Obesity, Lies, Burgers & Fries

"30 year old male, vomiting, abdo pain, NHS111"

Another shift, another young person referred by NHS111 and my guess, was another young person who has said the right words to ensure NHS111 send an ambulance. I'm convinced it's a generation thing! In general, you have less ambulances for the 45-65 than for the 25-45. Equally, that 25-45 group, generally have less wrong with them and 99% of the time would have been perfectly able to make their own way to hospital without the need for an ambulance. It also seems a generation that is a lot less equipped with dealing with illness and injury. The elderly don't call ambulances even when they are dying because they don't want to waste our time, whereas the younger ones call us if they cough once, sneeze once, have a headache for 5 minutes, vomit once, or have the shits! It's a generation of pathetic whiners who need to get a grip! AND STOP LYING! They ALL bloody lie! Today, was a case in point.....

30 year old males vomiting are not about to die. OK, one, once, probably vomited and then died but as a rule of thumb, they don't die. His partner was waiting at the door for us in her onsie. Some people don't lend themselves to onsies and this was a prime example but I wisely didn't comment. Or point and laugh. We were led upstairs to our waiting patient. 

We were greeted with a sorry, pained expression of pure suffering and angst. Unfortunately, the 1 hour history of vomiting did not warrant the sympathy he was after. I kept my questions and responses to his whimpering at a professional level without indulging in his drama. It really does infuriate me when people won't talk, use their words and attempt full sentences because they feel unwell! They are grown ups, but it is like trying to communicate with a 3 year old who is mid-tantrum!

The patient was a big guy, a very big guy, 25 stone plus. The irony of really fat people only being able to fit into sports wear was not lost me but he had no pride in anything about him. The flat was a tip, I could smell fried food, there were pizza boxes everywhere and a half drunk 2 litre bottle of coke next to him. Clearly, his extensive medical history had had no effect in kick starting a lifestyle change! I could have guessed he had diabetes, high blood pressure and high cholesterol before he offered up the information, I was hardly bold over with shock! 

My questions regarding his symptoms continued and led to food that could have caused this non-life threatening episode of vomiting. 

"What did you have for lunch today?"

"Just a salad."

Yes, I'm judgemental and when I fatter than I am, I started by eating more salads, but I have met a lot of patients and I can spot the ones trying to lose weight and the ones pretending to be trying. This guy was the latter. The who's who of takeaway boxes and fizzy drinks around the place told me everything I needed to know.

"Just a salad?"

"Yeah, well some crisps and that too."

"And that???"

"You know, yogurt, chocolate and stuff."

Before I could ask about the "and stuff" his girlfriend butted in!

"You bloody liar! What else did you have for lunch?"

"Nothing!" he exclaimed.

"OK, what did you have just before lunch?"

"What do you mean?"

"What do I mean? I mean what about those burgers and chips you were shovelling into your face sat in you car round the corner! I bloody saw you! And I bet there were apple pies too, I know you, don't forget that."

"Oh yeah, sorry."

I stepped in before it turned into a slanging match, or before he died of embarrassment! 

"So, lunch was a few burgers and chips, some apple pies, some crisps, chocolate, yogurt, and a salad?"

"Yeah, I suppose."

Some people are so unlucky to get diabetes! I could have had a health promotion field day with this guy but it was pointless. In 5-10 years he will be having limb amputations, be going blind, having heart attacks and strokes. Maybe then he will buck his ideas up. The one thing I advised him today, was not to lie! There is no need for it. We always know when someone is lying, save yourself the time and embarrassment by just answering all our questions truthfully! And eat less, a lot less! Oh, and don't call an ambulance because you're vomiting. And tidy your flat. And have a shave and a wash! Gahhh, I just wanted to kick him up the backside! 

It's so frustrating to watch someone so young just self destruct! I just don't know how these people can get help or even begin to help themselves. It's a sorry state of affairs when dietary advise is harder to come by than junk food! What has to happen for them to realise that this lifestyle is slowly killing them?! I would suggest it's too late for this generation. On the whole it is too fat, too lazy, expects everything for nothing and has a poor work ethic. The money is better invested in the next lot to come through, hopefully then, we will see the benefits in 20 years or so. Until then, I'll just grumble away!

A Life Of Grime

"59 year old female, collapsed behind closed doors."

There is that ominous feeling again! The one I get when those words appear on the screen. The apprehension that goes with the territory of entering someone's house, not knowing what you will find. Will the house be empty? Will you go from room to room hoping not to find a body? Will you find someone hanging? It's a horrible feeling and a job I never relish doing. 

We headed round to the house. It was an old Georgian terraced property in quite considerably disrepair. Flaking paint, rotten sash windows, dirty net curtains, ivy growing up the wall, an over grown garden, a boarded up window and a broken letter box. If I didn't know any better I'd have said the house wasn't occupied but we had it on good authority that someone was indeed inside. Two days worth of milk was in the porch which suggested that normally someone was there. I knocked and shouted through the letter box. To my surprise I heard a faint 'Help me' in reply. 

We couldn't get in and no one had a key so I requested police. While we were waiting a neighbour offered us access to her back garden. She also told us that the lady inside never goes out the house. We squeezed through a gap in the fence and peered through the window. Darkness! Luckily the old sash window wasn't locked and lifted up with relative  ease. I immediately wished it hadn't. The smell that hit me.....wow!

This job in general challenges your senses and often offends them. It is true that there are smells you can taste and this smell instantly made me gag. Covering my mouth and nose 

I pulled the curtain across and was met with literally a wall of rubbish. There was no way in, I couldn't see any part of the room. Back to the front!

By the time I'd clambered through the fence and got to the front door the police were on scene. After my explanation of the smell, we all donned masks and police forced the door in. I can't begin to describe the state of the house or convey the smell in words. It was beyond grim! As we made our way down the hallway, shuffling past the stacks of rubbish, I could feel the soles of my boots sticking to the floor. We followed the faint voice from the back of the house, all the while, the smell getting more intense. Maybe it's like touching something with a 'wet paint' sign on it, but despite knowing how vile the smell is I still found myself checking! 

My heart sank as I turned the corner at the end of the hallway. The piles of boxes and rubbish continued, making it almost impossible to get to her but my main concern was her! She was lying face down in the doorway of what I assume was her bedroom. When I say 'in the doorway', I mean literally wedged. She must have been 30-35 stone. There was no way to even roll her onto her back. She had also been there two days so was saturated in urine and faeces. For the first time in a long time, I didn't have a clue what to do, or where to start. How do we move her?! How do we get her up?! How do we get her out?! My crewmate checked her over and medically she was OK, apart from some dehydration. Clearly we couldn't manage on our own and our equipment wasn't large enough or strong enough to cope with her size. 

I phoned up control and had a discussion with our clinical support team. They decided to send HART (Hazardous Area Response Team) and an officer for starters. The benefit of HART, is like firemen, they tend to come on mass! There is normally six of them on their big truck so at least we'd have hands! Ideally we needed a removal company, pest control and a deep cleaning company but we don't always get what we want! Within 20 minutes or so the troops had arrived and like us, were perplexed as to what to do. 

The officer, rightly said we needed the bariatric ambulance to convey her, so he arranged that. Due to the lack of bariatric ambulances and the ever increasing number of obese people who need them they can only be requested by an ambulance officer, so they are not used inappropriately. Meanwhile, the head scratching continued. Eventually a plan was made!

It involved clearing the hallways for starters! Unfortunately, there was no space to put any of it! We ended up having to line the pavement with it all. Almost an hour later, the bariatric ambulance had arrived, a path was cleared, dead rats had been found amongst other unidentified dead creatures and we were all filthy. As for the smell, what smell?! We'd been around it for so long, I was over it! 

With a configuration of straps, sheets and a hoist we managed to get her onto her back, then to sitting, then onto a chair, out the house, onto the bed and off to hospital. We all then went for showers and a uniform change.

I've blogged about obesity at length and apart from saying how much this has cost the NHS in resources, I won't discuss the obesity issues. They are obvious enough. However, there are huge social issues and obvious failings in a flawed system. How can anyone be allowed to end up in a state like this? The council WERE aware of the situation and had done nothing. It was a council property and there was a resident clearly not able to cope. Why had social services not intervened? Time and time again we see people that have 'fallen through the cracks' in the system. I'm not being funny, but this isn't falling through a crack, this is simply not caring for people who need it. This hasn't happened overnight. This is the result of a lifetime of self neglect and being overlooked by the services that are in place to help. No one will be answerable for this situation. It's been left for the emergency services to sort out, again. No one should be allowed to live in such squalor, regardless of how obese they are, regardless of whether or not they are a hoarder and regardless of whether or not they can afford or want the help they need. Allowing anyone to 'fall through the cracks' is neglect. End of. 

Fat vs Fag

"56 year old male, chest pain, DIB"

Despite a large number of pedestrians trying their very best to throw themselves in front of my ambulance and numerous cyclists doing their uppermost to raise my blood pressure we made it to the address without any deaths on our conscious! Loaded up like a travelling circus, we headed round to the entrance to the flats and staggered up the stairs and knocked. The smell of stale smoke hit me even before the door was opened. Eventually, we were let in by our very breathless patient. He slowly walked back into the flat, pulling his oxygen tubing with him. 

Home oxygen is given to people with severe respiratory problems and our guy was a long term COPD (Chronic Obstructive Pulmonary Disease) sufferer. Sitting in his chair he panted for about 30 seconds until he was able to speak. The upshot of the story was his lungs were pooped. He was having a particularly bad day of 'pooped lungs' and it was causing him real discomfort. Whilst my crew mate was doing his ECG etc my Detective Columbo eyes were wondering around the room. On the table next to the patient was a blue inhaler, a purple inhaler, a brown inhaler, various tablets, a bowl with spit in it, a tin of Fisherman's Friends, a lighter, an ashtray and a pack of 20 Superking. 

"You're still smoking?!"

"Yeah, I know I shouldn't."

"How many a day?"

"Maybe 30 or 40"

"No wonder you're breathless!"

"I know I know, save the lecture, I've heard it before!" he said with a grin!

"You know I have to say something! We call it health promotion, you call it nagging!"

We had a good chuckle about flogging dead horses! He was a really nice guy with plenty of tales to tell which made the journey to hospital a lot more enjoyable than usual. Then he said something that firstly took me back a bit and then got me thinking.

"So, you wag your finger at me for smoking, do you wag your finger at fat people for over eating?"

It took me a good while of thinking to reply:

"No!"

"Well don't you think it's unfair to pick on us smokers! Besides, you're one to talk. If I'm not mistaken that's a pack of cigarettes in your top pocket!"

BUSTED! He had me hook, line and sinker! Nothing I could say now would have any credibility when it came to smoking! I felt like saying "Do as I say, not as I do" but I was laughing to much! I could hear my crew mate in the front laughing away too! 

"You just got schooled!" he shouted through.

It's true! I had indeed got schooled! We dropped him off at hospital to get the treatment he desperately needed and left. I could hear him chuckling as we walked away! He was awfully proud of himself! 

He had a bloody good point though. Why don't we berate obese people? Why is it acceptable to say 'filthy habit', 'can't stand the smell of smoke', 'do you have to do that near me?', 'it will kill you' and make the smokers smoke outside to be made a spectacle of?

Why is NOT acceptable to say to someone who is obese who is stuffing a burger into their face 'that's a filthy habbit' or 'I can't stand the sight of you shovelling food into your gob' or 'do you have to do that near me' or 'eating that stuff will make you fatter' or 'being so fat will kill you?' Why can't we tell them that their fatness is disgusting? Why can't we make them eat fast food standing outside under a gazebo and make a spectacle of them?

Because, as a country we are not quite there yet and too many of us love a Big Mac! Before you all tell me I am being harsh and horrible, I don't actually think all that stuff, nor would I want to say it but it is an interesting talking point. Smoking kills. That's a fact. As a result smoking has been made less and less appealing. Tobacco companies can't sponsor anything, their packets are covered in 'SMOKING KILLS' slogans and images of tumours. It costs more and more to buy them, you can't smoke anywhere in public and rightly so. Smoking costs the NHS in excess of £5 billion a year and that's not including the cost of lost productivity. It also causes 1 in 5 of all deaths. Why wouldn't we try and stop people smoking and make it as unappealing as possible?!

How about if I told you that but next year, obesity will be costing the NHS £6.3 billion a year. At the moment 1 in 10 deaths are caused by obesity but within 10 years that number is expected to treble. If that is the case obesity will be costing more and causing more deaths than smoking. Will it then be acceptable to malign the obese like we malign smokers?! Will Big Macs have photos of fat people on them with slogans like 'BIG MAC KILLS' plastered across them?! Will there be a huge tax added to all foods that make people fat?! Will companies like McDonald's be banned from advertising?! Will all fast food have to be served in plain packaging?! 

What do you think?! Should smokers be vilified? Should fat people be vilified? Do we allow free choice in this country only when it suits current political motives? When do we do with obesity what we have done with smoking? Do we wait 15 years until 70% of the UK population is obese or overweight? I don't know what to do. I would certainly feel uncomfortable sitting in the back of an ambulance telling someone they are too fat. I feel bad enough telling smokers not to smoke! Being a fat smoker myself doesn't put me in a good position to lecture either!!

Alternatively, you could scrap everything I've just said, promote smoking and encourage over eating because some studies say making the population healthy would cost the country more in the long term from a longer life expectancy and care costs! Basically, we are screwed whatever we do so I'm just going to eat, smoke, drink and be merry! You?!

Pains, Cranes and Automobiles

"19 year old female, stuck in house"

This week saw an article in the news about how 19 year old Georgia Davis, who weighs 63 stone, needed to have part of her house dismantled so she could get out and to a hospital. A team of 40+ people including doctors, paramedics, fire crews, police, council workers and scaffolders worked hard to 'free' her from her house. She had been confined to her bedroom for a number of months, due to her size, and it took the team 10 hours to cut a 10ft by 10ft hole in her 1st floor bedroom wall. She was then lifted by crane on to a purposely build ramp and onto a specially strengthened stretcher and into the reinforced bariatric ambulance. Weighing the same as a young elephant at just 19 she has diabetes, kidney disease, spinal problems, multi-organ failure and respiratory problems. This is a topic I have discussed at length before in Fat people, Stairs and Backs & Obesity: The cause, the cost, the solution due to my experience craning someone out of a window, but seeing these articles just highlights how little is being done. 

Georgia's obesity isn't just through being greedy and lazy; it would be naive to assume that. There are many other factors at play, none more so than her profound psychological problems. In her defence, she had a miserable childhood. She was the carer of her disabled mother and her father died when she was young. This doesn't excuse what spiralled and what has continued to do so unchecked but it goes some way to explaining where it began. She needs continual support, not just sporadic intervention, which she had when sent to 'fat camp' in the USA. What she needs is the constant support and treatment from a multidisciplinary team including doctors, dieticians, psychologists and counsellors. Yes, all this costs money in the short term but surely we are passed the point of prevention. Cure is the only way to stop the spiralling costs of her care. 

Once labelled 'Britain's Fattest Teen', Georgia had more help than most people get. She lost 15 stone in the USA, all paid for and began to look like she had turned the corner. Unfortunately, on her return, her first meal given by her 'loving' mother was a chip supper. Since then, her weight has ballooned to almost twice her pre-USA weight, to the point of having to be cut out of her house. Then again, with a daily diet of up to 13,000 calories are you surprised?! I'm not. Despite her psychological issues, this eating to excess has been allowed to continue, encouraged and supported. She can only eat what she is given and the blame lies solely with her mother. This didn't just happen overnight, it has taken a short lifetime. It isn't as if no one saw it coming either. She was over 20 stone aged 12, she was on the at-risk register at 13 but threatened to harm herself if social workers took her away from her family. She was removed from the register. At 14 she was 29 stone. There were chances to intervene. There were chances to stop it. Apparently threatening self-harm is reason enough to stop being 'at risk'.  She needed help and was let down by 'the system'. Now an adult, she is no one's responsibility. To be 33 stone at the age of 15 is more than comfort eating and there should be protocols in place to stop cases like this to continue. It is child abuse, plain and simple. How can you allow your daughter to put on 40 stone in 3 years?! To fuel the feeding frenzy her mother sold interviews about her extreme obesity and this has been tolerated because in our 'freak obsessed' society, her body was a money spinner, rather than something to be ashamed about. Her mother needs to be held accountable and charged for the abuse she has caused. That has to be the deterrent. I see little difference between this and beating children. The punishment should be the same. She was let down by the adults there to look after her. That is the bottom line.

Childhood is where it all starts. Nearly a quarter (23.1%) of children are overweight or obese by the time they start primary school, this increases to over a third (33.4%) by the time they finish. Health promotion is fraught with difficulties in school-aged children as poor management of obesity can result in life-long unhealthy eating habits and avoidance of medical help. The NHS has been forced to focus on treatment of illness rather than prevention due to increasing demands and costs. Obesity costs the economy not only in health care but also in sick days, workplace injuries and disability pay. The cost to the NHS is in excess of £500 million a year and to the tax payer, a cost of £2 billion in lost productivity. When will a stand be made? When will prevention be the focus? When will people see that paying for reinforced beds and ambulances, knocking walls down and sending fat kids to America is a short term fix for an ever growing problem (quite literally!)? Without the procedures in place to monitor these children the same will happen time and time again. It is estimated that by 2030, half the population will be dangerously overweight and at risk of an early grave thanks to diabetes, cancer, heart disease and pretty much any other illness you care to mention.

Clearly something has to be done. The tax payer will foot the bill for the scaffolders, the repairs to the house, the fire brigade, the doctors, the police, the ambulance service, the hospital fees, the treatment, the surgeries, the medication, the after care, the counselling, the calorie controlled diet, the benefits, the disability allowance and everything else she will need.  Sadly I have no faith that, even with all the recent costs incurred, anything will change. I hope I'm wrong, but I doubt it.




Here are some other articles about the extraction from her house:

Sky News: http://news.sky.com/home/uk-news/article/16235051

The Mirror: http://www.mirror.co.uk/news/real-life-stories/britains-fattest-teenager-georgia-davis-848297

The Sun: http://www.thesun.co.uk/sol/homepage/news/4337143/Medics-smash-house-to-save-63-stone-teen-Georgia-Davis.html

The Guardian: http://www.guardian.co.uk/lifeandstyle/2012/may/25/georgia-davis-what-support-was-she-getting

Obesity: The cause, the cost, the solution

"48 year old female, keeps fainting, patient is obese, weighs 35 stone"

A few months ago I wrote a blog called ‘Fat people, stairs and backs’. This particular post received a lot of praise but also angered a few. It was suggested I criticised without foundation or research and offered no reasoning to may argument. I did a follow up  post  which was a knee-jerk reaction to a rather abusive e-mail but decided I should in fact back up what I was saying with a much more researched piece. So I did! I wanted to look at the social reasons behind obesity and what impact obesity has when not prevented in childhood. I also wanted to highlight the benefits of using prevention rather than cure in tackling such a huge social problem. 

Obesity is a significant societal trend with effects being felt throughout the health care system, economy and society as a whole.  A person is deemed overweight if their body mass index (BMI) is between 25 and 30; a BMI over 30 is classed as obese and a markedly increased health risk. I attended a middle-aged female who had been experiencing DIB for several days as a result of chronic heart failure and episodes of fainting. The patient was of low socioeconomic status, weighed 35 stone and was in her upstairs bedroom.  We began treating her breathing while carrying out a risk assessment of her extrication.  Her condition was deteriorating but due to her size we were unable to safely carry her down the stairs. The decision was made to mobilise the fire brigade to assist us and the bariatric ambulance was called to convey.  The patient was taken out of the house through the window by a crane. This caused considerable delay in her receiving definitive care and despite aggressive management at hospital she died shortly after arrival. What led the patient to be in this position? Why was nothing done to avoid this situation? Why was she allowed to stay like this? How long had she been like this?

The NHS has been forced to focus on treatment of illness rather than prevention due to increasing demands and costs.  This leads one to question, however, where the responsibility for obesity prevention should lie.  Obesity costs the economy not only in health care but also in sick days, workplace injuries and disability pay.  Not only is the prevalence of obesity increasing in the Western community, those who are overweight are also heavier. This paints a bleak picture of a problem which has increased rapidly since the 1970’s; despite being on nearly every major government’s agenda.  The literature is focused towards prevention because ‘cure’ is a nearly impossible ideal and to achieve this we must look at children.

Nearly a quarter (23.1%) of children are overweight or obese by the time they start primary school, this increases to over a third (33.4%) by the time they finish. Health promotion is fraught with difficulties in school aged children as poor management of obesity can result in life-long unhealthy eating habits and avoidance of medical help. Our patient may have had a negative experience with a health care professional and avoidance behaviour is common in obese patients who do not want to be lectured or humiliated. Conversely to the conception that patients will use an illness to seek attention from their doctor, obese patients often avoid this interaction. There is risk of promoting the ‘sick role’ with obese children and all children could benefit from nutritional and physical activity advice. This should not be taught as ‘treatment’ for overweight children who may feel they have an illness as a result.

Obesity is not a disease, however it does appear to spread through social ties. There is literature to support that neighbourhood does increase childhood obesity especially when coupled with a lower socio-economic status. I firmly believe it is time for people to assume personal responsibility for the improvement of society. Although our patient’s obesity is juxtaposed to this ideal her individual community may have made her weight more acceptable. In the school environment however, a lower SES and being overweight are both major factors in teenagers suffering social marginalisation. This leads to emotional distress, low self esteem and lower expectations of their educational future . It is pertinent to note that class position is responsible for health, health does not determine class.

Careful education is imperative for these young people but education needs to be extended to the home. Our patient may have been obese for a number of reasons, however, it is likely she developed obesity from a young age. Poor family functioning, authoritarian parenting styles and single parent families have been cited as factors increasing the risk of childhood obesity . Other factors increasing the risk within the home are stressors; stressors in adults have been linked to obesity, this could be attributed to poor eating habits among stressed individuals and with a huge increase in incidence of stress these days it is of little surprise there is a similar increase in obesity.  This phenomena has been extended to children with specific factors being recognised for younger and older children. A positive association with obesity has been found in younger children who have a lack of cognitive stimulation and emotional support, whereas older children who live in a household with financial strain or members experiencing mental or physical problems (which could be a result of obesity) are at increased risk.

There is a strong correlation between obese parents and obese children and while there is an argument for a genetic predisposition, environmental factors are thought to be the most important. The increase in obesity has occurred among all socioeconomic groups therefore cannot be explained by genetics alone. Genetics can increase ones risk of developing the wide ranging complications of obesity, such as diabetes, high blood pressure and heart disease, some of which were observed in my patient. Obesity is associated with many chronic conditions  the cost of which have a huge impact on the economy. The parliamentary committee omit some of the most expensive areas of the cost of obesity from their calculations  this made it impossible to glean accurate figures for the true cost of obesity. It is estimated obesity costs the economy £4 billion a year and this is expected to rise to £6.3 billion a year by 2015. This kind of required financial support is not sustainable so a way to prevent the need for this financial burden is urgently needed.


Schools are the most appropriate setting for prevention, and therefor there is little we can physically do in the ambulance service other than refer.  The health promotion these kids need should only be undertaken by specialist educators as the message can be distorted.  Poor management can lead to starvation, laxative and slimming pill abuse amongst other drastic measures at a time when nutrition is vital for their developing bodies. If childhood obesity is allowed to progress to adulthood without specialist intervention the individual increases their risk of physical, emotional and social problems in later life.  I do not know the cause of our patient’s obesity or why it was allowed to continue to the situation I met her in.  Unfortunately, my patient did not get the help she desperately needed but hopefully if the right people set up the the right referral process maybe we as a nation can get to a point where prevention is a realistic option.