The Bariatric Patient

1. The Bariatric Patient The World is Growing Dixie Lee Davenport, RN, CEN, CCT-RN, PHRN EMS Outreach Manager Riverside Methodist Hospital OhioHealth

2. Disclosure • The author/speaker has no actual or potential conflict of interest in relation to this presentation • Vendor products mentioned and/or shown as examples • No unapproved or off-label usages will be discussed

3. Objectives • Define obesity • Review American and world statistics regarding the prevalence of obesity • Review of the pathophysiology of obesity • Identify co-morbidities associated with obesity • Identify special considerations related to trauma in the obese patient • Discuss challenges to prehospital and hospital providers in ergonomics • Discuss “sizism”, social stigma & sensitivity in dealing with the obese patient

4. Obesity Defined Condition of an excessive proportion of adipose tissue to total body weight that may lead to an unhealthy state.

5. Obesity Defined Definitions for Adults For adults, “overweight” and “obesity” ranges are determined by using weight and height to calculate a number called the "body mass index" (BMI)*. BMI is used because, for most people, it correlates with their amount of body fat. • An adult who has a BMI between 25 and 29.9 is considered overweight. • An adult who has a BMI of 30 or higher is considered obese.

6. Obesity Statistics - World • Obesity is a modern problem - statistics for it did not even exist 50 years ago. • Worldwide, obesity has more than doubled since 1980 • In 2008, more than 1.6 billion adults were overweight* • In 2010 more than 40 million children under the age of 5 were overweight • 65% of the world's population live in countries where overweight and obesity kills more people than being underweight • Overweight / obesity are the 5th leading risk in global deaths**

7. Obesity Statistics - World

8. Obesity Statistics – U.S. • A third of American adults are overweight • More than one-third of adults (35.7%) are obese • Combined, 68.8%of Americans are either overweight or obese • The CDC estimates 42% of Americans will be obese by the year 2030 • After smoking, obesity is America's biggest preventable cause of premature death • At the current rates of increase, obesity related health care costs are expected to exceed $300 billion by 2018 – more than double the $147 billion reported in 2008

9. Obesity Statistics – U.S.

10. Obesity Statistics – U.S. • In 2001 the initiative “Healthy People 2010” was introduced to spearhead lowering obesity rates to below 15% (In 2001, no state had an obesity prevalence of 30% or more.) • Nostate met the nation's Healthy People 2010goal. • Rather, in 2010, there were 12 states with an obesity increase of over 30%.

11. Pathophysiology • Why Are We Bigger?

12. Pathophysiology • Why Are We Bigger?

13. Pathophysiology • Why Are We Bigger? • High caloric intake • Low level of physical activity • Low level of metabolism • High insulin sensitivity? • Lack of anti-obesity hormone?

14. Role of Brain Neurotransmitters • Neurotransmitters govern the body’s response to starvation and dietary intake • Decreases in serotonin and increases in neuropeptide Y are associated with an increase in carbohydrate appetite • Neuropeptide Y increases during deprivation; may account for increase in appetite after dieting • Cravings for sweet, high-fat foods among obese and bulimic patients may involve the endorphin system

15. Obesity: A Higher Risk • Heart disease • Diabetes • Hypertension • Stroke • Osteoarthritis • Kidney disease/stones • Psychiatric issues • Impaired body image • Depression • Loss of self esteem

16. Obesity: A Higher Risk Heart Disease • Overall increase in both morbidity and mortality • Coronary artery disease • Atherosclerosis and hyperlipidemia • Hypertension • CHF • Sudden cardiac death • Peripheral vascular disease • As weight increases risks get higher

17. Obesity: A Higher Risk The Diabetes Epidemic • The prevalence of Type 2 diabetes worldwide has more than doubled since 1980 • Estimated 153 million three decades ago • 347 million in 2008 • 2 biggest risk factors for Type 2 (NIDDM) diabetes are heredity and weight • Over 80% of type 2 diabetic patients are overweight

18. Obesity: A Higher Risk Effect of Obesity on Diabetes • In normal food metabolism, glucose enters the bloodstream. • Glucose is the primary source of fuel for the body • Pancreas secretes insulin • Insulin moves glucose from the bloodstream into muscle, fat, and liver cells, where it can be used as fuel

19. Obesity: A Higher Risk Effect of Obesity on Diabetes • In the obese, food metabolism is slowed down because of lack of exercise. This causes the glucose level to exceed what the body can handle. • Excessive levels of glucose make it difficult for the pancreas to regulate, leading to insulin resistance which results in type II diabetes. THE MORE OVERWEIGHT OR OBESE YOU ARE, THE GREATER YOUR RISK OF DIABETES!!

20. Obesity: A Higher Risk • Children and Obesity + Diabetes • Mean age: 12-14 years old • Girls > Boys • 94% are in minority groups • 74-100% have a strong family history • 70% of overweight children become overweight adults

21. Obesity: A Higher Risk Pulmonary Problems • Decrease in lung volume • Increased work of breathing • Higher airway resistance • Higher chest wall • Decreased compliance • Flattened diaphragms • Altered lung volumes • About 70% of people with OSA are obese

22. Obesity: A Higher Risk Pulmonary Problems • Pulmonary hypertension secondary to: • Hypoxia • Pulmonary vasoconstriction • Depressed heart function

23. Obesity: A Higher Risk Pickwickian Syndrome Obesity-hypoventilation syndrome • 5% -- 10% of morbidly obese • Left and right sided heart failure common • Obstructive sleep apnea • Hypoxia • Hypercapnia • Marked daytime somnolence • Chronic respiratory acidosis

24. Obesity: A Higher Risk Cancer Mortality • Men: • Stomach • Prostate • Women: • Breast • Uterus • Cervix • Ovary

25. Obesity: A Higher Risk Obstetrics and Gynecology • Female infertility • Disrupted menstruation and ovulation • Early menstruation • Urinary incontinence • Abnormal labor • Increased progression to Cesarean section • Increased fetal size • Pre-eclampsia and eclampsia • Gestational diabetes

26. Obesity: A Higher Risk Obesity and Trauma • Displaced ankle and elbow fractures w/ minimal trauma • Higher incidence chest injuries • Physiologic airbag • Rib fractures • Pulmonary contusions • Higher mortality d/t respiratory causes

27. Obesity: A Higher Risk Obesity and Trauma • Higher incidence of pelvic fractures • Less likely to wear seat belts • Subcutaneous fat hides physical findings

28. Obesity: A Higher Risk Obesity and Trauma • Obese patients with critical injuries from blunt trauma have worse outcomes than do leaner patients* • Patients with higher BMIs had longer stays in both the intensive care unit and the hospital • Required more days of ventilator support • Significantly increased risk for acute respiratory failure, pneumonia, and urinary tract infection

29. Obesity Challenges Prehospital • Delays due to problems in moving and transport • Appropriate sized gurneys • Excessive tissue impeding access for IV fluids, taking BP • Mobilization of manpower • Managing airways • Pulse oximetry

30. Obesity Challenges Airway • Difficulties with intubation and BVM • Preoxygenation is critical • Desaturation is quicker • Sit upright or semi recumbent as long as possible • Reduced pulmonary compliance • Higher ventilatory pressures • May need to occlude pop-off valve to ventilate

31. Obesity Challenges • Airway Techniques • Rolled towels or blankets Between scapula • Displaces breast tissue • Chest wall can obstruct handle Under the occiput • Allows for sniffing position • Creates more space for the handle • Shorter than average handle • Adjustable angle laryngoscope

32. Obesity Challenges Alternate Airways • Awake oral intubation • Nasotracheal intubation • LMA • King Airway • Combitube • Cricothyrotomy

33. Obesity Challenges Anticipate a Difficult Airway • Awake techniques if possible • Pre oxygenate in reverse Trendelenburg • For RSI consider increased dose of meds • LMA has increased risk for aspiration • Neck anatomy distorted due to excess tissue

34. Obesity Challenges Sphygmomanometry • Inadequate width and circumference can artificially elevate blood pressure • Cuff width to arm circumference • Ratio of 2 : 5 • Bladder length 80% arm circumference • Important to have variety of cuffs • May need to use thigh cuff in the morbidly obese

35. Obesity Challenges Pulse Oximetry • Tissue thickness impedes light wave transmission • Other areas of placement: • Earlobe • Fifth digit of hand or foot • Nose • Lip • Temporal artery

36. Obesity Challenges Intravascular Access • Landmark vessels not visualized or palpated • Multiple attempts, delayed access • Higher complication rates • Secondary to multiple sticks • Wound infections • Phlebitis • Thrombosis • Standard 1.5-in needles not long enough • 3-4 in needles and catheters preferred

37. Obesity Challenges Improving Success for IV Access • Apply heat • Light tapping over vessels • Active pumping of extremity • Ultrasound • Topical nitroglycerin* • Intraosseous • Reactive Hyperemia • Occlude with BP cuff 3-4 minutes • Release 10-15 mmHg below diastolic

38. Obesity Challenges ECG Difficulties • Difficult landmarks for lead placement • Decreased or inconsistent voltage • Increased fat deposits around the heart • Flat/inverted T waves inferior leads • Consistent change in obesity • Non-specific

39. Obesity Challenges ECG Differences • P, QRS, and T wave axes were more leftward • More LVH • Left atrial abnormality • T wave flattening in the inferior and lateral leads • Prolonged QT interval

40. Obesity Challenges Hospital Equipment Costs

41. Obesity Challenges EMS Challenges • Transporting people in a manner that is as safe as possible both for the personnel and their patients, as well as in a respectful manner • 2000-2001 injuries related to transferring and handling of patients represented greater than 50% of Workers’ Compensation annual costs. • Usually only 2 or 3 people are available to move a patient from one spot to another • Just one injury could mean the end to an EMT or paramedic’s career

42. Obesity Challenges Meeting the Challenge • EMS providers must conduct pre-planning exercises to prepare for attending to special situations. • Experts advocate for the following: • creation of policy and procedures • pre-training • continuing education • request for lift assistance • community involvement • use of bariatric equipment Even with the best intentions, treating and transporting morbidly obese patients will take more time than almost any other type of call to which EMS responds

43. Obesity Challenges Obstacles to Removal • Removal considerations: • How to be packaged • Stokes stretcher • Body bag • Method • Carry drag • Lower • Ropes or slings • Removal route to ambulance • Need for additional resources • Collapse unit • Forklift • Flatbed truck

44. Obesity Challenges Obstacles to Removal • Non-mobile patients • Patients unable to fit through doorway • Solution can be in removal of walls or windows • Requires heavy rescue equipment • Rescuers with engineering/construction experience • Can lead to building collapse • Risk of injury to patient and crew

45. Obesity Challenges Obstacles to Transport • Removing patient from scene • Packaging and transferring • Moving to the ambulance • Transportation

46. Obesity Challenges Transferring • Standard backboard • Patient may not fit • Board unable to support weight • Rescuers must grasp and maintain board, lift carry and maneuver in sync • Must lift from ground level to waist • Restricts breathing from prolonged period of lying flat

47. Obesity Challenges

48. Obesity Challenges Transferring • Options to the standard backboard • Specialized backboards • Basket stretchers • Reeves stretchers • Warehouse style carts

49. Obesity Challenges Various Response Methods used by EMS agencies • Patients that are too heavy for a 2-person medic unit can request fire department • MAN-S.A.C. rated at 1600 lbs. • Heavy duty collapsible litters rated at 600 lbs. • Dispatching trucks with additional personnel for lifting • Flagged address so initial responses include extra crews if available • Hold-harmless contracts if patient exceeds rated capacity of the stretcher

50. Obesity Challenges More Questions than Answers • Is there a demand for a stretcher that could carry persons in excess of 500 lb? • Would a larger stretcher require a larger ambulance? • Would a larger stretcher require a different locking device? • Would a larger ambulance stretcher allow enough room to provide patient care?