Thursday, January 28, 2016
“I remember,” she said, “the day when it crossed into something else. Into that freakish range where mothers hiss to their kids to stop staring. At first you think that, just maybe, it's an accident. Then you realize that it isn't. They're whispering and pointing at you.”
I squinted my eyes and tried to imagine it. My patient, minding her own business and moving slowly through the aisles of a store. Maybe even doing something like picking up lightbulbs and hand towels in the home improvement section at Target. People walking by and doing those not-so-subtle double takes and her trying her best to not notice it. But she was right. This was more than just a little out of the range of normal. And though I wouldn't choose a word like “freakish” to describe it, I'd be lying if I said that it didn't somewhat fit the definition of that word. Even if it sounds mean to think that way.
Patients like her require special provisions. They bring in a special bed aptly or rather, horribly, referred to as a “big boy bed” to accommodate such a large body. It's hard not to hitch your breath and stare for a beat when you first see her and others of her body habitus. Legs easily larger than my husband's torso and a midsection that appears far too heavy to be supported even by those extremities. The adult in you tries not to see the large pannus lying flaccid over their thighs and fights those silly juvenile thoughts like, “What happens when it's time to go to the bathroom?” or, I'm even more embarrassed to admit, “How would she or he make love? “ I timidly raise my hand and admit that I do have these fleeting thoughts. The adult in me flicks them away. But every time, they appear and require that flick.
This encounter with me certainly wasn't helping her self-image. My patient had some shortness of breath and was, literally, too big to receive any of the diagnostic studies that we'd considered. She could not have a CT scan. Her circumference exceeded that of the scanner and her weight was more than 150 pounds beyond the limit of the table. A stress test or even an echocardiogram would be so limited in accuracy that it was almost deemed futile and a waste of her money and time to pursue. And to make matters worse, even if a stress test did find even some equivocal result, the cardiac catheterization lab wouldn't be able to handle 650 pounds on their support structure either.
Ever since I was a resident physician in Cleveland, Ohio back in the 1990's, this kind of issue has periodically come up. Without fail, no matter where you practice, some well-meaning person speaks of the urban legend of the city zoo being an option. And no, not with cackling mean-person sarcasm but with a full-on, dead serious expression. A medical student looks stunned and queries whether or not a patient can truly go to the zoo for such a thing at which point whomever is speaking affirms it as the gospel. All of it reminds me of those stories of funny names in newborn nurseries, like the woman who named her twins “Oranjello” and “Lemonjello” since that's what they fed her in labor and delivery before she had them. Somehow the mother of those twins has managed to live in Cleveland, Ohio; Nashville, Tennessee; and Atlanta, Georgia. That, or she doesn't exist.
The zoo thing, though, I must admit always intrigued me. So, a few years after I came to Atlanta, I called Zoo Atlanta on behalf of a patient of mine. He needed a cardiac catheterization and I wanted to actually sniff out this trail to see if it truly would lead somewhere. Several of my calls were met with chuckles. Even when I reached some nice tech in the Large Animal area, he notified me that the zoo veterinarians did have X-ray machines and even a cath lab made special for elephants and such, but that actually having human cardiologists come in to use them on humans wasn't something he was aware they did. After that I spoke to our cardiologists who calmly answered me (while staring incredulously) telling me that logistically, it would be too much.
“We couldn't really do interventions either, Kim.”
“Like place a stent or something?”
“Yes. And even if there was something significant enough for bypass, that wouldn't be an option either. The anesthesia risk would just be too great,” the cardiologist said.
“I appreciate you actually thinking this through,” I recall mumbling.
“This is really a sad, Catch-22 of a situation. I hate when it comes up.”
And that was just sort of where we left that. But some piece of me has always felt this weird mixture of better because I actually checked before and discouraged for the very same reason.
So the truth is that, there wasn't anything I could do other than talk to her and listen to her story. And since she'd navigated the last several years of her life as what some would deem a “freak” I just made up my mind to humanize her the best I could.
I noticed her light brown eyes that almost appeared amber, framed with sprawling black eyelashes. She had a dimple in her chin that I thought was cute, whether she was smiling or not. The right cheek had a beauty mark on it, the kind that many women wished for but she'd obviously been blessed with at birth. And her teeth were unusually straight, large and strong appearing. Even though she didn't smile so much.
And so. I listened to her story of the transition from “always a chunky kid” to “overweight” to “really obese” to “freakish.” I didn't rush her either. I just sat and paid attention and focused on her lovely eyes, her beauty mark and that cleft in her chin wondering what I could possibly do.
“Those surgeries scare me,” she finally said.
“Surgery is a big deal,” I replied.
“Yeah. I just feel like it would be such a failure to get an operation just because you couldn't stop eating.”
I twisted my mouth and paused before speaking. “Food relationships are complicated. I think of weight loss surgery as an option that is now available that wasn't before, you know? But yeah, surgery isn't something to treat lightly.”
“My relationship with food has never been healthy.”
“I understand.” I wondered if I should say the next thing in my head, but then decided not to overthink it. “I say just look into it. Make a decision after you look into it, you know?”
“Guess I'd not have much to lose, right?” After she said that we both chuckled at the unintended pun.
“Um … you could also look into … okay, have you ever heard of this organization called ‘Overeaters Anonymous?‘” I inwardly cringed when saying the name of it but felt she should consider it. I hoped she wasn't offended. But she shook her head and looked intrigued.
I told her about this 12-step organization that tackled food relationships much like other tried and true organizations helped patients deal with substance abuse issues. And we looked at the website right then and there on our cell phones and she promised me she'd check it out.
And that was that.
We discharged her a few hours after that. Honestly, there wasn't really any more tests I could order and, fortunately, she was doing well enough where most weren't indicated anyway after all was said and done. But I have found myself thinking of her. Pondering her world and that threshold of going from overweight into, to use her words, “freakish.” And usually it just leaves me feeling kind of sad.
That is, until this morning when I allowed myself to reflect on what I remember the most about her. Her smile, her enviously stunning eyes, that beauty mark that Marilyn Monroe had nothing on, the tiny indentation in her chin and especially her fearless transparency in describing her life. I realized that this is what I see in my mind when I think of her. And I see that part in greater clarity than anything else.
And that? That leaves me feeling hopeful that at some point something will happen that allows the entire world to see that, too.
Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.
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