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 Condition of an excessive proportion of adipose tissue to total body weightadipose tissue to total body weight

• Prevalence doubled over last 20 years and Prevalence doubled over last 20 years and still increasingstill increasing

• 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 Body mass index (BMI) used as a measurementmeasurement

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 Percentage of obese women increased by 50% increased by 50%

• More than 31% of adults in the US More than 31% of adults in the US are obese are 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 Decreased respiratory system compliancecompliance

• Flattened diaphragmsFlattened diaphragms

• Altered lung volumesAltered lung volumes

• Increased energy cost of breathingIncreased energy cost of breathing

Pulmonary ProblemsPulmonary Problems

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

• Pulmonary vasoconstrictionPulmonary vasoconstriction

• Depressed heart functionDepressed heart function

Obesity-hypoventilation Obesity-hypoventilation syndrome: 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 Obstetrics and GynecologyGynecology

• 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 Increased progression to Cesarean section 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 Higher mortality due to respiratory causescauses

• 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 Desaturation is

quickerquicker• Sitting upright or Sitting upright or

semirecumbent as semirecumbent as long as possiblelong as 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: Brazilian Journal of Anesthesiology, 2005; 55: 2: 256-2602: 256-260Tracheal Intubation of Morbidly Obese Tracheal Intubation of Morbidly Obese Patients: A Useful Device Ricardo Francisco Patients: A Useful Device Ricardo Francisco SimoniSimoni

Assessment of AirwayAssessment of Airway

Airway TechniquesAirway Techniques• Rolled towels or Rolled towels or

blanketsblankets• 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 Allows for sniffing

positionposition• Creates more space for Creates more space for

the handlethe handle

• Shorter than average Shorter than average handlehandle

• Adjustable angle Adjustable angle laryngoscopelaryngoscope

Brazilian Journal of Anesthesiology, 2005; 55: 2: Brazilian Journal of Anesthesiology, 2005; 55: 2: 256-260256-260Tracheal Intubation of Morbidly Obese Patients: A Tracheal Intubation of Morbidly Obese Patients: A Useful Device Ricardo Francisco SimoniUseful Device Ricardo Francisco Simoni

Alternate AirwaysAlternate Airways

• Awake oral Awake oral intubationintubation

• Blind nasotracheal Blind nasotracheal intubationintubation

• LMALMA

• Esophageal-Esophageal-tracheal double tracheal double lumenlumen

• CricothyrotomyCricothyrotomy

Anticipate airway Anticipate airway difficultydifficulty

• Awake techniques if possible  Awake techniques if possible  

• pre oxygenate in reverse pre oxygenate in reverse Trendelenburg positionTrendelenburg position

• for RSI consider increased dose of for RSI consider increased dose of medsmeds

• LMA has increased risk for aspirationLMA has increased risk for aspiration

• Neck anatomy distorted due to Neck anatomy distorted due to excess tissueexcess tissue

SphygmomanometrySphygmomanometry

• Inadequate width and Inadequate width and circumference can artificially circumference can artificially elevate blood pressureelevate 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 Tissue thickness impedes light wave transmissionwave transmission

• 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 Landmark vessels not visualized or palpatedpalpated

• 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 Active or passive pumping of extremityextremity

• 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 Increased fat deposits around the heartheart

• 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 ECGs of 100 obese subjects and 100

normal subjects no evidence of cardiac normal subjects no evidence of cardiac disease disease

• P, QRS, and T wave axes were more P, QRS, and T wave axes were more leftwardleftward

• More LVH More LVH • left atrial abnormality and left atrial abnormality and • T wave flattening in the inferior and T wave flattening in the inferior and

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

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

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

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

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

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

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

exercises to prepare for attending to special exercises to prepare for attending to special situations. 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 transporting morbidly obese patients will take more time than almost any other type of call to more time than almost any other type of call to which EMS responds which EMS 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 EMT Paramedic Curriculum minimally covers obese patients minimally covers obese patients • teaching that accommodations may teaching that accommodations may

be necessary be necessary

• Need to use appropriately sized Need to use appropriately sized diagnostic devicesdiagnostic devices

• 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 40- to 44-inch width inside of the patient

compartment compartment

• crash tested and rated for a payload max 1600 crash tested and rated for a payload max 1600 poundspounds

• 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 2 or 3 health care providers needed to care for the patient could together weigh 600 pounds patient could together weigh 600 pounds

• Little room is left for the equipment and supplies Little room is left for the equipment and supplies required.required.

FDNY GuidelinesFDNY Guidelines

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

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

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

FDNY GuidelinesFDNY Guidelines• Removal Removal

considerationsconsiderations• 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 Removing the patient from the scenescene

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

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

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

TransferringTransferring

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

backboardsbackboards

• Basket stretchersBasket stretchers

• Reeves stretchersReeves stretchers

• Warehouse style Warehouse style cartscarts

Creating Company Creating Company PolicyPolicy

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

Creating Company Creating Company PolicyPolicy

• Provide routine training that includes Provide routine training that includes new strategies for morbidly obese new strategies for morbidly obese patients in both emergency and non-patients in both emergency and non-emergency situations.emergency situations.

• Ensure pre-planning among responders Ensure pre-planning among responders and the community and 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 Equipment for securing the apparatus to the floor of the ambulancefloor of 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 Various Response Methods used by EMS Methods used by EMS

agenciesagencies• 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 Heavy duty collapsible litters rated at 600

lbs.lbs.• Dispatching trucks with additional Dispatching trucks with additional

personnel for liftingpersonnel for lifting• Flagged address so initial responses Flagged address so initial responses

include extra crews if availableinclude extra crews if available• Hold-harmless contracts if patient Hold-harmless contracts if patient

exceeds rated capacity of the stretcherexceeds rated capacity of the stretcher

Proflexx with LBSProflexx with LBS

More Questions than More Questions than AnswersAnswers

• Is there a demand for a stretcher Is there a demand for a stretcher that could carry persons in excess that could carry persons in excess of 500 lb?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 Many More Questions than Answersthan Answers

• 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 when transporting a morbidly obese patient in an ambulance that cannot patient in an ambulance that cannot secure the transporting device to the secure the transporting device to the vehicle?vehicle?

Some Helpful PointersSome Helpful Pointers

• Size-up building, check stairs and Size-up building, check stairs and other escape routes other 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 Appoint safety officer not working on the rescue to oversee health and the rescue to oversee health and safety issuessafety 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 Assigned staff member to specialize in bariatric transfersbariatric transfers

• 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 Evaluate patient mobility prior to transporttransport

More Helpful TipsMore Helpful Tips

• Scene assessmentScene assessment• Door widthDoor width

• Steps Steps

• Vehicle placement so terrain works in Vehicle placement so terrain works in your favoryour favor

• PersonnelPersonnel

• Have a back-up planHave a back-up plan

• Cot designed to hold patients specific Cot designed to hold patients specific weightweight