We met several months after I had finished my fellowship in 1985 and joined a pulmonary and critical practice in Pennsylvania. With my addition there were now five in the group and responsibilities were rotated among three hospitals. It was now my turn to staff the relatively smallest of the three. This is where I met Oscar. I had heard about him but this was my first encounter.
Oscar was 500 pounds plus; no one knew for sure as he couldn’t walk down to the loading dock scales to be weighed (that’s how we did it in 1985). If he had been 10 feet tall he might have been approaching ideal body weight but he didn’t come close. Hospitalizations were a recurrent theme for him; morbidly obese with chronic respiratory failure (at that time just starting to be recognized as the Obesity-Hypoventilation Syndrome).
Oscar’s care was always a challenge. His recurrent episodes of respiratory failure had lead to placement of a chronic tracheostomy tube so the easiest part of his care was attaching him to a ventilator; ventilating him was a different story. There was a massive chest that had to move in order to get lung inflation and we were using “state of the art” ventilator settings that, today, would make any self respecting pulmonologist cringe. Venous access (superficial veins quickly evaporated and cannulating central veins was always an adventure) and nutritional support (yes, even though he was obese starving him was not a good idea) were ongoing issues that always posed difficulties.
Nursing care was the lynchpin in Oscar’s recovery. The ICU nurses were always dismayed when he was admitted because they knew what was coming. Strained backs and shoulders (there were no lifts for this size patient back then), skin care, bowel regimens, clogged tubes and a host of other issues were recurrent themes. Yes, they would grumble (try changing a bed with an essentially immobile 500 pound person in it) and bitch but never ignore what needed to be done. And, in time, Oscar would get better and go home. Backs and shoulders would get better; “Oscar stories” would be swapped; all while awaiting the next go round.
Why did I tell you about Oscar? Because in 1985, Oscar was a relative rarity. Not any more. The explosion of Oscars, termed “super morbidly obese” in this day and age, has lead to a sea change in health care. Many hospitals have installed (at no small cost) ceiling lifts in some ICU rooms to take the physical burden off nurses. Utilization of smaller portable lifts (again $$) was an option as long as a certain weight wasn’t exceeded. Transfers between hospitals not infrequently occured when morbidly and, especially, super morbidly obese patients exceeded the weight limit of diagnostic radiology tables at the transferring hospital. Whether inpatient or outpatient more and more of these patients with their chronic respiratory failure require sophisticated ventilatory support either with a respiratory device termed “BiPAP” (Non-invasive Positive Pressure Ventilation = patient/machine interface by mask) or a “true” ventilator (patient/machine interface by tube in airway) adding to the cost of healthcare. And this is just some of the issues on the medical side. Think about the poor surgeon needing to surgically invade the abdomen or chest of one of these types of patients.
Will things change? I doubt it. Processed foods, lifestyle, the sense of entitlement, and lack of self responsibility all play into the mix. There are even TV shows about super morbid obesity (albeit not necessarily glorifying the situation). Some people get it; some try to do what’s right; many don’t. Some are successful with weight loss; unfortunately, the majority aren’t.
Let me leave you with two stories and a final thought.
Sometime in the not too distant past our group (my third practice) received in transfer an “Oscar” from an outside hospital. The patient had had a large thigh abscess that needed some extensive surgery and the patient had been intubated for this. There was concern at the other hospital that the patient might experience complications after extubation and so the reason for a weekend transfer. Extubation at my facility was successful and the patient did well but still needed a bit of time in the ICU. On rounds I was speaking with his nurse who brought up a situation she had with the patient and family the previous day, Sunday. The family had brought in a 12 piece fried chicken dinner with all the fixin’s. The nurse explained to them that the meal would have to be eaten elsewhere as not everyone could eat in the ICU room at the same time. She was then informed that this meal was entirely for the patient as this was their custom on Sundays and that she best not interfere. She didn’t. There were no leftovers.
The heaviest patient I ever helped care for weighed almost 1000 pounds. Although this person was recovering from a brief illness, because of their weight a longer hospital stay was required. I commented to one of the nurses one day of how nice the patient was (some aren’t). Her reply, “Of course they’re nice because they’re totally dependent on others for their care and food.” So I started to think about who were this patient’s enablers–parents? friends? aides?–who would continue to acquiesce to requests for “food” when a large portion of what was eaten was in the “junk” category (this was confirmed by the dietitians at the hospital).
So, what to do? The universal prescription is, “Eat right, eat less, exercise.” While a small part of the patient population may have a disease with a predilection toward obesity/morbid obesity, the larger part doesn’t. The plethora of self help books, advice columns, dietitian counseling (my daughter, a dietitian, commented once that one of the most frequent responses to her advice is, “I know, I know, but…”), physician and nurse counseling, and event TV shows (…”Biggest Loser”) have done nothing to stem the tide. So, for too many the prescription for self discipline is not picked up leading to continued poor dietary habits, lack of exercise, continued sense of entitlement, and an ever increasing strain on the health care system.
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