The Cheerful Oncologist's Little Book of Rules: Number 24

[Editor's note: No, you didn't miss the first 23 rules - the narrator is simply tossing them off as they materialize during the course of his normal work day. Speaking of working stiffs, unless he wins the lottery the C.O. will have more examples for you in due time]

In honor of all the doctors around the world who labor with diligence and equanimity to give their patients the best care possible, I would like to share some entries from my little black book stuffed with practical tips for the practicing physician. This is merely an attempt to show readers how clinical decisions are made, or in other words, how we do do that voodoo that we do so well.

I hereby dedicate this rule book to Samuel Shem, the nom de plume and writer of the most famous list of rules for doctors ever published - the Rules of the House of God (click on "Read On" to view the complete Rules).

RULE 24. WHEN ALL ELSE FAILS, EXAMINE THE PATIENT.

I got a call last week from a fellow M.D. who had one of our mutual patients in her office. The patient had developed a fairly severe case of hives and had been to the local E.R. for treatment. He was now on several medications for this and was only slightly better. I was puzzled by this diagnosis, but was willing to file it away as a complication of the patient's ongoing chemotherapy when I thought perhaps I should have a look-see at these hives myself (vide supra). So I did.

When I walked into the exam room it was clear to me (taking approximately 2.5 seconds, far from the record for the world's fastest diagnosis) that the patient did not have urticaria, at least in the classical definition. What he had were painful red blotches on his palms and soles and an erythematous face. This was indeed a complication of chemotherapy, but one that goes by a much more exotic name: palmar-plantar erythrodysesthesia. Patient examined - case closed. The little rule book comes through once again, or as we docs like to say when comparing war stories around the coffee pot, "Nullius in verba."

RULES OF THE HOUSE OF GOD:

I. GOMERS DON'T DIE.
II. GOMERS GO TO GROUND.
III. AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE.
IV. THE PATIENT IS THE ONE WITH THE DISEASE.
V. PLACEMENT COMES FIRST.
VI. THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14 NEEDLE AND A GOOD STRONG ARM.
VII. AGE + BUN = LASIX DOSE.
VIII. THEY CAN ALWAYS HURT YOU MORE.
IX. THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.
X. IF YOU DON'T TAKE A TEMPERATURE, YOU CAN'T FIND A FEVER.
XI. SHOW ME A BMS* WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.
XII. IF THE RADIOLOGY RESIDENT AND THE BMS* BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.
XIII. THE DELIVERY OF MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

*BMS: Best Medical Student