*From the American College of Physicians*
http://www.acphospitalist.org/archives/2008/10/book.htm
Laws of The House of God
The original rules of engagement and their meanings, with updated explanations:
#1. GOMERs don’t die.
Original meaning: The patients who seem the most hopeless—who return to the ER again and again—are the ones who are repeatedly admitted to the inpatient service, with little chance for improvement.
Update: On its own, the human body can withstand a broad range of disease and destruction, but with the right cocktail of medications, oxygen and nutrition, life can be sustained beyond all reason. The American population is aging, and the system may not be ready for them. Palliative care can save many from needless suffering.
#2. GOMERs go to ground.
Original meaning: There are two heights from which patients can fall: the orthopedic and the neurosurgical height. Either way, it leads to a “turf.”
Update: Falls in the elderly, both in and out of the hospital, are dangerous and common. The problem is not just the bed set to the “orthopedic height”; it’s the medications and lighting and urine-splattered floors and delirium. Admission for pneumonia is bad; admission for pneumonia complicated by a femur fracture is worse.
#3. At a cardiac arrest, the first procedure is to take your own pulse.
Original meaning: Don’t panic!
Update: Don’t panic!
#4. The patient is the one with the disease.
Original meaning: Yes, you’re going to die someday. Get over it, and go treat your patients.
Update: Don’t go too far in distancing yourself from the patient that you forget the patient is a person. One should try to keep a healthy perspective. When I’m a patient, I’d rather not be “the hip fracture with the UTI in 219a;” I’d prefer to maintain my own identity.
#5. Placement comes first.
Original meaning: The absolute first question should be: “How am I going to turf this patient?”
Update: When a patient gets admitted and it looks like he or she may need nursing home placement or another supportive environment, don’t wait until Friday afternoon to start the process. Don’t forget you need a three-day admit for the Medicare benefits to kick in.
#6. There is no body cavity that cannot be reached with a #14 needle and a good strong arm.
Original meaning: Don’t be afraid to go for a biopsy.
Update: The interventional radiologist is your friend. From diagnostic tap to therapeutic decompression, imaged needle placement beats the blind poke.
#7. Age + BUN= Lasix dose.
Original meaning: Simple memory tricks make decision-making easy.
Update: There is no shortage of peerreviewed, evidence-based, medical society-sponsored, comprehensive algorithms, some of which are actually quite good. Others lead us into a Kafka-esque labyrinth of arrows, text boxes and cross references from which we may never escape.
#8. They can always hurt you more.
Original meaning: They—that is, the patients—can always cause you more grief than they already have, so count your blessings.
Update: “They” can also include administrators, The Joint Commission, your insurance carrier, your patients’ family and students. They will only hurt you if you let them, so keep your chin up and your head on straight.
#9. The only good admission is a dead admission.
Original meaning: A very cynical statement about being overworked.
Update: I have had a few dead admissions. They were alive when they left the emergency room, but something happened along the way. Other times, they arrived in their rooms and took a fast trip to the ICU. On the other hand, some arrived ready to leave—same-day admit and discharge. The ideal admit is probably somewhere between these poles.
#10. If you don’t take a temperature, you can’t find a fever.
Original meaning: Don’t go looking for problems.
Update: If the consulting service comes by and tells you to get a “ceruloquat 1103a dimer level,” don’t forget to order the mixing assay. And if you don’t know what a test means, you probably should not order it.
#11. Show me a student from the “best medical school” (BMS) who only triples my work and I will kiss his feet.
Original meaning: Hard-working, eager medical students are a blessing and a curse.
Update: Foot-kissing is out, since it is definitely not politically correct to perform pedal osculation on your sub-I. In his speech entitled “The Hospital as College,” Osler said that students keep us sharp and up-to-date. With modern electronic record systems, there is only so much scut you can get them to do, and certainly not enough to bring them up to the level of “monkey.”
#12. If the radiology resident and the BMS both see a lesion on the chest X-ray, there can be no lesion there.
Original meaning: Beware the zealotry of newly minted residents and BMS’s.
Update: Students hear too many S4s and not enough consultants. If a heart murmurs in a forest and nobody hears it, did you order an echo? Wait for the final report and review the film yourself.
#13. The delivery of medical care is to do as much nothing as possible.
Original meaning: Primum non nocere. Do no harm.
Update: Primum non nocere sans documentum. Do no harm without proper documentation.
I second the Gawande books as well. The Spirit Catches You and You Fall Down by Anne Fadiman is a really worthwhile read (and definitely a different perspective).
