The Obese Patient: Confronting the Epidemic

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The first in a series of columns concerning the morbidly obese patient in the emergency department

Recently, a 35-year old female presented to an academic medical center as an outside hospital transfer for further evaluation of subarachnoid hemorrhage. She had an acute onset headache and photophobia without any preceding diagnosis of migraine headaches. Her outside hospital diagnostic dilemma was that she would not fit in their CT-scanner because she weighed 550 pounds.  Unfortunately, upon arrival at the receiving hospital, her body habitus was also found to preclude imaging of any kind including CT or MRI. Furthermore, a standard (blind) lumbar puncture attempt was unsuccessful and fluoroscopic guided LP could not be performed because the weight limit for their table was 350 pounds. When Neurosurgery was consulted for evaluation without any LP or imaging results, they balked, stating that even if an SAH were identified by some yet-to-be-determined diagnostic strategy, they’d be reluctant to intervene operatively or non-invasively given the operative risks inherent with her morbid obesity. Obviously, the patient’s diagnostic dilemma was challenging, yet given an ever-increasing burden of morbidly obese patients, the case was far from unique.  The enormous medical costs of obesity are both direct and indirect. The direct costs include diagnostics and therapeutic expenses. The indirect costs include the increased morbidity and mortality. In 2002 obesity-related medical expenses accounted for $92.6 billion, approximately half paid by Medicaid and Medicare. At the state level, obesity-related Medicare expenses vary: in Wyoming, $15 million; in California: 1.7 billion. With regards to Medicaid, Wyoming spent $23 million while New York state spent about $3.5 billion. Thinking of the preventable complications of obesity such as coronary artery disease, diabetes, hypertension, hypercholesterolemia, arthritis, and obstructive sleep apnea, it’s apparent that as emergency physicians, it’s our problem too.
The challenges morbidly obese patients place upon already overcrowded ED’s are staggering. How do pre-hospital systems extricate these individuals from their homes when they do not fit through the doors? What weight limits exist for our pre-hospital vehicles? Upon ED arrival, what weight limits do our gurneys have? How does one evaluate the dyspnic patient who cannot undergo CT imaging? What normal variants does the ECG display? Are any physiological or laboratory parameters considered normal variants of obesity? How does one obtain IV access or laboratory specimens when veins cannot be palpated? How should drugs be dosed in morbidly obese patients: ideal body weight or actual body weight? How does the therapeutic response and mortality for any intervention differ in morbidly obese chest pain (dyspnic, headache, trauma, stroke) patients differ from less overweight populations?
Our morbidly obese headache patient had gradual resolution of her headache. Calls were made to the local zoo and state veterinary school in search of larger scanners, but none could be found. Neurosurgery refused to attempt an unguided LP, but one confident EP finally bit the bullet and performed an LP without opening pressures which revealed no xanthochromia or pleocytosis. She was discharged home with NSAID abortive therapy and recommended follow-up with her physician within a week. Of course, without opening pressures pseudotumor cerebri couldn’t be excluded, but outpatient follow-up for further evaluation was felt to be appropriate by EM, Neurology, and Neurosurgery.
We learned several lessons from this case.  First, we were made aware of the weight limits of our various imaging modality tables and consultants’ reluctance to intervene or offer alternative diagnostic strategies when routine testing is unavailable. Second, we were made aware of the widely held misconception about large body scanners available at alternative sites such as veterinary
facilities. Finally, we quickly became aware of the lack of educational resources through which to learn more about overweight emergency management.
How would you have handled this case? Write in to and we’ll compile the answers.

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