# Need some help with writing new protocols.



## Insanerhetoric (Apr 18, 2012)

Hey everyone. I'm new here but I was hoping I could get some input from some of the more experienced guys (and gals) on here. I'm trying to write the new protocols for my service for bariatric patients. We've had several people get hurt lifting some of our larger patients due to a lack of manpower, and understanding on the owners part. To that end I'm presenting some new protocols at our upcoming managment meeting, and hopefully I can have them approved. This is what I've come up with so far. ANY input would be greatly appreciated. Thanks in advance.

Protocols for Transportation of Bariatric Patients
UMR 1st Edition


A bariatric patient shall be defined as any patient in excess of 136 Kg or 300lbs.
Individual patient size may be taken into account when deciding whether or not to use a bariatric stretcher for ambulatory patients up 400lbs, or non-ambulatory patients up to 350lbs. For example: A patient who is 6’ 3”  tall and 300lbs probably will not be a wide as a patient who is 5’ 4” tall and 300lbs, thus a bariatric stretcher may not be necessary. 
All ambulatory bariatric patients up to 400lbs shall have 4 EMT’s present to assist with ambulation and raising the stretcher. An exception may be made if a power stretcher is used, in which case only 2 EMT’s need be present. All ambulatory bariatric patients in excess of 400lbs shall have 6 EMT’s present, at least one of which shall be a supervisor to address any complications that may arise.
All non-ambulatory bariatric patients up to 350lbs, that must be moved using a “sheet lift” or “sheet drag” maneuver, shall be moved by 4 EMT’s minimum. All non-ambulatory bariatric patients exceeding 350lbs shall be moved by 6 EMT’s minimum, transported on a bariatric stretcher, and a supervisor shall be present to address any complications that may arise.


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## DrankTheKoolaid (Apr 18, 2012)

Change the bit about 4 EMT's to 4 lifters or whatever.  It does not have to be EMT's to lift.  Any joe blow first responder or nurses aid/ rn can help lift


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## Anjel (Apr 18, 2012)

Or just say 4/6 employees. 

We cant  have nurses help lift the stretcher due to liability issues.


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## Anjel (Apr 18, 2012)

And we have had a 200 pound person need the baricot because she had no legs from the hips down and all the weight was up top. She wouldnt fit on the normal stretcher. 

I think some should be left up to the crews discretion. 

If I have a non ambulatory 280 pound person. Im calling for help.


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## medicdan (Apr 18, 2012)

Corky said:


> Change the bit about 4 EMT's to 4 lifters or whatever.  It does not have to be EMT's to lift.  Any joe blow first responder or nurses aid/ rn can help lift



Agree, but the personnel need to be trained on safe lifting, or it's mucho liability for the company to have chair car drivers with herniated discs. 

Consider reframing to provider comfort rather than precide weights of the patient (where the weight may not be available). Do you have a policy for activating other resources for emergency patients requiring additional assistance? Does that include using other ambulance services? City Fire Departments?

Do you have specific bariatric equipment (Cot, securing device, ambulance/loading system, stair chair, etc.)? A policy for when it's used, and who brings it to a facility or scene?


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## DrankTheKoolaid (Apr 18, 2012)

Agreed that was an assumption on my part that a first responder or hospital patient care staff would know how to properly lift.   I should know better then that


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## Insanerhetoric (Apr 18, 2012)

emt.dan said:


> Consider reframing to provider comfort rather than precide weights of the patient (where the weight may not be available). Do you have a policy for activating other resources for emergency patients requiring additional assistance? Does that include using other ambulance services? City Fire Departments?
> 
> Do you have specific bariatric equipment (Cot, securing device, ambulance/loading system, stair chair, etc.)? A policy for when it's used, and who brings it to a facility or scene?



We don't have any policies for activating other resources. Its a NET service so we rarely have emergency patients. I've discussed the idea of working out some sort of mutual aid agreement with the local FD, but it's not really feasible given the call volume they have in our area, and the fact that we would be low priority. We are put under a lot of pressure to have pts at certain places on time, so that also kind of kills the idea of help from the FD if they're already on a call or something. Other ambulance services are also a no go since most of then are our competitors and it would be a bit of a conflict of interests. 

We have 1 bariatric stretcher, and 1 power stretcher, but the power stretcher is on a truck that can only be utilized for certain runs due to the fact that it is based out of a different office. Part of the reason I'm writing the new protocols is to try to convince the owners to buy more equipment to accommodate some of our larger pts, and to find some way of keeping my guys from getting hurt.

Thanks for the responses!!! Ya'll are offering some great suggestions!!


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## Veneficus (Apr 18, 2012)

Insanerhetoric said:


> A bariatric patient shall be defined as any patient in excess of 136 Kg or 300lbs..



Too heavy. 

Another pitfall to this is facilities waiting on IFT may misrepresent the weight of a patient to get a faster response.

You might actually be better off with a BMI of above 30. This will more acurately reflect the nuance of lifting people with different weight and complications like muscle atonia.




Insanerhetoric said:


> Individual patient size may be taken into account when deciding whether or not to use a bariatric stretcher for ambulatory patients up 400lbs, or non-ambulatory patients up to 350lbs. For example: A patient who is 6’ 3”  tall and 300lbs probably will not be a wide as a patient who is 5’ 4” tall and 300lbs, thus a bariatric stretcher may not be necessary..



Still too fixed on numbers.



Insanerhetoric said:


> All ambulatory bariatric patients up to 400lbs shall have 4 EMT’s present to assist with ambulation and raising the stretcher..



Nobody should be raising a stretcher on a 400lb ambulatory patient. There should be a ramp they can ambulate themselves into the truck on. (I have even seen a service manufacture a ramp that secured to the back of a truck)




Insanerhetoric said:


> An exception may be made if a power stretcher is used, in which case only 2 EMT’s need be present..


.

Too many if:then, why:wherefores. keep it simple.




Insanerhetoric said:


> All ambulatory bariatric patients in excess of 400lbs shall have 6 EMT’s present, at least one of which shall be a supervisor to address any complications that may arise.



Too much fixation on numbers. I have been part of 12-14 guys lifting 400-800pounders out of various places. (including an 800 pounder with only 1 leg.)



Insanerhetoric said:


> All non-ambulatory bariatric patients up to 350lbs, that must be moved using a “sheet lift” or “sheet drag” maneuver, shall be moved by 4 EMT’s minimum. All non-ambulatory bariatric patients exceeding 350lbs shall be moved by 6 EMT’s minimum, transported on a bariatric stretcher, and a supervisor shall be present to address any complications that may arise.



Far too exacting.

While I understand the purpose of these guidlines, they are not medical protocols, they are standard operating procedures.

I find them way too narrowly defined, and significantly underestimated.

In the interest of safety, acceptable weights need to be less than what might be considered "reasonable" by at least 10% probably closer to 20%.

The simple solution to bariatric patients, especially in difficult environments, like trailers or mobile homes, is to realize that your first issue isn't a medical problem. 

It is a Rescue. Appropriate resources for that include trained rescue professionals with the proper equipment. Not a bunch of non-rescue EMS providers trying to strong arm people.

Your 4-6 man rescue team, while nice in theory isn't going around a 90 degree bend. 

It isn't going down a 36" pathway.

And it certainly isn't going through a doorway.

You make very little account of side to side stability, and raising stretchers for the purpose of loading with 400lb plus people on them is just an injury waiting to happen.

If you are dealing with 400lb+ bariatric patients regularly, you need to be looking at special transport vehicles, etc. 

If you have a handful of already known patients, you really need to start preplanning rescues with multiple agencies, talking about DNRs, and the realization it may not be possible to transport these people safely with the resources you have.

This "protocol" and the circumstances that make it seem necessary is just a game of Russian roulette with somebody's back.

You may also need to take a leaf from the fire service and include a safety officer who can veto any order of a supervisor. The person calling the shots and the safety officer should not be the same person.


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## mycrofft (Apr 18, 2012)

Make the originating facility responsible for safe loading conditions, and for refering to a faclity/ofice that can handle loading issues. Have a provsion for what to do if thse cojnditions are not met.

See what lifting regs are in force in local hospitals and FD as examples. See if your EMSA has anything.

You will need to get into MOU's with facilities you are working with on these. We had a bariatric pt once ging home to nursing home, my partner hurt his bck at the house despite myself and two firefgters helping, and the staff at the receiving fac just stood back and crossed their arms. Don't let that happen.


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## Aidey (Apr 18, 2012)

Scrap the protocol and hold a few training sessions. The protocol can be summed up as "Use good judgement, and always ask for more help than you think you will need". 

I agree with Vene*, way too focused on the numbers. And I really don't understand the requirement for having a supervisor. What happens if the supervisor is already tied up on something else, do you wait to transport until they can come babysit? I also don't think that writing a protocol is going to get you new equipment. Showing the owners hard facts about the cost vs benefit will get you further. If your company is not willing to get the right equipment and there is another agency that specializes in bariatric transports you should probably look into sorting out some sort of contract with them. 

The only 'set' bariatric related number we have is when a patient automatically qualifies for the bariatric ambulance. Our dispatch has a height/weight chart, and anyone who falls into the red zone gets the bari bus. However, responder judgement can overrule this if you run into a unique situation.


*I've been saying that a lot lately.


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## Ewok Jerky (Apr 19, 2012)

Our gurneys are rated at 350lbs. Our physical test requires us to lift 150, so anything around or above this number gets the "phat wagon". Special gurney, ramps, and a winch, no lifting required. I'm pretty sure the only reason my employer provides this equipment is for a contract requirement with an hmo.

My career is not worth trading for a single lift, so anytime my partner and i need help with a lift we call in a lift assist.  I don't care who shows up, another crew, fd, or a supe... I'm not jeopordizing my career over one lift.

As far as SOPs go, not sure. Find out how much your employer pays for workmans comp and compare that too extra resources for these patients.


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## Veneficus (Apr 19, 2012)

beano said:


> Our gurneys are rated at 350lbs. Our physical test requires us to lift 150, so anything around or above this number gets the "phat wagon". Special gurney, ramps, and a winch, no lifting required. I'm pretty sure the only reason my employer provides this equipment is for a contract requirement with an hmo.
> 
> My career is not worth trading for a single lift, so anytime my partner and i need help with a lift we call in a lift assist.  I don't care who shows up, another crew, fd, or a supe... I'm not jeopordizing my career over one lift.
> 
> As far as SOPs go, not sure. Find out how much your employer pays for workmans comp and compare that too extra resources for these patients.



Or a disability suit win or lose.

I encourage any EMS provider who injures themself because of lack of safe procedures or equipment to sue the crap out of their employer.


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## duncklee5 (Apr 20, 2012)

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## mycrofft (Apr 20, 2012)

Oh HAYLE yayus!


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