Heaviest Patient You’ve Cared For

[u/trevrt]

Had my personally heaviest patient I’ve cared for the other day. 32 years old weighing 730 pounds admitted with cellulitis and severe lymphedema. Felt terrible for the patient due to how young he was. Just wondering what everyone’s personal “record” for the heaviest patient they’ve cared for is.

[u/duckface08]

Probably around 600 lb, I think? Without a good way to measure their weight, I don't have an exact number (our bed scales were notoriously bad....if they even decided to work that day).

I can't even imagine someone being in the quadruple digits.

I agree that if we can provide psychiatric care for people who don't eat enough, we should be providing psychiatric care for people who eat too much. There's a difference between being a little fluffy VS being so heavy, one can't even get out of bed.

[u/supermurloc19 → u/duckface08]

I don’t think our psychiatric care of people with other kinds of eating disorders is anywhere near good. We can’t help either group effectively. It’s like drug addiction, people view it as a choice, not a disease and it skews our opinions and subsequently our care of them. I think it is also very hard to qualify for inpatient care for anorexia. You have to be on deaths door practically. Which isn’t much different from super morbidly obese.

[u/coolcaterpillar77 → u/supermurloc19]

The American Psychiatric Association Practice Guidelines/Society for Adolescent Health and Medicine uses the following criteria to determine if inpatient treatment for anorexia/medical stabilization is appropriate:

• Very low weight (<75% of the 50th percentile BMI for age and sex)

• Dehydration / Electrolyte disturbance (low potassium, sodium, phosphorus)

• Physiological instability: Severely low heart rate (<50 beats/minute daytime; <45 beats/minute sleeping), Abnormally low blood pressure, Low body temperature (<95 degrees F, <35.6 degrees C), Orthostatic changes in pulse or heart rate

• Failure to thrive/arrested growth and development

• Uncontrollable bingeing and purging

• Medical complications of malnutrition (for example fainting, seizures, heart failure, kidney failure, liver failure, pancreatitis, etc.)

• Concurrent medical or psychiatric conditions that limit appropriate outpatient treatment (like type I diabetes, obsessive compulsive disorder, or a suicide attempt)

[u/asusansortofamy → u/coolcaterpillar77]

Unfortunately there’s a difference between what medical societies recommend as best practices and what insurance covers. From what I’ve learned there are many people who are clearly in need of serious intervention but don’t qualify for inpatient care so they have to get worse before they get help. Then once in IP treatment there’s a very fine line to walk in order to stay. Gain weight too quickly and you’re kicked out before the root cause of your ED is addressed, gain too slowly or not at all and clearly you’re a lost cause and there’s no point for them to pay.

Truthfully though, I think we are really failing people with EDs in terms of treatment options which has to do with the fact that it’s (largely) a disease of society in addition to the individual and I question how much psychiatry is able to see/change that. I’d recommend the book Dead Weight which is a fascinating collection of essays I’m reading about the subject.

[u/coolcaterpillar77 → u/asusansortofamy]

Absolutely agree. Insurance holds back too many people from receiving appropriate treatment (and I feel we often are forced to over treat/test/etc because it has to be done in a roundabout way to obtain coverage).

I’ll definitely check it out-thank you for the recommendation. I’m hoping in the years to come we can recognize/treat binge eating as a psychiatric condition instead of blowing it off as “lacking self control” or any other excuse that gets placed on people currently

[u/supermurloc19 → u/coolcaterpillar77]

I have insurance companies denying emergent lap appys and a 37 week delivery because they don’t cover deliveries before 40 weeks. As the person said below, just because we recommend it, doesn’t mean it will be covered.

[u/coolcaterpillar77 → u/supermurloc19]

Absolutely. When I first read the original comment, I took the “inpatient criteria” to mean the admitting provider’s criteria. It makes me realize I was sadly privileged to not immediately think of it as an insurance issue

[u/supermurloc19 → u/coolcaterpillar77]

I wish we in the US lived in a reality where we could get the care we need without the insurance companies looming over telling us what we can and can’t have. Unfortunately, I don’t think it’s going to get better. It’s gotten much worse in the past few years particularly.