The Obese ED Patient

In this modern era where human rights, political correctness and “anything goes” enjoy front row seats in our human society, coupled with the ever-increasing litigious tendency among people, I am not surprised that the medical fraternity is sometimes tiptoeing around the sensitive issue of obesity. Although very anecdotal, I have found that in our Emergency Practice here at Zuid Afrikaans Hospital, this subject is rarely touched upon or sometimes, even completely ignored in the appropriate patient population.

As Specialist Emergency Physicians, Emergency Physicians and Nurses with special training in Trauma, we are well trained in managing the Obese patient who presents to us in an emergency - many chapters in our textbooks and many an academic article has indeed been dedicated to exactly this subject. Even the different Paediatric disciplines have, over the last decade or so, also published many papers on this phenomenon of “childhood obesity” and even “early childhood obesity” - this as a direct result of our (and our children’s) sedentary lifestyle (read mobile phones, computer games and television here).

I read an article the other day of the average number of sweets children of today consume within one week in comparison with 30 to 40 years ago: it was a staggering 30 vs 2. I would have loved to place the reference here but unfortunately can’t remember where I read it. The ease of access to cheap, quick, ready-made and processed foods and the lack of physical exercise has contributed immensely to this major obesity crisis in our country and in the world as a whole.

Emergency Units, like General Practitioners, are in the coal face of healthcare and we are confronted with obesity, its complications and its consequences regularly. Diseases like Hypertension, Diabetes Type 2, Cardiac Failure, Ischaemic Heart Disease, Vascular Insufficiency and Cerebrovascular Disease (Stroke) are all common and well-known chronic diseases associated with obesity which we encounter on a daily basis. Syndromes like Sleep apnoea (Pickwickian syndrome), Syndromes associated with fatty liver disease and Syndrome X (Dysmetabolic Syndrome) are less well known although we have to deal with each of these (or combinations thereof) at least once a day.

Another issue we frequently have to deal with is poor wound healing. Not only is this a problem when obese patients suffer from an open wound injury, but it is also a huge issue in the post-surgical patient as blood supply to subcutaneous fatty tissue is very poor. One can just imagine its contribution to the already high medical costs associated with surgery, hospitalization and subsequent extended post-surgical wound care.

With the more acute medical emergencies, the obese patient presents us with massive challenges. With our ABC (or CAB) approach that most, if not all Emergency Healthcare Practitioners follow, assessing and maintaining an open airway (A) and inserting an Intravenous line (C) becomes increasingly difficult in increasingly obese individuals. Just imagine the force a rescue breather has to apply to administer rescue breaths (B) to an obese patient in an effort to lift the collapsed patient’s chest wall. Not to mention the increased pressure settings on the ventilator after a successful intubation.

While the physiology (or pathophysiology rather) and the psychology of the disease of Obesity and its suppression of the satiety center in the brain is very complex, the concept of losing weight does not have to be - it basically boils down to ingesting less energy (eating) than your daily energy expenditure (activity or exercise).

Like all other diseases most medical doctors regard Obesity as a medical disease and therefore we at Zuid Afrikaans Hospital A&E would like to assist obese patients in their quest for a more healthy life style, a healthy body and in the end, a healthy and happy mind.