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 10:00 pm 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.
About the author:
Edward Thompson was a family-practice faculty member at Eglin Air Force Base, Harrisburg Family Practice Residency and Morton-Plant Mease Residency, then went into emergency medicine full-time. He recently returned to family medicine and now practices in Frederick County, MD. He has three sons (a photographer in Brooklyn, an Air Force F-15 pilot and a graphic designer), is married to his wife of thirty-five years and travels the world to look for birds. He tries to watch his weight.
22 thoughts on “Supersize Me”
This article doesn’t show compassion or empathy and frankly it makes my stomach churn. I have been a RN for 13 years and have taken care of many morbidly obese patients. In no way does any of the staff show compassion or care to Donald, and it’s an absolute disgrace to treat a human being like this. The ER staff need to have some sensitivity training on bariatric patients and not be a bunch of ignorant unprofessional jerks making snide remarks about patients. I really hope that they learned a serious lesson from Donald’s case and hope management enforces training.
Donald’s case is an example of how far our health care system needs to change and grow. We have made some small clinical adjustments for bariatric patients like larger equipment and furniture but what really needs to change is an attitude to how medical professionals and assistants view obese and morbidly obese patients and treat each patient with the utmost respect and professionalism.
I took quite a beating on this column, but I would like to try one more time to make the point of the story. The ER staff was crass. And inappropriate. That was the point, and that is reality sometimes. But Donald, for all of his posturing, was quite vulnerable, as well as overwhelming from a physical standpoint. It may not have come across in the article, but I saw our common humanity (as I do with addicts, homeless patients, patients with mental health issues, etc) to the point where Donald would ask for me when he came in. I was frustrated by his lack of holistic care and did refer him to psychiatry. The point of the piece was to emphasize that we need to be careful about the people we judge; they are people with their own burden(s) and there is not really much difference between all of us when you get down to it. One Note: Of all of the criticism I took for this piece, not one person wondered if I struggle with obesity myself. And the answer is, I do.
A personal note…I have known the writer/physician since his first post-residency AF assignment at small Hahn Air Base, Germany in the mid 1980’s. I was also in my first post-residency AF assignment as a dentist. We were buds, not really best friends, but I knew, and know, Dr Thompson well enough to assure all that he is not lacking in compassion or empathy. I remember like yesterday that Dr Thompson was the MOD (Medical Officer of the Day), a lonely and stressful duty for any young doc, the night that four airmen from our small hospital flipped their car into a water-filled ditch, could not escape and drowned. Dr Thompson received their limp bodies that night. I can only hope that was the worst night of his ER career. I am glad he was there that night, not anyone else, to handle it. Imagine that experience, and know that he’s a great physician. I would trust him to treat me any day. He is truly a man of great heart. In this piece, he simply illustrates our imperfectness.
What a powerful story on so many accounts. As an ER doc you have a small window into the story of this man’s life. The larger he becomes, the less influential the medical professionals feel. A hopelessness is at the core of their snide remarks and false humor. You get to witness the patient’s and the caregivers’ helplessness.
The recent ACES research findings open a new window of understanding about what might lie at the core of so much suffering.
thanks for sharing this.
To Dr. Thompson: Since I am fairly certain you do not read the latest from the fat activist arena, I thought I would do you the service of providing a link to an article that examines yours. I did not write this, though I have to say I wish I had. What I can offer you, that comes directly from me, is my full name and credentials, so you, and the many anonymous commenters, can respond to me directly with any and all aggression and rationalization. http://www.shakesville.com/2014/02/today-in-fat-hatred.html
Rebecca Jane Weinstein, Esq, MSW. http://www.rebeccajaneweinsteinwriter.com
Our tax dollars at work. We pay a guy to sit at home and eat his way to 600 lbs., and then get the privilege of paying G-d only knows what for his medical care.
I am very large, and have been on the other side of experiences much like you describe. I must say, that your article does NOT sound compassionte, even slightly. To be honest, it shows a dramatic ignorance about obesity, and corresponding prejudices that just, wrong.
Virtually NOBODY gets that large because they want to. Virtually NOBODY that size has not put substantial effort into trying not to be that size. It’s my theory that most people who are very obese and don’t actively try to do anything about it have given up, because they have tried before to no avail.
You cannot begin to understand the emotional anguish involved in being a morbidly obese person in today’s culture. So, please don’t claim empathy where none exists. Nor knowledge where none exists. (8,000 calories? Really?)
A good start at understanding might be to watch Dr Robert Lustig’s presentation “Fat Chance: Fructose 2.0” on YouTube.
The patient may have had thyroid problems. I do and my weight has fluctuated by 150 lbs. So it might have been a metabolic problem. He possibly didn’t eat 8,000 calories per day. A more thorough exam might have revealed that. Right now, I am at 237, with a weight loss of 15 lbs. in about 2 weeks. I realize that my yo yo weight gain and loss has to do with an unstable dosage of thyroid hormone replacement therapy. I rely on the expertise of my endocrinologist to figure out what to do. I also have arthritis which limits my my activity. I’d like to do more, but I don’t want that cycle of pain to start again.
Unfortunately, the obese are the last group we can ridicule and discriminate against, You can’t look at a person and tell which obese person has had poor eating habits from childhood, or have become disabled and progressively depressed, developing poor eating habits along the way. Again many medications, contribute to obesity, especially mental health medicines. I can’t imagine any person with this level of obesity not being depressed. It’s all a viscous cycle.
And as for those with childhood obesity, often its matter of poverty. It less costly to feed a family from the dollar menu or a case of store brand mac and cheese, And it’s easier to sit back and ridicule obese persons, than try to change our way of thinking about how we should best care for them. The medical profession and society really needs to be more proactive on this matter rather wait until it’s a problem.
It’s too bad Donald didn’t get effective treatment for the root of his problem instead of treatment for the results of it. It’s also important to note that no one is able to get that large without help. It is simply physically impossible without an enabler close by, someone who knows that much food is bad for him but “doesn’t have the heart” to withhold the food so desperately wanted. It is a complex problem which most medical facilities are not equipped to address. Very sad but true.
Such a well written story to show the unintended consequences of stereotyping difficult patients.
Lois: I think you understood the story better than anyone. It was written to point out the common humanity we all have and how our prejudices and stereotyping get in the way of understanding and resonating with our patients. Based on the hate mail I received at other sites since publication, I’d say many other people missed the point altogether, busy as they were stereotyping physicians.
This is lovely and heartbreaking. Thank you for sharing your story, your honestly, and compassion.
For those who have a hard time feeling empathy for the morbidly obese, I recommend reading Heft by Liz Moore. The protagonist is this size. The book was well and widely reviewed, and is entertaining as well as enlightening.
I found this story so very sad. Donald was a human being like the rest of us with an insatiable appetite. He deserved compassion, empathy, and for everyone with whom he came in contact to show him the respect we each deserve – not ridicule said under one’s breath that he could hear anyhow to make him suffer that much more because he must have felt so alone. God rest his soul. Certainly he didn’t get much understanding or love here on earth.
Thank you for writing and sharing this piece. I appreciate your honesty, insight and compasssion.
This is a beautiful, emotionally honest, insightful piece
A well-written story, however I must admit to being mystified by the doctor’s reaction. Empathy with the patient, yes, certainly, and a keen recognition of a disease, perhaps a syndrome that speaks volumes about our culture… But no, I cannot identify closely with the patient in this case, any more than I can understand the author’s sense of guilt.
Whatever emotional pain the patient was trying to avoid, whatever comfort he was trying to find in his diet are topics far beyond the scope of even the most compassionate ER staff. Everyone did what they could, given the physical limitations and diagnostic challenges presented, arrived at a diagnosis, and offered a treatment plan. Where does one find room for remorse in a job well done?
As an RN, I agree that there is nothing to be guilty about in this situation. However, what Care Providers do to shield themselves and compartmentalize the pain they encounter is to offer side remarks, joke or else ignore their deeper feelings. I do not agree with that. Professionalism dictates that this is best done behind closed doors, discreetly, not ever where they can be seen or heard. The author illustrated this problem in stark words quite well and his compassion and understanding could be better understood in the word, ” connection”. For he found the kernel of truth to us all, the seed that sowed the symptoms: loneliness, despair, silent pain, hence anger soothed only by calories, ( or do we use alcohol, self-righteousness, medication, academia, artistry, sports, or gourmet meals? )It was this man’s suffering that he recognized in the course of his work, and he allowed the feeling instead of blocking it, to his human credit- simply told, well done! 🙂
Yes, a well written story indeed. Perhaps a reason for the guilt on the physicians’ part is the knowledge that the physical symptoms of the patient were being addressed, but the root cause of the obesity was not addressed. Donald did see a number of consultants, I wonder if psycholgy and psychiatry was high on the list. Emergency is usually not the place to treat the chronic disease – obesity. However, it is the place that patients present with the devasting complications from obesity. A holistic approach to patient care may have been a referal to psychiatry that could have explored and possibly treated some of the complex mental health issues that Donald lived with.
Still, the problem persists and we look for its origin: I’m a Clinical Pastoral Education student, a chaplain in training, and have acknowledged to the members of my cohort how great I find the challenges of relating compassionately to obese patients. In the recent documentary HOW TO SURVIVE A PLAGUE, Robert Rafsky, an AIDS activist who died in the late 1980s spoke about how compassion is often withheld from patients who are ill because of their own human vulnerability–because they ate too much, drank too much, had unprotected sex. Seems to me that the author is looking for some understanding of that reality. I think it’s also a control issue: why can’t these people control themselves? Loss of control is the source of fear and shame for many, if not most people.
A cautionary tale for gourmands! Well done.