EMRA App

- Aloha. My name is Mark Baker and I'm an emergency medicine physician in the Hawaii. And we really do say that and I am excited to both learn and to bring to you some educational information, related to apps that are coming from EMRA. So, I'm also board certified in clinical informatics and I would put a plug in for if anybody is interested in kinda like secondary career. I think informatics is really cool. So, this is being brought to you from ACEP, from an education subcommittee that's part of the HIT Committee, Health, Innovation and Technology. And I think the goal of innovation and technology is to make it easier for us to bring good care to our patients. At least that's the way I like to think of it. So, we've got two speakers for this. I'll introduce both of them and start with Dan McConnell. He's an attending physician at Mount Sinai Hospital in Queens in New York City. He is a IT guy. He's worked with tech startup space before his residency. Has both his MD and his MBA degrees from Columbia University. And Sarah Spelsberg, who is going to describe the EMRA apps, is an emergency medicine resident at UNC Southeastern and before medical school she was a PA, has worked at Mayo Clinic, Dutch Harbor, Alaska, Sierra View Medical Center. And what I think is really cool, because I like outdoor stuff, she is the Expedition Medicine column editor for the Wilderness Medical Society and director of US operations and a podcast host for "World Extreme Medicine." And that sounds like a whole different webinar. So, Sarah was willing to research and describe the EMRA apps and so I'm looking forward to learning about them. Thank you.

- Thank you for that great introduction Mark. And thank you to Joseph and Daniel for joining as a host today on this webinar where we're going to review the EMRA apps. There are several different apps. There's one cohesive app called MobileEM. It's a free download. There's free content within it as well as in-app purchases. And it's a good way to navigate, between all of the individual apps from one app seamlessly. There's an all access pass as well. Or you can just do download individual apps, such as their antibiotic guide and their toxicology guide, their ortho guide. So, they're available as individual apps from anywhere from a $1.99 to less than $10 per year per app. Some of them are free and there is an all access pass that grants you access to all of their apps for less than $40 a year. And it's a really good bargain for what you get from it. So, navigating MobileEM, this is what it looks like when you just first downloaded the app. You're able to scroll through and see which apps you might want to purchase to get access to. As well as over in my library, you'll be able to see all of the apps that you have access to for free. And so I am gonna take a look at this antibiotic guide, because I think I could use some help with that on shift. And then I see the all access pass. So, I'm gonna go ahead and purchase the All Access Pass. So, we'll be able to look at all of the apps today.

- And Sarah is this available both on, because I see the, you're downloading it through the iPhone store, the app store. Is this available also on Android devices as well?

- Yes, it's available anywhere you would get your app. So, Apple and Android are both supported platforms. And now we have access to all of these different apps. So, their antibiotic guide, this is the most recent version was published in 2022. And it is available in both iOS and Android. And it encompasses everything you could want to look up that you might need to prescribe antibiotics for. And it's organized by system. So, if you're looking at it, you would be able to see, oh, pulmonary or skin and then you'd be able to look up different diseases within that. It also comes as a book that you can buy on Amazon or through the ASEP bookstore. But I find the app is a really easy way to navigate this and get the information that you need quickly. So, from MobileEM, I'm gonna navigate to the EMRA Antibiotic app and then I'm gonna look up pulmonary and from there I'm gonna look through and see, oh, my patient is an adult inpatient with community acquired pneumonia, or no, I wanna send them outpatient now, because we don't have any beds, so I'm going to prescribe an outpatient antibiotic and what would be my options there for that? And so the antibiotic guide is really simple. It walks you through the systems, it walks you through the most common disease processes and the most up-to-date antibiotics for those disease processes. And it also walks you through options for if someone is allergic to amoxicillin, so many people are, what's your next step? And so that's what I love best, about the EMRA antibiotic app. And Daniel, this is one of the apps that I think I would say I use almost every shift, just to be sure I'm doing what's best and most current for my patients.

- And how often are these apps updated? Like how do they, I mean, how often are they staying up to date with changing antibiotics and changing resistance patterns and whatnot?

- That is great question.

- I was just wondering the same and I just googled that very same question and the antibiotic guide gets updated every other year. I didn't ask about the others.

- And that makes sense. And so we're do we're due for an update this year?

- Yeah.

- [Daniel] Excellent.

- That's a great question. And so moving on, they have the EMRA Emergency EKG Guide and this is also updated routinely and it's the most high yield EKG, can't miss tips. It covers everything from Brugada syndrome to STEMI equivalents. And this also comes as a print book as well as an app that's supported by iOS and Android and navigating this. So, I'll open up my MobileEM app and I'll go into the EKG guide and I'll scroll down. You can look up pediatric EKG findings, conduction abnormalities, tachy, brady. I'm gonna look up hereditary syndromes of sudden death, because those are things that terrify me of course. So, let's look up Brugada syndrome. It shows you what some of your EKG patterns are gonna look like. Your V2 is gonna be significant if you're looking up hypertrophic cardiomyopathy, if you're looking up other T-wave abnormalities and what they mean. Hyperacute T-waves, flatten T-waves, let's look up Wellens syndrome. That's just something I feel like I don't see very often. I don't know enough about it, 'cause as all of us are, we're good at what we see the most. So, some of those things kind of scare me and it's really nice just to be just a quick look and say, "Hey, this doesn't look normal, "which one is it?" And when you've studied enough, you know enough that you can search through the EKGs and find, oh yeah, this just does look like Brugada syndrome or this does look like Wellens.

- So, it seems like it's also, not only a good on shift resource for when something maybe seems abnormal on it, but just looking at it very briefly, it looks like it's also just a great general review if you see something on shift to come back to it a little bit later, especially as you're work learning to work your way through EKG, this is just seems like a great reference to be able to then follow up on interesting things you've seen in the department.

- This is a fantastic point, because I use this to study because it's just, it's brief and who has time to, I don't have time to revisit every textbook I've ever read. I need my memory refreshed and this is just an excellent way to do that. So, I actually use EKG and tox actually pretty often as a study guide. And so moving on, they have a tox guide and so we all know we can call the poison control center and I've got them on speed dial and they're some of my best friends, but it's also nice just to be able to look it up, like what if someone was stung by a scorpion? What do I do with a snake bite? What do I need to be on the lookout for? What labs are they gonna wanna know that I ordered once I call them? And so, the tox guide is great, 'cause sometimes someone's rolling in and they're retching and oh he ate a mushroom. Oh well okay, while we're drawing blood, what what am I looking for? And so it's a very helpful reference for that. And this is also available as a print book as well as the app. And I think it just helps you like quick and effectively treat a tox patient and at least helps you guide you with what you wanna be ordering and what you wanna be looking for. So, let's look in the app. We'll click on the tox guide.

- I just took care of somebody with ciguatera poisoning. Dunno what-

- Oh, it's terrible. So, let's say my patient ate a mushroom. Yeah, ciguatera is in here and ciguatera is the gift that keeps on giving. So, it takes you through your diagnosis, what labs you wanna order, what tests you wanna order. Does this patient need an EKG and what is the immediate treatments, all it has a whole host of plants that you can go through. So, even just as a study guide on a plane, just flipping through, refreshing your memory, this is just an excellent guide and oh ciguatera, it's just the symptoms like last for, I've had patients who have been symptomatic for years.

- Yeah. I just I can just see how you build this into, I mean, how useful this can be. I even just think about sort of my own clinical practice, trained in New York and so we don't necessarily see a lot of these types of things and I've spent some time now out in South Dakota, entirely different environment in a rural hospital and that my training and where I practice as an attending, doesn't necessarily prepare me for all the things you're gonna kind of see when you're traveling out to a very different area. I mean, I can just see how this builds into like my own sort of workflow and to have that safety net, even if like a toxicologist is not available for a single room coverage EM physician.

- Yeah, absolutely. And what if you're doing a locums work in New Mexico and someone comes in with a scorpion maybe, it's a bark scorpion, maybe it's something else, out in California we have some weird creatures. I have seen and treated more snake bites in North Carolina than everywhere else, including Colorado. And so it's just, it's a regional thing and it's just such a helpful app. And I probably used it most honestly, because tox cases aren't necessarily a multiple times a day thing, but I use it to study a lot. And so the ortho guide this and not a lot has changed in fracture management. And so per the app, this was last published in 2019, but it is an on shift resource for what's the best way to splint different types of fractures, what's the best treatment, can they be weight bearing, how quick do they need to follow up? Is it an emergency surgery and what to look for? And again, they have the book and then they have the app and navigating the ortho app here. Just quick and I'm just doing quick run throughs of the apps, just so people can get an idea of what you can look for. So, it goes through all these different body parts, let's say fracture basics. How to describe a fracture. What if you're a first or second year intern and you haven't seen a lot of fractures and now you have to call a grumpy orthopedic surgery attending and you have to explain this fracture to them. So, even just something as simple as how do I describe the fracture to my attending? How do I describe the fracture to a specialist? It goes through that, it goes through other associated injuries to look for, like what nerves do you need to focus on testing, based on certain types of fractures and then what their disposition could be. And so I love this app, I love it for dermatomes. I love it for just a quick refresh on, oh how should I splint this? And myotomes, dermatomes, it is so helpful.

- And does this go along with the splinting guide? 'Cause I noticed that the splinting guide is listed as being free. This one is part of both the All Access has bundle, but then it's also, you can have it as a separate standalone app it looks like.

- Yes, the splinting guide can be a separate standalone app and then is incorporated into this app. And this is so much more obviously, so much more than this splinting app. But the ortho guide, especially like if you're an intern and you're starting out in the ER and you wanna make a good impression on the specialists and the attendings. I think this is a great app to have, because it helps you just organize your thoughts and get ready for how to present the injury and what to look for and say, oh, I checked the axillary nerve and it's intact, so we're okay or they have pulses and just knowing what to look for. And it's again, it's just like a quick clinical guide. And actually I have attendings who end up downloading this app, because they're like that's just really helpful information for things we don't see every day.

- I really like the comment related to being able to converse with your orthopedist in their language so that they think you know what you're talking about.

- Yes, they like you a lot better when you can organize your thoughts the way that they organize their thoughts. And so the pain management guide is interesting. They have both like a regional anesthesia guide and then they go into some more like, palliative care type pain modalities, also opioid alternatives and things to look out for and things that work best for certain conditions. And so we'll take a look at their pain management guide here. And so everything from chest pain to renal colic, like okay, abdominal pain, we probably see this 10 times a shift. Musculoskeletal pain, vasal occlusive crisis and it goes through how they would treat it, what different medications you could try, their discharge recommendations. They have a buprenorphine initiation guide. I think as I think some ERs are stepping into an initiation of buprenorphine from the ER for some of these people and there's an initiation guide for that as well. So, it has a lot of information, and migraines and headaches sometimes are complicated to try to help these people and it's just really nice to have have those recommendations there from the pain specialists themselves.

- Yeah, I think this is a great app, mostly because the editor in chief of this, Dave Chesky was one of my chief residents when I was a second year resident. So, one of the smartest people I've ever met. And so it's one of the few, it's one of the apps I am actually a little bit familiar with. I do really like how they kind of arrange it, based on also like special use cases. I think that that's something even as I'm a first year attending, I run into so many problems with, it's how do I manage this pain when the first line or the second line doesn't work? That intractable abdominal pain, we're gonna end up getting two or three patients with sickle cell, pregnant patients, patients who are older. These are all the things that I think that sometimes when you get to that third line medication, it can be hard to sort of help guide and talk the patient through on like what you're doing. And so I love how organized it is and how it takes you kind of through an algorithm and it can kind of make, it can do a little bit of the thinking for you, but it also kind of helps to add that extra tool into your arsenal for management. Because pain is something we see every single day and we have to be experts on this.

- Absolutely, a hundred percent. And I believe you, he's one of the smartest people you know, because it is so well written and there's really, I couldn't think of anything that I could have ever needed that wasn't in there. And I think it's forward thinking also, looking into the future for what we might be doing and what's coming down the pipe. So, I think that's an excellent app to have in your arsenal also, which is why every year I do the MobileEM and so I can just have all of it.

- It seems to me like it goes way beyond what I think of as pain management, which I think of as just managing chronic pain and it's assisting with evaluation of multiple causes of pain.

- It does and it just guides you for alternatives. Sometimes I think you get into this threat where you're like, okay, it's pain, give it IV Tylenol or give it Toradol or give it fentanyl and there's so many more alternatives out there that these people, these specialists use every day. And it's just nice to have a repository of agreed upon and data-proven plans. And then, I don't know about you all, but I feel sad and scared whenever kids come into the ER. Sick kids break my heart and I just never, I wanna do my best for them and I never wanted anything to go wrong with them. And kids are always, I think kids scare a lot of us, maybe more than they should, but I think it's just because they're so special. But, so this app is just the pediatric emergency fundamentals and navigating this app. And so this is a little more, it'll go through their disposition. I mean penetrating neck injuries, like dental trauma, all these awful things that we hope we never, ever, ever see. And fortunately we don't see it a lot. And I may have pulled in the wrong video there, that was not the pediatric video.

- Looked okay to me.

- I mean it, well, it basically takes you through all the different trauma and what you're looking for. All the emergencies that can happen with kids and how to manage their belly pain. They're not just small adults, a kid with a belly pain who we're worried about an APIE. If it's a the younger person, were not gonna wanna radiate them, they're gonna wanna do an ultrasound and if the white count's really high and the ultrasound's equivocal, then maybe then maybe we go to a CT and some of it's the stuff that everybody knows, but it's just nice to have that outline there for what we can do for the kids. And then the next app in the list on MobileEM is PressorDex. And this is the critical care medication guide. And I don't know about you all, but we end up, I'm sure we all do end up with patients who should be up in an ICU, but they're in the ER for 24 hours, maybe 36 hours sometimes. And even if it's just six hours, it's still really important that we have a good grasp on all of these medicines. And so for a new intern in the ER and even an experienced one, pulling up the PressorDex app and it has sedation, there we go.

- Does it give recommendations related to specific causes.

- It does. Yes, it does. So, here like I pulled up tumor lysis syndrome and it'll go through pearls, additional therapeutic options and considerations and what kind of medications you're gonna wanna be giving these patients. And it goes through a lot of critical care, like single dose pressors. Are you just trying to bump this person up a little bit? Does this person need to be on a drip? Are they having an acute ischemic stroke? And it goes through all these different disease processes and it just has an outline of what your decision process is there. And this is another study thing that I use is I'll use PressorDex and I scroll down to the pearls and I read the pearls for the different disease processes. So, as a resident, I'm just trying to have some repetition for myself.

- And how do you build it into your, oh sorry.

- Oh no, go ahead.

- How do you build it into your workflow? Where do you kind of see this, the use case for this when you're like in the critical care rooms? I think that's always something that, I mean as an attending kind of struggle with is like, when should I be referencing something, when do I go on my clinical gestalt? How do you sort of see this building into a workflow for a sick patient?

- I, for my workflow, I pull this one up when I'm back at the desk. I mean, in a really critical room we're doing ACLS, we're doing ATLS, we're doing like the emergency things that we're taught. But if somebody has a known diagnosis and I'm like, gosh, I haven't seen tumor lysis syndrome in a year and a half, I'll sit down at my desk and I'll put in the orders that I know that I want and then I open it up quick and I just scroll and make sure I'm not forgetting anything. And I use it as kind of like a backup decision tree to what I'm trying to accomplish. And so that's where I pull it into my workflow. And like the ortho and the tox guides and the EKGs, I do use this as a study guide, as a study aid. And so then this is what we all think, we think thought we were gonna be doing all the time I think is the trauma guide. But this is great and this is something that every first year emergency resident should be reading, before their first shift or get the app and scroll all through it, so you know what to expect in the trauma bay. You know how you can help and you know what everybody's looking for. And so the trauma guide is really cool, 'cause it really, it's a beginner's guide to the trauma bay and it can be a pretty overwhelming place. And so they have chest trauma, abdominal trauma, general trauma. And so a trauma overview preparation. Get your airway equipment ready, what do you need to have by the bedside, what are we looking for? And what's our decision tree here? Like we wanna check their airway first, we wanna check their breathing, we check their circulation and it walks them through like these are the things that you want to check and want to note in these trauma patients. And so open book pelvic fracture, how would you wanna treat that? And it's all different types of trauma and it has these a pulseless, even it has like the ACLS algorithms rhythms in there. And so for like the ortho app does, for somebody who doesn't see a lot of orthopedic trauma with even just having how to describe the fractures to the specialists. The trauma guide is like, this is what you need to know your first day, walking into this trauma bay and this is what you need to be looking through for. So, you can look like you somewhat know what you're doing on your first day.

- I like how it's organized, because it seems like it can be useful for both kind of the single coverage type physician or even the physician who's working as part of a team in conjunction with a trauma team. So, it seems to be organized in that manner as well.

- It does. And I think these apps actually would be very useful for people in remote areas. I worked out in the Ellucian Islands in Alaska for years and I did use a lot of the study guides back, I had the books, but I referenced them pretty frequently. But I like it how it's laid out, it's so easy. You open the app, you click on the sub app you want, you click on the body system and it's just, it's so easy and so quick to find what you're looking for and what you want to read about and know more about.

- Yeah, I mean I think that that's something that I struggle with, 'cause I trained in a very academic center, both at a public hospital and a private hospital, but both of them, well integrated surgical teams into the emergency department, they'd come down for trauma activations. You had a very organized team, starting from like multiple attendings and having gone out and practiced for the first time in a single coverage emergency department in rural South Dakota. The kid in me who trained in Manhattan, it was very different. These types of things, it was how do I get the information? Like how am I supposed to quickly reference things that I need to do? And especially with trauma, when you're kind of taken outta the environment you train in. Having these kind of quick references, seems like it's the kind of having that like tool in the back makes it super useful to be able to like get through these types of things. So, I could actually see myself using this quite often, even as an attending

- It does, it's an incredible reference and it's just helpful to just organize your thoughts. And I peruse this before because I have done single coverage where as a PA I was by myself. And so it was interesting to sort of be in that situation where I have to sort of figure out how to do all the things and then coming into where we don't have a lot of resources where I am actually, but for what we are, we have a lot of resources. We have excellent pharmacists, excellent respiratory therapy. And so it actually took me some getting used to know how to navigate within a system where I actually do have somebody there to help. And I love having that. But this app even still, and sometimes we have a warning, sometimes we have these are the injuries that are coming in. So, in that lull, your ETA's 12 minutes because of extrication. I make sure my airway equipment's ready, I make sure I have everything I need in suction set up and then I'll pull this up while I'm waiting, just to refresh myself for what I might be looking for.

- That's an excellent point. It seems like it's also useful for any kind of, especially if EMS is sending like an EKG or EMS is calling it about a sick medical patient, same kind of thing. It's a great point you made.

- Yeah, I was thinking about the same thing, related to wilderness. It'd be nice for like Wilderness first responders or those who've taken some Wilderness Medical Training to have an app on their phone that can help them get through difficult traumatic situation that they're not.

- I could not agree more Mark. I think that Wilderness medical providers would love this app because whether somebody gets bitten by a snake or bitten by something else or they have a fracture, I mean it's all right there in one app. It's very helpful. And then one of the free things, so these are some of the free things that they offer, which I think is is very kind of them that, transgender care is not something that everyone's familiar with. It's not something that everyone's comfortable with. They may not have grown up in a time where it was as prevalent as it is now. And I think it's important to be able to communicate with people on the level that they want to connect. And so this helps you, reading this guide kind of helps you with tips for how to address people and how to communicate with people and how to broach these, what might seem like it's a very personal question, but some of these are very important questions. And so the transgender care guide has a lot of information in it for how to best help these patients, 'cause because especially in some communities they can be kind of a vulnerable, it can be a vulnerable population. And so just understanding their terminology, the different definitions, their risk factors, how to best perform a history and physical. And I will say I actually had a patient ask me for a referral to an endocrinologist and I didn't understand why and I said, well, are you diabetic? Do you have PCOS? Why do you need an endocrinologist? And they'd just been in for like a sore throat or something. So, I did not realize that that patient was transgender and they needed to establish with an endocrinologist for their hormones. And so I like to think that I'm open-minded and kind, but I did not know that this patient had a transitioned gender, because they looked a hundred percent, like every other woman I've ever seen. And so just understanding their needs and the things that they might want or need to talk about I think is important. And then the urgent care guide, this is more of like an urgent care clinic resource. A lot of things that, chest pain comes into the urgent care, they're going to be loaded into an ambulance and sent to the ER. But there's a lot of things that come into urgent care where it's like, gosh, am I supposed to give this antibiotics or not? They've been sick for eight days and so just different things that might come into the urgent care, skin, soft tissue issues, a viral rash and it's just the less emergent, more urgent care options, even sort of low surface area burns. It talks about how to manage those, talks about how to manage skin abscesses and infections, endocrine issues. And so this is a great reference for somebody in an urgent care clinic for how to best treat these people.

- Yeah, I don't know about you but my own program, I think that urgent care was not something that was a huge part of my training. It was an area we could moonlight in, but wasn't necessarily an area that we, was kind of built into our training. And I think that this is a, I don't know if this is a similar experience at your own program.

- Well, we're kind of the one stop shop. Like we're in a trauma desert in North Carolina and by the South Carolina border. We're an hour and a half from Wilmington, an hour and a half from Raleigh, two and a half hours from Charlotte. And so we're it. And so they come to us for urgent care, they come to us for emergency care. And so there's definitely like a step down area where an APP will take, the fours and the fives and manage those. And so as physicians, we don't necessarily, you do see it because we we're just trying to take care of as many people as possible as quickly as possible. But maybe some of the more urgent care stuff, we don't see as much of. But we see a fair amount, because we're all they have.

- I guess my point was more when I first started working in urgent care, kind of taking me out of the emergency department, where I felt very comfortable with, 'cause it even in fast track, I always felt like I was, oh I can take that patient, I can upgrade them, I can send them to the main portion of the ER, I can send them into the critical care room. But just like taking me from that environment and putting me across the street or putting me at one of our urgent cares is down is like five blocks away and then south by another five blocks. And that just being that entire environment, it's different team. It's a different team that's used to different approaches to patient. I think that's an area that I think that a lot of residency programs, I think tend to struggle with is that, 'cause it is, we train in the emergency department, but this is an entire area of practice that we can get introduced to. And in many ways I fundamentally belief EM should own the urgent care subspecialty if you were to think about it that way.

- I agree and I think you're right and I think I'm in a unique situation, because I worked as APA and so I did that. I staffed, I worked in urgent cares, I worked in emergency departments, I did a lot of things, but like I come from a different background in that aspect of it that's a really interesting point. And I think you're a hundred percent correct.

- And do you think that this type of app, would be sort of useful? Is it only geared towards the emergency medicine physicians or do you think that there's some value case for people who staff urgent cares or can staff other areas, even if we those to be owned by the emergency department?

- I think absolutely. I think like there's a course called CALS that they offer in Alaska to try to help family medicine physicians and APPs who are stuck out in these remote areas and might be forced to do an emergency C-section, even though they've never had that training, like that we get in the ER. And so it kind of runs them through, like sort of the most common low hanging fruit, lifesaving things. And I think yes, I think APPs, I think family medicine, someone who runs their own family medicine practice who has a lot of walk-ins and has their patients call and say, I have a sore throat or I have a headache, or whatever complaint they have, the urgent care app would be helpful for family medicine as well as emergency medicine and urgent care, because some people do go to their, depending on the practice and their availability and how busy they are, they might work in a certain amount of urgent care patients a day in a family medicine practice. And I think they would benefit from this app also. And so the next one is the stop human trafficking. Like it's actually, it's the EMRA conversation toolkit. So, it encompasses both firearm safety as well as human trafficking. And so it gives you like a conversation toolkit, how to start the conversation, how to keep it professional and copacetic, checklist, red flags and like sample questions for sensitive conversations. And I struggle with that sometimes. Like how do I broach this without sounding like accusatory. So firearm safety, like risk factors. How do approach the conversation, like people can get very sensitive about their firearms and broaching the subject of firearm safety, especially in a home with children I think is really important. And I probably see gunshot wounds 90%, I don't know about your your training, but probably nine outta 10 shifts. Somebody shot somebody or somebody accidentally shot themselves. Guns are a big problem in our community.

- Wow.

- Yep.

- Hawaii, I see less than one a year.

- Oh God.

- Even in New York City is high.

- Yeah, I bet you see a lot. My first month of intern year, I saw every day. I saw one every day. July must be like a particular month that they like to do that more maybe for some reason. And then the human trafficking questions, like how do approach the conversation. One of my tricks is I give the, if I'm worried about his situation, I give the guy, I offer him a lot of drinks, hoping that eventually he'll have to go to the bathroom and then I can quick ask her questions and make sure she's safe if I'm not being successful gently getting her away. But just tricks for how to handle those difficult situations that we're all gonna face at some point in our career. And then EMRA airway, meds and equipment. So, this I think would be like a must have for, especially for any intern. And just quickly, it's a quick reference for age appropriate medications, dosages and the equipment that you might need for emergency airway management, because we don't always see a pediatric airway and we don't always see this and have this as a repository. So, back here RSI airway card, it just is the quick reference for the RSI card and then it has the different medicines and about the airway card and how to order a print. You can order a print version on Amazon but that's just a quick table of airway meds, airway equipment and different sizes, dosages for, and that's a good quick one. If I know something's coming in and someone says, oh, it's an 11-year-old drowning victim or it's a 9-year-old, I might quick look just to be a quick reference.

- Yeah, I mean I think that that's an excellent point and I think that kind of highlights where these apps are seem to be most useful. I think you made that point brilliantly. It's like when you have the time to prepare, this is like a very easy thing to be able to quickly scroll through and whatnot, 'cause I know that working in a community site. I'm always a little uncomfortable whenever I hear a respiratory distress patient, coming in who's a peds, and that's something that I know I'm gonna have to transfer out and how do I stabilize this patient? So, I mean this is, I really see the value in this and this not only like from a residency standpoint, but just as an attending.

- It is and just as a study guide, just a quick, the more we repeat things and quick reference ourselves, the better. And like I said, once the situation is stable, I'll sometimes I'll quick reference the a different app, depending on what the needs of the patient are and just make sure, and sometimes you're like, "Okay, yeah, we thought of everything good for us," but sometimes it's like, "oh no, we forgot that, let's add that." And so it it's just a really great backup tool and it's just a way that I think technology has become so efficient and well organized and my hat is off to all the people who put all their effort into building these apps, because they are so easy to use and so well organized and it really is a helpful tool. And that was-

- They were a lot.

- Yeah, there's the standalone apps, like the peds meds. Oh, the regional anesthesia. Oh, this one is one of my favorites. So, this is nerve blocks and procedural pain management guides. So, for example, I had a patient, I was by myself in a clinic and in a three hours flight from the nearest hospital and I had a patient with their foot had been crushed by a pneumatic door and they were in so much pain and we're giving 'em a little bit of pain medicine. It's nothing's working. And I looked it up and I did an ankle block and suddenly he just calmed down and everything was fine. We could ask him anything, he could talk. And the flight crew said he didn't need any more pain medicine the whole way to anchorage. And so just this for anyone who is standalone clinic working in a remote area, like what if you're out in your clinic and you have a patient that you really normally would ship and need to ship, but what other precludes it? I had to keep a massive plural effusion with me for five days because of a storm and no one could fly. And so it's just these things can happen and having access to something like this there, the value of this for sports physicians, for emergency medicine, urgent care, family medicine, especially remote and on their own as well as a study guide for residents is just invaluable. This is really one of my favorite apps and I'll walk you through it and sorry some of my screen videos are a little fast. I was trying to keep it efficient for people. And so lower extremities, it'll show you what you're blocking, what part of the body you're actually blocking, what part of the anatomy you're looking for, how you would start, how you would position them. There's videos built in, where you would position your ultrasound probe. I mean, and what you're seeing on the ultrasound probe, they could not have done better on this app. I don't know if you do ultrasound procedures much, especially in a standalone clinic, but this is just invaluable to me.

- Yeah, this is quite, I mean I think that like, kind of referencing back to the pain guide that we talked about is that I always get so nervous when I have a femur fracture patient and I'm giving heroic doses of pain medication, escalating to laud or fentanyl and that concern for respiratory depression, that it just gets higher and higher and higher. Especially 'cause a lot of our patients who come coming the hip fractures, an elderly patient right? Who you don't wanna be overly sedating with opioids, 'cause that that risk is just so there. I like how this just kind of takes you easily through and I love that having the videos. That's the thing I'm always the most scared about is that I can see it on like a screen right? And I can see a photo of what the nerve should look like, but I'm always so nervous about going off of a photo and I'm gonna be doing something I'm not necessarily the most familiar with.

- It has been so helpful and I love the blocks to help with the hip fracture. And that ankle block was life changing for us and for that patient. It's just very, very helpful and it makes it easy. Like you look at, sometimes you watch the video and I'm like, yes, but where should I have my probe that's, I need you to back up and show me where I put the probe, because I need to go back that far. But there it's very, very helpful and for a beginning, especially especially an intern who's interested in ultrasound and ultrasound guided procedures. This is a must have app. And here's just, so they have different, they have the peds trauma, but then they have the peds meds and so you go in and you can put in their weight and kilograms or pounds and then you can go through, oh I need to give this kid an antidote to a poisoning, say they had an organophosphate poisoning. What am I gonna use for my antidote and what dose do I give? I mean the peds meds app is awesome. It goes through what if they come in cardiac arrest, how to treat peds tachycardia. And but like the antidotes to the toxins is just, I thought that was brilliant. And then how to treat pediatric anaphylaxis, how to treat pediatric cardiac issues and asthma, as well as like other common oral meds and endocrine issues. So, that pediatric meds app is outstanding and I think in a standalone clinic where I don't know how often you saw peds coming in with different complaints. It's just really nice to, oh my kid ate a bunch of, or drank a bunch of grandpa's pills, what do I do? Like, it's just nice. We have poison control but in addition to tox, this is pediatric specific and it helps you dose the antidote, which I like.

- Cool.

- That's the last app guys, thank you so much for going through this with me and I do apologize that some of the videos were fast but I wanted to keep us moving.

- No need to apologize.

- Great, thank you so much.

- Yeah and so I would definitely thank both Sarah and Daniel for contributing and a big thank you to Joseph Kennedy at ACEP who helped put this together and to all of the members of the HIT Education Subcommittee. Hopefully you'll be enlightened by this and probably I will start using some of the apps.