Bookends

The final week of my 3rd year, I scrubbed in on a hysterectomy for a 500 pound woman. I commented before the case that I had also seen her every morning for my entire internal medicine rotation, prompting my attending to comment to the patient, in the OR, that 'you're almost like a bookend' for my first year of clinical training.

Morbidly obese patients seem to make fantastic bookends. This final month of my clinical 4th year, that same woman is in the ICU with sepsis. Again. And, we had another patient admitted who was over 500 pounds, because he had fallen three times in the last week, and couldn't get up each time. His chief complaint was knee pain. Hmmmm.

As this article in the NY Times illustrates, fire departments and EMS providers around the country are buying 'bariatric' stretchers and 'bariatric' ambulances. Picture here courtesy Stryker on the NY Times website, so I may have to take it down.

Our attending commented that he doesn't think that this type of obesity is common, and that the obesity epidemic is more comprised of the just-barely-obese; I beg to differ. I've seen more morbidly obese patients than I have pancreatitis patients, or hepatitis patients, or AIDS patients (even in Milwaukee), or colon cancer patients.

When I say morbidly obese, it does get, well, morbid. As in, 'suggesting the horror of death and decay', here. It's hard to describe the reaction to someone of this size when they are sick. In my experiences, these patients could not perform any routine hygeine, and were sometimes incontinent not due to any urinary defect but due to an inability to reach the bathroom. One woman died of urosepsis from an indwelling catheter she used for this problem. She died because she couldn't get up and go to the bathroom. Their skin folds were so deep and extensive that they would become infected with yeast, which would allow the entry of bacteria, which often led to sepsis via panniculitis, or infection of the panus, the word for overlying fat rolls. They often had chronic ulcers, which again led to sepsis. And when they were intubated they couldn't breathe because the fat was too heavy for the lungs to expand properly.

The woman above, when she started to recover, didn't want to leave. She was the first patient where I was taught the trick of pushing down on someone's abdomen while listening, thereby hiding the fact that you were testing for pain. I pushed down the stethoscope; nothing. I pushed with my hands; Oh God, terrible pain, 10/10, doc, I can't stand it. I assume that the hospital nursing care was superior to the in-home care she had to receive.

Mountains of illness, geological formations of pestilence, people encased in double or triple the amount of pure protoplasm they should have, decay, stench. I don't describe this to be judgemental; obviously, these patients had reached an apex of obesity beyond that of the occasional trip to McDonald's and a failure to eat enough leafy greens. Everything was more difficult. Rolling them in the OR took five people instead of three. They didn't fit on the gurneys. The instruments weren't long enough. Their tissue died more easily because fat is poorly vascularized. And so on.

An epidemic, indeed. Bookends of illness against which I often feel helpless at the sheer enormity of it all.