Obese Patients

[docB]

I've recently had another spate of 400 lb + patients. I'm always amazed how these people have no concept of how hard it is to care for them. They can't fit in scanners or MRIs, they can only generate poor quality Xrays and VQ scans, IV access is very difficult and risky, airway is a nightmare and they all have sleep apnea. But they never seem to understand why they just can't get the same treatments/diagnostics as regular people. They yell at me that the scanner should be able to accommodate them. That's great. Why don't we call GE and tell them that. I'll get right on it! I feel like you should have to sign a special disclaimer stating that you understand that as a >400 lber you aknowledge that you can't get some things. We should do the same thing for anyone that claims over 3 "allergies."

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[mikecwru]

I feel like you should have to sign a special disclaimer stating that you understand that as a >400 lber you aknowledge that you can't get some things.

..... except Chicken McNuggets

mike

 

[Apollyon]

What's the closest vet school to the LV metro area? Only once have I considered NC State (for the large animal CT).

There is something else, though - the table's as strong as whatever you put on it. There's a story that a cardiologist here had a big fatty - ~700lbs. The table was rated for 350, but he called the manufacturer, and was told that the failure load was 1400. So, he put 700lbs of fellows on the table, and was able to cantilever it around, and thus was born the story that we have a "700lb cath table".

Interventional has the exact same table, but they were unwilling to try the 500lb guy on it. Cowards.

We ended up doing a flat plate (kind of ironic to call it that) and try an IVP, which were unsatisfactory. Ended up empirically treating the guy for renal stone vs. pyelo.

 

[DrMom]

I always like going into some morbidly obese DMII pt's room to find them lying in bed eating a bag of chips and Mountain Dew...with a snickers wrapper lying nearby. I swear that this exact scenario has happened more than once.

Because of these folks, our ICU now has beds that can hold 1000 pounders.

 

[Apollyon]

Because of these folks, our ICU now has beds that can hold 1000 pounders.

Oh yeah - the "big boy" (I am not making this up) bed.

 

[tonem]

Oh yeah - the "big boy" (I am not making this up) bed.

is that the same bed that has the lifting mechanism they use to pull engines out of cars built in?

 

[Apollyon]

is that the same bed that has the lifting mechanism they use to pull engines out of cars built in?

The big boy bed is reinforced, but doesn't have the Hoyer lift (what you're referring to).

 

[Jeff698]

I always like going into some morbidly obese DMII pt's room to find them lying in bed eating a bag of chips and Mountain Dew...with a snickers wrapper lying nearby.

Let's make a special hospital wing for these folks and put it right next to the courtyard where the trached, O2 dependent COPDers are out smoking in between coughing fits. And, for that matter, right next to the trauma SICU.

I thought my attending was loopy when he first said trauma is a chronic condition. Now I get it.

Take care,
Jeff

 

[DOrk]

There was an interesting piece about obese patients in the December 2004 issue of the Annals of Emergency Medicine ("The Loading Dock" page 660).

 

[la gringa]

jeff, only problem is you couldn't pay anyone enough to work in there!!!!

we had a 400lbs lady in the stepdown aka chronic vent unit... one day the nutritionist said she was "malnourished"... we all almost fell down laughing. while it is possible, i guess, it just sounded too hilarious to be true! also, you had to bribe her with junk food to get her to do anything at all. ugh.

 

[typeB-md]

well the problem is we have psychiatrists going around trying to get obesity labeled as a disease and disability. and eating is an addiction. when you have people like these fighting to justify obesity, it seems that this is going to be around for a while.

everytime i see 'obesity is a disease' i just think.. "nice, now these fat f#$*s have yet another excuse to be obnoxious and choose not to lose weight"

 

[Paws]

My favorite fat person experience was in a low-income primary care clinic when a 450 lb guy kept coming in trying to get a 'free' back surgery (oh, yea, 'free' as in donated by a nice doc in the community who wants to help out) because he had chronic lower back pain. I had to physically pinch myself in order to not LAUGH right in his face; what I really wanted to do was tell him to lose the *&^% weight and then maybe he wouldn't have the chronic lower back pain.

 

[docB]

What's the closest vet school to the LV metro area? Only once have I considered NC State (for the large animal CT).

You know, where I did residency we had a big vet school and every time the gihugic pt would roll in someone would mention it but I never ever saw anyone get a scan at the vet school. I think it's more a medical urban legend about using vet scanners for fat pts.

 

[Apollyon]

You know, where I did residency we had a big vet school and every time the gihugic pt would roll in someone would mention it but I never ever saw anyone get a scan at the vet school. I think it's more a medical urban legend about using vet scanners for fat pts.

Last year someone said they sent one the year before, but I wasn't interested at the time. I'll ask more tomorrow.

What I think happens with the huge fat ones is we go back to more traditional (ie, pre-radiography of any sort) medicine, in part because of the huge pain in the ass (excuse the pun) of even carting someone to one of those scanners.

 

[oompaloompa]

You know, where I did residency we had a big vet school and every time the gihugic pt would roll in someone would mention it but I never ever saw anyone get a scan at the vet school. I think it's more a medical urban legend about using vet scanners for fat pts.

sorry bro, I really wish it was. My school's hospital in Houston is right across from the zoo, where they have an MRI for the large animals. A resident told me that they had to send 400+ patients there because it was the only MRI in the city that could accomadate them. I too, thought this was a load of crap, so I asked the attending. He confirmed it saying he'd actually referred patients there before and that they had the number posted in the ER.

Ain't that some sh**?

 

[Apollyon]

I've emailed two veterinary radiologists (one at Tufts, one at NC State) as to putting humans in vet scanners. I'll update this post if/when I get a response.

Edit: Both NC State and Tufts Schools of Veterinary Medicine call this an urban legend. The fellow from Tufts said they get 2-3 calls per year for human patients, but can't accomodate them due to liability issues.

 

[hans19]

I've recently had another spate of 400 lb + patients. I'm always amazed how these people have no concept of how hard it is to care for them. They can't fit in scanners or MRIs, they can only generate poor quality Xrays and VQ scans, IV access is very difficult and risky, airway is a nightmare and they all have sleep apnea. But they never seem to understand why they just can't get the same treatments/diagnostics as regular people. They yell at me that the scanner should be able to accommodate them. That's great. Why don't we call GE and tell them that. I'll get right on it! I feel like you should have to sign a special disclaimer stating that you understand that as a >400 lber you aknowledge that you can't get some things. We should do the same thing for anyone that claims over 3 "allergies."

Interesting how 400+ pounders still manage to find a way to get pregnant. Not a judgement, just an observation.

 

[ERMudPhud]

When I was in New York I called the Bronx Zoo about an overweight patient and was told quite firmly, " I don't know where you people keep getting the idea that we do fat people. Please spread the word that we don't scan people!" I recall a similar response in Colorado. I suspect that this is mostly urban legend. Anyone here ever actually send a patient for a zoo scan? Not, I heard it from my attending or my friend did it last year.

 

[WilcoWorld]

Can you imagine how mortifying it would be to be told, "Sorry, but in order to get a scan of you we're going to have to use the hippo scanner." As a former fatty (though never close to 300, much less 400+lb's) I can sympathize with the terrible embarassment experienced when people look at you with those judgemental eyes. That said, I still feel that obesity is a self-inflicted condition, and that recent efforts to exculpate fat pople for their suffering is dangerously encouraging to the obese.

But the whole point of this post is to tell the following story I heard from an Orthopod:

He once saw a 400+ lb woman in his office who had come in to be evaluated for knee surgery. When he asked her what was bothering her and she said, "My knees hurt" and he simply responded, "No ****".

Wow, that's gutsy...or mean, depends on your perspective.

 

[Sessamoid]

My favorite obese patient story was told to me by an Ob resident (when I was back in medical school) who scrubbed on a procedure on a massively obese patient, the kind of obese they had to use the lifter to get on the table.

They're opening her up for some sort of pelvic procedures, what exactly it was I don't remember anymore. They keep dissecting and dissecting but they're having trouble finding the pelvic/abdominal cavity. Eventually, the scalpel hits something firm. A little dissecting revealed they had managed to dissect through loads of fat tissue only to reach the black surface of the operating table on the other side.

After an appropriate amount of cursing, they washed her out, reprepped and eventually completed the procedure.

 

[NateatUC]

My favorite obese patient story was told to me by an Ob resident (when I was back in medical school) who scrubbed on a procedure on a massively obese patient, the kind of obese they had to use the lifter to get on the table.

They're opening her up for some sort of pelvic procedures, what exactly it was I don't remember anymore. They keep dissecting and dissecting but they're having trouble finding the pelvic/abdominal cavity. Eventually, the scalpel hits something firm. A little dissecting revealed they had managed to dissect through loads of fat tissue only to reach the black surface of the operating table on the other side.

After an appropriate amount of cursing, they washed her out, reprepped and eventually completed the procedure.

Similar story happened to me a couple months ago on OB/GYN. We had a 350+ pounder on the table for an abdominal hysterectomy (not as heavy as many stories, but she was no more than 5'1" tall). Turned out that the usual instruments were just too short to reach. You know its a bad sign when they're opening a gastric bypass tray to get instruments that will reach.

And too further propagate the urban legend: As far as I know, San Antonio, TX does not have a major zoo. However, they do have Sea World! You thought the hippo scanner was bad, try the whale scanner!

 

[Katee80]

Interesting how 400+ pounders still manage to find a way to get pregnant. Not a judgement, just an observation.

Now there's a mental picture I won't get rid of anytime soon

 

[Febrifuge]

Can you imagine how mortifying it would be to be told, "Sorry, but in order to get a scan of you we're going to have to use the hippo scanner." As a former fatty (though never close to 300, much less 400+lb's) I can sympathize with the terrible embarassment experienced when people look at you with those judgemental eyes. That said, I still feel that obesity is a self-inflicted condition, and that recent efforts to exculpate fat pople for their suffering is dangerously encouraging to the obese.

Fair points, on both sides. But if we can promise to maintain civility and sensitivity in our dealings with patients, we're still going to need a good way to talk constructively about that self-infliction part.

He once saw a 400+ lb woman in his office who had come in to be evaluated for knee surgery. When he asked her what was bothering her and she said, "My knees hurt" and he simply responded, "No ****".

This nearly happened to me! Only my super-shutting-up powers saved me at the time. When I next shadow in Ortho clinic I want to have a more appropriate way to say "sir, you wouldn't haul cement in a Honda Accord, and that's what you're trying to do with your body. The frame is not rated for the load."

 

[AznTrojan]

here's another fatty story..

patient presented to the ED because he couldn't find his penis x3 days and had a rash on his lower abdomen x3 weeks.. when i went to evaluate him with my team.. we lifted his pannus and this horrid smell from the bowels of hell emitted from his belly.. nevertheless.. upon lifiting the pannus.. my team and i were still unable to see the patient's penis..

it turns out the guy was so fat.. that when he sat down.. his penis retracted into his belly and his pannus swallowed his genitalia.. hence.. he had been urinating all over himself for 3 weeks.. giving him a chemical rash from the urine all over his abdomen..

 

[DrMom]

Let me be the first to say "Ewwww"

 

[Katee80]

Where's that puke smiley when you need it?

That's disgusting.

 

[ERMudPhud]

here's another fatty story..

patient presented to the ED because he couldn't find his penis x3 days and had a rash on his lower abdomen x3 weeks.. when i went to evaluate him with my team.. we lifted his pannus and this horrid smell from the bowels of hell emitted from his belly.. nevertheless.. upon lifiting the pannus.. my team and i were still unable to see the patient's penis..

it turns out the guy was so fat.. that when he sat down.. his penis retracted into his belly and his pannus swallowed his genitalia.. hence.. he had been urinating all over himself for 3 weeks.. giving him a chemical rash from the urine all over his abdomen..

Now imagine the same patient with CC: "burning penile discharge" It took 3 of us just find and swab his urethra. I have no idea how he managed to get GC in the first place

 

[DrQuinn]

When I was in New York I called the Bronx Zoo about an overweight patient and was told quite firmly, " I don't know where you people keep getting the idea that we do fat people. Please spread the word that we don't scan people!" I recall a similar response in Colorado. I suspect that this is mostly urban legend. Anyone here ever actually send a patient for a zoo scan? Not, I heard it from my attending or my friend did it last year.

We have Busch Gardens here in Tampa, and among the Medicine Residents there is a rumor that they'll do our CTs. One of our PGY-2 EM residents had a 400 pounder who fell with a +LOC, we wnated to scan his head, so he called the radiology dept at BG. They said "seriously guys, this is an urban legend, we have never scanned a human before."

There is another zoo here in Tampa, we might have to try to call that one because Busch Gardens directed us there.

Q

 

[DrQuinn]

Now imagine the same patient with CC: "burning penile discharge" It took 3 of us just find and swab his urethra. I have no idea how he managed to get GC in the first place

Its those damn toilet seats.

Q

 

[Apollyon]

As a note, the guy who had been quoted in the lay press as having scanned people in the animal scanner but denied it in my email didn't add more, but the prof from NC State directed me to a guy from Washington State. I haven't emailed him yet.

Coincidentally, one of our chief residents said today that she indeed sent a patient to the Buffalo Zoo for a scan while she was a student - but that doesn't fit ERMudPhud's criteria!

 

[Jeff698]

OK, the missing-penis-boy story goes to the top of my gross list (and that's a fairly impressive list)!

BTW, San Antonio has a great zoo. Take a look: http://www.sazoo-aq.org/flashstart.html

Take care,
Jeff

 

[8744]

Fair points, on both sides. But if we can promise to maintain civility and sensitivity in our dealings with patients, we're still going to need a good way to talk constructively about that self-infliction part. This nearly happened to me! Only my super-shutting-up powers saved me at the time. When I next shadow in Ortho clinic I want to have a more appropriate way to say "sir, you wouldn't haul cement in a Honda Accord, and that's what you're trying to do with your body. The frame is not rated for the load."

Speaking of "super shutting up" powers, I was once talking to a psych patient who was relating to me his litany of substance dependencies.

After an extensive history of ongoing crack, PCP, meth, LSD, and Narcotic abuse he proudly stated, "but I quit smoking."

To which all I could reply was, "Well hooray for you."

I once spent about an hour talking to a pregnant 523-pound woman who came into the labor unit. Apparently, she was "passed around" at parties to groups of men who took turns having sex with her. As she told me, two of them wrapped sheets around her thighs and pulled them back for the other one. The way she described it was as if this was a common occurence, sort of like a wierd tupper-ware party for guys who are into fat chicks.

 

[dlung]

We have Busch Gardens here in Tampa, and among the Medicine Residents there is a rumor that they'll do our CTs. One of our PGY-2 EM residents had a 400 pounder who fell with a +LOC, we wnated to scan his head, so he called the radiology dept at BG. They said "seriously guys, this is an urban legend, we have never scanned a human before."

There is another zoo here in Tampa, we might have to try to call that one because Busch Gardens directed us there.

Q

Some Ohio State EM residents told me that they used to use the horse CT at the Columbus zoo for 400lb+ pts but have since stopped due to some liability issues in transporting the pts to and from the zoo.

 

[Jeff698]

Way to go Panda Bear, you've quickly managed to displace missing-penis-boy from my grossest list. Damn!

Take care,
Jeff

 

[la gringa]

we had a 500lbs guy on medicine who came in with LE cellulitis, had failed keflex and augmentin so we started him on naf. when his bun and cr bumped we wanted to know his uop and all and being on the floor, this wasn{t happening. we wanted urine eos too because we were suspecting AIN. well, turned out 5 or 6 nurses couldn't find his penis to put in a foley. he went downhill kind of fast and he was a helluva stick for a central line, but the upper level finally got it. a nurse in the icu finally got a foley with much assistance. good god.

 

[beanbean]

Good preventive health marketing strategy: Tell all male patients " if you don't stop gaining weight, your penis will disappear" The thought of obesity castration would probably would scare more guys than the "heart attack, diabetes, HTN" warnings we give now.