In the delivery of EMS services, we have similar situations. We respond to calls for falls, abdominal pains, breathing problems, chest pain or any of a variety of chief complaints with such regularity that we respond with our standard EMS response package without so much as a second thought or pre-arrival planning. But, if you have ever arrived on scene to find that this patient is physically larger than normal, then you already understand that you now are faced with a new dynamic.
Dealing with the bariatric patient is not a new dynamic in emergency services, but there does seem to be a trend that puts us in this position more often than ever before. According to the Center for Disease Control and Prevention, more than 35 percent of the adults in the United States are obese.(www.cdc.gov for more information.)
This article is not to promote any of the numerous commercial offerings for equipment to help package and move these patients. My intent is to encourage you to consider the fact that this is not a routine medical or trauma call and you will be required to think, plan and act accordingly. From the responder’s standpoint, it boils down to safety issues. Safety for the patient and, as much if not more, the safety of the crew working the call.
Much like when we arrive at a call for a structure fire, our actions are dictated by conditions that we see upon arrival. We react differently to light colored lazy smoke from a single window than we do to heavy black smoke pumping from the front door down to a foot off the deck. Likewise, we react differently to how we handle the larger than normal patient.
The greatest asset that we can apply to these situations is manpower. If your typical response package on a medical call is two on a transport ambulance, and four on an engine or whatever first responder package you get, call for more help early and often until you actually have more help on the scene. A good rule of thumb for moving a patient — up to 200 pounds can generally be managed by two to four responders. Consideration should of course be given to the physical size and strength of those who are involved in moving the patient. Simply put: Use the Jethroes on the fire truck. This is no time for egos or stubbornness. We must take every precaution to not allow two things to happen.
- Do not drop these patients from any level.
- Do not incur an injury to a responder.
Anytime you are adding personnel to a movement, as much as possible, add in even numbers to help keep the load balanced. Just adding one more to a side or end will cause an undue shift of weight across the plain of the patient increasing the workload on those opposite of the “helped” side or end. Try to make as many horizontal movements as possible. Limit vertical movements to only those which are absolutely necessary. Most fire departments have tarps or canvasses in their RIT cache that may be helpful in this situation.
Most commercially available standard ambulance stretchers have a load bearing capacity of 500 to 700 pounds. You need to know what is the capacity of the one you are using. I remember some 25 to 30 years ago, they were mostly rated up to 300 pounds. Know what you have. If your patient is so large that you cannot utilize the safety features like straps, handrails up and locked, access to releases, etc., then you need to consider alternate resources.
You hope that each of these encounters will be on the ground floor and moving down from a Division 2 level is not necessary. However, we all know that is not always the case. If you are faced with this situation, you just promoted your scene to a technical rescue event and should act accordingly. Just like with Hazmat, USAR or Vehicle Extrication, call for technician level assets early on. This type of scenario may get complicated and time consuming. Here is a list of considerations when the call reaches this level.
What is the Patient’s Overall Condition?
You may find yourself treating illnesses or injury on the scene for an extended period of time. This may require logistics that you may need to call for. The person in charge of patient care should contact their medical control to apprise them of the situation. This may even require medical staff coming to the scene.
Use the Proper Equipment
The technical rescue equipment that we work with has weight limitations that may require us to interface with the commercial community who may have equipment better suited for this extrication. We work in a world of 600 pound load limits with our equipment. Yes, there is a safety factor built in, but I strongly discourage breeching our preset limits. If we are considering a fire service aerial device as a high angle change of direction, know what the tip load capacity of that apparatus is. In most cases, you will max out somewhere between 500 to 1,000 pounds. If you do employ a commercial service for this event, make sure that they send a representative who is 100 percent knowledgeable of what their capability is. Attach this person to your safety officer for the duration of the event.
The building itself may need to be altered to facilitate the move. A window may need to be removed or enlarged. You may even be looking at some type of wall breach. If this is a possibility, you will need to make sure that the building owner is on board with you, and a building engineer on site would be a preference.
You may be required to alter the transport unit to receive the patient. If you are going to have to transport to the hospital on a platform other than the stretcher, then the horns in the floor of the ambulance will probably need to be removed. Make sure that in the end, you have a way to secure that platform in the back of the ambulance.
Do not forget that at the conclusion of the transport to the hospital, you will need to move the patient from the transport unit into the hospital. Again, it is important that the receiving facility is given due notice of what you are bringing. They may have logistics and personnel needed for the transfer.
Again, the intent of this article is to create awareness of what you may be faced with when dealing with the bariatric patient. If anything you have read herein is conflicting with your department SOGs or local medical protocols, revert to your local directives and/or suggestions for best practices.
Always remember that these patients are patients. They are people that we have sworn to take care of and treat with our skills, knowledge, and as importantly, our compassion and dignity. Adhere to a zero tolerance on unnecessary and unwanted remarks about their size or the dilemma they face. Do your job with the same respect and compassion that you would want to receive.
Protect yourself and those you work with. Always be safe.
John Phillips has spent over 37 years with Mint Hill Volunteer Fire Dept. in Southeast Mecklenburg County. He has served 35 years as EMT, 25 years as a paramedic. He held the rank of EMS Chief for 18 years and then Chief of Department for seven years. Phillips currently holds the rank as Deputy Chief.