Figure. ED:

, stress

The rules are different in the ED. Anyone who has spent much time in our beloved land knows this is true. It's an alternate reality, where the normal laws of nature are interrupted.

We could, of course, discuss the actual physical anomalies. The way people who should have died managed to survive thanks to some healing alchemy of bullets, alcohol, and methamphetamine. We could ponder the way those with relatively minor injuries or illnesses can seem destined for paralysis or the morgue, surprising us with their apparent fragility.

There's the way pus can leave a patient and be found in another room entirely, having erupted down halls and around corners. The temporal mystery by which labs are always being released at the very moment we call. The biological phenomenon that ensures the consultant, paged hours ago, will only call when your bladder has reached 120 percent of normal capacity. These are conundrums, violations of what seem like reasonable principles of physics and physiology.

But few things are as bizarre as the way the rules of human interaction are transmogrified in the ED. People and institutions can get away with things they wouldn't in other locales. Remarkably toxic, manipulative, or just silly human behavior can be acceptable within the walls of the ED (and the hospital at large) while the same behavior outside would be considered unacceptable, unprofessional, perhaps impolite, and sometimes criminal.

Urinating in a trash can, for example, not because of incapacity or intoxication, but simply because the trash can was there and the patient needed to go. Where else can one enjoy such remarkable liberty?

Consider the routine threats against staff. I'll come back later and kill all of you is generally deemed a crime outside our hallowed walls, but here it is often dismissed with Well, he couldn't help it; he was drunk. That time-honored excuse will not fly in the administrator's office or any local judge's chambers.

Assaults also seem to violate normal mores when they occur in the ED. A nurse or physician may be struck, bitten, kicked, or cut, only to be told that it would be great if he wouldn't press charges.

What of food and drink? Doesn't everyone shopping in a clothing store insist that the manager get him a sandwich and a cup of water because he didn't eat before he came to the store? Not because of diabetes and hypoglycemia, homelessness, or crushing poverty but because of mild hunger and the ineffable delight of being waited on by those who have almost no power to say no. When the customer is always right, he gets a sandwich and a drink.

Employees in the real world have a meal break. That's laughable in the ED where food and drink are routinely denied to staff. Intermittent fasting? Not by choice.

Where else can one demand to be taken after being arrested? Before I get booked, I'd like to shop for some new shoes please. My feet really hurt! That's a nonstarter. But a suspect can always come up with sudden chest pain or tendency toward seizure and be brought for evaluation and, of course, food and drink.

Annoyance with wait times is common and unpleasant, and it is easy to understand the frustration. But where besides the ED would a child of 8 look up from her iPad and say, Well, it's about time! when a professional adult walks into the room to provide a service?

Behavioral oddities, however, are certainly not limited to patients. Fellow physicians will say things to the ED staff that are sarcastic or profane simply because it has become acceptable to do so (and because we have become accustomed to this sort of abuse as endless interns).

But some of those who talk so unkindly would be scandalized to hear their fellow parishioners do the same in church and flabbergasted if the EP called their office and spoke like that. These sorts of things flow one way according to the strange rules that govern the discourtesy in medicine.

In most other businesses, customers have a general idea what they will be charged. Not so much in our vast hospital systems, where corporate America is careful to keep a tight lid on charges so that neither patients nor employed physicians have a true idea. Despite the mystery of billing, hospitals bill as aggressively as possible; the bill is transparent when it appears.

One would correctly assume in a restaurant that the bill was for the food and service. Imagine, however, if additional charges were levied, separately and significantly, for the use of the table, chair, napkin, silverware, every piece of ice, each visit by the waiter, each trip to the restroom, and the container in which the food was taken home! Yet that's the lay of the land in the hospital.

It's a strange place, the ED. But as the pressures mount and the rules diverge more and more from those of society, it will become an even harder place to do an already hard job. That's a pity because the staff and patients deserve much better.

Dr. Leappractices emergency medicine in rural South Carolina, is a member of the board of directors for the South Carolina College of Emergency Physicians and an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available atwww.nursingcenter.com, and Working Knights, Cats Don't Hike, and The Practice Test, all available atwww.booklocker.com, and of a blog,http://edwinleap.com/. Follow him on Twitter @edwinleap, and read his past columns athttp://bit.ly/EMN-Emergistan.

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