Reducing exposure to environmental tobacco smoke
Reducing exposure to cockroaches
• Remove as many standing water and food sources as possible to avoid cockroaches
Reducing exposure to pets
People who are allergic should not allow them in the home
At a minimum, pets should not be allowed in the bedroom of someone who is allergic
Reducing exposure to mold
Eliminating mold and moist conditions that permit mold
• Seek help from asthma resources:
Centers for Disease Control and Prevention (www.+cdc.+gov/+asthma/+faqs.+htm)
Allergy and Asthma Network, Mothers of Asthmatics (www.+aanma.+org/)
American Academy of Allergy, Asthma and Immunology (www.+aaaai.+org/+home.+aspx)
American Academy of Family Physicians (familydoctor.+org/+familydoctor/+en/+diseases-+conditions/+asthma/+treatment/+asthma-+action-+plan.+html)
American Academy of Pediatrics (www.+aap.+org/+health+topics/+asthma.+cfm)
Asthma and Allergy Foundation of America (www.+aafa.+org/)
The National Environmental Education Foundation (www.+neefusa.+org/+health/+asthma/+index.+htm)
• Join an asthma support group
Source: Centers for Disease Control and Prevention
12
KILLING US SOFTLY
My name crackled through the walkie-talkie, rising above the usual clatter in the emergency department one afternoon in late summer of 2002. I rushed across the room and grabbed the unit from the counter: “Dr. Davis here, go ahead.”
By then I was the doctor in charge. Just weeks earlier, I had become an “attending” physician, one of the doctors responsible for supervising residents. It had happened overnight. On June 30, 2002, I was a resident myself; then, at midnight, three years to the minute after my residency had started, it was over. Not only was I now on my own to make decisions about patient care, I was also in charge of others. Residents are allowed to assess and treat patients, but the treatment plans must be pre-approved by the attending physician, who closely monitors the young doctors. Since Beth is a teaching hospital, after the third year every resident who stays moves into the role of an attending physician, working as an instructor and passing on the details of emergency medicine to the next class of residents and interns. Other residents move on to work in smaller community-based hospitals, without the added responsibility of teaching.
“We have a seven-hundred-pound female coming to your hospital,” the emergency technician said through the walkie-talkie. “Can you please have a stretcher set up outside and someone to lend a hand with her? We’re five minutes out.”
A seven-hundred-pound patient would require major improvisation to our usual lifesaving procedures. I motioned for every available member of my team to head to the ambulance bay.
“Is she stable?” I asked. “What are her vital signs?”
The technician paused for a second. “She currently has labored breathing and an extremely faint pulse. The medic is starting a line, and we’re doing our best to secure her airway.”
I yelled out to the nurse in charge to get everything in place for the incoming patient, and then headed for the door. Within minutes, siren blaring, red lights flashing, the ambulance was backing into the bay area. When the back doors of the ambulance swung open, I was stunned. I’d never seen a human being this size before. The patient’s body spilled over the sides of the gurney, leaving no grabbing room to maneuver the stretcher from the ambulance. It took all ten members of my emergency team, including me, to transfer her to the oversized bed that we had wheeled outside. Sweat poured from our foreheads as we strained to lift her. Every one of us concentrated intensely to avoid dropping our patient, an African American woman, whose face looked young, like she was in her late thirties or early forties. Her ankles were the size of my thighs, and her toenails were unusually long and dark. She had silky salt-and-pepper hair, which had been braided neatly into two shoulder-length plaits. I focused on keeping her upper body as upright as possible and her airway open.
The transfer from the ambulance went smoothly, considering, but we were losing time. Every step that we normally zipped through with ease was much slower than usual—time away from treating our patient. The emergency team rolled the bed as quickly as we could from the parking lot to the resuscitation bay. On the way, the medic filled me in on what he knew. The patient’s name was Gloria, and the call for help had come from her neighbor, who checked in on her periodically. Gloria had been living alone for the past six months and was mostly bedridden because walking had become too painful. She had told her approximate weight to her neighbor, who had wanted to call for help sooner. But Gloria had begged her not to alert anyone. On the morning of the crisis, however, the neighbor had let herself in to check on Gloria and found her struggling to breathe and complaining of pressure in her chest. When the paramedics arrived, Gloria was barely conscious, lying in her own feces on a urine-soaked mattress in her bedroom. Snacks and empty junk food containers littered the room. Empty plates coated with dried food were scattered on the floor beside the bed. The stench in the room was almost intolerable, they said.
Gloria moaned as we began to work on her. Finally, we managed to get a stronger pulse. I stretched an extra-large cuff around her upper arm, but it wouldn’t fit. I slid it down to her forearm and took her blood pressure there; it was extremely low. An EKG showed a bumpy, abnormal heart rhythm. It wasn’t possible to do a CAT scan to determine whether she’d had a stroke. The maximum weight our machine could handle was 350 pounds. In non-emergency situations, we sent heavier patients to be scanned at the local zoo.
The paramedics had managed to insert an IV in her hand, but it was barely functioning and insufficient for all that we needed to do. We had to place a central line that would give us direct access to a large vein, where we could deliver fluids and, if necessary, lifesaving medication. In ordinary circumstances, we would have had three options: the jugular vein in the neck, the subclavian in the chest, or the femoral in the groin. Gloria had practically no neck, so going for the jugular was out of the question. The risks of the subclavian procedure were too high: The subclavian vein was too close to the lungs, and I didn’t want to risk the potential deadly consequences from puncturing the wrong thing. There was no way she would survive a collapsed lung. Plus, there would be no time for an X-ray to assure that the line was in the right place. I had to try for the femoral vein in her groin area. I called out for help, and two nurses rushed to my side. They pushed up the mound of abdominal fat hanging down over Gloria’s lap. Nurses and doctors are accustomed to seeing unimaginable things and are not easily grossed out, but all of us winced when we saw the abundance of raw sores and pockets of fungus growing within the folds of Gloria’s skin. The smell was putrid, like rotting meat.
I swabbed the area quickly with Betadine and draped a sterile paper cloth over it. My gloved fingers searched for the slight pulse of the artery closest to the vein. After several tries, I felt a faint throb, and inserted a large needle right next to it into the femoral vein. A flash of dark red blood into the syringe told me I’d found the right spot. I continued the procedure, but just as I was about done, things got worse. Gloria’s body suddenly became still and unresponsive. The cardiac monitor flatlined. I quickly checked her femoral artery for a pulse. Nothing. She was in cardiac arrest. My team immediately began CPR, but that process was hampered, too, by the circumstances. In most cases, we slipped a board between the patient and the thin mattress of the stretcher, keeping the body stiff and allowing the heart to absorb the weight of the chest compressions. But the oversized bed where Gloria lay—the only bed that could accommodate her size—had a regular soft mattress. We couldn’t put the board under her because it was too small. Gloria sank into the mattress with every chest compression, which did little to jump-start her heart.
“Come on, Gloria,” I whispered in frustration, as if she could control what wa
s happening. I wanted to win. I wanted her to win. But too much damage had been done over time. We kept the chest compressions going, but the flat line on the cardiac monitor didn’t budge. After several minutes I knew for sure things weren’t going to change. Gloria’s overworked heart just couldn’t take any more. She was dead.
I never saw any of Gloria’s family at the hospital, but our halls were abuzz for days about the seven-hundred-pound woman who’d been too big to leave her house. She had died in such a sad, lonely way. I wondered: Just who was she? What had happened in her life that had caused or enabled her to gain so much weight? Were there undiagnosed medical problems—perhaps an under-functioning thyroid, or an ankle or foot fracture that had contributed to her lack of mobility? Had she always been overweight? Had she experienced the breakup of a relationship or the loss of a parent that had caused a spiral into depression? Did she have friends and family who loved her unconditionally and had tried to help her?
I could only imagine how excruciating it must have been for Gloria to lie there helplessly in her own filth, unable even to wash herself properly or clip her own toenails. Long before her heart stopped, she must have felt like she was dying slowly with her eyes wide open. No one would want to live or die that way.
Gloria was the extreme, but practically every day I treat overweight black men and women—many weighing more than three hundred pounds—who are perhaps just one tragedy away from becoming her. They arrive at the E.R. with complications from diabetes, high blood pressure, or heart disease, referring to their ailments—“my sugar” or “my pressure”—as though they are old familiar belongings. For many of my patients, diabetes, high blood pressure, and heart disease indeed are very familiar. They’ve been handed down for generations, like family heirlooms, but at a very high cost. Nearly twice as many African Americans have diabetes, and twice as many die from heart disease and strokes, compared with our white counterparts. In most cases, the root of the problem is obesity. Eighty percent of people with diabetes are overweight. African Americans have the highest rates of obesity of all racial groups in the United States. The problem is most critical among African American women, about eighty percent of whom are overweight or obese. Scariest of all, though, are numbers showing the rate of obesity among children. Since 1980, the number of overweight children in the country has tripled. Today, about one in three children is overweight or obese. The crisis is even more severe in minority communities, where 40 percent of African American and Mexican American children are overweight or obese. In the emergency department at Beth, I regularly treated nine- and ten-year-old patients who weighed upward of 150 pounds and already showed signs of type 2 diabetes, the most common form, caused primarily by poor eating habits and lack of physical exercise. When I would consult with the mother, more times than not, she was obese, too.
There is no doubt that culture has heavily influenced this epidemic, starting perhaps with our attitudes. African Americans and Latinos tend to be more tolerant of extra weight than their white and Asian counterparts. I’ve always found that outlook mostly positive; it’s an affirmation to black and brown girls everywhere that they can be beautiful without looking like the needle-thin, airbrushed models on magazine covers. Throughout my life, I’ve watched black girls grow up proudly flaunting their curves. As a black boy, I learned early that a woman with a little extra weight in all the right places is a thing of beauty. The community of brothers around me often advised, “Man, don’t nobody want a bone but a dog.” To this day, the most beautiful women to me have a little “meat on their bones” and some “junk in the trunk.” My point: There is no one-size-fits-all standard of beauty, or perfect health, for that matter.
Still, the most universal guide to figuring out a healthy weight is the body mass index, or BMI, an adult man or woman’s estimated percentage of body fat, based on the individual’s height and weight. No doctor visit is necessary to get this number. Anyone with access to a computer search engine (for example, at a neighborhood library computer that provides Internet service) can plug an individual height and weight into a BMI calculator and get that important number with a few simple keyboard clicks. A BMI of 18.5 to 24.9 is considered within the normal range; from 25 to 29.9 is considered overweight; and over 30 is obese. Too often I’ve treated black women in the latter two categories who shrug off an unhealthy size—and thus, any attempt to do something about it—with a dismissive explanation that they are “big-boned,” or “just a big girl.”
Of equal concern to me, though, is research showing that weight-related attitudes and behaviors among African American and Latino women are swinging toward the opposite end of the spectrum, valuing extreme thinness over a healthy body weight. A 2001 California State University survey of 801 women and 428 men of all races found no measurable ethnic differences in how men and women viewed their own bodies and obesity in general. Women across the board were generally more dissatisfied with their bodies than men, and women of all races rated thin female shapes as more attractive than fuller shapes. Those findings were in line with separate studies in 2000 and 2003 showing that black women were as likely as white women to report binge eating and purging and even more likely than women of other races to report fasting and the abuse of laxatives and diuretics—all symptoms associated with eating disorders.
Many of our traditional soul foods—fried chicken, macaroni and cheese, pound cake, and peach cobbler, to name a few—work against a healthy lifestyle. Little black girls have stood at their mothers’ and grandmothers’ elbows for generations, learning how to cook with soul. That, of course, means adding ham hocks, fat-back, and lots of salt to otherwise healthy foods, such as collard greens and black-eyed peas. And our church dinners and family celebrations often center on the same spread of high-fat and highly seasoned dishes. In this age of immediate and abundant information, it should come as no surprise that many of the foods we love are loaded with artery-clogging fat. Yet there has been a major disconnect between what we know and what we do. The sad result is that we are losing our mothers, fathers, sisters, and brothers, who seem to be leading normal, busy lives when one day the unthinkable happens.
“I need a doctor now!” the nurse yelled, dashing into a patient’s room where I was surrounded by a group of residents. We were nearly finished with our rounds on the observation unit for stable patients when the nurse rushed in. Working at such a busy hospital, we were accustomed to being pulled from one case to another in an emergency. We abruptly ended the discussion and scurried down the hall to another room. There we found a middle-aged woman, perhaps in her forties, sweating profusely and unresponsive. The name on her chart—Mrs. Santos—told me she was likely Latino. Her heart rate had dropped suddenly from the normal 60 to 100 beats per minute down to 20 to 25 beats, far too low for someone so young. The monitor detected an extremely high blood pressure. She was not significantly overweight, but other factors, including diet, can cause high blood pressure.
My adrenaline soared as I instructed the technician to grab the EKG machine and told the clerk to order a portable chest X-ray. My senior resident sensed the escalating crisis and jumped right in, instructing the junior resident to get the equipment for intubation. Within seconds, the junior resident had her equipment in hand and began the process. The senior resident stood over her shoulder to monitor and offer support.
In anticipation of the next step, Mike, the clerk, paged a respiratory technician, who would be needed to put the patient on a ventilator to regulate the rate and volume of oxygen flowing to her. My intern stood at Mrs. Santos’s waist, inserting a large bore intravenous line through the leg to the femoral vein in the groin area. My role was to make sure the patient was receiving the best care as quickly and smoothly as possible. I moved toward the young man standing nervously in a corner of the room, presumably the patient’s son, to find out what had happened. He started talking as soon as I was within earshot.
“Doc, I found her passed out in the middle of the floor this evening when I came
home,” he said. “When I left this morning to go to work, she was fine. She was sitting at the table having breakfast and reading her paper. I was at the counter, fixing my coffee, and she was talking about all she had to get done today.
“She asked me to drop some clothes off at the cleaners because she had to go to the bank, the supermarket, and the doctor. That was the last time I talked to her until I got home. I can’t believe she was lying at home, possibly all day, without being able to move or call for help.
“Doc, what do you think is going on? She only has high blood pressure, has never smoked or drank a day in her life.”
Wait. High blood pressure. “Is she on medication for the hypertension?” I asked.
“Yes,” he replied. “But she doesn’t like taking it. She says she doesn’t like the way it makes her feel groggy and sleepy all the time. She says her pressure never makes her feel that bad, just a headache every once in a while.”
Right away, I knew she’d probably had a stroke. Mrs. Santos was being rushed off to get a CAT scan, and the respiratory therapist was at the head of the bed, pumping oxygen through a bag to deliver the right amount of air to keep her vulnerable organs alive. In my mind I predicted what the scan would show: a large injured area in the brain from the stroke. But for her and her family’s sake, I hoped I was wrong. I hoped she would pull through and I’d have a chance to explain to her how crucial it was that she took her medication. Her son’s face showed disbelief. His eyes seemed to ask: How could this be? How could a cheerful “good morning … see you later for dinner” end up here? I braced myself for what I knew would be his next question: “Doc, what are her chances?”
“Well, we just have to wait and see the results of the CAT scan,” I told him.
Living and Dying in Brick City Page 18
