Bariatric PatientsBariatric PatientsPresence Regional EMS System

September 2015

ObjectivesObjectives

• Define the terms “Bariatric” and “Obese”• Discuss the problem of obesity in the United

States• Discuss medical conditions complicated by a

patients who are morbidly obese• Outline the plan of care for patients who are

morbidly obese• Describe means to protect a morbidly obese

patient and care givers during care and transport

What is BariatricsWhat is Bariatrics

a branch of medicine that deals with the control and treatment of obesity and allied diseases.

a Bariatric patient is categorized as morbidly obese if they are:

100 pounds over ideal weight

50-100% over ideal weight

Body Mass Index over 40kg/m2

Obesity is one of the leading health care

problems in the United States today.

Obesity is one of the leading health care

problems in the United States today.

Obesity/BariatricsObesity/Bariatrics

Condition of an excessive proportion of adipose (fat) tissue to total body weight

Prevalence has doubled over last 20 years and still increasing

40% of adults are considered overweight (as many as 9 million adults)

Obesity related medical costs were estimated to be $147 million annually

Body Weight is the result of genes, metabolism, behavior,

environment, culture, and socioeconomic status

Body Weight is the result of genes, metabolism, behavior,

environment, culture, and socioeconomic status

How did this Bariatric Epidemic happen?How did this Bariatric Epidemic happen?

In last half of 20th century advent of tasty and readily available fast food; high in calories and saturated fats

Developing sedentary lifestyle 200+ cable channels

Video games

How do people become obese?How do people become obese?

Everyone requires a certain amount of fat to create minerals and vitamins for the body’s use.

There is an imbalance between calories taken in and calories used to meet energy needs.

Prevalence of obesity among adults 2009 from the CDC

Prevalence of obesity among adults 2009 from the CDC

Body Mass Index ChartBody Mass Index Chart

Caloric Balance EquationOverweight and obesity result from an energy imbalance, this involves eating too many calories and not getting enough physical exercise/activity

Behavior and environment play a large role causing people to be overweight and obese. These are the greatest areas for prevention and treatment

How To Achieve Caloric Balance How To Achieve Caloric Balance

Food DiaryWriting down foods and beverages you consume

Yes, there are Apps for that

Physical Activity DiaryDocument the physical activity you have done

Pedometers measure the number of steps taken daily

Medical Treatment for ObesityMedical Treatment for Obesity

DietaryReduce calorie intake

Feeling full on less

Healthy eating

Meal replacements

(energy shakes)

Increase ActivityExercise

Increase daily activity

Behavioral ChangesBehavior modification

Support groups

Prescription weight loss

Olistat (Xenical)Blocks the digestion of fat in stomach and intestines

Unabsorbed fat is eliminated in the stool

Don’t they have surgery for Obesity??

Don’t they have surgery for Obesity??

Surgical TreatmentSurgical Treatment

Lap BandOne Weight loss Component

Reduces the size of the stomach

Gastric BypassTwo Components

Reduce the size of the stomach

Reduce Caloric Absorption

Complications of Gastric Surgery Complications of Gastric Surgery

First 12 weeks after surgeryNausea and vomiting

Decreased ability to absorb fluids due to surgery

Sepsis due to leaking at surgical sites

Fluctuations in BP due to changes in body size and poor absorption of medications

Psychosocial Response to ObesityPsychosocial Response to Obesity

Obese patients may be embarrassed by their condition and fearful of ridicule as a result of past experiences.

Some of the negative interactions may have occurred with an insensitive health care professional.

Mobility and the person’s general quality of life are often negatively affected by their size.

Obese persons are often ridiculed publicly and are sometimes are victims of discrimination.

Many obese patients have not been out of their home for months or years.

When EMS is called these individuals find themselves the center or attention, surrounded by emergency vehicles, curious onlookers and sometimes the media.

Other Medical Problems Associated with ObesityOther Medical Problems Associated with Obesity

DiabetesHigh blood pressureElevated cholesterolHeart diseaseAsthmaSleep apneaGallstonesHepatitisHeartburnSkin infections/Ulcers

InfertilityUrinary leakageDepressionSelf-esteem issuesDementiaGoutImmobilityJoint PainOsteoarthritisBreast and colon cancer

Cardiac Disease: Seen at Younger AgesCardiac Disease: Seen at Younger Ages

Overall increase in both morbidity and mortality

Coronary artery diseaseAtherosclerosisHypertension

For every 5 lb. weight gain BP increases 3 mm/Hg

CHFSudden Cardiac ArrestPeripheral vascular disease

As weight increases risks increase

Pulmonary Diseases Pulmonary Diseases

Decrease in lung volumesIncreased oxygen demand due to sizeIncreased work of breathing

Higher airway resistanceDecreased respiratory system complianceFlattened diaphragmHypoxiaPulmonary vasoconstrictionDepressed heart functionTachypneaBecomes short of breath easily with only mild exertion

Pickwickian SyndromePickwickian SyndromeObesity hypoventilation syndrome

Unable to take in enough oxygen to meet body’s needs

5-10% of morbidly obese suffer this

Left and right sided heart failure

Obstructive sleep apnea

Short, thick neck and small oropharyngeal diameter

SymptomsCyanosis

Hypoxia

Chronic acidosis

Marked daytime sleepiness

DiabetesDiabetes80% of people with Type II diabetes are obese.

Type II diabetesProduce adequate amounts of insulin but

Insulin unable to effectively stimulate the cell to admit glucose

Increases weight = increase size of fat cells

Large fat cells have decreased proportion of insulin receptors

With weight loss insulin receptors in more appropriate numbers

Signs and symptoms of Type II diabetes recede

TraumaTrauma

Poor mobility due to weight

Interference with activities of daily living, axial loads and balance issues

Displaced ankle and elbow fractures with minimal trauma

Less likely to wear seat belts

Subcutaneous fat hides physical findings

Increased length of stay in hospital

Chronic Joint PainChronic Joint Pain

Morbidly obese patients may overcome mobility problems by pulling, rocking or rolling into position.

Constant strain on body structures may leave them with chronic joint injuries and/or osteoarthritis

The Bariatric Patient is first and foremost a

PATIENT.

The Bariatric Patient is first and foremost a

PATIENT.

Management of the Bariatric PatientManagement of the Bariatric Patient

Treat the patient with dignity and respect

Provide thorough and professional medical care.

Bariatric patients frequently have complex and extensive medical history so get a good medical history and perform a good physical exam

Bariatric patients tend to blame signs and symptoms of their illness on their weight

AssessmentAssessment

Remind the patient that their physical and psychological well being are your priority

Keep the patient upright to facilitate ventilation

Check for cyanosis inside lips or eyelids

Airway ManagementAirway Management

Extra skin and adipose tissue around the face, bottom of the chin/neck, and posterior upper chest can interfere with respiratory function when the patient is supine.

Extra adipose tissue in the cheeks, lower jaw and anterior neck place pressure on the tongue and glottic opening

Airway ManagementAirway Management

High risk for aspiration

If BVM ventilation required use 2 person technique to assure good seal and adequate ventilation

May need higher volumes to displace diaphragm

If using CPAP higher pressures (up to 10 cm3) may be needed

IntubationIntubation

Pre-oxygenation is criticalDesaturation is quicker because of decreased reserve and normal tendency towards hypoventilation

Sitting upright 25 degrees improves ventilation

Difficult ventilationNeed for higher ventilation pressures

Large tongue and head weight

Intubation challengesIntubation challenges

Mallampati ClassificationsUsed to predict ease of intubation

Extra tissue in airway leads to higher Mallampati Classifications and more difficult intubations

Airway Intubation Techniques Airway Intubation Techniques

Rolled Towels or BlanketsBetween scapulae

Displaces breast tissue

Under occiput to account for fat in backSniffing position

Elevate arms to move neck tissue out of the way

Combi-tube or King Airway frequently the best option

Breath SoundsBreath Sounds

Auscultate lung sounds anteriorly on chest to avoid dulling of sounds by adipose tissue

If listening posteriorly stay just below scapula on either side of spine.

Diagnostic EquipmentDiagnostic Equipment

Blood PressureInadequate width and circumference cuff can give elevated readings

If the Velcro “cracks” the cuff is too small.

In general with width of the cuff should be ½ to 1/3 the circumference of the arm.

Pulse OximetryTissue thickness impedes light wave

Consider alternate placementEarlobe

Smaller fingers

IV AccessIV Access

Difficult to visualize and palpateDelay in accessHigher complication rates

Multiple attemptsWound infectionsPhlebitisUnrecognized extravasation into surrounding tissue

Standard catheters of 1.5 inches may be inadequate in lengthIO needs a longer needle

Cardiac MonitoringCardiac MonitoringPlace monitoring electrodes on arms and thighs rather than chest

Difficult to find landmarks for 12 lead placement

Decreased or inconsistent voltage

Changes with obesityflat/inverted T waves in inferior leads

P, QRS and T axis more leftward

More left ventricular hypertrophy

Prolonged QT interval

Medication uptakeMedication uptake

Patients receiving oral medications must have their dosages and even routes adjusted for the changes in absorption capacity with and without Bariatric surgery

Excess body fat can alter medication absorption and storage, this does not seem to have an affect on IV resuscitation medications

Spinal Motion Restriction Spinal Motion Restriction

No Bariatric sized equipment currently available

Concentrate on Minimizing movement

Keep the patient as still as possible

Attempt to keep patient supine

Moving a Bariatric PatientMoving a Bariatric Patient

Planning

Patience

“Its not if…but when”“Its not if…but when”

Every agency needs to be prepared to handle a bariatric patient. The right equipment ensures not only patient safety but the safety of your crews.

Anticipate it will take up to 10X longer to extricate an obese patient from their home.

Pre-planningPre-planning

Where are the obese patients in your response area?

Can you communicate with them ahead of an emergency?

Where do they live in their house? (obese patients frequently limit their mobility within their home)

What equipment is available in your community. How quickly can you access it?

How can you get your equipment in and the patient out?

Moving the PatientMoving the Patient

Ask the patient how it is best to move him/her before attempting to do so.

Avoid trying to lift the patient by only one limp which could injury overtaxed joints

Have enough providers to move the patient safely. (4-6 minimum)

Coordinate and communicate all moves to all team embers prior to starting the lift

If the move becomes uncontrolled at any point: stop, reposition and resume.

Continually communicate with the patient regarding the move. Bariatric patients frequently are scared of moving and/or being dropped.

Assess for pressure or pinch points from equipment: can cause skin breakdown

Plan egress routes to accommodate large patients, equipment and sufficient numbers of lifting crew members

DO NO HARM

Notify the receiving facility early to allow for special arrangements to be made to accommodate the patient.

Bariatric Transport SafetyBariatric Transport Safety

Planning is essentialBariatric transport unit

Bariatric assets (cot, lifting/moving equipment)

Adequate number of personnel

CotsCots

Ferno

LBS System 1000 lb. capacity

Stryker Bariatric Cot

1600 lb. capacity

ReviewReview

Answer the following questions as a group.

If doing this CE individually, please e-mail your answers to:

shelley.peelman@presencehealth.org

Use “September 2015 CE” in subject box.

You will receive an e-mail confirmation. Print this confirmation for your records, and document the CE in your PREMSS CE record book.

IDPH site code # 067100E1215

ReviewReview

How is obesity defined based on Body Mass Index?

1.

What are two ways to try to manage obesity without surgery?

2.

3.

What are two surgical procedures that might be done to control obesity?

4.

5.

What are two ways that obesity might effect a patient psychologically?

6.

7.

List three medical conditions complicated by obesity.

8.

9.

10.

List 2 professional ways to approach the management of an obese patient.

11.

12.

List 3 ways you may need to modify patient care for someone who is obese.

13.

14.

15.

Consider your own agency and communityConsider your own agency and community

You and your team have been called to help a woman who weight 500+ pounds. She is having chest pain and needs to go to the hospital. She is in the living room of her house on a large recliner. What decisions to you need to make in order to move her safely? What equipment will you need? Where can you get this equipment? How many people will it take to move her safely? (There is no right or wrong answer for this. Brainstorm how your agency will manage this.)

AnswersAnswers

1. BMI of greater than 40 kg/m2

2. Reduce caloric intake: food diary, healthy eating, supplemental shakes;

3. Increase activity; behavior modification, support groups

4. Lap Band

5. Gastric bypass

6. Embarrassment

7. Fear of ridicule , isolation

8. Heart Disease

9. Pulmonary Disease, Hypoventilation

10. Type II Diabetes

11. Treat the patient with dignity and respect

12. Provide thorough and professional medical care; perform a good physical exam and history

13. Patient needs to sit upright

14. Use 2 people to BVM if needed; use towel rolls to position airway

15. Listen to breath sounds anteriorly

Place EKG leads on arms and thighs,

Use larger IV catheters, use larger BP cuffs, pulse oximetry on earlobes, modify spinal motion restriction.