Stage 1: Denial
The patient is large. Very large. At more than 600 pounds, he is a mountain of flesh.“My stomach hurts,” he says, his voice surprisingly high and childlike.Asked if he’s ever felt this kind of pain before, he says, “No, never. At least, not like this.”“Well, what’d you expect?” the unit secretary mutters, only half to herself.
Oh, you’re kidding me. Not again. Not another medical professional gawping at a fat person like they’re some strange, otherworldly animal, megafauna of the modern age -- a mastodon of flab! A ground sloth of bewildering corpulence. A freak in an old-timey circus. That can’t possibly be real. Can we not? Can we not do this?
Stage 2: Anger
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.
A former ER doctor named Edward Thompson has written an article that has been published in the Health & Science section of the Washington Post. It is an article that is neither healthy nor science-based, technically speaking, but is rather about a personal experience he had trying to treat a very large man in an emergency room.
The patient is in his 40s, and disabled, although whether he became disabled because he is so large, or became so large because he is disabled, is never quite clear. Details would probably just get in the way of assumptions anyway.
And it doesn’t matter, because his doctor has already made the only diagnosis that matters, the one that will unavoidably influence his perception of anything else that might be going on: the patient is fat. Really, extremely fat. He is probably in pain because he is fat. Even if he says this pain is new and different and sudden, it is because he is fat.
Nothing else can possibly be wrong, because when you are fat your organs disappear, all your body’s systems vanish into the milky pale abyss of your adipose tissue, which spills not only outward into the world in undulant rolls of flesh, but apparently inward as well, swallowing your respiratory apparatus, your digestive tract, all the parts that make you biologically human. Your humanness is erased and all that is left is a lumbering, soulless behemoth of cautionary tales, a thing other people look at and think, “How frightening,” “How ugly,” and “How did he let himself get that way.”
That’s not a question, however, because no one really wants to know.
I talk to the patient 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 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.”
As all their efforts -- from attempts at an x-ray to shot-in-the-dark drugs -- fail to produce results, the doctor is trying to be kind. It’s kindness to pretend there is more to this patient than his size. But the fat patient only wants to discuss his health problems, and the doctor is seemingly disappointed, as though the patient's health problems and chronic pain could not possibly be a primary force in his life. As though the patient’s frustration at his difficulty in receiving adequate care is not all-consuming and pervasive.
Irrationally, I want to slap this doctor and his colleagues, with their smug and insincere pity and their irritated asides while a man suffers in front of them and they are helpless to assist him. What is wrong with you? Your job is not to like everyone who comes to you for help. Your job is to diagnose the problem and direct its treatment. Your job is to not allow personal feelings of disgust to affect your work. I’m not even saying you aren’t allowed to have those feelings -- I am saying you have a responsibility never to let them prevent you from treating a patient with the same care and meticulousness as you would someone one-quarter his size. It's not acceptable behavior simply because it doesn't happen often, because this man is unusually large, and represents less than 1% of the obese population.
Everyone deserves to be treated with dignity and respect in a medical environment. Everyone.
Stage 3: Bargaining
Can it not be gallstones? Because that would be too obvious. Because the moment this story began, with a fat person in an emergency room complaining of unusual stomach pain, I thought, “Gallstones.” I am not a doctor. I don’t want to be a doctor. I certainly don’t want to be smarter or more intuitive than a doctor. I want doctors not to be horrible. That’s all. I’m willing to settle just for that.
A 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!
It’s gallstones. Elation!
Stage 4: Depression
First, do no harm.
Eleven years ago I spent a terrible night kept awake by a relentless stabbing pain in my abdomen, a pain with a precision and specificity I had never experienced before. Near dawn I began vomiting uncontrollably, although my stomach was empty, and all I was producing was volumes of bitter, searing bile. I could no longer deny that something was very wrong, and I was terrified, so I woke my husband to drive me to the ER. We had to stop three times on the way there, so I could retch convulsively on the side of the road.
In the emergency room, a blasé and indifferent doctor saw me. After reluctantly pressing on my stomach for a few seconds, he pronounced my problem to be food poisoning. “Just need to let it run its course,” he shrugged, refusing to look me in the eye. I insisted that I had never experienced food poisoning like this before, and repeatedly mentioned the strange and unfamiliar pain in my abdomen.
He did not seem to think it was important.
The drugs they gave me did nothing, much to my doctor’s candid irritation, which he expressed with sharply whispered remarks about me to the nurse. I lay curtained and undisturbed in the ER for several hours, still in pain, still vomiting up the water they gave me, until they gave me fluids via IV because I had become so dehydrated. I am quite sure they would have asked me to leave sooner, except the constant retching made it unlikely I would make it from the bed to the exit without throwing up on the hospital floor.
I was never referred for an ultrasound or an x-ray or any further testing. I was told to just wait it out.
I was less than half the size of the patient in the Washington Post story, but still "morbidly obese," as it is put.
A week later, I had a second attack, and I didn’t bother with the ER this time. I toughed it out at home, still terrified, but knowing I wouldn’t feel any safer in a hospital where my symptoms were being ignored. I made an appointment to see my own doctor the next day, who sent me for an ultrasound and found that I had gallstones.
Reading the Washington Post story, the space where my gallbladder used to be starts to twinge -- it’s not exactly a pain, it’s more of a pressure, a tension, like tugging on an old rubber band twisted and wrapped on itself, like flexing a stiff and atrophied muscle. This hasn’t happened in years, but it used to happen anytime I thought about my gallbladder experience, from the first attack to the post-surgery recovery. It makes me feel slightly sick. Lost. Worthless. Broken.
Stage 5: Acceptance
“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 the patient, 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. [...]He 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.The patient lies trapped in his own body, like a prisoner in an enormous, fleshy castle. And though he must feel wounded by the ER personnel’s remarks, he seems to find 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.
I refuse to accept that this is normal, or fair, or reasonable. I refuse to just shrug and say, “Well, that’s what medical culture is like, you just have to work within it.” Because too many people would rather go without healthcare than work within it.
Fat patients are frequently misdiagnosed, and given treatment for ailments they do not have. Sometimes, they aren’t given treatment at all, but are instead instructed to lose weight, as though weight loss is a simple universal cure, easily managed by an individual alone, without extensive support and information, and is a permanent solution -- as though a fat person has merely to realize they are wearing a coat of disease and can easily unbutton it, take it off and throw it away, and never put it back on again.
It is not so easy in real life. And in the meantime, the real problem may be worsening, making it more dangerous, and more expensive to resolve. This has happened to real people I know, with everything from broken ankles to potentially malignant tumors. Walking cures fractured foot bones. A restrictive diet will fix possible cancer.
When an erroneously-prescribed treatment -- or lack of treatment -- fails, if we’re lucky, the patient will go back to their doctor for follow up, having wasted time and money on treatment for an ailment that may not even exist, while in the meantime the actual problem is continuing unchecked. Many fat people don’t bother, though, instead preferring no medical care to medical care that is expensive and ineffective, and which often takes place in an environment that only makes them feel worse, both about their health and themselves.
And so many people are so eager to blame obesity for higher healthcare costs, as though cultural attitudes toward obesity couldn't possibly be an equally significant factor.
When the Washington Post article specifies “the balm of 8000 calories per day,” it doesn’t say where this number came from. Maybe the patient himself used it, though I doubt most people who could eat 8000 calories per day also count them meticulously enough to self-report. Or maybe the doctor in question is guessing, throwing out a crazy number, just assuming this man’s diet must be something outrageous and cartoonish like that.
It almost seems to suggest that the fat patient’s feelings don’t matter -- although he must feel wounded, he can just keep eating to feel better. And that’s sad, but it’s not sad because the kindest emotion that most people can probably manage to summon for this patient is curiosity. (We won’t talk about the worst.)
Rather, it’s sad because it implies that he is trapped in an alleged flesh-prison of his own making -- that the only possible reason he is in pain and suffering extreme mobility issues is because he chose this lifestyle. To this doctor, the tragedy is not that this hospital lacks either the equipment, the sensitivity, or even the basic improvisational skills to effectively treat an extremely large patient without making nasty comments and complaints. To this doctor, the tragedy is not that his patient is in pain and frustrated, and certainly hurt from overhearing endlessly cruel comments from the people who are supposed to help him, and probably very, very scared.
I know why my colleagues and I are so glad to have this patient 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.
Rather, this doctor seems to think the tragedy is that his patient eats a lot. He is so wrapped up in his own personal judgment that not only can’t he eat his own dinner, but he is incapable of seeing the hospital’s failure. His own failure, his helplessness. He would rather feel vague pity and make florid mirror analogies about how this patient makes the doctor feel, rather than consider the feelings of the patient himself.
The story ends with the patient dead a few months later. We aren’t told how or why he died. Maybe he finally did find a hospital to remove his gallbladder and there were complications after he got home. Possibly he gave up trying to get this issue resolved, and his gallbladder became perforated or necrotized, and the resulting infection spread throughout his vast body like slow poison, and killed him.
It doesn’t matter, really. Something killed this man, but it doesn’t matter what it was, because when a person is that fat, these details cease to be important. Of course he died. That’s what fat people do. What did you expect.
I refuse to accept this.
What I accept is that there is a lot of work still to be done to make any of these attitudes change.