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Bariatric Patients Pose Weighty Challenges

Bariatrics is the branch of medicine that deals with the causes, prevention and treatment of obesity, and the U.S. has the dubious distinction of having the highest rates of obesity of any developed country in the world. What's even more concerning is the rapid rate at which obesity has grown in a mere 10 years.

In 1995, all 50 states reported to the Centers for Disease Control and Prevention that no more than 20% of their population was considered "obese." But by 2005, only four states could make that claim; 17 states met or exceeded obesity prevalence rates of 25% and three states had obesity rates of 30% or higher.

And the future doesn't look any better. Reviewing federal data taken from surveys in 1976-1980 and 2003-2004, the prevalence rates in children have tripled: ages 2-5 years from 5% to 13.0%; 6-11 years, 6.5% to 18.8%; and 12-19 years, 5.0% to 17.4%. If this trend continues, 50% of the population in some Southern states could be obese within the next five to 10 years.

Obesity has become a leading public health problem for our nation. The myriad of deleterious health effects linked to obesity is too numerous to fully explain in this limited space, but some of the common comorbidities are: congestive heart failure, cardiac dysrythmia/arrhythmia, hypertension, type 2 diabetes, ovarian cysts/cancer, gastrointestinal reflux disease, liver disease, gallstones, colorectal cancer, urinary incontinence, kidney disease, uterine cancer, hyperuricemia (which predisposes to gout), osteoarthritis, stroke, paresthesia, dementia, dyspnea, obstructive sleep apnea and asthma.

Impact on EMS
Your system will be encountering more obese patients in the future, creating new concerns for administrators in the following areas:

Personnel. A recent study by the National Association of EMTs found that 47% of providers had suffered back injuries while performing their duties. If two-person EMS crews are having problems lifting and moving "standard" patients without injuring themselves, they likely will need the help of one or two other crews to lift and move some morbidly obese patients. So EMS administrators must plan for two or three EMS units to be out of the system for a few hours on one such assignment.

Equipment. Do you have the right equipment to move bariatric patients? Can your backboards, Reeves or rolling stretchers handle a patient weighing more than 350 lbs.? In recent years, some manufacturers have developed specially engineered patient-moving systems that include stretchers able to handle weight payloads of up to 800 lbs., air-powered lift systems, polycarbonate ramps and electric winches with automatic braking systems.

Sales of stretchers designed specifically for bariatric patients are expected to almost double from $29.6 million in 2004 to $50 million in 2012, and the sales of specialized lift systems are projected to rise from $75 million to $193 million.

Ambulances. Obviously, a larger ambulance may be necessary to safely transport larger patients while maintaining their dignity. Gone are the days when loading a patient on a piece of plywood in a pick-up truck was considered a reasonable alternative. Bariatric units usually include both customized stretchers and modified suspension/loading systems, with some now including a ramp-and-winch system as well.

Finances. Of course, additional personnel, specialized equipment and vehicles will affect your bottom line. Purchase of a bariatric ambulance with all the bells and whistles could run as high as $250,000. Retrofitting an existing ambulance with a ramp and winch could cost roughly $5,000 (without the stretcher). For smaller EMS services, absorbing the costs to provide this type of service can be economically unrealistic.

Solutions„Some large ambulance services recognized early in this decade that outfitting their systems with the equipment needed to handle bariatric patients was an investment in safety for both their employees and patients. But there are ways for small- and medium-sized EMS systems and services to help this patient population without breaking the bank. The simplest and most crucial steps are to establish clear company policies and offer a pre-planning for your staff.

Every agency should at a minimum:

  • Address concerns on the handling of patients at various weight limits;
  • Identify patient-movement strategies and set limits on the minimum number of people required to move a patient over a specified weight; and
  • Require staff to request lift assistance when confronted with a patient who exceeds the lifting limits of the crew on scene.
  • EMS systems should consider creating a special response unit that could be shared as a regional resource. Instead of purchasing an ambulance already equipped for bariatric patients, a more cost-effective solution might be to equip a trailer with such supplemental items as:
  • Heavy-rated basket or scoop stretchers lined with layers of blankets to be used as cushions and additional padding to elevate the patient's head;
  • Expandable/connectable flats made from extra-heavy-duty materials for the oversized patient;
  • Ramps for sliding a heavy patient (with a minimum amount of lifting) out of a building and/or into and out of the ambulance; and„
  • Equipment for securing the Stokes or stretcher to the ambulance floor.„

Conduct periodic trainings on bariatric transports, including new strategies for moving morbidly obese patients in both emergency and non-emergency situations. This type of exercise should also include fire and police agencies if they are used to augment EMS staff in your community.

Encourage your staff to improve your bariatric operations by providing ways for them to offer (and for management to consider) problem-solving suggestions.

Heavy Responsibilities
Beyond their medical challenges, bariatric patients' encounters with EMS serve as an operational challenge as well, requiring EMS administrators to consider multiple facets of their system, including crew configuration, equipment and ambulance design. Administrators must assess their systems and circumstances and review financial and operations realities prior to purchasing equipment, training personnel, establishing policy and working with other services. However, one element must be central in every equation: the patient. EMS administrators should constantly remind staff to remain nonjudgmental and insist they display professional decorum when handling every bariatric patient.

Raphael M. Barishansky, MPH, is executive director of the Hudson Valley Regional EMS Council in Newburgh, N.Y., and a frequent contributor to various EMS publications.

Katherine E. O'Connor, BS, EMT-P, is program coordinator for the Westchester Regional EMS Council in Valhalla, N.Y., and has been an EMS provider and educator for 16 years. 


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