21 July 2010

Let it be noted

The patient was in her late sixties. She presented with an acute headache and confusion. She was diabetic, with a high white blood count, and had a fever at home.  She also weighed 350 pounds and stood all of 5'2".

There was no way around the unpleasant fact that she needed a spinal tap.

I avoided the procedure for a solid hour, finding other important tasks to keep myself busy, but eventually I had to face the music and try the tap.  These are tough enough on only moderately plump folks, and in the morbidly obese patient they are incredibly difficult.  This lady was too weak to sit up on her own, so I had two techs wrestle her into an upright seated position, and, sweating, brace her in place while I contemplated her back.  There were no hints as to any landmarks but, sitting up, at least I had a vague idea of where the midline was. I (literally) closed my eyes and jabbed the needle in at random.   I shoved it all the way in, burying the hilt and even pushing it in further, indenting the skin and subcutaneous fat.

It is hard to register my shock and delight when pressurized CSF came jetting out.

I collected my specimens and the techs gratefully laid the patient back down.  I then proceeded to the nursing station where I did the "I Am So Awesome Dance of Victory and Unrestrained Joy."  One of the nurses put a couple of ice cubes down the back of my shirt, terminating the "I Am So Awesome Dance of Victory and Unrestrained Joy."

But I am still awesome.


  1. Wow, you are awesome. A few years ago, I had some unexplained illness (fever of 100+ for 22 straight days and lost about 20 pounds). Finally, a spinal tap was ordered. I'm 6'2" and 185 at the time. I was stabbed to the hilt, as you say, 6 times before number 7 brought back fluid. Wish you were working in that hospital on that day.

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  3. ah yes, there are few moments as satisfying as that one.....except for the one when the lab report comes back with no RBCs in tube #1!

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  5. Ha! I did that dance just a few days ago! See, I successfully did a blind cystocentesis (no u/s) on a grossly obese (138 lbs,) Labrador bitch whose owners had let her pee in the parking lot on the way in!!

  6. I did a similar dance when i hit the deep, barely palpable port on a 350lb, 6' guy with a 3/4 inch needle (all we had). Didn't close my eyes... but only because the patient could see my face. (;

  7. Are you sure it wasn't urine?

  8. Congrats!

    When do you decide to do it yourself and when do you send the patient to fluoro to do it there? Seems like a lot of the spinal taps in our hospital get done under fluoro (or maybe it just seems that way from a MI perspective).

  9. anon,

    Thanks for translating the Chinese span. That's hysterical.


    Radiology won't even try a tap under fluoro unless we have tried and failed first, which honestly strikes me as reasonable, especially when it is 2Am and they're home asleep.

  10. The ironic part is that the huge patients that you send to fluoro are the ones that it is hardest to see the spinal tap needle because of the massive scatter caused by their size (even with the filters in place).

    Big people just don't win against the laws of physics.

    Well done on getting the tap! That is impressive.

  11. was it complete and utter luck or were you able to feel around the spinous processes somehow? star quality nevertheless.

    as a rad in a hospital with pretty good er docs I have to say most of the lp's I do see are on those with a bmi over 35.


  12. As a person with a BMI over 35, knowing that we are a "growing" part of the population, it's really discouraging to read medical blogs that disparage the obese. (This one wasn't horrible, but an hour delay in care due to size is...disheartening.) I get that there are challenges, just as there are due to small size in pediatrics. Is there any research on easier/better ways to manage large patients--it doesn't look like we're going away any time soon and we ARE one of your "larger" profit centers.

  13. Dear person of girth:
    Put the donut down. Now!
    Too bad about the hurt feelings. We deal with all sorts of difficult patients, including, as you note, children, who tend to be of small stature. We also deal with people who have deficient veins, not all of whom are drug users, and many of whom say something apologetic about their small veins. Some of our patients are difficult because they were unfortunate enough to be born with cystic fibrosis, sickle disease, or have developed brittle diabetes, heart failure, or any of a number of congenital or acquired diseases along the way.
    You have donut poisoning. Not a slow metabolism, or low thyroid. You eat too much. The only cure for small stature is waiting a few years, not practical in the ED, where we measure wait times is days or weeks, not years. The other diseases that I mentioned cannot be cured, no matter what, but we help our patients manage the complications. There is a cure for obesity, but you don’t want to hear it. Move more, eat less. It’s 100% effective. No, really, 100%. It’s difficult to be compliant with this treatment regimen, but not impossible.
    And however difficult it may be for you to comply with this physician’s prescription, it pales in comparison to the difficulty that you inflict on doctors, nurses, and techs in the medical system. You take a lot more time to do the simplest things, such as starting a routine IV. SF’s success in doing the LP on a POG was reportable, with congrats due from all of us and well-earned. As a surgeon, working on you is a challenge at best, and you tend to have more complications, infections, and recurrences of many of your problems. You cost the medical system more in terms of resources and time, and because you are over-represented among the poor folks, we are reimbursed less, if at all, for your self-imposed problem.
    It’s especially galling that you resent that SF spent an hour (a whole hour!) doing “other important tasks” before attending to the POG’s spinal tap. Most docs are overscheduled and have to prioritize. We do the quick things first to optimize patient flow and set time aside mentally for the tasks that we expect to take extra time. It’s like a bonus when something such as a procedure on a POG goes quickly.
    You want research in how to more easily manage POGs? We buy lifts, take lessons in how to move POGs around without injuring ourselves in the process, and round up extra techs in the OR when we have to move you from the gurney to the OR table. You? You can put down the donut.

  14. @Anon - "There is a cure for obesity, but you don’t want to hear it. Move more, eat less. It’s 100% effective. No, really, 100%."

    No, it's not. Seriously, I get annoyed with the fat activism movement sometimes - usually about Type 2 Diabetes and certain issues with classism - but it is not always possible for people to lose weight. I have known people who go down to ~1,000 calories/day and still don't shift it, because their metabolisms have been screwed up by past habits and then go into starvation mode.

    I'm sure that, as a medical professional, you see a lot of people who are overweight and present no medical reason for it, and who do suffer from it, but you can't just gloss over, ignore, or mistreat the people who don't fit that type.

  15. As a tech I can relate to the anonymous surgeon. It's to the point that we get excited when a normal - sized pt. is rolled into the OR. The other day I finally had to break scrub to help a tiny circulator struggle to prep a leg as big as her waist. Longer instruments/supplies, sleds to make the OR bed wider, sore backs, difficult intubations, extra sets of hands just to hold the fat out of the way so the surgeon can even access the area to be operated on -these are now commonplace. A surgeon's job is tough enough - I don't blame him or her for feeling frustrated.

  16. To Anon @ 11:40. You are correct. I "can't just gloss over, ignore, or mistreat the people who don't fit that type." And I don't. I take care of them to the best of my ability. What I do not do is excuse them, or allow them to make me feel bad because I don't accept it when they claim to be a "profit center" for us, as the POG claimed to be. Except in the case of bariatric surgery, where nobody touches a patient until payment is assured, morbid obesity tends to be concentrated in the Medicaid or unfunded segment of our society, and therefore is not a profit center. Even when a POG has blue cross, it's difficult to make a buck taking care of people who have more than their share of complications.
    You can claim that you "have known people" who have failed to lose weight on 1000 cal/day diets. You will have to do better than your anecdotal claims- I have decades of nutritional science and the laws of thermodynamics on my side. Even in so-called starvation mode, everybody eventually loses weight. I'm not saying that starvation is a good or healthy way to go, but diet and exercise works every time.
    Anon tech @ 10:34. You guys are the unsung heroes of the OR- set up, help us, clean up, do it again. You are the guys and gals who truly move the meat. Thanks.


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