A key function of any mobile device is file management. For healthcare professionals, management of our electronic library of PDFs – journal articles, interesting talks, and so on – can be particularly painful.

This is especially true for our oncology and cardiology colleagues, for whom a new trial is released seemingly every day.

Every day, physicians, nurses, PA’s, and other healthcare professionals read and use PDFs on mobile devices for functions ranging from a quick literature review to inform clinical decisions to annotating notes during a lecture.

In the first part of this two part series, we looked at iBooks, Dropbox, iAnnotate, and Goodreader. Now in Part 2, we’ll look at Papers, Sente, and PDF Expert – and name our pick for best PDF management app for healthcare professionals.

PDF Expert

• iTunes:
• Price: $9.99

PDF Expert is very similar to GoodReader. It can also handle multiple file types and can import/export files from a wide range of online cloud storage locations. While it cannot boast the same breadth as GoodReader, it certainly covers all the major online storage providers such as Dropbox.

The user interface of PDF Expert is highly refined and ‘Apple-like,’ making managing and browsing PDFs easy and straightforward. There are advanced file management options including the ability to rename, move, copy and zip files. Files and folders can be synced over the air ensuring that all the files are always up-to-date.

PDF Expert has the best annotation functions out of all the apps noted here. Whilst the range of features is very similar to GoodReader (and thus not repeated here), their implementation is better and as a result it is quicker and easier to mark up PDFs using this app. There is a fantastic function where PDF pages can be moved around and extra pages can be added.

There are also functions that allow PDF forms to be filled in and signed on the go-useful when it is not possible to print or access a computer. This collection of features ensure that PDF Expert is as close to a full featured desktop PDF editor as can be.

Managing a medical literature library would certainly be possible with PDF Expert due to its ability to organize folders and files on-the-go. One sample folder structure that works particularly well is:

Year-Author-Journal-Article (See screenshots for sample)

Filing medical PDFs using this system will ensure that they will be easily found when required.

Summary:

PDF Expert offers a wide range of functionality and connectivity to manage collections of PDFs. This feature rich app allows extensive annotation options as well as an ability to move/add in pages. The ease of importing/exporting PDFs ensures that this app offers untold levels of functionality.

One point to note for both GoodReader and PDF Expert is that all the content is stored locally once it has been synced. This means that the iPad is not always reliant on internet connectivity which is an advantage. Both apps also offer a number of extra security options such as passcode locks.

The challenge of identifying and absorbing relevant medical literature will not abate anytime soon and the proliferation of services that purport to simplify or eliminate this problem for physicians is itself now becoming a distraction. The rapid adoption of web-enabled smart phones by physicians, such as the iPhone, is driving this dilemma from the theoretical realm directly to the bedside. The hope is that if relevant medical literature is immediately available at the point of care, physicians would be more inclined to use it.

At the same time, the mantra of practicing medicine that is evidence-based is ringing ever louder. Thus far, it seems to this reviewer that most physicians apply it most strenuously when criticizing other physicians’ decisions rather than applying it to their own practice. Nevertheless, large well-respected compilations like the Cochrane Abstracts are available and widely used.  They offer well constructed summaries of evidence-based diagnostic and treatment guidelines for thousands of pathologies.  It is into this nexus that the “Evidence Central” app enters.  This review will cover the features of this recently released medical application, which is technically “free” in the App Store, but requires a paid subscription of $79.95 in order to actually use.

Wiley-Blackwell, the venerable scientific publisher (“knowledge for generations” is their tagline) offers subscription web based access to the Cochrane database as well as other partially overlapping databases of clinical literature such as Evidence Based Medical Guidelines and Essential Evidence Plus. Unbound Medicine is a multi-platform mobile medical application developer. The two have partnered to port these databases into the Evidence Central App, available on the iPhone and Android devices.

Unbound Medicine has a long list of prominent electronic offerings including the Merck Manual (reviewed previously), the Oxford Handbook, and Harrison’s Manual.  The Evidence Central application is a mirror of a web portal to the three Wiley web databases mentioned above as well as partial web access to four well known journals, American Family Physician, Annals of Internal Medicine, JAMA and NEJM.

While the depth and breadth of information available through these databases is truly impressive, the application unfortunately also propagates the corresponding dilemma. Namely, it does not attempt to solve the problem of parallel entryways into the separate databases nor the multiplicity of similar sounding titles and topics.  It does not explain to the user how each database is different and, unlike the corresponding website, does not offer a global search across the databases.

What I liked about this app:

• The quality and breadth of the the abstracted information available in the three database families is impressive. Having it quickly available on your mobile device is a fundamental improvement from having one’s medical library taking up shelf space.
• The application is quite responsive as most of the content is apparently locally stored

What I didn’t like as much:

• There is no guidance available to the user as to where to search for information nor any ready description of the qualities of each database (to be fair, this information is hard to glean from the actual web databases themselves)
• There are some rough spots in the application’s user interface with the bottom navigation bar appearing and disappearing unpredictably, as well as the text search box

What I would like to see in future versions:

• A global search across the databases, akin to the website (perhaps this was omitted due to technical limitations of the platform)
• A more refined search experience, with more explicit guidance as to where to ask a particular question

(below picture is a screen clipping when using evidence central via your computer browser)

Conclusion:

The dilemma of the practicing physician basing complex decisions on incomplete information will undoubtedly remain inseparable in the future from the practice of medicine. However, closing the gap between available evidence based literature and the clinical question at hand is at least partially addressable with improving technology. In this case, Unbound Medicine’s “Evidence Central” assembles a highly potent collection of clinical evidence aimed directly at the practicing physician. Access to the Cochrane Abstracts alone might well justify the price of subscription.

However, what we are also seeing thus far with the first wave of clinically based applications is that more targeted products, e.g. Procedures Consult: Musculoskeletal, are more finely tuned to access via a hand held device.  This appears logical since it is significantly more difficult to synthesize thousands of pages of text and literature and have it instantly reborn on a mobile device, which is partially the huge task Evidence Central tries to accomplish.

In the future, it is inevitable that medical authors and publishers will start to primarily design for smaller form factors and this task will not be left solely to software developers. When this occurs, we should see a better translation of medical literature to mobile applications. Until then, we can certainly enjoy the wealth of knowledge that rich applications such as “Evidence Central” allow us to carry in our pockets.

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-Dr. Wodajo is a senior writer for iMedical Apps and we feel privileged to have him on board.  He brings an extensive clinical background to the medical app reviews. His blog can be found at http://www.orthoonc.com.

MedPage Today’s motto is, “Putting Breaking Medical News Into Practice”.  I’ve been a fan of the website, medpagetoday.com for a few years now because they provide great medical commentary in a short, concise manner.  I call it “high-yield” reading.  Their articles often highlight key papers from the New England Journal or other reputed journals.  Another reason I’m a fan is because of their partnership with the University of Pennsylvania School of Medicine to provide Continuing Medical Education(CME).  A partnership with a well respected academic institution definitely gives me greater respect for their articles.

All the content from their website has now been brought to the iPhone platform, and the app is free!  Although the application was released awhile back, it was recently updated with some nice additions.  In this review of the MedPage Today Mobile App I’ll cover how to best utilize the features this free application provides.

When you open up the application you’re asked to register, although you don’t need to provide any personal identifying information if you don’t want to, just your specialty and what type of topics you’re interested in.  In the settings menu you can change your specialty information and topics of interest.  You can also set up the twitter client you want to use if you plan on tweeting stories you read through the application.

Per your specialty and topics of interest, you’re shown different categories, such as Cardiovascular, Heme/Onc, etc.  After selecting a particular specialty, you’re presented with the latest related articles.  These articles deliver information through video, audio, or text.  Almost all the articles contain CME credit opportunities.  After reading, hearing, or viewing the information in an article, you can take a post test at the end to get CME credit.

What I liked:

• Ability to get CME credit in the palm of your hand
• You can tweet and e-mail the article your just read
• Once you load articles they are saved on your device and you can access them in “off-line” mode.
• One of my favorite categories is the default “Latest News” category.  Often this section correlates with the front page of MedPageToday.  It’s basically akin to CNN headlines made for healthcare providers
• Nice user interface
• Don’t need to register with username or password if you only want to read the articles

What I didn’t like so much:

I like to listen to the videos and audio when I have my iPhone hooked up to my car.  When the phone goes into sleep mode the audio and video stop, and the same thing happens when I click the hold button.  Hopefully this is a bug that will be worked out in the next edition.

What I’d like to see in future updates:

• more access to all the information on the website.  I find a lot of the commentary interesting, and instead of only one default category, “latest news”, it would be nice to add more specific categories of news and commentary.
• When you want to take the post test for CME credit you are linked to safari.  It would be nice to have the ability to take the test within the application.
• Ability to Bookmark your favorite articles
• Ability to share articles via Facebook.

Conclusion:

The ability to attain CME credits from the palm of your hand is definitely a huge service this application provides, but I feel the ability to get current medical news is just as beneficial.  Even if you aren’t interested in getting CME credits, the CME articles are extremely informative and concise. You can read and listen to them on the go in order to stay up to date with hot button topics related to medicine.  The app is useful for not only providers, but medical students and residents as well and would definitely be helpful in the wards when getting grilled by attendings on updated medical guidelines.

In the future, I’d love to see this application expand even more to include all the rich content included on the MedPage Today website, but overall, this is a great medical application and a must have for healthcare providers and students.

Also, MedPage Today has another app, CME store[iTunes Link], that bundles together CME articles related specifically to your specialty.  We’re working on a review of this app and will release it soon.

[itunes]

[website]

Update:

There actually is a save/bookmark button, contrary to what I said above.  My apologies on the oversight and thanks to the MedPage Today team for catching this.

A new radiology learning tool was just released in the App Store, the iRadiology App.  This app has a catalog of over 500 radiology cases designed to help medical students and residents improve their plain film,CT, and MRI reading skills.  The cases are derived from Dr. Gillian Lieberman, who is the currently Director of Harvard Medical Student training and Associate Director of the Residency Program at Beth Israel Medical Center.  This legitimizes the content of the application.  In this review we’ll discuss the application further and also show you how to turn on the “Zoom” feature built into the iPhone that will enable you to improve the utility of this medical app.

When you open up this application you are presented with the above screen.  With the search feature, you can search for various cases based on certain key words, such as cardiovascular, chest, or actual pathologies.  I didn’t find the Search function to be very helpful, but the topics section was great for navigating with the application.

Activating the “Zoom” feature on your iPhone:

Before writing about this application further, I’ll quickly show you how to turn on the native “Zoom” function of your iPhone.  While this app allows you to zoom into pictures,  you can’t zoom in as close as you’d like sometimes, but when you turn on the native “Zoom” function in your iPhone, you can get significantly closer, making these images even more useful.

Go to Settings, tap General, then Accessibility.  Once you tapped on Accessibility, tap Zoom, and slide the Zoom feature to the On position.  The instructions for how to use the extra Zoom feature are shown on the same page.  Make sure you know how to manipulate the “To change zoom” portion correctly.  Below is an example:

This feature will also be useful for other medical applications that require you to read detailed images.  Now back to iRadiology.  For the purpose of this review, I’ll select “Chest” from the Topics section, and then in the subcategory I’ll select Lungs.

Within the Lungs section there are further subcategories, showing the great diversity of cases this application possess.  I’ll select Sarcoidosis and go from there.

When you tap on Labels, you are presented with the above picture, revealing key areas of the image. 

If you have the Zoom feature turned on, as explained at the beginning, you can zoom in ridiculously close and get a better picture of these films.  I wasn’t able to include the pictures where I used the “Zoom” feature because the iPhone doesn’t take screen shots of these pictures.

When you tap on Findings, you are presented with further information about the radiology case at hand, in this case, sarcoidosis.  I found this section to include a great deal of high yield information that is often asked on the USMLE step 1 and step 2 exams.

What I liked:

• Great wealth of knowledge, over 500 radiology cases
• Labels section does a great job of showing the pathology of interest
• Great diversity in the cases present
• Legitimate source for the pictures and cases provided in the application
• Great explanations of the radiology pathology presented in the application
• It’s FREE

What I didn’t like so much:

• Zoom feature, using the traditional pinch motion, could be more robust, although the iPhone’s new native “Zoom” feature can be used
• Supports landscape mode, but the Findings section can only be viewed in vertical screen.

What I’d like to see in future updates:

• Quiz Mode
• Bookmarking of favorite cases to review
• Built in link to Wikipedia for more information about the radiologic case at hand

Conclusion:

We’ve reviewed other radiology related applications before, such as iAnatomy, and the Joslin Chest Atlas.  iAnatomy did a great job of providing cross sectional CT images for anatomy learning, but did not provide pictures of various disease pathologies.  Joslin’s Chest Atlas provided some great plain chest film images, but the amount of content is limited with less than 100 images.  The beauty with iRadiology is in the huge amount of content provided, with over 500 radiology cases, and these cases are high yield as well.  The majority of these cases are ones I’ve seen in the hospital or have learned about.  Oh by the way, this app included plain film x-rays, CT scans, AND MRIs.

This application has the full package and I’d definitely recommend it to medical students, residents, or any other health care providers who want to improve their radiology reading skills.  With the price tag of “free” this app is a no brainer to download.

[itunes]

[website]

This app is 137 mb, so make sure you’re connected to a dedicated WiFi connection when downloading.

Also, special thanks to one of our readers in Taiwan for alerting us of this application.  Remember, many of our post ideas come from you, our readers.

To our readers:

We will be providing commentary and short reviews to medpagetoday.com two or three times a month.  We feel honored to be included in their short list of talented and well respected bloggers.  The following is a little clip from our first post titled, Optimizing Your Medical Practice Experience with the iPod Touch. Rest assured, we’ll keep the frequency of our posts and reviews the same on our site.

There has been a great deal of commentary profiling medical applications that are useful for healthcare providers. However, there hasn’t been much talk about how mobile medical applications can enhance the doctor-patient experience and in turn, help optimize your practice’s overall experience. In future posts, we’ll focus more on applications for medical providers, but this post will discuss applications centered around the physician-patient relationship.   

 

We all know how busy clinic can be, and this leads to increased waiting times for patients.   Understandably, patients often complain that this is the most frustrating time for them, and none of us likes walking in excessively late on an angry patient because we had to deal with another patient’s medical emergency. So how can this downtime be made more bearable and productive at the same time? 

 

Here is where the iPod Touch comes in.  It runs basically the same operating system as the iPhone, and the applications I’ll discuss work for both devices. 

 

During a patient’s waiting time in the waiting room or exam room, you could give them an iPod Touch with some of the following applications pre-loaded. 

FDA Drugs is an iPhone application that functions as a mobile drug database. The user selects a drug and the application exposes brand and generic equivalent drug information, with the added twist of being able to display the actual FDA approval document.

The name is unfortunate as it implies that the application was developed by the FDA, which it is not. Rather, the developers draw on publicly available FDA data stores to display the label information for thousands of FDA approved prescription and over-the-counter drugs. When the label information is not stored inside the application, it displays a NIH website (“Daily Med”) where the user can search for FDA label information.

While seeing the original FDA document is of some satisfying curiosity, what is not immediately apparent to this reviewer is the additional benefit this application provides compared to other, more mature drug database applications, such as Epocrates or Medscape.

What I liked about this app:

• the ability search by active ingredient to find equivalent brand and generic drugs is nice

What I did not like about this app:

• there are some user interface quirks which are confusing, for example the “Legend” tab does not seem to do anything except simply redirect to the other 3 application tabs
• the large icons in the “Drug” view are distracting, more so since clicking on the majority of them results in no action
• for drugs where there is no stored labeling information, the application  simply opens to the home page of the website “DailyMed” after which the user has to again enter the drug name

What I would like to see in future versions:

• bug and UI fixes

Conclusion:

While the ability to quickly look up information on prescription and over-the-counter medications is of great utility for physicians, other mobile applications provide a richer interface to publicly available information  when compared to FDA drugs. For example, ePocrates not only provides prescribing information and drug interactions, but goes as far as providing the ability to identify a drug by the shape and color of the pill. These are very useful features for a prescribing physician. Thus, it would seem to this physician that the availability of a publicly available database led to the creation of this application, rather than an identified real user need.

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Current Clinical Strategies Publishing recently sent us some free promo codes for this app, ECG Interpreter(you may have noticed) and we were thrilled by the last app we reviewed by them, ACLS Advisor.  So then naturally, we had high expectations for this medical app.  ECG Interpreter is relatively inexpensive at $1.99(current price), but with so many ECG apps out there we wanted to know if this app was on par with similar applications and if it met our high expectations.

When you open the app, you’re given a few options to choose from: Start Analysis, Calipers, Saved Results, and ECG Library.  I’d have to say, the real meat of the app are the Analysis and ECG library sections, but the virtual calipers are also ingenious (and I’d have to say, a lot easier to get through airport security than my other ones).

Analyzing:

The app does a fairly good job of walking you through a step-by-step method of reading ECGs.  It’s similar to how you first learned to read radiology images: if you follow the same steps every time, you decrease the probability of missing something.  The app walks you through analyzing the following (and in this order): rate, rhythm, axis, hypertrophy, conduction blocks, ischemia / injury / infraction, AV nodal blocks, and finally, miscellaneous syndromes (hyper and hypo-kalemia K, hyper and hypo-calcemia; and myocarditis / pericarditis), supraventricular arrhythmias, and finally ventricular tachycardias.  After you walk through all of these questionnaires, it finally summarizes all of your information, and allows you to save the analysis or send it via email.

In their App Store description, this app boasts that not only can it “evaluate the 12-lead ECG” but that it “provides a diagnosis and recommends treatment”.  Now, some may have a problem with the details of the treatments recommended (or the lack thereof).  For example, when setting the calipers for a HR of 55, the output simply reads “Diagnosis: Bradycardia. Treatment: atropine, pacemaker.”  To be fair, not all of the diagnoses are this brief and this app is obviously not a replacement for sound clinical judgment.  (I for one would be terrified if I woke up with an HR of 55 and found a team ready at my bedside ready to float a pacer!)  According to the developer, the app is based on sound medicine, powered by the ACCI Cardiology Decision Engine, and follows 2009 AHA / ACCF / HRS / WHO guidelines.

ECG Library

So this is the part of the app I thought I’d get the most out of.  Who couldn’t use a quick pocket reference of a variety of common and not so common 12-lead ECGs. Au contraire, using this is not as easy as it seems.  When you initially click on ECG library, you’re greeted with an endless list of rhythms to choose from.  However, clicking them basically takes you to a picture file that has a zoom capable image of an ECG with a typed explanation above it.  Sounds good in theory, but not really when you take a closer look at the examples.  Too often I found myself scrolling back and forth on the zoomed image to read the cramped text, and then scrolling back down the image to see what they were talking about.

From a user interface perspective, I’d like to be able to see the ECG and read the explanation text at the same time.  I know that’s hard to do on an iPhone screen, but other apps have taught ECGs better (see our review on Instant ECG).  This app gives out really great information, but I’m just not sure if I’d use it in this format, and I think other apps do a better job.

Another aspect not helping this app’s cause is the fact the screen orientations in every mode are locked.  The ECG list is always in portrait, and the ECG images are always in landscape.  Needless to say, if you use the app for any decent amount of time, you end up flipping back and forth too frequently.  Even though I can magnify the images and drag to whichever lead I want, it comes nowhere close to the ability to look at an actual full size EKG on paper.  Also, I would’ve liked the ECG library section of the app to do a better job with the content provided, it really only works as a a quick refresher reference since I already know what to be looking for.

Conclusion:

So who would benefit from this app?  Like our other ECG app reviews, medical students and residents, particularly those on cardiology rotations would probably benefit the most.  If you spend a long amount of time looking at various ECGs and need a reference to remind you of the zebras, it wouldn’t hurt to have this around.  Additionally, if you need help remembering the routine for reading ECGs, this app walks you through it in a straightforward fashion.  However, if you’re looking for a quizzing or teaching app, this may not cut it for you.  If it stays at the low price of $1.99, it would be hard to go wrong either way.

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Free medical applications for the iPhone are being released on a daily basis, but not all of them are useful.  This isn’t a surprise since they are after all free to download.  However, there are definitely some free medical applications worth downloading.

This will be a regular column on iMedicalApps.com, where we will periodically post commentary on recently released free medical apps that are actually useful from a physician, medical student, or any other healthcare providers’ perspective.

In this post I’ll focus on three free medical applications related to the following: clinical trials, Framingham scale, and a radiology teaching app.

STAT Framingham Heart Age

We all know how the Framingham scale is a crucial tool for primary care physicians when trying to calculate morbidity and mortality of cardiovascular risk factors for patients.  Although there are other medical calculator apps that provide this for free as well, such as MedCalc, this app is simple to use and does the job quicker. You’ll see advertisements on the second page of this app, but it doesn’t hinder the functionality at all.  This app is quick as well, enabling you to show patients how much of an effect certain risk factors have while you’re sitting next to them.

App Links: iTunes, Website

Drug Trials

I’ll go ahead and say this medical app is a must download if you use clinicaltrials.gov to pull information about drug trials for your patients.  This app actually deserves a more full review, one we’ll try to get out soon.  It’s packed with features such as eligibility criteria, e-mail out functionality, and even pulling up google maps on your phone to show the location of the trial! We’ve reviewed another similar type of app awhile back, Clinical Trials, and when it comes to searching for drug trials, this app is just as good or slightly better.  Unlike Clinical Trials($7.99) though, this one is free.

App Links: iTunes, Website

MSK Radiology Teaching File – LITE

This is the lite version of Radiopaedia.org’s Radiology Teaching Files: Volume 3, an app designed to teach radiology.  Although this is a lite version, I was surprised to find out how much information it packs, 10 full cases.  This lite version comes included with some relatively common pathologies and even though its free, you could definitely get some good learning accomplished if you’re a resident or a medical student.  There are other LITE versions of Radiopaedia.org’s content, and each of these files contains 10 cases also.  Usually I wouldn’t include a LITE version of an application in this list of free medical apps, but this app had plenty of content.

App Links: iTunes, Website

Note: At the time of this post these applications were free, this can obviously change over time.  If you’ve got some free medical apps you love to use, make sure to comment and let the community know.

The interpretation of ECGs is a difficult art to master for medical students and house officers alike. We are all taught to keep to the “Dubin method” and work through each 12-lead study with consistent patience no matter how abnormal the ECG initially appears. A particularly talented cardiologist once told me that ECG interpretation is often equal parts evidence based science, art, and gut feeling. So how is one to navigate the complexities of ECG interpretation without getting overwhelmed? Instant ECG, a well polished ECG interpretation and study guide by iAnesthesia LLC, is how.  Currently the app is on sale for $0.99 in the App Store.  I have used this application for 2 weeks (although not on a cardiology service), and so far am extremely pleased with the results.  I’ve also used the ECG guide, which was previously reviewed on this site.  In the the conclusion I’ll discuss my favored app.

Creating a useful ECG application is difficult. One can try to create a decision tree that takes user input and spits out the possible diagnosis. Unfortunately, this approach is prone to multiple errors and it prevents the user from learning while the program makes all the decisions. An alternative method is simply a digitally indexed textbook that may be inclusive of information, but lacks quick clinical utility on the floor of the hospital. Instant ECG is, in my opinion, the best attempt to create a successful hybrid of the two. Structurally the app is more of a learning reference, but there are several key features that make this ECG application much more than a study guide and solidifies its position as the “app to beat” for ECG interpretation.

What’s to Love:

Instant ECG is an excellent study guide. With the most complete set of rhythm descriptions and examples (at least 3 examples are given for each rhythm) of any of the ECG applications and accurate text to describe ECG pathology, this application is basically an easy to navigate Dubin’s ECG Guide for the iPhone or iPod touch. Descriptions in the ‘ECG Basics’ section contain advice for reading ECGs accurately and quickly and include appropriate images (such as the cardiac axis vectors and action potentials) to aid the text. I found it interesting and informative to skim this application for clinical reminders when reading an ECG and as an organized review to pass the time.

This application is also a good ECG interpretation tool. Granted, it will not do the job for you, but due to its well organized menus, the user can easily search for and compare the findings of an ECG with the text and multiple examples within the application. Each example ECG can be pinch-zoomed and explored using the iPhone interface well. Another useful feature of this application is the inclusion of movies to view the ECG findings as they are seen on telemetry rhythm strips on the hospital floor.  This feature is exceptionally useful in practice to determine the next course of action when an abnormal rhythm is seen prior to obtaining a 12-lead ECG.

Instant ECG has exams! Unlike most medical reference guides reviewed by the iMedicalApps team, Instant ECG can actually test your knowledge of the material it presents within the application. There are 144 questions (multiple choice, true/false, and rhythm strip identification) included in this ECG application. Instant ECG keeps track of your answers and progress through the questions, but be warned: many of the questions are not cupcakes.

I also enjoyed the small ‘Reference’ tab on the bottom menu that provides a quick reference for normal measurements on a 12-lead ECG and the images found in the application.

It is impossible to touch on everything this application correctly includes and performs well. It is presented cleanly and is easy to navigate with an interface that is consistent throughout all screens.

What’s to Dislike:

What Instant ECG presents is nearly perfect and leaves little to complain about. Additional images in the ‘ECG Basics’ section demonstrating close up images of the pathology described in the text could be very helpful, especially for students or house-staff on a cardiology rotation. In particular, I would have enjoyed seeing examples of T-wave changes in ischemia while reading the text without having to switch to the ‘Rhythm’ section and zooming in on an example.

A complete search feature should also be included within Instant ECG that includes the text of each section. When interpreting an ECG with the help of this application, the user has to navigate to each section to create a differential for a particular ECG finding.  The ability to search for a particular finding (i.e. regularly irregular rhythm) throughout the entire application would make interpretation with the aid of Instant ECG a bit easier. As it stands, the application is extremely easy to navigate even without this tool.

The previous version of Instant ECG crashed frequently when loading movies, but this issue seems to be resolved.  In its current state the application is quick and responsive.

The Bottom Line:

Every medical professional who ever has to handle or make clinical decisions based on an ECG, or who even possesses the slightest curiosity about the electrical conduction of our miraculous pump should purchase this application. At their current promotional price of $0.99 in the App Store, this application is a steal. In a few weeks, I used this application in the hospital many times and refreshed my knowledge of ECG pathology outside of the hospital as well.

The movies of ECG pathology seem on a rhythm strip are at first glance a waste of memory, but ultimately priceless.  The text is complete and easy to read and capable of making even the most clueless sound like a cardiology fellow.  It is highly recommended for any medical professional: for students and residents for education and patient care, as well as any hospitalist or primary care physician who needs a reference when reviewing an ECG on the floor. Cardiologists may even find it useful as a teaching tool.  Instant ECG is one of the best ECG applications currently in the App store and better than the ECG Guide app we previously reviewed.

Links to Instant ECG app: iTunes, Website

There are few moments in medicine where your immediate actions lead to a direct, life altering result for your patient. Obstructed airways and anaphylactic reactions come to mind, but neither of those occur as often as a code (“code blue”, and I’m not talking about when the cold activated indicator on your beer lets you know it’s ready to drink).

Back in medical school, before we entered the wards 3^rd year, our school made sure we were ACLS certified. I realized how lucky I was that my school taught such a rigorous ACLS course when I was doing an away rotation at another medical school and students were complaining about their lack of ACLS training. Enter the “ACLS Advisor – Advanced Cardiovascular Life Support” App (currently $5.99 in the App Store) from Current Clinical Strategies Publishing.  This review will cover how this well organized and easy to use application walks you though various ACLS algorithms and then some.

When you open the app, you’re greeted by a brief welcome screen followed by a menu to choose the situation you need help with. These include the fundamentals of any ACLS course such as pulseless ventricular tachycardia, ventricular fibrillation, pulseless electrical activity (PEA), and symptomatic and asymptomatic tachycardia and bradycardia. Additionally, the application includes extra information outside the scope of ACLS, including treatment algorithms for asthma, stroke, electrolyte abnormalities, and a toxicology section as well as anaphylactic reactions.

One of my biggest pet peeves are applications that lack an intuitive navigation experience. Even if an application has all the information in the world, if the information is difficult to access I won’t end up using it. When you’re running form patient to patient, precious seconds add up, and I don’t want to waste time trying to find my way around an app.

Well, when it comes to navigation, this app hits a home run. Every screen (except for the home menu) has a “back” button at the top left, as well as a “home” button on the top right, so you always know how to get back to where you were. Additionally, the algorithms are very easy to navigate through. Let’s take pulseless V. tach for example. From the home screen, you select the “pulseless arrest, VT, VF” button. After telling you to begin compressions it then asks if the patient is in a shockable rhythm or not. In the heat of the moment, say you suddenly forgot which rhythms are shockable. Again, it walks you though, asking if it’s pulseless VF or VT, or PEA.

Another example, say you don’t remember what ventricular fibrillation looks like. Just click on the link, and it shows you a sample rhythm strip of V. fib. Really, it couldn’t get much easier; this is how an app should be built, and it’s just as straight forward and easy to use for other situations (bradycardia, ACS, asthma, etc).

What would I change?

Not much honestly, if you’ve been reading above, you could have probably guessed my answer. However, I would like the option to adjust the size of the font. This would be especially crucial when I’m reading medication dosages. It would really be helpful to have the ability to zoom in or just increase the size (I would hate to misread a mcg vs and mg, etc). This would be good not only for the regular screens, but also for the algorithm diagrams that are included. Additionally, on every screen, an EKG animation continues to scroll by at the top. I wish I had the option to turn that off. They do give you the ability to turn on or off the “splash screen” that greets you before the main menu pops up, but again, font size and the pesky animation are about it.

What does this app do great?

Again, if you’ve been reading above you’d know my answer already. In fact, I can’t wait to check out some of the other apps this developer already has in the App Store. What I was especially thankful to have in the application was an easy to navigate user interface (including back and home buttons) and I appreciated that they also included diagrams of the actual algorithms (accessible from the bottom left button at the main menu). The app is well polished and doesn’t look like someone just copied an ACLS card and made an app. It shows a plethora of additional information, such as sections on asthma, tox, stroke and peds (yes, a pediatric basic life support section is included because “children are not just little adults!”).

Who would benefit from this app?

Besides the patient coding, anyone that takes care of patients, or anyone at the bedside during a code. This includes physicians, residents, medical students, NPs, PAs, RNs, ANAs, etc. Granted, it’d be hard to use the app while doing compressions, but it never hurts to have as much knowledge at the bedside during critical moments. I’m a minimalist, and I’d much rather have this app on my phone, than to have to search through my white coat pockets to find a wrinkled, folded ACLS card. This application also makes for a great study aid if you’re about to take an ACLS course. Just treat the app like a set of flashcards and quiz yourself.

As always, no application is a replacement for good clinical judgment, however it’s always good to have solid references available during critical times. Especially if you’re a clinician who doesn’t often have to deal with medical codes, this application would make a great asset. I’d buy it again, if it wasn’t already on my iPhone.

[itunes]

[website]

The Merck manual is a venerable encyclopedia of medicine that, over the last century, has passed through eighteen editions and attained the generous girth of over 3000 pages. It has such a breadth of scope that, if similar a book were proposed to a publisher today, it would be quickly dismissed as unrealistically ambitious and lacking a clear audience.

However, by encompassing so many clinical and related topics and by virtue of its consistent, tightly honed writing style, it has paradoxically become useful to a large range of readers, including doctors, lawyers and, more recently with its home edition, to lay readers.

Seeking to expand the audience even further, the publishers have now produced an iPhone version of this textbook, which this review will cover.

The Merck Manual Professional Edition is a pedestrian representation of the full text, but, it easily succeeds in making the immense amount of information easily accessible. And, for about half the price of the text (and, even better, a far smaller fraction of the weight), it is indeed a very useful addition to the iPhone medical library of most physicians and residents. Nevertheless, the manual is generally addressed to the clinician with limited knowledge of any given subject matter and should not be considered a substitute for specific subject-matter textbooks.

What I liked about this app:

• an enormous amount of diagnostic and therapeutic information in your pocket – pretty amazing
• a clear writing style that avoids excessive detail
• topics that extend into statistics, medico-legal and even medical economics
• hyperlinks within the text to other sections (with a back button to return) that aid comprehension
• a clean and unobtrusive user interface

What I did not like about this app:

• display of graphics and tables is occasionally awkward
• keyword searches only identify articles, not the specific section or words

What I would like to see in future versions:

• links for further reading on a topic and more images would be very helpful, although the absence probably reflects the original text
• a “physician’s” lay version where specific sections can be clipped and printed (with attribution) to give to patients would be a nice feature

Conclusion:

The Merck Manual Professional Edition iPhone app is a clean and efficient implementation of a time-tested medical encyclopedia. Many clinicians will no doubt feel that the relatively brief descriptions of complex medical conditions is at odds with their specialized, in-depth knowledge. Over time, of course, this easy confidence is little match for the real-world variety of patients that walk in the door. Perhaps this is why the manual has succeeded over so many generations. It will be interesting to observe how the Manual fares in this era of information super abundance.

[itunes]

[website]

Dr. Wodajo is a guest contributor to the medical app review team and we feel privileged to have him on board. He brings an extensive clinical background to the reviews. His blog can be found at http://www.orthoonc.com.

MD on Call is a medical app aimed at interns, residents, and 3rd/4th year medical students. It’s a great app geared to help you with those 4am calls you get from nurses and is also a great reference for patient care in general. We did a full review of this app a few days back and were definitely impressed. MD on Call is available for $5.99 in the App Store.

The app’s creator, Marc-Emile Plourde was gracious enough to give our readers ten promo codes along with an exclusive interview. This is the first interview we’ve done and we hope to make it a more constant thing. It’s always interesting to see the creative minds behind some of these great medical apps. A note to our readers, due to the popularity of the site, we’ll be re-launching with a new layout and a new name, iMedicalapps.com. This transition will most likely occur at the start of next week. We’ll give you more details later this week.

The promo codes will be given out on a first come basis. Continue on for the interview and the 10 promo codes.

Interview:

Marc-Emile Plourde is a second year resident in Kingston, Ontario and the creator of the medical app, MD on Call.

What was the inspiration of this application? How long did it take to develop this app, and what were the biggest challenges you faced?

Marc-Emile Plourde: When I started residency (no internship in Canada; it’s med school year 4 to R1), There were quite a few situations where I found myself wondering “there must be an easier way” i.e. the patient is in stable rapid aFib and NPO: you know you should start a BB, but which one? what is considered a “normal starting dose”? During the day, it’s easy to find those answers (either you ask a senior or you spend a few minutes on Up-to-Date), but at night, 1-you usually don’t have the time because you’re running all over the place 2-your senior is at home and you don’t want to wake him up to ask him about metoprolol for a stable patient 3-you’re way too tired to read through one or two Up-to-Date topics.

After a year of doing calls, I thought I could put some of the things I’ve learned into an app that could actually be useful to med students, interns and junior residents going through the same thing. I wanted it to be like having a more senior resident helping you out.

It took me over 5 months to design the app, to write the vignettes and to learn html so that I could “present” the information in the way I wanted: lots of thoughts have been put on spacing, colours, fonts… the goal was to make it useful at the bedside, not to turn a book or a website into an app…

Biggest challenges… I expected to do something way more basic than what the app ended up being. Also, small things, such as the list of the acronyms being used in the app and creating metadata for the search function all ended up taking a lot of time compared to its apparent usefulness. So I guess overall time ended up being the biggest challenge (However, I’ll point out that I didn’t do the coding for the app, one of my friend did — the guy that did the speed bones, muscle and angio series)

How do you see this application being used in the clinic and hospital setting?

Marc-Emile Plourde: The app is meant to be used, you guessed it, when on call. However, different sections can be used thought the day, especially when a patient deteriorates.

Who was the target audience you were going for in this application?

Marc-Emile Plourde: As mentioned before, senior med students, interns and junior residents. Even though a lot of people will “outgrow” the app during residency (and I kinda hope they will), I think it can still be a good one to keep on your iPhone for those rarer situations, or to have those ECG values everyone tends to forget nearby.

What are some updates our readers can expect in the future for this application?

Marc-Emile Plourde: We are working on adding support for landscape mode and a few additions to the vignettes. Also, version 1.0.1 recently added a quick link to the “management” section (by taping on the vignette’s heading) — it’ll save you a good 2 seconds of scrolling!!!

Are you developing any other apps we should be on the lookout for in the future? If so, can you at least give us a hint on what the app might be about?

Marc-Emile Plourde: Nothing for the near future: I’m trying to put residency higher on my priority list

MD on Call App Giveaway, promo codes:

Remember to leave a comment letting others know which promo code you used! In order to redeem the code on your iPhone or iPod touch, open up the App Store. Go to the “Featured” section icon in the lower left of the screen. Scroll down, and you’ll see a “Redeem” option. Also, I believe these codes are only redeemable in the U.S. app store.

1. PW6X3N6XE976

2. 6ETP33XT4A4L

3. MANTLLF6FHYW

4. WYTHJ7L4AKJA

5. R3MNWY6YXRJF

6. 64LREK6JXPW3

7. TP4AN76AT4EH

8. LH34FYR4376E

9. WK3JXANT7HRP

10. 66LH6W3L6MRM

Our full review of the application can be found here.

The iTunes link of the application can be here.

The developers website.

-iMedical Apps Team

Please note: We were not able to upload the comments from this original post from our old website.  Needless to say, all the promo codes were used up pretty quickly.

Its 3 AM and you are the new intern on call covering far more than your share of patients for multiple services. Your pager goes off. Mrs. Smith is seizing and Mr. Jones is vomiting large amounts of blood and is hypokalemic. What do you do?

MD on Call ($5.99) hopes to provide these answers. The app is developed by MDMarkee Publishing and is a new addition to the App Store. It is a simple application with sometimes basic but vital information, especially useful at those early morning call hours.  This review will focus on the information provided and my experience using this application while being on call.

What is it?

MD on Call is a simple repository of 17 typical, bread-and-butter issues that can arise on call, quick advice on how to evaluate the problems and quick management suggestions. The app also contains sections devoted to abnormal lab findings, ECG pathologies, and ‘hardware’ (discussing common problems with central lines, NG tubes, etc.).

The Good

From an ergonomic standpoint, the application is extremely easy to use. Each section is alphabetically organized and searchable by keyword (although the search feature does not handle synonyms or phrases well). The sections on ECG and laboratory findings are particularly complete for any acute abnormality that required immediate action.

If, for example, your patient is hypocalcemic, the application reminds you to double check the patient’s Phosphate and consider other confounding factors, tells you what physical exam findings are commonly seen, and ways to correct the serum Calcium based on the severity. The information is correct and mostly complete: striking a good balance with its easy to read bullet points without being too verbose.

The application states the obvious, but also assumes at least a respectable level of medical knowledge as well. In the above hypocalcemic example, the application states that Chvostek’s and Trousseau’s signs are traditional physical exam findings without wasting space stating how they can be elicited. In the management section, it provides sound medication and dosing advice as well.

My first reaction to the 17 issues discussed by the application was doubt. Only 17? Surely that could not cover the wide variety and sheer quantity of ‘On-call’ issues that can arise. Once I put this put this assumption to the test, however, it was clear that I was wrong. This application is only meant to be a guide for when a patient has an acute change in status; most calls are patient specific medication changes or order related and are not meant for an application such as this.

The Not So Good

As I stated before, the issues covered are ‘bread-and-butter.’ As a result, the application is not perpetually useful. Either you already know what to do when you receive a call, or you quickly learn how to handle the situation and cease to need the application for reference. House officers or residents with substantial experience will not find this application very useful.

I did note a few instances where the information provided by MD On Call was lacking, but these tended to be very specific and minor. For example, the discussion of ‘Fever’ did not include any advice for a patient who was neutropenic, and the app did not offer any advice when documenting a patient’s cause of death and instead focused on the interaction with family when pronouncing death.

A few minor complaints about the interface should be noted as well. The font is very small and can be hard on the eyes when viewing on the run or after long hours on call and the application does not support the iPhone’s position sensor and will not rotate (no landscape mode).

Conclusion

In the field with this application, the section dealing with abnormal lab values has proven to be the most useful while on call and is much faster than trying to locate or sift through dense Up-to-Date chapters or case files.

This is a simple application that contains accurate and concise information for students and new interns. Seasoned residents with more experience will not find a huge benefit with this app. However, if you have ever needed a quick reference to learn on the fly or been stumped by a late night call while cross-covering and you are willing to spend a few dollars to avoid that feeling, you should consider this app.

[itunes]

[website]

If one wanted to get an idea of the potential of the iPhone as a tool for bedside medical and surgical education, this application by Modality and Elsevier would be a good starting place to get inspired. While it seems obvious that a portable device with a great user interface, a sophisticated operating system and great multimedia features should be a shoe-in for portable medical education, what is equally true is that the critical ingredient remains great instructional content.

“Procedures Consult: Internal Medicine – Musculoskeletal” brings together a highly detailed review of orthopedic bedside procedures, such as aspiration of small and large joints, splint application and reduction of joint dislocations, with a well crafted user interface to create an application that will genuinely be useful for emergency room physicians and junior orthopedic residents.  This review will cover how this medical application for the iPhone and iPod Touch goes about teaching these procedures.

The content is derived from Elsevier’s Procedures Consult website, which is a curated video site describing over 270 procedures spanning several disciplines. (Please see the recent review of the companion application “Procedures Consult: Internal Medicine – General” on this website. The content for this application is derived mostly from the emergency medicine/musculoskeletal section. The information for each procedure consists of pre-procedure and post-procedure check lists as well as step-by-step instructions of the procedure itself, accompanied by references. In addition, one or more videos for each procedure is embedded into the app, available for immediate viewing. Surface landmarks are shown graphically as is a simplified 3 cut-away dimensional graphic of the relevant deep anatomy. Some procedures, such as shoulder reductions, are also accompanied by a representative radiographs of the problem.

What I liked about this app:

• the attention to the relevant surface and deep anatomy, as well as the indications for each procedure is very helpful
• videos are of high quality and are embedded directly in the application. (refer to other Procedures consult review for more details)
• the techniques themselves are well-described and, I believe, few practitioners will find much cause to quibble with the instructions

What I did not like about the app:

• not much really, perhaps the post procedure care is unrealistically detailed for the typical bedside interaction

What I’d like to see in future versions:

• the content for this application is aimed mostly at ED procedures, which is surely a good market, however a future application with a more orthopedic focus, including closed fracture management and even surgical procedures would certainly be appreciated

Conclusion:

While there has been a proliferation of medical instructional websites over the last five years, bringing that information to the bedside is more than just a convenience, it is a critical next step. Websites and mobile applications will not replace peer-reviewed scientific literature nor the principle of apprenticeship in medical training. However, I can easily imagine when all post-graduate trainees are routinely expected to refer to mobile applications such as this one before undertaking unfamiliar procedures. This will undoubtedly reduce errors and enhance the care of our patients.

Title of app: Procedures Consult: Internal Medicine – Muscloskeletal

[itunes]

[website]

Dr. Wodajo is a guest contributor to the medical app review team and we feel privileged to have him on board. He brings an extensive clinical background to the reviews. His blog can be found at http://www.orthoonc.com.