It was 2 am after a typical Friday night in the ER. As always, the post-bar-closing stream of gunshot wounds, stabbings, and blunt head trauma was keeping the entire team busy.
Suddenly an ambulance call came in: the paramedics were transporting a critically ill 50-year-old patient. He had chest pain, dangerously low blood oxygen levels, and was struggling to breathe. They had already been working on him for hours.
Hours? I thought. That’s odd. Normally, a patient in that kind of distress would have been rushed to the ER within minutes. Stranger still, the paramedic sounded frustrated on the call, rather than his usual focused calm.
When the patient finally arrived, suddenly everything became clear: he was 500 lbs. The paramedics were exhausted from the effort of just getting him out of his house – an ordeal that had involved breaking down the frame of the front door in order to make a large enough passage. As the patient’s condition in the field deteriorated, the stress levels of all parties had exponentially increased.
We spend a lot of time focused on the chronic health problems that can come with obesity – heart disease, cancer, type 2 diabetes. But as an ER doctor, I’m struck by how obesity also makes treating the acute emergencies brought on by those conditions exponentially more difficult.
Why? Because ER doctors and nurses caring for obese patients must first overcome 5 big obstacles:
1. Obese patients are harder to examine
Whether it’s abdominal, back, pelvic, or chest pain, obesity challenges a clinician’s ability to examine a patient. Familiar anatomic landmarks become difficult to locate, and suddenly an otherwise simple exam becomes filled with uncertainty. The clinician often walks away not knowing if their exam was complete, and certain that it wasn’t thorough.
2. Obese patients are subjected to more tests
Once you walk away from the patient’s bed with uncertainty about your physical examination, the tendency is to order more tests to make sure nothing was missed. That means more needles, more imaging studies, more periods of observation, and even more admissions to the hospital just because you couldn’t use your hands in the way you were trained.
3. Obesity makes precision manoeuvres more complex.
Whether we’re putting in an IV, catheter, or chest tube, performing a spinal tap or an intubation — obesity demands far more dexterity. As such, several attempts are almost always required, resulting in a higher rate of complications, or, at the very least, increased patient discomfort. Similarly, sometimes we need to administer multiple medications as quickly as possible. That means we are forced to quickly recalibrate doses for medications originally formulated for an ideal body weight, a tricky calculation that doesn’t lend itself to precise results.
4. Obese patients suffer more physical and emotional discomfort
From the time they register, or are brought in by ambulance, obese patients are generally uncomfortable. What’s worse, the discomfort is on display for everyone to see. The chairs in the waiting room are too narrow. The gurneys too small. The blood pressure cuffs too tight. They cannot step on the weighing scale. Nor fit on a typical CT scanning table. Which means if they absolutely need an imaging study, they will be transferred to a special facility that can accommodate their weight. Never mind that the “special” facility is often one associated with a veterinary school where livestock undergo similar procedures. Not only will this prolong any physical pain they may be experiencing, but also magnify the potential for emotional anguish and embarrassment.
5. Worst of all: obese patients may not get the same level of empathy.
One of the toughest questions I’ve had to ask myself is whether medical teams suffer from unconscious bias against our obese patients. Do we hold them responsible for their obesity and for the ensuing medical conditions? Do we treat their pain as readily as we would that of a thin person, or show the same concern? I don’t have a uniform answer to this question, but the truth is I have found myself answering “yes” and “no” at different points in my training and career. I strive, as do my colleagues, to provide humanistic and empathetic care to everyone who asks for it. I know I fall short of that order many times. But I do keep trying.
Back to my patient. We managed a tricky intubation, and had to administer medications directly into his bone marrow since we couldn’t easily find a usable vein for a standard IV. We admitted him to the ICU but he was never stable enough to transfer for a CT scan of the chest or surgical intervention. Despite maximal interventions, he died a few days later from what was presumed to be a massive pulmonary embolism. He received the best care we could offer him in our ED. I only wish it could have been enough.