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Today we're going to be talking about wearables, your secret weapon to unlocking your wellness. So as far as disclaimers, I'm going to mention a lot of devices, some by name, but I don't receive any financial compensation from any company. And these are my opinions. So I want you all to think for a minute. How are you? And I'm going to ask you a series of questions that they think are helpful in thinking about our overall health. How many hours of sleep did you get last night? What percentage of your sleep was REM? What's your resting heart rate? What's your average heart rate variability? If you don't know the answer to any of these questions, that's totally fine. I didn't know them either about a year ago. But for the last year, I've been tracking a lot of that information with wearables. So we're going to talk about what is a wearable. And we're going to spend quite a bit of time in the presentation on heart rate variability, because I think this is the most important vital sign for emergency physicians and military physicians under high stress to be paying attention for yourself. We'll talk a little bit about patients. But really, this lecture is about your well being. And then we'll talk about how you can start to incorporate using a wearable in your life, but many of you are already using one. So how many people in the audience have a smartwatch on? Almost everybody. So you're all already using a wearable. So the technical definition is some type of device that you wear, that tracks some type of biometric data. So whether that's heart rate, the number of steps you take your respiratory rate. Now, most of us with a smartwatch, you can get your EKG tracing, it seems to keep going up and up the amount of information that we can get from these wearable devices. And yes, they said we talk a little bit about patients, how many of you have had a patient provide some information to you or have a question based on a wearable? Yeah. So when you look at the I don't know how many of you pulled any data about how good are these wearables? They're not bad. And I'll just go through one paper quickly. The New England Journal of Medicine, I looked at 400,000 Apple Watch users specifically around the question of atrial fibrillation. The prevalence of atrial fibrillation and the Apple Watch users was actually extremely low, less than 1%. Probably because most people that wear an Apple Watch are younger and healthier. So really low prevalence when they looked at the people that had a notification that they were in atrial fibrillation, and then sent them to get an EKG and I don't know exactly, they probably presented within 24 to 72 hours to get that EKG 35% More or less were in atrial fibrillation. When they went back and looked at the tracing that the Apple watch recorded up to 85%, around 85% had a tracing that reflected atrial fibrillation. So if your patient says that my watch notified me that I was in atrial fibrillation, there's a pretty good chance they were in afib. I also personally, I do find it helpful. You know, when you have that patient that says, I feel like my heart's racing. I was, you know, having palpitations during this period of time and they have a smartwatch on, I like to have them go ahead and pull up. Well, let's look what was your heart doing during that period. And especially for the people that have had multiple workups. And it's leaning towards anxiety, I start to introduce the concept of when you feel your heart racing, you can actually start to look at your watch, and maybe start to get some biofeedback, that I feel like my heart's racing, but my heart rates actually 65 I don't do that with everyone. It's usually somebody that's had a lot of work ups already. So heart rate variability. I think this is a really cool, vital sign. And we should really be thinking of it as the fifth vital sign, not the whole pain thing. Thankfully, that's gone. But it reflects our autonomic health. And I think our autonomic health is really important for physicians that are under a lot of stress, emergency medicine, military critical care, and heart rate variability is the only vital sign that also reflects our mental well, well being sensitive distress It also does improve with aerobic exercise, though. So it actually is a blended representation of several factors related to your health, probably why I think it's really cool. So people that have a lower heart rate variability than their age adjusted cohort, have increased risk of cardiovascular disease, depression, anxiety and PTSD. And this has been known in the literature for for like, 30 years, this isn't new at all. What is new is that we can really bring Heart Rate Variability monitoring, you know, to the individual. So quick review. So, you know, sympathetic response is our fight or flight. We spend a lot of time with our sympathetic response in the emergency department, we get a lot of surges, responding to emergencies responding to intense personalities, and parasympathetic response is our ability to calm down. You know, in our nervous system, our vagus nerve is the primary mover of the parasympathetic response. So if you look in, like the polyvagal literature, there's this term of how, how robust is your vagal brake, your ability to ramp up, and then pull yourself back down? So heart rate variability is kind of a way that you can start to track your ability to recover and have that robust parasympathetic response. So what about resting heart rate, resting heart rates, great. It's largely influenced, though, by just our overall fitness. And I'm sure we've all had the patient that has a resting heart rate in the upper 30s, maybe you have that time from being an intern getting woken up in the middle of the night, because the patient had a heart rate in the upper 30s. You know, are super well, you know, cardiovascular marathon ultra marathon people, they often have a super low resting heart rate. But then if you go and look at their heart rate variability, it might be terrible. So I think Heart Rate Variability provides a lot of information, and we'll get into it more about their ability to recover, which is also an important part of your overall well being. So again, resting heart rate doesn't give us that piece of information about your autonomic tone, and recovery. So how do we actually measure heart rate variability, so probably my least favorite thing and involves math. So we look at a lot of EKGs emergency physicians. Extreme heart rate variability is essentially if you're still in sinus rhythm is a sinus arrhythmia. You know, you see that sometimes on the top of the EKG, this is a sinus arrhythmia that's detecting that there's a lot of beat to beat variability well beyond, you know, if you go another layer down, and you do some math and look at the square root of the RTR interval, that is how you get heart rate variability. So there's a few different formulas out there. Different devices use different formulas. And if you really want to geek out on it, you can see what device is using what formula and what you think is the most accurate. So that's using an EKG tracing. And the research studies with heart rate, heart rate variability are largely based in lab data that involves EKGs. But none of us are walking around with EKG leads, right? I don't think you are, and you probably don't want to be. So how does your smartwatch measure your heart rate variability? Well, it uses light, it uses photo plus size monographie. So we might recognize that word from your anesthesia rotation. And remembering that the pulse ox machine uses light to transmit through a vascular bed and then there's a bunch of math and people good at physics will be able to explain how that creates, you know the pulse ox number, same idea but a little bit more complicated to create an EKG tracing. So you can probably imagine that if your your Apple Watch and maybe you're looking at your watch right now, you'll see that little green light flashing. That's how it's able to detect your EKG and your heart rate. But that's really susceptible to a lot of artifact. So that's where you start to lose the fidelity of the data compared to if you got an EKG tracing. But it's pretty good. And if you want to trap track this data you're going to use something that's feasible. So in the technology continues to improve so what should so if all of you pulled up your the data connected to your smartwatch right now and asked me if you had good heart rate variability, but you will only gave me a single data point, I wouldn't be able to tell you. So the thing that's weird about heart rate variability, and probably why we don't talk about it very much, is it's very individual. So there is a median, that's normal for age. And unfortunately, like most things, as we get older, our heart rate variability goes down. But you can kind of take, you know, look at this graph and be like, Okay, well, what's my age on the horizontal axis and go up. So you know, for me, pushing 40, my heart rate variability on the low end is 40, on the high end would be like 60 would be really good. But it's super individual. So again, I can't look at my heart rate variability on a single day in isolation, it really has to be compared to a trend, which can be hard for people to because now this is something you have to kind of watch over time. And again, the reason I think it's important is most of us are Type A personalities. And we don't like to slow down. And if you start tracking your heart rate variability, you start to see that, okay, maybe I'm been working a bunch of night shifts, and my heart rate variability is really bad right now. Or I'm training for a marathon. And I keep pushing, and I'm never getting a day where it bounces back up. That would be a red flag that you know, you need to kind of adjust and add in some more rest days. The other thing that's been fascinating about heart rate variability is it does detect or susceptible to changes related to actual illness. So I had COVID, in January. And the second arrow is the day I tested positive. And the day I got the test, I had the faintest scratch in my throat. It was so like light that I really thought that I was being a hypochondriac. But I was like, honestly, what made me go get the test, is my heart rate variability the day before had been such trash, like low 20s is really bad for me. It made me think that something was wrong, that I was probably sicker than I realized, then sure enough, I had COVID. The other thing I like about it is it takes maybe when I asked you earlier, how are you right now? You know, that's a very subjective question. And maybe some of us are better at tuning into how we actually feel versus how we want to feel. But I find that heart rate variability allows me to have a little bit more objective data when I'm going into a shift. So for example, I worked out in Twentynine Palms last year roll emergency medicine site, with the Marines, and I worked a 12 hour shift, like several in a row, and it was during daylight savings. So I work 6am to 6pm, went home or went to my hotel. And then I got one hour less of sleep, because it was spring forward. And so I woke up at like, 445 in the morning, and I'm like, Oh, this is terrible. Because I really felt like 345, right. And that's how I felt like I needed more coffee and like it's going to be a terrible day. Well, I looked at my score, my heart rate variability was on the high end for me, I only slept six hours, but I was 92% recovered. So as I was walking into my shift, and looking at this, I was like, hmm, perhaps my mindset is the problem, not really how I feel. It's how I'm thinking about how I feel. And I actually had a really good shift and a really good day, even though it was 12 hours long, because it really helps me kind of flip the narrative that I had developed about the day. So what are your options for devices? So there's a band device? And first of all, you might be saying, well, most of us just raised our hand and we have a smartwatch and you just told me that the heart rate variability is accessible. I'll show you a little bit more later. But yes, your smartwatch measures heart rate variability, but my understanding for the Apple Watch is it only checks it two to three times randomly throughout the day. So that's not very much information. And who knows when it's really checking that so I'm not sure if you can go in and change the settings to have it checked at specific times. But again, it's just not very much information, where devices like this band, and then there's a ring on the market. They're checking it more continuously. Some of how they're measuring heart rate variability is proprietary. But I have had conversations with some of the people that work for these companies. And they are measuring it more frequently, and probably more more fidelity than a smartwatch. But if you have nothing else, I think it's smartwatch is better than nothing. So what are the drawbacks to learning more about your biometrics? It's just more information, right? I think we're all in kind of like, information overload. And then there have been periods of time, actually interesting. So I co host on a podcast called the emergency mind. And the host is Dr. Dan Dorcas. And so he's really interested in performance under pressure. And he wears one of these devices. And I was asking him how his heart rate variability was during the the surge LA County in winter 2020 going to 2021. And he's like, I took it off. It was just so defeating to see how bad my recovery score was day after day that it was stressing me out. So and I've done that, after periods of time to that, it's like, my scores are just going to be really bad right now. And it's causing me anxiety. So I'm just not going to look for the next few days. Cost the devices that are kind of more for athletic performance that have like more, they're tracking your heart rate variability more frequently, are more expensive, or they get you on the back end. And it's very inexpensive to buy the device, but then there's a membership fee, which I personally, that really annoys me. So that's kind of the drawbacks to to these devices. And to give you a comparison of like, Okay, should I just use my smartwatch? Or do I want to upgrade to one of these band or ring devices, this is from the band device that I use. This was in February, so I was still recovering from COVID, my chips were actually really hard. My heart rate variability was bad. In the 30s. The Apple Watch set, it was a little bit higher. So for that same week, there was about a seven point difference. So this is what I think is really interesting. You know, we've How many of you have heard that it takes two days to recover from a night shift? Yeah, how many of you believe that? You know, so this is me the So Valentine's Day I worked the 13th overnight, I probably went to bed at eight in the morning, I guess I went to bed at 842. I slept for about three hours, my heart rate variability was 26. It's really bad for me. And then oh, the recovery score is proprietary calculation between your respiratory heart rate variability and sleep. So the following day, I slept more seven hours, got my heart rate variability up a few beats. But really, my recovery was more sleep related. And two days later, 96% 43. So that's closer to my norm. But this is helpful for me that it's not like, I give myself a pass to do nothing. For the two days after a night shift. That would be great. But that's not the world we live in. But I do try to plan when I look at the month coming up and I look at where my night shifts are. I am more deliberate about what type of activities am I doing for those two days following a night shift. And I really, honestly do try to avoid cognitively intense things. And if I am going to work out on those days, I tend to do less intense stuff like walking, swimming, just stuff that's more kind of in a recovery mode. So how do you boost your heart rate variability, some of this is very basic. Overtraining is bad for a lot of reasons, but it's also bad for your heart rate variability. Sleep is probably the most important thing. And then nutrition, but kind of the more detailed stuff. Alcohol really decreases your heart rate variability so and I can attest to this that if I wear my my band device when I'm here for a conference, it's trash is absolutely in the toilet. So I actually took it off today. I was like I'm wearing this dress, and I already know what my heart heart rate variability has been this weekend. cold water immersion. So this is super trendy. But there's actually data behind it that it does have some health benefits and specifically does help to increase your heart rate variability. And much to everyone's chagrin, in this room, night shifts are really bad for us circadian alignment is good for a lot of reasons. One of them being hurry variability. I'm sure many people in this audience know the the data on long term night shifts and increased cardiovascular risk dementia, all sorts of bad things. So the thing I like about wearables and specifically, heart rate variability, you can extrapolate it to other things like your resting heart rate, is, if you start tracking this information, it allows you to actually see objectively, beyond kind of the things a lot of us use, like the scale, if something's making a difference for you, personally, is, you know, there's always so much information coming at us like, oh, maybe I should start doing intermittent fasting, maybe I should be low carb, you know, maybe I should start doing high intensity interval training, well, you can actually start to track if that makes a difference for you. more individualized wellbeing. So this is an example of a tracking sheet that you could create, this has been adapted from a trainer that I've worked with, you can change this, I mean, the problem with this, and if you're type A, is you start to realize there's like a gajillion variables every day. I mean, most of us eat, kind of, we're not super regimented in what we eat. So you have to kind of play around with, you know, what are the big kind of blocks do you want to focus on. But if you do want to make a change, like maybe you're like, Well, I've been hearing a lot of people talk about this magnesium supplementation prior to sleep, so I'm going to do that. Now, what I can't tell you is should you track that for a week or two weeks, my gut for heart rate variability is probably one to two weeks to actually see if it's making a change. I will tell you, for me, my heart rate variability has gone up on average, about 10 points in the last three months. And I can't tell you that I've been working out or eating better, that just hasn't happened. The thing that changed is I've been meditating. And I use an app that tracks my meditation up to almost 600 minutes, and I'm doing it. Honestly, I'm probably at 99%. With, I think I missed one day in the last three months, maybe two. And I do it for 13 minutes, because that's what the data is suggesting is what we need to actually reap the benefits of meditation. And my heart rate variability has gone up the most, it's gone in a year. So I to a little bit of like me dying here. Meditation works, I think a lot of us resist it. But for nothing else, you know, we do know that heart rate variability is a pretty good predictor for a lot of bad things. If it's low, like cardiovascular disease, and it's pretty exciting to me, actually, that just sitting still, and doing nothing has made a huge impact on probably my overall health. Some of these apps and programs allow for built in tracking. So if you're like there's no way I'm going to take out a spiral notebook and, and track this by hand. For instance, the band device that I use, at the end of each actually in the morning, when I go to check my score for the previous day, it asked me about caffeine, the last time I had caffeine and how many servings previous day think it asks about alcohol and then allows for journaling. So you could type in, you know, whatever else you wanted to like I intermittent fast for 16 hours. And then it actually allows you to generate reports based on the variables that you're inputting. So you could get pretty sophisticated. And as we talked about, you know how long to track probably talk to someone smarter than me about like the fitness stuff. But it seems like most things probably one to two weeks when I'm really excited about is the potential to track heart rate variability in teams. So there's a company called arena labs that was founded by I believe it's two Navy SEALs, and for whatever reason, they have become really interested in health care team performance, and they have a lot of products, some of its curriculum around resiliency, but what they really want and what They're starting to move into is, again, how do we have data that any of the stuff that we're doing for wellness actually matters? If we put in a resiliency curriculum, does it actually change the way people are thinking if we do a meditation curriculum with a group of residents, does that actually benefit them? So they're looking at using heart rate variability, monitoring, to track wellness interventions across teams, so they d aggregate that data. So it's not being tied back to any one person. But then you could start to look at a health care system, that if you start to make changes, maybe maybe take the nursing schedule from 12 hours to eight, do you see an improvement in heart rate variability? Or maybe there was a toxic manager? That gets removed? Did everyone's heart rate variability go up? 10 points? I don't know. I think there's a lot of different exciting applications, of course, some risk involved. But I think it's pretty exciting. So what I'd like you to take away from today's lecture, is wearables have the ability to give you some objective information about your health. And heart rate variability, specifically, is the only vital sign that really gives you some pretty good information on your overall autonomic health. And this is an opportunity for you to start to really tailor your health and have an individualized look at what really helps you to keep living the best life you can as a person and emergency physician. So if you'd like to learn more, check out my website. And then we have a couple of podcasts on heart rate variability on the emergency mind, and I'm also on Twitter. Now open it up to any questions