06 June 2009

Obesity is a malignant disease (redux)

Transporting Morbidly Obese Patients « WhiteCoat’s Call Room
A 750 pound woman dies at home. According to police and the coroner’s office, there is no truck big enough to transport her to the morgue, so police call the towing company, they drag her out of her apartment on a mattress and load her onto a pickup truck to bring her to the morgue.
We see lots of bariatrics these days, I'm sorry to say.  (It even blows my mind that it's a widespread enough phenomenon to have acquired a name for the field, "bariatrics.")  Transport is only one of many problems the pose: the firefighters bring them in on special "big boy" gurneys, usually laying on cargo netting which is used to winch them up and down when they have to be moved.   We have special lifts in the ER which can allow a single staffer to move a 500+lb patient, but we usually work in teams.

IV access can be difficult to impossible.  If you are lucky, you can still find a peripheral vein underneath the rolls of fat, but it's difficult to put in anything large-bore for rapid volume resuscitation.  Central lines are just about out of the question in anyone over 400 lbs -- you can't find the landmarks to put the needle in the right place, and half the time they've no neck anyway, which is assuming that they can lay supine and still breathe while you make the attempt.   Also, the introducer needle is "only" 3-1/2 inches long, and in the truly obese the central veins are deeper than that.  It takes real guts to bury the hub of a 3-1/2 inch needle in someone's neck!

Airway management is also a nightmare.   There is so much redundant flesh that you can't see your internal landmarks, and the floppy tissue inside the throat collapses the airway the moment the patient is relaxed enough for intubation. And the trachea is buried deep in case you need to pursue a surgical airway, which is further complicated by the "no neck" phenomenon.  I remember a 700-pounder who needed airway management; I watched as an ER doc, an anesthesiologist, and a surgeon stood at the head of the bed and politely argued over who would have to try first.  I've good success in actually getting those airways, but it's always terrifying.

Once intubated, ventilation is difficult.  The impedance of the massive chest wall and the pressure exerted on the chest by the massive abdomen requires huge airway pressures to force air into the lungs.  I've seen people die simply because we were unable to effectively ventilate them.

And imaging also is tricky-to-unavailable.  Plain films are limited quality due to the technical limitations.  They can't fit on the x-ray table so the films are done portably, which degrades the quality.  Positioning the plate correctly is also hard. And the mass of the patient creates artifact, sort of "washing out" the image and defocusing it. Ultrasound usually does not have the penetration depth available to image the internal organs.  And most CT scanners have a table load limit of 400 pounds or so, so CT may not be an option at all.  If it is available, the patient sometimes still doesn't fit through the "donut hole" if their weight is concentrated around the belly, which either makes the scan impossible or creates beam hardening artifact.  I've heard tales of inpatients being sent by ambulance to the local zoo for CT scans, but I do not know if that's true.

Other procedures are tough.  I had a 450-lb patient recently who needed a paracentesis -- a procedure to take fluid off the abdomen for diagnostic analysis.  The CT scan we were lucky enough to get revealed that the distance between the skin and the peritoneum was 15cm (about 6 inches), and I just don't have a needle that long.  I punted -- the patient was being admitted and I had interventional radiology do it under guidance.

Even the simplest things with the morbidly obese are difficult.  Examining the patient is hard -- sitting them up, turning them, looking at their backsides for pressure sores, etc.  Not to mention that the hygienic challenges of obesity make this somewhat unpleasant as well.   Further, there seems to be an association, not 100% but a strong association, between severe obesity and personality disorders and other psychiatric conditions that makes the interpersonal element of caring for them difficult on top of all the other technical challenges.

If all this makes it sound like I don't exactly relish seeing a patient in the ER whose weight is best measured in fractions of a ton, then you're right.  These folks tend to be very sick, it's hard work taking care of them, and the tools we use are unavailable or ineffective.  And it's becoming epidemic.  What a brave new world we live in.

22 comments:

  1. CPR on a bariatric patient almost always results in one of the staff members getting a few days off work for a wrist injury, and it's not super effective anyway.

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  2. Great job of pointing out some of the many real medical complications of dealing with obese patients.

    These are problems that are not solved by sensitivity. A bunch of people whining about sensitivity is not helpful, when trying to actually treat a patient, or move a patient.

    Too many people don't see the difference between helping the patient and hiding the problem behind sensitive terminology and keeping the patient from being seen during transport.

    The family and neighbors should be ashamed. They are making a media circus out of a person's death for their own financial gain. How long until the lawyers attack?

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  3. This is particularly poignant for me right now in that I learned this morning that a friend of a friend of a friend recently died because his obesity prevented ER staff from securing his airway. I didn't know the guy personally, but it's still unfortunate.

    On the one hand, I want to say this is the reality of our population and someone should be working on finding new techniques that work for them. On the other hand, it's hard to imagine how the rules of physics can possibly be circumvented.

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  4. I can vouch for the zoo CT (in residency).

    Can also tell tales of not knowing a patient's weight at the time of her C/S - too heavy for the scale (500 pound limit, which was exceeded at 34 weeks). Let's just remark on her prolonged recovery, wound infection and DVT...or not.

    How about trying to operate on them?

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  5. We once managed to squeeze one into a big boy wheelchair -- but then the wheels of the chair bent inward so we couldn't push it. I'm not sure how they got her OUT.

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  6. The LP might be my least favorite part, when you have no idea if you're midline or even over a spinous process.

    Ultrasound is incredibly helpful for these patients.

    I had to put in a femoral central line to get access on one woman, and it would have been impossible without ultrasound. (She had absolutely nothing peripherally on ultrasound, either.)

    One story that sticks out is the woman having a STEMI who we had to lyse even though there's a cath lab 2 floors up because she would have broken the cath table motor with her weight.

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  7. Try putting a foley in one of these folks...

    The problems get even worse when they hit the floor, literally, We had a obese patient code (after choking on a piece of pizza, true story) and fall out of bed. This was before we had room lifts and our hoyer wasn't rated . It took all of us (8 nurses, plus the code team) to get her back into bed to transport her to the ICU. Very difficult.

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  8. A while ago I was reading that surgeons in Alberta wanted to charge the provincial health plan extra for operating on morbidly obese patients because of the complications and specialized equipment involved - don't know if that plan went through or not.

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  9. Neither calls for sensitivity nor scolding from the fat-acceptance movement can detract from the realities you've outlined here: obesity is deadly, not just in and of itself, but in the severe limitations it places on the very lifesaving techniques medical professionals rely on to save lives.

    It is important to speak out against the unrealistic and unhealthy body images (particularly for women) on display in movies and fashion. As someone who worked in those fields years ago and, further, who studied ballet since childhood, I am left with what I've come to accept are lifetime body-image and eating issues. Thus, my weight problems are of the opposite kind, and that's what I've written about. It is important to accept your body--or to make a decent attempt to do so--if you're ever going to treat it nicely, feed it well, and have it hold up under stress.

    But I worry that the Fat Acceptance movement denies the very real problems--life-shortening ones, not just issues of finding jeans that fit--associated with obesity. I've read female commenters state that they are happy as can be with their weight at "over 350 pounds", and oh, how pleased they are to have found this place of acceptance.

    Of course everyone should have a place of acceptance and support! But isn't 350+ pounds getting just a little bit close to those very weights Dr. SF says are cut-off weights for commonplace devices like X-ray machines and CAT scanners? And if the person in question is in her twenties, won't that 350 keep climbing in the next two decades? Shouldn't someone, somewhere in that supportive environment, help this person avoid an early grave and, who knows, lessen or eliminate the medications she has to take and even be able to participate in dance or sports?

    Isn't there substantial middle ground between Morbidly Obese and simply Not Being Nicole Ritchie?

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  10. What is your opinion on bariatric surgery?

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  11. LawdHaveMRSA6/08/2009 3:40 AM

    I have had my armpits on knee rolls, my elbows holding back thigh layers, and my "dirty" hand fighting to even enter the area where a more detailed search for a meatus could continue, as well as the other 2 people attempting to restrain the pannus from above, and another retracting the opposite lower extremity, and somehow sometime later, a stream of urine within a tube...to gravity.
    I am sure the entire thing was hell for the pt, but what price comes with the choice/submission to remain in such a daily prison, as a body so obese it cannot run/walk/or eventually even stand?
    The aspect of obesity and mental health disorders is interesting, The effect of psych meds on weight, the likelihood food is a coping/soothing tool used maladaptively,as well as deepening depression when weight loss seems unattainable, gives need for some sensitivity, but the fact that obesity kills needs to be addressed.the price of a pack of cigarettes is 60% tax or more, why are quadruple bacon/cheddar/swiss burgers basically subsidized by the gov. so we can fatten up while we sit in our running cars in the drive thru, on our cells, and eat it while driving 3 blocks back home to return inside and sit on a couch, alone in a 2000sq/ft home w the a/c at 68 degrees...Hell lets colonize the moon so I can get to 900 or more and still maybe be able to walk.
    wtf lol my verify word is tallow is this thing a comedian, or some omniscient being. I vote George Carlin's ghost, bless his hilarious ornery soul.

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  12. We also need more specific terms than "obesity" and "morbid obesity" Since Brad Pitt is obese, and Shaq and I both morbidly obese by BMI, are these terms really usefull? I mean, I am fat, but wear a size 16 and can leg press 400lbs at the gym. This makes MY "morbid obesity" a wee bit different than the 700 pounders. Maybe we need a graded scale, like for Cardiac Disease or Alzheimers progression, so we all know that Stage II morbid obesity (Shaq and I) is not nearly as problematic as Stage VI. OK, any bariatric docs out there wanna write this paper up?? Just mention me kindly in the introduction!

    Pattie, RN

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  13. How bout when they get admitted and the fold-down toilet seats that many hospitals use these days simply break off when the morbidly obese sit on them.

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  14. We indeed sometimes sent patients to the academic animal hospital which supposedly can scan even elephants with their CT.

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  15. A few comments...

    1. The zoo-scanner is an urban myth. It actually exists, but you can't refer patients to it. I tried when I was a resident at Harborview. No go.

    2. You're an ER doc, so you don't need me to remind you of this- but don't forget the intra-osseus line. Its now ACLS approved for adults. The needle is fairly short, but most obese patients do not have inches of pre-tibial fat, and the fat they do have is compressable.

    3. Airway issues- percutaneous trachs. A life-saver.

    4. Central lines? Do you really need one with a good IO line (can't keep them in long-term). The ex-J line, placed under ultrasound, is short, stout and reliable.

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  16. I hate to sound harsh, but these people chose to become this obese. Nobody forced them to stuff their face and become morbidly obese.

    A consequence of this choice is that they may not be able to receive life saving medical care. They should accept the fact that they may die or suffer complications because of this.

    Why should a medical provider be injured, either during CPR as Nurse K mentioned, or when moving/lifting these patients?

    People refuse to accept the consequences of their actions and want someone else to fix it.

    So the next time a 500 lbs patient arrests, then just let him die instead of potentially injuring someone.

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  17. Obesity is not a choice behavior - it is a learned behavior.

    Try teaching yourself not to open your eyes when you wake up.

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  18. Pattie, Brad Pitt is NOT obese. He may have touched the line of "overweight," but he's never been anywhere near obese. And Shaq just barely makes it into the "obese" range with a BMI of 32, and unless you're an idiot, you can look at him and see whether or not he's too fat.

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  19. "Obesity is not a choice behavior - it is a learned behavior"

    Explain to me how it is a learned behavior and not a choice.

    You choose to grab food with your hand, you choose to stuff the food into your face, and you choose to repeat this over and over with the food that you choose.

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  20. Um, to those who think it's as easy as eating less or eating the "right foods" please explain why (depending on the study) 95-98% of diets fail within 2-5 years. (Failure = lost weight being gained back, usually with reinforcements.) Also, even when a diabetic is strict with their diet, there isn't usually a great deal of weight loss achieved. Some people are just fat, period. Yeah, there are people who eat way too much or don't ever exercise, but there are also a lot of people (like myself) who have a very physical job and rarely eat more than 1500 calories a day and will never get below 215 lbs. (I'm not dieting, I just don't have much of an appetite.) The fat acceptance movement might seem unhelpful or unrealistic, but when you have a 5% chance - at best - of losing weight and keeping it off long-term, it seems kind of crappy to heap a bunch of guilt on top of it. Making me feel bad about myself isn't going to magically put me in another weight bracket, or I'd have been within the "normal" range years ago.

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  21. I am 400 plus pounds.


    I learned to just keep eating at the dinning table every night to keep from breaking down and crying in front of everyone. When biting my lip and tounge didn't work I would say I needed to go to the bathroom. My thoughts everyday were to dream of a new life, of being rescued. And I was thinking of suicide since about age six and I was going to kill my self when I learned how to when I got older. But at a church service a loud minister was yelling his sermon and I was laying on the floor or church seat with my five brothers and sister, when the man said if you commit suicide you would go straight to hell! I was broken hearted, I went to the bathroom and cried.

    My uncle came to our house six out of seven days a week. He ate dinner with us every time. My uncle went on all our vacations.
    He was always trying to chase or tickle me.

    I was sexually molested by my uncle at about age 4 until about age 7 at age 6 I remember thinking if I just pretend to be asleep he won't wake me up to do it. I was wrong, he elbowed me and said "Get the lotion" he would smear a bunch inside my vagina and on his penis. Then have sex with me.
    This ended when I was about eight. because my brother having seen what happened and told a neighbor. My mother was called and we went to the neighbors house. I cried and welled in tears sure I was in trouble. My mother said my sister and I could not stay the night there anymore.( I could tell by my mother's body language the problem was not to be discussed ) I was relieved, it was over, my nightmare was over! WRONG!

    I had infections all the time. My doctor said; my peeing of my pants was because I was lazy. My mother found a doctor, that found a medical problems and I had surgery.


    My father the jerk now targeted me. After surgery I was to sleep on the sofa bed no climbing stairs. My mother worked nights and so my father came to me and took me to the restroom and attempted sex then in my mom and dads bed. He only tried three different times in two week period. My dad never figured out how to get penetration.
    He would call me a slut, tramp and whore for years after that.
    Until I was about twenty tears old and slapped him across the face. 'THAT FELT SO GOOD!

    So when I was nine and examined, how come they did not help me ???
    Why didn't medical staff say something ?

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