Auscultation

Chamber 1

In August 2007 we all waited to hear news of 6 miners trapped 1500 feet underground by a massive cave-in at the Crandall Canyon coal mine in Utah, a catastrophic collapse so intense that it registered as a 3.9 magnitude earthquake on seismographs. As rescuers began the arduous 3-day process of digging the men out, they also erected seismic listening devices on the surface and set off 3 dynamite charges, a signal to any surviving miners to make noise. Lots of noise. The electronic ears listened for the sound of hammers pounding on the rock and on roof bolts, the telltale rap-and-thump of human life. We listened and listened but never heard a thing.

Six miners missing. Six boreholes drilled into different areas of the mine. They sent oxygen sensors, cameras, and microphones down through PVC pipe, fishing in each hole, searching every possible area for the men. Oxygen levels were misread, confused, and ultimately determined to be dangerously low. Three rescue workers trying to dig the trapped miners out were also killed when a wall of the mine “explodes”, crushing them. We never saw or heard any sign of the miners, and all 6 men were considered missing and presumed dead. All rescue efforts were eventually abandoned. I don’t know if there is a signal for this, another series of blasts to say goodbye, or some other ceremonial end to the search. Maybe they just switch off the drills and unplug their ears.

The owner of the mine, Bob Murray held a press conference and said, “Had I known that this evil mountain, this alive mountain, would do what it did, I would never have sent the miners in here. I’ll never go near that mountain again.”

Finally a seventh hole was bored into the mountain and through this hole they pumped thousands of gallons of mud and debris, filling all remaining cavities and sealing the tomb off permanently with the missing miners still inside.

Researchers today at Utah State University are working to create more effective listening and noise-making devices to help trapped miners – some of them seemingly crude and simplistic, yet still effective. One plan calls for 4 x 4 inch iron plates to be placed at regular intervals in the tunnels, with sledgehammers kept nearby – the idea being that a trapped miner can find his way to a station and slam the hammer into the iron plate over and over again. Think of the noise below. Think of your ears. Geophones on the surface – the kind of sensors they use to anticipate earthquakes – would register the sound waves created by the hammer pings and create a listening grid, a kind of sound map of the mine, which they would then use to pinpoint the exact location of any miners still kicking below the rugged skin.

Chamber 2

Recall the ice-cold press of the metal disc against your cavity, the sting and soft burn as it warms on your clavicle, your breastbone, fingers moving metal across your naked chest, around behind, fingertips stepping down your spine, one hand on your hip, maybe your shoulder, the other sliding around your ribcage, always, always with the whispered command, breathe . . . breathe . . . good, and the eyes staring not at you but at the cold diaphragm, the metallic spot on your body, listening as if your body possesses a voice of its own and speaks in a language only others understand. The diaphragm will only broadcast its secret to the touch. It knows you. And when it touches you, it sings sounds of your body, noises you can barely imagine – the hypnotic pump of organs, the soft ebb and flow of blood in your veins, and the breathy whisper of lungs at work – noises that can name you normal, healthy, or not. The intimate instrument – the stethoscope – knows your body in a way your own hands and ears never can.

Chamber 3

Some heart doctors train their ears on classical music – Mozart and Bach and Chopin – learning to discern the individual instruments: to hear baritone from trombone, trumpet from sax, and the tum-tum of kettle over bongo or bass. They learn to listen for the flaws and failings of the heart, to recognize the music of machine-like muscle efficiency, and to understand when a noise is a bad noise. They depend on the stethoscope for more than diagnoses. They need it to be whole. Nothing promises Doctor like a stethoscope draped around an exposed neck or curled over a pressed, collared shirt, perhaps tucked neatly into the pocket of a white lab coat, or clutched firmly in hand, authoritatively like a craftsman’s hammer, a plumber’s seat wrench, or a surgeon’s scalpel – the only tool for a specific job. You are familiar with the flexible latex tubing, the chrome-plated ear tubes, the hard metal diaphragm – cold, round, smooth as pearl, reflective as a mirror. The stethoscope immediately identifies a doctor – an icon of care and pain management, a reliquary of body knowledge, someone you trust with your life. Think of the things you’ve allowed another person to do and say to you, mainly because he wore the uniform of doctor and carried a stethoscope. We don’t check resumes or credentials, don’t ask for service reviews or certificates. We expect and accept the object. Even if it’s never used (but it’s always used), its appearance conjures a sense memory of that repeated sweet burn when pressed to your flesh. Regardless of physical context or attire (say at a crowded beach, in a subway, or on a mountain trail) the stethoscope speaks. It says, “I am a doctor,” and in so doing it grants rights and responsibilities, obligations and expectations. It tells us you will do no harm. It tells us you know what you are talking about. Every child’s Doctor play-set comes with a plastic stethoscope because you can’t dress up as a doctor without one.

As object, it functions as both necessary and sufficient condition of “Doctorness.” But this identity and image – of the Doctor as listener, as diviner of significant sounds through a stethoscope, the magician of auscultation – is a relatively new one, just over 150 years old. The French doctor René Laennec is credited by many for inventing the first stethoscope, or at least for introducing the diagnostic practice of auscultation. In a paper published in 1819, he says:

I was consulted by a young woman with symptoms of a diseased heart … percussion was of little avail on account … of fatness. The application of the ear … inadmissible by the age and sex of the patient. I recollected a fact in acoustics … the augmented sound conveyed through solid bodies.… I rolled a quire of paper into a cylinder and applied one end to the heart and one end to the ear … and thereby perceived the action of the heart … more clear and distinct. I have been enabled to discover new signs of the diseases of the lungs, heart and pleura.

It wasn’t until the 1851 invention by Arthur Leared, and the refinement in 1852 by George Cammann, of the binaural stethoscope – a simple but incredibly significant instrument – that the practice of refined auscultation began to develop and doctors could listen in stereo to the sounds of the body. Before that it was a crude monaural amplifying horn, Laennec’s ear-trumpet, which offered little more than a distant thump against the rib cage. Without binaural stethoscope technology, auscultation was more like listening for trees falling in a distant forest or miners tapping faintly in a deep pit. But doctors still pressed ears to chest cavities and listened for the pings, trying to read the heart’s noises and tremors. L.A. Conner (1866-1950), the founder of the American Heart Association, is said to have carried a silk handkerchief to place on the wall of the chest for ear auscultation.

For 100 years cardiologists relied on Cammann’s binaural scope to detect the slightest abnormality, arrhythmia, skip, hop, hammer, block or stutter. 1952 and 1964 saw further refinements of the traditional binaural stethoscope, with many cardiologists believing that the now all-but-obsolete Rapport-Sprague was the finest auscultation device ever made or used, allowing them unprecedented clarity and consistency.

Current research is focused on developing a reliable electronic amplified stethoscope, which is not actually a listening device but a noise translator that generates a reproduction of the heartbeat, bullying the human ear out of its place as the direct register of the heart.

I first heard the whoosh-whoosh of my daughter’s heart as reproduction, as an electronic transmission through a fetal heart monitor strapped to my wife’s belly – an electronic stethoscope. The sound is less a thump than a slosh. More valve and flap than muscled push. But it is still a treasured sound. For most of our prenatal visits, medical intervention extended only as far as placement of the fetal heart monitor. The first thing we did – doctor and parents – was listen. All together. We awaited the news of life. And anyone who’s been in this place understands the simple comfort of that sound, the reassurance of that noise – or more directly, the doctor’s recognition that this is normal noise.

A baby’s heartbeat is the first sensory experience a father has with his child, often the first moment that a father begins to think of the fetus as a child. A baby: body and brain and lungs and drumming hearts. An identity: the first hint of possibility filtered through an electronic translator, reproduced from a tiny speaker. Nothing promises person like these first heart sounds. Nothing says, it begins, like the wish-wish-wish noise of the stubborn pump – and I say this with both knowledge and ignorance of the ethical implications for some.

Perhaps because of facts, stats, opinions, and ideas – or perhaps because I had no other way to feel my wife’s pregnancy – fatherhood was mostly an abstraction. I never really began to feel like a baby’s father until I heard the thumping inside, that tell-tale tapping. Or perhaps my son was not a son, my daughter not a daughter, at least in part, until their first heart noises registered in my ear – a formation of identity that wasn’t even possible when my grandfather was born in 1906, or my father in 1945, and was still only a rough science when I was born in 1971. But I know that, in many ways, I did not identify myself as a father until I heard my child’s heart, and that I couldn’t have heard this without the aid of a stethoscope. Most of us identify a doctor by the stethoscope, that intimate disc. But it also identifies parent and child. All three fledgling identities intertwine in that examination room, hopelessly dependent on the curl and twisting turns of simple listening technology, the only tool for the vital job of reading and feeling the rhythmic thumps of the heart, that tap-tap-tap signal of life we cannot see and I can in no other way sense.

Chamber 4

The year is 2002, and 9 coal miners are trapped in the Quecreek Mine in Pennsylvania by rising water released after a drilling machine punches through a wall into an underground spring. The 9 men – a father and son among the crew – retreat to the highest spot in the mine and rope themselves together. They listen for the signal from the surface – 3 small explosions – but don’t hear anything. They start pounding on the roof bolts with their hammers, hoping to make some noise the surface can recognize. They pound and pound, but background noise on the surface interferes, and the seismic listening devices can’t hear them. The men write notes to family members, seal them in a metal lunch box, and wait to die. As rescuers work frantically to pull water from the mine with massive diesel-powered pumps, they also drill down from the surface to pump oxygen into the cave where the rescuers hope the men have retreated. If the miners are alive, they can only be in one place, all of them protected by a small womb of air against the rising flood. The miners continue pounding on the roof bolts, but they get no response. The miners’ families gather on the surface, huddled in a tent around the drill operator – because perhaps he is more than an operator and more than muscle: he’s more like the human side of the machine, the listening side, the man with the touch, who watches the spin of metal, waiting. When the drill finally reaches the light-less room, 240 feet down, and punches like an amnio-needle into the pocket, the drill operator shuts off the machine, quiets the crowd, and listens. I wonder what it was that he listened for. How faint? How rhythmic? He listens, his hands on the machine, until he finally hears or feels the rhythmic noise of the trapped men hammering at the steel – the sole musical evidence of survival. Above them, on the outside, the expectant wives and mothers rejoice. They hug the man at the drill and slap each other on the back and think of how they can’t wait to see and touch and smell their babies again.

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