Emergency Medicine Palm Tool

[mward04]

I've been working on a Palm PDA tool for Emergency Medicine and would love some feedback. This is a free program called EM Rules that has clinical scores, calculators, decision rules and frequently forgotten tables to help risk stratify patients. Additionally, some of the rules/scores have discussion sections that help the user better understand pros/cons of the rule and how to use it better.

Anyway, you can download it at http://www.handhelddoc.com/emrules.prc and it is available for Palm only (sorry Windows folks!)

I would love to hear about the following:

• Navigation-is it intuitive and easy?
• Anything I am missing (i.e. should I add a new table, rule etc)?
• Any errors (either in the medicine or the programming)?
• Anything else you would like to see?
• Graphics-any problems?
• Any other suggestions?

Thanks in advance for your help with this project!

Mike

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[Jeff698]

I'm away from my primary computer right now so I can't play with these immediately, but they sure do look appealing. Thanks for putting these together (and programming them if that was you).

I'll let folks at my program know about them as well.

I have PEPID which has most of these things in them but there are so many calculators I frequently get lost. I like the clean, streamlined approach that your demos seem to have.

Take care,
Jeff

 

[mward04]

I have PEPID as well but I don't like the layout/navigation plus the annual price is fairly steep. Any feedback would be great!

Thanks!
Mike

I'm away from my primary computer right now so I can't play with these immediately, but they sure do look appealing. Thanks for putting these together (and programming them if that was you).

I'll let folks at my program know about them as well.

I have PEPID which has most of these things in them but there are so many calculators I frequently get lost. I like the clean, streamlined approach that your demos seem to have.

Take care,
Jeff

 

[Dr.Evil1]

Just installed the programs to my PDA. I will let you know what I think and how useful they are. If they are useful, I will distribute to the rest of the residents in my program since we were all given palm based pdas.

 

[dchristismi]

Installing now... I tried PEPID, but didn't like the interface. (Or the cost)

 

[mward04]

regardless, I would still like to hear your feedback. Thanks!

Just installed the programs to my PDA. I will let you know what I think and how useful they are. If they are useful, I will distribute to the rest of the residents in my program since we were all given palm based pdas.

 

[Jeff698]

I've got them on my Treo and, so far, really like them. I like clean, streamlined programs and these are both.

Good job.

Take care,
Jeff

 

[mward04]

Thanks Jeff. Anything you don't see in there that you would like to see?

Mike

I've got them on my Treo and, so far, really like them. I like clean, streamlined programs and these are both.

Good job.

Take care,
Jeff

 

[bulgethetwine]

Thanks Jeff. Anything you don't see in there that you would like to see?

Mike

BIG BULGE ENDORSEMENT!!!

 

[Jeff698]

BIG BULGE ENDORSEMENT!!!

Is that 'cause you like the product or your were just very happy to see it?

Take care,
Jeff

 

[bulgethetwine]

Is that 'cause you like the product or your were just very happy to see it?

Take care,
Jeff

Nicely sized to fit in your pocket

 

[Dr.Evil1]

I like the program as I see it so far. Couple of things though that I figured out though as I sat in a tox grand rounds:

The QTc calculator has the RR interval has the units listed as ms but in order to get the right answer you have to enter it as a decimal. This should be seconds then right?

I would LOVE to see a new table consisting of various the pressors/ionotropes and their receptor activities.

Thanks for the program it is easy and free.

 

[mward04]

I was already planning on doing the vasopressors, so now it just reinforces that other people want it. I also fixed the QTc calculation. Thanks!

Mike

I like the program as I see it so far. Couple of things though that I figured out though as I sat in a tox grand rounds:

The QTc calculator has the RR interval has the units listed as ms but in order to get the right answer you have to enter it as a decimal. This should be seconds then right?

I would LOVE to see a new table consisting of various the pressors/ionotropes and their receptor activities.

Thanks for the program it is easy and free.

 

[mward04]

vasopressors are now included in v1.03!

I like the program as I see it so far. Couple of things though that I figured out though as I sat in a tox grand rounds:

The QTc calculator has the RR interval has the units listed as ms but in order to get the right answer you have to enter it as a decimal. This should be seconds then right?

I would LOVE to see a new table consisting of various the pressors/ionotropes and their receptor activities.

Thanks for the program it is easy and free.

 

[DeLaughterDO]

vasopressors are now included in v1.03!

Mike;

Great program! I just installed it on my pda the other day and have finally had some time to sit down and play with it. I think it will be very useful - thank you for the great work.

I note that you have included the vasopressors in the latest version, which I also think will be useful. However, I am having some difficulty with getting any of the pressors other than dobutamine to come up - I've tried all the other pressors and have run into the same results - no results at all

Don't know if anyone has told you of this yet, but thought I would pass my findings along.

Thanks again for your excellent program!

jd

Edit: I've found the source of the problem - the download link on the handhelddoc website points to version 1.02, not version 1.03. This is why the program does not show the results of selecting any other pressor.

jd

 

[mward04]

this is fixed, thanks for pointing it out!

Mike

Mike;

Great program! I just installed it on my pda the other day and have finally had some time to sit down and play with it. I think it will be very useful - thank you for the great work.

I note that you have included the vasopressors in the latest version, which I also think will be useful. However, I am having some difficulty with getting any of the pressors other than dobutamine to come up - I've tried all the other pressors and have run into the same results - no results at all

Don't know if anyone has told you of this yet, but thought I would pass my findings along.

Thanks again for your excellent program!

jd

Edit: I've found the source of the problem - the download link on the handhelddoc website points to version 1.02, not version 1.03. This is why the program does not show the results of selecting any other pressor.

jd

 

[CS_22]

this is fixed, thanks for pointing it out!

Mike

Awesome program Mike... Actually have used it more than PEPID recently.

Two requests: Any word on putting the Vancouver Chest Pain Rule (not yet validated, but it should happen)? Also, any psych rules/scores you can add?

Chet

 

[mward04]

I'm not familiar with the Vancouver Chest Pain Rule, do you have a reference? I also don't know of any psych stuff, any that you are familiar with.

Here is a list of what I plan on adding in the coming weeks/months:

• Well's DVT Criteria
• Indications/Contraindications to tPA in PE, ACS, CVA
• How to Reverse INR
• Suture stuff i.e. when to return, types of suture
• Indications for Hyperbarics after CO Poisoning
• Contraindications to Xigris
• EMT Death Rule
• Broselow Tape for Peds
• Airway drugs
• Injury Severity Score
• Revised Trauma Score
• Croup Score
• Stages of Shock
• Peds/Infant burn management
• Rochester Criteria for FUO

Awesome program Mike... Actually have used it more than PEPID recently.

Two requests: Any word on putting the Vancouver Chest Pain Rule (not yet validated, but it should happen)? Also, any psych rules/scores you can add?

Chet

 

[EM Guy]

Outstanding program. Thanks a ton for putting it together and making it available. Really useful at point of care and covers a lot of important topics. Can you include some different guidelines/algorithms for pediatric fever? Thanks again!

 

[CS_22]

I'm not familiar with the Vancouver Chest Pain Rule, do you have a reference? I also don't know of any psych stuff, any that you are familiar with.

Here is a list of what I plan on adding in the coming weeks/months:

• Well's DVT Criteria
• Indications/Contraindications to tPA in PE, ACS, CVA
• How to Reverse INR
• Suture stuff i.e. when to return, types of suture
• Indications for Hyperbarics after CO Poisoning
• Contraindications to Xigris
• EMT Death Rule
• Broselow Tape for Peds
• Airway drugs
• Injury Severity Score
• Revised Trauma Score
• Croup Score
• Stages of Shock
• Peds/Infant burn management
• Rochester Criteria for FUO

Again, first off a BIG thank you for putting together this resource.

The Vancouver Chest Pain Rule has not yet been validated prospectively, but here's the reference --

Christenson J, et al. Ann Emerg Med 2006;47(1):1–10

Along the lines of psych rules, I was thinking along the lines of the SAD PERSONS scale (Psychosomatics 24: 343-349, 1983).

Thanks again for the awesome tool.

Chet

 

[Hard24Get]

Hey, very nice, thanks! How about TIMI and Framingham?

 

[mward04]

Hey, very nice, thanks! How about TIMI and Framingham?

TIMI is already included with a discussion written by Seth Krupp MD. Not really sure Framingham is that applicable to the ER. What do the rest of you think?

Actually, Seth is writing a section on Pediatric fever and Rochester criteria. Shortly, that will be included as well.

I'll probably eventually include the chest pain stuff but right now, there's a lot more higher priority stuff (i.e. list I included) that I want to get in there. Stuff that is used far more frequently and is validated or very high yield.

Keep it coming, I love it, thanks!
Mike

 

[Hard24Get]

TIMI is already included with a discussion written by Seth Krupp MD. Not really sure Framingham is that applicable to the ER. What do the rest of you think?

Actually, Seth is writing a section on Pediatric fever and Rochester criteria. Shortly, that will be included as well.

I'll probably eventually include the chest pain stuff but right now, there's a lot more higher priority stuff (i.e. list I included) that I want to get in there. Stuff that is used far more frequently and is validated or very high yield.

Keep it coming, I love it, thanks!
Mike

Sorry, it took me a while to find the other tab, I was just seeing the "Decision Rules" tab and was like, "is that it?"

I just mentioned Framingham because it is in my EMRA book and I don't have it memorized.

Thanks!

 

[mward04]

Rochester Criteria is added to v1.05 available at handhelddoc.com and although it's not officially ready until I get a pharmacist to review it, I added the following to v1.06 (you can get v1.06 at www.handhelddoc.com/emrulesbeta.prc):
Thrombolytic indications/contraindications, GPIIb/IIIa dosing calculator, heparing dosing calculator, indications for tpa in MI/stroke/DVT/PE, also Differential of Bandemia was added.

Outstanding program. Thanks a ton for putting it together and making it available. Really useful at point of care and covers a lot of important topics. Can you include some different guidelines/algorithms for pediatric fever? Thanks again!

 

[Jeff698]

Let me once more say thank you for the strong work you're doing on this.

Very helpful. I'm particularly pleased to see the indications/contraindications for lysis in CVA. The vast majority of CVA patients I see are clearly not candidates so I don't use the criteria all that often. It's good to have in a readily accessible location for when I do need it.

Take care,
Jeff

 

[CS_22]

Something I caught...

On the CURB-65 rule, I noticed that you had Urea>7 as one of the points. Isn't it supposed to be Urea>19?

CS

 

[mward04]

Something I caught...

On the CURB-65 rule, I noticed that you had Urea>7 as one of the points. Isn't it supposed to be Urea>19?

CS

CS-thanks for your email. I think there's a debate about what number to use, but the Urea is 7:
Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study
W S Lim et al Thorax 2003;58:377–382

Mike

 

[deleted87716]

it is available for Palm only (sorry Windows folks!)

Don't worry, they were probably already sorry.

Strong work, by the way!

 

[DeLaughterDO]

I've been using this program for a few weeks now, and I can honestly say I have found it to be singularly useful in several situations.

Nothing like arguing with an admitting team about an admission, you pull out your palm and show them this person has a 23% chance of dying in the next 24 hours from their condition.

Argument over Complete with references for their own edification!!!

Thanks Mike!! (and everyone else at Cinci who has helped put this together)

jd

 

[hyperbaric]

Very easy to navigate! Thanks for sharing. This will be a great help to me.

There is a minor typo on the PORT score calculator. It lists temp >35 or > 40.

Thanks again!

 

[CS_22]

CS-thanks for your email. I think there's a debate about what number to use, but the Urea is 7:
Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study
W S Lim et al Thorax 2003;58:377–382

Mike

Okay, I'm going to ask a really dumb question, but tonight I'm not in a position to look it up.

Is Urea a different measurement that "BUN"? Seems like a BUN of 7 is pretty normal, so I'm assuming (perhaps incorrectly) that you would send a separate lab?

Thanks for anyone's input.

CS

 

[CS_22]

Okay, I'm going to ask a really dumb question, but tonight I'm not in a position to look it up.

Is Urea a different measurement that "BUN"? Seems like a BUN of 7 is pretty normal, so I'm assuming (perhaps incorrectly) that you would send a separate lab?

Thanks for anyone's input.

CS

Sorry about the double post -- but I actually did have a minute to look this up, and I think I found the disparity.

BUN >7 is measured in mmol/L, and I'm pretty sure this is a British thing. In our hospital (and America?) labs are reported in mg/dl.

7 mmol/L = 19 mg/dl

Again, sorry about the double post.

 

[mward04]

New updates to the site including a mobile version for the ACS and Stroke tools available at handhelddoc.com/mobile and upgraded versions of the EM Rules program (to v1.10) and Sepsis EGDT (to include the 2008 Surviving Sepsis Campaign Guidelines). All are available for free at www.handhelddoc.com As always, please feel free to send feedback my way.

Mike

 

[deleted109597]

Any chance this could be ported to WinMobile? I really can't justify purchasing another PDA simply for this, and I don't want a Treo.
Or, conversely, anyone have any success with styletap? Does it work reasonably well and stable as an emulator?

 

[mward04]

Any chance this could be ported to WinMobile? I really can't justify purchasing another PDA simply for this, and I don't want a Treo.
Or, conversely, anyone have any success with styletap? Does it work reasonably well and stable as an emulator?

My understanding is that it works pretty well on Styletap. Plus, the ACS and Stroke tools are available on any browser now at handhelddoc.com/mobile and I'm building the sepsis version as well. If there's strong demand, I can build the EM Rules mobile version too.

Mike

 

[thorg12]

I would use the email rules mobile bc I use a blackberry. Thanks

 

[Dr. Will]

My understanding is that it works pretty well on Styletap. Plus, the ACS and Stroke tools are available on any browser now at handhelddoc.com/mobile and I'm building the sepsis version as well. If there's strong demand, I can build the EM Rules mobile version too.

Mike

Yeah man, I'm all for it being available on blackberry. l ditched that POS treo that does nothing but crash/freeze on me. I'll talk to you about it now that I'm out of the MICU

 

[CraftyMed]

I would LOVE it to be available on Crackberry. There are so many people complimenting the program, but I'm not willing to give up my BB.

 

[mward04]

I would LOVE it to be available on Crackberry. There are so many people complimenting the program, but I'm not willing to give up my BB.

I'm actually talking with a company now about making it available on all formats. But the windows should do for now...

Mike

 

[Dr. Will]

This will essentially drive the final nail into the coffin of Palm and their treo line and make apple completely dominant in the smart phone industry. Blackberry should even look out now.

http://www.engadget.com/2008/05/30/styletaps-palm-os-emulator-officially-coming-to-iphone-and-ipod/

Pretty huge news for 3rd party applications until these programs can run natively.

BTW...I think apple is making a huge mistake by keeping the iphone soley for ATT. There coverage sucks in comparison to Verizon, and they're losing out on a hell of a lot of (MORE) business by keeping the iphone an exlusive for 4 more years.

 

[mward04]

This will essentially drive the final nail into the coffin of Palm and their treo line and make apple completely dominant in the smart phone industry. Blackberry should even look out now.

http://www.engadget.com/2008/05/30/styletaps-palm-os-emulator-officially-coming-to-iphone-and-ipod/

Pretty huge news for 3rd party applications until these programs can run natively.

BTW...I think apple is making a huge mistake by keeping the iphone soley for ATT. There coverage sucks in comparison to Verizon, and they're losing out on a hell of a lot of (MORE) business by keeping the iphone an exlusive for 4 more years.

that's great to know, thanks!

 

[pseudoknot]

BTW...I think apple is making a huge mistake by keeping the iphone soley for ATT. There coverage sucks in comparison to Verizon, and they're losing out on a hell of a lot of (MORE) business by keeping the iphone an exlusive for 4 more years.

The mistake was Verizon's, as they were offered the iPhone first but were not willing to agree to the terms (no carrier branding, modifying network for Visual Voicemail, whatever financial crap).

AT&T's not bad in most places I've been to, but not ideal either.

 

[deleted109597]

Trying it on styletap, it seems to work.
Although I haven't found a way for the Pittsburg rules to not get an Xray, regardless of how I answer yes/no for all of them.

 

[Dr. Will]

The mistake was Verizon's, as they were offered the iPhone first but were not willing to agree to the terms (no carrier branding, modifying network for Visual Voicemail, whatever financial crap).

AT&T's not bad in most places I've been to, but not ideal either.

Well I hope that Verizon has been kicking itself in the ass with the continued success and public demand for the iphone. Talk about a botched business decision. As a verizon customer, I'm pretty embarrased for them. I would be on cloud 9 with an iphone.

 

[Jeff698]

This will essentially drive the final nail into the coffin of Palm and their treo line and make apple completely dominant in the smart phone industry. Blackberry should even look out now.

Oh my.

That IS cool.

How do they propose loading it on the iPhone prior to release of the 2.0 software upgrade? Would doing so void the warranty or be subject to "brickification"?

Take care,
Jeff <- Eagerly awaiting June 9th.

 

[bulgethetwine]

Oh my.

That IS cool.

How do they propose loading it on the iPhone prior to release of the 2.0 software upgrade? Would doing so void the warranty or be subject to "brickification"?

Take care,
Jeff <- Eagerly awaiting June 9th.

Actually, until the iPhone has an interface to reliably view and edit .word docs, I won't be putting any pennies down on this (er, again ) I bought one of the original iPhone's. I sold it two weeks ago because of this shortcoming. I've got too many little cheat sheets, etc. that I like to access (like a phone list of all our ER numbers and all the consultant numbers in the hospital).

Anyway, I won't be surprised if there *is* plans for this on the way (or at least a 3rd party app) I just haven't seen one yet.

 

[mward04]

This will essentially drive the final nail into the coffin of Palm and their treo line and make apple completely dominant in the smart phone industry. Blackberry should even look out now.

I agree somewhat. I think the fact that other companies are innovating so much more than Palm will eventually kill it off. While the centro has been selling really well for the Palm, there's not much to it.

In terms of Apple's worldwide domination, keep in mind that Apple is way off in terms of worldwide sales from the biggest other smartphone producers ($1.7B in Q1 2008 vs. Nokia's $14B and RIM's $4.3B) http://www.gartner.com/it/page.jsp?id=688116 Note that Palm isn't even listed and Blackberry's market share actually INCREASED after the iPhone came out from 8.3% to 13.4% of the mkt. However, the fact that the iPhone has only been out a year, has had tremendous growth and they just cut prices will obviously bode well for it.

 

[brokensword]

This is a very good palm tool. I just wanna ask where did you get the CURB65 mortality? You have it 0.7, 3.2, 3, 17, 41.5, 57% for score of 0,1,2,3,4,5.

I have it as 0.6, 2.7, 6.8, 14, 27.8 from this link http://www.aafp.org/fpm/20060400/CURB65.pdf

 

[mward04]

This is a very good palm tool. I just wanna ask where did you get the CURB65 mortality? You have it 0.7, 3.2, 3, 17, 41.5, 57% for score of 0,1,2,3,4,5.

I have it as 0.6, 2.7, 6.8, 14, 27.8 from this link http://www.aafp.org/fpm/20060400/CURB65.pdf

Thanks for the feedback.

I used the Lim reference cited on the CURB Score page in EM Rules (click on the 'i') and at the bottom of the page of the AAFP article. It was the original derivation study. The numbers you cited are a "weighted average" of two different studies (including the Lim study)

 

[brokensword]

Thanks for the feedback.

I used the Lim reference cited on the CURB Score page in EM Rules (click on the 'i') and at the bottom of the page of the AAFP article. It was the original derivation study. The numbers you cited are a "weighted average" of two different studies (including the Lim study)

Thanks for the clarification. There is a typo in your tool, curb65 score of 1 is 3.2% but score of 2 is even lower at 3%.