I read Samuel Shem’s House of God twice — once in my late college/early med school years and another sometime during my pulmonary/critical care fellowship. The first time, I recall thinking it was drop-dead hilarious. I eagerly shared it with friends and family. Absorbing the wisdom of the fat man, the catchy vocabulary, and the cynicism of the narrator made me feel somehow like an insider wise to the game even before I’d gotten on the field.
The second time, I was horrified. By that time I had completed a (pre-1990) internal medicine residency, as well as an even harder spell of every other night call as an ICU fellow … which is to say that I had many more sleepless nights than Roy Basch did in his one year in the House of God. I realized that the book probably reflected a lot more about the author than it did the patients he was privileged to serve. After several years of casually using the term “gomer” (get out of my emergency room) to describe older patients, I dropped that word from my vocabulary and encouraged others to do the same. I didn’t buy the idea that one could use that language behind the scenes and not be impacted by it. I considered the author to have abandoned those LOLs in NAD (little old ladies in no acute distress) that he claimed to have such tender feelings for.
Then, for a long time, I forgot about it. A career of taking care of the sickest of the sick — and often confronting times when caring did not mean curing — happened. If “The HOG” informed my actions or thoughts at all, I was not aware of it.
But, as my career in the ICU wound down, well past the age where most practitioners have “burned out,” I began looking at the ICU differently. Not as a place where we skillfully employ advanced sepsis care, sophisticated ventilator management, and slick technical skills to turn around unstable patients. Not even as a place where we gently transition to palliative care and helped loved ones deal with devastating losses. Rather, it is a place where failures land. Where failures of elder care, child protection, addiction treatment, affordable housing, mental health services, and equitable delivery of primary care to the whole community all lead to catastrophe, and to me.
Especially elder care. Day after day, I meet frail people who have fallen. At home, at the SNF, at assisted living, even upstairs on the wards. And when they fall, they break things. Hips. Ribs. Subdural blood vessels.
So it was that I took note a recent salvo of remembrances about the House of God. And I was reminded most particularly the second of the fat man’s rules: Gomers go to ground.
My ICU is the place where gomers go when they go to ground. I still reject that term — but the law has an important kernel of truth. It’s gravity that gets us. We’re all going to go to ground. Every human being lives with gravity every moment of our lives( shush about astronauts). We obey this law without fail every day. So why are we so surprised by it? Why don’t we plan for it? Why do we spend billions on ICU care, and now on “post-acute care” that simply returns our frail elderly to the perilous 1G world? Where they will, without fail, go to ground again.
There are many complicating factors underlying these questions — cultural, economic, political, spiritual, and more. The answers, however, depend on accepting the truth of rule number 2. The author of the House of God may ( or may not have) written that law from a place of self-pity and smug superiority — but he was right. And I, who sent two (great) kids to college and built a nice mountain home on income generated thanks to gravity— what was I?
Bill Kinnard is a critical care physician.
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