AskDrRachel.com

Scenario: Imagine that you are a person who weighs over 450 pounds.  You are one of between 5-7% of the American population described as "severely obese."  You are at higher risk of heart attack, stroke, diabetes, arthritis, chronic pain, and disability than even a merely "obese" person.  You are more likely to live in poverty, and yet your medical costs are almost double what a person of normal weight can expect every year.  You find it difficult to keep your body clean from its daily functions, so you sometimes notice an unpleasant personal odor.  Add to that the derisive staring and finger pointing you encounter almost daily by passers-by and your quality of life is already much lower than it would be if you were thinner.

Now, imagine being gripped suddenly with the worst abdominal pain of your life.   From the floor of your bathroom you drag yourself to the phone to dial 911, knowing you cannot make it any further.  What you may not know, however, is that despite the healthcare team's best efforts, your obesity itself may cause you to receive a lower quality of medical care than others who seek help that night.  Read on to see how obesity affects our ability to provide the best care for you, our imaginary (but all too often real) patient, and extrapolate how the continued obesity epidemic could affect the future costs of healthcare for all of us.  Note: the information presented below is based upon multiple studies discussing the challenges of caring for obese patients - I did not make this up...

TRANSPORT: NO EASY ROUTE

When the ambulance arrives, the crew realize that their normal gurney will not support your weight, and that the two paramedics who came to the door cannot lift you safely by themselves.  It will be another 30 minutes before the fire department can come with a crew of strong men and a tarp, and if you live in a big enough city, a "bariatric" transport vehicle equipped for the severely obese patient.  You may continue to lie on the floor in pain during that time, because it will be difficult for the paramedics to find a vein into which to place the I.V. in order to give you medicines.

Once you are rolled onto a tarp and lifted into the special vehicle (or onto a flatbed truck - REALLY - if a special vehicle is not available) you will be brought to the Emergency Department.  Many hospitals now have beds that can accomodate patients up to 500-800 pounds, so if one is available you'll be placed on it; if not, they'll try to make due with whatever they can find.  Beds have collapsed beneath obese patients for no other reason than that a more secure bed was not available.

IN THE EMERGENCY ROOM: LIMITED IMAGING

The ER staff and physicians will begin their assessment of your concern as they would for any other patient, but the abdomen is a difficult area to examine in the skinniest patients, and imaging is frequently necessary to help find the source of your pain.  Herein lies your next problem: almost every hospital in the nation has CT and MRI scanners.  Most do not have scanners that can accomodate your girth.  The limit on most machines is between 300-350 pounds, with very few able to handle a patient weighing 400 or more pounds before the platform buckles under the weight.  These machines cost beaucoups, and the hospital has to make business decisions when choosing which machines to buy.  Some bariatric surgery centers and outpatient MRI facilities have scanners that could help, but they won't allow an unstable ER patient to be imaged there at midnight.  The local zoo might have a scanner big enough, but none of them will allow humans to be imaged there due to liability concerns.

Plain x-rays cannot reliably penetrate your fat with the x-ray beams, and doctors know that you have double the risk of us missing a diagnosis on x-ray because of your size.  So, instead of having a quick CT scan of your belly to make sure your appendix hasn't ruptured, you sit in the ER while the physician decides whether to call the surgeon or to monitor you a bit longer.  In the interim, whatever is causing your severe pain continues to brew in your belly, and the doctor and nurses are as frustrated as you are with being unable to make a rapid diagnosis.  You could be incredibly ill or simply very constipated, but it will be hard for the doctors to know.

IN THE OPERATING ROOM: LIMITED EQUIPMENT

The ER physician speaks to the surgeon and the surgeon decides you need an operation tonight to find the source of the problem.  They are again faced with the dilemma of finding a surgical table that will support your weight.  You will need to be intubated and placed on a ventilator for the operation, but because of the excess fat around your neck, it will be harder for the anesthesiologist to find your vocal cords and pass the breathing tube.  It may be more difficult for the anesthesiologist to calculate the correct dosage of medicine to paralyze you and to put you under because medications are often processed in fat cells, and the more fat you have, the more difficult it can be to fine-tune the process.

Once you are under, the surgeon scrubs and opens your belly.  This is normally done laparoscopically, using cameras and tiny instruments on the end of tubes inserted through little holes in the abdomen, which has been inflated with gas so the surgeon can see what she's doing.  To hold the holes open and to keep the air inside, tools called trochars are poked into the belly and stay there throughout the procedure.  However, most trochars are only a few inches long, and the standard ones are not big enough to penetrate your skin, fat, muscle and abdominal lining, so special - and yes, more expensive - trochars must be found.  There are fewer large trochars in the supply room than regular ones, and if the last surgery was also done on an obese patient, you'll have to wait while they sterilize them for your surgery.  If your hospital doesn't have larger trochars, the surgeon's job will be more difficult, because she'll have to push on them harder to be able to see what she needs to see, and the tubes will slip out of place frequently.  Your surgery will be, by definition, more difficult than surgery performed on a normal weight person and you will have an increased risk of complications despite the doctors' best efforts.

ON THE FLOOR: DIFFICULT RECOVERY

Successfully out of the O.R. after having your appendix removed, you are sent to the surgical ward.  Like every other patient, you are likely assigned to a team of nurses and nurse aides who work together to care for you.  However, it will take twice the number of staff members to transfer you from the gurney to the bed, twice the number to turn you and provide your basic care needs.  You may become frustrated by what you perceive as lack of response to your requests for toileting assistance and other needs, because the staff have to recruit other people away from their other duties to help them care for your concerns.  In the best of circumstances, the staff will have access to special machines to lift you out of bed and to transport you, but more often than not, your movements will become part of an elaborate ritual of request, answer, wait for recruitment and difficult response.

You will be in the hospital longer, have more complications (such as diabetes, heart attack, pneumonia, bed sores and blood clots) and be more dissatisfied with your care than a person of normal weight.  Your stay will have cost more, and more likely than not, the bill will be paid by the taxpayers. 

OPINION: We need to do more to prevent obesity and to treat its causes.  As we continue to work toward safe and compassionate care for patients of all ages, backgrounds and weight classes, we must include a discussion of the obesity problem as we debate the future of our healthcare system.  And I will continue my efforts to harp on the benefits of healthy lifestyle for myself and my patients.

For more information or to suggest a subject for the blog, please visit my Facebook Page, "Dr. Rachel Franklin" and send me a message.  Here's to a better life for us all!