Rules of the House
Every house manual needs some basic rules to practice medicine. Inspired by The House of God : The Classic Novel of Life and Death in an American Hospital” by Samuel Shem here are some "rules". Not all of these are original, but rather than compromise some fine physician-teachers, names have not been included.
Science seeks the most elegant solution, while medicine seeks the best solution at that time.
Don’t forget to look at the patient.
Blue is not a good color in a patient.
The body has a finite number of pathophysiological responses to an infinite number of insults.
The generic/stall out answer to the question, “Doctor what do you do?”:
Basic metabolic panel
X-ray of the affected area
Understand and learn your attending’s three keywords.
Bottom line its all about the Benjamins.
The HONDAS Syndrome:
A lab test or imaging study is ordered for a specific reason, know why, what it means, and what to do about it…and always, always follow up.
Ninty five percent of the work in the world is performed by five percent of the people.
Laws of Radiology
Symmetry is good.
Straight lines and sharp corners are bad.
Real findings are in a perpendicular view, too.
All females are pregnant until proven otherwise.
Happiness is good shoes.
It’s good day if you can go home and wipe your own @$$.
Make a diagnosis
Find a treatment
Nun’s don’t get cervical cancer, but do get endometrial cancer. The first is an STI, the second is high risk for nulliparity and obesity.
Cardiology in a nutshell: Dead meat don’t beat.
Trade names should leave a bad taste in your mouth.
Anaerobe treatment: clindamycin above the diaphragm, metronidazole below.
If they have don’t have a story they are schizophrenic.
If they give you a headache during the interview they have one or more personality disorders.
Getting drunk, smoking some pot, and popping 5 benzos of your choice is not a suicide attempt…its a party.
Observed or ordered is recorded: The medical chart is the lab notebook of medicine. When you come back a few years later it must have enough evidence to write a thesis, publish a scholarly paper, or defend your actions in a court of law.
Medicine is a function of time: Acute problems are treated acutely, chronic problems are treated chronically, and to truly cure anything, prevent it in the first place.
The YIVAS Criteria, what we wish we and all our patients were:
The condition called life has a 100% mortality rate.
The best way to learn to be a doctor is to be a doctor.
Be cautious of the charming, affable patient, they will unintentionally circumvent your diagnostic inquiry and complicate the appropriate therapeutic intervention.
The more benign excuses the patient or family makes for pathological findings the more serious the underlying disease is.
Placebo effect, both blessing and curse.
There is no such thing as an interesting patient. They are all interesting.
Very interesting never carries a good prognosis
Your patient’s agenda and your own are not the same. You worry about what will kill them soonest while they worry about what scares them the most. Stick to your agenda but recognize theirs.
Patients come to the ED for one of five reasons:
A note for work
Do not argue with the person without pants on.
On doing “everything”: Just because we could, doesn’t mean we should.
One fun thing at a time is OK, two fun things send people to the ED, and three or more to the ICU.
To sleep comfortably on call never go the bed with a guilty conscience.
Trust no one, least of all yourself. Double check everyone else, triple check yourself.
Do the right thing because it is the right thing to do.
The B-52, the cure for the violent patient: haloperidol 0.5 mg IV/IM and lorazepam 2 mg IV/IM repeat until pacified (or the QTc gets too long).
You're always right if you go to the bedside.
Vitals, it's an acronym for Verify If They Are Living Still.
Positive staph aureus blood cultures always have a source.
Delirium is a symptom of something
Beating (Cardiac Output)
Bleeding (Decreased oxygen carrying capacity)
Gourd (Seizures and Stroke)
Rheumatology in a nutshell: If you focus on the effected joint you will miss the diagnosis, but if you don't you will miss the treatment.
What appears intuitively true must be verified by experiment.
A history and physical is incomplete until you ask the question no one else is comfortable with and you stick your finger into at least one orifice.
Hospitalist medicine in a nutshell: decreasing acute mortality and chronic morbidity while increasing efficiency and quality of care.
Platform + opinion ≠ fact
Transfer Sign: A critical finding that requires transfer to a "higher level of care" that is noticeably absent on arrival.
Rule of Pagers: A pager will only sound when both hands and brain are otherwise engaged or the instant you fall asleep.
O-sign: Patient unconscious, mouth agape, a poor prognostic indicator.
Q-sign: Patient unconscious, mouth agape, tongue protruding, a worse prognostic indicator.
Palliative care is like intubation, if you think they need it, do it.