A patient trapped in his own body

Donald is large. Very large.

At more than 600 pounds, he is a mountain of flesh with a small opening at the top through which he speaks.

“My stomach hurts,” he says, his voice surprisingly high and childlike.

It is 10:00pm in the emergency room, and I am already swamped with patients I’m trying to move through the ER before my shift is over.

Asked if he’s ever felt this kind of pain before, Donald says, “No, never. At least, not like this.”

“Well, what’d you expect?” the unit secretary mutters, only half to herself.

Donald is in his forties. He spends his days on the sofa at home, surviving on disability checks for his back pain.

Facing him, I feel momentarily put off. I’m not sure just where to start the examination, and when I begin, my hands look small and insignificant against the panorama of skin they’re kneading.

It’s hard to tell, exactly, but I think his pain is coming from somewhere around his stomach.

I call the surgeon. When he finds out how much Donald weighs, he says that he’ll be down to see him “in a while.”

Awaiting his arrival, we try to shoot some x-rays. When we roll Donald onto his side, though, he turns an unnatural shade of blue-gray and can’t tolerate the position long enough for us to put the X-ray cassette behind his back.

We try a chest x-ray, turning up the power to the maximum setting. All we see is white. Donald’s body is just too thick to allow standard x-rays to penetrate to the bones; he is a walking lead shield.

We start an IV and get some blood work, all of which is normal. Our standard GI cocktail of shot-in-the-dark digestive tonics plinks into Donald’s stomach without any effect. Morphine at doses high enough to make me dance on tables merely makes him a bit drowsy.

I talk to Donald between procedures, trying to get a sense of him as a person. He recites a litany of consultants he’s seen for his back pain, his headaches, a chronic rash on his ankles, his shortness of breath, his weakness, his insomnia and his fatigue.

“All of them have failed me,” he says, adding that the EMS paramedics didn’t have the proper ultra-wide, ultra-sturdy gurney to accommodate his body.

“The Americans with Disabilities Act says that they should have the proper equipment to handle me, the same as they do for anyone else,” he says indignantly. “I’m entitled to that. I’ll probably have to sue to get the care I really need.”

I don’t quite know how to respond, so I say nothing. We’ve placed Donald in a room with an oversize hospital bed, so at least he’s resting comfortably.

Finally, we move an ultrasound machine into Donald’s room — it barely fits between the bed and the wall — and the technician goes in to take some diagnostic images.

Minutes later, he emerges.

“I need to get the radiologist to help me,” he says. “This is impossible.”

One half-hour later, the chief of radiology comes out of the room, rings of sweat under his arms.

“I think we have something,” he says. “A gallstone.”

Elation surges through me. At last we have something to work with!

Paged again, the surgeon finally shows up, muttering, a full two hours after our initial conversation.

After examining Donald, he thinks for a bit, then brightens.

“We could send him to the University of Maryland — they have an oversize OR table and beds.”

He’s now a man on a mission: to unload Donald on another unsuspecting hospital.

Hours later, he learns that there’s no room for Donald on the surgery wards of either the University of Maryland or Johns Hopkins. He must admit Donald to our hospital’s upstairs ward until tomorrow, when he can try the transfer again.

The surgeon is most unhappy. He bellows orders over the phone at a nurse several floors above us.

“Don’t put him in a room right over the ER,” whispers the unit secretary to the admission clerk. “The floor won’t support him — he’ll come crashing through and kill us all.”

Glancing across the hall at Donald, I see by his eyes that he’s heard her comment, and I’m suddenly sure that he’s heard all of the “side” remarks aimed his way.

Finally, a slew of huffing, puffing, grunting attendants wheel him down the hall, leaving me to reflect on his plight.

Donald lies at the very large center of his own world — a world in which all the surgery mankind has to offer cannot heal the real pain he suffers.

He’s trapped in his own body like a prisoner in an enormous, fleshy castle; encircled by a moat of fat, he shouts from the parapets to anyone who might give him succor. And though he must feel wounded by the ER personnel’s remarks, he seems to find his own succor in knowing that there’s no comment so cutting that it can’t be soothed by the balm of 8,000 calories per day.

Later on in my shift, still feeling the eldritch traces of Donald’s presence, I sit and stare at my 700-calorie dinner, all appetite gone, wondering where empathy ends and compassion begins.

I know why my colleagues and I are so glad to have Donald out of the ER and stowed away upstairs: he’s an oversize mirror, reminding us of our own excesses. It’s easier to look away and joke at his expense than it is to peer into his eyes and see our own appetites staring back.

I push the food around on my plate, then give up and head back to the ER, ready to see more patients.

Though I’ve no way of knowing it, within a few months a crane will hoist Donald’s body through a hole cut in the side of his house so the EMS personnel can lower Donald, found dead and alone in his upstairs bedroom, onto their new ultra-wide, ultra-sturdy gurney.

Edward Thompson is an emergency physician. This piece was originally published in Pulse — voices from the heart of medicine, and is reprinted with permission. 

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  • Suzi Q 38

    Sad but interesting story.
    Tonight on channel 183 is a documentary on obese people like Donald.
    All of their stories are sad.
    How can we get help to these people before the 600 or 700 pound weight?

    He is a reminder of what can happen if we eat too much and don’t exercise.
    Some of us have difficulty exercising because of spine problems. If we exercise too much we get worse and we can’t walk.

    If we don’t walk, we can’t burn up calories…. or we will gain weight.
    Although I am not 700 pounds, the thought of figuring out how to lose 10 pounds is daunting.

    I weigh 158, and feel as if I weigh 200.
    I think I will try to go to bed early tonight, instead of eating dinner.

    • querywoman

      Your spinal stenosis is probably still the main problem. I can exercise and walk three or four miles a week, which is a great luxury for me, freedom when I am out on errands.
      Have you tried aquatic exercise? My mother couldn’t walk do to bone problems in her feet and did some aquatic exercise, though she feared water, and she liked it.

  • Gibbon1

    I can’t help but chime in with something. I sat across the table from my mother for 20 years at dinner. She was never stuffing her face, or obviously over eating. And as far as will power is concerned my mother had it in spades. If being thin was a matter of eating and will power, she wouldn’t have been fat but she was.
    I’m not going to say no one, but no one gets to 600lbs because of mere issues with ‘will power’. And blaming the victim is one of the unclassiest things people do.

  • querywoman

    I lost significant weight from getting off insulin (used to use very high doses) and getting on Victoza. I’m still fat, but my doc is very pleased, and so am I.
    He says he’s only seen this kind of weight loss in one or two other patients. For him, I think that means in three different countries and in two American states.
    I always wonder if I will regain it. My doctor, who is an endocrinologist, would gladly admit that medicine really doesn’t know much about weight and how to lose weight.
    In Wales, a very fat young woman, Georgia Davis, was cut out of her house. She had multiple organ problems, but is apparently doing much better. Nevertheless, she had previously lost a bunch of weight at an American “weight camp” and regained it all. So will her excess weight come back. Both she, her mother, and stepfather, apparently eat tons of food. Not every fat person does.
    Donald was right in mentioning the ADA. Did the medicos make him as comfortable as they could? It’s over for Donald.
    There are no easy answers for Donald. I often wonder if the Welsh doctors have tried Victoza with Ms. Davis. It has cut my appetite, but I still eat the same foods, just less, so there’s no deprivation. My doc and I are both pleased with that, that I am still me.
    I mention my own experience, knowing that my weight loss is unique to me, only to point out that new advances are being made in weight and appetite control.
    Living into the forties is still culturally new. Most of humanity before us died before age 30.

  • querywoman

    All the Medicare D companies seem to cover it. If you need it, perhaps you could get it free or low cost from the manufacturer.

  • querywoman

    I’d like more details about Georgia Davis’ treatment. Limiting her calories in the hospital is one thing. Before, at home, the whole family was ordering huge deliveries of food.
    She’s supposed to be a motivated, bright young woman,

  • Suzi Q 38

    I would if the pain level got really high.
    My pain is a chronic 5 or 6 (out of 10) without meds.
    I can’t sleep, no matter what position I sleep in.
    With meds, it is a manageable 2-3.
    My problem is that one of the main side effects of the tricyclic antidepressant (Elavil) is weight gain.
    I don’t need that side effect. For some reason I really crave carbs while on it.

    • querywoman

      I do feel for you and count myself lucky that I can walk a half mile for my errands and back. It helps blow out my lungs. I can walk home when I want, and don’t have to wait 30 mins or an hour for the bus.

    • Becky

      I’m sorry to hear that.

      • Suzi Q 38

        Thanks.

  • Sara Stein MD

    He needed residential treatment in a skilled nursing facility with bariatrics, however those programs are few and dwindling. We had a program in Ohio that was sabotaged by the patient rights rules for nursing homes – stating that patients could go out and eat what they wanted, and that people could bring them food in if desired, and the nursing home could not llimit their food. Some people still managed to do well, they could have bariatric surgery when they got below 500 lbs. Anybody know what’s going on with the Michigan program?

  • Sharon

    This statement says a lot, right here. I think it is something that isn’t discussed enough among professionals.

    “I sit and stare at my 700-calorie dinner, all appetite gone, wondering where empathy ends and compassion begins.”

  • rbthe4th2

    I think there are a couple items at work. Its hard to balance the fact that another hospital might be more appropriate for a patient and their issues than another. Its a two way street: if you have a patient that you or the facility can’t handle, isn’t it better for the patient go elsewhere, if they can? At the same time, at this point, Donald probably has access through insurance to bariatric and/or psychological and/or obesity resources to help him with issues. It wouldn’t be unreasonable for people to think they should access them. I have supported people in the past who did have surgeries and those who didn’t. What I support is people taking personal responsibility and trying to do what they could for their health issues. I would guess that the response of the medical professionals could not have been just “attitude” but the expectation that someone would take advantage of opportunities to help rather than the “sue you because you can’t help me” attitude on Donald’s response.

  • Zoann Murphy

    I think something else that should be a reminder to all EMS, ER, and hospital staff members is that patients can hear you speak about them. Even from as far away as the nursing station. And FYI, Dr. Thompson, that kind of overheard “cutting remark” is not “soothed away by the balm of 8,000 calories per day.” Nothing can sooth away the memory of a disparaging remark.

  • querywoman

    I don’t think Donald was, ” reminding us of our own excesses.” I think they were frustrated because they didn’t do know what to do for him.
    Weight loss is very, very difficult to achieve.
    Cutting through all that flesh to get to his gall bladder is also risky.

  • leslie fay

    I always find it interesting that our society has great compassion for people with eating disosrders like anoriexia or bulemia who starve themselves to death but zero compassion for people who are massively overweight who are eating themselves to death. They also have some kind of eating disorder, just the other end of the spectrum. You will never convince me that someone who can no longer get up to even go to the bathroom and needs a hole cut in the wall to get out of their bedroom does not have some sort of disorder and some body dysmorphia. They also obviously also have enablers. If you can’t get out of bed how are you continuing to get all that food(though once you stop moving you really don’t need as much as you would think to keep gaining) and who is cleaning you since you can’t get up to the bathroom?

    • querywoman

      Just like many people are born with defective organs, the very fat are probably born with improperly food processing systems. But society blames them and sees it as controllable.
      There are no easy answers.
      Donald, if he had been able to lose weight, still went to the emergency room because of horrible pain. He needed treatment for pain, but couldn’t drop the weight quickly to get surgery. That’s impossible. It would have taken months for him to lose any appreciable weight.

    • DoubtfulGuest

      I’m not sure society has great compassion for anorexia or bulimia patients. At least the medical community doesn’t, from what I’ve seen. I was mistaken for having an eating disorder, but it turned out I have a different disease that was keeping me too thin until it was diagnosed and treated. A few doctors talked to me as though I was manipulative and faking. One responded as though any symptom must have something to do with my appearance. Like with my leg muscle weakness, she assumed I was anxious about how they looked (*facepalm*), even though I tried to tell her I was having trouble walking up and down stairs. No one tried to get any evidence or diagnose me with an eating disorder. Which makes me think people who actually have them often get the same treatment or worse.

      That said, I agree with you, and I do have compassion for overweight people. I was so thin that people told me I looked “disgusting”, and I don’t want anyone else to feel bad like that. I know one concern of medical people is the injuries they receive while trying to move and care for obese people. I’d never thought about that til recently when I read another blog post about it. I have compassion for them, too. It’s very difficult.

  • querywoman

    Google Manuel Uribe in Mexico for a man who once weighed over 1000 pounds and has been able to lose some weight.

  • wiseword

    How many obese people were there in concentration camps?

  • Dorothygreen

    Donald had an eating disorder. It doesn’t have DSM code because the medical community would rather use obesity as a disease, even though it is a risk factor, because treating obesity will produce more revenue than preventing or treating an eating disorder before it becomes a metabolic problem very difficult to reverse.

    Most Americans and, in fact, most humans have some sort of craving for sweet, salty or fatty food. But in the US 34% are obese and and another 34% are overweight. It is a so called epidemic. Big Food and Big Ag are owners of our politicians and are the pushers here,

    The Surgeon General gave a talk about the evils of tobacco recently: how many folks were dying from cigarette smoking, how many kids will die, on and on “enough is enough”. But tobacco smoking is no longer the leading risk factor for chronic preventable diseases, disability and premature death. The US rate of smoking is now one of the lowest in the world having peaked at 60% it is now 17%. The leading risk factor now for chronic preventable diseases it a diet high in calories and low in nutrients, subsidized, cheap and available 24/7.

    Donald was enabled – by our government who gave him his disability check “unconditionally” and by whoever was bringing him this food. Other addicts buy or stead their high of choice – mostly illegal. But, because the US will not deal with our unhealthy eating culture many will continue to eat themselves into disease and or death while stressing health care resources and wasting income taxpayer’s money.

    There is enough blame to go around but like tobacco smoking it is a public health issue and until there is recognition by our government that a high caloric rich, nutrient poor diet is public enemy #1 we will continue to be on an unsustainable path of food insecurity , malnutrition and out of control health care costs.

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