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August 1, 2012

Managing and moving the very large EMS patient

With the changing nature of the American body habitus, EMS providers have been increasingly challenged to provide care for very large patients, and a comprehensive approach is necessary to address the problem without harming patients or the providers.

Obesity can be defined based on either the patient's weight or Body Mass Index (BMI), but calls for patients weighing 350 pounds or more, which many EMS leaders consider requiring special movement capabilities, come almost daily in many districts. Patients topping 500 pounds must be transported by emergency teams with the right training, equipment and processes.

EMS agencies need to serve the patient with the right process in the right place and time, using effective, patient- and provider-safe principles and delivery. Very large patients have the right to expect professional and timely emergency care, and providers have the obligation to deliver such care without risking their own health.

The most successful EMS programs have enhanced overall patient transport operations, reduced patient and personnel injuries and avoided the spectacle of moving a person on planks, tarps or the floor of an ambulance.

A comprehensive program begins with a link through the 911 communication center (or equivalent) and a dispatch protocol that initiates a response appropriate for patient needs and system efficiency.

The management process could have a caller interrogation process for EMS call takers and dispatchers to send a response appropriate to a patient's size and the complexity of the building.

Some 911systems maintain databases linking information about known complex patients to an address. Or a caller may volunteer information that a patient is very large and/or in a location that will make transport difficult.

These enhancements allow dispatching proper transportation and personnel resources to treat and transport the large patient.

When a bariatric patient needs treatment or transport, an incident management plan will be necessary for timeliness, effective care and safety of the patient and emergency personnel. Some emergency services develop a protocol, including adding a safety officer to the usual Incident Command procedures. The protocol will include provisions for personnel, equipment, communications, medical care and safety. Here's a sample protocol:

EMS bariatric protocol

The large patient who requires emergency care has the right to timely, effective and safe care. When an emergency occurs with a patient whose weight is in excess of 300 pounds, this protocol will be considered. It will be utilized when the patient's weight exceeds the ability of the EMS crew to lift and move the patient safely.

  • At no time should a patient who weighs more than 300 pounds be moved without at least four individuals to assist. At the scene, EMS and fire personnel may be supplemented by other public safety personnel as appropriate. For every 50 to 100 pounds more than 300 pounds, add another provider to assist in safe lifting and movement of the patient.
  • If a moving a patient requires extra manpower or extrication, a Safety Officer will be designated to oversee the safety of the operation in conjunction with Incident Command. It may be necessary to remove doors, walls or windows. The priorities are similar to extrication from a vehicle, although fixed property repair costs might be higher.
  • Patient care will take place with appropriate equipment and supplies. A large gown or two will cover the patient. The patient may need to be moved using fabric devices with a number of handles. If backboards are needed, at least two backboards or other adequate transfer devices may be considered for support.
  • Medical care will be delivered with larger-sized equipment. An appropriately sized blood pressure cuff will be used. Intramuscular injection will be given with a longer needle.
  • The proper site for patient care will need consideration. If this is a very large patient who is unable to ambulate and there are significant issues with removing the patient from the structure (long narrow stairs, patient in the attic, etc.), contact medical control and a supervisor. There may be situations where EMS will provide care to the patient at that site rather than attempt to remove him or her to a hospital.
  • The patient is to be loaded on a cot that is in the down position, and the cot is to be kept in the down position at all times.
  • Two EMS personnel are to accompany the patient in the patient care area during transport. If additional personnel are needed, they must travel in a separate vehicle.
  • Consider what hospital is appropriate for transport if the patient will be removed. Some hospitals have special bariatric services and equipment (extra large CT scan). Those hospitals should be considered as appropriate destination sites for transport of the large patient.
  • Notify the hospital where the patient is being transferred to allow its staff time for adequate preparation. The patient will be loaded directly from the squad onto a special hospital bed for this type of patient, which may be brought to the ED entrance.
  • Communication with the hospital shall be in a timely and professional manner. Respect for the patient's privacy and feelings will match the respect for all EMS patients.
  • If individuals in the community are known to fall within this special category, it may be possible to link them with a notification process in the 911 system. Pre-plans may be drafted to assist providers in necessary dispatch procedures, scene management and destination hospital.

Medical care equipment issues

For initial assessment of the patient, large blood pressure cuffs will be necessary. Several versions of cuffs are now extra-large in both length and diameter. The size of the cuff needed is roughly two-thirds of the upper arm and a large enough diameter for the cuff to maintain closure.

For some patients, auscultation through a very large arm is not successful, and a Doppler sound probe may be needed to obtain a systolic blood pressure. Some emergency medications may need adjusted doses, and if this is an important consideration, medical control may be needed for advice and orders.

Long-length IM needles will be needed to deliver those medications to the appropriate site. The same consideration will be needed for needle decompression of the chest.

Patient extrication and immobilization

Stabilizing the spine of a large patient will require atypical use of packaging equipment. Even the largest cervical collar will not fit the very large patient, so blanket or towel rolls may be fashioned along with lateral head pillows fastened securely to the backboard. Some manufacturers offer large backboards. In certain cases, the patient can be stabilized on two backboards secured together or a crisscrossed stack of backboards and plywood.

There are an increasing variety of lifting devices, such as special textile sheets that are useful as a lift and transfer device by an appropriate number of personnel.

Soft sling devices used in some hospitals and nursing facilities have capacity more than 1,000 pounds.

Reinforced plastic patient slide devices help move patients between beds and stretchers, and some devices use small, compressed air mechanisms to inflate a mat to lift more than 1,000 pounds.

The ambulance cots can be widened to 30 inches or more, which provide increased load area while still being able to pass through most structural doors.

The largest bariatric stretchers have 1,100 pound weight limits and are usually matched to ambulances fitted with ramps and a winch to load it in a safe manner.

It is likely that these specialized devices are available only in small numbers in any metropolitan area, so it is cost- and time-efficient to have those special resources available through mutual aid or other shared resource agreements.

Process considerations

Moving large patients through smaller and older buildings may require the safety officer to check for structural integrity and obstacles along the transportation pathway:

  • Are narrow doorways wide enough for the larger cot?
  • Are floors, stairs, ramps and elevators able to support the weight and size of the patient, the crew and the equipment?
  • Can service elevators, special lifts and ramps provide a safer path?

The movement of a very large patient on scene and in a vehicle must also maintain the dignity of the patient. If the patient's own clothing isn't available or must be removed, a large patient gown will be beneficial, in addition to sheets or blankets.

EMS services should know which hospitals have special capabilities to manage the bariatric patient. A first step is to contact medical control and the destination hospital regarding patient status so that preparations can be made prior to arrival.

The hospital will need to understand the patient's clinical condition, approximate size, time needed for preparation and any other considerations for transferring the patient from EMS equipment to hospital equipment. During that communication, the EMS provider must remember to consider patients' sensitivities concerning their health and status.

Summary

Managing the bariatric patient is one of the most complex challenges EMS providers encounter. To provide patient- and provider-safe care, EMS agencies should consider equipment, personnel and process guidelines to ensure timely and high-quality emergency care and movement for the very large patient. 

About the Author

James J Augustine, M.D., is medical advisor for Washington Township Fire Department in the Dayton, Ohio, area. He is Director of Clinical Operations at EMP Management in Canton, Ohio, and a clinical associate professor in the Department of Emergency Medicine at Wright State University. He formerly served as Assistant Fire Chief and Medical Director for Washington, DC Fire EMS. He has served 29 years as a firefighter, and was the first Chair of the Ohio EMS Board.
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