MDM post from July

One of the things I've learned to like most about Orthopaedic surgery is the quick turnaround time. Patients come to Dr. Rana's clinic in almost unbearable pain from bad knees and bad hips. At first, they are unable to walk, unable to work, and unable to live normal lives. With a fairly straightforward joint replacement operation and within a matter of weeks, however, many patients are back on their feet and feeling better than ever.

But operations aren't for everyone. Unfortunately, the operation comes with its risks. And while the risk to most patients is minimal, Ms. R was not so furtunate. Ms. R is one of only a few patients I've seen that we haven't been able to do anything for. My stomach sunk through the floor when I saw her reaction to this news.

Many if not most of the patients that come through Dr. Rana's degenerative join clinic are obese (the excess weight really does a number on the joints). Ms. R is what I might describe as morbidly obese. Slightly disheveled, she came to clinic dressed in a lime green T-shirt and matching tights both bulging at the seems as if they were the only size at the salvation army large enough to accommodate her. Both legs and ankles were swollen to the extent that normal shoes did not fit. Hardly able to walk on her own, she kept her walker within arms reach as she barely managed to squeeze into the patient room chair. Without even looking at her X-rays, a history of asthma, atrial fibrillation, diabetes and numerous other co-morbidities made it very clear that life had not treated her well.

Despite rapidly deteriorating joints, surgery was out of the question. Even cortisone shots to relieve the pain were contraindicated given her uncontrolled diabetes. After explaining the circumstances to her, the best option we could give was a referral to Wellness Clinic - in essence telling her to "lose weight". By the way she hushedly uttered the words "Oh, I see", I could tell that weight loss was a familiar nemesis.
Leaving clinic that day, I felt helpless. It was as if we had handed Ms. R a death sentence. Ms. R's condition is lamentably commonplace in American society. Too often, patients end up seeking secondary and tertiary care for problems that could have and SHOULD have been addressed in a primary care setting or on a public health level. Clearly, preventing future Ms. R's should be a priority for healthcare and public health, but as for the many Ms. R's currently suffering, options are less apparent.