In medicine, a peripheral brain contains an assortment of much needed medical facts, drug doses, and diagnostic work-ups for an assortment of medical problems. Most doctors and especially medical students, carry their peripheral brains in small spiral bound notebooks, or stacks of 3x5 index cards. Information is collected haphazardly and an extra page or 3x5 card is added from time to time. Often information is handed down from one generation of doctors to the next by photocopying over and over again leading to almost unreadable text! I knew there had to be a better way.
As a student, I started using the 64K Casio B.O.S.S. as my peripheral brain. The limited memory and smallish display on the Casio forced me to consider other options. Soon after starting residency in emergency medicine, the HP 95LX became available. It was an obvious winner. The HP had enough memory, a usable keyboard and a large enough display to use as a peripheral brain, and was also a useful PIM (personal information manager). I wrote a grant proposal to the Hewlett-Packard Company asking for some HP Palmtops in order to study medical applications. A short time later, 35 HP 95LXs arrived, one for each doctor in our emergency medicine residency program.
We have been using the devices ever since then. The HP's along with their content of medical "lore" are passed on from one generation of residents to the next. Of course, many of our residents have purchased their own when leaving the program since they've come to depend on them in so many ways. Many of us have also upgraded to the HP 100LX over the past year. I'd like to share a few ways in which the HP palmtops can make the tasks of practicing medicine so much easier.
Where the Action Is
First a word about emergency medicine. The E.D. (now called the emergency department, not emergency room) is a fast paced, action packed arena in which medical practice depends on split second decision making. There is a real need for information which is clinically relevant and quick to be had.
The Palmtop fills the bill in this role. Often our roles as emergency care providers take us outside of the ED. I practice medicine at the site of the Indianapolis 500 Mile Race, the sidelines of Indianapolis Colts games and in the skies as a flight physician for the Lifeline air ambulance service. Regardless of where I practice, my Palmtop is always put to good use.
Using Lotus 1-2-3 for Drug Dosing
A busy shift in the ED comes along and I heed the call for "Cardiac-one in bed 5, now!" A patient with a myocardial infarction (heart attack) awaits in need of help. We need to administer life saving therapy with thrombolytics ("clot busting" medication), blood thinners, and nitroglycerin. When confronted with a patient in need of multiple emergency cardiac drugs, I use a spreadsheet preloaded with calculations for each specific drug. I enter the patient's weight, and the dose is calculated for each drug automatically. I don't have to flip though dosage cards, fumble with a pocket calculator, or worst of all, "guess."
Many cardiac drugs are infused at a particular rate, where the dose depends on the weight of the patient and the concentration of the drug. Spreadsheets are just the ticket for this application. A drug dosing spreadsheet called DRIPS.WK1 is available on the CompuServe HP Handhelds forum submitted by Robert S. Williams, MD under the name MED100.ZIP <ON DISK ICON>. The program also contains other useful files for physicians.
Fortunately, not every case in the ED is life threatening. My next patient may be a youngster with a fever caused by an ear infection. A few days of antibiotics are the cure. I also use a spreadsheet for pediatric medications. I enter the patient's weight at the top of the screen, and each specific drug's dose is calculated in seconds. I choose the appropriate drug and fill out the prescription for the amount to be given.
The spreadsheet also figures out the amount of medication in teaspoons by applying a formula based on the number of milligrams of drug per kilogram of patient weight and the concentration of the mixture. Since most parents know their child's weight in pounds, I use the spreadsheet to make this conversion automatically. If I also need to prescribe Tylenol or some other pain medication for fever, these doses too are already calculated.
I use the 100Buddy <ON DISK ICON> program to launch the Lotus 1-2-3 spreadsheets directly from the FILER. I set the defaults on 100Buddy to automatically replace without saving since my spreadsheets change with each patient weight I enter, and this speeds up the process of switching from one to another.
Medical Equations
Aside from spreadsheets, the Solver function in the HP calculator is very useful. Let's say a young person experiencing a sudden onset of shortness of breath arrives at the ED. We draw blood from an artery to analyze the oxygen saturation. I can use an equation to help figure out if the result is low enough that the patient needs to have further testing done, in this case a lung scan. Many other equations are available to provide these much needed medical facts and figures.
An example of a medical equations file is available in the MED100.ZIP<ON DISK ICON> file under the name MED.EQN, written by David E. Goodman, and enhanced by Dr. Steve Zweibel and Alan M. Galitz, MD. Having the appropriate equation handy in situations where snap decisions are needed can make the difference in some cases. Often it would be very unhandy to find a book, look up the equation, and use a pocket calculator to find the answer.
In-Flight Operations
Another exciting part of my job is taking care of ill or injured patients on our hospital's Lifeline helicopter service. Each year we transport over 1000 patients back to our hospital and other area hospitals for advanced medical care. Most of our flights are for trauma patients, often injured in motor vehicle accidents, but we take care of heart attacks, gun-shots and an assortment of critically ill or injured patients. The Palmtops are ideally suited to helicopter service. They fit nicely into the pocket of medical uniforms and allow both hands to be free for patient care.
I use the HP's MEMO function to record information about patients. After we take off and are en route to the patient, I call the hospital on the radio to get more information about our patient. I use a template of essential questions to make sure that I get all the facts. The events around the time of the accident, whether there was a loss of consciousness, the patient's past medical history, medications and allergies are just a few essential points. I also open up the appropriate spreadsheet file and enter the patient's weight so all of my drug dosing will be ready to go as soon as we land.
During the return flight I record the patient's vital signs; blood pressure, pulse, etc., and any resuscitation interventions we employ. I then use the radio to report this information ahead to our hospital.
When we arrive in the Trauma Center, I can hand the Palmtop to a trauma recorder who can supplement their chart with the information I've recorded. Eventually, I'd like to make this transfer of information electronic. We are looking into wireless technology to do this.
Paperwork, Paperwork, Paperwork
Healthcare generates mountains of paperwork. Once flights are over, I must fill out internal quality control documents, fill out a medical chart and dictate a letter to the referring hospital. I use the MEMO editor with the flight information I've already entered to do this.
Often I'll want to look up this patient's outcome on the hospital computer system sometime in the future. I'll use the Appointment book to remind me to look up this information by making an appointment and transferring the patient information with a cut and paste from the MEMO file. I can also use 100Buddy to link the APPT file with the applicable MEMO file. The hospital wide information exchange platform provides me with access to the patient's diagnostic results, as well as dictated summaries stored electronically. I use the HP to track of all the patients I contact, their diagnoses and any procedures I perform with a Lotus 1-2-3 spreadsheet.
Finding Answers to Clinical Questions
As an emergency physician, I encounter new and challenging situations daily. I use the HP Palmtop to find answers for clinical questions. The peripheral brain of my HP has extensive fact files about particular medical diagnoses. I have over 200 separate files stored on a 1MB flash RAM card. I use the FILER to search for the appropriate file, then launch it into the MEMO editor using a "double click" under 100Buddy. An example of these files available from the HP Handhelds forum on CompuServe under the file name of MED-NDB.ZIP <ON DISK ICON> uploaded by Robert S. Williams, MD. These files are quite extensive and are very handy for day-to-day questions, or for refreshing your memory about a particular topic. When faced with a particularly tough question, however, I may have to turn to other resources.
The Palmtop can dial up an on-line database to search bibliographic data, or sometimes the full text of medical articles. A modem can connect physicians with the National Library of Medicine resources, marketed through various providers. (I use a service called BRS Colleague). I enter a search strategy into a program called GRATEFUL MED which simplifies the command syntax used to search for medical information. Some resources, such as the Scientific American Medicine series, are available in full text version on-line. After finding the appropriate citation, I can turn on the Capture function in DataComm to store the information for later use. Ideally, a cellular modem would actually allow one to make these inquiries right at the bedside.
Healthcare Behind the Times?
Many readers outside of the healthcare industry probably think that hospitals are really behind the times when it comes to employing information technology. They're right! Healthcare reform is forcing us to look at ways to automate processes and replace the old paper-based information flow. Palmtop or other point-of-care technologies are one way to cope with the problem.
Mobility is a fact of life in healthcare. Our patients move from the ambulance to the ED to the operating room to the ICU. Nurses and doctors travel from one patient's room to another, to the operating room, and x-ray facilities, not to mention remote offices and clinics. Mobility demands mobile computing, and wireless technology is the solution for this environment.
Portable medical computing has made a dramatic improvement in how I and many others practice medicine. It's my hope that other doctors will see the utility of this approach and more widely use it in the future.