Bariatric Transport Challenges: Part 2

     In Part 1 in the April issue, we reviewed some basics of bariatric lifting and moving. This article examines some practical scenarios of showing how these skills can be put to use. Think about how you would handle each of these patients if you experienced a clinical encounter with them during duty hours.

SCENARIO #1
     Dispatch: "Medic 132, Engine 62, 2976 Lake Drive at the Chardonnay Bariatric Hospital for a 43-year-old male patient with respiratory distress."

     This facility is a freestanding hospital that performs only bariatric weight loss surgeries. They generally call when a patient has difficulty weaning from the vent or reversing from anesthesia. The dispatch and call location imply that you will be treating a bariatric patient who requires specialized intensive care between facilities. Though this incident could be considered an interfacility transfer, local protocols dictate that if the center calls for a 9-1-1 ambulance for what the staff feels is a true emergency, an emergency ambulance will respond and perform the transfer.

     Because this facility lies in your primary response area, you have prepared in advance for this type of incident. En route, you attach the Ferno LBS (large body surface board) to the stretcher to make it appropriate for a bariatric patient. Also on the stretcher should be your transport vent, if local protocols allow, heart monitor, end-tidal CO₂ monitor, and primary drug and respiratory equipment.

     When your crew arrives at the patient's bedside, they find him in a post-anesthesia-care unit that wouldn't be out of place at any large university hospital; it's just in smaller scale. The anesthesiologist is bedside and explains that the patient's sedation was reversed after his otherwise uneventful procedure. After the patient was extubated, he was unable to maintain his oxygen saturation and had to be reintubated in the post-anesthesia-care unit. After several unsuccessful attempts to wean him from the ventilator, arrangements were made with a local resource hospital for the patient to be transported to their ICU.

     The patient is stable and has been given additional sedation just prior to your arrival. The time that you will spend transferring from the bariatric hospital's equipment to yours will be well worth it. A heart monitor and ETCO₂ detector—the two best indicators of adequate oxygenation and ventilation—should be the first pieces of equipment applied. Capnometry and/or capnography are preferable, but a colorimetric indicator is acceptable in their absence. You place the patient on a ventilator and move his infusions to your stretcher. Knowing what infusions your system allows is important to avoid scope of practice issues.

     Once all of the patient's equipment has been exchanged for its prehospital counterparts, all that remains is to move the patient. The facility staff brings out a transfer device designed to allow the patient to roll over a conveyor belt between beds, allowing one or two staff members to move him from one surface to another with very little effort and no lifting, pulling or disruption of sheets. The lightweight patient roller will transfer patients up to a height of 3" (e.g., from a hospital bed to an uneven stretcher). This product is designed for use in the OR or x-ray, for physical therapy or general transfer, and uses aluminum rollers with steel ball bearings. The heavy-duty cover cleans with soap and water or disinfectant.

     Once the patient is safely packaged on the stretcher, he may be moved to the ambulance. While you were inside moving the patient, the engine company was assembling the ramp and winch system your unit utilizes to move bariatric patients into the truck. You use six people, including members of the engine company, to move the stretcher to its lowest (most stable) position. One rescuer guides the stretcher up the ramp into the ambulance, while the other operates the winch that is pulling the patient.

     The ride to the hospital is uneventful. The patient's ETCO₂ creeps up above 45 mmHg, so a minor vent adjustment is made. Otherwise, the patient remains as stable as one who is chemically sedated can be. You notify the ED that you are transferring the patient directly to ICU and request additional human power for moving and logistics.

     The process is repeated in reverse on arrival at the resource hospital. The emergency department staff seem relieved that they aren't receiving this complex medical patient. The ICU looks like a ghost town, and you wonder where the extra people you told the hospital would be needed are. You radio the engine company to come up to the second floor to help move the patient to an ICU bed. Four firefighters in full personal protective equipment tromp from the elevator to bed #6 to help you. Once the patient is moved and your equipment disconnected, you are free to clean up your ambulance and restock for the next challenge.

SCENARIO #2
     Dispatch: "Medic 132 respond to 1010 Juniper Court, Apartment B-129 for leg pain." Time out is 0606. You hear your partner mutter something about not even being on duty long enough to perform your daily apparatus checks.

     After you communicate to the radio room that you are responding, they inform you that the patient is in excess of 500 pounds. You immediately add an engine company for additional assistance with packaging and unloading the patient. You also remember that an operator for your bariatric unit is sleeping at the station. After three trips to voice mail, he finally picks up the phone with an angry "What?!" Given the opportunity for overtime on the bariatric unit perks him up pretty quickly, and the truck is soon underway, with no lights or sirens.

     The patient's apartment is in the middle of a U-shaped courtyard with adequate sidewalks, except for the dozen steps distributed throughout their length. You have no choice but to bring the stretcher over the grass to the sliding glass patio doors from which you are being signaled. You find an unkempt apartment with significant refuse on the floor, a smell that testifies to the three cats in the house, and dirty dishes in the sink and on the stove and counter. Despite your uncertainties about this environment, you enter to find the patient standing in the hallway between the living room and bedrooms. The morbidly obese patient says she has had diarrhea for the last three days and the loperamide she has taken isn't working for her. She says she has had more than 20 episodes over the last two days. Her vital signs are: BP-104/88, pulse-116, respiratory rate-20, SpO₂-96% on room air, and her blood sugar is 176 mg/dl.

     Based on the patient's morbid obesity, you decide to use the engine company that has arrived on scene to help with the transport, in addition to the bariatric transport unit that is still responding from your station.

     When the bariatric truck arrives, you recruit three fire department personnel to assist with moving the stretcher over the grass courtyard to the patient's apartment, as well as packaging and moving the patient back to the ambulance. The patient is able to ambulate to the stretcher, although she becomes moderately exertionally dyspneic.

     The patient is seated in a high Fowler's position on the stretcher and is transported to the ambulance using the fire department to assist with moving and stretcher stability.

     The patient is loaded using the truck's indwelling ramp and winch system. Once in the ambulance, she is placed on supplemental oxygen by nasal cannula due to a room air oxygen saturation of 91%. On 4 liters per minute of oxygen, her O₂ saturation increases to 98%. You contact the medical command physician with a patient report, and he orders 500 ml normal saline fluid bolus and another if the patient's heart rate isn't below 110 after the first bolus. The emergency department is notified via cellular phone to expect the patient and is advised what special resources will be required to facilitate her movement and subsequent treatment. The ED staff and several extra personnel are waiting for your arrival with a hospital bed, and the patient is transferred without incident.

CONCLUSION
     The fact remains that we will be required to transport an increasing number of morbidly obese and bariatric patients. Our mission is to transport bariatric patients safely, efficiently and with attention to patient dignity. How would you handle these two patients? Do you have the resources to meet the mission?

Christopher B. Haber, EMT-P, is owner of MEDPRO EMS Education, an EMS training and education center headquartered in Langhorne, PA. Contact him at chaber@medproems.com. www.emsresponder.com

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     To access a lesson plan on bariatric patient lifting and moving, visit www.emsresponder.com/lessonplans.