Practical Technology for The Technology Enhanced Scenario – and a Physiology Refresher (Part 1)
By SimGHOSTS Scott Crawford, MD CHSOS
Readership for these articles is split between those with a clinical/healthcare background and those with an interest in technology, and certainly these traits are not mutually exclusive. This blog will discuss the unique care aspects of both hospital-based and field medical conditions, and the utility of available devices to perform patient evaluation. The cases described will reflect experiences from a personal perspective and offer suggestions for real management and considerations for technical staging to train clinical reasoning and patient evaluation for these unique situations.
I work as an emergency medicine physician and provide training to residents and medical students in the same specialty. I love to share unique and challenging experiences through the magic of simulation to challenge the norm and develop the critical thinking abilities of my learners. What I will share below are some unique technology-based examples of innovative care that could be worked into a scenario design.
Figure 1- Apple Watch heart rate detection screen with elevated heart rate shown around
2 p.m. and
"I’m having palpitations”
Greeted one night by a young woman who appeared without significant medical disease complaining of palpitations, I was preparing to give a quick bit of reassurance and provide a limited medical evaluation. But upon discovering that she had been diagnosed with complete heart block (no transmission of electrical signals from the atrium to the ventricles of the heart) at a young age, and that she had an implanted pacemaker, the complaint became much more concerning. Palpitations in general are difficult to evaluate as they are frequently transient and, in many cases, never observed or reproduced. Although the symptom may portend troubling diagnoses such as atrial fibrillation, ventricular tachycardia, or thyroid disease (among many others), most commonly this symptom is without a concerning diagnosis. The management for low-risk patients is often referral for a Holter monitor (a medical device worn for 24 hours to monitor the electrical activity of the heart) to try and detect a recurrence.
While palpitations should be uncommon, or impossible, in a patient with complete heart block, the possibility must be evaluated. This patient happened to be wearing an Apple watch. A quick review of the recorded heart rate data showed the image above. This confirmed that at the time the patient reported the palpitations, she did very likely have an elevated heart rate in the range of 150 beats per minute (a normal heart rate is reported between 60 and 100 beats/min). This discovery brought several questions forward as the heart rate for this patient should be entirely controlled by the pacemaker and should not be allowed to reach a rate as fast as recorded. This simple discovery supported the need for immediate cardiology evaluation and pacemaker interrogation (downloading of data recorded by the implanted device via a local wireless connection using a special device from the pacemaker manufacturer).
Figure 2 - Screenshot of heart rate detection in Samsung Health app on a Samsung S10. This detection is performed using a bright light to illuminate the finger of the user when it is placed near a sensor on the back of the device.
This unique wearable-technology assisted assessment is not the first of its kind and may be an increasingly available option to evaluate recent cardiac events. Wearable heart rate monitors have been successfully used to identify arrhythmias and affect medical management by providing clinically relevant data about timing and onset of rapid heart rates, such as those caused by atrial fibrillation. Apple has also recently provided more detailed medical monitoring and reporting capabilities with the 5.1.2 watchOS released in December 2018 for the Apple Watch 4. This watch’s monitoring ability is reported to be 98.3% sensitive for the diagnosis A-fib. Devices made by manufacturers such as Fitbit, Garmin, Samsung, and Apple, among many others, can detect the heart rate of the wearer by using light emission and detection in the wrist. Similar technology is included in many smart phones either using the phone’s light or similar light-emitting diode and a special detector that will illuminate the finger of the user and allow detection of the heart rate by observation of the color pulsation of the illuminated capillary bed.
The next time your simulation program is planning a scenario where the patient complains of palpitations, consider integrating information provided by wearable technology. Use of the above image could help to spark some additional discussion about how to think through this complaint and make the scenario more relevant to current patient evaluations.
Coming next month: “I’m feeling weak” and “Is there a doctor on board?”