Heavy Subjects

Delivery of emergency care to obese patients

 

 
 
 

James J. Augustine, MD | | Friday, January 30, 2009


An EMS unit receives a call to evaluate an ill person. On arrival, the crew finds a man in a third-floor bedroom of a big home. His complaint is shortness of breath, and he's noted to be a very large patient, lying on a very large bed. He's unable to move out of the bedroom, stating his size does not allow him to move through the doorway. He has bathroom access through a doorway that has been crudely widened by carving out one side of the door frame. He says he has no known medical problems but adds that he hasn't seen a physician in about 30 years. A family member is in the house with the patient and verifies his history.

On physical exam, the patient is found warm and diaphoretic. His respirations are labored at 40/min, pulse at 56/min, pulse oximetry reading is 82%. He's placed on 100% oxygen via non-rebreather mask, and his pulse oximetry reading increases to 90%. The crew asks him if he usually rests flat on the bed. He states that a family member had suggested he lie flat, but that position seems to have worsened his breathing. The patient is assisted to a 45_ upright position, and his pulse oximetry increases to 100%. He denies chest pain, nausea, vomiting or syncope. He is on no medications and has no allergies. He says his family brings him food and water during the day.

The physical exam is remarkable for his large size, but the patient doesn't know his weight. The crew estimates his weight to be more than 600 lbs. He has no signs of trauma. His legs are swollen more than would be proportional to his size. He has a rash on his lower right leg, but no other skin ulcers. His neurologic status is intact.

The assessment of this patient indicates he's at high risk for infections, cardiac disease and pulmonary embolism. His respiratory effort has been stabilized by placing him in a more upright position and giving him supplemental oxygen. The patient has already stated that he's too large to fit through the doorway, and he feels too ill to ambulate on his own. The crew now faces a decision regarding treatment and transportation.

Heavier Patients

We've all heard, read and seen the statistics: A significant percentage of the U.S. population is now obeseƒmore than 60 million people, according to the CDC.

How is obesity defined? The original definition of morbid obesity was any individual who was greater than or equal to twice their ideal body weight, or greater than or equal to 100 lbs. above their ideal body weight as determined by the 1983 Height and Weight Standards of the Metropolitan Life Insurance Company.

The current definition of obesity is based on body mass index (BMI) as presented in thePractical Guide to the Identification, Evaluation and Treatment of Overweight and Obesity in Adults,a joint publication of the National Institutes of Health National Heart, Lung, and Blood Institute, and the North American Association for the Study of Obesity.

Body mass index compares body weight (in kg) to height (in meters)ƒBMI = weight/height2. ˙NormalÓ values are less than 24.9 kg/m2, and ˙overweightÓ individuals have a BMI between 25 and 29.9 kg/m2. ˙ObeseÓ patients are placed in three classes: Class 1 = BMI 30-34.9 kg/m2, Class 2 = BMI 35-39.9 kg/m2, and the ˙Morbidly ObeseÓ Class 3 = BMI = 40 kg/m2. In emergency response systems, a morbidly obese patient is generally one with a weight in excess of 350-400 lbs. over the recommended weight.

Management of these very large patients is one of the complex challenges EMS providers might encounter. Several key questions arise in such situations. Do we have the proper equipment? Do we have the appropriate manpower available? How can we respect these patients' needs and sensitivities? How do we balance patient-care needs, moving and transport issues, efficiency, effectiveness, and personnel safety?

Current literature offers little in the way of guidelines for emergency personnel caring for obese patients, so an innovative plan is needed. First, it's imperative that emergency department (ED) staff and EMS providers understand the high-risk nature of the care and transport of these individuals. Obese patients have the right to expect professional and prompt emergency care, and providers have the obligation to deliver such care without risking their own health.

It's critical for EMS agencies to ensure a safe work environment and mitigate the health risks to providers who lift, transport and care for large patients. Thus, developing and initiating policies and procedures for the emergency management of these patients is of the utmost importance.

Operating Priorities

Like other complex emergency patient encounters, management of the very large patient has emergency care priorities: Serve the patient with the right process, in the right place and time, utilizing principles that are patient safe and effective, and in a delivery method safe for the provider.

For cases in which a group of expected service interactions by anEMS agency requires these principles to be managed simultaneously, development of operating protocols and policies is also required. The management of the very large patient is one of a small set of patient encounters in which management principles must also consider what service is equitable, and have a cost/benefit ratio that is appropriate.

To provide patient- and provider-safe care for the morbidly obese patient, the service must have access to appropriate equipment and supplies to assess the patient and provide care. Services should consider engineering controls to ensure the safety of the emergency care and patient movement process.

For initial assessment of the patient, large blood pressure cuffs will be necessary. Several versions of extra-large cuffs now exist, with some extra long and some of larger diameter. The recommended size of the cuff is roughly two-thirds of the upper arm, and with a large enough diameter for the cuff to maintain closure using its own Velcro_ strips. For some patients, auscultation through a very large arm is not successful, and a Doppler sound probe may be needed to obtain a systolic blood pressure.

Consider that dosages of emergency medications may need to be adjusted for size, and if this is an important consideration, medical control may be needed for advice and orders. If intramuscular (IM) medication is ordered, long-length IM needles will be needed to deliver that medication in the appropriate site. The same consideration will be needed to perform a needle decompression of the chest.

The movement of a very large patient, on scene and in a vehicle, will need consideration for safety and patient comfort. If the patient is to be moved in a public area, the modesty of the person must be maintained. If the patient's own clothing isn't available or must be removed, a large patient gown should be available, in addition to sheets or blankets to cover them.

Stabilizing the spine of a large patient will require atypical use of packaging equipment. Because cervical collars often don't fit very large patients well, immobilization may need to be accomplished with large bulky objects placed on the sides of the head and fastened securely to the backboard. A standard-size single backboard may not be big enough to move the patient or allow an adequate number of rescuers to participate in lifting. Some manufacturers offer large backboards and lifting devices made of special textiles that are useful as an appropriate transfer device. In certain cases, the patient can be stabilized on two backboards secured together. A crisscross stack of backboards and plywood may also be used.

Lifting must be done with proper personnel and body mechanics to ensure rescuer safety. A minimum of four physically fit personnel are required to lift any of these larger patients, particularly in situations where a lift and rotate procedure is needed (removal from a vehicle following an accident). The maximum load capacity of the cot must accommodate the patient, and the manufacturer's safety guidelines must be known and followed. Many services place this maximum weight on the cart itself.

The large patient should always be loaded onto the cot in the down position with the cot kept in this position at all times. Enough rescuers must then be available to lift and place the cot in the transporting vehicle, and then available again when unloading the cot at the health-care facility. If lift-assist devices are available and the providers are trained on them, they should be used.

Once in the ambulance, an immobilized and very large patient may need to be rotated, should they have a risk of vomiting. Sufficient personnel, with enough strength to accomplish this maneuver safely, must be present; suction alone is not enough.

In some situations, extremely large patients have required extrications from homes or apartments, and there are simply no methods to accomplish this with rescuers alone. Services have called for assistance from cranes, mechanical lifts, airport hydraulic food-service vehicles and forklifts to provide the necessary movement capability. Anecdotally, this has also included incidents in which the patient had expired and personnel from the medical examiner's office cannot safely manage the movement of the deceased.

Structural modification may need to be performed, including building ramps, widening doorways or opening walls to accomplish the removal. (Patient extrication from particular types of scenes is further discussed in the sidebar on p. 76.)

Calling for Assistance

In certain cases, patient removal and transportation may be extremely expensive and risky. In such situations, at the point when Incident Command (IC) is evaluating removal options for the patient that are risky to providers, calling medical control to request a physician or physician extender to the scene should be considered.

Making such a request typically involves four factors: 1) The patient is very large; 2) removal from the home environment will require structure modification and/or risk to the emergency personnel to perform; 3) the medical condition is one that could be managed without immediate removal to an ED; and 4) the home environment is compatible with the possibility of the patient remaining there.

It's clearly an option to request on-scene medical direction when the very large patient is in cardiac arrest and removal will be dangerous forEMS personnel. In these situations, the risk/benefit ratio of removing a patient with no expected benefit from emergency removal will swing the IC decision toward bringing care to the scene. If resuscitative efforts are successful, then removal plans can be engaged. If resuscitative efforts are not successful, the patient can be pronounced dead and appropriate medical contacts made.

In such a case, rescuers will then need to communicate with the medical examiner's authority to plan for safe removal to an appropriate site (e.g., funeral home, medical examiner's office or the morgue) for the deceased. This plan needs to be implemented in careful communication with the family. The medical examiner's office frequently has less equipment than the emergency service, so IC may need to make those same tactical decisions about moving the body out of the building. This is where building modification and the use of lifts or cranes may need to occur.

In situations in which removal will take place, transport decisions will be made by IC and the leadEMS person. They will have to consider how to prioritize the need for patient care and transportation. For the very large patient with a longer path to the ambulance, a safety officer should be appointed, and that individual should have no patient care or lifting responsibilities. This person must be solely dedicated to evaluating the work of the rescuers and making decisions regarding the safety of the operation.

Is the Hospital Prepared?

The next decision with regard to transportation is destination. Personnel will need to determine the correct hospital for the patient's care and make timely communication with that center. The destination transport decision should include the determination about which hospital has a bariatric service and which hospital has a large CT scan for diseases that may require that service.

An early consideration is to contact medical control or the destination hospital regarding patient status, so that preparations can be made prior to the patient's arrival. When that communication is made, theEMS provider must remember to consider patients' sensitivities concerning their health and status. Use appropriate language when discussing any patient, particularly those who have a condition that may be embarrassing to them. The hospital will need to understand the patient's clinical condition, their approximate size, the time allowed for preparation and any considerations for transferring the patient fromEMS equipment to hospital equipment.

Operating Protocol

To be prepared for such calls, the emergency service leadership must develop an appropriate guide for successful management of this patient interaction. It's important to incorporate the discussed elements of patient care into an operating protocol, which should assist the department in avoiding predictable problems.

Very large patients can often be identified inEMS systems via previous calls to the same home, false alarm calls or even police interactions. In such cases, a flag system should identify the resident's special need. When the call to dispatch occurs for the indexed patient, the system might be able to identify the individual and add resources to the initial response.

EMS and fire agencies should also structure programs to avoid patient drops and injured emergency workers. Equipment should be available to match the needs for patient care, including evaluation and treatment supplies. The plan will need to avoid damage to patient care cots by patients too large for stretcher design. Mutual aid providers may have larger capacity stretchers, and even bariatric-capable medic vehicles. These resources should be included in a special needs plan.

A comprehensive incident management plan will give you the option to bring atypical resources to the scene, including medical providers capable of delivering definitive care and alleviating the need to transport the patient. (Agencies that bill for services might consider charging a fee for this special, resource-dependent service.) Bringing a physician or a physician extender with home health support and bedside diagnostics to the scene could also prevent expensive building modification and personnel injury.

In addition, the protocol should emphasize documentation. The special needs of very large patients should be managed in a respectful manner, as with all patient and public interactions. To help avoid patient embarrassment and the potential of anADA claim, the operating protocol and personnel training should include discussions on documenting the professional behavior by which patient management and communications were accomplished.

The Versatile ED

The ED can be a repository for large-body moving equipment in the hospital. In facilities that have bariatric centers, the ED may see a disproportionate number of patients moving into or through that set of services. It's reasonable that a store of bariatric stretchers, wheelchairs and transport assist devices be available in the building to facilitate care and prevent injuries to hospital staff. The ED can be a perfect site to place those specialized items and make them available when needed for a patient in the emergency system.

In addition to movement items, facility modifications may be needed in the ED. Renovations of doorways, stretcher spaces and commodes may be necessary to accommodate larger patients. Some hospitals have purchased small, crane-like lift devices to help move extremely large patients, and those may even require a higher ceiling to accommodate.

The ED clinical practice may also be adapted to the larger patient. Many elements mirror the prehospital essentials: safety for patient and staff, extra-large blood pressure cuffs, larger needles and weight-based medications. Larger gowns will provide modesty for the patient. Some hospitals have been able to add needed diagnostic tools, such as the larger gantries for CT scans and Doppler machines to diagnose deep venous thrombosis. The ED that has these assets should communicate their availability to theEMS agencies in the region, and among the sets of emergency providers, pathways for the management of very large patients should be implemented.

In addition, combined sensitivity training forEMS and ED personnel can improve satisfaction levels and care delivered to the very large patient.

Case Review

The crew evaluated the patient and potential issues with removal. They contacted anEMS supervisor and the service's medical director, who met with the crew on scene. The crew had already met the patient's immediate needs by repositioning the patient and providing supplemental oxygen, so contact was made with the family's primary physician and a consultant at a hospital that had a bariatric service.

The immediate medical issue was cellulitis of the leg, causing the patient to have a fever. He could be treated at the site with IV doses of antibiotics. A home health agency was contacted to provide this service starting that day, and the bariatric service also sent a consultant to the scene.

All agencies conferred and discussed the management options with the patient and his family. It was agreed that his immediate medical needs would be best cared for in the home. He needed bariatric surgery, and the outpatient preparation for that would be done at home. The patient would soon need to go to the hospital for that service, so access to the hospital would need to be arranged using a localEMS agency that had a large patient movement vehicle.

The patient's family had knowledge of a contractor who would modify the interior of the home to get the patient down to the first floor and set up a care area for the patient.

The family was made aware that any emergency needs would be responded to with a call to 9-1-1. The regional 9-1-1 center was instructed to flag the address as having a patient with special needs, in case of a fire or medical emergency.

The patient ultimately recovered from the acute event, and with home health involvement, was prepared for surgery and the trip to the hospital. He was able to ambulate to the transport vehicle at that time, and received the surgery. At the last follow-up, he was doing well and had lost considerable weight.

Summary

Emergency medical providers cannot pick their patients or circumstances; therefore, a systematic plan is needed for all situations.

As the numbers of obese and morbidly obese patients continue to rise in theU.S., it's important for emergency services to initiate and implement safe and effective work practices. The basic steps include the opportunity to obtain equipment and supplies, train the emergency service staff, and develop innovative safety approaches to the care of this group of patients. Many emergency services memorialize this process by developing a protocol, including the provision to add a safety officer to the usual IC procedures.EMS services should be aware of hospitals with special capabilities to manage the extremely obese patient.

Sensitivity to the patient's needs and considerations of appropriate care will satisfy theADA regulatory issue, and more importantly, will allow safe, effective management of this patient population and help ensure provider well-being from the scene to the ED.

Resources

SCENE-SPECIFIC INCIDENT MANAGEMENT

Certain incidents involving obese patients require specific on-scene management to best allocate resources and provide appropriate patient care.

MVCs:Operational flexibility is the critical element. Large patients will typically be able to tell the rescuer how they entered the vehicle, and what exit pattern will likely be the easiest. If at all possible, the patient should assist the rescuers in self-extricating. The most difficult situations occur when the vehicle has been compacted in the collision or the vehicle position after the accident makes the usual exits inaccessible.

The unconscious, severely injured and very large patient in a crushed vehicle presents the greatest difficulty. Your safety officer must make rapid decisions about how to best remove the vehicle from the victim as rapidly as possible, by bending or cutting away the pieces. In some situations, a wrecker must be deployed to help move the vehicle and give better safe access to the victim. Air bags can be used to lift and support portions of the vehicle (or patient) to give better access as well. Ramps or slides can be rapidly made or assembled to allow the patient to be slid out of the vehicle to the stretcher. Ladders, plywood and large-capacity textile sheets can be used to give more rescuers lifting capability, if needed.

In minor accidents, in which the vehicle is still safe and roadworthy but the patient or family requests hospital transport, it may be most appropriate if the vehicle is used to drive the patient to the hospital, keeping an EMT with the patient. This special circumstance is similar to that of transporting a patient in a wheelchair via their specially equipped vehicle rather than the ambulance for safety precautions. The ED physician may be able to clear the spine or even completely evaluate the patient in the vehicle, and then the patient can be asked to assist in self-extricating from the vehicle or be allowed to return home.

House incidents:Unexpected incidents with extremely large persons typically occur in home situations. In some instances, large patients are in homes, group homes, apartments or hotels with routine access and adequate egress. Evaluation can occur with the standard tools, and then egress and transport with weight-capable stretchers. Occasionally, a ramp can be hastily assembled to make short stairs or rises easier to manage.

However, in cases when the large patient has not left the home setting for some time, the access and egress pathways may be limited. If time is on the side of the patient and rescuers, a greater number of options can be considered and special equipment brought in to assist.

When removal is necessary, the patient's life and safety are the first concern and a safety officer must be designated. Renovations of doorways, rails and furnishings can then be performed with this oversight.

If complex extrication is needed, obtain necessary tools and manpower, and request mutual aid assistance. Regional distribution of special equipment and vehicles is likely due to the high costs, and a regional database should be available to ascertain where such resources may be located. The field use of air bags, ramps and even cranes can move the patient safely out of the structure. Doors, windows and walls may also need to be removed to facilitate vertical patient movement. The situation is no different than extrication from a vehicle, although fixed property repair costs may be higher. Once outside the structure, additional equipment may be needed for lifting the patient into the transport vehicle and moving to a hospital.

Extended care facilities:It's common for morbidly obese persons to receive care in extended care facilities. Some facilities may even specialize in the care of very obese patients and thus look after many such residents. Facility personnel should communicate to dispatch that the patient is large enough to require special consideration. If these facilities have special lifts and ramps, they should be used whenever possible to assist in packaging the patient for transport.

James J. Augustine, MD, FACEP,an emergency physician from Atlanta with 26 years' experience as a firefighter and an EMT-A, serves on the clinical faculty in the Department of Emergency Medicine at Emory University in Atlanta. He also serves as medical director for the Atlanta Fire Department, which includes operations at Atlanta Hartsfield Jackson International Airport. He has published numerous articles on emergency services and has participated in national and state leadership activities on emergency and trauma systems.


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Related Topics: Accessories, Extrication and Rescue, Specialty Vehicles, Vehicle Operations, Special Patients, Patient Management

 
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