obesity: the bariatric challenge obesity: the bariatric challenge

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Obesity: Obesity: The Bariatric Challenge The Bariatric Challenge Chad S Lewis, MD Chad S Lewis, MD Emergency Medicine Resident Emergency Medicine Resident Albany Medical Center Albany Medical Center

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Obesity: Obesity: The Bariatric ChallengeThe Bariatric Challenge

Chad S Lewis, MDChad S Lewis, MDEmergency Medicine ResidentEmergency Medicine Resident

Albany Medical CenterAlbany Medical Center

Obesity DefinedObesity Defined

• Condition of an excessive proportion of adipose Condition of an excessive proportion of adipose tissue to total body weighttissue to total body weight

• Prevalence doubled over last 20 years and still Prevalence doubled over last 20 years and still increasingincreasing

• Some estimates are half of all adults are Some estimates are half of all adults are considered to be overweightconsidered to be overweight

• Worldwide estimates 1.1 billion overweight Worldwide estimates 1.1 billion overweight people with 250 million are classified as obesepeople with 250 million are classified as obese

• Body mass index (BMI) used as a measurementBody mass index (BMI) used as a measurement

Epidemic Proportions:Epidemic Proportions: US 1991 through 1998 US 1991 through 1998

• Percentage of obese men doubled Percentage of obese men doubled • Percentage of obese women increased Percentage of obese women increased

by 50% by 50% • More than 31% of adults in the US are More than 31% of adults in the US are

obese obese • More than 64% of Americans are More than 64% of Americans are

overweight overweight

PathophysiologyPathophysiology

• High caloric intakeHigh caloric intake• Low level of physical activityLow level of physical activity• Low level of metabolismLow level of metabolism• High insulin sensitivity?High insulin sensitivity?• Lack of anti-obesity hormone?Lack of anti-obesity hormone?

BMIBMI weight and height weight and height

• 25 to 29.9 kg/m25 to 29.9 kg/m22: overweight : overweight • 30 to 34.9 kg/m30 to 34.9 kg/m22: obese : obese

(class I obesity) (class I obesity) • 35 to 39.9 kg/m35 to 39.9 kg/m22: moderately obese : moderately obese

(class II obesity) (class II obesity) • 40 to 49.9 kg/m40 to 49.9 kg/m22: severely obese: severely obese

(class III obesity)(class III obesity)• >50.0 kg/m>50.0 kg/m22: super morbidly obese : super morbidly obese

(class IV obesity) (class IV obesity)

Higher riskHigher risk• Heart diseaseHeart disease• Diabetes Diabetes • HypertensionHypertension• StrokeStroke• OsteoarthritisOsteoarthritis• Kidney disease/stonesKidney disease/stones• Psychiatric issuesPsychiatric issues

• Impaired body image Impaired body image • Depression Depression • Loss of self esteemLoss of self esteem

Heart DiseaseHeart Disease

• Overall increase in both morbidity and Overall increase in both morbidity and mortalitymortality• Coronary artery diseaseCoronary artery disease• Atherosclerosis and hyperlipidemiaAtherosclerosis and hyperlipidemia• HypertensionHypertension• CHFCHF• Sudden cardiac deathSudden cardiac death• Peripheral vascular diseasePeripheral vascular disease

• As weight increases risks get higherAs weight increases risks get higher

Pulmonary ProblemsPulmonary Problems• Decrease in lung volumesDecrease in lung volumes• Increased work of breathingIncreased work of breathing

• Higher airway resistanceHigher airway resistance

• Higher chest wallHigher chest wall

• Decreased respiratory system complianceDecreased respiratory system compliance

• Flattened diaphragmsFlattened diaphragms

• Altered lung volumesAltered lung volumes

• Increased energy cost of breathingIncreased energy cost of breathing

Pulmonary ProblemsPulmonary Problems

• Pulmonary hypertension secondary to:Pulmonary hypertension secondary to:• Hypoxia Hypoxia

• Pulmonary vasoconstrictionPulmonary vasoconstriction

• Depressed heart functionDepressed heart function

Obesity-hypoventilation syndrome: Obesity-hypoventilation syndrome: Pickwickian syndromePickwickian syndrome

• 5% -- 10% of morbidly obese 5% -- 10% of morbidly obese • Left and right sided heart failure Left and right sided heart failure

commoncommon• Obstructive sleep apnea Obstructive sleep apnea • HypoxiaHypoxia• HypercapniaHypercapnia• Marked daytime somnolenceMarked daytime somnolence• Chronic respiratory acidosis Chronic respiratory acidosis

Cancer MortalityCancer Mortality

• Men:Men:• Stomach Stomach

• Prostate Prostate

• Women:Women:• Breast Breast

• Uterus Uterus

• CervixCervix

• OvaryOvary

Obstetrics and GynecologyObstetrics and Gynecology

• Female infertility Female infertility

• Disrupted menstruation and ovulationDisrupted menstruation and ovulation

• Early menstruation Early menstruation

• Urinary incontinence Urinary incontinence

• Abnormal labor Abnormal labor

• Increased progression to Cesarean section Increased progression to Cesarean section

• Increased fetal size Increased fetal size

• Pre-eclampsia and eclampsia Pre-eclampsia and eclampsia

• Gestational diabetes Gestational diabetes

Obesity and TraumaObesity and Trauma

• Premorbid risk factorPremorbid risk factor• Interference with activities of daily Interference with activities of daily

livingliving• Displaced ankle and elbow fractures Displaced ankle and elbow fractures

with minimal traumawith minimal trauma• Less likely to wear seat beltsLess likely to wear seat belts• Subcutaneous fat hides physical Subcutaneous fat hides physical

findingsfindings

Obesity and TraumaObesity and Trauma

• Head injury protection in blunt trauma Head injury protection in blunt trauma • Higher incidence chest injuriesHigher incidence chest injuries

• Physiologic airbagPhysiologic airbag

• Rib fracturesRib fractures

• Pulmonary contusionsPulmonary contusions

• Higher mortality due to respiratory causesHigher mortality due to respiratory causes

• Higher incidence of pelvic fracturesHigher incidence of pelvic fractures

Prehospital ChallengesPrehospital Challenges

• Delays due to problems in moving and Delays due to problems in moving and transporttransport

• Appropriate sized gurneysAppropriate sized gurneys• Excessive tissue impeding access for Excessive tissue impeding access for

giving fluids, taking BPgiving fluids, taking BP• Mobilization of manpowerMobilization of manpower• Managing airwaysManaging airways• Pulse oximetryPulse oximetry

AirwayAirway• Difficulties with Difficulties with

intubation and BVMintubation and BVM• Preoxygenation is Preoxygenation is

criticalcritical• Desaturation is quickerDesaturation is quicker• Sitting upright or Sitting upright or

semirecumbent as long semirecumbent as long as possibleas possible

• Reduced pulmonary Reduced pulmonary compliancecompliance

• Higher ventilatory Higher ventilatory pressurespressures

• May need to occlude May need to occlude pop-off valve to pop-off valve to ventilateventilate Brazilian Journal of Anesthesiology, 2005; 55: 2: 256-260Brazilian Journal of Anesthesiology, 2005; 55: 2: 256-260

Tracheal Intubation of Morbidly Obese Patients: A Tracheal Intubation of Morbidly Obese Patients: A Useful Device Ricardo Francisco SimoniUseful Device Ricardo Francisco Simoni

Assessment of AirwayAssessment of Airway

Airway TechniquesAirway Techniques• Rolled towels or blanketsRolled towels or blankets

• between scapula between scapula • Displaces breast tissue Displaces breast tissue • Chest wall can obstruct Chest wall can obstruct

handlehandle

• under the occiputunder the occiput• Allows for sniffing positionAllows for sniffing position• Creates more space for the Creates more space for the

handlehandle

• Shorter than average Shorter than average handlehandle

• Adjustable angle Adjustable angle laryngoscopelaryngoscope Brazilian Journal of Anesthesiology, 2005; 55: 2: 256-260Brazilian Journal of Anesthesiology, 2005; 55: 2: 256-260

Tracheal Intubation of Morbidly Obese Patients: A Useful Tracheal Intubation of Morbidly Obese Patients: A Useful Device Ricardo Francisco SimoniDevice Ricardo Francisco Simoni

Alternate AirwaysAlternate Airways

• Awake oral Awake oral intubationintubation

• Blind nasotracheal Blind nasotracheal intubationintubation

• LMALMA• Esophageal-tracheal Esophageal-tracheal

double lumendouble lumen• CricothyrotomyCricothyrotomy

Anticipate airway difficultyAnticipate airway difficulty

• Awake techniques if possible  Awake techniques if possible  • pre oxygenate in reverse Trendelenburg pre oxygenate in reverse Trendelenburg

positionposition• for RSI consider increased dose of medsfor RSI consider increased dose of meds• LMA has increased risk for aspirationLMA has increased risk for aspiration• Neck anatomy distorted due to excess Neck anatomy distorted due to excess

tissuetissue

SphygmomanometrySphygmomanometry

• Inadequate width and circumference Inadequate width and circumference can artificially elevate blood pressurecan artificially elevate blood pressure

• Cuff width to arm circumferenceCuff width to arm circumference• Ratio of 2 : 5Ratio of 2 : 5

• Bladder length 80% arm circumferenceBladder length 80% arm circumference

• Important to have variety of cuffsImportant to have variety of cuffs

Pulse OximetryPulse Oximetry

• Tissue thickness impedes light wave Tissue thickness impedes light wave transmissiontransmission

• Other areas of placementOther areas of placement• EarlobeEarlobe

• Fifth digit of hand or footFifth digit of hand or foot

• NoseNose

• LipLip

• Temporal arteryTemporal artery

Venous AccessVenous Access• Landmark vessels not visualized or palpatedLandmark vessels not visualized or palpated• Multiple attemptsMultiple attempts• Delay in accessDelay in access• Higher complication rates Higher complication rates

• Secondary to multiple sticksSecondary to multiple sticks• Wound infectionsWound infections• PhlebitisPhlebitis• ThrombosisThrombosis

• Standard 1.5-in needles not long enoughStandard 1.5-in needles not long enough• 3-4-in needles and catheters preferred3-4-in needles and catheters preferred

Improving Chances at Improving Chances at Venous AccessVenous Access

• Applying heatApplying heat• Light tapping over vesselsLight tapping over vessels• Active or passive pumping of extremityActive or passive pumping of extremity• Topical nitroglycerin*Topical nitroglycerin*• IntraosseousIntraosseous• Reactive HyperemiaReactive Hyperemia

• Occlude with BP cuff 3-4 minutesOcclude with BP cuff 3-4 minutes

• Release 10-15 mmHg below diastolicRelease 10-15 mmHg below diastolic

ECG DifficultiesECG Difficulties

• Difficult landmarks for lead placementDifficult landmarks for lead placement• Decreased or inconsistent voltageDecreased or inconsistent voltage• Increased fat deposits around the heartIncreased fat deposits around the heart• Flat/inverted T waves inferior leadsFlat/inverted T waves inferior leads

• Consistent change in obesityConsistent change in obesity

• Non-specificNon-specific

ECG DifferencesECG Differences• ECGs of 100 obese subjects and 100 normal ECGs of 100 obese subjects and 100 normal

subjects no evidence of cardiac disease subjects no evidence of cardiac disease • P, QRS, and T wave axes were more leftwardP, QRS, and T wave axes were more leftward• More LVH More LVH • left atrial abnormality and left atrial abnormality and • T wave flattening in the inferior and lateral T wave flattening in the inferior and lateral

leads leads • Prolonged QT interval Prolonged QT interval

• Alpert et al American Journal Cardiology 2000Alpert et al American Journal Cardiology 2000

EMS ChallengesEMS Challenges

• transporting people in a manner that is as safe as possible both transporting people in a manner that is as safe as possible both for the personnel and their patients, as well as in a respectful for the personnel and their patients, as well as in a respectful mannermanner

• 2000-2001 injuries related to transferring and handling of 2000-2001 injuries related to transferring and handling of patients represented at least 50% of Workers’ Compensation patients represented at least 50% of Workers’ Compensation annual costs. annual costs.

• 2 or 3 people are available to move a patient from one spot to 2 or 3 people are available to move a patient from one spot to another another

• Just one injury could mean the end to an EMT or paramedic’s Just one injury could mean the end to an EMT or paramedic’s career career

• transporting people in a manner that is as safe as possible both transporting people in a manner that is as safe as possible both for the personnel and their patients, as well as in a respectful for the personnel and their patients, as well as in a respectful manner manner

Transporting the Morbidly Obese Patient: Framing an EMS Challenge Journal of Emergency Nursing Transporting the Morbidly Obese Patient: Framing an EMS Challenge Journal of Emergency Nursing August 2002August 2002

Meeting the ChallengeMeeting the Challenge• EMS providers must conduct pre-planning exercises EMS providers must conduct pre-planning exercises

to prepare for attending to special situations. to prepare for attending to special situations. • Experts advocate for the following:Experts advocate for the following:

• creation of policy and procedurescreation of policy and procedures• pre-training pre-training • continuing education continuing education • request for lift assistance request for lift assistance • community involvement community involvement • use of equipment that helps patients without harming use of equipment that helps patients without harming

workers.workers.• Even with the best intentions, treating and Even with the best intentions, treating and

transporting morbidly obese patients will take more transporting morbidly obese patients will take more time than almost any other type of call to which EMS time than almost any other type of call to which EMS responds responds

Transporting the Morbidly Obese Patient: Framing an EMS Challenge Transporting the Morbidly Obese Patient: Framing an EMS Challenge Journal of Emergency Nursing August 2002Journal of Emergency Nursing August 2002

Current EducationCurrent Education

• EMT Paramedic Curriculum minimally EMT Paramedic Curriculum minimally covers obese patients covers obese patients • teaching that accommodations may be teaching that accommodations may be

necessary necessary • Need to use appropriately sized diagnostic Need to use appropriately sized diagnostic

devicesdevices• Maintain professionalismMaintain professionalism• Notes that the paramedic may require Notes that the paramedic may require

additional assistanceadditional assistance

Provider ChallengesProvider Challenges

• LogisticsLogistics• Labor intensiveLabor intensive• Equipment unaccommodatingEquipment unaccommodating

• Securing antler must be dismantledSecuring antler must be dismantled• Transport from ambulance floorTransport from ambulance floor

• Unsafe transportsUnsafe transports• Undignified transportsUndignified transports

• Medication requirementsMedication requirements• BiasBias

Safety in equipmentSafety in equipment• A standard box-shaped ambulance A standard box-shaped ambulance

• 40- to 44-inch width inside of the patient compartment 40- to 44-inch width inside of the patient compartment • crash tested and rated for a payload max 1600 poundscrash tested and rated for a payload max 1600 pounds

• Patient weighing 700 pounds Patient weighing 700 pounds • can measure 50 to 55 inches widecan measure 50 to 55 inches wide• 2 or 3 health care providers needed to care for the patient 2 or 3 health care providers needed to care for the patient

could together weigh 600 pounds could together weigh 600 pounds • Little room is left for the equipment and supplies required.Little room is left for the equipment and supplies required.

FDNY GuidelinesFDNY Guidelines

• Paramedic unit is called to the scene to Paramedic unit is called to the scene to determine:determine:• Patient’s conditionPatient’s condition

• If removal is emergent/life threatening or If removal is emergent/life threatening or non-emergentnon-emergent

• If patient can be treated at the scene or If patient can be treated at the scene or must be moved to the hospitalmust be moved to the hospital

FDNY GuidelinesFDNY Guidelines• Removal considerationsRemoval considerations

• How to be packagedHow to be packaged• Stokes stretcher Stokes stretcher • Body bagBody bag

• MethodMethod• Carry dragCarry drag• LowerLower• Ropes or slingsRopes or slings

• Removal route to Removal route to ambulanceambulance

• Need for additional Need for additional resourcesresources

• Collapse unitCollapse unit• ForkliftForklift• Flatbed truckFlatbed truck

Obstacles in TransportObstacles in Transport

• Removing the patient from the sceneRemoving the patient from the scene• Packaging and transferringPackaging and transferring• Moving to the ambulanceMoving to the ambulance• TransportationTransportation• PreplanningPreplanning

Challenges of RemovalChallenges of Removal

• Non-mobile patientsNon-mobile patients• Patients unable to fit through doorwayPatients unable to fit through doorway• Solution can be in removal of walls or Solution can be in removal of walls or

windowswindows• Requires heavy rescue equipmentRequires heavy rescue equipment

• Rescuers with engineering/construction Rescuers with engineering/construction experienceexperience

• Can lead to building collapse Can lead to building collapse

• Risk of injury to patient and crewRisk of injury to patient and crew

TransferringTransferring

• Standard backboardStandard backboard• Patient may not fitPatient may not fit

• Board unable to support weightBoard unable to support weight

• Rescuers must grasp and maintain board, Rescuers must grasp and maintain board, lift carry and maneuver in synclift carry and maneuver in sync

• Must lift from ground level to waistMust lift from ground level to waist

• Restricts breathing from prolonged period Restricts breathing from prolonged period of lying flatof lying flat

TransferringTransferring

• Options to the Options to the standard backboardstandard backboard• Specialized backboardsSpecialized backboards

• Basket stretchersBasket stretchers

• Reeves stretchersReeves stretchers

• Warehouse style cartsWarehouse style carts

Creating Company PolicyCreating Company Policy• Address the concernsAddress the concerns• identifies strategiesidentifies strategies• sets limits on how few people may sets limits on how few people may

attempt to move a patient over a attempt to move a patient over a specified weight.specified weight.

• Ensure policy that personnel call for lift Ensure policy that personnel call for lift assistance when confronted with a assistance when confronted with a patient who exceeds the lifting limits of patient who exceeds the lifting limits of the crew on scene.the crew on scene.

Creating Company PolicyCreating Company Policy• Provide routine training that includes new Provide routine training that includes new

strategies for morbidly obese patients in both strategies for morbidly obese patients in both emergency and non-emergency situations.emergency and non-emergency situations.

• Ensure pre-planning among responders and Ensure pre-planning among responders and the community the community

• Remind all providers to remain non-Remind all providers to remain non-judgmental judgmental

• Problem-solving suggestions given by Problem-solving suggestions given by providers for consideration providers for consideration

Company PolicyCompany Policy• Obtain proper equipment that is reasonably Obtain proper equipment that is reasonably

pricedpriced• Heavy rated stokes baskets or scoop stretchers Heavy rated stokes baskets or scoop stretchers

lined with layers of blankets to be used as lined with layers of blankets to be used as • cushion cushion • additional padding to elevate the patient’s headadditional padding to elevate the patient’s head

• Expandable/connectable flats made from extra Expandable/connectable flats made from extra heavy-duty materials for the oversized patientheavy-duty materials for the oversized patient

• Equipment for securing the apparatus to the floor Equipment for securing the apparatus to the floor of the ambulanceof the ambulance

• Ramps used to slide the patient, with the least Ramps used to slide the patient, with the least amount of lifting, during egress from a building amount of lifting, during egress from a building and/or loading into and out of the ambulance and/or loading into and out of the ambulance

Various Response Methods Various Response Methods used by EMS agenciesused by EMS agencies

• Patients that are too heavy for a 2-person Patients that are too heavy for a 2-person medic unit can request fire departmentmedic unit can request fire department

• MAN-S.A.C. rated at 1600 lbs.MAN-S.A.C. rated at 1600 lbs.• Heavy duty collapsible litters rated at 600 lbs.Heavy duty collapsible litters rated at 600 lbs.• Dispatching trucks with additional personnel Dispatching trucks with additional personnel

for liftingfor lifting• Flagged address so initial responses include Flagged address so initial responses include

extra crews if availableextra crews if available• Hold-harmless contracts if patient exceeds Hold-harmless contracts if patient exceeds

rated capacity of the stretcherrated capacity of the stretcher

Proflexx with LBSProflexx with LBS

More Questions than AnswersMore Questions than Answers

• Is there a demand for a stretcher that Is there a demand for a stretcher that could carry persons in excess of 500 lb?could carry persons in excess of 500 lb?

• Would a larger stretcher require a Would a larger stretcher require a larger ambulance? larger ambulance?

• Would a larger stretcher require a Would a larger stretcher require a different securing/locking device? different securing/locking device?

Many More Questions than Many More Questions than AnswersAnswers

• Would a larger ambulance stretcher allow Would a larger ambulance stretcher allow enough room to provide patient care?enough room to provide patient care?

• Are there federal or state regulations Are there federal or state regulations requiring mandatory transport of the requiring mandatory transport of the morbidly obese patient?morbidly obese patient?

• What liability exposure the provider has What liability exposure the provider has when transporting a morbidly obese patient when transporting a morbidly obese patient in an ambulance that cannot secure the in an ambulance that cannot secure the transporting device to the vehicle?transporting device to the vehicle?

Some Helpful PointersSome Helpful Pointers

• Size-up building, check stairs and other Size-up building, check stairs and other escape routes escape routes

• Think outside the boxThink outside the box• Don’t exceed equipment ratingsDon’t exceed equipment ratings• Know cot capacity and weight limitsKnow cot capacity and weight limits• Appoint safety officer not working on the Appoint safety officer not working on the

rescue to oversee health and safety issuesrescue to oversee health and safety issues

Best PracticesBest Practices

• Non-emergent transportNon-emergent transport• Ascertain patient sizeAscertain patient size• Schedule crew appropriatelySchedule crew appropriately

• Size up the sceneSize up the scene• Know patient’s weightKnow patient’s weight• Match crew capability with taskMatch crew capability with task• Call for assistance before neededCall for assistance before needed

More Helpful TipsMore Helpful Tips

• Treat patient with dignityTreat patient with dignity• Establish a system Establish a system

• Write protocols Write protocols

• Practice runsPractice runs

• Assigned staff member to specialize in bariatric Assigned staff member to specialize in bariatric transferstransfers

• Locate obese patients, preplan for future Locate obese patients, preplan for future plans to each patients houseplans to each patients house

• Evaluate patient mobility prior to transportEvaluate patient mobility prior to transport

More Helpful TipsMore Helpful Tips

• Scene assessmentScene assessment• Door widthDoor width

• Steps Steps

• Vehicle placement so terrain works in your Vehicle placement so terrain works in your favorfavor

• PersonnelPersonnel• Have a back-up planHave a back-up plan• Cot designed to hold patients specific weightCot designed to hold patients specific weight