lub-DUB

You can learn alot from the second heart sound. The dub of the perpetual lub-dub rhythm. If you listen closely, you can hear it split into two separate sounds when a healthy person breathes in, corresponding to the closure of the aortic, then pulmonic valves. This sound can also do other things, and a staggering amount of information can be gleaned from whether there is wide splitting, fixed splitting, reversed splitting, or fusion of the different components of the second heart sound. Things like valvular abnormalities, bundle branch blocks, Wolf-Parkinson-White syndrome with left ventricular pre-excitation - you know, stuff like that.

I had an assignment to report on all the subtle nuances of the second heart sound on monday morning. And, the diligent medical student that I am, I made a long, complicated, but extremely well-organized list on the white board in the conference room. We're talking diagrams. We're talking different colors for the different valves. We're talking complex organizational style. (Caveat: I am not normally such a gunner, but I was on call in the hospital, waiting for a patient, and had nothing else to do).

As a final touch, I wrote "DO NOT ERASE 3/5/06" in red with a circle around it. Merely as a precaution. This was the whiteboard that had the same thing written on it for the past 2 weeks and which was clearly rarely used by anyone. But what did I see when I came back to the ward on monday morning? My entire presentation had been erased, only to be replaced with a diagram of a breast.

A giant boob.

And we're not even talking complicated breast anatomy. We are talking about the most simplified diagram imaginable, consisting of a giant boob with three ducts drawn carelessly in blue. The kind of diagram that would clearly not be helpful, unless one desperately needed to illustrate the fact that breasts contain ducts. You don't need to draw that on the board! You can just say it outloud! I can't even begin to imagine the thought process on that one. "Well, Dr. Burke, as you know breasts make milk... wait, this is far too complicated for words alone.. let me just illustrate this for you... what's this?.. a complicated diagram deliniating the phsyiology of cardiac valve closure and the possible etiologies of variability in S2?... this clearly does not look important, nor does it appear to have any indication of when it was placed upon this writing board... i'll just... there we go... all gone!"

Perfect. I did my presentation without any visuals, and it was fine, but very very boring.

The worst thing about this story is, I have a patient right now who actually has reversed splitting of his second heart sound. And when asked about it, I totally fumbled and messed stuff up. I blame Family Medicine.