Catherine Williams
@cathjw.bsky.social
NW EM/PEM physician. ACCS TPD.
Chronically opinionated.
Chronically opinionated.
Do we REALLY not have time for that? Sometimes “thinking out loud” and concluding in a sentence or two would be more than enough. Would benefit the resident doctors, bedside nurses and whoever is scribing too.
We need not to make education an added extra or afterthought
We need not to make education an added extra or afterthought
April 28, 2025 at 10:44 AM
Do we REALLY not have time for that? Sometimes “thinking out loud” and concluding in a sentence or two would be more than enough. Would benefit the resident doctors, bedside nurses and whoever is scribing too.
We need not to make education an added extra or afterthought
We need not to make education an added extra or afterthought
Productivity in healthcare is a problematic term because it is hard to define and near impossible to measure, if we accept the premise that quality is at least as important as quantity.
March 26, 2025 at 11:25 PM
Productivity in healthcare is a problematic term because it is hard to define and near impossible to measure, if we accept the premise that quality is at least as important as quantity.
Remember this is the very small % that have passports and have ever left the boundaries of the USA.
March 14, 2025 at 2:51 PM
Remember this is the very small % that have passports and have ever left the boundaries of the USA.
News to me!
However if I were to guess, I’d suggest that farming out minor injuries provision to private providers (with varying levels of actual minor injury training), and not ensuring EM doctors actually get decent minor injury training, probably hasn’t helped?
However if I were to guess, I’d suggest that farming out minor injuries provision to private providers (with varying levels of actual minor injury training), and not ensuring EM doctors actually get decent minor injury training, probably hasn’t helped?
March 13, 2025 at 8:10 PM
News to me!
However if I were to guess, I’d suggest that farming out minor injuries provision to private providers (with varying levels of actual minor injury training), and not ensuring EM doctors actually get decent minor injury training, probably hasn’t helped?
However if I were to guess, I’d suggest that farming out minor injuries provision to private providers (with varying levels of actual minor injury training), and not ensuring EM doctors actually get decent minor injury training, probably hasn’t helped?
Reposted by Catherine Williams
Fundamentally, this document encapsulates deep misunderstanding about Medicine.
We TEACH medical knowledge in a sliced and diced up way, because the subject is vast and one has to arrange knowledge somehow.
The PRACTICE of Medicine is essentially COGNITIVE. How we think
9/
We TEACH medical knowledge in a sliced and diced up way, because the subject is vast and one has to arrange knowledge somehow.
The PRACTICE of Medicine is essentially COGNITIVE. How we think
9/
March 12, 2025 at 11:56 AM
Fundamentally, this document encapsulates deep misunderstanding about Medicine.
We TEACH medical knowledge in a sliced and diced up way, because the subject is vast and one has to arrange knowledge somehow.
The PRACTICE of Medicine is essentially COGNITIVE. How we think
9/
We TEACH medical knowledge in a sliced and diced up way, because the subject is vast and one has to arrange knowledge somehow.
The PRACTICE of Medicine is essentially COGNITIVE. How we think
9/
Define “everything”. Are we proposing crashing them onto ECMO? (Presumably not, though at this point I’m no longer sure!)
Offer everything reasonable that has a realistic chance of success. But these things aren’t realistic or reasonable. Neither is CPR in this population
Offer everything reasonable that has a realistic chance of success. But these things aren’t realistic or reasonable. Neither is CPR in this population
March 4, 2025 at 5:42 PM
Define “everything”. Are we proposing crashing them onto ECMO? (Presumably not, though at this point I’m no longer sure!)
Offer everything reasonable that has a realistic chance of success. But these things aren’t realistic or reasonable. Neither is CPR in this population
Offer everything reasonable that has a realistic chance of success. But these things aren’t realistic or reasonable. Neither is CPR in this population
Same reason as not offering them a heart transplant or ECMO. It won’t work, it’s a futile brutal burdensome treatment.
March 4, 2025 at 5:33 PM
Same reason as not offering them a heart transplant or ECMO. It won’t work, it’s a futile brutal burdensome treatment.
And medically nonsense, but Americans going to American I guess!
March 4, 2025 at 2:26 PM
And medically nonsense, but Americans going to American I guess!
Good reason: patient is 100 years old, frail and underlying cause for death is not reversible (given its old age).
March 4, 2025 at 2:09 PM
Good reason: patient is 100 years old, frail and underlying cause for death is not reversible (given its old age).
I think it’s pretty cruel actually for doctors to abnegate responsibility and expect grieving relatives with no medical training or understanding of what CPR can and cannot do, to effectively say “yes let grandma die”.
The framing of the explanation is key. CPR does not work in ordinary dying.
The framing of the explanation is key. CPR does not work in ordinary dying.
March 4, 2025 at 2:02 PM
I think it’s pretty cruel actually for doctors to abnegate responsibility and expect grieving relatives with no medical training or understanding of what CPR can and cannot do, to effectively say “yes let grandma die”.
The framing of the explanation is key. CPR does not work in ordinary dying.
The framing of the explanation is key. CPR does not work in ordinary dying.
I would immediately take the family aside and explain that their relative has died and that we would be discontinuing CPR because it was not going to be effective and was denying them peace and dignity at their last moments. This would very much be a (kind & gentle) statement of fact not a question
March 4, 2025 at 2:00 PM
I would immediately take the family aside and explain that their relative has died and that we would be discontinuing CPR because it was not going to be effective and was denying them peace and dignity at their last moments. This would very much be a (kind & gentle) statement of fact not a question
The unrealistic portrayal on TV is unhelpful, and the unrealistic expectations of families can be hard to manage. Frank and timely conversations are important.
I’d expect that someone frail should have been given the protection of a DNACPR/RESPECT form while able to discuss
I’d expect that someone frail should have been given the protection of a DNACPR/RESPECT form while able to discuss
March 4, 2025 at 1:54 PM
The unrealistic portrayal on TV is unhelpful, and the unrealistic expectations of families can be hard to manage. Frank and timely conversations are important.
I’d expect that someone frail should have been given the protection of a DNACPR/RESPECT form while able to discuss
I’d expect that someone frail should have been given the protection of a DNACPR/RESPECT form while able to discuss
No I mean the converse, when CPR is appropriately not done.
I’m on board with sueing regarding battery and desecration of a corpse!
I’m on board with sueing regarding battery and desecration of a corpse!
March 4, 2025 at 12:48 PM
No I mean the converse, when CPR is appropriately not done.
I’m on board with sueing regarding battery and desecration of a corpse!
I’m on board with sueing regarding battery and desecration of a corpse!
In the UK at least there is no obligation for healthcare professionals to provide futile and inappropriate treatments. In reality, second opinions, long conversations etc.
What if they demanded a heart transplant, or ECMO? Why do we treat CPR differently?
What if they demanded a heart transplant, or ECMO? Why do we treat CPR differently?
March 4, 2025 at 12:22 PM
In the UK at least there is no obligation for healthcare professionals to provide futile and inappropriate treatments. In reality, second opinions, long conversations etc.
What if they demanded a heart transplant, or ECMO? Why do we treat CPR differently?
What if they demanded a heart transplant, or ECMO? Why do we treat CPR differently?
Sue on the grounds of what exactly? They were never going to survive? How bizarre
March 4, 2025 at 12:20 PM
Sue on the grounds of what exactly? They were never going to survive? How bizarre
Yep. But how are “middle ground” cases handled? So let’s say an 88 year old with pneumonia and bronchospasm- where IV antibiotics and oxygen maybe appropriate, but say NIV and bronchoscopy may not be.
Or a ‘well’ 104 year old who would like antibiotics for sepsis, but definitely shouldn’t have CPR?
Or a ‘well’ 104 year old who would like antibiotics for sepsis, but definitely shouldn’t have CPR?
March 4, 2025 at 12:18 PM
Yep. But how are “middle ground” cases handled? So let’s say an 88 year old with pneumonia and bronchospasm- where IV antibiotics and oxygen maybe appropriate, but say NIV and bronchoscopy may not be.
Or a ‘well’ 104 year old who would like antibiotics for sepsis, but definitely shouldn’t have CPR?
Or a ‘well’ 104 year old who would like antibiotics for sepsis, but definitely shouldn’t have CPR?
So this may be part of the US-UK disconnect with this case. UK nursing homes are generally for those with high level nursing care needs (bed bound, dementia, multimorbidity, frailty).
We’d use the term “residential home” for those receiving bed &breakfast and social support
We’d use the term “residential home” for those receiving bed &breakfast and social support
March 4, 2025 at 8:34 AM
So this may be part of the US-UK disconnect with this case. UK nursing homes are generally for those with high level nursing care needs (bed bound, dementia, multimorbidity, frailty).
We’d use the term “residential home” for those receiving bed &breakfast and social support
We’d use the term “residential home” for those receiving bed &breakfast and social support
That’s fairly disgusting and depressing. All the more reason though to embed and discuss ceilings of treatment and DNACPR preemptively.
From this side of the pond it feels like the US has a dichotomy between “do everything” and “hospice” (which seems to be do nothing?) without middle ground?
From this side of the pond it feels like the US has a dichotomy between “do everything” and “hospice” (which seems to be do nothing?) without middle ground?
March 4, 2025 at 8:30 AM
That’s fairly disgusting and depressing. All the more reason though to embed and discuss ceilings of treatment and DNACPR preemptively.
From this side of the pond it feels like the US has a dichotomy between “do everything” and “hospice” (which seems to be do nothing?) without middle ground?
From this side of the pond it feels like the US has a dichotomy between “do everything” and “hospice” (which seems to be do nothing?) without middle ground?
Though after a prolonged prehospital low flow period, prognosis is almost certainly dire in a patient like this regardless of all the cleverness and advanced techniques. In which case some kindness, privacy and calm is probably a better management plan.
March 4, 2025 at 12:18 AM
Though after a prolonged prehospital low flow period, prognosis is almost certainly dire in a patient like this regardless of all the cleverness and advanced techniques. In which case some kindness, privacy and calm is probably a better management plan.
I’m not sure there’s enough info on baseline in the original post to determine this (in UK ‘nursing home) implies high care needs/advanced frailty and I’m not sure if this is the same in the US. In advanced frailty all this is clearly inappropriate, futile and undignified.
March 4, 2025 at 12:16 AM
I’m not sure there’s enough info on baseline in the original post to determine this (in UK ‘nursing home) implies high care needs/advanced frailty and I’m not sure if this is the same in the US. In advanced frailty all this is clearly inappropriate, futile and undignified.
In a situation like this where a DNACPR or RESPECT form has unfortunately not been completed, & resus commenced, the receiving team would make an assessment of prognosis and appropriateness of ongoing resus
March 4, 2025 at 12:14 AM
In a situation like this where a DNACPR or RESPECT form has unfortunately not been completed, & resus commenced, the receiving team would make an assessment of prognosis and appropriateness of ongoing resus
In patients who have a low likelihood of meaningful recovery following a cardiac arrest, the ideal scenario is a preemptive discussion with patient and family to explain that “full resus” would not be in the pts best interest for these reasons.
March 4, 2025 at 12:13 AM
In patients who have a low likelihood of meaningful recovery following a cardiac arrest, the ideal scenario is a preemptive discussion with patient and family to explain that “full resus” would not be in the pts best interest for these reasons.