When a motor vehicle accident results in significant damage, it can be extremely difficult to remove any person; if the entrapped victim is obese the task is that much more difficult. The patient may have limited mobility and be unable to assist in extrication. The vehicle’s seatbelt may not be able to accommodate the girth of the patient leading to increased injury severity.
It can be especially hard to maintain c-spine immobilization during the extrication. There is the possibility for prolonged extrication times and need for specialized equipment, such as the Jaws of Life, to aid in getting the patient out of the vehicle. Extra providers are likely needed for assistance in extrication, lifting, and transport of the bariatric patient. Early notification of fire, police, or specialized transport teams -— where available — may help reduce the time required to get the these patients to the hospital. ‘
During this process it is important to maintain professional demeanor and patient dignity, doing everything possible to prevent patient embarrassment and minimize bystander proximity. As with all emergencies, training is key. Heavier manikins are available for training scenarios to prepare EMS personnel for these situations (figure 1). Preplanning and well drilled protocols help ensure safe and effective extrication and transport.
Vehicles with altered structure secondary to a crash are not the only locations that present extrication difficulties. With some patients, especially those in the “super obese” category (BMI >50), bathrooms or the upper floors of a house may present significant obstacles. Bathrooms are a common place for injuries and can be extremely challenging when numerous providers are needed to move the patient. Door widths and the angles of corners may be impassable. These potential confounders should be accounted for prior to attempting to move the patient. Fire and police personnel may be able to assist in removing door frames to accommodate transport. At times extreme measure, such as cranes or forklifts, may need to be utilized in order to remove a patient from a compromised position.
Often standard immobilization equipment will not accommodate the obese patient, and some creativity may be required. Regardless of methods, providers must remember to avoid excessive tightness with a c-collar. This may compress the carotid arteries supplying blood to the brain, and the jugular veins which drain blood from the cerebral circulation. If the cervical collar is impractical other methods are needed to maintain spinal immobilization.
Towels may need to be placed under the patient’s neck to prevent hyperextension from excessive adipose tissue on the back. A sandbag on both sides of the head and tape across the forehead to the backboard is one method that may be effective in immobilization. Many obese patients suffer from sleep apnea where excessive soft tissues obstruct the airway when the patient is supine. Asking the patient if they use CPAP or BiPAP to help sleep may identify these patients. Sleep apnea, along with limited chest excursion from excess weight, indicates that their respiratory status may rapidly decline when lying supine. A reverse Trendelenburg position may facilitate lung expansion (see part one of this article).
Establishing IV access is another aspect of prehospital care often complicated by obesity. Normal landmarks may be distorted, and visualization of veins may be impossible. Ultrasound guidance and central venous catheters are often used in hospitals with patients whose weight makes peripheral IVs problematic. Carefully consider the need for intravenous access prior to transport. Evaluate the possibility of using intraosseous or intramuscular routes for medication administration. These may not be straightforward either; longer IO needles may be required. Spinal needles may need to be used to penetrate subcutaneous adipose tissue and reach the muscle to give IM medications.
IV administration is preferred for drug dosing due to variable absorption of subcutaneous/adipose tissue drug administration. Dose adjustments may also need to be made in medications administered to obese patients. Medication pharmacokinetics are multifactorial and difficult to predict. All drugs with potential cardiovascular depressant effects must be used with caution in obese patients whose physiologic reserve is limited. Knowing the attributes of the drugs carried by your service, i.e. whether they are lipophilic versus hydrophilic will help determine if the dose needs to be increased due to excessive weight.
Be aware that not all drugs will need to be given in higher doses. One general principle can help to simplify this: hydrophilic drugs should be dosed according to ideal body weight and lipophilic drugs should be dosed according to total body weight. For instance, etomidate and succinylcholine should be dosed on total body weight, but rocuronium and vecuronium should be dosed according to ideal body weight. Benzodiazepines as a single dose are more effective when dosed upon total body weight, but have increased half-life in obese patients, so some authors advocate using ideal body weight for subsequent doses or continuous infusions. Caution when administering opiates is also prudent, as they are also lipophilic and may require higher doses, but response is difficult to predict and excessive doses have potential for harm.
There are many challenges facing pre-hospital personnel in the management and transport of morbidly obese patients. In order to adequately meet these challenges, it is essential to have established policies and procedures. The familiar methods of “winging it,” or relying on common sense, are likely to expose the patient and pre-hospital personnel to possible physical injury. This could potentially result in medico-legal or workman’s compensation lawsuits. The components of a reasonable policy should include the elements of communication, personnel, equipment, and the procedure to bind them together.
The first essential element is communication. Unfortunately, the information that the patient may be morbidly obese is often not provided with the original EMS dispatch. The dispatch service can somewhat mitigate this deficit by prompting the caller for such information or by using a database to keep track of morbidly obese patients in the region. Once it is determined that the call involves an obese patient, this information needs to be communicated to all necessary personnel. Once all essential components are on the scene, the plan of transport needs to be communicated to the entire team. Finally, it is important to relay this patient information to the receiving facility in order for the necessary preparation to begin.
Obesity is also a factor when the mode of transportation is an issue. Often from remote scenes, air medical transport is the most efficacious transportation when time maters — the golden hour of trauma, MI, and stroke. Depending on the helicopter, its configuration, time of year, fuel load, distances to be traveled, and crew size, etc., many obese patients are too heavy to be transported by air.
No single weight is too heavy, but patients over 350 pounds are rarely flown due to these limitations. If air medical transport is not available, crews may be forced to take patients to the nearest, but perhaps not most capable, hospital for the situation. It is important for EMS to communicate effectively with air teams and regional hospitals to ensure the most appropriate mode of transportation and destination hospital.
Most medic units are two person units. Rarely can two people safely transport a patient that is morbidly obese, even if the patient is able to assist. Additional assistance should be provided by either first responders or other EMS personnel. It is crucial that all personnel are adept at proper lifting techniques. They also need to be familiar with special equipment that is utilized. If necessary, the additional personnel should accompany the ambulance to the hospital in order to assist unloading and transporting into the facility.
As a result of considerable need, there have been many recent innovations in equipment available to transport morbidly obese patients. This includes super-sized wheelchairs, backboards, stokes baskets, and scoop stretchers which can not only accommodate the excessive weight, but can also manage the excessive girth of the patient. There are also a number of options for lifting patients, including inflatable air bags and winch driven lifting devices.
It is essential that all personnel are cognizant of the weight limitation for each item implemented. Some systems also employ a designated oversized ambulance to transport these patients. These vehicles provide ample room to work in order to care for the patient. In addition, they contain the specialized equipment as well as a reinforced means to secure the transport device to the vehicle. In rare circumstances, heavy equipment may be necessary to assist in extracting the patient from the scene. There are many incidences of the creative use of lift trucks, cherry pickers, construction equipment and other items in the extrication of obese patients. There should be an established strategy for obtaining and utilizing any required equipment should the occasion arise.
With all of the necessary tangible assets in place, key policies and procedures should tie everything together. It is important for such procedures to include all possible means to preserve the patient’s privacy, dignity, and comfort. Practice drills should be implemented to aid in familiarizing all prehospital care providers with the proper procedures and equipment. Varying scenarios can provide an opportunity to identify inadequacies in procedures, equipment, and policy awareness.
The same challenges facing EMS face hospitals in dealing with the bariatric patients. Most current stretchers and hospital beds are not rated to handle the morbidly obese patient. Specialized bariatric beds can accommodate patients over 1000 pounds and 60 inches wide. In addition to supporting these patients they are especially designed to help prevent pressure ulcers, respiratory and circulatory compromise, facilitate changing position, and even transferring from bed. Bariatric wheelchairs, hoyer lifts, and other specialized equipment are required to safely manage these patients in the hospital.
Additional challenges face the physician in diagnosing the obese patient. Just as with EMS, obtaining IV access is a challenge. Moreover, obtaining radiographic images are equally problematic. Plain films may be limited due to body habitus and inadequate x-ray penetration and patient positioning. Obese patients also are difficult to evaluate using CT and MRI scanners. Most CT scan tables support 300 pounds and the highest capacity can support 500 to 600 pounds. Even if weight is not an issue, the circumference of the obese patient may not allow the body to fit within the bore of the CT/MRI — typical bore diameters 70 cm and 60 cm respectively.
Similar issues arise when patients require mechanical ventilation, surgery, etc. Knowing which hospitals within a region have the necessary equipment to evaluate and care for the morbidly obese patient may influence hospital triage decisions.
Legal and Safety Issues
There are significant liability risks for all participants in the transportation of morbidly obese patients. The patient can easily shift due to “unpredictable excessive flesh movement.” This can result in harm to both the patient and transporters. If the patient is injured, the personnel and agency involved with the transport may be held liable. This is especially true if proper procedures were not followed, or weight limits for transporting devices were exceeded. The agency can also be held liable in the event of an injured employee. Lifting injuries make up the greatest number of workman’s compensation cases. This stresses the importance of sound policies, procedures, and training.
The obesity epidemic requires all healthcare providers to become engaged and knowledgeable. Ideally through partnership and education we collectively can reverse obesity trends. Until that time, preparation, collaboration, and training are critical to allow prehospital care providers to effectively and safely deliver critical interventions to the injured and ill bariatric patient.
To read part 1 of this series, click here.