Joining the Percussion Bandwagon

      No Comments on Joining the Percussion Bandwagon

Like the rest of my social-media savvy colleagues in the emergency department, discussions about the latest and greatest in clinical innovation occurs on social media. Some posts are clearly venting outlets of new unit policies or outdated practices. Some, however, like this one below highlights something that we usually take for granted:

A quick Google search shows that this question has been asked before by both experienced nurses and new-grads. Like anything else in social media, the answers are quite different and (occasionally) divisive:

School has engrained in me that percussion is an essential part of the assessment. IPPA: Inspection, palpation, percussion, auscultation. Traditionally, percussion is an tool with great diagnostic power for:

  • Identifying gas, fluid, or a solid mass in the thorax and abdomen (and in emergencies, determining if there’s gas or fluid in a place where it shouldn’t be)
  • Estimating the borders of the liver and spleen
  • Estimating the borders of the heart when other techniques have failed
  • Estimating the presence of a bone fracture (such as in the hip or knee) [1]

If comments in social media are any indication, many nurses say that it’s the physician or nurse practitioner that usually does percussion in their assessment – as one nurse puts it, “after all, their diagnosis is dependent on it while my (nursing) treatment does not.” In a very informal survey of Vancouver, British Columbia nurses, the vast majority of them said that they did not perform percussion in any of their assessments in the past year, and of those that did, less than 10% did it routinely. Understandably, it’s the “obvious” assessments of vital signs and inspection that usually made the checklist of routine core assessment skills [2]. It is also, however, difficult to master. As GomerBlog eloquently describes:

“The challenging but critically-important skill is difficult to master, but over time you should be able to play Mozart’s Requiem with pleasure and ease using only the patient’s lung field and your fingers.”

The troubling part is that some physicians are also finding percussion unnecessary – one commentor on a Reddit post about medical school teaching “that has little significance in real practice” mentions percussion as one of those practices. In part, percussion as an assessment technique was created centuries ago when our modern diagnostic tests weren’t around so it makes sense that our reliance on things like radiography have a special place in our assessment toolkit. One article identifies the combination of diagnostic testing and the medical history as being perceptually more important to creating a medical diagnosis over any aspect of the physical examination [3].

Of course, the dissidents to the whole “percussion is overrated” school of thought highlight the failures of diagnostic testing: one, you may be in an area where xrays or ultrasound may not exist (or the staff trained in those modalities may not be present); and two, xrays or ultrasound are hindered by the patient’s condition (such as the failure to see shifts in a morbidly obese patient). Diagnostic tests can also be unnecessarily expensive and so the physical examination, whose cost is simply the fee of the physician or nurse, is a more affordable option.

That being said, the mere growing presence of a group of clinicians and providers who never use percussion in their assessments doesn’t bode well for an otherwise difficult skill to master.  This could potentially lead to an increase in false negatives or positives when percussion is done by those individuals. Even amongst those who do percussion routinely, when diagnostic tests are available the provider or clinician will generally order those tests anyway to correlate with their examination.

In a busy urban emergency department, our growing time constraints and reliance on diagnostic testing usually means percussion is a technique/skill that’s being kept more and more in the back of our assessment toolkit versus being front-and-centre. When percussion could be indicated, it appears to largely be related to risk-stratifying and prioritizing patients rather than to provide definitive treatment [4].

A Google search shows no difficulty in finding what and when the “experts” say percussion should be used in the nursing assessment.  Not surprisingly, it ends up being the nursing unit’s culture and reliance on the provider’s assessment (if they do it) as a major influence of if nurses do percussion. The consequence is that there is a plethora of policy and educational material that recommend an assessment technique that a good proportion of staff aren’t doing. If the Facebook thread above was any indication, there’s definitely a divide between nurses who do percussion and nurses who don’t and it will be interesting to see this discussion play out.

At the end of the day, clinicians are responsible for the assessments they carry out and if they don’t feel percussion is a necessary assessment for whatever reason, it is ultimately their choice to omit it. Assessment, however, can be time critical and so lack of provider or lack of technology should not be a reason that a traumatic hemothorax was missed. It can be daunting when, as the informal survey above showed, urban nurses are not routinely doing this and probably wouldn’t be confident in their skills. Like any skill, though, it merely requires practice.

  • If you haven’t done percussion in a while and not quite sure what to listen for, what to expect, or even what to do, there are a lot of videos on YouTube that demonstrate this. One videos that I thought was particularly helpful was created by Stanford School of Medicine on percussion of the chest.
  • As mentioned above, many providers and clinicians correlate their findings with radiography tests. Try the reverse: if diagnostic testing finds a tension pneumothorax or an enlarged spleen, try percussing yourself and see if you can hear the difference from normal.
  • Simply add percussion to your focused examination. Naturally, if a person came in for a broken finger you’re probably not going to be percussing their chest; however, if someone did come in for suspected pneumonia, try percussing and see if you can hear dullness instead of the normal resonance. No one is going to fault you for doing an assessment – more than likely, patients might be more satisfied in simply having a more “thorough” examination done.

Going back to the original questions, what about you: do you perform percussion in your normal assessments? Is it deferred to providers or diagnostic testing in your practice?

References

[1] Bickley LS. Bates’ Guide to Physical Examination and History Taking. 9th Edition, 2007.

[2] Osborne et al. The Primacy of Vital Signs – Acute Care Nurses’ and Midwives’ Use of Physical Assessment Skills: A Cross Sectional Study

[3] Henry, M. The Birth of Percussion. 2006. http://www.the-hospitalist.org/hospitalist/article/123104/birth-percussion

[4] Markent, RJ et al. Comparative Value of Clinical Information in Making a Diagnosis. 2004. https://www.medscape.com/viewarticle/480241

Leave a Reply

Your email address will not be published. Required fields are marked *