Introduction

The explosive growth of medical applications for smartphones, launched by the  debut of the innovative Apple iTunes App store in 2008, promises to fundamentally change the physician’s tool set. While many specialties have always been heavily dependent on technology, such as radiology and cardiology, the ubiquity of these small, interconnected computers means that every physician will soon have access to a broad array of software and hardware to help them perform their daily work.

 

At iMedicalApps.com, we have been reviewing the most interesting medical apps on the market today as well as watching for trends in mobile medical technology. The most popular categories thus far have been clinical reference and utility apps.  Some of the largest download numbers have been for apps that provide drug and disease reference information, such as the encyclopedic Medscape app, or medical calculators.  

However, more targeted apps that are specialty specific are slowly coming on the market. Some early ones, not surprisingly, were reference and self-assessment apps for radiology. These include the popular Radiology 2.0: One Night in the ED, iRadiology and Radiopaedia apps. More substantively, mobile image viewing apps promise to liberate radiologists from their workstations, including the recently FDA approved Mobile MIM app for the iPad.

We are now seeing an increasing number of apps for surgeons coming to the app stores. Presently, this is primarily on the iOS platform although the popular ones will no doubt be coming to the Android platform. Below is a survey of notable apps currently available for surgeons.

In our next column, we will explore how mobile devices may fit into the armamentarium of the future surgeon. In particular, we explore the possibilities of augmented reality to enhance intraoperative surgical visualization and how sensors already built into existing mobile devices could provide ways to manipulate and measure data inside the operating room.

1. In The Office

SurgAware

Patients undergoing surgery are anxious and, even if they seem like they followed the preoperative counseling in the office, undoubtedly will have questions as soon as they leave. These two apps help patients navigate the informed consent process.

According to the developers of SurgAware, patients forget “70% of what is said in a doctor’s consulting room” within 24 hours. In order help them remember, SurgAware:

...puts all those risks into writing, in a format that can be emailed to anyone who needs to know. If you are a patient, you can either email the list to your doctor for discussion at your next appointment, or check to see that all topics have been covered. If you are a doctor or a nurse, you can use the list as a reference during the process of taking consent, email your patient, copy the email to yourself, and then have evidence of having disclosed the information.

 

 

 

 

 

 

 

Heart Surgery Risk

Coronary artery bypass grafting (CABG) is a commonly performed procedure. Despite the immense technical complexity, the risks to most patients are low. However, they are not the same for all patients. For patients to whom CABG has been recommended, HeartSurgeryRisk:

is designed to give patients and their families and friends an estimate of what the chances for complications or death are for a patient who is considering CABG surgery. The calculator is based on data from the Society of Thoracic Surgeons National Database© and the Online Risk Calculator©.

 

 

 

 

 

 

 

 

ShoulderDecide MD

One of the most challenging aspects of communicating surgery with patients is explaining anatomy. Whereas, the names of anatomical structures are the lingua franca of surgeons, they are almost uniformly foreign to patients. Therefore, many apps are available to help bridge this gap. One such series is available from OrcaMD  which makes patient counseling apps for orthopedics and plastic surgery. Some surgeons also use general anatomy apps, such as the well known Netter Flash Cards. According to the ShoulderDecide MD's developers:

The purpose of ShoulderDecide is to educate the non-medically trained patient about their shoulder problems. It aims to enhance understanding of common conditions of the shoulder area while answering in an informed, practical guide which conditions may require surgical treatment.

 

 

 

 

 

 

 

 

2. Surgery Planning

PreOpEval

Once the decision for surgery is made, then the real preparation work begins. For many patients, it is important to anticipate how their existing medical conditions could possibly complicate surgery and anesthesia. Preoperative testing could range from a basic history and physical all the way to invasive cardiac testing. In many surgeons’ offices, what constitutes adequate pre-surgical testing is based more on local tradition than evidence. According to the developers of PreOpEval, it helps guide testing:

... based upon the guidelines on this topic from the American College of Cardiology & American Heart Association of 2007 and 2009, the Institute for Clinical Systems Improvement of 2006, and the American College of Chest Physicians of 2008…

The app addresses such common questions as:- who needs bloodwork before surgery?- who needs an EKG or a CXR?- how do I handle patients on Warfarin, Aspirin, and Clopidogrel?- which patients are recommended to get perioperative B-blockers or statins?- which active cardiac conditions preclude surgery?- how long after MI should a patient wait before surgery?

 

 

 

 

 

 

 

 

iTraycer

For surgical sales reps, managing inventory of implants and trays can be challenging. Although not intended for direct use by surgeons, iTraycer is an interesting solution that helps these very mobile reps manage and locate their equipment by:

providing tracking and real-time tracing of medical trays, devices and implants, including lot numbers, part numbers, from manufacturer to patient.

 

 

 

 

 

 

 

 

3. Night Before

Zollinger

Reading up on tomorrow’s case is not just for residents, reviewing “old” texts often brings forth new appreciation even for practicing surgeons . Now, with the availability of major surgical textbooks in app format, these resources can be available anywhere. For general surgeons, the Zollinger series is a well known reference, covering almost every major abdominal procedure and hernia repairs. According to the the app publisher, the Zollinger apps:

...allow you to access step-by-step instructions and superb line drawings for numerous general surgical procedures. Many procedures also include fully-narrated, slideshow presentations outlining each step in the procedure, from Intro and Indications through Post-Operative Care.

 

 

 

 

 

 

 

 

Campbell's Orthopedics

For orthopedic surgeons, the most ubiquitous surgical technique text is undoubtedly Campbell’s Orthopedics. Now in its 10th edition and still going strong, it was one of the early textbooks to be adapted to app format. That also allowed multiple videos to be included, which contributes to the hefty 870Mb download. It does not include every procedure in the paper text but, according to the publisher,  the app format allows user to:

Navigate through 242 techniques and more than 1000 corresponding images with the flick of a finger

• View almost 20 high quality procedure videos

• Bookmark techniques for convenient reference

• Quickly locate any technique in the entire app using the comprehensive search index

 

 

 

 

 

 

 

 

Current Diagnosis and Treatment Surgery

For residents and students preparing for surgery and even for surgeons, this large volume contains information on diseases most likely to be treated surgically. According to the app publisher, it offers:

Wide-ranging coverage that encompasses general surgery and all the important subspecialties including otolaryngology, urology, gynecology, orthopedics, plastic and reconstructive surgery, and pediatrics •More than 600 informative photographs and illustrations •Detailed treatment algorithms

•Completely rewritten chapters on Wound Healing, Anesthesia, Otolaryngology/Head & Neck Surgery, The Heart, Neurosurgery, Gynecology, and Orthopedic[s]

 

 

 

 

 

 

 

 

AO Surgery Reference

For orthopedic surgeons involved in trauma care, the principles of operative fracture management developed by the “AO”of Switzerland remain the benchmark. Their fracture classification scheme and treatment algorithms have been disseminated throughout the globe. Now they are available in two free apps. The AO Surgery Reference, according to the publishers, recognizes this important fact about surgeons:

The idea behind this service is the realization that reference in daily clinical life is often difficult. Frequently, there is little time during a hospital day to consult books or journals, or even to perform a literature search in order to gather evidence for a decision. The AO Surgery Reference allows surgeons to access much of the body of surgical knowledge for reference purposes during their clinical work.

A second app, the Müller AO Classification of Fractures - Long Bones, makes the sometimes complicated AO fracture classification scheme approachable by converting it into a series of simple screens and touch controls.

 

 

 

 

 

 

 

 

4. Day of Surgery

Mobile MIM & OsiriX HD

In anticipation of an upcoming procedure, the surgeon often runs through the steps in her head. For procedures and specialties, which are dependent on cross sectional imaging, being able to review the CT or MRI is a very effective way to mentally prepare for surgery. Two robust iPad radiology viewing apps offer this ability without requiring a PC or radiology workstation, providing the surgeon has access to the “DICOM” imaging data, as is usually the case if the patient has brought a CD ROM from the imaging facility.

Mobile MIM allows DICOM data to be uploaded directly from a CD ROM to their secure cloud based service, after which the images can be viewed on an iPhone or iPad. This is a very convenient service that even allows studies to be easily shared among physicians. However, there are charges associated with uploading and viewing studies.

OsiriX HD requires a WiFi connection to OsiriX , a remarkable free & open-source Macintosh desktop DICOM reader application. It can also interface with a hospital DICOM server, if access is granted.

 

 

 

 

 

 

 

 

Safe Surgery

Before making incision, every surgeon should observe a pause to confirm with the OR team that the correct procedure is being performed on the correct side on the correct patient. The safety benefits of the pre-surgical checklist have been amply documented and are now part of a worldwide initiative by the World Health Organization to reduce surgical errors. The WHO checklist has now conveniently been placed in an app which prompts the user to verify each of the components of the checklist have been completed:

1. Sign In (Before induction of anaesthesia) With at least nurse and anaesthetist

2. Time Out (Before skin incision) With nurse, anaethetist and surgeon.

3. Sign Out (Before patient leaves operating room) With nurse, anaethetist and surgeon.

 

 

 

 

 

 

 

 

5. After Surgery

Surgical Logbook

Every surgeon needs to keep a log of his or her surgeries. For residents, this is required by the ACGME for program accreditation. Even beyond that, surgeons may have to document cases to apply for hospital privileges not to mention to follow their patients’ outcomes and conduct research. For those surgeons looking for simple, lightweight logging software, a few mobile applications are available.

Surgical Logbook, as per its description, provides:

* Customisable and simplified menus to allow practical logbook entry

* Description recall feature allows previously entered fields to be saved for future use

* Add operative or identifier photos to logbook entries

* Backup individual entries or the complete logbook via email in spreadsheet format.

* Logbook statistics filtered by procedure, surgeon or operative role

* Security Password feature to aid in keeping data confidential

 

 

 

 

 

 

 

 

Surgichart

The idea behind SurgiChart seems to be broader than replicating a paper logbook. It is intended to serve as a communication platform between the surgeon, office, implant representative, referring doctor and patient family. In addition to the iPhone and iPad app, there is also a web interface. The idea is to provide a common location where information about an upcoming case as well as intraoperative images and surgical findings can be loaded. The referring physician can get an immediate email at the conclusion of the procedure while images can be shared with family. According to the description, version 1.0 is intended only for spine surgery with other surgical specialties “coming soon.”

 

 

 

 

 

 

 

 

Conclusion

The flexibility and ubiquity of smartphones has made them a natural platform for app developers targeting surgeons - among the most mobile of physicians. In just two to three years, a panoply of options has already become available to serve the surgeon. But while this period of growth has been rapid, it will no doubt just be preparation for applications yet to be imagined.

We have become accustomed to entire planets being constructed by computer graphics and interactive games that sense players’ movements from across the room. Are these the avenues for future mobile devices to enhance surgical practice? In the next column, we will see explore a few such examples of “augmented reality” in surgery as well as clever applications for sensors in mobile devices that could be useful in the operating room.

 

Felasfa M. Wodajo, MD
Musculoskeletal Tumor Surgery
Senior editor, iMedicalApps.com
Assistant Professor, Orthopedic Surgery, VCU School of Medicine, Inova Campus
Assistant Professor, Orthopedic Surgery, Georgetown University Hospital

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