“You have to hold the pannus up,” she says. “This is sort of horrifying, but what we actually do is put tape on the pannus and tape it up to the anesthesia screen as we’re setting up for the Caesarean so that we can get to the lower abdomen.
“I can only imagine what that seems like to the patient—to have her big fat stomach taped up to the surgical drape with pieces of adhesive tape to try to get to where you’re making your incision. Otherwise, what you end up doing is holding the pannus up with one arm while you’re trying to do everything with your other arm. It’s very hard on your body as you’re going through the surgery.”
And after all that effort to get the baby out, the challenges for mom and for the surgeons looking after her don’t end. Obese women who have Caesareans are at huge risk for infections, says the OBGYN resident. “You know that when you cut into their skin that you’re going to see them in the emergency room four or six weeks later with a soft-tissue infection. It’s challenging, at best.”
In general, a C-section is performed when a vaginal delivery would put the health of the baby or the mother at risk. According to a review article published in 2012 in the North American Journal of Medical Sciences, obesity has a dramatic effect on the outcome of the pregnancy. It increases the risk of gestational diabetes, high blood pressure, pre-eclampsia (high blood pressure and significant amounts of protein in the urine that can lead to a life-threatening condition), pre-term delivery, blood clots in the lung and other conditions. There are increased risks for the baby as well. Morbid obesity itself significantly increases the likelihood of a C-section delivery. In a study published in the journal Anesthesiology in 1993, the rate of emergency C-section was just 9 percent in women of normal weight and up to 50 percent in women who are morbidly obese.
The female OBGYN resident I spoke to said it can be quite difficult to tell whether an obese woman requires an emergency C-section or can be delivered vaginally. “We talk about vaginal pannus and vulvar pannus and the labial pannus,” says a former OBGYN resident. “There’s just more of all that tissue and it’s really hard to find the cervix often. You need an extra large speculum. You can’t position them on the bed.”
These aren’t theoretical concerns. I heard a story from an attending OBGYN that made my heart stop.
The doctor was doing a vaginal delivery on a very obese woman. The first part of the delivery took place without incident. Suddenly, a fetal monitor attached by the doctors to make sure things were okay showed that the baby’s heart rate was slowing down—a sign that the baby was in distress. With each passing second, there was a greater and greater risk that the baby would asphyxiate and suffer permanent brain damage. To make it as easy as possible for the baby’s head to pass through the birth canal, the OBGYN did a large episiotomy.
An episiotomy is a surgical incision made in the perineum, the skin and underlying tissue roughly between the vagina and the anus. It’s done during the last stages of labour and delivery to expand the opening of the vagina to prevent tearing. Once commonplace, episiotomies are performed as little as possible today, in preference to a more natural childbirth in which a tear may or may not occur spontaneously.
The woman was so large that the OBGYN couldn’t make out the anatomical landmarks to do a proper episiotomy. She made the incision as quickly as possible and got the baby out safely.
Crisis over, the obstetrician prepared to stitch the episiotomy—or so she thought. As she pulled back the skin billowing voluminously on both sides of the woman’s vulva and perineum, the OBGYN was astounded to see that both were completely intact. The doctor went looking for the incision she knew she had made, and realized with a gasp that she had made it through the woman’s thigh, which she had mistaken for the vulva.
It was only then that the OBGYN realized that at the time the baby was in distress, it had already been born, but was suffocating under the mother’s large thigh.
Stories like these get passed around by everyone from attending physicians to residents, along with the inevitable black humour, such as having to find a veterinary speculum—or one large enough to push away the floppy vaginal tissue. These jokes—distasteful though they may be—come from frustration mixed with despair.
“You get lots more skin and vulvar infections,” says the former OBGYN resident. “I’m ashamed to say but it’s smellier. I would always feel ashamed of myself that I’m frustrated about this. I don’t want to do it because I’m thinking how much harder it is for her. No matter how hard I’m trying to hide my feelings, she must have radar for them. How humiliating must that be for her that I’m frustrated doing the vaginal exam?”
Arya Sharma agrees that it’s paramount for health professionals to empathize with bariatric patients. “When you actually think of a woman lying there in labour, that’s probably one of the most vulnerable moments that you can imagine anybody to be in,” says Sharma. “She is surrounded by doctors and nurses who are using this kind of language. Irrespective of whether she hears the language or not, from a professional standpoint it’s an ethical question.”
But to many health professionals, it’s also a clinical question. In the OR, on the other side of the surgical drapes, anesthesiologists like Dr. Jay Ross have their own troubles keeping morbidly obese patients alive during surgery. Being obese means that the tissue inside the throat and the airway is also large and floppy. “That makes getting the endotracheal tube into the trachea more difficult and even ventilating them more difficult because it’s sometimes harder to get a seal of the ventilation mask over the mouth,” says Ross.
Ross says these problems mean that the oxygen levels of obese patients can drop quickly. These patients are more likely than thinner patients to die on the table.
I put to Dr. Sharma the litany of clinical issues related to the treatment of morbidly obese patients that I heard from dozens of attending surgeons, OBGYNs, anesthesiologists and residents.
“Well, it’s all true,” Sharma concedes. “What makes it different is the attitude with which you approach it. We can have difficult patients who present us with a technical challenge or a diagnostic challenge. You need to be professionally trained to know how to address it. You need to make sure you have the right equipment in place that is going to allow you to deliver the best care.
“When it comes to obese people, we often don’t have that equipment. You’re looking for seven guys to help get this guy out of his bed and on a commode when a ceiling lift can be operated by one person and can do this in a much safer way, both for the provider and for the patient. But if you don’t have the ceiling lift, you’re lacking the equipment that’s out there. It’s available.”
Lifting a morbidly obese patient is no minor issue. Generally speaking, patients can transfer themselves from a stretcher to the operating room table because they’re awake. Immediately following surgery, when they’re just beginning to awaken from anesthesia, they are usually unable to transfer themselves back to the stretcher.
“I know of a resident who actually slipped a disc lifting a patient from the bed to the gurney,” says Ross. “She had to have an operation after that. So there are obvious health risks to us as well, like throwing out your back and straining muscles. You’re obviously also concerned whether you can actually get these patients safely from one bed to another without hurting them or having them fall on the floor.”
Even that example didn’t move Sharma.
“That resident had no business even trying to lift that patient,” he says, “because that resident should have known that she was putting herself at risk trying to do that—unless this was a huge emergency and there was absolutely no other option. If I’m putting myself at risk as a provider, that is unprofessional conduct. We’re talking 2013 here; we have lifting devices. We’ve got equipment and materials that have been specifically designed for use in larger patients.”
When I asked Jay Ross about using a mechanized lift in t
he OR for heavier patients, he called it “not a bad idea,” as though no one at his hospital had thought of getting one.
Bariatric equipment exists but it isn’t cheap. For example, in 2011, a blog written by Whitecoat published on kevinmd.com notes that Boston Emergency Medical Services had recently debuted an ambulance with a mini-crane and reinforced stretcher to transport patients weighing up to 850 pounds—at a cost of tens of thousands of dollars per ambulance. That prompted Whitecoat to ask this question: “Should it ever be right to tell patients that if they let themselves get so obese that traditional ambulances can’t carry them that dispatchers will refuse transport and they will be responsible for their own transportation to the hospital?”
When a doctor doesn’t know how to care for bariatric patients, Sharma says, it’s the doctor’s fault; when the doctor can’t care properly for these patients because the hospital or ambulance service don’t purchase bariatric equipment, it’s the system’s fault. Either way, doctors are becoming increasingly frustrated, and bariatric patients are losing their dignity—and all too often something more.
In 2012, Ida Davidson of Shrewsbury, Massachusetts, went looking for a new primary-care physician. According to a story posted to wcvb.com in August 2012, Davidson called on Dr. Helen Carter, who refused to take her on because at the time Davidson weighed more than 200 pounds. “After three consecutive injuries [with other patients] trying to care for people over 250 pounds, my office is unable to accommodate a certain weight and we put a limit on it,” Carter told reporter Pam Cross.
In 2011, the South Florida Sun Sentinel reported that fifteen of 105 obstetrics and gynecology practices likewise refused to see otherwise healthy women who weighed more than 200 pounds. A 2013 article in the New England Journal of Medicine, bioethicist Holly Fernandez Lynch noted that Ethical Rule 10.05 of the American Medical Association (AMA) permits doctors to refuse to treat patients whose medical problems are beyond their competence and to provide services that go against the doctor’s personal, moral or religious beliefs. The AMA adds that doctors cannot refuse to care for patients based on race, gender, sexual orientation, gender identity “or any other criteria that would constitute invidious discrimination.”
Fernandez Lynch wrote that the right of doctors to refuse to care for patients has been reduced further by state laws that prohibit what are known as places of “public accommodation” (including doctors’ offices and hospitals) from discriminating—not just on the basis of the AMA criteria, but also on “medical condition, disability or other personal features.” The Americans with Disabilities Act (ADA) of 1990 prohibits discrimination “in any place of public accommodation.”
Does that mean doctors cannot refuse to care for bariatric patients? Not necessarily. Fernandez Lynch goes on to say that refusing patients based on the ADA might be perfectly legal if it can be shown that an obese person is not disabled: “Discrimination on some grounds may be legally impermissible, whereas discrimination on other grounds is only morally blameworthy, but these cases are newsworthy precisely because they are so unexpected from a profession with a strong tradition of helping people in need and rejecting the stigmas that may bias other members of society.”
Dr. David Katz, one of America’s most celebrated experts in obesity, notes that obese patients are less likely than thin patients to receive appropriate care of medical problems that have little if anything to do with their weight. “I met a woman who should have had cancer screening tests but had not,” Katz wrote in 2011 in the Huffington Post. “I met a woman who should have had screening tests for cardiac risk and [who should have] received select immunizations—who had not. I met a woman who had been driven from any and all benefits that modern medicine might offer her by the cold and denigrating judgment offered her by almost every modern medical practitioner she had met.”
Dr. Marjorie Greenfield believes that obese patients need to accept that, in some cases, circumstances may compromise their care. “I don’t think it’s on purpose, but I think a lot of times people can’t get the same level of care because there’s a part of the quality of your care that has to do with your participation,” says Greenfield. “There’s sort of a price that you pay in terms of the quality of care you can get either when you’re very obese or also when you haven’t gotten good prenatal care and haven’t taken good care of yourself. And I think there’s a price that you pay in terms of outcomes for the pregnancy—like the rate of birth defects, labour progress not going well, things that are actual complications of pregnancy.”
To Dr. Arya Sharma, that’s blaming patients for being the way they are. “Let’s assume that you’re working in a rehabilitation centre where part of your job is dealing with paraplegic patients and getting upset at these paraplegic guys who are peeing in their pants all the time,” says Sharma. “If that’s your attitude, you shouldn’t be working in a place that looks after people who have paraplegic problems.”
Sharma says if you take “paraplegic” and substitute “bariatric,” it’s exactly the same problem. The Centers for Disease Control says that 68.8 percent of Americans are either overweight or obese. Close to four million Americans weigh more than 300 pounds, and close to half a million (mostly men) weigh more than 400 pounds.
“You should have known that two-thirds of your patients are going to be overweight or obese,” says Sharma. “If you don’t like overweight and obese people, then you shouldn’t be in medical practice—period.”
Far from shaming patients into slimming down, there’s evidence that the bias against obese people has the opposite effect. A 2013 study of more than 6,000 people published in the journal PLOS ONE found that people who experienced weight discrimination are more than twice as likely to remain obese as those who do not experience such prejudice.
Sharma says it’s not too late to turn things around. “Everybody went into medical school because they wanted to help people who have problems, and being obese is a problem,” he says. “And even if I don’t have a treatment and I don’t know what the hell I’m talking about, at least I can show concern and understanding and empathy, and say that I cannot possibly imagine what it is like waking up every morning and being 300 pounds and then realizing that you’re going to have to lift those 300 pounds out of your bed, shower, clean yourself and dress.”
There are uncomfortable parallels between the slang used by doctors to talk about obese patients today and the slang term GOMER, popularized by Dr. Stephen Bergman in The House of God. “These are the new GOMERs,” says Bergman. “The GOMER still exists but care of those people has actually improved a great deal in terms of medical care and hospice care and other kinds of care for the elderly. They’ve made big strides.”
And obese patients? “I think the epidemic is like a tsunami coming at us,” says Bergman. “I can’t imagine being a surgeon operating on these people. Imagine if you had to do that surgery all the time.”
For those who do it, no imagination is required.
10. Frequent Flyers
A woman enters the ER where Not Nurse Ratched is on duty. By the time she arrives at the registration desk, her name, birth date and allergies—even her social security number—have already been typed into the computer. A game of rock-paper-scissors has determined which triage nurse has to take the patient this time.
I’ll call the patient Anna. She’s in her early forties, weighs close to 400 pounds and has missing teeth. Her multiple tattoos are visible because she’s inappropriately dressed for the weather. She’s been known, for example, to walk into the ER in the dead of winter with bare feet and wearing nothing but a tank top and sweatpants. Her clothes are often unwashed and her body carries a stale smell.
Anna is familiar to the ER staff at this Kansas community hospital because she visits several times a week. Not Nurse Ratched knows Anna well. Too well. After being triaged by the rock-paper-scissors loser, Anna is placed in her section of the emergency department.
> It’s a busy night. Not Nurse Ratched is already caring for two patients—one with a serious illness, the other suffering a trauma—when she gets to Anna. Thankfully, assessing Anna usually doesn’t take much time: the ER nurse is familiar with her medical history, and Anna knows the routine.
“Hi, Anna,” Not Nurse Ratched says. “What is it tonight?”
Anna never takes offence at the nurse’s direct line of questioning. In fact, she appreciates the ER nurse’s efficiency. “Abdominal pain. I can’t stop puking.”
“What’s your pain?” Not Nurse Ratched asks, referring to a standard scale used in the ER to assess pain, though it varies depending on who’s asking. I usually ask patients to name the most pain they’ve ever been in, label that a 10, and then rate their current discomfort by comparison. On a scale concocted by Not Nurse Ratched, childbirth is an 8.
“A 10,” Anna answers.
“Right,” says the ER nurse matter-of-factly. Anna’s pain is always a 10.
After checking Anna’s vital signs and her oxygen saturation, Not Nurse Ratched determines Anna’s not, in fact, sick. Later, the ER physician on duty does a history and physical examination and comes to the same conclusion. But given how busy the ER is that night, no one’s available to discharge Anna right away, so she has to wait. Anna doesn’t mind. She props herself up in bed, turns on the TV and cracks a can of soda she’s brought with her.
Regardless of her apparent comfort, Anna repeatedly rings the call bell, complaining of nausea and requesting an IV with pain medication. Not Nurse Ratched keeps sticking her head back in the room, repeating the same thing each time: “You’re not getting an IV. You’re waiting for me to discharge you.”
The Secret Language of Doctors Page 20
