Beyond the Basics: Bariatric Emergencies

CEU Review Form Bariatric Emergencies (PDF)Valid until October 5, 2007

Case Study
     You are finishing an uneventful 12-hour shift with your local EMS company. So far, you've only had two BLS transports to the emergency department. As you watch TV, the radio squelches out, "Medic 12, respond to 1020 Elm St. for a 32-year-old male with difficulty breathing." While responding, you begin to contemplate potential etiologies for respiratory distress in a 32-year-old. Being it's mid-summer, you consider seasonal causes like anaphylaxis, extrinsic asthma or exacerbation of congestive heart failure due to the increased humidity and temperature. As you arrive in a seemingly safe middle-class neighborhood and exit the squad, a female approaches the ambulance from the house, frantically waving her arms and yelling, "I don't think he's breathing." At the patient's side, your initial assessment yields a 32-year-old male in obvious respiratory distress, with shallow irregular respirations at 14 per minute. It is readily evident that his breathing is inadequate, as there are no vesicular breath sounds, his skin is dusky blue, and the pulse oximeter yields 84% on room air. Your partner begins assisting the patient's breathing with a bag-valve mask attached to 100% oxygen as you continue your assessment. After completing the initial assessment and a rapid medical assessment, you obtain vitals: BP 130/68, pulse 104 and regular, and a modest elevation in the pulse oximeter reading.

     You ask the family about the SAMPLE history and learn that the patient was released from the hospital four days ago after bariatric surgery. He is also an insulin-dependent diabetic with hypertension. Ongoing ventilatory assistance only produces breath sounds in the upper lobes, with minimal to absent breath sounds in the middle and lower lung fields. A blood glucose level obtained after the IV start is 44 mg/dl. Per protocol, you administer 25 grams of dextrose and continue assisting the patient's respirations while preparing to transport to the local hospital.

     With a short transport time of only two minutes and backup not yet on scene, you decide to depart the scene while you continue BVM assistance and radio your report to the receiving facility. The physician and staff are ready when you wheel the patient into the emergency department. After assuming care from you, they begin to assess the patient, whose vitals are now: BP 132/88; pulse rate 104 and irregular; pulse ox 92%. The cardiac monitor shows sinus tachycardia with occasional premature atrial contractions, and the patient's temperature is noted as 101.3°F.

     The physician prepares intubation equipment while the respiratory therapist places a Bi-PAP face mask on the patient, draws an ABG and orders a portable chest x-ray. The x-ray is displayed on the digital monitor in the room. Looking at the film you wonder how and why a 32-year- old is in heart failure, as evidenced by bronchial congestion and what appears to be pulmonary edema in the lower lung fields extending into the midvesicular region. Before you can ask the doc any questions about the patient and your interpretation of his chest film, your portable alerts you to another Code 3 call.

The Obesity Imperative
     The U.S. Department of Health and Human Services has recognized obesity as a "neglected health problem." Obesity is defined by body mass index (BMI) of 30 kg/meter2. BMI is a calculation that takes into account the patient's height and weight, which allows for fluctuations due to the patient's body size instead of establishing a one size/weight formula to fit all. According to this formula, a person is overweight if his/her BMI is between 25 and 29.9 kg/meter². There is also a BMI scale for adolescents and pediatrics, taking into account their physical stature.

     Since the mid-1980s, government programs have attempted to reduce weight in children and teens by increasing physical activity in schools and reducing the amount of junk food available to youth. The initiative is aimed at trying to prevent obesity at a younger age. The physical and emotional problems associated with obesity are important concerns; however, the morbidity and mortality associated with this disease are readily recognized by all healthcare practitioners. Some major disease states that are often caused by or associated with weight gain are diabetes mellitus, hypertension, coronary heart disease, obstructive sleep apnea, dyslipidemia, nonalcoholic fatty liver disease and depression. Table 1 details the effects of excess weight on major body organ systems.

Combating Obesity
     Since obesity has been recognized as the second-leading cause of preventable deaths in the United States, public and private entities have spearheaded a number of treatment strategies in an attempt to stifle the growing increase in obesity. More than $80 billion in public and private healthcare money is spent each year to combat obesity and its associated disease states. Treatment plans include numerous diets, herbal supplements, medications and surgical procedures endorsed by the National Institutes of Health in 1991.

     Bariatric surgery, the focus of this article, is a prevalent and popular treatment for patients who are classified as morbidly obese (BMI between 40-49.9 kg/meter²). There are four common surgical procedures that can be divided into two broad categories: restrictive surgical procedures, or procedures that result in malabsorption of food and water. In order to be considered for a surgical procedure, the patient must be classified as morbidly obese and have one or more of the previously discussed comorbidities. Even when the patient fits these criteria, surgery is still not the first option. Initially, patients must complete a battery of psychological and physiological testing to be cleared for surgery. Psychological counseling is focused on lifestyle modifications that need to be made both before and after surgery. Most physicians require patients to enter into a structured diet program to prove they cannot satisfactorily lose the weight but can demonstrate the willpower to follow through with necessary lifestyle modifications after surgery. Physiological testing is performed to determine if the patient is stable enough to endure surgery. Physiologic testing may include a cardiac stress test, diagnostic heart catheterization, pulmonary function test, diabetes testing, endocrine testing and others. After the patient has completed this first step, the surgeon decides what type of surgical procedure to perform.

Types Of Surgical Procedures
     Restrictive surgical procedures include the adjustable-banded gastroplasty (ABG), currently one of the most popular techniques. It can be performed laparoscopically, which decreases the potential complications often associated with opening the abdominal cavity. The surgery involves placing an inflatable cuff (resembling a rubber band) around the cardiac region (upper portion) of the stomach and connecting it to a reservoir that is placed subcutaneously in the abdominal wall. The reservoir can be injected with saline to increase the pressure exerted by the band and cause a feeling of "fullness," which should result in decreased calorie intake. A subtype of this procedure is a vertical-banded gastroplasty, which can also be performed laparoscopically. This procedure involves stapling a portion of the patient's stomach closed and banding the remaining portion, resulting in the same feeling of fullness after only a few bites of food.

     Malabsorption surgical procedures are more complicated, as they involve opening the abdominal cavity. Opening the abdomen is required because the procedure(s) involve dissecting the normal GI tract and rerouting the stomach and a portion of the small intestines. The most common procedure is the Roux-en-Y bypass, which involves partitioning off a small portion of the stomach by stapling and connecting (anastomosing) it to the distal jejunum. By rerouting the GI tract, any oral intake rapidly passes through to the lower small intestine and large intestine without much chance of being absorbed. There are a number of variations of this procedure involving different sites of anastomosing to the jejunum, various lengths of jejunum used, and pouch size created by stapling the stomach. Other types of malabsorptive surgical procedures include the biliopancreatic diversion and biliopancreatic diversion with a duodenal switch. In a biliopancreatic diversion, a portion of the stomach is removed and the remaining portion is connected to the lower portion of the small intestine. In a biliopancreatic diversion with a duodenal switch, a smaller portion of the stomach is removed and the remaining stomach is still attached to the duodenum (the upper part of the small intestine). The duodenum is connected to the lower part of the small intestine.

     Although numerous types of surgical and nonsurgical procedures have been used (with varying degrees of success) in the management of obese patients, the common theme with all is minimizing the patient's food intake or minimizing absorption through the gastrointestinal tract.

     Despite the goal of restricting caloric intake, another issue occurs as a result of these procedures. Absorption of other necessary nutrients and vitamins needed by the body is minimized. To combat this, the patient with bariatric surgery will remain on various dietary supplements for the rest of his/her life.

Prehospital Considerations
     When an emergency occurs, assessment of the bariatric surgical patient follows a typical medical assessment format. After completing the scene size-up and taking BSI precautions, evaluate the patient's mental status, airway patency, breathing mechanics and circulation adequacy in accordance with the initial assessment. Although bariatric surgery does not involve manipulation or removal of respiratory structures, the patient's body habitus can present a challenging situation for all EMS providers. Obese patients may have "extra" skin and adipose tissue around the face, bottom of the chin, neck and on the posterior surface of the upper thorax. When the patient is standing or sitting forward, the extra tissue usually doesn't interfere with normal respiratory function; however, when the patient is placed in a supine position, problems can develop. Extra adipose tissue in the cheeks, lower jaw and anterior neck place pressure on the tongue and on vital airway structures, including the glottic opening and trachea. Additional airway closure can result from the "fat pad" or "buffalo hump" sometimes seen between the patient's shoulder blades. Partial obstruction of the glottic opening is clinically recognized by the diagnosis of obstructive sleep apnea. Patients may be undiagnosed or unable to remember the medical terminology, so you should ask if they wear CPAP or BiPAP devices to sleep, or if they snore when they sleep.

     Airway occlusion can be prevented by proper positioning of the patient. If the patient is conscious, allow him to assume a position of comfort-usually sitting upright or in a slightly reclined position. If the patient is obtunded or unable to protect his own airway, you must ensure that the airway is maintained in a neutral position to allow air to pass through the glottic opening. A technique that is often overlooked is proper airway positioning of obese patients. Multiple towels or blankets can be placed under the shoulder blades and behind the neck (if no cervical injury is suspected) to provide atlanto-occipital extension. This will align the laryngeal and pharyngeal axes and improve airway patency.

     To anteriorly displace the tongue mechanically, use an oral or nasal pharyngeal airway. Remember that the oral airway can stimulate vomiting if placed in a patient with an intact gag reflex. If that is the case, a nasal pharyngeal airway should be used. Along with an artificial adjunct airway, you may need to provide a modified jaw thrust to move the jaw and tongue and prevent a partial airway obstruction.

     If the patient requires endotracheal intubation, have a plan for what to do if the intubation is unsuccessful. If the patient's condition allows, evaluate potential intubation difficulty by using the Mallampati classification and measuring the thyromental/sternomental distance. The Mallampati classification is a proven and well- documented technique used by providers to grade anticipated difficulty that may be encountered when performing endotracheal intubation. The technique is performed by having the patient open his mouth and stick out his tongue. Do not have the patient say "Ahh," however. Enlisting the musculature to do so may provide a false sense of security and a Grade III may be rated as a Grade II. In instances of sedation or paralysis, they will be unable to replicate this sound later.

     A Grade I or II rating shouldn't present significant difficulties. A Grade III rating is predictive of a difficult intubation; Grade IV is predictive of an extremely difficult intubation, and an alternative airway maneuver, device or technique should be considered. If the patient is already unresponsive, consider measuring the thyromental distance. This assessment should yield (hopefully) at least three finger breadths between the thyroid cartilage (Adam's apple) and the anterior apex of the mandible. A distance of less than three fingers has been associated with poor laryngoscopic view. Another consideration is how far the patient can flex his neck due to osteoarthritis. If the patient can't extend or flex his neck without pain (or at all), cervical manipulation by well-intentioned EMS providers can result in fractures and other musculoskeletal injuries.

     A number of precautions/options should be considered before endotracheal intubation. First, do you have enough providers to assist with a two-person BVM to provide cricoid pressure and intubate? If the patient is still conscious, the prudent technique is to allow him to breathe on his own and assist ventilations with a BVM. If this fails, consider an awake intubation. The airway assessment should guide you as to anticipated difficulty. Caution is advised when using sedative or paralytic agents with obese patients, however. Loss of muscle tone to the adipose, muscle and associated tissue could completely occlude the patient's airway and make it nearly impossible or impossible to intubate or ventilate. Most important, have rescue airway devices set out and ready to use. Obese patients tend to desaturate rapidly because they have a decreased functional reserve capacity. The pulse oximeter reading will fall rapidly and thus limit your laryngoscopy time. If the patient desaturates during the procedure, pull out and immediately ventilate him with a BVM. Failure to adequately ventilate the patient manually should prompt you to insert a rescue airway (single-or double-lumen device) and resume ventilations.

     Once the airway is secure, turn your attention to oxygenating and ventilating the patient. If the patient presents postoperatively (less than 6-8 weeks postsurgery), he may still have a large bulky dressing extending from the abdomen to his lower chest and/or may still have drains in place. Ventilation in this patient may be impaired by his body habitus or from splinting due to surgical site pain or wound dehiscence (opening of the surgical site).

     When assessing for ventilatory adequacy, remember that it is anatomically difficult to ventilate a patient who is supine. In the supine position, the posterior thoracic wall has limited mobility and the anterior thoracic wall is now under direct pressure from the patient's own adipose tissue. Rapid fatigue of the intercostal muscles and sternocleidomastoid muscle may leave the diaphragm as the final muscle preventing respiratory failure. In an attempt to compensate for decreased respiratory effort, the patient's respiratory rate may be tachypneic. But with tachypnea comes hypopnea (shallow breathing), so you must always remember that a breathing patient does not equal an adequately breathing patient. Along with the rate of ventilation, you must be astute in assessing the depth of ventilation. If the patient needs ventilatory assistance or requires mechanical ventilation, the patient's size must be taken into account. It is significantly more difficult to ventilate a patient weighing 180 kilograms versus a patient weighing 90 kilograms. Common causes of ventilation/perfusion deficits that may result in respiratory distress include abdominal splinting due to pain, pneumonia related to decreased ventilatory effort, decreased ventilatory rate due to use of prescribed narcotic pain medications, decreased thoracic cavity expansion due to increased intra-abdominal pressure, increased capillary permeability caused by any underlying hypertension, and decreased pulmonary perfusion due to a pulmonary embolism.

     After the airway is secured and oxygenation and ventilation have been established, a rapid circulatory assessment can be performed. One of the first signs of inadequate circulation and perfusion is a change in mentation. Alterations in heart rate (tachycardia or bradycardia) and blood pressure (hypotension or hypertension) can cause cerebral hypoxia. Another dysfunction that can affect circulatory status is an infection leading to sepsis. To this end, you should remember that the most common cause of mortality within the first 12 weeks post-surgery is an intra-abdominal infection from a leaking anastamosis. Even before the body responds by resetting the hypothalamus temperature switch and raising the core temperature, pain and anxiety will cause an increased heart rate. Thus, any patient presenting with an elevated heart rate should be evaluated thoroughly, appropriately treated and transported to the hospital. Other circulatory signs of infection include an increase in temperature and erythema (redness) at the wound site.

     Another common postoperative problem associated with bariatric surgery is nausea and vomiting. As stated previously, the goal of surgery is to decrease absorption of food and/or fluid in the patient's body. As such, the patient's ability to absorb fluid will be greatly decreased after surgery. As the GI tract adapts to the new "arrangement" of organs and physiology, nausea and vomiting are to be expected. Intense nausea and vomiting accompanied by "dumping syndrome" (caused by an inability to absorb fluid as it rapidly passes through the GI tract, resulting in watery diarrhea/bowel movements) can lead to profound dehydration. This dehydration can present with tachycardia; warm, dry skin and pallor to the mucosal membranes; and decreased urinary output.

     Fluctuations in blood pressure can also be expected in the first few months postsurgery. Most morbidly obese patients have a preoperative diagnosis of hypertension and are usually treated with a number of medications. Immediate post-operative pain and anxiety can cause sharp increases in the patient's blood pressure. The blood pressure may also fluctuate because the patient is not able to digest his medication due to postoperative nausea and vomiting (as mentioned previously). As the patient's BMI decreases after a successful operation, his blood pressure will begin to fall within normal parameters. As this happens, the physician should alter the patient's anti-hypertensive medication(s) to prevent overtreatment and hypotension.

     As mentioned above, another cause of cardiovascular dysfunction seen postoperatively is an infective process. Infections of the abdominal cavity are often associated with the release of bacterial endotoxins from a leaking anastamosis, resulting in peritonitis and encompassing the entire body in a septic presentation. Signs of localized infection include erythema at the surgical site and an increase in the patient's temperature.

Treatment
     Treatment priorities are aimed at stabilizing the ABCs. To secure the airway, you may only need to properly position the patient or insert a simple airway adjunct. If endotracheal intubation is required, do a thorough pre-assessment, and primary and secondary plans should be developed to prevent an overt airway catastrophe. Utilizing the assessment techniques previously discussed will help avoid or prevent a "can't intubate-can't ventilate" situation. If intubation is required, the most experienced provider should make the first attempt, with another provider applying the "BURP" maneuver (backward, upward, rightward pressure) on the cricoid cartilage to bring the glottic opening into better view. There should also be a number of alternative blades, ET tubes and rescue airways readily available.

     Once the airway is secured, ventilate with a BVM and consider using PEEP to recruit alveoli collapsed secondary to pneumonia or ventricular failure (in some instances, higher levels of PEEP may be warranted). Avoid nasogastric or orogastric intubation to decompress the stomach. Bariatric surgery can alter the length and size of the esophagus and stomach, making it easy to blindly perforate the esophagus, the newly created epigastric pouch or an anastomosis, and cause further hemorrhage and a route for infection.

     Frequent alterations in the cardiovascular status of postoperative patients are caused by dehydration secondary to decreased oral intake, nausea and vomiting, sepsis and increased output from dumping syndrome. Physical assessment characteristics include weak, thready or rapid pulse; delayed capillary refill; dry and cracked oral mucosa; evidence of oral and lower GI output; and decreasing blood pressure. Initial stabilization of the cardiovascular system includes assessing the surgical site, stopping any profuse bleeding and maintaining an adequate circulating volume. Obtain intravenous access using a large-bore, short- length IV catheter and administer a crystalloid solution. Lactated Ringer's or 0.9% normal saline can be administered, with controlled boluses of 250-500 ml each time. After each bolus, assess the patient's pulse, BP, respirations, mentation and lung sounds to guide further fluid therapy. Current literature and research recommend not increasing the systolic blood pressure too rapidly in an attempt to correct and obtain the patient's "normal" pressure. Systolic blood pressures of 80-90 mmHg correlate to adequate perfusion of the body's vital organs (heart, brain, lungs, kidneys). Rapid attempts to increase BP can not only cause hemodilution from continued bleeding, it can also cause pulmonary congestion and respiratory failure.

     Once the patient is stabilized, contributing medical conditions may necessitate further assessment or treatment. Dyslipidemia caused by the patient's prior unhealthy lifestyle has resulted in distribution of plaque throughout the vascular system. Plaque deposits inside the coronary arteries could cause ischemic heart disease, leading to angina and ultimately resulting in an acute myocardial infarction. Plaque deposits throughout the peripheral vascular system can cause hypertension and renal failure. The increased workload placed on the heart by having to pump against clogged (plaque) and constricted (HTN) arteries often results in further ischemia and left ventricular failure. Providers should be aware of the plethora of cardiovascular complications and how they are interwoven to result in numerous pathologies. If the patient is suffering from angina or anginal-equivalent symptoms, initiate oxygen, 12-lead ECG, IV and MONA (morphine, oxygen, nitroglycerin and aspirin) therapy. Pulmonary congestion and left ventricular failure can be treated with standard ALS (IV, O₂, 12- lead ECG), CPAP or BiPAP ventilatory support, IV nitroglycerin or judicious diuresis. Hypertension is often caused by increased secretion of catecholamines, hypoxia and stress. Continued verbal reassurance, transport in a quiet manner and standard ALS care often result in a decreased third or fourth BP reading.

     If the patient is suffering a hypertensive crisis, IV nitroglycerin is a good choice if the patient has associated cardiac pathology, and diuretics if the patient has associated pulmonary congestion. Another option is a short-acting beta blocker (like labetalol) for emergent BP crisis if the patient has no reactive pulmonary disease.

Case Study Wrap-Up
     You return to the same emergency department with your next patient. After giving a report, you walk over to the previous patient's room, peek in and find him hooked up to a facemask for BiPAP administration, an IV of D5.45NS hanging, and a nitroglycerin drip running at 4 mcg/min. The physician is just finishing inserting a radial arterial line to help manage the patient's BP and draw additional ABGs. You ask the doc about the patient's status, and he tells you that, based on the chest x-ray, the patient has bilateral pneumonia with consolidations (not overt CHF); his 12-lead revealed ischemia in the lateral leads (when compared to his preoperative ECG from eight days ago); he was hypoglycemic by your initial BGL; and he appears to be in the early stages of sepsis. The doc explains that he inserted the arterial line to help manage the nitroglycerin infusion (for coronary artery dilatation and perfusion), while balancing a borderline blood pressure of 98/46. The patient will need antibiotic therapy, continued pulmonary support (an attempt to prevent endotracheal intubation), continuous ECG and ST segment monitoring (to prevent further cardiac ischemia) and diligent BP monitoring to maintain adequate end organ perfusion.

     On your next shift, you return to the ED and ask the doctor how the patient fared. He informs you that the patient developed peritonitis and went back to the operating suite in an attempt to locate the source of infection. Unfortunately, the patient developed a massive myocardial infarction and died in the OR. You discuss the prehospital and emergency department treatment, and the doctor agrees you provided optimal treatment to the patient.

CEU Review Form Bariatric Emergencies (PDF)Valid until October 5, 2007

Preparing for the Bariatric Patient
     Health officials have confirmed that we're becoming a nation of large people. If that's true, there's a good chance you have obese residents in your call area and may have already experienced an uncomfortable moment when you lacked adequate equipment to transport one of them.

     The entire key to being prepared for that bariatric patient call is preparation, says Tim Perkins, EMT-P, EMS systems planner for the Virginia Department of Health, Office of EMS. "Knowing ahead of time that you have a bariatric patient can be vital," he says. "Agencies need to have SOPs already developed to respond to those calls. Just like with other special situations, providers need to know the answers to a lot of questions like: 'How much does the patient weigh? Where is he located? Is he wedged between a commode and the tub in a bathroom, or between his bed and the wall? Is she in an upstairs apartment where you may have to cut out a wall? How mobile is she? What other resources are needed, and what resources might fall outside the public safety model?' One thing I tell people is, not many fire services or EMS agencies have forklifts or flatbed trucks as part of their apparatus, but they may need them."

     The consequences of not being prepared were confirmed in a recent e-mail Perkins received from an EMS agency looking for information its members could use for training. "An obese patient ended up coding and dying while they were trying to get him out of his house," says Perkins. "One of the most important things EMS agencies can do is learn where the obese patients are in their communities, which may involve asking the local social services agency for information. A lot of obese people are homebound or in need of specialized attention, and EMS and social services can work together to locate those individuals."

     The idea of using already limited financial resources to purchase special equipment can pose a dilemma, says Perkins. "There are some creative ways to move and transport bariatric patients," he says, "but, at the same time, I don't think agencies want to say they condone using vehicles and equipment in any manner outside the manufacturer's recommended guidelines." On the other hand, he adds, equipping a larger ambulance or buying equipment that's designed to handle more weight can be used for any patient-they're not just for bariatrics. From that perspective, it may be money well-spent."

     So, what are some things EMS providers should do or not do when working with obese patients? "Medically, your approach to an obese patient isn't a lot different than any other patient," says Perkins. "Obviously, you need a large BP cuff, and you have to be aware there's more muscle and fat for your defibrillator pads to go through. One thing providers should definitely not do is try to move a 400-lb. patient by themselves, and they should not exceed the manufacturer's requirements on things like backboards, stairchairs and stretchers. When I was in the field, I remember bringing a 450-lb. woman in cardiac arrest downstairs in a Stokes basket, where the fire department had set up a stretcher. Just as I was about to say, 'Don't put her on it,' they did, and the four wheels of the stretcher went in four different directions. An incident like that can harm the patient and be very embarrassing. Bariatric patients need to be treated with respect. They know what their situation is, and they don't need it rubbed in their face by EMS. It takes a tactful approach."

     Again, says Perkins, it all comes down to training and pre-planning. "Obviously, there will be situations where EMS will pull up on a scene and not realize they'll be dealing with a bariatric patient, but they can report it to dispatch for future calls. Once you identify those people, I suggest you hold training sessions at their homes. If I was an obese patient, I would appreciate it if the EMS agency in my area came and helped me get through the door of my house at a time when I didn't need it so, when the time comes, they'll know what to do."
-Marie Nordberg, Assoc. Editor

What's the Big Idea? Montreal Service Protects Patient Pride, Employee Backs With Bariatric Unit
     It may comfort you to know that the problem of increasing patient size isn't limited to your agency or even your country. Our neighbor to the north is seeing it too.

     And like many of their U.S. counterparts, services in Canada have had to take measures to accommodate obese patients and their unique needs.

     "Here in Montreal now, 48% of people are overweight," says Michael Harding, special operations supervisor for Urgences-Santé, the sixth-largest EMS system in North America, which serves roughly 2¼ million residents of Montreal and Laval in the province of Quebec. "This past year they represented around 13% of our call volume. So basically, necessity became the mother of invention for us because so many of our people were getting injured."

     The problem dates to the early 1990s. For much of that decade, Urgences-Santé contracted with another agency to do its bariatric transports. That arrangement eventually became too cumbersome to continue, so four years ago, the service decided to outfit one of its own vehicles for the purpose.

     The emergency support unit it uses today features a specially designed system of rails for loading (usable with any ambulance in Quebec), mechanical and hand-powered winches and a Stryker stair chair modified to sit atop a sturdy dolly of the sort used to move vending machines. It can move up to 1,200 lbs. A wraparound sling that can hold up to 1,000 lbs. is utilized to help get patients into the chair.

     To help get patients out of their homes, there's a system of ropes and anchors by which they can be raised or lowered. Specially trained medics evaluate the stability of such structures as stairs and balconies. These can, if necessary, be bolstered with metal poles and other supports.

     "The principle is that our guys don't pick up, with their own bodies, any weight," says Harding. "It's always being done through mechanical assistance."

     Urgences-Santé has created a database of known bariatric patients in its service area and dispatches the unit when one of them calls for assistance. With new patients, crews evaluate their structure and situation and determine how best to remove them, then record that information for future occasions.

     The bariatric unit is also used for transfers to and from aircraft, physical support in cases of difficult access, and certain treat-and-release and other specialty calls.

     The idea with bariatric patients is to help them retain some dignity-something that's difficult when your entire street is blocked off and the neighbors are out gawking at you being wrestled to the rig. The local fire department once managed such removals, but was less equipped to address the range of conditions and other medical ramifications of extreme size.

     "Somebody who weighs 650 lbs. probably hasn't been out of their home in months, if not years," notes Harding. "When you're that big, you can't really take care of yourself. You can't get in and out of the bathtub, you can't wipe yourself after going to the bathroom, and so you get all kinds of health problems. They're often not very clean by the time they call for our assistance."

     Appreciative patients have been one benefit of the unit, but even more important has been reduced injury risk for Urgences-Santé personnel.

     "We haven't had any work accidents with that unit since it's been operational," Harding says. "Our regular paramedics continue to get injured on bariatric calls, because we only have one bariatric unit."

     That, along with a strong demand for the unit from mutual-aid communities throughout the region (and even interest from local funeral directors, whose employees face comparable challenges with obese patients), has led to plans for a second bariatric rig, which the service hopes to roll out by the end of the year.
-John Erich, Associate Editor

CEU Review Form Bariatric Emergencies (PDF)Valid until October 5, 2007

Matthew Zavarella, NREMT-P, RN, is a flight nurse with STAT MedEvac Air Medical Program in Pittsburgh, PA. He is currently pursuing a second master's degree in Nursing Anesthesia from the Excela Health School of Anesthesia in Latrobe, PA.

Randall W. Benner, MEd, MICP, NREMT-P, is an instructor in the Department of Health Professions at Youngstown (OH) State University. He currently serves as the director of the Emergency Medical Technology Program at Youngstown.

William S. Krost, BSAS, NREMT-P, is an operations manager and flight paramedic with the St. Vincent/Medical University of Ohio/St. Rita's Critical Care Transport Network (Life Flight) in Toledo, OH, and a nationally recognized lecturer.

Joseph J. Mistovich, MEd, NREMT-P, is a professor and chair of the Department of Health Professions at Youngstown (OH) State University, author of several EMS textbooks and a nationally recognized lecturer.

Daniel D. Limmer, AS, EMT-P, is a paramedic with Kennebunk Fire-Rescue in Kennebunk, ME, and EMS Program Coordinator at York County Community College in Wells, ME. He is the author of several EMS textbooks and a nationally recognized lecturer.

Tim Perkins is a featured speaker at EMS EXPO, October 11-13, in Orlando, FL, where he will present a class on how to treat bariatric patients. For more information, visit www.emsexpo2007.com.

Randy Benner, Will Krost, Joe Mistovich and Dan Limmer are all featured speakers at EMS EXPO, October 11-13, in Orlando, FL. For more information, visit www.emsexpo2007.com.