All You Need to Know About Bariatrics

A BLS ambulance is dispatched to transport a bed-confined patient from a dialysis center back home. After arriving at the center and assisting the patient onto the ambulance stretcher, the crew pushes the stretcher out to the loading area. As they maneuver around cracks in the sidewalk, a wheel catches a crack, and the stretcher begins to tip. The crew tries to stop the patient and stretcher from falling over but are unsuccessful. The patient, strapped to the stretcher, topples to the ground, landing on his side.

After examining the patient for injury and rearranging the stretcher, they successfully place him back on it. The crew is then able to successfully load the patient into the ambulance and transport him home. There he is transferred to his bed, and the crew returns to their office to document the incident.

The incident is reported to the patient’s healthcare provider and the dialysis center. The crew is asked whether the patient being morbidly obese, with a BMI of 42, played a role in the incident. The patient’s healthcare provider has been recommending weight loss and recently discussed possible bariatric surgery. For future transports of this patient, the ambulance company will assign an ambulance customized for bariatric patients.

Bariatrics is the branch of medicine that deals with the causes, prevention and treatment of obesity. Obesity is a significant concern in the United States and has been recognized as a chronic disease since 1985. In 2008 more than one third of U.S. adults were considered obese. The incidence of obesity was approximately 33% among men and 35% among women. From 2009–10 nearly 36% of individuals 20 years or older were considered obese, with more than 60% considered overweight.^1–5

Obesity is associated with many health problems, including heart disease, stroke, diabetes, high blood pressure, sleep disorders and pulmonary problems. It is considered the second-leading cause of preventable death, exceeded only by cigarette smoking. A 20% or greater increase above desirable weight is considered the point at which excess weight becomes a health hazard. Obesity is associated with a reduction in lifespan of 10 years, and obesity-related deaths have been reported to exceed 400,000 annually. In 1998 the financial impact of obesity was more than $78 billion; in 2008 it was estimated at more than $145 billion.²

Anatomy

Prehospital providers will often encounter patients who are overweight or obese. Providers may also be involved in the transport of patients following weight-loss surgery, which is becoming more common. It is important to be aware of the pertinent anatomy in order to understand changes in organs and/or tissues, as well as the type of surgery performed, which we cover in an online sidebar at www.emsworld.com/11304902.

The abdomen is a large cavity in the body between the thorax (chest) and pelvis. The diaphragm, which separates the abdomen from the thorax, forms the upper border. The abdomen ends inferiorly at the pelvic bones. The abdominal wall is considered to be the anterior border, with the spine and muscles of the back forming the posterior border. The lateral walls, or the sides, are the flank areas and contain the kidneys. The epigastrium is the mid-upper abdominal area located just below the xiphoid process of the sternum.^6–7

The abdomen is protected by a thin, tough layer of tissue called fascia. Anterior to the fascia are the abdominal muscles and skin. Back muscles can be found behind the posterior abdominal wall. The majority of the abdominal organs are contained within a membrane called the peritoneum. Some organs, such as the kidneys, are retroperitoneal, or behind the membranous peritoneum. Intra-abdominal organs include the stomach, small intestines, large intestines, pancreas, liver, gallbladder, kidneys and spleen. The organs are held together loosely by connective tissues called mesentry. The mesentry allows organs to expand and slide against each other. Additional anatomical structures, such as blood vessels (including the aorta and inferior vena cava), are contained within the abdominal cavity.⁶

Following a weight-loss surgical procedure, the patient may have sutures, bandages, drains or other devices in place. They may have excess skin in large, loose folds when large amounts of underlying tissue were removed. Their skin may be more pliable than normal.

Providers should also be familiar with the abdominal quadrants, especially if transporting a patient who has recently had surgery. The abdominal quadrant system involves visualizing vertical and horizontal planes that pass through the umbilicus at right angles. The abdomen is subsequently divided into four quadrants: right upper, right lower, left lower and left upper. Figure 1 provides an example of the quadrants and organ location.⁶

There are additional anatomical considerations to be aware of when caring for an overweight or obese patient. For example, the patient’s face, chin, neck and upper back may appear edematous from stretched skin and/or excessive adipose tissues. In such cases the provider must remain attentive for potential airway compromise. The patient’s extremities are often larger in diameter; in such situations larger assessment equipment (e.g., blood pressure cuff) is needed. Identifying veins and establishing intravenous access can be difficult due to overlying adipose tissue obscuring visual and palpable landmarks as well as increasing the depth of the vessels.^7–8

Impact of Being Overweight

Being overweight can have a significant impact on an individual’s overall physical health and emotional well-being. For example, patients may experience social stigma due to their weight. This may influence their emotions and result in additional stress, anxiety and depression. Combined, such factors may exacerbate underlying medical and psychological conditions.

Due to the presence of excess fatty tissue, especially on the diaphragm, abdomen and chest wall, the overweight patient may experience difficulty breathing as well as a reduced respiratory drive. As a result, they may develop obesity hypoventilation syndrome (OHS), which can lead to hypercapnia. Excessive fatty tissue of the anterior and posterior neck may contribute to airway obstruction. Additional physiological and chemical changes may occur within the body, further contributing to a compromised respiratory drive and less-effective respirations.⁸

The addition of fatty tissue can impact nearly every organ and system in the body. An individual may experience an increase in systolic or diastolic blood pressure. This, in turn, especially on a long-term basis, can also influence other systems such as the renal system, leading to additional workload for the kidneys. Peripheral edema, skin infections, skin abnormalities and arthritic complications are also possible.⁸

Complications of Weight-Loss Surgery

In part because of the health problems suffered by obese patients, complications from bariatric surgery are more common than from surgery in the general population. Approximately 20% of people who have weight-loss surgery experience complications, and 10%–20% need follow-up operations to correct complications.^{2, 9–13}

Examples of early complications include bleeding, infection, intestinal site leakage, diarrhea, thrombus and emboli. Long-term side effects can include nutrients being poorly absorbed. This may be the case with patients who are noncompliant with recommended supplemental vitamins and minerals. If not managed, diseases may occur, along with permanent damage to the nervous system. Examples include pellagra (caused by lack of vitamin B3/niacin), beriberi (caused by lack of vitamin B1/thiamine) and kwashiorkor (caused by lack of protein). A reduction in the amount of food, vitamins and mineral absorption can contribute to complications such as anemia and osteoporosis.^{2, 9–13}

Other complications can include strictures, or narrowing of the sites where the intestine is joined. A hernia, a part of an organ bulging through a weak area of muscle, may also occur, as may nutritional deficiencies, such as protein malnutrition and low levels of nutrients such as vitamin B12, vitamin D, iron, calcium and folate. The nutritional deficiency incidence post weight-loss surgery is more than 25%. Diagnosing complications related to bariatrics will likely require assessment by hospital providers.^{2, 9–14}

The nature of the surgery performed may relate directly to the complication. For example, if a band procedure was used and the band slips, the patient may experience a variety of symptoms, including discomfort and tachycardia. Surgical intervention may be required. The patient may develop an ulcer, perforation of the intestine, bowel obstruction, or surgical site wound infection and become febrile and dehydrated and experience tachycardia. Acute weight loss following bariatric surgery can lead to diseases such as gallbladder disease and choledocholithiasis, or bowel obstruction. The creation and subsequent movement of a blood clot (e.g., embolus or thrombus) may result in circulatory compromise. The cause and acuity of the complication will often dictate the treatment provided.^{2, 10–14}

Assessment                                                                                                                                                                    

Assessment of the patient will be guided by their chief complaint, medical history and current overall health. Similar to the opening scenario, an EMS crew may be required to assess a patient who does not have an initial complaint, such as during a transfer. In other cases they may need to assess a patient experiencing a complication to a surgical procedure, such as an infection. Each situation is unique.

Assessment should begin before physical contact is made. As you approach, consider the patient’s overall appearance. Do they appear to be conscious? Do they have a chief complaint? Do they complain of abdominal pain? Are they guarding their abdomen? What is their skin color? Does it appear to be pink, pale, cyanotic, ashen or gray? Are there clues on scene that reveal a possible cause, such as empty prescription bottles?^{7, 15}

If the patient’s chief complaint is abdominal pain, there can be numerous potential causes. As a result, the provider must perform a thorough assessment. In some cases the patient may be able to provide a detailed description and location of the pain; in other cases it may not be as straightforward. For example, if the patient had weight-loss surgery a week ago and now has abdominal pain, the crew will need to consider the possibility of a surgical-related event. Prehospital providers should focus on performing a thorough assessment, forming an appropriate treatment plan and determining the appropriate destination for the patient. Intervention should not be delayed in an effort to determine a diagnosis.^{7, 15}

History

The patient assessment should include obtaining an accurate medical history, such as by using the SAMPLE technique. Consider the history carefully, as it may suggest an etiology. It may include private and potentially sensitive topics; assure the patient the detailed history is intended to promote optimal care and will not be shared with anyone other than healthcare providers. If the patient is female and resources permit, consider having a female healthcare provider available to assist in the history and physical exam.^{7, 15}

History questions will vary depending upon the situation. For examples, see the accompanying sidebar. Consider questions related to the menstrual cycle and pregnancy when interviewing any female of childbearing age who presents with abdominal pain.^{7, 15}

Obtain a complete set of vital signs. There are nuances to be aware of when assessing an overweight or obese patient. For example, when listening to breath or lung sounds, consider listening on the patient’s back, where there tends to be less adipose tissue. Consider placing EKG patches on the lateral sides of the lower abdomen, as signals do not transmit as well through adipose tissue. Ensure the blood pressure cuff is appropriately sized. It may be necessary to use a thigh cuff on the arm or forearm for an accurate reading. The pulse oximetry may need to be applied to the patient’s earlobe, nose or little finger, as there tends to be less adipose tissue there that may influence the reading.^{7–8, 15}

Treatment

Treatment should be guided by the patient’s chief complaint, provider discretion and local protocol. In all cases, the patient’s airway, breathing and circulation should be the priority.

Overweight patients can present with unique airway challenges. An effective means to avoid airway obstruction from excessive adipose tissue is to keep the patient upright. Airway support, including manual bag-valve mask or mechanical CPAP-assisted ventilations, may be performed effectively in a semi-upright position.

In the supine position additional adipose tissue can place pressure on the tongue and airway structures, potentially causing airway compromise. In this situation, assuming there is no cervical injury or trauma, consider placing towels or blankets under the shoulder blades and behind the neck. This may support alignment of the airway anatomy and assist in maintaining airway patency.^7–8

Depending on the situation and level of potential airway compromise, providers may also need to consider performing a modified jaw thrust to assist with moving the patient’s tongue. Some patients may use a noninvasive CPAP device to assist with their breathing. Factors such as these should alert the provider to the potential of a more challenging airway situation.^{7–8, 15}

Airway management may include the use of an adjunct such as an oropharyngeal or nasopharyngeal airway. Recall that an oropharyngeal airway can trigger the patient’s gag reflex. An NPA may be better tolerated, especially if the patient is conscious or semiconscious and requires airway support. ^{7–8, 15} Consider using bilateral nasopharyngeal airways if tolerated.

More advanced airway devices and techniques may be required. Examples include the laryngeal mask airway, blind nasotracheal intubation and visualized oral endotracheal intubation. Prior to performing more advanced airway procedures, ensure that adequate resources are available, including suction, supplemental oxygen, mechanical ventilator support and additional personnel to assist with the procedure and subsequent support of the patient’s breathing. Providers should remain focused and attentive when managing the patient’s airway. The presence of additional adipose tissue and/or skin may make procedures and management more difficult than in patients who are leaner. ^{7–8, 15}

Intravenous access may be indicated. As previously noted, obtaining it can be challenging. Depending on local protocols, consider use of an intraosseous system. A longer needle may be necessary, and some manufacturers offer specialized IO kits for such situations. ^{7–8, 15}

If you suspect the patient is suffering from a condition that may warrant aggressive fluid replacement or if they are a possible surgical candidate, consider IV access. Fluid selection and flow rate should be determined in part based on the patient’s overall condition. Prehospital blood samples should be obtained in accordance with local protocols. If available, a dextrose reading may be obtained.^{7–8, 15}

Depending on the situation, medication may need to be considered for the relief of symptoms. For example, with abdominal pain, fentanyl may be administered intravenously or nebulized. Other analgesics may be suitable, depending on the patient’s overall condition and vital signs. A benzodiazepine may be considered for muscle spasm or pain control. If the patient is experiencing vomiting, an antiemetic is possible. A combination of medications may also prove helpful in managing numerous symptoms. For example, giving ondansetron to patients receiving opioids for pain may reduce the incidence of nausea and vomiting. Metoclopramide, promethazine hydrochloride and Phenergan are other potential antiemetics.^16–18   

If the patient is experiencing abdominal pain, it can cause varying levels of distress, and the patient may experience the extremes in comfort and positioning. Providers will need to ensure the patient’s safety if the patient is moving about on the stretcher. This is especially important during transport. Depending on the size of the patient, the use of specialized equipment, such as a bariatric stretcher, may be necessary.^{7–8, 15}

Other specialized equipment for transporting patients who are overweight or obese includes larger stretchers, winch systems to assist with loading into the ambulance, and modified oversized patient compartments. Ambulance stretchers are often designed to accommodate patients weighing up to 700 pounds and are usually 23 inches wide. In cases of obese patients, stretchers are available that can accommodate as much as 1,500 pounds, with a width up to 40 inches. Had such a resource been available in the opening scenario, a different outcome might have been possible.^{8, 15}

Conclusion

Managing an overweight or obese patient in the prehospital setting can present unique challenges. Providers will need to consider the anatomical and physiological differences that result from the excessive weight. This will potentially impact the assessment, management, treatment and transportation provided. Providers will also need to ensure that appropriate resources are available to provide optimal care.

References

1. Centers for Disease Control and Prevention. FastStats: Obesity and Overweight, www.cdc.gov/nchs/fastats/overwt.htm.

2. National Association for Weight Loss Surgery. Weight Loss Surgery Statistics and Definitions, www.nawls.com/public/102.cfm?sd=2.

3. American Society of Bariatric Physicians. Frequently Asked Questions (FAQs), www.asbp.org/patients/faqs.html.

4. Sturm R. Increases in clinically severe obesity in the United States, 1986–2000. Arch Intern Med, 2003 Oct 13; 163(18): 2,146–8.

5. Roller Weight Loss & Advanced Surgery. Obesity, www.rollerweightloss.com/info/obesity.html.

6. Spence A, Mason E. Human Anatomy and Physiology, 3rd ed. Menlo Park: The Benjamin/Cummings Publishing Company Inc., 1987.

7. Chapleau W, Burba A, Pons P, Page P. The Paramedic. Boston: McGraw-Hill, 2008.

8. Collopy KT, Kivlehan SM, Snyder SR. How Obesity Impacts Patient Health and EMS. EMS World, www.emsworld.com/article/10654895.

9. International Atomic Energy Agency. Dual Energy X ray Absorptiometry—Bone Mineral Densitometry, https://rpop.iaea.org/RPOP/RPoP/Content/InformationFor/HealthProfessionals/6_OtherClinicalSpecialities/DEXA/.

10. U.S. Food and Drug Administration. Obesity Treatment Devices, www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ObesityDevices/default.htm.

11. Weight-control Information Network. Bariatric Surgery for Severe Obesity, win.niddk.nih.gov/publications/PDFs/Bariatric_Surgery_508.pdf.

12. Agency for Healthcare Research and Quality. Pharmacological and Surgical Treatment of Obesity, https://archive.ahrq.gov/clinic/epcsums/obesphsum.pdf.

13. Weight-control Information Network. Bariatric Surgery for Severe Obesity, https://win.niddk.nih.gov/publications/gastric.htm.

14. American Society of Plastic Surgeons. Obesity Epidemic Means Bariatric Surgery Rates Continue to Rise: Plastic Surgeons Play Key Role in Body Contouring After Massive Weight Loss, www.plasticsurgery.org/news-and-resources/press-release-archives/2012-press-release-archives/obesity-epidemic-means-bariatric-surgery-rates-continue-to-rise.html.

15. National Highway Traffic Safety Administration. National Emergency Medical Services Education Standards: Paramedic Instructional Guidelines, www.ems.gov/pdf/811077e.pdf.

16. McManus JG Jr, Sallee DR Jr. Pain management in the prehospital environment. Emerg Med Clin North Am, 2005 May; 23(2): 415–31.

17. Cohen MJ, Schecter WP. Perioperative pain control: a strategy for management. Surg Clin N Am, 2005; 85: 1,243–57.

18. Bartfield JM, Flint RD, McErlean M, Broderick J. Nebulized fentanyl for relief of abdominal pain. Acad Emerg Med, 2003 Mar; 10(3): 215–8.

Paul Murphy, MS, MA, EMT-P, has administrative and clinical experience in healthcare organizations.

Chris Colwell, MD, is director of emergency medicine at the Denver Health Medical Center and medical director of the Denver Paramedic Division and Denver Fire Department.

Gilbert Pineda, MD, FACEP, is medical director for the Aurora Fire Department and Rural/Metro Ambulance in Aurora, CO, as well as an attending physician in the emergency department at the Medical Center of Aurora.