Homebody

Attack One responds to a person having difficulty breathing. The call is for a middle-age man found lying on his couch. His door was opened by the apartment superintendent, a woman who came to visit the man today because he had not paid his rent. The man has lived there for several years but never been seen by the superintendent. His third-floor apartment has no elevator access, and the woman reports he probably could not have moved around much because of his size.

The Attack One crew now understands why the 9-1-1 center dispatched an additional engine company to the call: By the paramedic’s estimate, the man weighs about 600 pounds. He has moderate difficulty answering questions and cannot fully sit up on the couch for assessment. The room is very musty, and there are remnants of food and containers of urine around the couch.

“Sir,” the paramedic invites, “tell us about your trouble breathing.”

“I always have trouble breathing,” the man says, “and today isn’t much different than the last few weeks. I’ve reached the point where I can’t walk anymore, and today I can’t even get to the bathroom. I really need some help.”

The paramedic moves through questions related to the man’s current illness and past medical problems. The man was told he had asthma years ago but has not seen a doctor “for about 30 years.” He has a cough but no fever, no chest pain and no vomiting. He does not smoke and is on no medicines.

 “I’ve gotten pretty heavy and not been able to do anything to control it,” the man adds. “My family delivers my food, and I take care of my mail, and I haven’t left this apartment in a few years. I can’t stay here any longer by myself, so my sister has told me I have to go to the hospital. I guess I’m ready to go!”

The patient wheezes on exam but has only a dry cough and does not feel warm to touch. He is started on a nebulizer treatment. The EMTs try to get a blood pressure, but the cuff is barely able to stretch around the man’s arm, and the best value they can get is around 250 systolic. The paramedic realizes that number can’t be right and they’ll need an appropriate-size cuff to obtain an accurate value.

The pulse oximeter provides a great reading, though, and the man’s pulse is normal, with a rate of around 120. With a little oxygen and the breathing treatment, his oxygen saturation is above 90%. The BP will need to be obtained when a larger cuff is available; in the meantime the pulse oximeter shows good perfusion.

The paramedic steps away to talk with the other crew members. With the man’s size, it is likely he will not fit through the doors of the apartment. The engine captain has been looking through the building and suggests they do not have the resources needed to move the man out. The paramedic adds that they also do not have an ambulance on scene that can safely transport him.

“Fortunately, this man is not suffering an acute medical illness that requires transport in the next few minutes,” the medic says. “We not only need to figure a way to get him out of the apartment and down to the street, but we need appropriate-size medical equipment and a larger stretcher. We also need to take him to the right hospital for care that can accommodate his size. I will make some phone calls for the medical stuff if you’ll get a battalion chief and safety officer here.”                                                                                                                                                                      

The Attack One crew chief calls the emergency department at a hospital that advertises its bariatric unit in local media. His discussion leads to an agreement to access the hospital’s specialized ground transport unit for large patients and a crew that has larger equipment, like very large blood pressure cuffs. It will take about 30 minutes to get the crew together and to the scene, but it will have the specialized gear needed for ongoing care.

The paramedic goes back to talk with the patient and confirm the incident management plan. At that point the man is breathing more easily and beginning to get very emotional about being taken out of his apartment. He wants to know how this will be managed so that he won’t hurt someone or be embarrassed as he goes out to the street and hospital.

“Thank you for helping us address each of these issues, sir,” the paramedic reassures him. “We are going to cover you for modesty and move you safely through the building and to a special stretcher and ambulance that will transport you to a hospital that provides great care for large patients. We’re bringing in a specialized team to make the movement safe for you and our staff, and we’ll do it in a way that does not inconvenience your neighbors. We will work with the apartment supervisor to make sure your apartment is locked up safely. I want to introduce you now to our battalion chief and another lady who will serve as the safety officer for this operation. We will be working together, with your help, to make this safe.”

With that the patient becomes very tearful but cooperates with the officers as they begin to lay out the plans for movement.

The bariatric transport unit arrives at the scene, and the staff comes to the patient. They have a large cuff and obtain an accurate blood pressure of 170/100. They have a large gown that fits the patient well, and the EMTs help the patient get cleaned up before donning it. He tries once to bear weight but is unable to carry himself. The nebulizer treatment has produced good results, and the man’s wheezes are almost gone, so the only ongoing medical treatment needed now is supplemental oxygen with a cannula.

The paramedic of the bariatric unit is assigned primary responsibility to oversee patient care and needs during movement from the apartment to the hospital. The paramedic from Attack One is assigned as Medical Operations, which includes not only supporting patient care but working with the safety officer to ensure everyone proceeds without injury or compromise in care. The Attack One EMTs work on all supplies needed to move the patient. Firefighters will be responsible for his physical movement.

It’s fortunate the building supervisor is on scene, because the heavy-rescue crew assigned to the incident has to do some building modification. They plan a path out the door of the apartment, along a hallway to a larger outside set of stairs where, with some cuts in the stairwell, they will be able to move the patient out a lower gate and to the ambulance. The door to his apartment will have to be widened, and the rails on the stairwell removed in certain places. An alternative plan to cut open the walls of the apartment and use a crane to lower the patient to the ground is considered and rejected.

The patient is placed in a gown and onto a fabric sheet fitted with a number of handholds. The weight limit on the textile device is 1,000 pounds. The rescue crew has as part of their technical-rescue equipment a narrow four-wheeled cart that can assist in moving the patient down the interior hallway. Movement down the steps will be all by hand but can be assisted by using sheets of plywood as ramps down the stairwells. These are cut to appropriate width. The gate at the bottom is wide enough to accommodate the patient and cart, but not a stretcher. The bariatric stretcher will be outside the gate, and another sheet of plywood will assist in safely sliding the patient onto that stretcher. The transport unit has a winch to load the stretcher and patient into the vehicle.

Each step is walked through by the battalion chief, safety officer, rescue captain and both paramedics. The lighting, stairway surfaces and doorways are all examined, and all surfaces are smoothed down to make sure no sharp edges can catch the patient or crew members.

The patient remains stable and calm as the building modifications are carried out. He is offered a towel to cover his face if he wants to maintain further modesty. He is told to use the word “safety” if he becomes uncomfortable, short of breath or concerned with any part of the movement. On that command the operation will stop, and the paramedic will resolve any issues. The crew members also have a command to use if they have immediate concerns about their welfare or the operation’s safety.

The movement goes well, including the difficult pass down the steps. No safety issues arise until the lower gate is found to be barely wide enough to allow the patient to pass. The surfaces are coated with vegetable oil just to make sure the pass is safe and doesn’t injure the patient.

The load into the ambulance is the easiest part of the operation, and then transport follows. Several vehicles accompany the patient and ambulance to the hospital to make sure the offload occurs safely. There the patient is offloaded onto a large hospital stretcher and weighed on a device before entering the ED.

The media is present at the scene and at the hospital, and the public information officers of the department and hospital share responsibility for discussing the case while protecting the identity and privacy wishes of the patient.

Patient documentation is completed, the rescue crew assists workers in securing the building, and a debriefing session is conducted afterward to gather everyone’s input on the operation.

Emergency Department Management

The ED nurses and physician are prepared for the man’s arrival. He receives care in the ED, then is moved to the special-admission unit. He undergoes surgical treatment and a long rehabilitation, then is released back to his apartment and family. At a much slimmer weight, he is able to walk to his apartment himself.

During his rehabilitation, he calls the department to offer his thanks for the safe operation. He has one suggestion to offer for improvement, and it is to the paramedic from Attack One: The patient says the medic underestimated his weight by a fair margin, and that his actual weight on arrival at the ED was more than 700 pounds. With a smile in his voice, he says he’s going to come in and provide a lesson on weight estimation when his own weight gets down to his target of 250 pounds.

Case Discussion

Humans are getting taller, wider and heavier. EMS providers are challenged to provide care for very large patients, and a comprehensive approach is necessary to address their safety problems. Very large patients have the right to expect professional and timely emergency care, and providers have an obligation to deliver such care without risking their own health.

A number of EMS programs have enhanced transport operations, reduced patient and personnel injuries, and avoided the spectacle of moving a person on planks, tarps or the floor of an ambulance. A comprehensive program begins at the 9-1-1 communication center (or equivalent) with a dispatch protocol that initiates a response appropriate for patient needs and system efficiency. The caller-interrogation process should gather the information necessary to send a response appropriate to a patient’s size and the complexity of the building. Algorithms are in development whereby a caller may volunteer information that a patient is very large and/or in a location that will make movement difficult.

It is beneficial to have knowledge and preplans that allow for the use of regional resources to move very large patients. The largest bariatric stretchers have 1,100-pound weight limits and are usually matched to ambulances fitted with ramps and winches for safe loading. Such resources are likely available only in small numbers in any metropolitan area, so it is cost- and time-efficient to have them available through mutual aid or other shared-resource agreements.

As in this case, when a bariatric patient needs to be moved for treatment, an incident management plan will be necessary for timeliness, effective care and safety of the patient and emergency personnel. A safety officer is often added to the usual Incident Command procedures. Sample protocols are available.

To deliver emergency medical care, appropriate equipment and supplies are necessary. A large gown or two will cover the patient. For initial assessment, large blood pressure cuffs will be necessary. Several versions of cuffs are now extra-large in both length and diameter. The size of the cuff needed is roughly two-thirds of the upper arm and a large enough diameter for the cuff to maintain closure. A longer needle will be needed for intramuscular injections, relief of tension pneumothorax and sometimes for intraosseous lines. Some emergency medications may need adjusted doses; if this is an important consideration, medical control may be needed for advice and orders.

The proper site for patient care will need consideration. If you have a very large patient who is unable to ambulate and there are significant issues with removing them from the structure (narrow stairs, patient in the attic, etc.), contact medical direction and an EMS officer who may be aware of alternative care options. There may be situations where EMS will provide care to the patient at the site rather than attempt to remove them to a hospital.

It is rare that a very large patient needs spinal immobilization. If it is necessary, stabilizing the spine will require blanket or towel rolls to be fashioned along with lateral head pillows fastened securely to the rigid board or plywood being used.

There are an increasing variety of devices such as special textile sheets that are useful for lifting and transferring with an appropriate number of personnel. These fabric devices have a large number of handles, allowing more rescuers to assist. The patient should be loaded on a cot that’s in the down position; move the cot in the down position at all times.

EMS agencies should be aware of which regional hospitals are appropriate to receive very large patients. Some have special bariatric services and equipment (e.g., an extra-large CT scanner). Notify the hospital to which the patient is being taken to allow its staff time for preparation. This type of patient will typically be loaded directly from the ambulance onto a special hospital bed, which may be brought to the ED entrance. Specialized hospital equipment with bariatric capabilities includes reinforced plastic slide devices to help move patients between beds and stretchers. Some hospitals and extended-care facilities utilize small compressed-air mechanisms to inflate mats that can lift more than 1,000 pounds.

The process of moving large patients through smaller and older buildings may require EMS personnel or a safety officer to check for structural integrity and obstacles along the pathway. Are narrow doorways wide enough for the larger cot, and are floors, stairs, ramps and elevators able to support the weight and size of the patient, crew and equipment? Can service elevators, special lifts and ramps provide a safer path?

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. He spent 32 years as a firefighter and EMT. Contact him at jaugustine@emp.com.