How to discharge Severely, morbidly Obese (BMI>50) patients?

[DrMetal]

For the hospitalists in the group:

How do you discharge your grotesquely morbid obese patients? How do you get them out of the hospital, if they're too fat to get out of bed, but otherwise medically complete/ok? If they can't bear any weight on their legs?

Can't go to a SNF (because they can't participate in PT). Can't go home (its not a 'safe discharge', despite the fact that many came from their God-awful mess of a home). Can't do LTAC.

I have one BMI > 70, total jerk of a patient too, rude to every one.

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[chessknt]

We send demented people to SNF and they can't benefit from PT either, why not the obese?

In reality they just live in the hospital forever. Put them on a calorie restricted cardiac renal carb controlled diet to motivate them to leave 'ama,' but even that isnt a strong enough motivator for all then youre just screwed. Make sure you take away anything that might be detrimental to them making 'progress' (like narcotics, anxiolytics etc) and if they stop participating in PT you might be able to get support for forceable discharge depending on your state laws (eg discharge pt, if they dont leave call the police and have them arrested for trespassing).

Most hospitals have some kind of charity fund that just pays for them to leave and go to a SNF or something because the cost is less than being stuck in the hospital.

 

[DrMetal]

We send demented people to SNF and they can't benefit from PT either, why not the obese?

If they can participate in PT/OT, then yes demented go to SNFs. Otherwise, to a 'Memory Care Facility' (whatever the hell that really is).

Make sure you take away anything that might be detrimental to them making 'progress' (like narcotics, anxiolytics etc)

I'd love to. The only problem in doing this, is you only cause consternation for nursing, especially if the patient is an a**hole.

My Chinese and Russian friends tell me that in their home countries, these patients kinda just 'disappear'. I wonder what that's all about?!

 

[sloh]

Put them on a calorie restricted cardiac renal carb controlled diet to motivate them to leave 'ama,' but even that isnt a strong enough motivator

That’s quite impressive. On the part of the patient haha.

 

[sloh]

If they can participate in PT/OT, then yes demented go to SNFs. Otherwise, to a 'Memory Care Facility' (whatever the hell that really!

I round at SNF’s. You’d be surprised how many demented patients who can’t participate in PT/OT reside in SNF’s. Criteria can be fudged.

 

[VA Hopeful Dr]

If they can participate in PT/OT, then yes demented go to SNFs. Otherwise, to a 'Memory Care Facility' (whatever the hell that really is).



I'd love to. The only problem in doing this, is you only cause consternation for nursing, especially if the patient is an a**hole.

My Chinese and Russian friends tell me that in their home countries, these patients kinda just 'disappear'. I wonder what that's all about?!

Had this happen in residency. No nurse would have him as a patient more than once every 3-4 days, helped prevent any single nurse from getting burnt out on him. Nurse manager and charge nurse would even take shifts where they took care of him as needed.

It was immensely frustrating as I had this guy for 3 weeks, but after he finally left he stayed gone for at least the next 18 months (until I graduated). It sucked at the time but had a good pay off.

 

[DrMetal]

Had this happen in residency. No nurse would have him as a patient more than once every 3-4 days, helped prevent any single nurse from getting burnt out on him. Nurse manager and charge nurse would even take shifts where they took care of him as needed.

It was immensely frustrating as I had this guy for 3 weeks, but after he finally left he stayed gone for at least the next 18 months (until I graduated). It sucked at the time but had a good pay off.

What a wonderful country we live in, that we care for these slobs (and sometimes at no cost to them, as they have no insurance and no means to pay). That we provide so many social and medical services for them, that they don't comply, are rude, and still we care for them . . .is all a testament to what a generous place the U.S. is.

I tell ya, lest anyone criticize healthcare in the United States; in other countries/societies: patients like this would be left for dead (maybe even euthanized).

 

[NewYorkDoctors]

and at the same time we have doctors and other health care figures saying we need to body positive and not shame patients.
I agree with that statement from a functional perspective. Shaming obese patients accomplishes nothing and merely makes them not want to do anything.

But these same hand holding, tree hugger "obesity medicine specialists" offer ZERO ACTUAL SOLUTIONS besides talk talk talk talk and make academic meetings after meetings and just talk some more. oh sure there is semgalutide and tirzepatide but good luck getting those approved outside of someone with very good commercial insurance (which in that case few of them are so obese due to better SES)
there is always phentermine but good luck having patients shell out money. heavne forbid they shell out money for their health. hey patients you know what does not cost money? walking 10,000 steps per day while watching TV In your home. just don't sit on the couch. stand up behind the couch and walk in place or pace aroudn while watching TV and use a $5 pedometer to track your steps. it takes about 100 minutes of pacing around at a walking pace to get 10,000 steps. you can't even do that while watching TV??

My solution for the obese patients I see (well no one at BMI 70.... for that person my advice will not work) is give them a pedometer and email.
As they spam my email with BS about something they read online, I spam them back about why they have not gotten their steps up yet?

I can count on my two hands the number of patients who have responded to this motivation and have dropped 20-30 lbs with using a pedometer and walking 10,000+ steps a day (doing so indoors in their comfort of their own homes without any judging eyes) by walking around and pacing around in the home.

why do I bother? because these sleep apnea patient all refuse CPAP and just come to me to complain otherwise. if I say RTC PRN, their ****ing PCPs gaslight the patients to return. it's a vicious endless cycle if I dont step up and step in and do the Internist's job as well.

 

[Splenda88]

We had a patient like that at the VA (BMI > 70) when I was in residency. Very obnoxious and would call his congressman when he did not get his way. He was there for at least 5 years (I was told he died last year)

Getting that guy out of his room to get a CT was like the US preparing to go to war with China or Russia.

We all proposed for the VA to build a house for him.

 

[Splenda88]

What a wonderful country we live in, that we care for these slobs (and sometimes at no cost to them, as they have no insurance and no means to pay). That we provide so many social and medical services for them, that they don't comply, are rude, and still we care for them . . .is all a testament to what a generous place the U.S. is.

I tell ya, lest anyone criticize healthcare in the United States; in other countries/societies: patients like this would be left for dead (maybe even euthanized).

When it comes to healthcare, US is a LOT more generous than they should IMO.

I got reported already to patient relation for suggesting a patient to lose weight after she complained of knee pain.

 

[DrMetal]

ese patients I see (well no one at BMI 70.... for that person my advice will not work) is give them a pedometer and email.

Give them your email?! You are a brave soul.

We had a patient like that at the VA (BMI > 70) when I was in residency. Very obnoxious and would call his congressman when he did not get his way. He was there for at least 5 years (I was told he died last year)

Getting that guy out of his room to get a CT was like the US preparing to go war with China or Russia.

We all proposed for the VA to build a house for him.

I actually tried to transfer a patient once to the local zoo, to use their elephant scanner. Nobody thought it was funny, but I did (and that's what's important, my amusement).

When it comes to healthcare, US is a LOT more generous than they should IMO.

Quite true. It's our own fault.

 

[VA Hopeful Dr]

We had a patient like that at the VA (BMI > 70) when I was in residency. Very obnoxious and would call his congressman when he did not get his way. He was there for at least 5 years (I was told he died last year)

Getting that guy out of his room to get a CT was like the US preparing to go war with China or Russia.

We all proposed for the VA to build a house for him.

There's a guy on a vent for 2 years in the VA ICU when I rotated through is a student. They kept trying to get family to pull the plug but they were enjoying his VA benefits too much to want him to die.

 

[NewYorkDoctors]

Give them your email?! You are a brave soul.



I actually tried to transfer a patient once to the local zoo, to use their elephant scanner. Nobody thought it was funny, but I did (and that's what's important, my amusement).




Quite true. It's our own fault.

well it's a work email that has an auto-reply for "if this is a medical emergency pleas call 9-1-1-"

yep I must filter all the junk and not waste valuable office time talking about a laundry list of **** and ****. I'd rather link them youtube and UpToDate links for them to read while not wasting my office time.

anyway I recall in residency there was an individual BMI > 70. this individual needed a CT scan and we literally called the Bronx Zoo to use their scanner. it was quite the feat to get that CT scan done and scans relayed to our hospital's radiologists.

 

[DrMetal]

There's a guy on a vent for 2 years in the VA ICU when I rotated through is a student. They kept trying to get family to pull the plug but they were enjoying his VA benefits too much to want him to die.

If we charged the family with the $2K/day hospital bill, I bet they'd think twice about said benefits.

this individual needed a CT scan and we literally called the Bronx Zoo to use their scanner. it was quite the feat to get that CT scan done and scans relayed to our hospital's radiologists.

Did you actually get it done?! That's amazing. I was blocked by the local veterinarian who needed the scanner to diagnosed a pack of sick baby elephants. I don't blame her, she was right to block us. The lives of baby elephants are way more important than that of some human beings.

 

[NewYorkDoctors]

If we charged the family with the $2K/day hospital bill, I bet they'd think twice about said benefits.



Did you actually get it done?! That's amazing. I was blocked by the local veterinarian who needed the scanner to diagnosed a pack of sick baby elephants. I don't blame her, she was right to block us. The lives of baby elephants are way more important than that of some human beings.

yes. case management was on track and got it done. i don't know what favors were done. i just knew i did not have to cover that patient for a few hours

 

[Splenda88]

There's a guy on a vent for 2 years in the VA ICU when I rotated through is a student. They kept trying to get family to pull the plug but they were enjoying his VA benefits too much to want him to die.

This is how crazy the system has become. We need to get these damn lawyers and these so called ethicists from these ivory towers out of medicine.

 

[NewYorkDoctors]

speaking of benefits, I have recently found a cohort of patients I see with GERD cough (yes the PCPs keep sending and resending and gaslighting these patients to see me.. I have done bronchoprovocation testing and ruled out asthma, CT chest to rule out bronchiectasis, and barium esophagrams have shown GERD... these patients never want to go to academic GI for bravo studies..) have been clamoring about wanting prior authorization for Nexium. This is rather odd as it is OTC. Yes I am cognizant poor folk cant afford $20 for Nexium a month. BUT they do have $150 of OTC money on an OTC card from their medicare a month. When I bring that up, they are mum. On talking to certain patients, it seems that loca unscrupulous pharmacies (mom and pops) are giving the patients $100 worth of vouchers for local grocery stores in exchange for taking the $150 of OTC money....


and thus I get asininine whining yelling screaming old people wanting PA for their Nexium.

Ive told them go see PCP but PCP gaslights them straight back to me.

in order to get a moments of peace, I give them their PA for Nexium... but they at least GERD cough finally calms down.... or at least that's what they tell me... I see a lot illegal street vendors selling nexium on the streets of NYC these days....

 

[Splenda88]

speaking of benefits, I have recently found a cohort of patients I see with GERD cough (yes the PCPs keep sending and resending and gaslighting these patients to see me.. I have done bronchoprovocation testing and ruled out asthma, CT chest to rule out bronchiectasis, and barium esophagrams have shown GERD... these patients never want to go to academic GI for bravo studies..) have been clamoring about wanting prior authorization for Nexium. This is rather odd as it is OTC. Yes I am cognizant poor folk cant afford $20 for Nexium a month. BUT they do have $150 of OTC money on an OTC card from their medicare a month. When I bring that up, they are mum. On talking to certain patients, it seems that loca unscrupulous pharmacies (mom and pops) are giving the patients $100 worth of vouchers for local grocery stores in exchange for taking the $150 of OTC money....


and thus I get asininine whining yelling screaming old people wanting PA for their Nexium.

Ive told them go see PCP but PCP gaslights them straight back to me.

in order to get a moments of peace, I give them their PA for Nexium... but they at least GERD cough finally calms down.... or at least that's what they tell me... I see a lot illegal street vendors selling nexium on the streets of NYC these days....

You seem to have issues with the PCPs in your town...

I am not an outpatient PCP but I have noticed that some patients don't listen to their PCP and tend to lie about things.

 

[NewYorkDoctors]

You seem to have issues with the PCPs in your town...

I am not an outpatient PCP but I have noticed that some patients don't listen to their and tend to lie about things.

most local PCPs just refer everything and don't do any heavy lifting. they are not incentivized to do so. they are incentivized to take care of the lowest of brush hanging fruit and then referring every thing out with no real workup or initial management.
condense that same 99213 into a 2 - 5 minute encounter at most.

while I thank them for their business... this also means im stuck handling primary care level "nuisances" when chronic and serious disease is ruled out. in the long run, this is NOT profitable for me seeing all these low level 99213s.

I have gotten acute cough referrals.....

patient coughing with purulent sputum
auto z-pak
cough not better
refer to patient to see me by day 7.

so what am I to do?
assess asthma, pneumonia, sinusitis/PND ....
talk the patient out of a CT chest
induce some sputum to evaluate for any ongoing bacterial processes
get them some nebulized saline for pulmonary hygiene to clear out all that "phlegm."
treat and manage their GERD and postnasal drip.
a little much? perhaps... but the sure feel better.... I think

even for patients with stable disease like GINA Step 1/2 asthma or COPD GOLD A/B that is overall stable... I write a consultation note explaining this.. if patient stable PCP can renew said inhaler or what not

local PCPS tell patients they cannot refill their inhalers and they must come see me. total gaslighting of the patient


edit I am not trying to bag on all PCPs like "that jerk arrogant specialist."
I do PCP myself as well for certain patients. With my subspecialty background I have a higher threshold for referring out (unless a procedure is needed) due to that cockiness I guess...
some PCPs really do their job and they send the appropriate referrals that I say I take full ownership of.
those PCPs usually send me workup and their brief notes and rationale

the PCPs that send nothing to me are usually sending nuisance referrals... i doubt they even write notes... probably jsut file a 1500 form claim with ICD and CPT codes only and dont write anything. would not surprise me

 

[chessknt]

I've long been an advocate that if a group of doctors decides that care is no longer appropriate that the cost burden of care be shifted onto the patient or their surrogate decision makers if they aren't making their own decisions and be removed immediately once financial support was no longer available

 

[VA Hopeful Dr]

You seem to have issues with the PCPs in your town...

I am not an outpatient PCP but I have noticed that some patients don't listen to their and tend to lie about things.

I think PCPs in NYC are worse about this than most.

 

[wamcp]

This is how crazy the system has become. We need to get these damn lawyers and these so called ethicists from these ivory towers out of medicine.

The most blatant exploit of the US healthcare system I ever saw was a non-US citizen patient flown in from Pakistan by his daughter. He had a chronic GI condition but otherwise was fine - he could eat and drink, just had chronic pain NOS. however also had Parkinsons and needed at least assisted living care. The freeloading f*** of a duaghter had him kept inpatient for over FIVE YEARS. Not continuously but bounced hospital to hospital. She did NOT want to take on the financial burden of taking care of her father- not at home with services and did not want him to live with her and disrupt her life- and also didn’t want to pay for a facility.

She was ALWAYS unreachable when we wanted to discharge him every day. Eventually required legal to send notice of imminent court proceedings to remove daughter as guardian and allow an attorney decide for him to discharge. Then she would magically appear and take him out via wheelchair….only to dump him at another ER across the street. Where he would stay for months until rinse and repeat

Millions of taxpayer dollars wasted on a non citizen who legally needed to be deported but this was not going to happen in the state i was working at the time.

And this is why i am a nocturnist. I can’t change the system and i don’t want to deal with the daily BS if I can’t

 

[NewYorkDoctors]

The most blatant exploit of the US healthcare system I ever saw was a non-US citizen patient flown in from Pakistan by his daughter. He had a chronic GI condition but otherwise was fine - he could eat and drink, just had chronic pain NOS. however also had Parkinsons and needed at least assisted living care. The freeloading f*** of a duaghter had him kept inpatient for over FIVE YEARS. Not continuously but bounced hospital to hospital. She did NOT want to take on the financial burden of taking care of her father- not at home with services and did not want him to live with her and disrupt her life- and also didn’t want to pay for a facility.

She was ALWAYS unreachable when we wanted to discharge him every day. Eventually required legal to send notice of imminent court proceedings to remove daughter as guardian and allow an attorney decide for him to discharge. Then she would magically appear and take him out via wheelchair….only to dump him at another ER across the street. Where he would stay for months until rinse and repeat

Millions of taxpayer dollars wasted on a non citizen who legally needed to be deported but this was not going to happen in the state i was working at the time.

And this is why i am a nocturnist. I can’t change the system and i don’t want to deal with the daily BS if I can’t

i see plenty of "undocumented migrants" in NYC now... they "just came to America" a few months ago. I'm not going to get all political about this on SDN.

but let's say they all have managed Medicaid. it's free lol. i can only say NYC is the only place in the US i can think of (maybe LA im not sure) where anyone can come and get free healthcare. in contrast my colleagues down in FLorida says undocumented people only have some form of emergency medicaid and can't ge tanything done.
NYC managed medicaid is sweet too.
no deductibles, no copays, very easy prior authorization for radiology, it's very easy to get PA for Ozempic for weight loss too... just lie about the diabetes no notes required lol, some people have cancer or SLE and then get hooked up with a community onc or rheum and get their disease under quick control... this is literally better than concierge medicine


dont get me started on ESRD.... those patients get managed Medicare + Medicaid very quickly and very easily....

 

[NewYorkDoctors]

You seem to have issues with the PCPs in your town...

I am not an outpatient PCP but I have noticed that some patients don't listen to their PCP and tend to lie about things.

to be fair most patients want to hear "good news only" and don't want to hear "anything tough."

plus many patients want to see that good old friendly country boy/girl family doctor from back in the day who would carry a big of tools around and say things like "now you take two and call me in the morning dear."

yeah that's not how modern medicine works. one can say those things.... but only after ensuring all the Ts are dotted and all the Is are crossed.
im not sure about what the state of EBM was back then in the 50s and 60s