"I was once on a ward round where the consultant wouldn't even examine a patient who was morbidly obese and admitted hypoxic and septic. His attitude was very much 'what's the point  - i won't be able to hear heart sounds, feel a pulse, palpate any organs and so on."

Tom, let's move beyond the desire to proclaim your consultant's actions politically incorrect. Perhaps he was actually right. Have you thought of that possibility?

Given the clinical situation, a physical exam at that point might have made almost zero difference to the medical actions over the next six hours, even under the best of circumstances. In the context of a morbidly obese patient (on a ventilator -- we don't know), in whom you can't actually hear the heart sounds there may have been absolutely no point at all.

Boy, I think we'll all have to watch our words very carefully around you for fear of being thought ideologically unsound!

Hi Dave - thank you, you made me laugh. Looking over my post I can see my sanctimonious side leaping off the page. But ideological disapproval wasn't my emotion at the time - i was more surprised than anything.

You say "a physical exam at that point might have made almost zero difference to the medical actions over the next six hours" but you can only know that retrospectively.

Out of interest, do you have a weight/BMI limit on accepting people for aortic aneurysm screening? If so, is this based on the decreased quality of imaging or the fact that people over a certain BMI won't be operated on.

Hi All,

This is interesting ! I didn't have that morbidly obese patients but they are not rare even in developing countries and I can imagine in the Western Set up! They are increasing even in the developing world with the changing life style and dietary habit.

I was in my third year of medical training and I was in surgery. One of the on-duty doctor was presenting the duty cases of the shift in the morning conference. He said 'so fat ..so fat ...so fat...terribly fat lady - coundn't be transferred to OT table so had to operate on Trolley " ! That was the case of obstructed hernia and she was in ICU next day when we were in round. She was doing fine in fact.

Professor had smiled and said ' ok, she is morbidly obese, right?"! The doctor replied, "I  have never seen such fat lady in my life!!!" They had done good job though on their shift.

I think people harbour some kind of different attititude towards obese people if not negative. It might be just something else but avoiding to examine clinically is weird.

I have read some of the write ups  mentioning extremely difficulty to perform Ultrasonography, ascultation and as simple as percussion and palpation!

Thanks!

Best wishes,

mati

Tom,

When you've been a consultant for a while you know that palpating the abdomen of a morbidly obese person is a waste of time without having to try it in each case. And actually, a physical exam is often a waste of time, whatever the BMI of the patient.

Anyway, we all have preconceptions -- there is no way of getting away from that -- and that is not such a big deal if one recognises it. The problem comes if there is no insight. I teach a course for OOH GPs on telephone triage and one of the first things I say is to read the call sheet, get a picture of what you think may be happening before you pick up the phone, then pick up the phone and discard those preconceptions or they will catch you out.

Anyone who just thinks 'fat people are lazy' is basically a dullard and should be ignored. I don't think at all that's what this consultant was doing, from your description.

As far as AAA screening goes, we don't have a BMI cutoff, but we have hardly ever had to abandon a scan because the patient was too fat. Probably less than five in 16,000.

Best,

David