Friday, August 14, 2009

Morbidly obese

I was on my first overnight call of my subinternship on a general medicine service. I got a text page from the transfer center notifying me of an admission we were to get later in the night from a small community hospital in Ohio. The terse description stated “55 year old male with headaches, dizziness, morbidly obese.” This had all the makings of a case in which this hospital was either incapable or unwilling to take care of this patient, or, as one of my residents stated bluntly, a "dump case."


Sure enough, around midnight, I get the page that he had arrived on the floor, and I made my way to his room. Before I entered, the nurse who gathered his vitals was leaving the room, and she whispered to me that the bed scale weighed him at 570 lbs. I then walked in the room. The lights were out, and as I turned to my left to face the bed, I saw this massive figure. Although I had known his weight, his size was astonishing. It appeared as though there were another person underneath the covers with him. A woman was in the room with him, who I soon learned to be his wife. I introduced myself to her, and she began to tell me that he has had a devastating headache that has lasted two weeks. It was accompanied by dizziness and vomiting. He otherwise had no other medical problems other than some high blood pressure and newly diagnosed diabetes. I then woke up the man, to hear the story from him. He clearly was in considerable pain, and did not want to offer much more history, other than he was having double vision an overwhelming sensation of the room spinning if he changed his position. My exam was essentially normal, other than nystagmus (a abnormal rapid oscillating of the eyes often associated with vertigo). His story and exam were clearly concerning for a brain tumor.


Before I left, the wife asked me if we were going to get a scan of his brain. The whole story immediately became clear. The community hospital he came from heard his story and was stuck. They did not have a MRI large enough for him so they punted him to our hospital. I had a suspicion that he was even too large for our scanners. I dodged the question by stating "I would discuss your story with my resident and let you know what we are going to do." He agreed that he had some kind of mass in his brain and absolutely needed a scan. I called the MRI room, who informed me that their weight limit was 550 lbs and they refused to scan him. An appropriate treatment plan could not be decided without an answer as to what was causing his headaches without a MRI. Additionally, his symptoms indicated that his intracranial pressure was approaching dangerous levels, and something needed to be done soon or he was probably not going to survive the next few days.


I spent the next day calling every major medical center in the state of Ohio, discovering that our hospital had the largest weight limit at 550 lbs. Even the zoo refused to take him. I called the MRI room again, and asked to speak with the head technician. I explained the direness of the situation, and had her measure the circumference of the magnet and had his nurse measure the circumference of the patient. He was fortunate to be narrow enough to fit through the bore of the magnet, and the technician and me developed a plan to get him imaged. The next day, numerous masses lit up his cerebellum on his scan, and the radiologist called to tell us he had signs of dangerously high intracranial pressure. We consulted neurosurgery, who initially wrote off the consult, saying we needed to "find where the cancer is coming from." When they learned that we could not image him anywhere else, they agreed to take a biopsy of one of these masses. Before he got to the operating room, however, anesthesiology refused to allow him to have surgery because his risk of dying while under anesthesia was too high. The anesthesiology resident chimed in "he needs a gastric bypass."


In the midst of all of this fighting with various departments in the hospital, he started feeling much better after we had started steroids to lower his intracranial pressure, and was able to carry on conversations. My resident and I both explained the seriousness of his condition, and he probably didn't have but a few more months left to live. I learned that one of his children's wives was pregnant with his first grandchild, who was due in a few months, and he wanted more than anything to be around for that. When I saw him every morning, he would seem overjoyed to see me and cheerfully say "oh here comes Jamie." Being the medical student on the team, I didn't quite understand why he was so excited to see me, so I attributed it to him just being a nice fellow. One afternoon, I came by his room to see him, and he introduced me to a close friend of his who was visiting. She immediately said, "Thank you for all you've done for him." I shrugged this off, stating that we were doing everything we could to make him comfortable, but then the friend caught me completely off guard. "You're the one who saved his life." I didn't know what to say. "Oh, umm, what do you mean?" was all I could mutter. He chimed in, "you don't take no for an answer."


It occurred to me, for all the care he sought regarding his brain tumors, he was denied services at nearly every stop. It was either "too risky," or "against our protocol," or some other excuse to deny this man the care he needed. He later told us that he had felt a mass in his groin, what felt like enlarged lymph nodes. The surgical oncologists saw him, and refused to biopsy them, stating "they did not feel like cancer." (Why ask for a biopsy in the first place if you can just touch them to know?) Nobody would image him, surgeons came up with reasons not to touch him, anesthesia did more of the same and even added some colorful commentary regarding his size. There are indeed technical limitations of scanners and well-studied peri-operative morbidity and mortality risk-stratification to elective surgeries. One could argue that these guidelines are the reason why nobody would perform procedures on this man, but the guidelines are not why the health-care system miserably failed this man. It seemed doctors saw this man as extremely obese and found the first reason not to do something. While they were correct in applying the guidelines to their procedures, nobody offered suggestions as to what could be done. Stigma against the morbidly obese is a whole other topic to be discussed, but it unfortunately contributed to this man's care. There are surely a lot of rules, studies, and guidelines to learn about in medicine (and its not easy to do so), but even knowing them and applying them in a cook-book fashion is unacceptable. Doctors are paid to think and problem-solve, and had more of that been done, a potentially treatable form of cancer could have been diagnosed and his management would have changed considerably.


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