June 21, 2022 • 28 mins
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Andrea Austin (00:14):
Today we're going to be talking about wearables,
your secret weapon to unlockingyour wellness. So as far as
disclaimers, I'm going tomention a lot of devices, some
by name, but I don't receive anyfinancial compensation from any
company. And these are myopinions.
So I want you all to think for aminute. How are you? And I'm
(00:37):
going to ask you a series ofquestions that they think are
helpful in thinking about ouroverall health. How many hours
of sleep did you get last night?
What percentage of your sleepwas REM? What's your resting
heart rate? What's your averageheart rate variability? If you
don't know the answer to any ofthese questions, that's totally
(01:02):
fine. I didn't know them eitherabout a year ago. But for the
last year, I've been tracking alot of that information with
wearables. So we're going totalk about what is a wearable.
And we're going to spend quite abit of time in the presentation
on heart rate variability,because I think this is the most
(01:23):
important vital sign foremergency physicians and
military physicians under highstress to be paying attention
for yourself. We'll talk alittle bit about patients. But
really, this lecture is aboutyour well being. And then we'll
talk about how you can start toincorporate using a wearable in
your life, but many of you arealready using one. So how many
people in the audience have asmartwatch on? Almost everybody.
(01:46):
So you're all already using awearable. So the technical
definition is some type ofdevice that you wear, that
tracks some type of biometricdata. So whether that's heart
rate, the number of steps youtake your respiratory rate. Now,
most of us with a smartwatch,you can get your EKG tracing, it
(02:10):
seems to keep going up and upthe amount of information that
we can get from these wearabledevices. And yes, they said we
talk a little bit aboutpatients, how many of you have
had a patient provide someinformation to you or have a
question based on a wearable?
Yeah. So when you look at the Idon't know how many of you
(02:32):
pulled any data about how goodare these wearables? They're not
bad. And I'll just go throughone paper quickly. The New
England Journal of Medicine, Ilooked at 400,000 Apple Watch
users specifically around thequestion of atrial fibrillation.
The prevalence of atrialfibrillation and the Apple Watch
users was actually extremelylow, less than 1%. Probably
(02:56):
because most people that wear anApple Watch are younger and
healthier. So really lowprevalence when they looked at
the people that had anotification that they were in
atrial fibrillation, and thensent them to get an EKG and I
don't know exactly, theyprobably presented within 24 to
(03:16):
72 hours to get that EKG 35%More or less were in atrial
fibrillation. When they wentback and looked at the tracing
that the Apple watch recorded upto 85%, around 85% had a tracing
that reflected atrialfibrillation. So if your patient
(03:36):
says that my watch notified methat I was in atrial
fibrillation, there's a prettygood chance they were in afib. I
also personally, I do find ithelpful. You know, when you have
that patient that says, I feellike my heart's racing. I was,
you know, having palpitationsduring this period of time and
they have a smartwatch on, Ilike to have them go ahead and
(03:59):
pull up. Well, let's look whatwas your heart doing during that
period. And especially for thepeople that have had multiple
workups. And it's leaningtowards anxiety, I start to
introduce the concept of whenyou feel your heart racing, you
can actually start to look atyour watch, and maybe start to
get some biofeedback, that Ifeel like my heart's racing, but
(04:20):
my heart rates actually 65 Idon't do that with everyone.
It's usually somebody that's hada lot of work ups already. So
heart rate variability. I thinkthis is a really cool, vital
sign. And we should really bethinking of it as the fifth
vital sign, not the whole painthing. Thankfully, that's gone.
But it reflects our autonomichealth. And I think our
(04:43):
autonomic health is reallyimportant for physicians that
are under a lot of stress,emergency medicine, military
critical care, and heart ratevariability is the only vital
sign that also reflects ourmental well, well being
sensitive distress It also doesimprove with aerobic exercise,
though. So it actually is ablended representation of
(05:07):
several factors related to yourhealth, probably why I think
it's really cool.
So people that have a lowerheart rate variability than
their age adjusted cohort, haveincreased risk of cardiovascular
disease, depression, anxiety andPTSD. And this has been known in
(05:27):
the literature for for like, 30years, this isn't new at all.
What is new is that we canreally bring Heart Rate
Variability monitoring, youknow, to the individual. So
quick review. So, you know,sympathetic response is our
fight or flight. We spend a lotof time with our sympathetic
(05:48):
response in the emergencydepartment, we get a lot of
surges, responding toemergencies responding to
intense personalities, andparasympathetic response is our
ability to calm down. You know,in our nervous system, our vagus
nerve is the primary mover ofthe parasympathetic response. So
if you look in, like thepolyvagal literature, there's
(06:12):
this term of how, how robust isyour vagal brake, your ability
to ramp up, and then pullyourself back down? So heart
rate variability is kind of away that you can start to track
your ability to recover and havethat robust parasympathetic
response. So what about restingheart rate, resting heart rates,
(06:36):
great. It's largely influenced,though, by just our overall
fitness. And I'm sure we've allhad the patient that has a
resting heart rate in the upper30s, maybe you have that time
from being an intern gettingwoken up in the middle of the
night, because the patient had aheart rate in the upper 30s. You
know, are super well, you know,cardiovascular marathon ultra
(06:58):
marathon people, they often havea super low resting heart rate.
But then if you go and look attheir heart rate variability, it
might be terrible. So I thinkHeart Rate Variability provides
a lot of information, and we'llget into it more about their
ability to recover, which isalso an important part of your
overall well being. So again,resting heart rate doesn't give
(07:20):
us that piece of informationabout your autonomic tone, and
recovery. So how do we actuallymeasure heart rate variability,
so probably my least favoritething and involves math. So we
look at a lot of EKGs emergencyphysicians. Extreme heart rate
variability is essentially ifyou're still in sinus rhythm is
(07:43):
a sinus arrhythmia. You know,you see that sometimes on the
top of the EKG, this is a sinusarrhythmia that's detecting that
there's a lot of beat to beatvariability well beyond, you
know, if you go another layerdown, and you do some math and
look at the square root of theRTR interval, that is how you
(08:03):
get heart rate variability. Sothere's a few different formulas
out there. Different devices usedifferent formulas. And if you
really want to geek out on it,you can see what device is using
what formula and what you thinkis the most accurate. So that's
using an EKG tracing. And theresearch studies with heart
(08:25):
rate, heart rate variability arelargely based in lab data that
involves EKGs. But none of usare walking around with EKG
leads, right? I don't think youare, and you probably don't want
to be. So how does yoursmartwatch measure your heart
rate variability? Well, it useslight, it uses photo plus size
(08:48):
monographie. So we mightrecognize that word from your
anesthesia rotation. Andremembering that the pulse ox
machine uses light to transmitthrough a vascular bed and then
there's a bunch of math andpeople good at physics will be
able to explain how thatcreates, you know the pulse ox
number, same idea but a littlebit more complicated to create
(09:09):
an EKG tracing. So you canprobably imagine that if your
your Apple Watch and maybeyou're looking at your watch
right now, you'll see thatlittle green light flashing.
That's how it's able to detectyour EKG and your heart rate.
But that's really susceptible toa lot of artifact. So that's
(09:31):
where you start to lose thefidelity of the data compared to
if you got an EKG tracing. Butit's pretty good. And if you
want to trap track this datayou're going to use something
that's feasible. So in thetechnology continues to improve
so what should so if all of youpulled up your the data
(09:53):
connected to your smartwatchright now and asked me if you
had good heart rate variability,but you will only gave me a
single data point, I wouldn't beable to tell you. So the thing
that's weird about heart ratevariability, and probably why we
don't talk about it very much,is it's very individual. So
there is a median, that's normalfor age. And unfortunately, like
(10:17):
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 myage on the horizontal axis and
go up. So you know, for me,pushing 40, my heart rate
variability on the low end is40, on the high end would be
like 60 would be really good.
But it's super individual. Soagain, I can't look at my heart
(10:43):
rate variability on a single dayin isolation, it really has to
be compared to a trend, whichcan be hard for people to
because now this is somethingyou have to kind of watch over
time. And again, the reason Ithink it's important is most of
us are Type A personalities. Andwe don't like to slow down. And
(11:07):
if you start tracking your heartrate variability, you start to
see that, okay, maybe I'm beenworking a bunch of night shifts,
and my heart rate variability isreally bad right now. Or I'm
training for a marathon. And Ikeep pushing, and I'm never
getting a day where it bouncesback up. That would be a red
(11:28):
flag that you know, you need tokind of adjust and add in some
more rest days. The other thingthat's been fascinating about
heart rate variability is itdoes detect or susceptible to
changes related to actualillness. So I had COVID, in
January. And the second arrow isthe day I tested positive. And
(11:57):
the day I got the test, I hadthe faintest scratch in my
throat. It was so like lightthat I really thought that I was
being a hypochondriac. But I waslike, honestly, what made me go
get the test, is my heart ratevariability the day before had
been such trash, like low 20s isreally bad for me. It made me
(12:18):
think that something was wrong,that I was probably sicker than
I realized, then sure enough, Ihad COVID. The other thing I
like about it is it takes maybewhen I asked you earlier, how
are you right now? You know,that's a very subjective
question. And maybe some of usare better at tuning into how we
(12:40):
actually feel versus how we wantto feel. But I find that heart
rate variability allows me tohave a little bit more objective
data when I'm going into ashift. So for example, I worked
out in Twentynine Palms lastyear roll emergency medicine
site, with the Marines, and Iworked a 12 hour shift, like
(13:04):
several in a row, and it wasduring daylight savings. So I
work 6am to 6pm, went home orwent to my hotel. And then I got
one hour less of sleep, becauseit was spring forward. And so I
woke up at like, 445 in themorning, and I'm like, Oh, this
is terrible. Because I reallyfelt like 345, right. And that's
(13:28):
how I felt like I needed morecoffee and like it's going to be
a terrible day. Well, I lookedat my score, my heart rate
variability was on the high endfor me, I only slept six hours,
but I was 92% recovered. So as Iwas walking into my shift, and
looking at this, I was like,hmm, perhaps my mindset is the
(13:50):
problem, not really how I feel.
It's how I'm thinking about howI feel. And I actually had a
really good shift and a reallygood day, even though it was 12
hours long, because it reallyhelps me kind of flip the
narrative that I had developedabout the day. So what are your
(14:12):
options for devices?
So there's a band device? Andfirst of all, you might be
saying, well, most of us justraised our hand and we have a
smartwatch and you just told methat the heart rate variability
is accessible. I'll show you alittle bit more later. But yes,
your smartwatch measures heartrate variability, but my
(14:34):
understanding for the AppleWatch is it only checks it two
to three times randomlythroughout the day. So that's
not very much information. Andwho knows when it's really
checking that so I'm not sure ifyou can go in and change the
settings to have it checked atspecific times. But again, it's
just not very much information,where devices like this band,
(14:58):
and then there's a ring on themarket. They're checking it more
continuously. Some of howthey're measuring heart rate
variability is proprietary. ButI have had conversations with
some of the people that work forthese companies. And they are
measuring it more frequently,and probably more more fidelity
(15:21):
than a smartwatch. But if youhave nothing else, I think it's
smartwatch is better thannothing. So what are the
drawbacks to learning more aboutyour biometrics? It's just more
information, right? I thinkwe're all in kind of like,
information overload. And thenthere have been periods of time,
(15:41):
actually interesting. So I cohost on a podcast called the
emergency mind. And the host isDr. Dan Dorcas. And so he's
really interested in performanceunder pressure. And he wears one
of these devices. And I wasasking him how his heart rate
variability was during the thesurge LA County in winter 2020
(16:07):
going to 2021. And he's like, Itook it off. It was just so
defeating to see how bad myrecovery score was day after day
that it was stressing me out. Soand I've done that, after
periods of time to that, it'slike, my scores are just going
to be really bad right now. Andit's causing me anxiety. So I'm
just not going to look for thenext few days. Cost the devices
(16:32):
that are kind of more forathletic performance that have
like more, they're tracking yourheart rate variability more
frequently, are more expensive,or they get you on the back end.
And it's very inexpensive to buythe device, but then there's a
membership fee, which Ipersonally, that really annoys
(16:53):
me. So that's kind of thedrawbacks to to these devices.
And to give you a comparison oflike, Okay, should I just use my
smartwatch? Or do I want toupgrade to one of these band or
ring devices, this is from theband device that I use. This was
in February, so I was stillrecovering from COVID, my chips
(17:16):
were actually really hard. Myheart rate variability was bad.
In the 30s. The Apple Watch set,it was a little bit higher. So
for that same week, there wasabout a seven point difference.
So this is what I think isreally interesting. You know,
(17:36):
we've How many of you have heardthat it takes two days to
recover from a night shift?
Yeah, how many of you believethat? You know, so this is me
the So Valentine's Day I workedthe 13th overnight, I probably
went to bed at eight in themorning, I guess I went to bed
(17:56):
at 842. I slept for about threehours, my heart rate variability
was 26. It's really bad for me.
And then oh, the recovery scoreis proprietary calculation
between your respiratory heartrate variability and sleep. So
(18:17):
the following day, I slept moreseven hours, got my heart rate
variability up a few beats. Butreally, my recovery was more
sleep related. And two dayslater, 96% 43. So that's closer
to my norm. But this is helpfulfor me that it's not like, I
(18:39):
give myself a pass to donothing. For the two days after
a night shift. That would begreat. But that's not the world
we live in. But I do try to planwhen I look at the month coming
up and I look at where my nightshifts are. I am more deliberate
about what type of activities amI doing for those two days
following a night shift. And Ireally, honestly do try to avoid
(19:02):
cognitively intense things. Andif I am going to work out on
those days, I tend to doless intense stuff like walking,
swimming, just stuff that's morekind of in a recovery mode. So
how do you boost your heart ratevariability, some of this is
very basic. Overtraining is badfor a lot of reasons, but it's
(19:25):
also bad for your heart ratevariability. Sleep is probably
the most important thing. Andthen nutrition, but kind of the
more detailed stuff. Alcoholreally decreases your heart rate
variability so and I can attestto this that if I wear my my
band device when I'm here for aconference, it's trash is
absolutely in the toilet. So Iactually took it off today. I
(19:50):
was like I'm wearing this dress,and I already know what my heart
heart rate variability has beenthis weekend. cold water
immersion. So this is supertrendy. But there's actually
data behind it that it does havesome health benefits and
specifically does help toincrease your heart rate
variability. And much toeveryone's chagrin, in this
(20:10):
room, night shifts are reallybad for us circadian alignment
is good for a lot of reasons.
One of them being hurryvariability. I'm sure many
people in this audience know thethe data on long term night
shifts and increasedcardiovascular risk dementia,
all sorts of bad things. So thething I like about wearables and
(20:36):
specifically, heart ratevariability, you can extrapolate
it to other things like yourresting heart rate, is, if you
start tracking this information,it allows you to actually see
objectively, beyond kind of thethings a lot of us use, like the
scale, if something's making adifference for you, personally,
(20:59):
is, you know, there's always somuch information coming at us
like, oh, maybe I should startdoing intermittent fasting,
maybe I should be low carb, youknow, maybe I should start doing
high intensity intervaltraining, well, you can actually
start to track if that makes adifference for you. more
individualized wellbeing. Sothis is an example of a tracking
(21:25):
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'retype A, is you start to realize
there's like a gajillionvariables every day. I mean,
most of us eat, kind of, we'renot super regimented in what we
eat. So you have to kind of playaround with, you know, what are
(21:47):
the big kind of blocks do youwant to focus on. But if you do
want to make a change, likemaybe you're like, Well, I've
been hearing a lot of peopletalk about this magnesium
supplementation prior to sleep,so I'm going to do that. Now,
what I can't tell you is shouldyou track that for a week or two
weeks, my gut for heart ratevariability is probably one to
(22:09):
two weeks to actually see ifit's making a change. I will
tell you, for me, my heart ratevariability has gone up on
average, about 10 points in thelast three months. And I can't
tell you that I've been workingout or eating better, that just
hasn't happened. The thing thatchanged is I've been meditating.
(22:32):
And I use an app that tracks mymeditation up to almost 600
minutes, and I'm doing it.
Honestly, I'm probably at 99%.
With, I think I missed one dayin 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 toactually reap the benefits of
(22:55):
meditation. And my heart ratevariability has gone up the
most, it's gone in a year. So Ito a little bit of like me dying
here. Meditation works, I thinka lot of us resist it. But for
nothing else, you know, we doknow that heart rate variability
(23:15):
is a pretty good predictor for alot of bad things. If it's low,
like cardiovascular disease, andit's pretty exciting to me,
actually, that just sittingstill, and doing nothing has
made a huge impact on probablymy overall health.
Some of these apps and programsallow for built in tracking. So
(23:39):
if you're like there's no wayI'm going to take out a spiral
notebook and, and track this byhand. For instance, the band
device that I use, at the end ofeach actually in the morning,
when I go to check my score forthe previous day, it asked me
about caffeine, the last time Ihad caffeine and how many
(24:00):
servings previous day think itasks about alcohol and then
allows for journaling. So youcould type in, you know,
whatever else you wanted to likeI intermittent fast for 16
hours. And then it actuallyallows you to generate reports
based on the variables thatyou're inputting. So you could
get pretty sophisticated. And aswe talked about, you know how
(24:22):
long to track probably talk tosomeone smarter than me about
like the fitness stuff. But itseems like most things probably
one to two weeks when I'm reallyexcited about is the potential
to track heart rate variabilityin teams. So there's a company
called arena labs that wasfounded by I believe it's two
(24:44):
Navy SEALs, and for whateverreason, they have become really
interested in health care teamperformance, and they have a lot
of products, some of itscurriculum around resiliency,
but what they really want andwhat They're starting to move
into is, again, how do we havedata that any of the stuff that
(25:06):
we're doing for wellnessactually matters? If we put in a
resiliency curriculum, does itactually change the way people
are thinking if we do ameditation curriculum with a
group of residents, does thatactually benefit them? So
they're looking at using heartrate variability, monitoring, to
track wellness interventionsacross teams, so they d
(25:30):
aggregate that data. So it's notbeing tied back to any one
person. But then you could startto look at a health care system,
that if you start to makechanges, maybe maybe take the
nursing schedule from 12 hoursto eight, do you see an
improvement in heart ratevariability? Or maybe there was
a toxic manager? That getsremoved? Did everyone's heart
(25:53):
rate variability go up? 10points? I don't know. I think
there's a lot of differentexciting applications, of
course, some risk involved. ButI think it's pretty exciting. So
what I'd like you to take awayfrom today's lecture, is
wearables have the ability togive you some objective
information about your health.
And heart rate variability,specifically, is the only vital
(26:15):
sign that really gives you somepretty good information on your
overall autonomic health. Andthis is an opportunity for you
to start to really tailor yourhealth and have an
individualized look at whatreally helps you to keep living
the best life you can as aperson and emergency physician.
(26:36):
So if you'd like to learn more,check out my website. And then
we have a couple of podcasts onheart rate variability on the
emergency mind, and I'm also onTwitter. Now open it up to any
questions
Today we're going to be talking about wearables,
your secret weapon to unlockingyour wellness. So as far as
disclaimers, I'm going tomention a lot of devices, some
by name, but I don't receive anyfinancial compensation from any
company. And these are myopinions.
So I want you all to think for aminute. How are you? And I'm
(00:37):
going to ask you a series ofquestions that they think are
helpful in thinking about ouroverall health. How many hours
of sleep did you get last night?
What percentage of your sleepwas REM? What's your resting
heart rate? What's your averageheart rate variability? If you
don't know the answer to any ofthese questions, that's totally
(01:02):
fine. I didn't know them eitherabout a year ago. But for the
last year, I've been tracking alot of that information with
wearables. So we're going totalk about what is a wearable.
And we're going to spend quite abit of time in the presentation
on heart rate variability,because I think this is the most
(01:23):
important vital sign foremergency physicians and
military physicians under highstress to be paying attention
for yourself. We'll talk alittle bit about patients. But
really, this lecture is aboutyour well being. And then we'll
talk about how you can start toincorporate using a wearable in
your life, but many of you arealready using one. So how many
people in the audience have asmartwatch on? Almost everybody.
(01:46):
So you're all already using awearable. So the technical
definition is some type ofdevice that you wear, that
tracks some type of biometricdata. So whether that's heart
rate, the number of steps youtake your respiratory rate. Now,
most of us with a smartwatch,you can get your EKG tracing, it
(02:10):
seems to keep going up and upthe amount of information that
we can get from these wearabledevices. And yes, they said we
talk a little bit aboutpatients, how many of you have
had a patient provide someinformation to you or have a
question based on a wearable?
Yeah. So when you look at the Idon't know how many of you
(02:32):
pulled any data about how goodare these wearables? They're not
bad. And I'll just go throughone paper quickly. The New
England Journal of Medicine, Ilooked at 400,000 Apple Watch
users specifically around thequestion of atrial fibrillation.
The prevalence of atrialfibrillation and the Apple Watch
users was actually extremelylow, less than 1%. Probably
(02:56):
because most people that wear anApple Watch are younger and
healthier. So really lowprevalence when they looked at
the people that had anotification that they were in
atrial fibrillation, and thensent them to get an EKG and I
don't know exactly, theyprobably presented within 24 to
(03:16):
72 hours to get that EKG 35%More or less were in atrial
fibrillation. When they wentback and looked at the tracing
that the Apple watch recorded upto 85%, around 85% had a tracing
that reflected atrialfibrillation. So if your patient
(03:36):
says that my watch notified methat I was in atrial
fibrillation, there's a prettygood chance they were in afib. I
also personally, I do find ithelpful. You know, when you have
that patient that says, I feellike my heart's racing. I was,
you know, having palpitationsduring this period of time and
they have a smartwatch on, Ilike to have them go ahead and
(03:59):
pull up. Well, let's look whatwas your heart doing during that
period. And especially for thepeople that have had multiple
workups. And it's leaningtowards anxiety, I start to
introduce the concept of whenyou feel your heart racing, you
can actually start to look atyour watch, and maybe start to
get some biofeedback, that Ifeel like my heart's racing, but
(04:20):
my heart rates actually 65 Idon't do that with everyone.
It's usually somebody that's hada lot of work ups already. So
heart rate variability. I thinkthis is a really cool, vital
sign. And we should really bethinking of it as the fifth
vital sign, not the whole painthing. Thankfully, that's gone.
But it reflects our autonomichealth. And I think our
(04:43):
autonomic health is reallyimportant for physicians that
are under a lot of stress,emergency medicine, military
critical care, and heart ratevariability is the only vital
sign that also reflects ourmental well, well being
sensitive distress It also doesimprove with aerobic exercise,
though. So it actually is ablended representation of
(05:07):
several factors related to yourhealth, probably why I think
it's really cool.
So people that have a lowerheart rate variability than
their age adjusted cohort, haveincreased risk of cardiovascular
disease, depression, anxiety andPTSD. And this has been known in
(05:27):
the literature for for like, 30years, this isn't new at all.
What is new is that we canreally bring Heart Rate
Variability monitoring, youknow, to the individual. So
quick review. So, you know,sympathetic response is our
fight or flight. We spend a lotof time with our sympathetic
(05:48):
response in the emergencydepartment, we get a lot of
surges, responding toemergencies responding to
intense personalities, andparasympathetic response is our
ability to calm down. You know,in our nervous system, our vagus
nerve is the primary mover ofthe parasympathetic response. So
if you look in, like thepolyvagal literature, there's
(06:12):
this term of how, how robust isyour vagal brake, your ability
to ramp up, and then pullyourself back down? So heart
rate variability is kind of away that you can start to track
your ability to recover and havethat robust parasympathetic
response. So what about restingheart rate, resting heart rates,
(06:36):
great. It's largely influenced,though, by just our overall
fitness. And I'm sure we've allhad the patient that has a
resting heart rate in the upper30s, maybe you have that time
from being an intern gettingwoken up in the middle of the
night, because the patient had aheart rate in the upper 30s. You
know, are super well, you know,cardiovascular marathon ultra
(06:58):
marathon people, they often havea super low resting heart rate.
But then if you go and look attheir heart rate variability, it
might be terrible. So I thinkHeart Rate Variability provides
a lot of information, and we'llget into it more about their
ability to recover, which isalso an important part of your
overall well being. So again,resting heart rate doesn't give
(07:20):
us that piece of informationabout your autonomic tone, and
recovery. So how do we actuallymeasure heart rate variability,
so probably my least favoritething and involves math. So we
look at a lot of EKGs emergencyphysicians. Extreme heart rate
variability is essentially ifyou're still in sinus rhythm is
(07:43):
a sinus arrhythmia. You know,you see that sometimes on the
top of the EKG, this is a sinusarrhythmia that's detecting that
there's a lot of beat to beatvariability well beyond, you
know, if you go another layerdown, and you do some math and
look at the square root of theRTR interval, that is how you
(08:03):
get heart rate variability. Sothere's a few different formulas
out there. Different devices usedifferent formulas. And if you
really want to geek out on it,you can see what device is using
what formula and what you thinkis the most accurate. So that's
using an EKG tracing. And theresearch studies with heart
(08:25):
rate, heart rate variability arelargely based in lab data that
involves EKGs. But none of usare walking around with EKG
leads, right? I don't think youare, and you probably don't want
to be. So how does yoursmartwatch measure your heart
rate variability? Well, it useslight, it uses photo plus size
(08:48):
monographie. So we mightrecognize that word from your
anesthesia rotation. Andremembering that the pulse ox
machine uses light to transmitthrough a vascular bed and then
there's a bunch of math andpeople good at physics will be
able to explain how thatcreates, you know the pulse ox
number, same idea but a littlebit more complicated to create
(09:09):
an EKG tracing. So you canprobably imagine that if your
your Apple Watch and maybeyou're looking at your watch
right now, you'll see thatlittle green light flashing.
That's how it's able to detectyour EKG and your heart rate.
But that's really susceptible toa lot of artifact. So that's
(09:31):
where you start to lose thefidelity of the data compared to
if you got an EKG tracing. Butit's pretty good. And if you
want to trap track this datayou're going to use something
that's feasible. So in thetechnology continues to improve
so what should so if all of youpulled up your the data
(09:53):
connected to your smartwatchright now and asked me if you
had good heart rate variability,but you will only gave me a
single data point, I wouldn't beable to tell you. So the thing
that's weird about heart ratevariability, and probably why we
don't talk about it very much,is it's very individual. So
there is a median, that's normalfor age. And unfortunately, like
(10:17):
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 myage on the horizontal axis and
go up. So you know, for me,pushing 40, my heart rate
variability on the low end is40, on the high end would be
like 60 would be really good.
But it's super individual. Soagain, I can't look at my heart
(10:43):
rate variability on a single dayin isolation, it really has to
be compared to a trend, whichcan be hard for people to
because now this is somethingyou have to kind of watch over
time. And again, the reason Ithink it's important is most of
us are Type A personalities. Andwe don't like to slow down. And
(11:07):
if you start tracking your heartrate variability, you start to
see that, okay, maybe I'm beenworking a bunch of night shifts,
and my heart rate variability isreally bad right now. Or I'm
training for a marathon. And Ikeep pushing, and I'm never
getting a day where it bouncesback up. That would be a red
(11:28):
flag that you know, you need tokind of adjust and add in some
more rest days. The other thingthat's been fascinating about
heart rate variability is itdoes detect or susceptible to
changes related to actualillness. So I had COVID, in
January. And the second arrow isthe day I tested positive. And
(11:57):
the day I got the test, I hadthe faintest scratch in my
throat. It was so like lightthat I really thought that I was
being a hypochondriac. But I waslike, honestly, what made me go
get the test, is my heart ratevariability the day before had
been such trash, like low 20s isreally bad for me. It made me
(12:18):
think that something was wrong,that I was probably sicker than
I realized, then sure enough, Ihad COVID. The other thing I
like about it is it takes maybewhen I asked you earlier, how
are you right now? You know,that's a very subjective
question. And maybe some of usare better at tuning into how we
(12:40):
actually feel versus how we wantto feel. But I find that heart
rate variability allows me tohave a little bit more objective
data when I'm going into ashift. So for example, I worked
out in Twentynine Palms lastyear roll emergency medicine
site, with the Marines, and Iworked a 12 hour shift, like
(13:04):
several in a row, and it wasduring daylight savings. So I
work 6am to 6pm, went home orwent to my hotel. And then I got
one hour less of sleep, becauseit was spring forward. And so I
woke up at like, 445 in themorning, and I'm like, Oh, this
is terrible. Because I reallyfelt like 345, right. And that's
(13:28):
how I felt like I needed morecoffee and like it's going to be
a terrible day. Well, I lookedat my score, my heart rate
variability was on the high endfor me, I only slept six hours,
but I was 92% recovered. So as Iwas walking into my shift, and
looking at this, I was like,hmm, perhaps my mindset is the
(13:50):
problem, not really how I feel.
It's how I'm thinking about howI feel. And I actually had a
really good shift and a reallygood day, even though it was 12
hours long, because it reallyhelps me kind of flip the
narrative that I had developedabout the day. So what are your
(14:12):
options for devices?
So there's a band device? Andfirst of all, you might be
saying, well, most of us justraised our hand and we have a
smartwatch and you just told methat the heart rate variability
is accessible. I'll show you alittle bit more later. But yes,
your smartwatch measures heartrate variability, but my
(14:34):
understanding for the AppleWatch is it only checks it two
to three times randomlythroughout the day. So that's
not very much information. Andwho knows when it's really
checking that so I'm not sure ifyou can go in and change the
settings to have it checked atspecific times. But again, it's
just not very much information,where devices like this band,
(14:58):
and then there's a ring on themarket. They're checking it more
continuously. Some of howthey're measuring heart rate
variability is proprietary. ButI have had conversations with
some of the people that work forthese companies. And they are
measuring it more frequently,and probably more more fidelity
(15:21):
than a smartwatch. But if youhave nothing else, I think it's
smartwatch is better thannothing. So what are the
drawbacks to learning more aboutyour biometrics? It's just more
information, right? I thinkwe're all in kind of like,
information overload. And thenthere have been periods of time,
(15:41):
actually interesting. So I cohost on a podcast called the
emergency mind. And the host isDr. Dan Dorcas. And so he's
really interested in performanceunder pressure. And he wears one
of these devices. And I wasasking him how his heart rate
variability was during the thesurge LA County in winter 2020
(16:07):
going to 2021. And he's like, Itook it off. It was just so
defeating to see how bad myrecovery score was day after day
that it was stressing me out. Soand I've done that, after
periods of time to that, it'slike, my scores are just going
to be really bad right now. Andit's causing me anxiety. So I'm
just not going to look for thenext few days. Cost the devices
(16:32):
that are kind of more forathletic performance that have
like more, they're tracking yourheart rate variability more
frequently, are more expensive,or they get you on the back end.
And it's very inexpensive to buythe device, but then there's a
membership fee, which Ipersonally, that really annoys
(16:53):
me. So that's kind of thedrawbacks to to these devices.
And to give you a comparison oflike, Okay, should I just use my
smartwatch? Or do I want toupgrade to one of these band or
ring devices, this is from theband device that I use. This was
in February, so I was stillrecovering from COVID, my chips
(17:16):
were actually really hard. Myheart rate variability was bad.
In the 30s. The Apple Watch set,it was a little bit higher. So
for that same week, there wasabout a seven point difference.
So this is what I think isreally interesting. You know,
(17:36):
we've How many of you have heardthat it takes two days to
recover from a night shift?
Yeah, how many of you believethat? You know, so this is me
the So Valentine's Day I workedthe 13th overnight, I probably
went to bed at eight in themorning, I guess I went to bed
(17:56):
at 842. I slept for about threehours, my heart rate variability
was 26. It's really bad for me.
And then oh, the recovery scoreis proprietary calculation
between your respiratory heartrate variability and sleep. So
(18:17):
the following day, I slept moreseven hours, got my heart rate
variability up a few beats. Butreally, my recovery was more
sleep related. And two dayslater, 96% 43. So that's closer
to my norm. But this is helpfulfor me that it's not like, I
(18:39):
give myself a pass to donothing. For the two days after
a night shift. That would begreat. But that's not the world
we live in. But I do try to planwhen I look at the month coming
up and I look at where my nightshifts are. I am more deliberate
about what type of activities amI doing for those two days
following a night shift. And Ireally, honestly do try to avoid
(19:02):
cognitively intense things. Andif I am going to work out on
those days, I tend to doless intense stuff like walking,
swimming, just stuff that's morekind of in a recovery mode. So
how do you boost your heart ratevariability, some of this is
very basic. Overtraining is badfor a lot of reasons, but it's
(19:25):
also bad for your heart ratevariability. Sleep is probably
the most important thing. Andthen nutrition, but kind of the
more detailed stuff. Alcoholreally decreases your heart rate
variability so and I can attestto this that if I wear my my
band device when I'm here for aconference, it's trash is
absolutely in the toilet. So Iactually took it off today. I
(19:50):
was like I'm wearing this dress,and I already know what my heart
heart rate variability has beenthis weekend. cold water
immersion. So this is supertrendy. But there's actually
data behind it that it does havesome health benefits and
specifically does help toincrease your heart rate
variability. And much toeveryone's chagrin, in this
(20:10):
room, night shifts are reallybad for us circadian alignment
is good for a lot of reasons.
One of them being hurryvariability. I'm sure many
people in this audience know thethe data on long term night
shifts and increasedcardiovascular risk dementia,
all sorts of bad things. So thething I like about wearables and
(20:36):
specifically, heart ratevariability, you can extrapolate
it to other things like yourresting heart rate, is, if you
start tracking this information,it allows you to actually see
objectively, beyond kind of thethings a lot of us use, like the
scale, if something's making adifference for you, personally,
(20:59):
is, you know, there's always somuch information coming at us
like, oh, maybe I should startdoing intermittent fasting,
maybe I should be low carb, youknow, maybe I should start doing
high intensity intervaltraining, well, you can actually
start to track if that makes adifference for you. more
individualized wellbeing. Sothis is an example of a tracking
(21:25):
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'retype A, is you start to realize
there's like a gajillionvariables every day. I mean,
most of us eat, kind of, we'renot super regimented in what we
eat. So you have to kind of playaround with, you know, what are
(21:47):
the big kind of blocks do youwant to focus on. But if you do
want to make a change, likemaybe you're like, Well, I've
been hearing a lot of peopletalk about this magnesium
supplementation prior to sleep,so I'm going to do that. Now,
what I can't tell you is shouldyou track that for a week or two
weeks, my gut for heart ratevariability is probably one to
(22:09):
two weeks to actually see ifit's making a change. I will
tell you, for me, my heart ratevariability has gone up on
average, about 10 points in thelast three months. And I can't
tell you that I've been workingout or eating better, that just
hasn't happened. The thing thatchanged is I've been meditating.
(22:32):
And I use an app that tracks mymeditation up to almost 600
minutes, and I'm doing it.
Honestly, I'm probably at 99%.
With, I think I missed one dayin 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 toactually reap the benefits of
(22:55):
meditation. And my heart ratevariability has gone up the
most, it's gone in a year. So Ito a little bit of like me dying
here. Meditation works, I thinka lot of us resist it. But for
nothing else, you know, we doknow that heart rate variability
(23:15):
is a pretty good predictor for alot of bad things. If it's low,
like cardiovascular disease, andit's pretty exciting to me,
actually, that just sittingstill, and doing nothing has
made a huge impact on probablymy overall health.
Some of these apps and programsallow for built in tracking. So
(23:39):
if you're like there's no wayI'm going to take out a spiral
notebook and, and track this byhand. For instance, the band
device that I use, at the end ofeach actually in the morning,
when I go to check my score forthe previous day, it asked me
about caffeine, the last time Ihad caffeine and how many
(24:00):
servings previous day think itasks about alcohol and then
allows for journaling. So youcould type in, you know,
whatever else you wanted to likeI intermittent fast for 16
hours. And then it actuallyallows you to generate reports
based on the variables thatyou're inputting. So you could
get pretty sophisticated. And aswe talked about, you know how
(24:22):
long to track probably talk tosomeone smarter than me about
like the fitness stuff. But itseems like most things probably
one to two weeks when I'm reallyexcited about is the potential
to track heart rate variabilityin teams. So there's a company
called arena labs that wasfounded by I believe it's two
(24:44):
Navy SEALs, and for whateverreason, they have become really
interested in health care teamperformance, and they have a lot
of products, some of itscurriculum around resiliency,
but what they really want andwhat They're starting to move
into is, again, how do we havedata that any of the stuff that
(25:06):
we're doing for wellnessactually matters? If we put in a
resiliency curriculum, does itactually change the way people
are thinking if we do ameditation curriculum with a
group of residents, does thatactually benefit them? So
they're looking at using heartrate variability, monitoring, to
track wellness interventionsacross teams, so they d
(25:30):
aggregate that data. So it's notbeing tied back to any one
person. But then you could startto look at a health care system,
that if you start to makechanges, maybe maybe take the
nursing schedule from 12 hoursto eight, do you see an
improvement in heart ratevariability? Or maybe there was
a toxic manager? That getsremoved? Did everyone's heart
(25:53):
rate variability go up? 10points? I don't know. I think
there's a lot of differentexciting applications, of
course, some risk involved. ButI think it's pretty exciting. So
what I'd like you to take awayfrom today's lecture, is
wearables have the ability togive you some objective
information about your health.
And heart rate variability,specifically, is the only vital
(26:15):
sign that really gives you somepretty good information on your
overall autonomic health. Andthis is an opportunity for you
to start to really tailor yourhealth and have an
individualized look at whatreally helps you to keep living
the best life you can as aperson and emergency physician.
(26:36):
So if you'd like to learn more,check out my website. And then
we have a couple of podcasts onheart rate variability on the
emergency mind, and I'm also onTwitter. Now open it up to any
questions
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