”
He was speechless, surprised and I left with a big smile.
I kept thinking throughout the day, wondering how many times I would use my stethoscope today. Do I rely more on my Geriatric scales or my stethoscope? In Geriatrics we look at our patients holistically and functional assessment is paramount. I love scales, numbers and maths, and one of the things that made me choose Geriatric Medicine is the presence of lots of scales. I am always trying to memorise them and often use them on my small cell phone. Cognitive assessment scales, GCS, Frailty scale, AMT, 4 AT, NIHSS etc. My personal feeling is that they are more important than the stethoscope.
Of course, the stethoscope, like the white coat, is linked with our identity and has been a symbol of our medical frame for a long time. In the current pandemic era, things have changed a lot. COVID-19 has impacted everything, including how we work and dress. Uniforms and sterile stethoscopes are now part of the infectious disease guidelines and dress code.
Now I am trying to remember how many times I have used my stethoscope. Probably for every patient I have seen. It is part of our weaponry against negligence and malpractice. My rehabilitation patients are usually admitted with falls, fractured neck of femurs, reduced mobility or post step-down from ICU, sepsis or just generally unwell. I have discovered the following uses of the stethoscope in the rehabilitation ward. First, it helps to tell my delirious patient that I am from a medical field and probably helps the patient realise they are in hospital (reorientation), which is a strong tool in delirium management. Then, we can approach the routine of assessing breath sounds, heart sounds, bowel sounds and murmurs.
Back to the helicopter sign - an 86 year old gentleman was admitted following recurrent falls. One of the challenges in Geriatric medicine is that everything is atypical. We don’t expect the full house of signs to diagnose a condition and often the physical, mental and social factors create the problem list and formulate the management plan. For this gentleman, the description from our physiotherapist in the MDT gave a hint that this patient could be struggling from a condition known as orthostatic tremor.
Orthostatic tremor is characterized by unsteadiness when standing that is relieved when sitting or walking; it is confirmed on neurophysiological recording by the presence of a fast tremor of 13–18 Hz in the legs, trunk, and, sometimes, the arms, which is coherent in all muscles studied (1). Auscultation using a stethoscope of the gastrocnemius muscle characteristically reveals a barely audible noise akin to the sound of distant rotor blades of a helicopter (the helicopter sign) (2). It is often misdiagnosed as essential tremor, Parkinson’s disease, restless leg syndrome, lumbar stenosis, and especially non-organic (psychogenic/functional) balance disorders (3). Clonazepam is probably the first-line medication in the treatment of primary and secondary OT (4).
Back in the evening and over a cup of coffee with my Cardiology roommate reflecting on our day, I was taking the lead with the academic arguments. I convinced him that rehab Geriatrician doctors need stethoscopes for more than AS.
(1) Deuschl G, Bain P, Brin M. Consensus statement of the Movement Disorder Society on Tremor. Ad Hoc Scientific Committee . Mov Disord 1998; 13(Suppl. 3):2–23. doi: 10.1002/mds.870131303.
(2) Brown P. New clinical sign for orthostatic tremor. Lancet 1995; 346:306–307. doi:10.1016/S0140-6736(95)92190-7.
(3) Gerschlager W, Munchau A, Katzenschlager R, et al. Natural history and syndromic associations of orthostatic tremor: a review of 41 patients. Mov Disord 2004;19:788–795. doi: 10.1002/mds.20132.
(4) Jones L, Bain PG. Orthostatic tremor. Pract Neurol 2011;11:240–243, doi: 10.1136/practneurol-2011-000022.