The S3; Or Why I Became a Rheumatologist

I was an R2 doing a mock oral exam with my senior, a third year resident who I knew was going into gastroenterology at the end of the month.  The patient was a sweet elderly lady who had difficulty giving her complete history because she was very short of breath.  The exam was fairly simple, an obvious case of congestive heart failure.  A snap right?  Should have been, but there was always the tricky question of that third heart sound, the S3.  I had heard of the mythical entity, since the earliest days of medical school.  During our first bedside lessons in second year we had a cardiologist who patiently let us all listen to the 'best' S3 he had heard in ages.  We all listened intently, trying our hardest to parcel out that little lub or dub or whatever was supposed to be there.  After we had all had a turn he asked me if I had heard it.  Perhaps foolishly, I was after all only in second year, I admitted that I had not, even though it was the best he had heard in ages.  Perhaps stiffened by my admission, every one of the six students admitted the same.  The cardiologist looked at us with something between contempt and disgust and said, "what are you all bloody deaf?"  He told us to listen again and promptly left as we fiddled with our stethoscopes.   I then knew that the S3 must exist.

Over the next few years I learned the the S3 was a sign of congestive heart failure, appeared in almost all charts of CHF patients.  Apparently everybody could hear the damn thing, on an amazingly regular basis.  Everybody, that is, except me.  I had never, ever, ever, heard an S3.  Sure I wrote it in the chart.  Almost any patient with heart failure got a big S1S2S3 for heart sounds, but only because I knew it had to be there.    I never sought help for my S3 handicap, though psychologically  my stethescope became an instrument of shame.  Oddly though,  it didn't seem to have much impact on my day-to-day functioning. Occasionally a more senior resident would disagree with my assessment, but I was never given a hard time about it.  As I got more experience though, I started to see signs that maybe I was not alone.  My dirty little secret seemed to be shared by more than a few of the housestaff.  I noticed that my juniors would often mention the S3 during discussion of the case with the same learned assurance I gave, but when I would ask them how sure they were, or if we examined the patients together, they would often add qualifiers.  "Well at least I heard it this morning when she was worse, I'm not sure about this afternoon."  Soon it seemed that rather than  being a dirty secret, it was more like a secret society.  A society of S3 deniers.  With time, it began to seem like a rather large secret society, but with no membership list to prove it. 

 So back to my oral exam.  My R3 came in with a real seriousness that took the mock out of mock exam.  I rolled through the history and physical right up to the heart sounds where there must have been a just-discernable pause where I might have hesitated a fraction before lying with conviction about the presence of the CHF-related S3.  I then demonstrated all the signs I could think of  to prove that the patient was in fact in heart failure, a heart failure so classical that surely the S3 was a given. The senior resident raised an eyebrow and slowly pulled off her stethescope that had been draped over her neck.  She leaned over the patient and listened for what must have been a half-hour or so, flipping from bell to diaphragm a couple of times.  Then she straightened, looked me in the eye, and said, " yup, a loud S3".  A tiny smile then formed in the corners of her mouth as she wandered out of the room and into the saner world of gastroenterology where borborygmi are borborygmi, loud and clear.  No secret handshake, no codewords exchanged, but no doubt either that I had just met a fellow member of the society of S3 deniers.

Comments

[ariel]

In nursing school they played us tapes of heart sounds.

Even on the tape, I just couldn't hear it. I felt sooo dumb as all my classsmates were going "wow, that's very clear." I'm glad to know I'm not the only one.

[3+speckled]

I had one cardiologist mentor who said that if you hear a clear S3, it's not an S3. I say that if you hear any S3, enjoy the delusion.

[Letitia]

Thanks for writing this.

[fussball]

Gute Arbeit hier! Gute Inhalte.

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