Donald is large. Very large.

At more than 600 pounds, he is a mountain of flesh with a small opening at the top through which he speaks.

“My stomach hurts,” he says, his voice surprisingly high and childlike.

It is 10:00pm in the emergency room, and I am already swamped with patients I’m trying to move through the ER before my shift is over.

Asked if he’s ever felt this kind of pain before, Donald says, “No, never. At least, not like this.”

“Well, what’d you expect?” the unit secretary mutters, only half to herself.

Donald is in his forties. He spends his days on the sofa at home, surviving on disability checks for his back pain.

Facing him, I feel momentarily put off. I’m not sure just where to start the examination, and when I begin, my hands look small and insignificant against the panorama of skin they’re kneading.

It’s hard to tell, exactly, but I think his pain is coming from somewhere around his stomach.

I call the surgeon. When he finds out how much Donald weighs, he says that he’ll be down to see him “in a while.”

Awaiting his arrival, we try to shoot some x-rays. When we roll Donald onto his side, though, he turns an unnatural shade of blue-gray and can’t tolerate the position long enough for us to put the X-ray cassette behind his back.

We try a chest x-ray, turning up the power to the maximum setting. All we see is white. Donald’s body is just too thick to allow standard x-rays to penetrate to the bones; he is a walking lead shield.

We start an IV and get some blood work, all of which is normal. Our standard GI cocktail of shot-in-the-dark digestive tonics plinks into Donald’s stomach without any effect. Morphine at doses high enough to make me dance on tables merely makes him a bit drowsy.

I talk to Donald between procedures, trying to get a sense of him as a person. He recites a litany of consultants he’s seen for his back pain, his headaches, a chronic rash on his ankles, his shortness of breath, his weakness, his insomnia and his fatigue.

“All of them have failed me,” he says, adding that the EMS paramedics didn’t have the proper ultra-wide, ultra-sturdy gurney to accommodate his body.

“The Americans with Disabilities Act says that they should have the proper equipment to handle me, the same as they do for anyone else,” he says indignantly. “I’m entitled to that. I’ll probably have to sue to get the care I really need.”

I don’t quite know how to respond, so I say nothing. We’ve placed Donald in a room with an oversize hospital bed, so at least he’s resting comfortably.

Finally, we move an ultrasound machine into Donald’s room — it barely fits between the bed and the wall — and the technician goes in to take some diagnostic images.

Minutes later, he emerges.

“I need to get the radiologist to help me,” he says. “This is impossible.”

One half-hour later, the chief of radiology comes out of the room, rings of sweat under his arms.

“I think we have something,” he says. “A gallstone.”

Elation surges through me. At last we have something to work with!

Paged again, the surgeon finally shows up, muttering, a full two hours after our initial conversation.

After examining Donald, he thinks for a bit, then brightens.

“We could send him to the University of Maryland — they have an oversize OR table and beds.”

He’s now a man on a mission: to unload Donald on another unsuspecting hospital.

Hours later, he learns that there’s no room for Donald on the surgery wards of either the University of Maryland or Johns Hopkins. He must admit Donald to our hospital’s upstairs ward until tomorrow, when he can try the transfer again.

The surgeon is most unhappy. He bellows orders over the phone at a nurse several floors above us.

“Don’t put him in a room right over the ER,” whispers the unit secretary to the admission clerk. “The floor won’t support him — he’ll come crashing through and kill us all.”

Glancing across the hall at Donald, I see by his eyes that he’s heard her comment, and I’m suddenly sure that he’s heard all of the “side” remarks aimed his way.

Finally, a slew of huffing, puffing, grunting attendants wheel him down the hall, leaving me to reflect on his plight.

Donald lies at the very large center of his own world — a world in which all the surgery mankind has to offer cannot heal the real pain he suffers.

He’s trapped in his own body like a prisoner in an enormous, fleshy castle; encircled by a moat of fat, he shouts from the parapets to anyone who might give him succor. And though he must feel wounded by the ER personnel’s remarks, he seems to find his own succor in knowing that there’s no comment so cutting that it can’t be soothed by the balm of 8,000 calories per day.

Later on in my shift, still feeling the eldritch traces of Donald’s presence, I sit and stare at my 700-calorie dinner, all appetite gone, wondering where empathy ends and compassion begins.

I know why my colleagues and I are so glad to have Donald out of the ER and stowed away upstairs: he’s an oversize mirror, reminding us of our own excesses. It’s easier to look away and joke at his expense than it is to peer into his eyes and see our own appetites staring back.

I push the food around on my plate, then give up and head back to the ER, ready to see more patients.

Though I’ve no way of knowing it, within a few months a crane will hoist Donald’s body through a hole cut in the side of his house so the EMS personnel can lower Donald, found dead and alone in his upstairs bedroom, onto their new ultra-wide, ultra-sturdy gurney.

Edward Thompson is an emergency physician. This piece was originally published in Pulse — voices from the heart of medicine, and is reprinted with permission.