Obesity: The Bariatric Challenge: Obesity: The Bariatric Challenge Chad S Lewis, MD Emergency Medicine Resident Albany Medical Center


Obesity Defined: Obesity Defined Condition of an excessive proportion of adipose tissue to total body weight Prevalence doubled over last 20 years and still increasing Some estimates are half of all adults are considered to be overweight Worldwide estimates 1.1 billion overweight people with 250 million are classified as obese Body mass index (BMI) used as a measurement


Epidemic Proportions: US 1991 through 1998 : Epidemic Proportions: US 1991 through 1998 Percentage of obese men doubled Percentage of obese women increased by 50% More than 31% of adults in the US are obese More than 64% of Americans are overweight


Pathophysiology: Pathophysiology High caloric intake Low level of physical activity Low level of metabolism High insulin sensitivity? Lack of anti-obesity hormone?


BMI weight and height: BMI weight and height 25 to 29.9 kg/m2: overweight 30 to 34.9 kg/m2: obese (class I obesity) 35 to 39.9 kg/m2: moderately obese (class II obesity) 40 to 49.9 kg/m2: severely obese (class III obesity) andgt;50.0 kg/m2: super morbidly obese (class IV obesity)


Higher risk: Higher risk Heart disease Diabetes Hypertension Stroke Osteoarthritis Kidney disease/stones Psychiatric issues Impaired body image Depression Loss of self esteem


Heart Disease: Heart Disease Overall increase in both morbidity and mortality Coronary artery disease Atherosclerosis and hyperlipidemia Hypertension CHF Sudden cardiac death Peripheral vascular disease As weight increases risks get higher


Pulmonary Problems: Pulmonary Problems Decrease in lung volumes Increased work of breathing Higher airway resistance Higher chest wall Decreased respiratory system compliance Flattened diaphragms Altered lung volumes Increased energy cost of breathing


Pulmonary Problems: Pulmonary Problems Pulmonary hypertension secondary to: Hypoxia Pulmonary vasoconstriction Depressed heart function


Obesity-hypoventilation syndrome: Pickwickian syndrome: Obesity-hypoventilation syndrome: Pickwickian syndrome 5% -- 10% of morbidly obese Left and right sided heart failure common Obstructive sleep apnea Hypoxia Hypercapnia Marked daytime somnolence Chronic respiratory acidosis


Cancer Mortality: Cancer Mortality Men: Stomach Prostate Women: Breast Uterus Cervix Ovary


Obstetrics and Gynecology: Obstetrics and Gynecology Female infertility Disrupted menstruation and ovulation Early menstruation Urinary incontinence Abnormal labor Increased progression to Cesarean section Increased fetal size Pre-eclampsia and eclampsia Gestational diabetes


Obesity and Trauma: Obesity and Trauma Premorbid risk factor Interference with activities of daily living Displaced ankle and elbow fractures with minimal trauma Less likely to wear seat belts Subcutaneous fat hides physical findings


Obesity and Trauma: Obesity and Trauma Head injury protection in blunt trauma Higher incidence chest injuries Physiologic airbag Rib fractures Pulmonary contusions Higher mortality due to respiratory causes Higher incidence of pelvic fractures


Prehospital Challenges: Prehospital Challenges Delays due to problems in moving and transport Appropriate sized gurneys Excessive tissue impeding access for giving fluids, taking BP Mobilization of manpower Managing airways Pulse oximetry


Airway: Airway Difficulties with intubation and BVM Preoxygenation is critical Desaturation is quicker Sitting upright or semirecumbent as long as possible Reduced pulmonary compliance Higher ventilatory pressures May need to occlude pop-off valve to ventilate Brazilian Journal of Anesthesiology, 2005; 55: 2: 256-260 Tracheal Intubation of Morbidly Obese Patients: A Useful Device Ricardo Francisco Simoni


Assessment of Airway: Assessment of Airway


Airway Techniques: Airway Techniques Rolled towels or blankets between scapula Displaces breast tissue Chest wall can obstruct handle under the occiput Allows for sniffing position Creates more space for the handle Shorter than average handle Adjustable angle laryngoscope Brazilian Journal of Anesthesiology, 2005; 55: 2: 256-260 Tracheal Intubation of Morbidly Obese Patients: A Useful Device Ricardo Francisco Simoni


Alternate Airways: Alternate Airways Awake oral intubation Blind nasotracheal intubation LMA Esophageal-tracheal double lumen Cricothyrotomy


Anticipate airway difficulty: Anticipate airway difficulty Awake techniques if possible   pre oxygenate in reverse Trendelenburg position for RSI consider increased dose of meds LMA has increased risk for aspiration Neck anatomy distorted due to excess tissue


Sphygmomanometry: Sphygmomanometry Inadequate width and circumference can artificially elevate blood pressure Cuff width to arm circumference Ratio of 2 : 5 Bladder length 80% arm circumference Important to have variety of cuffs


Pulse Oximetry: Pulse Oximetry Tissue thickness impedes light wave transmission Other areas of placement Earlobe Fifth digit of hand or foot Nose Lip Temporal artery


Venous Access: Venous Access Landmark vessels not visualized or palpated Multiple attempts Delay in access Higher complication rates Secondary to multiple sticks Wound infections Phlebitis Thrombosis Standard 1.5-in needles not long enough 3-4-in needles and catheters preferred


Improving Chances at Venous Access: Improving Chances at Venous Access Applying heat Light tapping over vessels Active or passive pumping of extremity Topical nitroglycerin* Intraosseous Reactive Hyperemia Occlude with BP cuff 3-4 minutes Release 10-15 mmHg below diastolic


ECG Difficulties: ECG Difficulties Difficult landmarks for lead placement Decreased or inconsistent voltage Increased fat deposits around the heart Flat/inverted T waves inferior leads Consistent change in obesity Non-specific


ECG Differences: ECG Differences ECGs of 100 obese subjects and 100 normal subjects no evidence of cardiac disease P, QRS, and T wave axes were more leftward More LVH left atrial abnormality and T wave flattening in the inferior and lateral leads Prolonged QT interval Alpert et al American Journal Cardiology 2000


EMS Challenges: EMS Challenges transporting people in a manner that is as safe as possible both for the personnel and their patients, as well as in a respectful manner 2000-2001 injuries related to transferring and handling of patients represented at least 50% of Workers’ Compensation annual costs. 2 or 3 people are available to move a patient from one spot to another Just one injury could mean the end to an EMT or paramedic’s career transporting people in a manner that is as safe as possible both for the personnel and their patients, as well as in a respectful manner Transporting the Morbidly Obese Patient: Framing an EMS Challenge Journal of Emergency Nursing August 2002


Meeting the Challenge: Meeting the Challenge EMS providers must conduct pre-planning exercises to prepare for attending to special situations. Experts advocate for the following: creation of policy and procedures pre-training continuing education request for lift assistance community involvement use of equipment that helps patients without harming workers. Even with the best intentions, treating and transporting morbidly obese patients will take more time than almost any other type of call to which EMS responds Transporting the Morbidly Obese Patient: Framing an EMS Challenge Journal of Emergency Nursing August 2002


Current Education: Current Education EMT Paramedic Curriculum minimally covers obese patients teaching that accommodations may be necessary Need to use appropriately sized diagnostic devices Maintain professionalism Notes that the paramedic may require additional assistance


Provider Challenges: Provider Challenges Logistics Labor intensive Equipment unaccommodating Securing antler must be dismantled Transport from ambulance floor Unsafe transports Undignified transports Medication requirements Bias


Safety in equipment: Safety in equipment A standard box-shaped ambulance 40- to 44-inch width inside of the patient compartment crash tested and rated for a payload max 1600 pounds Patient weighing 700 pounds can measure 50 to 55 inches wide 2 or 3 health care providers needed to care for the patient could together weigh 600 pounds Little room is left for the equipment and supplies required.


FDNY Guidelines: FDNY Guidelines Paramedic unit is called to the scene to determine: Patient’s condition If removal is emergent/life threatening or non-emergent If patient can be treated at the scene or must be moved to the hospital


FDNY Guidelines: FDNY Guidelines Removal considerations How to be packaged Stokes stretcher Body bag Method Carry drag Lower Ropes or slings Removal route to ambulance Need for additional resources Collapse unit Forklift Flatbed truck


Obstacles in Transport: Obstacles in Transport Removing the patient from the scene Packaging and transferring Moving to the ambulance Transportation Preplanning


Challenges of Removal: Challenges of Removal Non-mobile patients Patients unable to fit through doorway Solution can be in removal of walls or windows Requires heavy rescue equipment Rescuers with engineering/construction experience Can lead to building collapse Risk of injury to patient and crew


Transferring: Transferring Standard backboard Patient may not fit Board unable to support weight Rescuers must grasp and maintain board, lift carry and maneuver in sync Must lift from ground level to waist Restricts breathing from prolonged period of lying flat


Transferring: Transferring Options to the standard backboard Specialized backboards Basket stretchers Reeves stretchers Warehouse style carts


Creating Company Policy: Creating Company Policy Address the concerns identifies strategies sets limits on how few people may attempt to move a patient over a specified weight. Ensure policy that personnel call for lift assistance when confronted with a patient who exceeds the lifting limits of the crew on scene.


Creating Company Policy: Creating Company Policy Provide routine training that includes new strategies for morbidly obese patients in both emergency and non-emergency situations. Ensure pre-planning among responders and the community Remind all providers to remain non-judgmental Problem-solving suggestions given by providers for consideration


Company Policy: Company Policy Obtain proper equipment that is reasonably priced Heavy rated stokes baskets or scoop stretchers lined with layers of blankets to be used as cushion additional padding to elevate the patient’s head Expandable/connectable flats made from extra heavy-duty materials for the oversized patient Equipment for securing the apparatus to the floor of the ambulance Ramps used to slide the patient, with the least amount of lifting, during egress from a building and/or loading into and out of the ambulance


Various Response Methods used by EMS agencies: Various Response Methods used by EMS agencies Patients that are too heavy for a 2-person medic unit can request fire department MAN-S.A.C. rated at 1600 lbs. Heavy duty collapsible litters rated at 600 lbs. Dispatching trucks with additional personnel for lifting Flagged address so initial responses include extra crews if available Hold-harmless contracts if patient exceeds rated capacity of the stretcher


Proflexx with LBS: Proflexx with LBS


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More Questions than Answers: More Questions than Answers Is there a demand for a stretcher that could carry persons in excess of 500 lb? Would a larger stretcher require a larger ambulance? Would a larger stretcher require a different securing/locking device?


Many More Questions than Answers: Many More Questions than Answers Would a larger ambulance stretcher allow enough room to provide patient care? Are there federal or state regulations requiring mandatory transport of the morbidly obese patient? What liability exposure the provider has when transporting a morbidly obese patient in an ambulance that cannot secure the transporting device to the vehicle?


Some Helpful Pointers: Some Helpful Pointers Size-up building, check stairs and other escape routes Think outside the box Don’t exceed equipment ratings Know cot capacity and weight limits Appoint safety officer not working on the rescue to oversee health and safety issues


Best Practices: Best Practices Non-emergent transport Ascertain patient size Schedule crew appropriately Size up the scene Know patient’s weight Match crew capability with task Call for assistance before needed


More Helpful Tips: More Helpful Tips Treat patient with dignity Establish a system Write protocols Practice runs Assigned staff member to specialize in bariatric transfers Locate obese patients, preplan for future plans to each patients house Evaluate patient mobility prior to transport


More Helpful Tips: More Helpful Tips Scene assessment Door width Steps Vehicle placement so terrain works in your favor Personnel Have a back-up plan Cot designed to hold patients specific weight