Bariatric Patient Care

The late-afternoon training session is interrupted by the dispatch tones, and Attack One is requested to respond for a “person unresponsive.” The crew notes an extra piece of equipment—a ladder truck—is also asked to respond on this incident. No further information is available.

The scene is at the edge of a downtown park, where a group of bystanders surrounds a patient. The Attack One crew parts the crowd and finds a middle-aged man who is strapped into a large-person conveyance scooter, slumped over the steering mechanism. He is breathing but pale and withdraws only to painful stimuli.

A helpful bystander reports they noticed the man coming out of the park on his scooter when he gradually slowed and came to a stop on the sidewalk. He lowered his head onto the steering handle, and bystanders found him to be unresponsive, not just sleeping. No one is familiar with the man.

The Attack One crew takes control of the man’s head. His skin is pale and cool, he is breathing, and his pulse is palpable at his neck. He is very large, weighing perhaps 500 lbs. They find a wallet with his identification but no indication of medical problems or alerts. He lives in an apartment near the park. His cell phone is available, and one of the younger crew members opens it and identifies an emergency contact in the directory, but unfortunately that person is not available when called.

Initial Assessment

A 38-year-old male in moderate distress, responsive only to painful stimuli. No obvious trauma.

Airway: Not compromised.

Breathing: Moderate distress, no wheezing.

Circulation: Pale, cool skin, no diaphoresis.

Disability: Withdraws from painful stimuli.

Exposure of Other Major Problems: Found unresponsive.

Vital Signs

Time                 HR                    BP                    RR                Pulse Ox.

1608                140               Unknown                28             Not obtainable

1616                124                80/palp.                 24                   90%

1622                124                90/palp.                 24                   92%

1630                 94                130/palp.                24                   95%

AMPLE Assessment

Allergies: None known.

Medications: None.

Past Medical History: No known problems.

Last Intake: Unknown.

Event: Very large patient, with some difficulty breathing when lying flat.

The crew members work quickly with the patient still upright on the scooter. He is maintaining his airway, and eventually they want to lie him down, but would prefer to have a large stretcher in place before they attempt to move him.

“Dispatch, we need an ambulance with a large-capacity stretcher sent to our scene,” the paramedic requests. She appreciates the 9-1-1 center has dispatched the additional truck company to the call, but they will need the larger stretcher to move the patient.

The paramedic moves through a structured physical examination to look for the source of the man’s altered level of consciousness. She finds no signs of trauma; no smell of intoxicating beverages; no track marks; no unusual breath smell; and no diaphoresis. His pupils are dilated, and his pulse rate is rapid. No medical alert indicators are present. No insulin pump is found. A blood sugar is obtained as the crew rapidly starts an intravenous line—it’s about 150.

The paramedic ponders a minute. This patient is minimally responsive and has a rapid pulse, low blood pressure and poorly perfused skin. His lungs are clear. They cannot determine if he has neck vein distention due to his size. He is not warm to the touch, nor does he smell like he has an infection. That means he is in shock, with cardiogenic shock or anaphylaxis as the only reasonable causes. With his rapid heart rate, anaphylaxis seems most likely.

The paramedic decides to treat this as anaphylaxis, so the intravenous line is opened and a bolus of one liter started, and an epinephrine injection of 0.5 ml of 1:1,000 concentration is drawn up. That medicine will have to be administered intramuscularly to begin, since the patient’s skin is not perfusing well and a dose placed subcutaneously won’t likely be picked up and delivered to the vascular system. The paramedic tells the EMTs she will give the patient 4–5 minutes to respond to the intramuscular dose; then they will have an intravenous dose ready for administration. That gives the crew enough time to do the initial treatment and then have enough responders and the stretcher available to do a safe removal off the scooter.

The IM epinephrine dose is administered into the upper arm with a long needle, and then the arm rubbed to improve delivery of the medicine. The patient’s condition doesn’t change. Oxygen is being administered, and the fluid infusion is going smoothly.

When the ambulance with the large-capacity stretcher arrives, the responders bring the large textile movement tarp over, gently roll the patient onto it, then slide him onto the stretcher. All hands are used to effect a safe transfer.

A timely phone call then arrives on the patient’s cell phone. It’s the emergency contact returning the message left on her phone; she reports she’s the man’s sister. She lives in the city but will not be able to join her brother for a couple of hours. Importantly, she reports the man has no medical problems other than his extreme obesity. She is not aware of him being ill recently or having any allergies.

The crew gives her the information about the hospital to which they’ll be transporting. She advises that the siblings’ parents are out of town, and they have a special van the man has to be moved in with his high-capacity scooter. They left the area a couple days ago, and the patient was aware he would not have access to a van for about a week. The sister will find a way to contact them and have them call the hospital.

The patient and stretcher are moved into the ambulance using ramps and a winch.

As the Attack One paramedic jumps in the ambulance, she notices the large scooter is the only object being left behind. She asks the captain from the ladder crew if he can find a way to get the scooter to the hospital.

“Sure,” he replies, “although I have no idea how to get that done. It won’t fit on our apparatus. I’ll try to get the police or metro bus service to move it there.” But he is fairly sure those will not really be good options.

So the ambulance rolls off to the hospital emergently, and the captain evaluates his alternatives. The scooter is large, weighs several hundred pounds and is no doubt very expensive. It cannot be parked on the sidewalk, or something is likely to happen to it. It has some personal materials left with it. The police officer who came to the scene says he has no idea what to do with it, and the police department doesn’t have a vehicle to transport it.

The captain places a call to an EMS supervisor and asks his crew to hail down any metro bus that comes by, so as many options as possible are explored at the same time.

In the ambulance things are going better. About five minutes after receiving the intramuscular epinephrine, the patient begins to stir. The paramedic has been mixing up a solution of epinephrine by taking a vial of epi and injecting it into a smaller bag of intravenous fluids. It is prepared to be added to the line where the fluid bolus is going in.

The patient’s eyes open, and he speaks: “What happened? Who are you people?” The pulse oximeter starts giving an audible signal.

“Sir, you are with metro EMS,” the paramedic tells him. “You were found unconscious on your scooter, and it appears you are having an allergic reaction to something. How are you feeling?”

“I feel completely washed out. It’s hard to breathe lying on my back. Can you lift my head?”

The head of the stretcher is raised slowly, and the patient reports he feels much better as it is. His skin begins to pink up, and his radial pulse and the oximeter on his finger are both responding.

The patient finds a position of comfort with his torso upright at about 45 degrees and asks to remove the oxygen mask. His pulse is down to a rate of around 120, and with the oxygen mask off, his oxygen saturation is above 90%. The blood pressure is palpable at about 80 mmHg. Most important, the patient is now beginning to speak.

“I felt like I got stung by something as I was going through the park. It was on my back, so I couldn’t tell what happened. Can you look to see? I have never had a problem like this before. And I’m starting to feel sick to my stomach.” He advises he has no chest pain.

The paramedic can’t find anything examining the patient’s upper back but can’t do a complete exam at this time due to the patient’s size. “We will look again when we get to the hospital,” she tells him. “Before we get there, I’m going to give you some other medicines we use for allergic reactions. I will also give you some medicine for your nausea.”

The paramedic administers a dose of diphenhydramine, a dose of methylprednisolone and a dose of ondansetron for nausea. By the time the ambulance arrives at the hospital, the patient is sitting up and comfortable receiving oxygen by cannula. His blood pressure is palpated at 130 mmHg.

“Great for you, sir—you seem to be getting better,” the medic tells him. “The emergency department staff will be glad you’re able to talk with them as we go in. Our report from the scene indicated you were unconscious.”

The gentleman is turned over to ED staff in much better shape than when found. As he is he tells the Attack One crew, “Thank you for making me feel better. Where is my scooter?”

Emergency Department Management

The patient is loaded onto an oversize ED cot, and during the transfer he is completely disrobed. On his lower back is an area that is raised and inflamed, consistent with a bee sting. The emergency physician congratulates the EMS team on an outstanding pickup based on clinical findings, without a history or physical evidence of a sting.

The nurses and patient are asking about the scooter, as they anticipate he will be released from the hospital after a few hours of observation. The EMTs are asked to contact the captain to find it. The radio traffic has depicted a concerted effort to locate a transport vehicle that could safely move the scooter; in the city’s maintenance division was finally found a medium-duty truck with a lift gate that could lift it for transport. The scooter is stabilized in the truck’s bed for a short ride. The ladder truck follows the support vehicle to the hospital to ensure safe movement during the ride, off the truck and into the ED. The scooter will not fit in the patient’s room, so they park it in the ED hallway.

Case Discussion

The “unconscious unknown” patient is a significant challenge for EMS providers. Lack of known medical history makes it even more challenging. Difficulty in being able to obtain vital signs makes things harder still.

The most common treatable causes of altered level of consciousness for emergency providers relate to a blood sugar that is low or an intoxicating-substance level that is high. Both have characteristic findings on physical evaluation. A glucometer offers a dramatic improvement in the ability to find abnormal blood sugars, both high and low. A normal sugar allows the EMT the assurance to look for other causes.

There are four substances that offer “wake up” opportunities for EMS. These are glucose, naloxone, oxygen and epinephrine. The first three are very safe. The fourth can have significant complications. Epinephrine is lifesaving when given for allergic reactions. A recent estimate is that 1.6% of persons in this country have had severe allergic reactions, with the most frequent triggers being medications, insect stings and foods. Foods are becoming more prevalent as a cause.

Epinephrine has been used for years in emergency care. Recent years have seen the drug placed in the hands of the public in automated injectors. But the availability of these auto-injector devices has been challenged, and the price of the devices has risen dramatically. Some EMS services have developed much less expensive approaches to epinephrine availability for EMTs and EMT-Intermediates.¹

EMS providers must be able to provide care for very large patients and the devices that are used to maintain their health and prevent injuries. Very large patients have the right to emergency care, and providers have the responsibility to deliver care without risking injury.

It is beneficial to have resources in the region to move very large patients and their devices. Some of these patients use scooters or large wheelchairs for conveyance. These are expensive and cannot be left on the street or in other public places if the patient is transported away. Movement of those devices cannot be done in an ambulance or a standard supervisor vehicle, fire engine or ladder truck.

Thus agencies may have the opportunity to work with a local ambulette service, metropolitan transit service or other public agency to move these devices. There are a variety of events that may require such a resource to be readily available. It is cost- and time-efficient to have those special resources available through mutual aid or other shared resource agreements.

Learning Point

Anaphylaxis is a life-threatening condition that is sometimes difficult to identify. Epinephrine is the lifesaving treatment. Very large patients require special preparation for their treatment, transportation and management of the devices used in their daily activities.

Reference

1. Aleccia J. King County drops EpiPen for cheaper kit with same drug. Seattle Times, January 14, 2015; https://seattletimes.com/html/localnews/2025464333_countydropsepipensxml.html.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.