Endless ear exams

My least favorite part of the physical exam is looking in ears. It's especially difficult in kids because their ear canals are small and crooked, and of course kids tend to squirm and scream when you try to stick something in their ear. Go figure. But a good ear exam is absolutely essential in pediatrics. That's why I made a point to hammer away at the ear exam until I got the hang of it.


Tough going, at first. Too often I would look in a kid's ears and just see a ball of wax, or the sides of the ear canals but no tympanic membrane. When ear pain wasn't a chief complaint and I wasn't concerned about an ear infection, I just nodded my head reassuringly and continued with my exam. This falls under the category of "Fake it until you make it" - first to avoid alarming parents that they are entrusting the care of their child to such an amateur, and second to protect my own ego. But I would return to my attending, tail between my legs, and sheepishly report "Tympanic membrane not visualized" in the physical exam section of my oral presentation.

The attendings are for the most part understanding that a third year medical student isn't going to do a first-rate ear exam. In fact, they seem to expect it. One attending said, "I don't even expect pediatric interns to give a good ear exam. You have to look at thousands of ears to get good at it." Fair enough. Being that we're in the middle of flu season, I've gotten a good jump-start on those thousands.

I think I'm already getting better. I'm probably visualizing about two-thirds of all the ears I look in, at this point, up from around 0-5%. If there's wax, I remove it and try again. If the kid is squirming, I coach the parent on how to hold the kid down. If the kid is screaming, I ignore it. I'm such a meanie.

But being a heartless sadist has paid off. Today a kid came in tugging at her right ear. I looked in the left ear first, then the right, and thought I saw infection in both. The left ear actually looked much worse with erythema in the canal, no light reflex, and yellowish fluid behind the tympanic membrane obscuring the bony landmarks. I described these details to my attending, aware that they were at odds with the patient's history. After doing her own exam, she said five words that every medical student loves to hear from their attending: "I agree with your findings."