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Obesity: The Bariatric Challenge Chad S Lewis, MD Emergency Medicine Resident Albany Medical Center.

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Presentation on theme: "Obesity: The Bariatric Challenge Chad S Lewis, MD Emergency Medicine Resident Albany Medical Center."— Presentation transcript:

1 Obesity: The Bariatric Challenge Chad S Lewis, MD Emergency Medicine Resident Albany Medical Center

2 Obesity Defined Condition of an excessive proportion of adipose tissue to total body weightCondition of an excessive proportion of adipose tissue to total body weight Prevalence doubled over last 20 years and still increasingPrevalence doubled over last 20 years and still increasing Some estimates are half of all adults are considered to be overweightSome estimates are half of all adults are considered to be overweight Worldwide estimates 1.1 billion overweight people with 250 million are classified as obeseWorldwide estimates 1.1 billion overweight people with 250 million are classified as obese Body mass index (BMI) used as a measurementBody mass index (BMI) used as a measurement

3 Epidemic Proportions: US 1991 through 1998 Percentage of obese men doubledPercentage of obese men doubled Percentage of obese women increased by 50%Percentage of obese women increased by 50% More than 31% of adults in the US are obeseMore than 31% of adults in the US are obese More than 64% of Americans are overweightMore than 64% of Americans are overweight

4 Pathophysiology 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?

5 BMI weight and height 25 to 29.9 kg/m 2 : overweight25 to 29.9 kg/m 2 : overweight 30 to 34.9 kg/m 2 : obese (class I obesity)30 to 34.9 kg/m 2 : obese (class I obesity) 35 to 39.9 kg/m 2 : moderately obese (class II obesity)35 to 39.9 kg/m 2 : moderately obese (class II obesity) 40 to 49.9 kg/m 2 : severely obese (class III obesity)40 to 49.9 kg/m 2 : severely obese (class III obesity) >50.0 kg/m 2 : super morbidly obese (class IV obesity)>50.0 kg/m 2 : super morbidly obese (class IV obesity)

6 Higher risk Heart diseaseHeart disease DiabetesDiabetes HypertensionHypertension StrokeStroke OsteoarthritisOsteoarthritis Kidney disease/stonesKidney disease/stones Psychiatric issuesPsychiatric issues Impaired body imageImpaired body image DepressionDepression Loss of self esteemLoss of self esteem

7 Heart Disease Overall increase in both morbidity and mortalityOverall increase in both morbidity and mortality 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

8 Pulmonary 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 complianceDecreased respiratory system compliance Flattened diaphragmsFlattened diaphragms Altered lung volumesAltered lung volumes Increased energy cost of breathingIncreased energy cost of breathing

9 Pulmonary Problems Pulmonary hypertension secondary to:Pulmonary hypertension secondary to: HypoxiaHypoxia Pulmonary vasoconstrictionPulmonary vasoconstriction Depressed heart functionDepressed heart function

10 Obesity-hypoventilation syndrome: Pickwickian syndrome 5% -- 10% of morbidly obese5% -- 10% of morbidly obese Left and right sided heart failure commonLeft and right sided heart failure common Obstructive sleep apneaObstructive sleep apnea HypoxiaHypoxia HypercapniaHypercapnia Marked daytime somnolenceMarked daytime somnolence Chronic respiratory acidosisChronic respiratory acidosis

11 Cancer Mortality Men:Men: StomachStomach ProstateProstate Women:Women: BreastBreast UterusUterus CervixCervix OvaryOvary

12 Obstetrics and Gynecology Female infertilityFemale infertility Disrupted menstruation and ovulationDisrupted menstruation and ovulation Early menstruationEarly menstruation Urinary incontinenceUrinary incontinence Abnormal laborAbnormal labor Increased progression to Cesarean sectionIncreased progression to Cesarean section Increased fetal sizeIncreased fetal size Pre-eclampsia and eclampsiaPre-eclampsia and eclampsia Gestational diabetesGestational diabetes

13 Obesity and Trauma Premorbid risk factorPremorbid risk factor Interference with activities of daily livingInterference with activities of daily living Displaced ankle and elbow fractures with minimal traumaDisplaced ankle and elbow fractures with minimal trauma Less likely to wear seat beltsLess likely to wear seat belts Subcutaneous fat hides physical findingsSubcutaneous fat hides physical findings

14 Obesity and Trauma Head injury protection in blunt traumaHead 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 causesHigher mortality due to respiratory causes Higher incidence of pelvic fracturesHigher incidence of pelvic fractures

15 Prehospital Challenges Delays due to problems in moving and transportDelays due to problems in moving and transport Appropriate sized gurneysAppropriate sized gurneys Excessive tissue impeding access for giving fluids, taking BPExcessive tissue impeding access for giving fluids, taking BP Mobilization of manpowerMobilization of manpower Managing airwaysManaging airways Pulse oximetryPulse oximetry

16 Airway Difficulties with intubation and BVMDifficulties with intubation and BVM Preoxygenation is criticalPreoxygenation is critical Desaturation is quickerDesaturation is quicker Sitting upright or semirecumbent as long as possibleSitting upright or semirecumbent as long as possible Reduced pulmonary complianceReduced pulmonary compliance Higher ventilatory pressuresHigher ventilatory pressures May need to occlude pop-off valve to ventilateMay need to occlude pop-off valve to ventilate Brazilian Journal of Anesthesiology, 2005; 55: 2: Tracheal Intubation of Morbidly Obese Patients: A Useful Device Ricardo Francisco Simoni

17 Assessment of Airway

18 Airway Techniques Rolled towels or blanketsRolled towels or blankets between scapulabetween scapula Displaces breast tissueDisplaces breast tissue Chest wall can obstruct handleChest wall can obstruct handle under the occiputunder the occiput Allows for sniffing positionAllows for sniffing position Creates more space for the handleCreates more space for the handle Shorter than average handleShorter than average handle Adjustable angle laryngoscopeAdjustable angle laryngoscope Brazilian Journal of Anesthesiology, 2005; 55: 2: Tracheal Intubation of Morbidly Obese Patients: A Useful Device Ricardo Francisco Simoni

19 Alternate Airways Awake oral intubationAwake oral intubation Blind nasotracheal intubationBlind nasotracheal intubation LMALMA Esophageal-tracheal double lumenEsophageal-tracheal double lumen CricothyrotomyCricothyrotomy

20 Anticipate airway difficulty Awake techniques if possibleAwake techniques if possible pre oxygenate in reverse Trendelenburg positionpre oxygenate in reverse Trendelenburg position for RSI consider increased dose of medsfor RSI consider increased dose of meds LMA has increased risk for aspirationLMA has increased risk for aspiration Neck anatomy distorted due to excess tissueNeck anatomy distorted due to excess tissue

21 Sphygmomanometry Inadequate width and circumference can artificially elevate blood pressureInadequate width and circumference can artificially elevate 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

22 Pulse Oximetry Tissue thickness impedes light wave transmissionTissue thickness impedes light wave 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

23 Venous Access Landmark vessels not visualized or palpatedLandmark vessels not visualized or palpated Multiple attemptsMultiple attempts Delay in accessDelay in access Higher complication ratesHigher 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

24 Improving Chances at Venous Access Applying heatApplying heat Light tapping over vesselsLight tapping over vessels Active or passive pumping of extremityActive or passive pumping of extremity Topical nitroglycerin*Topical nitroglycerin* IntraosseousIntraosseous Reactive HyperemiaReactive Hyperemia Occlude with BP cuff 3-4 minutesOcclude with BP cuff 3-4 minutes Release mmHg below diastolicRelease mmHg below diastolic

25 ECG Difficulties Difficult landmarks for lead placementDifficult landmarks for lead placement Decreased or inconsistent voltageDecreased or inconsistent voltage Increased fat deposits around the heartIncreased fat deposits around the heart Flat/inverted T waves inferior leadsFlat/inverted T waves inferior leads Consistent change in obesityConsistent change in obesity Non-specificNon-specific

26 ECG Differences ECGs of 100 obese subjects and 100 normal subjects no evidence of cardiac diseaseECGs of 100 obese subjects and 100 normal subjects no evidence of cardiac disease P, QRS, and T wave axes were more leftwardP, QRS, and T wave axes were more leftward More LVHMore LVH left atrial abnormality andleft atrial abnormality and T wave flattening in the inferior and lateral leadsT wave flattening in the inferior and lateral leads Prolonged QT intervalProlonged QT interval Alpert et al American Journal Cardiology 2000Alpert et al American Journal Cardiology 2000

27 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 mannertransporting people in a manner that is as safe as possible both for the personnel and their patients, as well as in a respectful manner injuries related to transferring and handling of patients represented at least 50% of Workers’ Compensation annual costs injuries related to transferring and handling of patients represented at least 50% of Workers’ Compensation annual costs. 2 or 3 people are available to move a patient from one spot to another2 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 careerJust one injury could mean the end to an EMT or paramedic’s career transporting people in a manner that is as safe as possible both for the personnel and their patients, as well as in a respectful mannertransporting people in a manner that is as safe as possible both for the personnel and their patients, as well as in a respectful manner Transporting the Morbidly Obese Patient: Framing an EMS Challenge Journal of Emergency Nursing August 2002

28 Meeting the Challenge EMS providers must conduct pre-planning exercises to prepare for attending to special situations.EMS providers must conduct pre-planning exercises to prepare for attending to special situations. Experts advocate for the following:Experts advocate for the following: creation of policy and procedurescreation of policy and procedures pre-trainingpre-training continuing educationcontinuing education request for lift assistancerequest for lift assistance community involvementcommunity involvement use of equipment that helps patients without harming workers.use of equipment that helps patients without harming workers. 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 respondsEven 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 Transporting the Morbidly Obese Patient: Framing an EMS Challenge Journal of Emergency Nursing August 2002

29 Current Education EMT Paramedic Curriculum minimally covers obese patientsEMT Paramedic Curriculum minimally covers obese patients teaching that accommodations may be necessaryteaching that accommodations may be necessary Need to use appropriately sized diagnostic devicesNeed to use appropriately sized diagnostic devices Maintain professionalismMaintain professionalism Notes that the paramedic may require additional assistanceNotes that the paramedic may require additional assistance

30 Provider 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

31 Safety in equipment A standard box-shaped ambulanceA standard box-shaped ambulance 40- to 44-inch width inside of the patient compartment40- to 44-inch width inside of the patient compartment crash tested and rated for a payload max 1600 poundscrash tested and rated for a payload max 1600 pounds Patient weighing 700 poundsPatient 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 patient could together weigh 600 pounds2 or 3 health care providers needed to care for the patient could together weigh 600 pounds Little room is left for the equipment and supplies required.Little room is left for the equipment and supplies required.

32 FDNY Guidelines Paramedic unit is called to the scene to determine:Paramedic unit is called to the scene to determine: Patient’s conditionPatient’s condition If removal is emergent/life threatening or non-emergentIf removal is emergent/life threatening or non-emergent If patient can be treated at the scene or must be moved to the hospitalIf patient can be treated at the scene or must be moved to the hospital

33 FDNY Guidelines Removal considerationsRemoval considerations How to be packagedHow to be packaged Stokes stretcherStokes stretcher Body bagBody bag MethodMethod Carry dragCarry drag LowerLower Ropes or slingsRopes or slings Removal route to ambulanceRemoval route to ambulance Need for additional resourcesNeed for additional resources Collapse unitCollapse unit ForkliftForklift Flatbed truckFlatbed truck

34 Obstacles in Transport Removing the patient from the sceneRemoving the patient from the scene Packaging and transferringPackaging and transferring Moving to the ambulanceMoving to the ambulance TransportationTransportation PreplanningPreplanning

35 Challenges 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 windowsSolution can be in removal of walls or windows Requires heavy rescue equipmentRequires heavy rescue equipment Rescuers with engineering/construction experienceRescuers with engineering/construction experience Can lead to building collapseCan lead to building collapse Risk of injury to patient and crewRisk of injury to patient and crew

36 Transferring Standard backboardStandard backboard Patient may not fitPatient may not fit Board unable to support weightBoard unable to support weight Rescuers must grasp and maintain board, lift carry and maneuver in syncRescuers must grasp and maintain board, lift carry and maneuver in sync Must lift from ground level to waistMust lift from ground level to waist Restricts breathing from prolonged period of lying flatRestricts breathing from prolonged period of lying flat

37 Transferring Options to the standard backboardOptions to the standard backboard Specialized backboardsSpecialized backboards Basket stretchersBasket stretchers Reeves stretchersReeves stretchers Warehouse style cartsWarehouse style carts

38 Creating Company Policy Address the concernsAddress the concerns identifies strategiesidentifies strategies sets limits on how few people may attempt to move a patient over a specified weight.sets limits on how few people may attempt to move a patient over a specified weight. Ensure policy that personnel call for lift assistance when confronted with a patient who exceeds the lifting limits of the crew on scene.Ensure policy that personnel call for lift assistance when confronted with a patient who exceeds the lifting limits of the crew on scene.

39 Creating Company Policy Provide routine training that includes new strategies for morbidly obese patients in both emergency and non-emergency situations.Provide routine training that includes new strategies for morbidly obese patients in both emergency and non-emergency situations. Ensure pre-planning among responders and the communityEnsure pre-planning among responders and the community Remind all providers to remain non- judgmentalRemind all providers to remain non- judgmental Problem-solving suggestions given by providers for considerationProblem-solving suggestions given by providers for consideration

40 Company Policy Obtain proper equipment that is reasonably pricedObtain proper equipment that is reasonably priced Heavy rated stokes baskets or scoop stretchers lined with layers of blankets to be used asHeavy rated stokes baskets or scoop stretchers lined with layers of blankets to be used as cushioncushion additional padding to elevate the patient’s headadditional padding to elevate the patient’s head Expandable/connectable flats made from extra heavy-duty materials for the oversized patientExpandable/connectable flats made from extra heavy-duty materials for the oversized patient Equipment for securing the apparatus to the floor of the ambulanceEquipment for securing the apparatus to the floor of the ambulance Ramps used to slide the patient, with the least amount of lifting, during egress from a building and/or loading into and out of the ambulanceRamps used to slide the patient, with the least amount of lifting, during egress from a building and/or loading into and out of the ambulance

41 Various Response Methods used by EMS agencies Patients that are too heavy for a 2-person medic unit can request fire departmentPatients that are too heavy for a 2-person medic 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 lbs.Heavy duty collapsible litters rated at 600 lbs. Dispatching trucks with additional personnel for liftingDispatching trucks with additional personnel for lifting Flagged address so initial responses include extra crews if availableFlagged address so initial responses include extra crews if available Hold-harmless contracts if patient exceeds rated capacity of the stretcherHold-harmless contracts if patient exceeds rated capacity of the stretcher

42 Proflexx with LBS

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47 More Questions than Answers Is there a demand for a stretcher that could carry persons in excess of 500 lb?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 larger ambulance? Would a larger stretcher require a different securing/locking device?Would a larger stretcher require a different securing/locking device?

48 Many More Questions than Answers Would a larger ambulance stretcher allow enough room to provide patient care?Would a larger ambulance stretcher allow enough room to provide patient care? Are there federal or state regulations requiring mandatory transport of the morbidly obese patient?Are there federal or state regulations requiring mandatory transport of the morbidly obese patient? What liability exposure the provider has when transporting a morbidly obese patient in an ambulance that cannot secure the transporting device to the vehicle?What liability exposure the provider has when transporting a morbidly obese patient in an ambulance that cannot secure the transporting device to the vehicle?

49 Some Helpful Pointers Size-up building, check stairs and other escape routesSize-up building, check stairs and 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 the rescue to oversee health and safety issuesAppoint safety officer not working on the rescue to oversee health and safety issues

50 Best 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

51 More Helpful Tips Treat patient with dignityTreat patient with dignity Establish a systemEstablish a system Write protocolsWrite protocols Practice runsPractice runs Assigned staff member to specialize in bariatric transfersAssigned staff member to specialize in bariatric transfers Locate obese patients, preplan for future plans to each patients houseLocate obese patients, preplan for future plans to each patients house Evaluate patient mobility prior to transportEvaluate patient mobility prior to transport

52 More Helpful Tips Scene assessmentScene assessment Door widthDoor width StepsSteps Vehicle placement so terrain works in your favorVehicle placement so terrain works in your favor PersonnelPersonnel Have a back-up planHave a back-up plan Cot designed to hold patients specific weightCot designed to hold patients specific weight


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