Friday, 18 April 2008

Friday Morning, 08:30

It’s 0830 and I’m going to see Mrs Bailey, a lady who is on today’s orthopaedic surgery list and is due to have her knee replaced.

Throughout the clinical years of medical school, we are taught that you gather an awful lot of information about a person from just looking at them. It’s a skill that doctors develop throughout their training and it means that before you even speak to the patient, you can deduce a great deal about nearly all of their body systems, mental state etc… etc…

The thing that immediately strikes me about Mrs Bailey is that she’s fat. Not fat as in she has “love-handles,” not fat as is she has a “bubbly personality,” not even fat as in she has a “middle-aged spread.” I’m talking seriously obesity.

From my point of view as an anaesthetist, fat people are difficult because being obese make general anaesthesia far more difficult (and therefore more dangerous) in so many ways. Everything is trickier with obese people. From the little things like the fact it’s harder to find a vein to site a cannula and the blood pressure cuff often doesn’t fit around their arm to big things like they have a small functional residual capacity and desaturate in seconds and fat necks mean that airway obstruction is much more common and more severe. Off the top of my head I can think of at least a dozen ways in which it’s harder to give an anaesthetic to an obese person.

But, at the end of the day, Mrs Bailey needs her knee operation. She’s been waiting X number of months for it and I’m sure having chronically painful arthritic joints must make life a misery. I’ll have to do the best I can for her.

I walk up and speak to her and ascertain her medical and anaesthetic histories. I explain what an anaesthetic involves and let her know what to expect before and immediately after the operation. I always ask my patients if they have any questions or if there’s anything they’re unsure about or particulary worried about.

“There is one thing,” she says. “It’s about my weight.”

She looks down at the floor then brings her eyes up to meet mine once more. “I know I’m big… I know I’m too big.” At this point, she’s becoming visibly upset. “I’ve been trying to lose weight, I really have. I’ve lost three and a half stones in the last six months. I know I need to lose more but I want to ask you, doctor. Will my size affect the anaesthetic?”

And I’m caught. Should I be honest and tell the truth and probably upset her more just before major surgery? Should I lie to try and spare her feelings? If I decide to be truthful, how truthful should I be? Does she really want to know the details? Should I gloss over it and not acknowledge it as an issue? Should I ignore her question and try and change the subject?

If you were me, what would you say?


Anonymous said...

Cuff size is very important:-

Also, few clinicians realize that conventional blood pressure cuff bladders have off-centered tubes that are typically right or left arm specific. Unless properly placed, pressure may be exerted on the bone instead of on the artery which can lead to inaccurate readings.

TRIMLINE's BALANCED Bladder design has centered tubes, is longer, and more fully encircles the arm as recommended by the American Society of Hypertension and the American Heart Association. This design facilitates accurate blood pressure readings on both right and left arms and helps practitioners achieve optimal arterial compression.

Jo said...

Wow... What a difficult question...
My initial thought was "of course, tell her that there may be issues." But then, as you said, that might upset her before an operation, and I presume that being stressed (even more than a person would normally) is not a good thing medically.
It wouldn't be right to lie to her (not just because even white lies are wrong) - if someone has told her that her weight will affect the anasthetic, (they probably told her that to get her to lose weight in the first place), and you then say 'no', then they will either not trust you (not a good thing if you are going to be giving them an anasthetic!), or not believe whoever told them (and then potentially resent the pain they've had to go through to lose the weight).
A Truth-Light would be how I would go if I was in your situation - "It does make it harder, but I really appreciate the effort that you have gone to lose weight already."
How did you answer?

Also - What does "they have a small functional residual capacity and desaturate in seconds" mean?

Anonymous said...

what jo said, but perhaps you would also do well to reassure her of your own abilities as an anaesthetist. tell her you are pleased she has lost weight, and that yes, it poses problems but not to worry so much because you have been trained to deal with these and you will (cliche coming up!) do everything you can (aha!) for her. and maybe when she gets this operation, she will find it a lot easier to continue improving her health! :)

i hope the operation is a success and she is happy with whatever it is you decide to tell her!

S said...

She asked for it, you tell her the lot ...

this is your legal position and you must cover your back too.

Anonymous said...

Tricky. I'd have gone with good-bad-good news; it's great that you've lost some weight, there are risks associated with being larger, you're in good health and I'm confident everything will go well. Obviously not all in the one breath but something like that.

I work as an anaesthetic nurse and I have to say I hate it when we get morbidly obese patients. Short necks, massive faces, can't get BP cuffs on, difficult to cannulate, hard to move, desaturate in seconds.....basically everything you've said. Not only that but they're usually young and on loads of medications. You can bet your bottom dollar that they're diabetic as well. They're in Recovery for ages as well.

S said...

Legally, a patient has the right to all the answers 'before' they sign your concent form, hence, the 'informed' concent. If I were you, I would answer all her questions in a calm manner then reassure her that you will perform to the best of your ability and get help if need be. On no account should you inflate your abilities or reassure her that she is in good health and that everything will be fine.

The truth but with a calm and friendly tone.

That's if you do not want to end up with a law suit for obtaining concent through giving false information + the result of anything that may go wrong during the operation.

Anonymous said...

S, I'm not sure if your post is is response to mine but I'll answer as though it is. She might well be in good health. Michael hasn't mentioned any co-morbidities, just the fact that she's obese +++. I still like my good/bad/good theory. She's clearly making an effort to reduce her weight but the fact that she's in for a knee op means that she won't be able to exercise properly anyway. Stuck between a rock and a hard place.

By all means inform her of the risks but leave on a reasonably positive note. Watching tears roll down peoples cheeks as they go off to sleep is never very nice.

'desaturate in seconds' means the patients oxygen level drops dramatically very, very fast. The patient goes a dusky colour and our machines start beeping. We don't like it very much.

So Michael, what did you say to her?

the little medic said...

you should tell her about the risks, you can't lie to her and it sounds like she already knows that it'll increase her risk so I think you should just be straight about it.

Anonymous said...

You should inform her that the excess weight makes your job more difficult, and the risk of morbidity is increased. But you don't have to give details of all the possible complications that may arise - unless she asks specific questions. Aim for a truthful but anodyne response.

Alternatively, expand your "toolkit". For example,

rob said...

i would have gone with:

"yes mrs smith your size does make it a bit more difficult. clearly it would be wrong of me to say that it didnt. but you have already told me that you have lost several stone which has made things easier and reduced your risk.

also that you have done that with a duff (insert joint here) means that there is every chance that it will be easier for you to lose weight after said joint has been fixed.

whilst there is an increased risk to you the risk is not severe enough for us not to give you an anaesthetic. we will be there to look after you throught the procedure and this is something we do very often and as a team we are very experienced at doing this. i hope that makes you a bit less worried."

i am interested to here what your response was.

would probs have a discussion with the cons as well just to make sure there was some around in case it did all go tits up.

Michael Anderson said...

I think it’s wrong to tell outright lies to my patients (or to anyone else for that matter), so my answer to her question was this:

“It (your weight) will make things more difficult for me, but I’ll cope. I’ve safely anaesthetised people bigger than you before. I think the most important thing for you to do today is to try and concentrate on getting yourself better after the operation. I know it’s easy for me to say but try not to worry too much and try to remember that, hopefully, things will be much better when you have your new knee.”

She seemed to be OK with what I said to her. She didn’t cause me any real problems on the operating table and the operation went smoothly.

I should point out that at the time when she asked me if her weight would make a difference, I'd already been through all the "standard anaesthetic risks" with Mrs Bailey, as I do with all my patients. I couldn't give her hard figures about the degree of additional risk that her obesity poses because I don't know them. I don't think anybody really knows because the research just hasn't been done.

Jo, anon - I think you're right, and looking back, I probably should have given her some praise for the weight she'd already lost. I'll remember this for next time.

S, TLM - whilst I take your points, I'm not sure she wanted to hear "everything." I could bang on for ages about obesity and the ins and outs of how it affects anaesthesia, but I really don't think she'd want to hear it, or even understand half of it.

I think, deep down, Mrs Bailey already knew the answer to her question and, reading between the lines what she was really asking is the question that every patient wants to know: “Will I be alright, doc?”

S - you bring up an interesting point about informed consent. In my opinion, generally we are very bad at doing this in anaesthesia, I'll write more about this another time

Rob, I'm still a "baby" (first year) anaesthetist and I ALWAYS let a consultant know what I'm planning, especially if I can see there are potential problems. I wouldn't have considered giving Mrs Bailey an anaesthetic unless I knew that a consultant knew what was going on and was available to bail me out if necessary. It's better for the patients and it's better for me.

Tazocin said...

It's impossible to ignore a question like Mrs. Bailey posed, and unethical to lie. I think you handled it well. I'd also have congratulated her on her 3 stone weight loss and encouraged her that with her new knee she should continue her efforts to take more and more exercise on a gradual basis in an effort to continue her weight loss. I would inform her that being larger does carry extra anaesthetic risk but assure her that it was still more likely that she would not experience any major complications and in the off chance they did occur she would be in good hands.

Faith Walker said...

I'd have told her- warts and all. Then again, I'm not known for my tact.

Shrink Wrapped said...

I'm interested in why you would want to gloss over it, ignore it or change the topic. What were your thoughts and feelings at the time and what were you aiming to do? Were you feeling embarrassed and thinking, "I hate this conversation" and wanting to move it on. Were you feeling worried that she would be more upset if you told her the risks and would get more upset and that would make you uncomfortable? It's interesting to think how our own thoughts and feelings about certain issues, like obesity influence how we respond to those who come to us for help.

I would want to attend to her affect. So I would acknowledge she's upset and embarrassed and that it might be difficult for her to talk about but say I'm glad she asked. I'd tell her the risks in a very matter of fact way, emphasising that there are risks with anyone having an anaesthetic and that yes, those are elevated in larger people. Then I'd say that you felt confident and have worked with people of her weight and bigger before and that you will worry about the anaesthetic and she is to worry about getting herself better.

People are uncomfortable talking about size issues, but imagine how she would feel if you glossed over it, ignored it or attempted to change the subject. She might be terrified thinking you weren't being honest with her as the risks were huge. She might think you didn't care or didn't understand (and trust me, she'll have plenty of experience of medical professionals who don't know how to talk sensitively about weight issues).