Assistant Medical Director of St John Providence Occupational Health Partners/Associate Health & Wellness. Certified Medical Review Officer

Victor Abuel, MD

Each month, physician reviewers will evaluate

a particular app or category of apps that provide some functionality for medical practices and/or patients. 

One of the tools a physician uses every day is a calculator. No, not just the simple ones that are used to add, subtract, multiply, and divide. These are medical calculators that help healthcare providers make critical decisions based on likelihood and evidence.

In a perfect world, these clinical tools would be a standard electronic health record (EHR) tool to provide meaningful use to both providers and the patients they are caring for. But alas, they are not. Next to my stethoscope, my smartphone is the most important tool I carry with me. When I pick up my smartphone to use a medical calculator tool, my go-to app is MDCalc.

 is the brainchild of two emergency physicians: Joe Habboushe, MD, MBA, and Graham Walker, MD. Since 2005, they have provided registered users free access to hundreds of clinical calculators from multiple specialties. In 2016, they released their mobile application for both Android and iOS platforms.

If you have used their website, the app will look quite familiar. The green banner on white background with black text and pops of yellow provide a clean interface. There is a large search bar at the top. A notification bell icon to the right of the search bar indicates any updates to current calculators or new additions. Beneath the search are four icons: Favorites, Recent, My Specialty, and All.

As its name suggests, Favorites are where you can quickly reference calculators that you have saved using the star icon. Recent shows the last 10 calculators you used. My Specialty is determined when you register and select your practice specialty. Once selected, those calculators are pre-populated. And then there is All, which gives you access to the entire library regardless of specialty.

Once you select a formula, such as Well’s Score for PE, it quickly displays that calculator. The title of the calculator appears at the top along with four secondary navigation tabs:

- The default display is the actual tool where you click on the appropriate criteria. Once you fill in the options, the result will be displayed at the bottom in a large green box. The calculator option has a local navigation with three useful tabs to select from: When to Use, Pearls/Pitfalls, and Why Use. The When to Use option provides a brief description of the tool and its utility. Pearls and Pitfalls provide doctors information with considerations for using this tool, and Why Use explains to doctors what the test validated.

- provides information as to what needs to happen after doctors have calculated the score and also gives some critical action steps not to miss.

- provides facts and figures, links to the original or primary research, and links to the validation journal article.

- provides a quick professional biography of the calculator. For example, Phil Wells, MD, MSc, speaks to the use of his scores in the app and his opinion on testing in medicine for MDCalc. Note: not every calculator has this information.

MDCalc is one of my essential apps, and I tend to use it frequently during an Emergency Department shift. This app is quick and responsive, and the interface is uncluttered. I find the most useful option to be the Next Steps tab that details an action plan. I have not used any other calculator with anything remotely comparable. Next Steps can be a lifesaver, no pun intended.

It’s also nice to have the option to review the primary research article and the validation articles. Though the app may have access to more than 300 calculators, they do not have them all. I have found some in other medical calculator apps that I would like to have. Fortunately, MDCalc is updated frequently, and users can easily submit a request to consider adding a missing calculator.

Overall, for the price of just registering, MDCalc is the most robust evidence-based medical calculator available. If you haven’t tried it, I encourage you to run, not walk, and sign up.

Victor Abuel, MD, FACEP, is the Assistant Medical Director of Associate Health and Wellness/Occupational Health Partners Ascension’s Michigan Market. He previously worked as the Director of Emergency Medicine/Urgent Care at St. John Medical Center in Macomb Township, Mich.

Articles

This month, Victor Abuel, MD, reviews an app for medical calculators that adds up to a handy tool.

App Review: MDCalc

Each year, 475,000 Americans die from cardiac arrest, according to the American Heart Association (AHA). More than 350,000 cardiac arrests, nearly 75 percent, occur outside of the hospital. Ninety percent of those who experience an out-of-hospital cardiac arrest die. However, studies show that almost 45 percent of those who experience an out-of-hospital cardiac arrest survive when a bystander administers CPR. Unfortunately, only about 46 percent of those suffering from an out-of-hospital cardiac arrest received bystander CPR.

Why then, if the studies show that earlier administration of CPR results in better outcomes, is bystander CPR administered less than half the time? It could be related to bystanders not having prior training. They could be fearful of causing more harm if CPR is performed incorrectly. They could be sitting on the sideline waiting for someone else. They could be concerned about spreading or receiving an illness as a result of performing CPR. Or, they could be concerned about the false idea of having mouth-to-mouth contact with a stranger; the current recommendations for layperson CPR are chest compressions only. Whatever the reason(s)-from self-doubt to being grossed out-it is my opinion that we need to help educate bystanders on how to perform CPR in a pinch, should the situation arise.

The more I thought about it, the more I wondered if there were apps designed for laypeople, non-healthcare professionals, that could help train them by virtually placing them in a situation as a potential bystander. I specifically looked at apps that provided a virtual reality (VR) experience. These apps do require some form of device to place your phone into to get the full experience. They can range from a Google Cardboard VR display to any of the multiple plastic devices you can find on Amazon. I used the View-Master VR Headset to review the following five apps.

CPR Training, created by Warp Industries BV, is a free app that requires the user to wear a VR headset. After a brief instructional tutorial, you are “warped” into a scenario at a mall where you witness an elderly man collapse due to cardiac arrest. You are then tasked to select the correct option from a list of at most four options based on the situation.

The application does an excellent job of building the scenario and allows you to look around in all directions. Despite the excellent VR, the overall experience was rather clunky. Scenarios would end suddenly without explanation, and there is no education to reinforce or correct mistakes.

VirtualCPR does not require a VR headset. Instead, the app, created by Virtualware 2007, places you in a scenario of a virtual body that can perform basic life support. It appears that you can log in if you have an account, but it was not specifically spelled out, nor was there a readily seen help option. I could access the tutorial, which allows you to enter the simulation. The interface was cluttered and didn’t identify labels for the given options. The tutorial took you through step-by-step as to what needed to be performed on the simulator.

It gamified the basic life support procedures and scored you on how well your compressions were, calculated by percent ineffective compressions versus percent effective compressions, response time. It was quite basic, and I was rather disappointed I couldn't get into the actual app to try the scenarios.

There were few customizations during the scenario you could select. For example, if your compressions were ineffective, you could turn on the metronome that plays The Bee Gees’ hit song “Staying Alive” to sync your compressions to the rhythm. It was OK, but I still felt there could be an app that provided a better experience for the layperson.

The app VR Clinic, created by Mad development Co, gave me more of what I was looking for. Like the others, this app is also free. Once you download the app on your phone, you can choose which scenario you want: adult, child, or infant. The scenarios include one-person rescue, two-person rescue, and choking.

The application educates you by having you watch a virtual movie/scenario first. You then move onto the “testing” option, which lets you pick the appropriate step from floating options based on the current situation. It then scores you and reviews any mistakes or missteps.

You are also given the option to use the app with or without a VR helmet. The VR helmet offers an immersive experience. You can look all around the setting you are in. The situations tend to be more of a choose your own adventure but could be a useful option to prepare laypeople. It is the only app I used that offered scenarios for children or infants.

Virtual Rescue Hero and Virtual Rescue Mobile

These two apps are variations of each other. Both were created by VR Lab BV for Zoll. Both require a VR helmet, and they take you through a scenario of being outside an office building when someone collapses. Where the two apps diverge is the approach to how they present the scenario:

The Virtual Rescue Hero presents the scenario as a virtual movie. You float over the bystander who is performing compressions and utilizing the Zoll automated external defibrillator (AED). The AED provides you a metronome to keep your compressions in sync. It also tells you if your compressions are ineffective and need to push harder.

The Virtual Rescue Mobile puts you in the shoes of the bystander. You can actually place your hands on a sofa cushion as you look down on the virtual patient and perform chest compressions. As you are performing the chest compressions, you can actually see the chest rise and fall on the patient.

Granted these apps are an advertisement for Zoll AEDs, they provide a good sense of immersion and interaction I would expect the average bystander to have in real-life.

Many of the apps were good in terms of providing basic information and placing bystanders in clinical scenarios to recognize, activate, and begin the chain of survival. I feel the Zoll apps and the VR Clinic would be a good place for laypeople to start. These apps can help build confidence so if they were in that scenario, they could potentially change an outcome of out-of-hospital cardiac arrest.

These apps are still not a replacement for basic CPR certification but hopefully they would encourage laypeople to take action if the opportunity presents itself. Something these apps could do better with regards to bystander CPR is to be more current with the AHA’s recommendations.

With AEDs more ubiquitous in public settings, I would hope that these apps could empower laypeople to take it upon themselves to administer CPR and save a life instead of watching helplessly and waiting for someone else. Time is muscle!

A look at apps that provide some guidance on how non-healthcare professionals can learn more about CPR in the event they are a bystander to out-of-hospital cardiac arrest.

App review: Virtualized bystander CPR training

Phone Calls. As a physician, there is no way of avoiding them. Making or returning phone calls to patients is a part of our clinical practice at every level of training as residents or as practicing attendings. This typically is not a problem when you are in a clinical setting, such as a hospital or a physician’s office. But what if you are off-site and you receive a page? Or, what if you are out of the office and need to contact a patient regarding a critical lab result or diagnostic report? What if you are not working but want to perform follow-up calls on patients’ conditions?

The problem: making a phone call without inadvertently giving patients your personal number.

I’m sure we’ve all dialed *67 prior to calling patients to block our outgoing number from being visible. And there are those who go into their phone settings to disable their caller ID from being viewed. There are even paging services like PerfectServe, which my institution utilizes, to make such phone calls that are first routed through a server.

But those previous methods typically lead to a common end: the patients you are trying to contact never answer the call. They do not pick up because the number is blocked, displays as an unknown number, or appears a 1-800 number. Patients think they are being harassed by yet another telemarketer. You typically leave a message, explain that you will call back again in a few minutes, and ask them to pick up the phone. Hopefully, the game of phone tag ends.

Frustrating. It wastes your time and your patients’ time.

The organization Doximity is tackling the problem with the Doximity Dialer application. The app is available to physicians, nurse practitioners, physician assistants and pharmacists in the United States. It is free for both iPhones and Android phones and available on their respective app stores.

The user interface is fairly simplistic yet straightforward. The one main requirement to use the app is you must have a Doximity account. For those who are not familiar with Doximity, think of it as a hybrid of LinkedIn and Facebook-but only for clinicians. To sign up, you will need to provide some background information like your medical education and residency training along with current practice. You also need to enter your phone number to use the app, but that number will not be displayed when using the app.

The killer feature of Doximity Dialer is that you can set receiving display. The app allows you to dial out while showing the number as you want it to appear on patients’ phone. That number can be a clinic, hospital, emergency room, office extension or answering service line. You can store multiple numbers and give them nicknames to help you stay organized.

When you make a call through Doximity Dialer, you pick your “clinic” number to call from and enter the patient’s phone number. From there, the app basically acts like a switchboard by contacting Doximity first via your cellular connection. Doximity then calls whoever you are trying to reach and connects you to the patient displaying the number you want it to show on the receiving phone. If you set the phone number as the main clinic line, patients who have that number saved as a contact would see the clinic name in the caller ID.

If you have multiple clinics, you can create specific “numbers” for each of your clinical settings. For example, I work in both an Emergency Room setting and an outpatient clinical setting with multiple clinics in a tri-county region. From an ER perspective, I can call patients I saw the shift prior to check on their statuses and for the Practice Improvement component of the American Board of Emergency Medicine’s Maintenance of Certification. From the office setting, I can respond to patients’ questions or concerns from the convenience of my cell phone knowing my personal number would not be inadvertently exposed.

The application also connects to your phone’s contact list, if you allow it. There is also a recent calls list of those frequent numbers with evolving issues.

The functionality of the app is also fully integrated into the Doximity application as well as Epic Haiku for those on that EHR platform. Doximity does not store or record any of these calls, making this app HIPAA-secure. For many of us, that ability to call patients using our personal cell phone without exposing our number is really useful.

The one downside is that there is no ability to set up a virtual number where someone can call you back directly. Unless you use your actual phone number, patient’s may end up calling the “clinic” that was seen on their caller ID. The application is also limited to only U.S. phone numbers.

Still, this app is a must-have tool for any clinician. I give it a 5 out of 5 Stethoscopes.

Victor Abuel, MD, is the Director of Emergency Medicine/Urgent Care at St. John Medical Center in Macomb Township, Mich.

An app that gets patients to pick up their phone without giving them your personal number.

App review: Doximity Dialer

I am not a fan of paper. I try to lead a 'digital life' if possible. If I need a text book or reference book, I will look for a digital copy. If I get a stack of documents that warrant keeping, they become PDFs that are available on any of my devices. But occasionally there are things that you can't avoid, like journals. It would be great if they all could come digitally, but not every journal provides that service - especially if it's a journal that is provided free or part of your college specialty.

Do I read these journals from cover to cover? No, but I typically find the articles that I find interesting or germane to my practice. If I found an article worth keeping, I would typically keep the issue versus throwing it out. But over time, you have a massive stack of journals in which you can't remember what articles you were referencing and your significant other is asking you to turn back from a mountain into a molehill.

Over the years, this process has evolved. There are now a growing class of apps that allow physicians to read academic journals on their mobile devices. These apps include Docphin, Read by QxMD, and BrowZine. The majority of apps are limited to specific medical and health content, but 

 is different and that is why I prefer it over the others.

Whereas most of the the other apps in that class use the free data from the PubMed Database, BrowZine works with the publishers and the hospital/institution's library to get their content to you. The big names are there such Elsevier, Wiley, Springer, JAMA, and the New England Journal. But there can be other medical society journals included, culminating in a large collection of journals.

After setting up the relationship with the publisher, BrowZine then works with the individual libraries. The libraries and the institution pay an annual licensing fee. They make the app available to their staff for free. A majority of the libraries text holdings match up with the journal list provided to you in the app. You can then see the journals with the full text which are available because your institution either paid for full text access or the journal is already freely available. There are journals that unfortunately do not work with BrowZine even though your library pays for them-they are not included or seen in the app.

Once you download the app, you can start using it without having to create a specific BrowZine account. If you had access to your library remotely through gateways such as ATHENS, you will need your log-in and your password when asked after selecting your hospital or institution in the BrowZine app. If you want synchronized content between mobile devices, you will need to create a BrowZine account.

After selecting and logging into your hospital or institution, you can see the content that you have access to.

The interface is a bit skeuomorphic with a customizable bookstand or newsstand display. You can go through your institutional content and select your favorite journals. You can then add journals to the bookshelf. It has an appearance very similar to the iBooks app on iOS devices.

You can customize shelves and place particular journals on that shelf in terms of subject matter, specialty, or just alphabetically.

When you select a journal, you can add it to your selected shelf by dragging it in. You can view a list of available issues for that title. Once you select an issue you can view a list of articles which are in PDF format. You can then select articles to be read or saved/downloaded to your device to be available in any app which can read a PDF. You can share these articles via email.

For example, if you have a journal club and all of the journals are available within BrowZine, you can select the articles and forward them electronically to your group, residents, etc and not have to go to the library and photocopy and then scan them, and then forward electronically. The app can even notify you when there is a journal available to be read, if you choose to have it provide notifications.

It is quite self explanatory to use. It is easy to use. But mostly it is convenient. I can have the app on my iPhone and iPad, go on a flight and have downloaded articles I want to read, or be notified that a new journal is available and to simply browse through the list of articles and download the ones I want to take with me right before the flight. Though some may be annoyed by the appearance, it looks and feels intuitive right from the app opening. The downside is that you may not have all the journals you need based on your hospital/institution agreements. But if you are looking for a convenient way of keeping up to date without carrying a bag full of journals, this may be your app.

BrowZine is a must for anyone looking to carry a wealth of knowledge with them on-the-go.

App Review: BrowZine

One of the things that I still struggle with in my practice is using the ultrasound. Yes, there are excellent courses provided within our state and nationally where you can learn the basics to expand your skill. But in the end, it still comes down to repetition and practice. Seeing that I always have my smartphone and iPad with me, I began to wonder what apps there may be that I could look at during downtime to help improve my skill with ultrasound, here's what I found.

One of the first things that I found was podcasts. One of the better podcasts is the 

. Episodes are roughly a half hour in length and also available in video format. Each podcast is topic-specific and provides great information to apply to your clinical practice.

I also found an app associated with the podcast called the 

. It's free, has some good video, but is not as helpful as subscribing to the formal podcast. Both the podcast and the app are available on iOS and android.

, which is essentially an app for the text book of the same name. It's a quick, handy guide with lots of images and links to video to assist the clinician. It is available on both iOS and android through their respective app stores. The downside to the program is that it costs $70.

As far as apps go, if I had to choose one app, then I would select 

. It is, in my opinion, the best ultrasound reference to have on your mobile device. It's succinct and easy to read, while providing an extensive library of studies with plenty of images. The app provides you with a step-by-step guide to get the best images for your study, and it only costs $5.

The only drawback I could find is that the app is only for iOS devices and for android through Amazon's App Store. You may also be disappointed that there aren't as many videos of cases compared to the number of static images that you see. But for the amount of information you receive with this app, it is a definite purchase in my book.

 is another app option. Originally, when it first came out, it was very rudimentary. But with recent updates, it has had a significant improvement in interface and content. The app is designed to be an interactive tutorial with excellent resolution videos and images. You can select your specialty and a "playlist" of videos and images are easily accessible. It also offers video tutorials of particular ultrasound machines (if they are made by SonoSite). There are also case studies for the physician to review. SonoAccess is free and available through the Google Play Store and Apple's App Store for both iPhones and iPads. What more could you ask for?

Another great reference to have on your device that is free is ACEP's 

. It's an extremely well done eFAST overview with a great interface and tons of video.

I am by no means an ultrasound guru, nor do I think I will become one. But, with great references like these, I can improve my skills and hopefully have a positive impact the care I can provide to my patients.  

Looking to brush-up on or further your ultrasound skills? Here are a few apps, podcasts, and references you should check out.

App Review: Clinical Ultrasound Reference Tools

If you were to ask any physician, "What is the one piece of equipment you cannot leave the house without?" Though I am sure there are a few that would say their smartphone, I would guess that most physicians would probably say their stethoscope.

 Construction, Lightweight, Sensitivity, Versatility in use depending on clinical situation, great customer support, "cool factor."

 Does require intermittent charging, iOS app needs to be updated to support 64 bit architecture of iOS11, pricey ($499).

The first stethoscope was created by Rene Laennec in 1816. But George Cammann developed essentially the standard binaural stethoscope in 1852, which has been the basis for current day stethoscope design. While digital and electronic stethoscopes have been introduced, they have kept the same design of a traditional stethoscope. For approximately 200 years, our main diagnostic tool has essentially been unchanged. All stethoscopes work in the same manner - transmitting sound from a chest piece through hollow rubber tubes to our ears. There really is no need to change. If it isn't broke, why fix it?

Well, a company from Colorado, ThinkLabs Medical, begs to differ. They are known for producing high- end stethoscopes. But their product, the ThinkLabs One, has taken the classic design of the stethoscope and has given it a modern twist. Their creative stethoscope is only the chest piece. No earpiece. No tubing. No stem.

The digital chest piece is an electronic device, which is battery powered and houses a very highly sensitive microphone that can amplify the sound captured 100x. The sound can be filtered between low (heart), midrange, and high (lung) frequencies. And there are filters to keep out ambient noise. But no earpiece.

How do you hear using the device? There is a 3.5mm phone jack so the physician can use a pair of quality headphones or earphones. Plus, you can connect it to your smartphone or tablet to record the sounds and waveforms with ThinkLabs' app (which is both iOS and Android compatible). At this time the iOS app has not yet been updated to support the new iOS11.

The unit is fairly lightweight even though it is slightly bulkier than the average stethoscope chest piece. But given that all of the electronics are in the chest piece it is surprising that it isn't much larger than the normal stethoscope chest piece. The unit ships with a protective case which includes the USB charging cable, ThinkLink adapter, and cables as well as a set of ear buds. It does cost $499 which is on the higher end of other digital stethoscopes, but it does have a radically different design.

The chest piece has a sapphire crystal display which indicates battery level, volume, and frequency selected. It is constructed of polished aluminum. The headphone jack also serves as the charging port, typically requiring 1-2 charges per week, depending on the amount of usage. There are four buttons. The top two buttons adjust the frequency of the stethoscope (i.e. bell vs. diaphragm mode), while the bottom two adjust the volume. Pressing any of the four buttons will power on the device and there is an auto shut off mode which turns it off to conserve battery.

The stethoscope ships with an adapter called the ThinkLink which allows you to connect the stethoscope chest piece to your smartphone and then connect your headphones/earbuds to the ThinkLink. This not only allows physicians to auscultate the patient, but also to record heart or lung sounds to their app or other third party audio recording app.

In an academic setting, imagine allowing students or residents to hear a finding all at once through a speaker as a group, rather than having a patient disturbed to be examined on separate occasions.

Other clinical settings allow a physician to attach a Bluetooth adapter to the chest piece and use Bluetooth headphones and use the device on a patient with contact isolation precautions. A doctor can also use the device for telemedicine, so the clinician on the other end can hear the chest exam in real-time rather than with a recording.

In practice, I found the ThinkLabs One to be easy to use. It is by far the lightest stethoscope I have ever used. I don't like to wear my coat while working in the emergency department, so I tend to wear my stethoscope around my neck. Switching to the ThinkLabs One was revealing-I never realized how much that rubber tubing weight was noticeable until using this stethoscope. I found the stethoscope to be quite sensitive on the lowest settings compared to my non-digital stethoscope and was able to hear clearer especially in a bustling ER. I found myself using a pair of wired Beats earbuds with the device. I find that the bass brings out the heart sounds better compared to the included earbuds-besides its kind of neat when the patients look at you and say "Cool, that's your stethoscope?"

Thinklabs One stethoscope separates itself from the pack with its light weight design and superior sound quality. 