How smartphones and apps are changing emergency department care

A mainstay of the “Star Trek” TV and movie franchise is the medical tricorder. This versatile piece of technology allows doctors to scan a patient and instantly receive a complete diagnosis of their injury or illness.  

Though we don’t yet have tricorders, we have access to sophisticated information-gathering and diagnostic programs in our emergency department. And one of our most vital pieces of equipment is something many of us have in our pockets or purses: the smartphone. With access to the internet and dedicated medical apps wherever we are, we can spend more time with patients and less time searching books for medical information. These tools help us make specific medical recommendations for each patient.  

In my experience, patients appreciate that we double-check our recommendations with medical apps and additional research. It’s comforting to them to know that there’s additional evidence supporting medical decisions besides an emergency-department doctor they’ve never met before telling them they’re OK or that they need additional treatment. 

Patients appreciate that we double-check our recommendations with medical apps and additional research. -Dr. Jeffrey Dubin via @MedStarWHC

The transition away from medical books

It’s simply not possible for doctors to memorize every piece of medical information needed to treat patients. That’s especially true in the emergency department, where we care for everything from cases of heart attacks,  trauma and burns and everything in between, as well as other conditions that just can’t wait for a doctor’s visit in the morning.

When I was doing my medical training, and for a number of years after that, every emergency department used to have reference books. These textbooks were there for doctors to refer to when they needed to refresh their memories on how to do a procedure or treat a condition. But nobody does that anymore.

The internet has replaced the old practice of reading pages of dense medical textbooks to find the snippets of information we need. Medical textbooks are available online, and they’re searchable, which saves us valuable time. Many e-book versions of medical textbooks include embedded videos that demonstrate procedures. Videos of many procedures are available online specifically for doctors’ reference.  

Powerful medical apps for smartphones

Our emergency department doctors spend less time finding information and more time treating patients thanks to mobile medical apps. We’ve incorporated some of these clinical decision-making tools into our electronic medical record to help us make patient care decisions.  

Mobile medical apps let emergency-department doctors spend less time finding information and more time treating patients. via @MedStarWHC

I don’t like cluttering my phone with screen after screen of medical apps. I tend to find one or two apps that do the jobs I need and stick with them. Two I use frequently are MDCalc and Epocrates.  

MDCalc

MDCalc provides a range of clinical decision-making tools that include calculators for determining patients’ risks for various conditions and rules for when to order diagnostic tests or provide treatments.

A good example of how I use MDCalc is when a patient comes in after a car accident. Cars are so well-built these days that they usually absorb all the forces from a typical fender-bender. Most people walk away with no significant injuries, but they may want to get X-rays to make sure nothing’s broken.

MDCalc has collected clinical decision rules from published research doctors for determining when someone who’s been in a car accident actually needs to have X-rays taken and when we shouldn’t to minimize the person’s radiation exposure. If I need to double-check these rules, it’s really easy. I just open the app, type in the rule I’m looking for and refer to it during the patient’s exam.  

Some other features of MDCalc that I use include:

  • A list of questions to determine if a person has a problem with drinking alcohol
  • Scoring systems for a person’s risk for stroke
  • Key identifiers that a patient may have appendicitis  

Epocrates

Epocrates is a database of medications and their safety information, including dosing, side effects and potential interactions with other medications. I can pull up a specific medication’s listing and walk the patient through its possible side effects.  

Epocrates also is useful for comparing a patient’s symptoms to their listed medications. I often have patients come in and tell me they feel dizzy or have an itchy rash, and sometimes those are side effects of a new medication or a possible interaction between two medications.  

We no longer have to refer just to textbooks from 10 or 15 years ago for clinical data. With smartphone apps built specifically for doctors, we can access the most accurate, up-to-date information to help us make accurate recommendations for our patients. These and other innovations will continue to improve the way emergency department doctors like me practice medicine and care for our patients. 

When to go to the emergency department for heart palpitations

Most people barely notice their hearts beating. And that’s natural. But any noticeable change in the heartbeat should be concerning. Heart palpitations can be a sign of a serious condition, but some heart palpitations are totally normal.

I describe the feeling of heart palpitations as the heart-pounding sensation you get after running up a flight of stairs. But for people with heart palpitations, that feeling could just show up while they’re sitting on the couch.

What are heart palpitations?

A heart palpitation is the feeling of the heart racing or pounding. Heart palpitations may feel like the heart is:

  • Beating irregularly
  • Beating too quickly
  • Beating too strongly
  • Skipping beats

We see one or two patients per day who are complaining of these or similar symptoms. Patients sometimes tell me they can see their shirts move because their hearts are beating so hard.

Most heart palpitations aren’t dangerous. But they can be signs of several serious heart conditions. Get help if you feel heart palpitations that don’t go away quickly on their own. We’ll work to find what’s causing palpitations and refer you to additional care from a cardiologist if necessary.

"Get help if you feel heart #palpitations that don’t go away quickly on their own." via @MedStarWHC

What causes heart palpitations?

Older adults are more likely to have medical conditions that can increase their likelihood of having palpitations. But heart palpitations can show up in people of any age.

Some of the heart conditions that can cause heart palpitations include:

  • Cardiac arrhythmia (an irregular heartbeat), including atrial fibrillation (also known as A-fib) and atrial flutter
  • Supraventricular tachycardia (SVT)
  • Premature atrial complexes (PACs)
  • Premature ventricular complexes (PVCs)
  • Tachycardia

Other issues that can cause heart palpitations include: 

  • Being dehydrated
  • Caffeine, nicotine or alcohol
  • Certain medications, including decongestants or inhalers for asthma
  • Hormonal fluctuations in women who are menstruating, pregnant or about to enter menopause
  • Problems with electrolytes, including low potassium levels
  • Strong feelings of anxiety, fear or stress, including panic attacks

Overactive thyroid, also known as hyperthyroidism, can throw off the heart’s normal rhythm, causing palpitations. This type of thyroid disorder is treatable with medications to slow the heart rate and treat the overactive thyroid.

Heart palpitations and anxiety

Heart palpitations sometimes can be caused by extreme anxiety, rather than a heart condition. That might lead to a patient needing treatment for a possible anxiety disorder from a psychiatrist.

But we still have to make sure patients are checked out by a cardiologist for any possible heart problems first. We do have some patients who have been diagnosed before with anxiety and know that’s what’s happening. For the majority of patients, however, we don’t want to label their condition as an anxiety attack before knowing for sure that there isn’t a heart problem we need to address.

When to get help for heart palpitations

Most people’s hearts beat between 60 and 100 times per minute. If you’re sitting down and feeling calm, your heart shouldn’t beat more than about 100 times per minute. A heartbeat that’s faster than this, also called tachycardia, is a reason to come to the emergency department and get checked out. We often see patients whose hearts are beating 160 beats per minute or more. The body can’t sustain that for long periods of time.

You also should get checked out if you feel like your heart’s beating irregularly. The heart should beat steadily, like a metronome. If you feel like it’s pausing or skipping beats, that could be a sign of an abnormal heartbeat, which can increase the risk of a stroke.

"You should get checked out if you feel like your heart’s beating irregularly." via @MedStarWHC

If a patient comes into the emergency department while the palpitations are going on, we may be able to provide medications to slow the heart rate or convert an abnormal heart rhythm to a normal one. In extreme cases where medications aren’t enough, we may need to do a cardioversion. That’s when we shock the heart so it can reset itself to a normal rhythm. Patients are sedated during this procedure so they do not feel the electrical shock.  

Further testing for heart palpitations

In most cases, we see patients in the emergency department whose palpitations have either gone away or aren’t critical by the time they arrive. Like a car problem that clears up when you visit the mechanic, this can be frustrating for patients.  

We reassure them that just because we don’t see an abnormal heart rhythm now doesn’t mean that they didn’t have one before. We check for any signs of damage or injury, and we may monitor patients for a few hours at the emergency department to see if they have another episode of palpitions, but there may not be enough time to capture an abnormal heart rhythm that comes and goes.  

We often refer patients who have had heart palpitations to a cardiologist in the MedStar Heart & Vascular Institute. For example, we might diagnose an abnormal heart rhythm in the emergency department, but it’s not something that needs emergency treatment. Or we might not see evidence of an abnormal heart rhythm, but we think the patient could benefit from additional monitoring to rule out possible heart problems.  

A cardiologist can provide patients with special monitoring equipment to examine the heart’s rhythm. There are two main types of monitoring equipment. A Holter monitor will record the heart’s rhythm continuously for a defined time limit (often 24-48 hours), while an event recorder will only record briefly when a patient has symptoms of palpitations and presses a record button. If this testing shows evidence of a heart condition, our cardiologists work with patients to create an effective treatment plan.  

A normal heartbeat is easy to take for granted. So when we feel heart palpitations, it can be very scary. But with quick medical attention and advanced monitoring, your heart can beat steadily for a long time to come.