5/19/19 8:00 PM-6:00 AM, 10 hours; 5/22/19 8:00 PM-6:00 AM, 10 hours; 5/23/19 8:00 PM-

6:00 AM, 10 hours; 5/24/19 8:00 PM-6:00 AM, 10 hours

Hours worked this week – 40
Total hours – 80/456

This week was enlightening in terms of being more aware of different roles. The receptionist,

the triage nurse, the intake paramedic, the fast-track nurse, the nurse practitioner in fast tract

and the various nurses that handle actual patient care. This week I wanted to focus on the

diseases that are associated with obesity. There are a surprising number of obese and morbidly

obese persons that frequent the ER. For my project my supervisor and I have agreed that

developing a health service portfolio contain numerous services that are offered in the

community will benefit the ER tremendously. This portfolio will be available in the ER to inform

the patients that there are other places they can go to get medical help rather than waiting for

hours to be seen at the ER. My presentation will contain the problems that this community

faces with statistics and talk about what each health services could offer.

Sunday 5/19/19

Today, I met Larry - he is 28 yrs old, weighs 425lbs with a BMI of 68. He has COPD,

diabetes, HTN, sleep apnea and multiple venous stasis ulcers on his lower legs which is what

prompted his visit. His lower legs were draining copious yellow fluid because he was unable to

get to his wound clinic appointment. The medical van was unable to come yesterday and he is

too large for Ubers. During his physical, he was found to be hyperglycemic, severely

hypertensive and tachycardiac. He was admitted to the hospital for IV antibiotics. His stay in the

ER was complicated by not having a stretcher or bed to accommodate his size, finding an extra-
large blood pressure cuff and gown. He was obviously uncomfortable with the attention he was

receiving and looked like he wanted to leave if he could.

Wednesday 5/22/19

Mary presented to the ER with complaints of difficulty breathing. She smokes 1 pack per

day, wears oxygen and weighs about 300lbs. She should be on BiPAP at night for sleep apnea,

but states she does not wear it because it is uncomfortable. Despite multiple warnings not to

smoke while on oxygen – or indeed to smoke at all – she says she takes the oxygen off to

smoke. She would be unable to get out of her house quickly in the case of a fire. She has run

out of her inhalers and most of her medications. We start her on BiPAP in the ER and admit her

to the hospital for continued care.

Thursday 5/23/19

Michael comes in by EMS with worsening abdominal pain, Nausea/vomiting and fever

for 48hrs. I knew the workup for abdominal pain includes either an abdominal x-ray or CT scan.

Unfortunately, Michael was easily over 500 lbs and would not fit thru the CT. X-ray were

inconclusive due to poor penetration and physical exam unreliable. They had a hard time even

placing IVs because of the large amount of adipose tissue. The surgeon came in to evaluate the

patient who was demonstrating signs of some kind of infection, but was such a high surgical risk

that the surgeon was reluctant to proceed with abdominal surgery. He said as dangerous as it

was to wait, it was more dangerous to proceed without a definite plan as to what was wrong.

Unfortunately, the medical technology has not kept up with the size of the population. They

were going to try to be conservative and continue careful monitoring.

Friday 5/24/19
 Peter presented with chest pain for 3 days with difficulty breathing. Once in the ER, all

his tests indicated that he had had a heart attack. Due to his late presentation, there was no

option of angioplasty, just medical management. When asked why he waited so long, he said

that he did not want to come in and have people make comments about his weight (400 lbs) or

hear about all he can do better. My preceptor Suzy explained that he had every risk factor and

would now likely had worsening heart function and heart failure that would make everything

worse. We had a patient earlier who came in with an acute heart attack and was rushed to the

cath lab within 20 minutes and will likely have no sequela, whereas Peter has now gone from

bad to worse.