This week I wanted to die, in a sustained and sincere manner, rather than return to work after my first shift back from vacation.
Because I had a patient. Who weighed six hundred pounds. That's a BMI of 79.9 if you're counting, and not something that you want to aspire to. However, the trouble was not the patient. The trouble was one of her family members, the one Person You Should Never, Ever. Be.
This Person was, she claimed, a cousin-level relative of my patient and, she claimed, a neuro ICU nurse. The fact that she was a neuro ICU nurse at a hospital in the most far-flung district of the most distant, inbred county of Back Of Beyond that Texas can provide didn't matter; she was, by God, an ICU nurse who dealt with brains and That was It.
She questioned why we were doing her relative's transesophageal echo under general anesthetic with intubation rather than at the bedside. They do them all the time at the bedside in her ICU, after all. I was forced to point out that with an airway that doesn't even register on the Mallampati scale (graded from 1 to 4, with 4 being the most difficult to maintain), a BMI of nearly 80, and the need for continuous BiPAP while awake, her cousin was not the best candidate for living through bedside sedation.
Then she accosted our doctors, asking why we hadn't either given TPA or done a clot retrieval on her cousin. Her cousin presented to her small-town ED ten hours after her symptoms began, thus making her ineligible for clotbusters. And she'd had a watershed stroke, which means that there are a lot of itty-bitty clots along one pathway that one large artery follows, so nothing to retrieve.
In short, the Family Member You Should Never Be knew just enough to be dangerous. We had it out when I found her increasing the rate on the IV pump. My patient had congestive heart failure, and CHF patients can't take a lot of IV fluid, even if their kidneys are working well, which this woman's weren't.
We all fell suddenly and irrevocably in love with Dr. Hernandez, who took the brunt of her questioning. When her voice reached near-hysteria levels as she demanded, "Why didn't you do MORE?? You haven't done ANYTHING!" he responded, "Why didn't *you* do more before your cousin reached six hundred pounds?"
Because, People, this is the thing: nobody weighs five or six hundred pounds without somebody helping them out. At that point, it's difficult, if not impossible, for your average five-foot-four woman to get her own food. Extreme obesity is like heroin addiction, but with family support and enabling. It's harder to treat than heroin addiction, but just as deadly. And the families of these folks have often been the go-to people for high-calorie food in quantities that would blow your mind.
So yeah, that happened.
It was kind of a long week.