By KAREN OWENS
Scenario: You are dispatched to a victim with chest pain and difficulty breathing at a nearby residence. On arrival, you conduct a quick survey of the residence as you walk to the door; nothing appears to be out of the ordinary. You are directed to the back bedroom, where you find your patient: a severely overweight female with obvious signs of respiratory distress.
Every week you hear stories about how the average weight of the nation is increasing. The Centers for Disease Control and Prevention (CDC) reported that in 2007-2008, 32.2 percent of adult men and 35.5 percent of adult women were considered obese.1 Although the growth of that percentage has slowed some, as medics we have the opportunity every day to face an obese patient.
A 2009 report from the CDC found that 33 states had a 25 percent or greater prevalence of obesity; nine had a prevalence greater than 30 percent; and only Colorado and the District of Columbia have an obesity prevalence of less than 20 percent.2 When referencing patients who are severely overweight, the terms obese and bariatric are often used.
Obese individuals have a higher potential for a significant number of health problems, which may lead to the individual requiring emergency medical services care. These health problems include, but are not limited to, the following:
- Coronary heart disease.
- High blood pressure.
- Respiratory problems.
Each patient you encounter will provide a variety of complications; this does not change with the bariatric patient. Obese patients may suffer from a variety and multitude of health problems and also present issues related to patient assessment, treatment, and transport.
During your patient assessment, you find that your patient weighs 675 pounds and has a variety of medical problems including high blood pressure, heart disease, chronic obstructive pulmonary disease, and diabetes. She has called 911 because of an increasing amount of respiratory distress.
ASSESSING AND TREATING THE “CABs”
Scene size-up (which you must always do) and patient assessment begin as they would with any emergency incident. Not only will an effective scene size-up ensure that the scene is safe, but it will also give you a better picture of your immediate needs/actions. Table 1 provides an overview of the elements of an effective scene size-up. One of the most important elements is determining whether or not you have adequate assistance. If you do not, request the appropriate assistance.
Safely removing and transporting a bariatric patient are huge considerations. Once you have completed your scene size-up, move directly into checking his circulation, airway, and breathing (CABs) as you would any other patient. However, when assessing a bariatric patient’s CABs, consider the impact that his weight and physicality will have on your assessment and his condition.
Circulation. Previously, assessment of airway and breathing took precedence over circulation. With greater understanding of the importance of circulation on survival during resuscitation, the paradigm has changed. In a bariatric patient, palpation of a pulse may be hindered because of the excessive soft tissue in the areas normally used to assess pulses. You should also have an increased suspicion of circulatory compromise because of the impact of the excessive weight on the cardiovascular system. Even in nonemergency situations, obesity increases total blood volume, raises cardiac output, and leads to increased peripheral resistance. (2) These patients will also have a higher basal heart rate, which means that any emergency can put an even greater strain on the heart and blood vessels.
When assessing circulation, using the appropriate size blood pressure cuff is important to ensure an accurate reading. If a sufficiently large cuff to encircle the upper arm is not available, consider placing an appropriate size cuff on the lower arm, auscultating over the radial artery. The cuff needs to be at mid-heart level during measurement.
Additionally, when considering the use of IV fluid resuscitation in your obese patient, consider the impact additional fluids will have on the heart, potentially increasing the demands on an already overworked heart. Consider using an IV with a slow drip, a saline lock, or a similar device to provide IV access without continually infusing large amounts of fluid into the patient.
Airway. Opening the airway of an unconscious bariatric patient will present additional challenges. Because of the accumulation of adipose tissue in the neck and shoulders, you may have to place towels or blankets under the head/neck/shoulders to provide a more supportive structure for maintaining an open airway. (2) This is equally important when preparing to intubate a bariatric patient.
If intubation is necessary, consider the ability to conduct conscious intubation. Paralytic medications used by advanced life support providers cause loss of muscle tone, which can result in complete occlusion of the airway. You may also struggle finding landmarks in the neck and pharynx for intubation or surgical airways because of excessive soft tissue.
Breathing. Assessing the rate, rhythm, and quality of breathing will also provide some challenges. Bariatric patients have a decreased lung capacity and, as a result of the increased body mass index, a lower oxygen reserve. These deficiencies mean that you should be more prepared for a significant decrease in respiratory capacity during the call. (2)
If respiratory distress becomes significant enough to warrant bagging, ensure that you have a proper mask-to-face seal, which can be hindered by the soft tissue and skin along the neck and jaw line. As a result, use a two-person bagging technique; it allows for a more effective seal, closer observation, and effective ventilation.
After assessing your patient’s CABs, you find the following:
- The airway is open.
- The patient is experiencing labored breathing with audible wheezing.
- The patient has a weak, palpable, radial pulse.
- The patient’s vital signs are beats per minute (BP), 190/94; Pulse, 110; Respirations, 26 (labored, rapid, with audible wheezing); and skin is flushed, warm, and sweating.
You’ve also determined that your patient has a history of angina, high blood pressure, and asthma. The patient has prescriptions for both nitroglycerine and albuterol. You place the patient on 10 liters by nonrebreather mask and begin determining the best way to transport.
From your initial scene size-up, there is an immediate need to determine the additional resources you require to safely move the patient from the residence to the ambulance, and then from the ambulance to the hospital. You have to consider not only whether additional staffing is needed to lift the patient but also whether or not your equipment is rated to handle the patient’s weight.
Patient movement equipment. Recognizing the increased size of Americans, many manufacturers have created (or are creating) devices for obese patients to assist the medical crew in providing a safer transport. HoverTech, Stryker, and Ferno have all developed transfer and transportation devices designed to assist in moving the bariatric patient, whether from the floor to the bed, from the bed to the stretcher, or from the stretcher to the hospital bed.
These devices are designed to handle the weight of the patient or provide assistance in the transfer of the patient from one location to another while requiring less physical lift assistance by the providers. Some of these devices rely on air to assist in movement; others just provide a smooth surface (to decrease resistance) for moving the patient. This equipment is often rated to assist in moving patients weighing between 800 and 1,600 pounds; some devices have no weight limits.
Following are a list of some devices and their purposes:
- HoverJack® (HoverTech International) is a patient-lift device that uses air to move patients from the floor to a bed or stretcher through a series of inflatable cushions that lift the patient to the desired height.
- HoverMatt® (HoverTech International, photo 1) is an air-based lateral transfer and patient-positioning device. There is no weight limit for this device; it uses handles for easier transfer.
- Transfer-Flat (Stryker) and MegaMover Plus (Graham Medical) are transferring devices for moving patients to stretchers or beds. Their maximum weight limits are 1,600 and 1,500 pounds, respectively.
|Photo courtesy of HoverTech International.|
Transport vehicles. Additionally, recognizing that standard ambulances are not weighted or prepared to handle transporting an obese patient, ambulance manufacturers have put together specifications for bariatric ambulances, which are designed to keep the patient and EMS provider safe during the transport of an obese patient. Table 2 provides a few features recommended for bariatric ambulances.
Regardless of the equipment made available, you should consider almost immediately on arrival the need for additional personnel. All of the latest equipment provides only assistance in moving the bariatric patient. Additional personnel help ensure that movement is done safely and with minimal chance of injury to the patient or the EMS providers. During your scene size-up, you should have recognized the need for additional personnel and made the request for assistance early on. Delaying the request for help delays transport. Also, remember that when considering the weight to be lifted, you must factor your stretcher and any other equipment into the total weight. This may increase the weight up to 50 pounds or more!
With the assistance of an engine crew, you have placed your patient in a seated position on the stretcher and moved her into your ambulance. Before they leave, you remind the engine crew members that you will need their assistance moving the patient into the hospital and request that they follow you. As you climb into the driver’s seat, you remind your partner to let the hospital know the special circumstances and the potential need for specialized equipment. With that, you begin your drive to the hospital.
All patients, regardless of gender, race, or size, will have specific and widely different concerns affecting your ability to care for them. Regardless of the issues you face, the key is to ensure that you provide high-quality care with appropriate respect for the patients and their dignity.
1. Flegal, KM, Carroll MD, Ogden CL, et al. Prevalence and Trends in Obesity Among U.S. Adults, 1999-2008. 2010, Jan 13. Retrieved July 18, 2011, from http://jama.ama-assn.org/content/303/3/235.full?ijkey=ijKHq6YbJn3Oo&keytype=ref&siteid=amajnls.
2. Long W, McGary B, Jauch E. EMS challenges with bariatric patients: Treatment and techniques. 2011, Jul 5. Retrieved September 14, 2011, from www.carolinafirejournal.com/articles/article-detail/articleid/1586/ems-challenges-with-bariatric-patients.aspx.
3. Admin. EMS and obese patients. 2009, Sept. 9. Retrieved September 14, 2011, from http://buyempblog.com/2009/09/ems-and-obese-patients.
4. University of Washington Hospitals and Clinics. Preventing EMS injury associated with bariatric transport. 2009. Retrieved September 18, 2011, from www.uwhealth.org/files/uwhealth/docs/pdf/Level_One_Spring_09.pdf.
KAREN OWENS is the emergency operations assistant manager for the Virginia Office of EMS, where she has been employed since 2001. She oversees the Emergency Operations Training programs including MCI Management, Terrorism Awareness, and Vehicle Rescue. Owens has a BA in psychology and an MA in public safety leadership. She is a Virginia-certified firefighter and has been a Virginia EMT-B instructor since 2002. She authored Incident Command for EMS (Fire Engineering).
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