Physician Under the Knife
by Dr. Mo Lerner

Dr Mo

Not many writers will give you the details of their own experiences in hospitals, especially when operations are involved. There are a number of reasons for this. First, it is personal. Second, people often don’t know what actually is going on. Third,—especially for large people—is the natural dread of ridicule and shame in our society regarding the exposure of one’s naked fat body in front of thin fato-phobics. Well, I am about to break that bond of disgrace.

The precedent
Almost a century ago, an English surgeon became the first to write an auto-experimental book about being “The English patient” (you will forgive the reference to a recent popular romantic tear jerker movie). After years of cutting patients and teaching students, he woke up one morning with severe abdominal pain. By writing a book about his own personal experience with Appendicitis, Sir Zaccary Cope not only received a royal knighthood, but he also educated his colleagues on what it was like to be on the receiving end of medical procedures.

My experience
A few years ago I noticed a small balloonlike bulge in my bellybutton. It insidiously became larger, more transparent, and tender. I had always had a sensitive “inny,” but now I even dreaded rinsing the area with water. Let’s take a look at the issue:

When the umbilical cord is cut, many infants are left with an “outy” belly button (an Umbilical Hernia). Usually the insides of the abdomen—the bowel and its associated linings—are far away from this protuberance. If, however, vital contents slip in and out of this dome, it is referred to as a Sliding Hernia. Sliding Hernias are usually harmless unless they progress to a point where the bowel becomes trapped in the dome (Incarcerated). Then they become exposed to the hazards of the outside world, which causes further expansion of the bubble in a vicious cycle of enlargement and exposure. In some cases, herniated parts of bowel become twisted upon themselves just like those funny balloons animals. This process is called strangulation. Not only can the bowel get blocked, but the blood vessels and nerves that trail along with the segments can become compromised as well. Large people are especially prone to hernias because of the intra-abdominal pressures of gravity and larger abdominal contents. This is especially true of the belly button region with its relatively thin stretchable skin. Surgery may be the only solution.

My hernia was becoming bothersome and I consulted an old football consulted an old football also happened to be an excellent and fat friendly surgeon. He was initially confident that he could repair the hernia by simply cutting it and sewing up the area. However, as I spoke with other colleagues, there was concern that the intra-abdominal pressures might cause the hernia repair to split. This is a danger as large people are typically also at greater risk of infection because fat and higher blood sugar levels create a potentially lethal breeding ground for bacteria.

Over the year and a half that I awaited surgery, my case kept getting bumped because operating room time is always at a premium and my situation was less urgent than that of, say, cancer patients. This seemed quite reasonable.

I soon realized, however, that there were other motives involved as well. The nursing and operating room staff—well aware of my size—weren't thrilled at the prospect of taking care of a “large load.” Although I had lost some weight through the natural stresses of life without dieting, I encountered some of the other usual obstacles of fat oppression. My surgeon’s assistant—herself a BBW—confided that the senior operating room nurse had made a snide comment that “my guts might fall all over the operating room floor and the surgeons would never be able to get them back in.” When some of my thinner colleagues heard of this, they were shocked. After all, some of the doctors and nurses at the place had once been my students and knew that and knew me as a professional and also as a human being with human feelings and needs.

In any case, we decided to do a “dry run” with the plastic and general surgery teams in the operating room to see if the task could be accomplished. The staff was on their toes to be polite, at least at this initial visit. In the OR, the team realized that I was not as large, nor the task at hand as cumbersome, as they had expected.

When I finally got the call, I prepared for my date with destiny. I ensured that there were hospital gowns large enough to accommodate me. (Some standard “large” gowns are actually adequate for big people. In a pinch, you can use two gowns applied back and front, or purchase your own large size gown from resources advertised in this magazine.) I visited the anesthesiologist who gave me a number of options. I chose to have an Epidural rather than the standard form of General Anesthesia where the patient is rendered unconscious and a large tube inserted in the windpipe. This procedure presents several risks, especially if there is difficulty in inserting the tube. Awake Intubation is preferred in many cases, and—although uncomfortable— affords the anesthetist more control of the situation. I chose the Epidural route for a number of reasons. Because of my Sleep Apnea, I felt that the intubation would be difficult and had the potential to trigger dangerous heart rhythm irregularities. More importantly, though I am not the world’s bravest soul, I have a high pain tolerance and wanted to be awake through as much of the procedure as possible so that I could experience, and report on, the procedure.

A few days prior to my operation, I learned that the scheduled anesthetist was trying to pass the procedure on to another colleague. I wasn’t upset over this, nor did I feel he chickened out. Trepidation is a healthy attribute in the operating room. Over-confidence or a cavalier attitude can be deadly. On the day of my procedure, my designated anesthetist nonetheless appeared at my side.

Special gear
The operating room staff had obtained a special hospital bed designed for large people. Being a physician, I was to report on my experiences with this device and educate the staff on its use throughout my hospital stay.

I also brought in my Sleep Apnea CPAP (see my previous articles on the subject) machine which was fitted with a sample adapter to allow supplementary oxygen to flow into the facemask.

Prior to surgery, there are a few key points that I would advise anyone undergoing a similar procedure to make clear. First and foremost, one should point out that large people are, like all others, entitled to dignity and gentleness. Areas of privacy on the body should be covered whenever possible. Second, the risk of infection, always present, is an even greater threat to big people and staff should be keenly adhering to the rules of hygiene.

Once on my specially outfitted bed (which would serve as my operating table and the only bed I would need for my entire time as a patient), I was wheeled into the OR suite. I found that most of the staff there had once been my students and the orderly who held me forward as my back was needled had been a patient of mine. The anesthetist began to sweat after several unsuccessful attempts at catheter insertion. Though having been referred to by my health care cohorts as the “needle” because of my downright legendary accuracy, I knew that anyone can have unlucky days, and I told him to take his time and that I was in no discomfort. On the seventh attempt I felt a vague tingling sensation down my right leg and knew he was in the spinal canal lining.

I laid down flat, put my mask on, and began to chat as a variety of drugs were administered in order to numb the lower half of my body. Unfortunately, I had a natural resistance to the freezing solution —usually the same old-fashioned Xylocaine used to numb skin and teeth for minor procedures) and thus felt the nurse inserting a catheter into my penis.

At this juncture I should remind those of you who are undergoing any procedure of the abdomen or pelvis to ask ahead of time if urinary catheterization will be performed. Although it is definitely advantageous for the staff in that untoward leakage or incontinence need not be cleaned, it is also advisable from a patient’s point of view. While one is asleep, if half of the body is “frozen,” involuntary urination (or retention) can cause infection, not to mention embarrassment. One should always insist that the catheter be inserted in the operating room. Otherwise, the task is often given to the pre/post-operative team to perform. Patients are often enough in pain.., the stress of awake catheterization on the ward is less than desirable.

On the other hand, catheterization may not always be necessary if the procedure is relatively minor and it is expected that normal bladder function can be handled naturally. Ask and/or advise your team accordingly before the surgery.

Trying to maintain an air of bravery, I carried on with idle conversation as I felt the knife cutting into my flesh. I was apparently having so much fun chatting and joking with my surgeon about the good old football days that they finally decided to shut me up. I was administered a miracle drug called Propafol that not only put me into an immediate and blissful sleep, but actually created retrograde amnesia for virtually all of my alleged raunchy banter.

I awoke just as the final stitches were applied. The surgeons had split me from hip to hip and discovered that my seemingly innocuous hernia had indeed become incarcerated and infected, making my surgery necessary, and timely, after all.

After surgery I was transported to a recovery area where I was greeted by a less than friendly nurse who was compelled to inquire: “Well then, when are you going to lose weight?” Not in the mood to enter into a debate, I advised her that the subject was complex and that I would be pleased to discuss it later. I became intensely aware that the lower half of my body was frozen and I could not move my legs.

After about an hour I was transferred to a Post Surgical Intensive Care unit. This is an appropriate safety measure for any high-risk surgery. The tactless nurse described me as “Mr. Lerner here.” To her, apparently, my large size meant that I no longer merited the title of “Doctor.” She told the receiving nurses that the reason I had this special new bed was that I would break a normal stretcher. I told her that as an ER physician I had spent many a night resting on standard stretchers and had never so much as caused a squeak in their springs. I also pointed out that in this special bed I could literally take care of myself, freeing the staff from a lot of manual labor normally necessary with average-sized patients, like lifting and maneuvering.

My favorite nightingale departed with a grunt, leaving me with one last present. For as my body thawed, I began to feel the unmistakable sensation of urinary retention. When the nurse lifted my sheets, blood was everywhere. My urinary catheter, with the anchoring balloon still inflated, had somehow been carelessly ripped out of my penis, probably somewhere in transport. The lesson to be learned is that one should remind all staff to maneuver patients with catheters gently and to always check under the covers post-operatively.

After two more hours of trying to void on my own, I could not even convince the staff that the trauma of this misadventure has caused retention and that I needed to be recatheterized. In desperation, I engaged the assistance of a sympathetic male nurse whom I had once worked with elsewhere and catheterized myself. “But it was only 400ccs” quipped the guilty staff. Large people often have smaller bladder capacity and, in any event, no one should ever be doubted if they sense urinary urgency.

After a sleepless night I was transferred to a regular ward. My $48,000 adjust-a-bed allowed me to prop myself up and soon I was walking. The staff was amazed at how independent I was. The bed was so sophisticated that it even displayed my weight every minute—a feature I’ll surely disarm next time I return to that ward).

Two large drainage tubes, attached to devices resembling turkey basters (Hemovacs), were left in my belly in order to drain blood and debris—a common sequel to this type of operation. I drained approximately four cups of fluid a day from these containers. Despite my apparent rapid recuperation, the urologists were concerned about the potential damage caused by the catheter mishap and felt I might require surgical intervention (yikes!). I removed the tube myself and decided to let nature repair the damage. Fortunately, I began to void on my own.

Eventually, the surgeons decided to remove the drainage tubes and sending me home. Within 24 hours, it felt as if my abdomen was going to burst, and I knew they had removed the devices prematurely. Despite stabbing my belly several times in an attempt to drain the build-up of blood, I became Septic. The fluid became a broth for dangerous bacteria that spread throughout my body causing fever and Anemia. I had to be readmitted to the hospital and underwent a second operation so that new drainage tubes could be installed.

If you are large, you should advise surgeons to leave drainage tubes in place until only three tablespoons (30 cc’s) drain from each site. This may take several weeks but, as in my case, you can take care of the drainage tubes at home. Tubes should always be removed one at a time at least a few days apart in order to avoid what I experienced. Furthermore, even though many surgeons believe it is not necessary, extended courses of adequate doses of antibiotics should be used to avert life-threatening infection.

My encounter under the knife was a valuable learning experience both for myself and the hospital staff. There were a number of mistakes made in administering my medication, the application of surgical technique, and in tending to my basic needs. However, amidst a sea of inexperience and insensitivity with regard to treating large patients, I also found some islands of compassion.

True, I could have ventured to an institution more familiar with handling large patients, but I wanted to feel what most lay patients (large and small) must feel. And as a physician, I knew when to speak up and intervene. As a result, my local hospital and its staff will now be more cognizant of—and hopefully more sensitive toward—the growing majority of North Americans who don’t fit the traditional mould.

I am fortunate to have recovered, for the most part, from my surgery. I believe that every health care professional should have at least one such experience in their lives in order to gain insight into being on the other side of the curtain, beneath the covers, or under the knife.

Heretic Physician