Soup's Happy Place

I still remember those days when I was a kid. I was carefree then. Oh, how I miss those days (and nights)! My closest childhood friend growing up was Zev. We spent almost every single day together, and quite a bit of that time was spent playing video games. One of the games we spent the most time playing was Duke Nukem 3D.

I wasn’t exactly the most skilled player, so I always played with cheat codes. There are two that I always used and have them memorized by heart even to this day. There is “God mode” as they call it, which is dnkroz. This gives you invincibility (as well as unlimited jetpack if you want to get specific). There is also a code for every single weapon in the game as well as unlimited ammo, which is dnstuff.

That was the story of much of my childhood when Zev’s parents didn’t force us to go outside. Running around in a virtual world filled with aliens, armed with plenty of firepower as well as invincibility. All of this while living a carefree life as a child.

Fast forward to present day, where things aren’t care-free and there is a lot of responsibility on my end. I make countless decisions at work, some of which are mundane, and others, which have significant implications on someone’s life. One of the most important concepts of medicine is patient autonomy, where the patient is able to make their own decisions about their care. This was drilled into us in medical school, and is something that always needs to be respected.

This is much easier when you are able to work (mostly) objectively with patients you do not know personally, versus family or friends. On a typical workday, I will make many decisions. The first will be what color scrubs I’m wearing. Bright colors or something boring? Where will I get food if I’m not working out. Taco Bell? These two examples will have no impact on patient care. How about some further decisions in the workday? The color gown a patient wears? Pepsi or Starry? Again decisions that likely have minimal impact. Then what about treating infection? Will I use piperacillin/tazobactam or cefepime? In many cases they are similar in efficacy. The patient will probably not know the difference. How about making some decisions that are blatantly wrong? Someone is severely overloaded due to an acute exacerbation of their congestive heart failure? Give them more fluids! This is a decision that would have a negative impact on the patient, and is hopefully something that isn’t done.

So what’s the moral of the story? Countless decisions are made daily, where some are of miniscule importance and given little thought. Others can be straightforward but important. Finally, others are not so straightforward and can make you sweat due to the potential outcomes. This brings me back to two experiences that have really stuck with me.

As for the first experience, I admitted a healthy middle-aged lady for a minor problem to the hospital. What is it (kidney stone, acute cholecystitis)? I honestly don’t remember, because it was that unremarkable. Throughout my entire encounter, she would laugh nervously every time I asked a question. Finally it came down to the very last question, which is about code status. I usually ask people: “This is what we ask everyone, regardless of age and medical conditions. If something were to happen to you, such as your heart stops or you stop breathing, do you want to be what is called ‘full code?’ This means we will do CPR to bring you back, and this doesn’t mean we will indefinitely keep you alive on machines.” Every now and then I get an angry response where the patient says “why would you ask me something like that?!” In this case, she started to laugh loudly and is if something was funny. She said: “Why would you ask me this?!” I said, “Because we can’t play God.” Her response: “You’re right. You’re not God.” This stuck with me.

Another experience is from a personal friend. He was looking for a new primary care physician and made a post on Facebook for recommendations. He was specifically asking for “body positivity friendly” physicians. I wrote back stating that when you go to see a physician, you are going there so you can either maintain good health or address an issue. Obesity unfortunately has a negative impact on one’s health through many different ways. Ultimately, when you are choosing a physician, you are looking for someone to objectively improve your health. You are not looking for a drinking or golfing buddy. This stuck with me.

As for the lady with the uncomfortable laugh, this stuck with me because as someone in a position of power, I cannot play God. I’ll make a lot of different decisions in regard to patient care, some which are mundane, and others that are vital (such as types of antibiotics, intravenous fluids, diuretics, etc). A patient will put their trust in the physician to make these decisions regarding their health, and most of the time will not question this. What are patients’ thoughts about my preference for pencillins over cephalosporins? I can’t say that I have ever seen one ask for one over another, though I’ve been asked specifically about which antibiotic(s) I’m using. Finally, I have had patients outright refuse certain treatments or diagnostic studies. Some that come to mind are refusing a heparin drop for a non-ST elevation myocardial infarction. Another that comes to mind is refusing a CT scan with concern for small bowel obstruction. Although I do not agree with their decision and vice versa, it is of upmost importance to respect patient autonomy when they are capable of making their own choices. I criticize their choices the same way they may criticize any I have made earlier that day, such as specific scrub color or food choice before shift. After all, we are all human. We are not God where we are capable of making the correct decision 100% of the time.

Unfortunately, someone close to me was recently diagnosed with metastatic gastric cancer. He went to his primary care physician due to constipation. One CT scan later he was found to have peritoneal carcinomatosis with an unknown primary. He had an MRI performed thereafter, which also failed to show the primary malignancy. He asked for my advice, and I laid out my “guns blazing” approach. He told me his life has been rough and he is “beyond” what he expected himself to live, and that whenever he is ready to go he will go. I had to stand back, which is a whole lot harder to do when you personally know the person, and respect his autonomy. This is so hard to do, especially when your opinions differ from theirs’. Ultimately, the pain became so bad that he was admitted to the hospital for debulking and subsequent chemotherapy. It has been a rough road, because of course, the worst things always happen to the best people.

As for my friend looking for a specific kind of primary care physician, this brings up a whole other subject. Be your own best advocate. I commute for work and when I’m there, the patients have 110% of my undivided attention. I take great pride in the care that I am able to provide. My goal is to not say the phrase “I don’t know” when it’s pertaining directly to their current condition. I will be the best patient advocate that I can be. If I half-assed my work, I can see either more patients or finish with hours to spare. But guess what? I’m not going to take any shortcuts when someone is entrusting their care to me, in what is ultimately a “bad day” for them. Sometimes it’s a “really bad day.” Unfortunately, sometimes it’s even “the worst day of their life.”

So who am I to them? I’m someone that they will meet on their journey of life. I live 330 miles from the hospital, so I’m not someone that they will see around town. Despite being this random person, I am always hoping to have the most positive impact on their lives. I don’t want any stones eft unturned. I will do whatever I can to avoid saying “I don’t know.” I’ll be the best patient advocate that I can be, but ultimately, the greatest one will be yourself.

My friend’s mother is one of the kindest and most generous people you will ever meet. She was diagnosed with colon cancer, and was horribly mismanaged from the start. After being told she was “cured,” she ended up with eventual metastatic disease. We talk frequently, and it is always difficult to hear how things are progressing. I tell her to find a new oncologist, to ask for the best treatments, and just to advocate for herself as best as she can. At the end of the day, while her colon cancer is her entire life, she is still just one of the many patients a doctor will meet on the journey of life.

This brings me to the song “Where Were You” by Jeff Beck. It’s a wonderful instrumental piece by the late great guitarist. It’s a question that I have asked myself as well as others. I still remember one of my hardest stretches at work ever. There was a two day period where I saw 3 extremely difficult (emotionally-speaking) cases nearly back-to-back. In fact, one of them shook me to the core. I broke down, and I gave the patient the biggest hug I had ever given someone I have only just met. I turned and tosses after that shift, and slept horribly (I usually sleep very well). This weighed down on me for the rest of the stretch, where I was constantly thinking about it.

It wasn’t until I was back home with my family, that I did something therapeutic. I was in bed watching TV with my wife at night. She had already fallen asleep. I logged into Epic on my phone and looked at the lists for the nocturnists working. Why was this important to me? This shows that while I’m at home in bed watching “Chicago Fire,” that my fellow coworkers are still admitting sick patients coming to the hospital. That after all, life still goes on whether I’m there or not.

Recently when I had a few minutes to take a breather, I was schmoozing with one of the nurses. We were talking about video games, Diablo IV, in particular. This brings me back to that time I was watching television at night. While I’m grinding to level up a character class, there are terrible things happening in the world. The most horrific event that ever took place did not happen to a patient, but instead to someone I personally knew. I do not want to get into specifics. But it happened while I was back at home from work. Where were you?

Where was I? Was I grinding in Diablo III? Was I at the park with my children? Was I at a restaurant with friends? Where were you?

I was doing something when someone’s life ended, and when their family’s world stopped. Was I laughing? Was I having fun? I was certainly doing something when the most horrific event imaginable occurred.

This brings it back full circle. I can’t type in dnkroz and dnstuff to give myself God-mode and limitless possibilities. What I can give you is 110% of my undivided attention. I will be the best advocate that I can personally be for you. I will try to make what I believe are the best decisions for you, but will also respect your wishes. But at the end of the day, I’m just another person you will meet on the journey of life. When your life is your health, you always need to be your best advocate. Don’t be scared to ask questions or question things that are being done. It should be a collaborative process. Ask why. Always. You deserve nothing less.