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Taking Charge (5)

Big Bums
This chapter may be provocative and get me into all sorts of trouble (as if the rest of this book won’t!). But when you are lying in bed paralysed you have time to think seriously about things you may have noticed, laughed about and dismissed, when in fact there are serious implications.
I have always thought that as a health practitioner I should be authentic. That is I believe I should practice what I preach. When I was first a doctor, I made the mistake of continuing to smoke cigarettes – for a total of 10 years, roughly from aged 21 to aged 31, although like many young people I practiced at smoking on and off from about the age of 13. I smoked French cigarettes, untipped Camels and small cigars, although ultimately I settled for Benson and Hedges tipped cigarettes.
I had been brought up in a family where my mother was a heavy smoker, as were other relatives during my childhood and youth, and while many of my friends and colleagues did not smoke, many did. The ‘mistake’ was in fact a composite of bits of denial. First was that during my training in medicine, the evidence was mounting that there was a direct relationship between smoking and cancer of various sorts; eventually it became irrefutable, but for many years I dismissed it, despite the early public awareness campaigns. Second was that my mother died from aggressive lung cancer at the age of 50 when I was 26 and had just entered general practice; I cannot believe that I went on to smoke for another 5 years when the personal family evidence was so strong. Third, I cannot believe that I smoked when I had three young children; I pray that there is no long-term consequence. Fourth, I cannot believe that my wife put up with kisses for all those years that must have tasted like an ashtray. She came from a family of non-smokers, and while she had practiced smoking alongside me during our teenage years, she made the right decision and stopped. Finally, coming back to the substance of this chapter, I cannot believe that I smoked in my general practice surgery, while I was giving advice to my patients with a variety of cigarette related medical problems. So I am a ‘reformed inauthentic’ – probably the worst kind of authentic.
For the first time, I have been a patient looking at the system from the inside. And I worry that as a health system we are inauthentic; I see it all around me. We have unhealthy people working in an unhealthy system, preaching about health to patients, who must so often laugh behind our backs.
Just as an introduction to this topic of big bums, I offer a little story. Several years ago, a younger colleague and I used to fly from Adelaide to Mount Gambier by small plane once a month to do clinics in Child and Family Psychiatry. I remember on one occasion having been escorted to the Navajo Chieftain 9-seater by a very very large man in his 40s. He was wearing the livery of the company who coordinated the flights, but it never crossed my mind that he might be the pilot. Anyway, we were all strapped in, and this guy climbed in through the rear door (which would have been a feat in itself, given my memory suggests he must have well exceeded 120 Kgs). The rear door is the only access point to the plane, and as he worked his way to the front, we all had to lean away from the central aisle, because he overflowed on both sides. As he got to the pivot point, the plane suddenly tipped forward (thankfully onto the front wheel) to a chorus of sharp intakes of breath. He literally had to manoeuvre himself into the pilot’s seat with much huffing and puffing, and must have been uncomfortable in the extreme. I was surprised he could find the joystick. Anyway, obviously we all survived, but I can remember the mounting anxiety as we took off, when normally I would be quite sanguine about flying. With all that weight up the front, surely we would never get the lift needed to take off. Of course we did, but I swear I could hear the engines straining.
I have had several conversations about this story with pilots since, and my understanding is that there are strict rules about health and fitness. When you are in a situation of control over many lives, you have to be very fit and with low risk for a range of medical emergencies. Airlines go out of their way to ensure that their pilots only work certain hours at a time, have rest and recreation in between tours of flying, and maintain their fitness to fairly stringent standards. 
Why does the health system not do the same?
I remember one day walking out of the Mental Health Centre onto the main hospital connecting corridor shortly after I first arrived in Brisbane, to be met by this vision of three ginormous women in nurses’ uniform walking ahead of me. They seemed to be similar in height and width, were walking three abreast and deep in conversation as they ambled along with large black-trousered buttocks swinging from side to side in unison – left, right, left. They seemed deeply unconcerned that they were literally taking up the whole corridor, and that several people had attempted to bypass them, faltering at the last minute – perhaps out of politeness, perhaps in fear of being squashed. In a hurry, I did eventually manage to squeeze past, hugging the wall, pretending not to notice them, legs forcing the pace (could not do that at the moment!). They obviously took no notice of me, not a second glance, lesser mortal that I am. 
Over the next couple of years, these visions of large women seemed to become more and more frequent, everywhere I looked. Eventually, I came to the somewhat quirky conclusion that all enormous women in hospitals (whatever they were wearing) were nurses until proved otherwise. I would comment to colleagues “Must be a nurse”, and they would look at me strangely (probably wanting to ask: “How long have you had these funny ideas, Graham?”). Then I began to notice something else. You could see, under all the rolls of fat, that many of these women were (or had been) quite beautiful. Seriously, if you took the time to look, you could see the effervescent laughing child these very obese people had once been. In fact (being someone who plays with words) I coined an acronym OWB (once was beautiful) From time to time I mutter this to the consternation of colleagues, and deep frowns from my wife who disapproves of such criticism.
Of course being a psychiatrist, I began to wonder why so many women wanted to cover up. Did it just happen; is it the result of patients leaving vast boxes of chocolates and other goodies in gratitude for the quality of care they had received? Was it the long hours on the night duty roster, with all the patients tucked up in their beds, and nothing else to do but eat? Or was it deeper than that? Some dark need to avoid looking beautiful and cease the fawning of all those annoying male medical students? 
I began to notice several other things. First, they rarely seemed to be happy. They were all so serious, sometimes even downright miserable. Never the jolly fat ladies of stories of my youth; just ‘grumps’, unhappy with their lot. The second thing was that the further up the nursing hierarchy you looked, the more likely nurses were to be obese, not necessarily like the three ginormous nurses I had had to squeeze past in the corridor, but certainly overweight. I was delighted some months ago to see in the newspapers that the new President of the Australian Council of Trade Unions was a nurse, and a very fit-looking one too! The previous president had also been a nurse, but had been in my ‘ginormous’ category, often shown by media struggling to move thunder thighs along some pathway or corridor to an important meeting. What sort of example does it set? Another example of a senior nurse in my ginormous category, frequently on television, is a nurse cum whistleblower in a high profile legal case against a surgeon, followed excitedly by the press. She, too, was also shown to be struggling down corridors. I wondered whether these two very senior ladies had set a trend, sort of ‘follow-my-leader’. Perhaps there is this deeply ingrained belief that to be very important or to become very senior in the nursing profession, you have to be large. Bigness seems to have become equated with importance.
I am being cruel, and the vast majority of nurses are nowhere near obese, especially those who come from Asia or the Indian subcontinent. There are also some stunning exceptions to my observation that the more senior you go, the bigger you have to look; I have several senior nurse colleagues who are in my ‘stunning’ or at least ‘very fit’ categories. But my recent experience as a patient has confirmed my views to a certain extent, and I think raises some very serious questions. 
One night early on, when my limbs just would not move much at all, I was tended by this short but very large lady nearly busting out of her nurses uniform. She was quite friendly, and (one of the very few) wanted to know what had happened to me. She seemed to have time for chat, and I was grateful. But her shape! She was very large up front, and then seemed to have a very large bum in her black trousers – sort of ‘S’ shaped or rather ‘S’ shaped. In the old medical textbooks she would have been described as having ‘steatopygia’.
I began to speculate about what might happen if I fell on the floor. Purely theoretical, you understand given I could not move much, and the cot sides were up! But if I were to do so, this nurse would have had no capacity to assist me to get back to bed. She could barely manage to carry her own weight, and when rushing (which she seemed to do a lot), she was often out of breath. Of course, I know she would simply have solved the problem by calling a ‘wardie’, who might have arrived in time to rescue me (they are often covering several wards at night, and can get very busy). All right, maybe not such a good example. 
Well, supposing that lying in bed with the cot sides up I inhaled some vomit (you can get a bit hysterical and have some weird ideas when locked up in a hospital bed unable to move). Again, I had no intention of doing so, but just suppose. This woman, this nurse, would have not have had the capacity to even turn me on my side to stop me inhaling more. She was physically just too out of condition.
Several nights later there was another one - again, at night. I had not received my nightly injection of blood thinner Clexane for some reason, nor my Coloxyl with Senna. Waking up after a short sleep, I rang the bell (one of the rare times) to see what had happened. When the nurse eventually arrived I had almost fallen asleep again, and I got a serious shock when this apparition appeared by my side with a sort of miner’s nightlight in bright red strapped to her head. Weird. I got over the shock, forced myself not to giggle, and we had our discussion. When she returned she had obviously been hurrying for some reason, and was huffing and puffing. It was then that I noticed her size. She, again, was both short and ginormous, had on a uniform blouse which did not fit, and uniform trousers over the top of which were large rolls of fat. Obviously slightly eccentric, she actually was both friendly and helpful. But all those questions about size were revived.
So why does a health system allow people like these to be in charge of patient care? It does not matter what their qualifications are, or how caring and chatty they are; when you get down to it, neither one could have responded to an emergency. And why was I noticing such things more at night rather than during the day?
As a patient (even a doctor patient married to a dietitian), it is not my job to even broach the subject of overweight with a professional in the process of just doing their work. And both of my examples had been (and continued to be) quite pleasant and chatty when they were on, and allocated to my ward. I would not have wanted to upset either one of them (and I sort of hope that neither of them reads this book). But why doesn’t the system have minimum standards of health and fitness to include measurement of Body Mass Index (BMI). And if there is a problem, why does the system not take some responsibility to help those employed to look after others, to maintain their own health and fitness? I understand that in most hospitals there may be an arrangement of reduced fees at a local Fitness Club. But I am talking about something more serious than just providing for those who actually want to maintain shape and fitness. I think regular fitness assessments should occur as a routine, and where there is a problem it should be mandatory for staff to work hard on their health and be monitored to do so. It is just simply too dangerous for the patients if this is not considered.
There is another odd observation to be made here, and that concerns night nurses. I reckon if you did a survey you would find that the average weight of night nurses would exceed that of the day nurses. I must admit that I don’t understand how rosters are worked out. It is possible that all nurses have to do their fair share of night duty (which would wreck my proposed research of course). But I did talk to many nurses who seemed to be on permanent night duty, and you have to wonder whether they chose to do night duty because they are obese and know that they cannot manage the pace of daytime nursing or the lifting and routine bathing of patients, or whether for some social reason they are somehow forced to do nights, and then sit around looking at all the gifts from grateful patients.
Before we move on, I need to say that what I have said is in no way sexist, or meant to be disparaging of women; I am trying to make a serious point about a troubling issue that is not being addressed. In fact I came across two male nurses during my inpatient sojourn who were also in my ginormous category. Both were actually tall, and if you looked behind the fat you could see that they were at some stage quite good looking, and might have been very fit as younger men. Both had a very similar shape, though; what my dietitian spouse would have called the ‘apple’ shape. That is they were fat round the waist, with shirts and trousers that were bursting at the seams. They moved more slowly than others, and my impression was that they thought more slowly as well. I watched one of them respond to another patient’s semi-urgent call, and it took some time for them to arrive (which perhaps is more common than you might think), their clinical approach was not really particularly hurried (although that might have been warranted), and they seemed resentful at having their evening interrupted. Sort of “I only work here, I don’t actually have to do anything”… Which came first, the overweight or the attitude? I don’t know. But if as a system we were serious about fitness to nurse, or more generally fitness to work, we might find out.
Health systems should be serious about providing quality of care. To my mind that means employing staff who are patient focussed, and have qualities of empathy and the ability to maintain a caring approach, whatever the personality or current mental or physical state of the patient. In addition, of course, they have to be highly trained, and able to do a myriad of jobs that, at least theoretically, are in the realm of the nurse. I am not sure that truly ginormous people are able to do some aspects of nursing at the acute or semi-acute level, even when they are willing and dedicated. They seem to be lacking in energy, even when they caring and friendly. They would appear not to have the physical capacity to do some jobs. And they seem physically and mentally slow. I think a part of this comes back to a very old adage: “Mens sana in corpore sano” (a healthy mind in a healthy body). My observations, having been a customer of health systems for some months is that we are failing in the ‘care’ department, and that one of the small (or actually, large) signs of this is not ensuring that staff are fit enough to do the job when the going gets tough. It is my belief that health systems have some responsibility to choose staff carefully and one criterion for nursing staff would seem the possession of physical capacity to do heavy parts of the job in the temporary absence of someone like a wardsman. Once a staff member is employed, I believe the health system then takes on a duty of care that includes regular checks on physical and mental fitness, and some access to remedial help if this is required. My belief is that the health system should contribute to the cost of this maintenance of peak health in their staff; it is after all in the system’s interests. It is a matter of occupational health and safety.
I am probably just blowing in the wind. I think the day is probably over for bureaucratic systems actually caring for staff in an optimal way. As long as the paperwork has been completed bureaucrats don’t really require anything else. Risk management seems to be central to bureaucratic thinking, and sadly I am not talking about risk management for the patient (or even for staff). I am talking about risk management for the system, measured by a low level of public complaints, and/or a low level of ‘ministerials’. As long as there are systems in place for reporting on how risk was managed, and all the boxes have been ticked, then bureaucrats and their political masters can sleep at night. 
I am blowing in the wind (not just probably). I still believe that if you are employing a person to do a job for you, then you have a responsibility to ensure that they can access your service at no extra cost to them. All staff in a hospital, whatever their level of qualification should have access to free parking during their shifts. They are working for the system; the system should provide. It is slightly obscene that systems believe that they have the right to charge you to come in to do their highly-prised job. How old fashioned an attitude is that? Systems including public hospital systems don’t think like that. They just see staff as grist to the mill of extra income from car parking. “Hey, we are giving you the opportunity to work for us. How you get here, and how much it costs you is of no concern to us”.
So, I can imagine the comments I am going to receive about ginormous and possibly unhealthy staff who may not have the capacity to provide aspects of clinical care? The first response will be: “What ginormous people?” To which my answer will be: “Actually, the ones who may be putting your bureaucratic risk management system at considerable risk!” The second response is likely to be: “You realise, Dr. Martin, that your comments are defamatory, and quite possibly discriminatory?” To which my answer will be: “I know! But I believe that all hospital bureaucrats should have the privilege of spending some weeks in one of their own hospitals.” Oh, but that wouldn’t work, would it? You can imagine the special care they would all expect, demand, and probably get.