| The Medical Palm Review June, 2003 (V4N6) - The Big Picture... Now that I have a new PDA with a good colour screen, I can finally put some graphic images in my pocket. But how?
...Is Worth a Thousand Words In previous issues, I have discussed getting reference and teaching text material onto a Palm PDA. I can whip them out whenever I need a refresher or for impromptu teaching sessions with students. It would be nice to have examples of cardiac arrhythmias, or photos of skin rashes as well. Over the past two years I experimented a bit with black and white (well, black and green) ECGs and sketches but found this unsatisfactory. Image resolution at 160 X 160 pixels was not able to convey much detail. Gray and black do little to make a skin rash photo intelligible. Also, the small screen forced one to make an ugly tradeoff: either shrink the image file to fit the screen or make the user scroll around to view different parts of the full size image. Enter my new Clié NZ90. A bright screen with brilliant colour and a resolution of 320 X 320 or 320 X 480 opens up new possibilities for graphic images. Newer model Palms (Tungsten and Zire series) have similar screen quality. And there is no shortage of software to display graphics on these colour PDAs. My Clié comes with several for photos (Clié album, Clié Viewer, PhotoStand) and one all-purpose file display program (Picsel Viewer) that can handle graphics or text files with embedded images.  If your PDA lacks such software, there are no end of freeware and commercial programs available. AcidImage and Fotogather are representative examples. Both programs can display full-screen 320x480 pixel images on my Clié. AcidImage can handle several file formats (JPG, GIF, and BMP) without converting to a special format for the Clié. Images can be loaded onto an accessory memory card straight from your PC. Fotogather requires a desktop conversion program before you can view the files on your PDA. Another viewer is HandStory which will handle web pages and text as well.
Some programs which are designed to display websites or text files on your Palm will convert images as well. Plucker and iSilo use a PC program to convert files. You can set the parameters for the conversion - image size, colour depth, and resolution. A separate program lets you view the files on the handheld. The nice thing about this approach is that you can use Microsoft Word or a Web page editor to create a document with pictures of, say, herpes rashes and attach notes about each photo. Once iSilo converts such a document, you will have a tidy little reference file with embedded images. Where do I get the images I use? I scan them from text books or copy them from websites. (Note: if you are planning to create materials for distribution, please respect copyright and obtain permission from the publisher before using other people's graphic materials. It wouldn't hurt to provide attribution of your sources either. Fortunately, copying for personal use is not illegal. Yet). For example, over the years I have been collecting ECG teaching cases from medical journals. I used to keep them in a manila folder, but now I scan them into my PC using a flatbed scanner. Before I bought my own machine, I would get this done at a copy shop. Now, after scanning the page(s) into computer files, I use IrfanView to crop the extraneous text, convert the format to JPG (uses less memory storage), and manipulate the image size and colours (reduces memory storage even more). IrfanView is hardly the only program that can perform these tasks but it is very good and it is free. You may prefer to use Adobe PhotoShop for photographs, or ACDSee or PaintShop Pro for image manipulation on a Windows PC. I incorporate the ECG scans into a large file, built like a website with Dreamweaver. I have an index with links to each case, which has an explanatory note attached. Copied onto a CD, the file makes an excellent tool to fill a few minutes when teaching medical students - I just need to pop it into a PC and run a web browser. That leaves just one problem to discuss - size. The newer PDAs with their high-res screens open up the possibility of not just more detail but also getting larger pix at low resolution onto the screen. Is it better to shrink a picture to fit on-screen, but sacrifice some clarity of detail? Or is it preferable to keep the image oversized, and let the user scroll around to appreciate different parts of it separately? I think the answer to that question lies in the content. For high resolution photos of subtle rashes, I prefer to not shrink the image. But for photos of a fractured limb with a deformity, I like to have the entire area of interest fit on one screen. In contrast, because we are used to looking at ECG tracings one lead at a time, they lend themselves very well to being scrolled. I shrink them by about 50% first unless important details are very subtle. Once again, the Sony Cliés with virtual Graffiti areas can display a larger rectangular images (320 X 480 pixels) than most other PDAs, which are restricted to a square region 320 X 320 pixels in size. Checking your images before HotSyncing is another job the Palm emulator can help with. Install the pictures and software you plan to use on your PC then test whether the size and organization of the images works for you. If you have a PDA with virtual Graffiti, there is a nice Sony Clié emulator with the appropriate virtual screen dimensions. The other aspect of size is storage memory. Bigger images with more colour and finer resolution need more space. They also take longer to load. If you are storing the files on a memory card, you can save precious main RAM but loading times are slightly increased. Newer, faster PDAs make the difference in load times almost imperceptible and save main RAM for executing programs. If your handheld makes it possible, you should use software that can take advantage of VFS memory cards. All things considered, I am quite enthusiastic about storing graphic images on my PDA and plan to make more use of it in future.
Let's All Go to The Movies
What about videos? If you want to show short video clips with newer colour Palms, it can be done. All the usual technical restrictions apply (eg. how much RAM storage have you got on your accessory memory card?) And all the same user considerations apply (eg. can the topic be appreciated on a small screen?). I have been known to hold my PDA under a student's nose for a few seconds to display an example of a rash, but I wouldn't want to stand there for a half hour while a talking head reviewed stroke protocols. You will need to convert existing video material for viewing on your PDA, as standard video CD or MP3 files are not compatible. This topic was aired in some detail in a recent article in The Computer Paper.
There are three software packages to help you: - TealMovie Encoder - TealPoint wants you to buy the Encoder software. To create a market, they are giving the handheld movie viewer for free. This works well for teachers who want to distribute the final product to many students.
- Kinoma Producer - also asks you to pay for the encoder program but offers a free viewer.
- Sony Image Converter only works for storage to, and playback from, Sony's memory stick media. The software comes free with their PDAs.
 With any of these packages, converting video is not simply a matter of pushing a button. Video and audio quality may be okay or there may be lots of noise and banding. Tinkering may get a settings mix that works but even then the results may be unsatisfactory. Other issues that you will need to evaluate include not just whether the video plays well on the small screen but also how many people will be viewing it at once (more than one or two and some will be unable to see the screen) and whether the software allows you to rotate the playback to take advantage of the virtual Graffiti zone on the screen for a "widescreen" mode.
Medical "Doc" of the Month ED Tracker is a standalone application for PDAs. What this means is that you use it on your handheld PC to help care for your patients, but there is no link to a central database of patients, or lab data. You can, however, export data to a spreadsheet or database on your desktop PC. The ability to export reports to memo pad is handy. When I am on duty I find that taking out a PDA, turning it on, firing up the application I want, making a notation about a patient, then putting it all away again is just too slow. Often, all I want is to jot down a quick note to myself to, say, look up a CT result in an hour. I can accomplish that more rapidly using a clip board and a piece of paper. For that reason, I found ED Tracker a bit cumbersome to use but it may be effective for some users. With customization, it could be used by housestaff physicians, nurses or paramedics. And you can't beat the price - it's free. The company also has a procedure log and some other software for sale. All worth a look.
Hack of the Month  Palm OS 5 doesn't support hacks, and that means my new Sony PDA doesn't either. As a result, this section is going to be more and more about what I do to replace the hacks that I used to employ on my late, lamented, Handera 330. One program I liked was MiddleCaps. This program made it easy to write capital letters using Graffiti. Recently, I have found a substitute for MiddleCaps. It's Capper which has several ways of helping you make upper case letters with Graffiti. Still in early release, Capper seems to have great potential for Graffiti duffers like me.
Medical Computing A recent article on TelehealthNet discusses how telemedicine as we know it will disappear (ie. become so pervasive it will become part of the background rather than an explicit activity). Things that will bring on this change include: - wireless mobile computers with enough bandwidth and storage to permit you to carry around videos, CTs and other imaging data
- videophone capability in your mobile computer to permit real-time consultation from the patient's bedside or surgical theatre with remote experts.
Coming soon: morning report with consultants who attend only "virtually". If you paste up a photo of yourself in front of the videophone camera, your boss won't even know you are asleep....
The founder of medical reference company Pepid recently wrote an article on the use of PDAs to reduce medical errors.
Finally, a team of researchers is using Palms to research hypoxia and cognitive impairment on Mount Everest. Read about it at InfoSync.
In Times to Come Next month will be our summer double issue. I should explain that the purpose of the double issue is to give me an excuse to take a vacation and not produce an August MPR. So there is no guarantee that it will actually be double the usual size. That point made, I will say that it also lets me include a variety of news items that don't merit a full article but seem worthwhile. Meanwhile, enjoy the summer weather.
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