I'm not really all that mysterious

reviewing the fat man's rules from the house of god

The House of God is a satirical novel written in the mid 1970’s by a physician who goes by the pseudonym Samuel Shem. The book is about the experience of an intern physician trying to survive the rigors of the residency program associated with the mythical Best Medical School (a thinly veiled reference to Harvard.) The Fat Man is one of the senior residents in this residency program, and he came up with a set of rules that I find terrifyingly useful.

  1. Gomers don’t die

Now, what exactly is a gomer? Supposedly, the word was devised as an initialism that stands for “get out of my emergency room”, which is what the ER physician will say when they find one of these folks hanging out in triage. It is actually a somewhat difficult word to define, although I think we eventually all get a sense of what a gomer is. At the VA, these are the guys who have (as we like to put in chart lore) multiple medical problems, which generally include COPD and PTSD. And despite having multiple types of cancer (lung cancer, prostate cancer, colon cancer, etc.) and despite having experienced multiple cardiac arrests, they still manage to survive on.

Unfortunately, those episodes of cardiac arrest aren’t inconsequential, and sometimes they leave their indelible hypoxic/ischemic mark on the brain. Hence, the O-sign, and the Q-sign.

At a county hospital, these kinds of gomers don’t really show up much. For one thing, if you’re forced to subsist on Medicaid, or if you’re truly indigent, you probably won’t survive to live this long anyway. Instead, what we have are “frequent fliers” who are generally younger than their VA counterparts, and who often have rather exotic chronic medical conditions owing to some heroic surgical measure (often performed when the patient was a pediatric patient) that did not really take into account the patient’s social situation. Lots of kidney and liver transplant victims recipients. A lot of their problems are due to (1) the lack of available funding or (2) simple non-adherence to treatment regimens. Although I have to say, I’ve met a few frequent fliers who actually like coming back repeatedly to the hospital. (I suddenly think of a poor woman with lupus nephritis who was given a renal transplant that eventually failed because she didn’t always take her meds. Her technique for getting into the hospital was to pop her colostomy bag so that stool would leak over her chronic panniculitis and lower extremity ulcers, immediately generating a fever. And then there was that creepy lady in the ER who shows up every week begging that a male resident perform her pelvic exam.)

  1. Gomers go to ground

In this era with so many neuroleptic agents, this actually isn’t as much of an issue (although it’s still true.) Most patients can be kept in their beds without even so much as putting on a posey vest, much less four point restraints. All you need to do is order a little “Vitamin H” (haloperidol) or even some “Vitamin R” (risperidone) which is available as an orally disintegrating tablet, and your patient will remain blissfully staring at the ceiling for almost an entire nursing shift. That said, it is well to bear in mind that you can indeed raise the bed to different levels, and if you forget to reset it after performing whatever procedure you had to perform, you may well be guilty of malpractice. I am still amused by Shem’s discursus into the different levels you can adjust the bed: the orthopedic height (where if your patient falls, they’ll break a hip), the neurosurgical height (where if your patient falls, they’ll have an epidural or subdural hematoma), and the pathologic height (where if your patient falls, they’re going to get transferred to the morgue.)

  1. At a cardiac arrest, the first procedure is to take your own pulse

While TV depicts every “code blue” as a traumatic, high-stress situations, in reality, they rarely are. Some care units will call a code blue if your patient sneezes funny or actually does start breathing at 20 breaths per minute (the alleged “normal” respiratory rate which is actually faster than physiological.) A lot of times, they get called because someone got a little too aggressive with the opiates or benzodiazepines, and the respiratory tech had to manually bag your patient for a little while until the narc wore off, or until someone administered the antidote. But many times, it’s because the patient never really had a chance in the first place, you knew they were going to code when you admitted them but forgot to or were too chickenshit to ask the family to change the code status, and now all you’re really doing is breaking their ribs, and pissing away thousands of dollars of life-saving pharmaceutical agents before you package them up for the transfer on the metal gurney to the basement. Whatever the case, remember what the Hitchhiker’s Guide to the Galaxy advises, and “Don’t Panic!” There is no situation that yelling will not fail to make worse.

  1. The patient is the one with the disease
    There are actually a lot of ways to interpret this one. The obvious one is that you should never so strongly self-identify with the patient that you get emotionally wrapped up in their suffering. As my ethics instructor was wont to remind us, there is a great difference between empathy, and sympathy. And once you lose your ability to rationally assess your patient, the probability that you’ll do more harm than good increases.

The other thing is that remember, you’re not the one who’s sick. While being on-call for 30 hours without sleep actually mimicks being sick fairly well (even to the point that you’ll probably develop a slight leukocytosis with neutrophil predominance), your chances of ending up in the morgue are probably still a lot less than your patient’s chances. (Unless you drive home delirious from sleep-deprivation and get hit by a Mack truck, which is certainly possible, but I digress.)

The more subtle interpretation is the whole “treat the patient, not the numbers” mantra. Just because the monitor says ventricular fibrillation does not make it so.

  1. Placement comes first

Thankfully, most training hospitals now come well-equipped with discharge planners who have the infinite patience to deal with the circuitous madness known as health insurance coverage. If there’s funding, there’s always somewhere you can send them. But it is a little disturbing to have to write the order: “discharge to street.”

  1. There is no body cavity that cannot be reached with a 14-gauge needle and a good strong arm.

Disturbingly, this is probably now very less true because of the awful obesity epidemic going on in this country. There are places in certain patients where even an angiocath cannot go, no matter how many people you have holding up the pannus. And while we now have interventional radiologists who can wield said 14-gauge needles with impunity because at least they don’t have to go in blind, most IR suite tables can’t handle people who are over 350 lbs, 450 lbs max.

  1. Age + BUN = Lasix dose.

I used to think this was a pure joke until I realized that the correct way to dose any drug is to determine their kidney function through their glomerular filtration rate (GFR). Since direct measurement of the GFR is tedious, it’s way more expedient to estimate it. A popular way to estimate it is by using the Cockcroft-Gault equation:

estimate creatinine clearance = (140-Age) x mass x 0.85 if female/72 x serum creatinine.

An even more complicated formula is the MDRD formula

estimated GFR = 186 x serum creatinine^-1.154 x Age^-0.203 x 1.21 if black x 0.742 if female

hilariously, BUN does factor in a more elaborate version of the MDRD formula

estimated GFR = 170 x serum creatinine^-0.999 x Age^-0.176 x 0.762 if female x 1.180 if black x BUN^-0.170 x albumin^0.318

  1. They can always hurt you more.

Essentially a more succinct version of Murphy’s Law. Just when you think it can’t get any worse, it almost certainly will. My senior resident when I was an intern put a positive spin on it, though: They can always hurt you more, but they can’t stop the clock. There’s something reassuring about knowing that you do get to sign-out when 1 p.m. rolls around post-call, that a rotation won’t last more than 28 days, and that an internal medicine residency program lasts only 3 years. Unfortunately, the rest of your career doesn’t have quite as well-defined end-points, and the only real way out is retirement or death.

  1. The only good admission is a dead admission.

I never bought this one, because even if they come in dead, you still have to write a history-and-physical and a discharge summary. About the only good thing is that (1) the admission will still count towards your admission cap and your census cap and (2) at least you know where the patient is going to be discharged to.

  1. If you don’t take a temperature, you can’t find a fever.

This is basically a core internal medicine superstition. Do not order tests on things that you don’t need to know, because you will find something abnormal, and you’ll end up going down some god-awful circuitous route that mandates invasive testing and probably surgery that will probably lead to your patient’s death, when all they came in with was a simple case of pneumonia, and all they really needed was an overnight stay for some IV fluids and antibiotics, and they would’ve lived if you didn’t fuck with them.

  1. Show me a medical student who only triples my work, and I will kiss his feet.

It really all depends on the medical school and the medical student. The medical school I went to basically threw us to the wolves and lots of us practiced medicine without a license. The medical school associated with my residency program barely let their med students do anything. The fact of the matter is that most medical students don’t know enough to understand the previous rule, and this will almost certainly increase your work load by an order of magnitude, mostly to prevent the proceduralists and the surgeons from trying to stick things into/take things out of your patient. What is particularly grueling is working with the so-called sub-intern, who is supposed to function like an intern, except that he/she can’t actually write orders. I would like to know whose bright idea this was. It was probably Willian Henry Osler’s, while he was high on amphetamines.

  1. If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion there.

Don’t get me wrong. Without the radiology department, I would’ve killed far many more people than was necessary, but sometimes it all seems so futile when they dictate “significant of this finding is unclear, recommend clinical correlation.”

  1. The delivery of good medical care is to do as much nothing as possible.

The fact of the matter is that the human body is a whole hell of a lot better at fixing itself than any of our poisonous medications and crude surgical tools, and a sure sign that you’re doing something wrong is that the number of consults and invasive procedures you’re ordering are rapidly increasing, even as your patient’s lab values and vital signs all drift toward abnormality.

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