According to a recent survey, 67% of Australian adults are now overweight.
On top of that, about a third of Australians are obese (meaning they have a Body Mass Index of 30 or more).
There is widespread evidence that obesity is linked to higher rates of surgical site infections.
However many patients who are overweight or obese are not given straightforward information about their surgical risks. Even if they were, the idea of being killed by a hospital procedure instead of getting better, seems far fetched to most people.
Our health system is very focused on medical procedures to fix problems. Weight loss is not even funded by the government, even though it is closely linked to multiple diseases and is difficult to achieve.
And simply saying 'no' to sick people is fundamentally difficult for Doctors.
'...some reports reveal that the increased risk of Surgical Site Infections among obese patients is as high as 60%.'
A woman in her sixties we will call ‘Maria’ had been unable to walk freely for several years. She had advanced arthritis in both her knees. She was also very overweight.
Maria was 150 cm tall and weighed 120 kilos. This made her obese class 3, with a Body Mass Index of 53.3.
Maria's local Doctor referred to a public hospitals orthopedic clinic, to see if she was suitable for knee replacement. The surgical team assessed as a suitable candidate. Due to the severity of her condition and lack of mobility, they decided to do both knees in one operation.
Maria was put on the public hospital waiting list.
Eighteen months later her number came up.
While vague references had been made about her weight by the surgical team who assessed her, Maria was never told directly that she must lose weight. No referral was done to a dietitian.
The orthopedic team at this hospital did not use a Surgical Risk Calculator as part of her pre op assessment.
In turn, Maria asked no questions of her doctors. She just passively accepted what she was told, and waited for her time for surgery to come.
After surgery Maria was sent up to a general surgical ward. A few nurses had postgraduate orthopedic training, most did not.
Being physically large and having both knees operated on, made Maria a complex patient to manage. The ward was not allocated any extra resources to cope with her.
Getting Maria out of bed, standing up, walking a few steps then sitting in a chair was a complex procedure that required two nurses and one physiotherapist and the best part of one hour. Organising this many staff to spend time on one patient involved a lot of negotiation among ward staff.
The result was that Maria spent more time in bed than other postoperative patients. This meant she did less deep breathing and coughing to clear her lungs.
Long periods of lying in bed allowed Maria's blood pressure to remain low.
And the infrequency of her exposure to the normal pain of mobilising after surgery, made the experience more traumatic. Soon, pain killers had to be added to her medications before she could be got out of bed. The less she walked, the less she wanted to.
On top of all this, Maria's wounds were slow to heal. They oozed haemoserous fluid, slowly but continuously.
Maria was not assessed as having a sub optimal recovery from surgery.
Maria began to complain about vague pain.
"I don't feel so well" she would moan. "Can you help me please?"
More pain killers were given.
By this time, nursing staff saw Maria as a difficult patient, that would be on the ward for a long time.
Along with constantly low blood pressure and oozing wounds, Maria also had a persistent, low grade temperature.
The nurse unit manager responded by getting nurses to fill out generic nursing assessment paperwork -
- An air bed was ordered (which made moving her even more difficult)
- A special hoist designed for obese patients was sourced from another ward (It needed extra large slings, that had to be sourced from the physio department)
Maria didn’t eat her meals, the food tray came and went untouched.
Maria just lay in the bed, unhappy, moaning, with both knee wounds slowly oozing.
After a week her dressings came down. The surgical team were not happy. Her knee wounds was still wet, with watery, bloody ooze.
Both surgical sites were swabbed. The results showed that Maria had an infection. IV, then oral antibiotics were started.
While her dressings were constantly changed, there was no systematic approach.
Her surgical wounds were not measured, photographed or assessed by a wound specialist.
Four weeks after her surgery, Maria had what is called a 'vasovagal'. A code blue was called and the resus team rushed in.
Nursing and physio staff had tried to get Maria out of bed and put her in a chair. Unused to being upright, in pain and overwhelmed with the infection, her blood pressure dropped suddenly and she lost consciousness. Maria slid off the chair and down on to the floor.
She was revived, fluids and intravenous antibiotics were started and a large team of people eventually got her back on to the bed.
Maria was taken to Intensive Care and assessed. They found she was -
- On the wrong antibiotics for her surgical site infections
She was given IV fluids, vitamins, protein drinks and new antibiotics. Maria was sent back to the ward the next day.
Maria lay on her back, moaning about the pain, not eating or drinking. Her knee wounds continued to slowly ooze, despite numerous different dressings applied, in an add hoc manner.
The bed manager had Maria moved on another floor, to a general medical ward. The nursing staff had no orthopedic training and just tried to get her out of bed when they could find the staff, the large hoist and the sling. Most days, Maria stayed in bed.
Six weeks after surgery, Maria went into cardiac arrest.
She was taken back to Intensive Care were she stayed for a week. They found she had -
- Pulmonary oedema (fluid in her lungs)
There was no beds on either the orthopedic ward of the general medical ward.
So Maria ended up in an aged care ward, where there were few Registered Nurses.
Her surgical team saw her very infrequently.
The aged care ward did not have a physiotherapy team.
Maria did not sit out of bed at all.
Eight weeks after her surgery, Maria arrested again.
This time she could not be revived.
There was no formal enquiry. No changes were implemented to improve the management of high risk surgical patients.