Adopting a positive, non-judgmental, UPR-like attitude and character enhances both our own enjoyment of emergency medical practice and the patient’s perception of quality care. Fewer lawsuits? Perhaps, but more important, our leadership and example in this area create an atmosphere of mutual respect and healing – a win-win for patients and staff.

ACEP’s Code of Ethics for Emergency Physicians states that we care for all patients regardless of their race, creed, color, or outward appearance.³ Of course, it would be patronizing to issue pretentious platitudes like “be compassionate” and pretend that this is a simple matter: If it were easy, everyone would be doing it.

We would like to arm you with at least one other candidate antidote for doctor indifference: See excess patient mass as excess patient pain. Consider the plausibility that the morbidly obese patient overeating before you experiences pain daily on a per kilogram basis.

While not always “true,” consider that comfort foods are their preferred means of coping. Certainly, we want to encourage obese patients to adopt healthier dietary and exercise habits, but we might do this better by appreciating that they wear their burdens for the whole world to see. Perhaps envisioning proportionality between BMI and pain may help us generate more empathy when evaluating the next morbidly obese “belly pain” patient.

Morbid obesity and the standard of xare

Despite our contentions that material resources should be guarded, stewarded, and equitably distributed,³ we submit that caring and compassion should be given generously if not equally in the ideal emergency department setting. However, beyond the very real resource and stigmatization challenges of caring for morbidly obese patients, there is a third ethico-legal challenge: the sliding scale standard of care. While it might be ideal to examine, test, and ultimately treat all patients equally given similar chief complaints, this is not always possible when a patient is morbidly obese. Indeed, the risk/benefit quotient changes when an emergency physician is managing an airway threat using RSI versus noninvasive ventilation; the safety of standard options changes in an ectomorph versus a small-mouthed, short-necked, double-chinned Mallampati IV.

Similarly, an emergency department might have a policy or care pathway mandating IV analgesia for patients in pain; while this “best practice” is an ideal way to titrate and deliver parenteral analgesia, intranasal, subcutaneous, or even suboptimal intramuscular injections might need to be considered.

Empathy is important, not only with patients, but also with our peers when they are managing morbidly obese patients. A spirit of magnanimity should pervade conversations about colleagues who might deviate from a guideline or miss a subtle physical exam finding, for example, after performing a pelvic exam in an obese woman with a large pannus. While lawyers and risk managers might contend, cookie cutters in hand, that all patients with a given complaint should receive identical standard care, a “one-size-fits-all” attitude defies our reality. The standard certainly shifts by body habitus and available resources in many cases.