Published in the May 2012 issue of Today’s Hospitalist
“YOU’RE TAKING ER PATIENTS TODAY, right? I got a 500-pounder here with panniculitis…”
Take a deep breath. Hospitals can expect to keep admitting morbidly obese patients for a long time to come, and as bariatric surgery becomes more available, you will probably be asked to provide part of their inpatient care. What do you need to know and do to make their hospital stay as safe as possible?
The very first question
Before you even begin the admitting orders, you need to know one thing: Does this patient have impaired breathing?
Even if patients and their families deny that patients snore or fall asleep easily, they can still have dangerously low oxygen levels during sleep and naps “as well as other complications of sleep apnea like life-threatening arrhythmias, pulmonary hypertension and right-sided heart failure. Few hospitals offer inpatient sleep studies, and transporting individuals to an outpatient facility may be as hard as finding one willing and able to accommodate them.
So you’ll have to make do with what you’ve got: pulse oximetry during sleep, telemetry for the first couple of days to spot arrhythmias, and physical examination for pitting edema and elevated jugular venous pulsations. If there are enough suspicious findings, insurance companies may be persuaded to allow the testing that qualifies patients for positive-pressure ventilation when they go home.
Remember that sleep apnea and obesity-hypoventilation syndrome are both associated with sudden cardiac death “and that CPR simply does not work on very obese patients. It’s worth taking every possible precaution to diagnose and treat them.
The nuts and bolts of equipment problems
You have probably heard of the “Big Boy” bed, which is not only longer and wider than a regular hospital bed but reinforced to prevent sagging or breakage.
Extra-heavy patients also require stronger chairs, stretchers, lifts, wheelchairs and, yes, toilets (the ones at my hospital are stainless steel with an extra beam across the bottom that patients find reassuring). Many beds have built-in scales that avoid those difficult trips downstairs “which are humiliating for patients “to use the kitchen scale when you need daily weights while treating CHF.
Before you order noninvasive testing, check with the department where the test is done. It used to be that 400 pounds was the limit for CT scanner tables, but many now accommodate people up to 600 pounds.
Even if patients meet that weight limit, however, they may not be able to have more than a head scan because the arch of the machine may not be wide enough for their shoulders. And you probably already realize that ultrasounds are of dubious value. Remember, echocardiograms work on the same principle, so you won’t get reliable information from a study for a patient who weighs more than 350 pounds.
Invasive procedures will be more difficult, of course, and some are downright impossible. Heart catheterizations and angiograms are all done on the same kind of tables, and a patient who even looks able to break the equipment is going to get sent back to her room. Your surgeon friends have no doubt told you at length about how slowly adipose tissue heals due to its poor blood supply and lack of mechanical strength. And the OR will need reinforced tables.
The real work of patient care
For turning limited-mobility patients, more hands (and backs) will be needed; a good rule is one person for every 150 pounds that a patient weighs.
Foley catheters for female patients, according to urologists and experienced nurses, can most easily be placed with the patient lying on her left side and three or four assistants raising the right leg to allow access to the urethra “still not easy for any of those involved. It doesn’t hurt to remind your helpers to avoid positions that strain their backs. Beds with pneumatic devices to vary pressure will help minimize decubitus ulcers and cut down on the amount of turning needed. (A trapeze over the bed sounds like a good idea, but first be sure that both the trapeze and its support rod will bear a patient’s weight.)
Respiratory therapy can help by trying a variety of masks for CPAP or BiPAP, and by checking pulse oximetry to be sure a patient’s home settings are doing the job. Oxygen masks and cannulas, fortunately, do not require special equipment.
Social work to the rescue
Is this patient disabled? While the answer may seem obvious, becoming “officially” disabled via a government agency can be a huge help for patients and families, both financially and in making bariatric surgery possible. Medicare and many Medicaid programs cover laparoscopic surgery for obesity once certain criteria have been met, so a social worker who helps with applications for these programs can literally be a lifesaver.
A social worker or case manager can also arrange home visits and look into the family situation. Patients who are too heavy to get out of bed cannot shop or prepare food, so somebody needs to ask who feeds them. A referral to Adult Protective Services may be in order; at the very least, patients and families may learn about community services they don’t know exist. Sometimes a psychiatric social worker will identify body-image issues or depression that prevent changes in eating habits.
Your attitude is important too
Very obese patients are reminded dozens of times a day that there is something wrong with them. They don’t need any reminders from you or other members of the staff.
If you can’t be pleasant, at least be professional, and leave the elephant jokes behind when you enter the hospital. Family members’ attitudes can vary wildly. From some you hear, “She won’t listen, so what’s the use?” while others may tell you, “There’s no problem, he’s just always had a big healthy appetite.” Make sure they understand the likely consequences of extreme obesity. Taking the time to emphasize that both of you want a patient to live long and prosper is the first step toward turning “enablers” into helpers.
We’ve known about the dangers of obesity for decades, but the availability of laparoscopic surgery offers a different approach, even if it’s one that should be undertaken very carefully, for those crippled by extreme obesity. Many bariatric programs offer lengthy counseling and dietary restrictions before the actual procedure. If you have such programs in your area, offer patients information about them.
Whether you’re helping with the care of postop patients or making others aware of ways to lose weight, you have a chance to make a major difference in the lives of the morbidly obese. You can do the best possible job if you’re aware of your hospital’s limitations, and of how much other health care professionals can help.
Stella Fitzgibbons, MD, has been a hospitalist since 2002 and has worked at numerous hospitals in the Houston area. She is presently with Intercede Healthcare in a hospitalist group whose percentage of bariatric patients is … well … getting larger.