Pissed off about CP

[VentMedic]

Arizonaffcep

No need to apologize.

I have worked in healthcare long enough to know there are many inequalities and the haves or the have nots in a system. It just makes it a little easier when the healthcare professionals themselves can get on the same page or at least the same book (does not mean "cook book") to understand various resources and reasons.

A little hospital stuff that goes on everyday:

ED wants the patient up to the floors or CCU NOW. Which patient is the least critical to get turfed to the floor to make room? The floors and/or the CCU are moving patients around as fast as they can while also transferring a truck load of personal belongings. It is shift change. The ED or the CCU wants to unload before report. The doctors are busy and can't arrange the orders or do an acceptance consult. Too many patients here. Not enough staff there. Ambulances showing up, bringing and taking. Everyone wants attention now and those that don't say something probably deserve the most. And then, getting the right equipment for a bariatric patient? The problem does not lie in whether the hospital can handle bariatric patients, it is keeping enough supplies and equipment to handle the growing number of bariatric patients.

It sometimes amazes me that anybody survives their hospital stay. But, it is organized despite its chaotic appearance.

[crotchitymedic1986]

OK, everyone take a deep breath and relax, this is a good post and I would hate to see it get locked down because of bruised egos. Lets get back to the topic:

I forgot who asked it, but a good point was raised: Why couldnt the patient be transferred to a bariatric facility ? But then the next question is, would a bariatric facility do a cath or CABG on this patient ? Most bariatric facilities that I knew of, were bariatric in bed, toilet, physical therapy equipment, and other equipment; I did not know any that did any invasive therapies.

You mentioned Lasix, was there any other "treatment" occuring during those hours ?

I am also guessing that the patient was probably diabetic (maybe undiagnosed) with a cholesterol level over 800, and hypertension. While I am not advocating no treatment, some patients are not good candidates for some procedures even though their life is at risk. I dont think you would do a heart transplant in a patient with Metastatic CA. I dont think it was your ER or CCU that failed the patient, instead I would say that:

1. The patient and his family failed himself, he didnt gain 400lbs in the last month. There is a reason you dont see any 500lb 80 year olds roaming the earth.

2. The patient's private doctor failed the patient. I remember working in an ER with a doctor who frequently told parents the truth about their fat little children, and why they needed to be on a diet. You would have thought he called them the "N" word and spit in their face, by the reaction of the parents. It was obvious that although the kid that was 50lbs overweight had a pediatrician, the pediatrician had never suggested a diet (this was the early 90s).

[VentMedic]

OK, everyone take a deep breath and relax, this is a good post and I would hate to see it get locked down because of bruised egos. Lets get back to the topic:

It was a misunderstanding that has been taken care of without your help.

I forgot who asked it, but a good point was raised: Why couldnt the patient be transferred to a bariatric facility ? But then the next question is, would a bariatric facility do a cath or CABG on this patient ? Most bariatric facilities that I knew of, were bariatric in bed, toilet, physical therapy equipment, and other equipment; I did not know any that did any invasive therapies.

This patient is having an MI. He doesn't need gastric bypass or PT at this time. Many hospitals are now capable of handling bariatric patients as I previously mentioned and do have some equipment inhouse. Whatever else is needed can be rented. Accomondations can be made if at all possible since this is becoming a growing population within the hospitals.

You mentioned Lasix, was there any other "treatment" occuring during those hours ?

I am also guessing that the patient was probably diabetic (maybe undiagnosed) with a cholesterol level over 800, and hypertension. While I am not advocating no treatment, some patients are not good candidates for some procedures even though their life is at risk. I dont think you would do a heart transplant in a patient with Metastatic CA. I dont think it was your ER or CCU that failed the patient, instead I would say that:

His risk factors must be taken into consideration and the patient may also have made an informed decision based on the risks vs benefits presented to him.

1. The patient and his family failed himself, he didnt gain 400lbs in the last month. There is a reason you dont see any 500lb 80 year olds roaming the earth.

2. The patient's private doctor failed the patient. I remember working in an ER with a doctor who frequently told parents the truth about their fat little children, and why they needed to be on a diet. You would have thought he called them the "N" word and spit in their face, by the reaction of the parents. It was obvious that although the kid that was 50lbs overweight had a pediatrician, the pediatrician had never suggested a diet (this was the early 90s).

You are very quick to judge this person yet you know nothing about him. There are medical conditions as well as psychological reasons with both the patient and the enabler that may also need to be considered. Have you studied bariatric medicine enough to know the causes of morbid obesity besides just what you believe as their own fault by over eating? Do you even know at what age he started to gain weight? I don't believe that was mentioned so you are guessing and assuming which means you are making a personal judgement about this patient and not one that is based on science or medicine.

And what is your fixation on the "N" word? Yes obesity can have some issues for different ethnic groups but there are other factors involved also.

[crotchitymedic1986]

You missed the main point, I wasnt suggesting that he needed PT or bypass --- my point was that I do not know if any Bariatric facilities do open heart or caths. If he can be transferred to a hospital that can do the procedure, that would be great. But you cant risk "table collapse" while you are doing a delicate cardiac procedure.

And yes, I am well aware of the reasons for morbid obesity, none of which have any bearing on whether or not he is a good candidate for CABG or Cath. If anything, those reasons, would probably keep him from having the procedure.

P.S. There are several surgeries/procedures that doctors will not do if you are a smoker -- professional plastic surgeons will not give you a breast job to every woman that asks for it.

[VentMedic]

You missed the main point, I wasnt suggesting that he needed PT or bypass --- my point was that I do not know if any Bariatric facilities do open heart or caths. If he can be transferred to a hospital that can do the procedure, that would be great. But you cant risk "table collapse" while you are doing a delicate cardiac procedure.

No I didn't miss the point. Read my posts about bariatric patients and hospitals trying to accomondate the patients. Hospital professionals are not going to risk over extending their equipment either and will get the appropriate equipment if necessary.

P.S. There are several surgeries/procedures that doctors will not do if you are a smoker -- professional plastic surgeons will not give you a breast job to every woman that asks for it.

Elective surgeries are a little different than emergent procedures. Risks vs benefits must be considered for any invasive procedure.

[crotchitymedic1986]

Risk versus benefit must be weighed for ALL procedures.

[Camulos]

Some interesting answers on this topic. Being a newbie here I am mildly reluctant to weigh in on this one (no pun intended). But I do enjoy adventure so what the heck.

Arizonazaffcep - I guess we all get frustrated by a perceived lack of appropriate care of some pts from time to time. I have certainly not been immune to this in the past. I believe frustration is good though as it shows that we actually care about ensuring best outcomes for our pts. When this occurs, one thing I have learnt is to enquire why certain treatments are / are not being done. The best person to give you this info is the decision maker themselves, so in this case I guess the cardiologist. In my past experience it has sometimes been a lack of education / understanding on my behalf and when the decision process has been fully explained to me it all falls into place. Admittedly sometimes it still doesn’t make sense after this process however I understand that medicine is just like that sometimes. But don’t be afraid to ask questions if you believe they require answers. Indeed as a pt advocate it is your responsibility.

It is difficult to make a proper educated judgement on what was the best treatment for this particular pt without all the info I would normally ask for. That aside I’ll go with what I have been given.

We know that this pt weighs 540lb. Not understanding pounds, we use kilos in the land of oz, my calculator tells me that is around 245kg. I note this pt is also only 5’7” tall. This equates to a BMI of 84.6!!! As such this pt would certainly cause some logistic nightmares in all of the hospitals I have previously worked in. This pt’s size alone makes him an extremely poor candidate for any invasive treatment. Let’s look at some potential problems with cardiac cath alone. Difficult femoral access due to physical size, inability to lie supine on the table due to resp compromise therefore requiring airway control, shocking anaesthetic risk at that size perhaps compounded by other premorbid health problems associated with his obesity, table and cath lab not large enough to cater for a pt of this size and I’m sure the list goes on. Don’t get me wrong, I am not advocating that this pt does not deserve treatment, only that there are unfortunately existent logistical problems at this size that may make the risks of such a procedure greater than the perceived benefits. Perhaps some of these came into play with this particular pt when the decision was made. Maybe you could enquire and let us know.

The next point I notice from your initial post is that you stated that you and the RN later noted ST segment elevation in lead II. The casualty was then given lasix. Again, it is hard to make an educated decision here without all the info, but on this I would say to be very careful administering lasix to someone who is experiencing an inferior MI – characterised by ST elevation in leads II, III and aVF – without first ruling out isolated right ventricular infarction. Any elevation in the above leads mandates a right sided ECG. If an isolated right ventricular infarction is confirmed, the proper management consists of volume loading to maintain adequate right ventricular preload. Lasix in this condition could cause huge problems. If you require any further info on this please let me know. It is getting late here (0255hrs) and I am off to bed.

Keen to hear others thoughts on this and also if Arizonazaffcep has had a chance to do any further follow up.

Stay safe all,

Curse :evil:

[Arizonaffcep]

You missed the main point, I wasnt suggesting that he needed PT or bypass --- my point was that I do not know if any Bariatric facilities do open heart or caths. If he can be transferred to a hospital that can do the procedure, that would be great. But you cant risk "table collapse" while you are doing a delicate cardiac procedure.

And yes, I am well aware of the reasons for morbid obesity, none of which have any bearing on whether or not he is a good candidate for CABG or Cath. If anything, those reasons, would probably keep him from having the procedure.

P.S. There are several surgeries/procedures that doctors will not do if you are a smoker -- professional plastic surgeons will not give you a breast job to every woman that asks for it.

Don't think that was it...the table itself is about 20 inches wide. Pt is about 3-4 feet wide.

My main beef was, from my vantage point, it just seemed like not EVERY option was explored and developed, and regardless of if this patient hasn't taken care of himself up til now, this may be a turning point for him, so every option really SHOULD be explored to give this guy every chance he can get.

[crotchitymedic1986]

cant argue with that, I wasnt there, which is why I defended the point early on, as I think there are many patients who do not get the optimum care due to a bias of some sort, whether they be black, poor, uninsured, obese, gay, or for any other reason. WIth what little that has been presented about this patient though, I am not sure that more could be done. Maybe one of the docs will chime in.

[VentMedic]

My main beef was, from my vantage point, it just seemed like not EVERY option was explored and developed, and regardless of if this patient hasn't taken care of himself up til now, this may be a turning point for him, so every option really SHOULD be explored to give this guy every chance he can get.

Did you happen to notice if transfer orders had already been written or some protocol to be initiated? Occasionally but not that often, CCU, PCU or tele orders will be written but unfortunately the patient may not get transferred to the floor or unit for a long time and the orders don't get started. The ED orders will continue. There may have been more aggressive orders waiting in the wings. That is what I meant earlier by becoming familiar with what the other units and floors do especiallly when certain protocols may have been initiated in those areas. Serial labs and diagnostics as well as additional meds may be started. A cardiologist will probably be consulted and additional tests or meds will be ordered. What may appear as a slow process to you may be for the reasons of caution with the patient's overall condition.

And, what choices did the patient make if and when he himself was presented with the risks and benefits? The physician may have said something like we can offer you this treatment (could be cath lab) but this, this and that have a great possibility of happening. Or, we can treat you more conservatively with this treatment and monitor. All the information will be laid out and the patient can make an informed decision with the physician about the risks and benefits of each procedure. When patients present with numerous risk factors, it is usually very clearly presented to them as to what can happen with each option.

crotchity

think there are many patients who do not get the optimum care due to a bias of some sort, whether they be black, poor, uninsured, obese, gay, or for any other reason.

Everything has to be about race or sex with you. While there are inequalities that do exist in any system since employees like you will be around, some healthcare professionals actually manage to function quite well above the discriminatory factors to provide quality health care.