My Rules of the ER


A guest post by Hueydoc

After almost 30 years in the ER, I have found that many of the Rules from “The House of God” are oh so accurate. But let me add a few new ones, based on my own experiences:

1)  The correct answer to any problem is “Whatever screws the ER the most”. All policies and procedures end up leaving the patient as the ER’s problem. Period.
2) The staff in the ER are the only people in the county who are responsible for anything. Not the nursing home. Not the police. Not EMS.
3)  Yes, it is true that if you say “Boy, it sure is quiet tonight,” you will immediately experience the worst night in the history of the hospital. This is also a felony — punishable by death in certain states.
4)  The quickest cure for severe diarrhea is to ask the patient for a stool sample.
5)  No hospital policy ever changes until an administrator is a patient and is adversely affected by the policy.
6)  Administrators will never back you up. Ever. Get used to the view of the underside of the bus.
7)  When you are firmly convinced that the patient with the bizarre complaint is a crock, you’ll be wrong.  When you are firmly convinced the narcotic seeker is finally legit, you’ll be wrong.
8 )  If you page two different doctors, both will call back at the same time, no matter how far apart you paged them.
9)  The more demanding a patient is, the less likely it is that they need medical care.
10)  I have never, EVER seen a patient who told me “I can’t afford this medicine – you have to give it to me” who wasn’t smoking 2 packs a day. When you point out to them that they are spending over $200 a month to kill themselves but can’t afford their $4 prescription, they either get very upset or sit there with their mouth open like a stunned fish.
11)  NEVER ever go to work sick. Not only will it be an incredibly busy day, but you will be sicker than most of the patients you see.
12)  All ER physician schedulers are either hopelessly clueless, or evil and insane. I suspect the latter in most cases.
13)  The more difficult the stick, the more likely the lab is to lose your patient’s blood sample.
14)  There is a sensor on the bottom of the doctor’s bed that, when the doctor actually lays down, activates a Batman like beacon into the sky advertising “Free Vicodin” to the entire community, resulting in numerous patients suddenly checking in to the ER.
15)  No extra shift that you reluctantly volunteer to work will ever be an easy shift.
16)  You are more likely to see Elvis in the ER than a staff pediatrician.
17)  No specialty will complain about the treatment their patient received in the ER more than the pediatricians – yet pediatricians are most likely to dump their patients in the ER.
18)  The nicer the patient and family, the worse the outcome will be.
19)  I can not tell the difference between very rich patients and very poor patients – they both act the same. “When it comes to my health, money is no object!”

Feel free to add your own!


  1. This list was awesome…some of your points are spot on, and some of them are simply hilarious. We are a different breed in the ER, yes? Probably due to the unbelievable experiences we all encounter.

    Thanks for the laughs.

  2. I agree that lots of Peds will send kids to the ER with pretty light symptoms, though quite a few of those tend to be nurse advice line dumps. But I’ve had much more luck with the Peds staff accepting patients without argument and the Peds consultants happily coming to the ER at all hours compared to many adult consultants.

    20. You know you are in for the long haul when a parent arrives with their child accompanied by a portable DVD player, two “special” blankies and several named toys, and asking for EMLA before even stating the chief complaint. The kiddo is always either heme/onc or GI.

    21. A pedi resus between 5-7am is almost always a SIDS and will almost never end well.

    22. There is not an orifice on the body or protruding body part that some child, somewhere, has not inserted something into or gotten something stuck on. The parents are usually more upset about the situation than the child.

    23. Unlike adults, the promise of stickers, a popsicle, or blowing bubbles will gets most kids to agree to just about anything.

  3. 24. Any person brought to the ER in police custody will start their H and P with “I was minding my own business when…”

    25. Any person who will be asked how much they have had to drink will always say “2 beers”…I wonder who is selling gallon sized beers out there…

    26. Patients with their legs crossed on the stretcher almost never have anything serious wrong with them (my own personal observation that I am tempted to formally study but it would never get past an IRB)

    27. 20 of etomidate and 100 of suxs cures all and speeds disposition

    28. As soon as you place an endotracheal tube, someone in the room will start barking for the tube size and depth before you even get it secured.

    • I worked for over 7 years in the Records section of my local police department. The normal DUI statement: “Had a couple of beers and was heading home.” Apparently, ‘a couple’ means more to some people, or they were 40s.

  4. 15 (a). If you switch a shift with someone because of a personal commitment or desire to do something fun, the new shift will be crazy busy and the one you gave up will be a cake walk.

    29. People complaining of “chest painS” never have anything wrong with them. Chest pain – yes. Chest pains – no.

    30. People who close their eyes when they talk to you (and flutter their eyelids) never have anything wrong with them.

    31. Administrators decide to “walk through” the ED at the worst possible time. For example, while you are running 2 codes simultaneously (and you have the curtain open between beds so you can be in 2 places at once – even though you are violating HIPPA), granny (who is parked in the hallway) takes her gown off screaming “help me help me”, a prisoner is yelling “f*** you all, I will kill everyone here”, someone has horrendous eye-watering melena, you have 10 holders in the hallway who are all pissed, and 3 EMS crews are lined up to drop off patients (and no one is available because everyone is in the codes). One of the hall patients will invariably ask the CEO for water because “no one in the ED will help me”.

  5. 32. there are only two things that will prevent an adverse event from happening again: more staff or fewer patients. instead, the new policy created by administrators in response to an adverse event is always: fill out another mandatory form

  6. 33. if you see zero patients during the first hour of your shift, the rest of your shift will be a living hell.

  7. 34. if your patient tells you she’s never had sex, she is 10 times more likely to be pregnant or have chlamydia.

  8. 35. the more snot nosed children stuffing cheeto’s into their mouths get signed in simultaneously by the same parent, the sicker the one child they didn’t sign in will be.

      • i once saw mom and 4 of her kids for cold symptoms at 3am on a saturday overnight. the 4 kids were running circles around a baby, on the stretcher in a car seat retracting from bronchiolitis and not registered as a patient.

        baby went to picu, everyone else got d/c’d. it took forever to write up all the charts.

      • Positive Cheeto Sign: the severity of illness is inversely proportional to the number of Cheetoes he or she is stuffing into his/her mouth

        It’s quite accurate!

  9. 36. if a local pmd calls you to give you a “heads up” on a sick patient they are sending in from their office by private car, they will show up 2+ hours later with a bag of mcdonald’s.

    • Well, you don’t know WHEN you’re going to see the doc. My spouse got a nasty stab wound from a dishwasher screwup… but no, we weren’t leaving the house without food!

      In fact, we got very quick service… when the nurse learned that the wound was in my spouse’s BUTT. Everyone just HAD to come hear the story.

  10. I forgot “The chance of a patient surviving an injury is inversely proportional to their value to society”.
    One of our famous narcotic seekers had passed out alongside the road and was RUN OVER by a car ! There were tire tracks on this persons back- after multiple xrays, not a single bone was broken !

    • usually, yes.

      although i did once have a homeless guy brought in “sleeping on train tracks”- ems said this guy claims he was hit by a train.. he’s just looking for a place to sleep for the night.

      turns out he had a flail chest/ptx. hmm…

  11. #13…so effing true!! I worked the phleb side in a trauma center. The pt. who was drawn was not only diabetic, but had cancer. There was no central line. I was lucky enough to find a fat vein in between a finger, and used a 23g butterfly. I got just enough for the cbc, chem12, in peds tubes. They lost them both. SOoooo frustrating. I did work with another lady who really could get blood from a stick. So we hand carried it back and watched them analyze.

  12. #5 is absolutely true every time. And likewise, if they don’t complain of diarrhoea, they are more likely to shit all over the place.

  13. “No good deed goes unpunished “.
    And my favorite,new ACLS guidlines recommend scrotal placement of AED leads if patient is a trial lawyer.

  14. The degree to which a patient wants to stay in the hospital is inversely proportional to the amount they actually NEED to be in the hospital.

  15. Post and comments …EXCELLENT …and exactly why I was drawn into the land of medblogdom. That and a few other reasons …but just love the EXQUISITE medial humor. 🙂

  16. “If a patient reports a pain level not on the chart, such as “11” or “20” on the 1-10 scale, they are drug seeking or malingering. An insured and employed patient with multiple injuries or an acute abdomen will sheepishly report a pain level of ‘maybe a seven’ when s/he is close to syncope from the severity of the pain.”

  17. Severe renal colic =7 ..easily.

    Stuck kidney stone w/vomiting = 10

    Stuck kidney stone w/o vomiting = 9-10.

    May it n-e-v-e-r happen again.

    Just venting.

    I hear pain scale and kidney stone is my reference. *Worse* than labor.

    • Been there, done that. Several times.
      When someone tells me their pain is an Eleven, I ask them why they are not on the ground screaming and writhing…….

  18. The CRF patient who missed 3 weeks of haemodialysis with a potassium of 9 will be the most stable person in the ED.

  19. While I agree pediatricians seem to be sending more patients to the ED, as a pediatric hospitalist I go to the ED whenever asked.

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