500 Pound Man Driver in Head On Collision

[VentMedic]

500 Pound Man Involved in Head On Collision

http://www.emsresponder.com/article/article.jsp?id=11742&siteSection=1

This was a recent headline and it would be interesting to know what are the capabilities of your EMS and FD for vehicular extrication of a patient weighing 500 or even 350+ pounds? We know that IFT of bariatric patients has improved greatly provided the facilities have nice beds and Hoyer lifts to assist in getting the patient moved to the much improved EMS stretchers. But, what about moving a large patient from inside a wrecked vehicle safely? The word "safely" applies to the patient, EMT(P)s and the FFs.

What's the load limit for your local HEMS? Do you know this in advance or do you let them make the decision?

What about IV access or IO on the very obese? Sternal IO capability?

Blood pressure cuffs or where would be the best location to take a BP?

Difficult airway scoring considerations? What airway would you choose? Considerations for each device?

Considerations for decreased sensation and peripheral neuropathy? Diabetes? Chest pain or lack of?

Any other medical considerations that might complicate a "trauma" on a patient this size?

BTW, there are few thing more difficult than being a quadriplegic or even a paraplegic for a patient of this size and for the health care providers caring for them both short and long term.

New EMTs: Was the bariatric patient discussed at length in your EMT class? Has your agency discussed this patient with you as a safety issue?

 

[lightsandsirens5]

Wow that would be a tough one.

Vent, I know that bariatric pts received maybe 2 or 3 hours in my basic class and not a word in my ILS class other than the occasional joke. This is definatly a topic that needs much more coverage during classes, especially basic.

I have learned safe practices through experience and also through the SEI at the service I am with now. Our coordinator/safety officer is also really big on making sure that we use the bariatric stuff and proceedures for those patients.

 

[NomadicMedic]

Interesting scenario.

At the service where I am riding we do not have any baraiatric c-spine gear.
We do have longer bari needles for our EZ-IO. When we need to transport a bariatric patient, we call a local private service that has a Bariatric unit and we bring the ALS gear in their truck. We don't use HEMS here. We do have a HUGE BP cuff, although I've managed to take BPs on larger patients by putting a cuff on their calf and listened at the posterior tibialis. As far as an airway goes, if the patient was in arrest, I might not dink around trying to get a tube ... I'd go for a supraglottic airway (king LT)

This a great scenario...and I'll bring it up with my preceptor tomorrow morning. I'm curious if they've thought this stuff out.

 

[VentMedic]

Head immobilzation is also a factor since some of these patients take "no neck" to another level. As well, there would be spinal displacement issues in certain positions that may need to be supported. Lying flat would be extemely difficult for both breathing and the low back. Some must raise their upper body to about 45 degrees to breathe and to settle their lower legs without stressing their back.

If CPAP is used, the traditional 5 cmH2O or even 10 may not be adequate given the BP is adequate.

 

[Melclin]

What's the load limit for your local HEMS? Do you know this in advance or do you let them make the decision?

Good question, never thought about it even being an issue. I know the winch limit is 600 pounds, but in terms of the weight it could actually transport, I'm not sure. It would be a matter of calling the clinician/air ambulance commanders, to consult on the distances involved and the physical size of the patient. I would think size would be more of an issue than actual weight.

What about IV access or IO on the very obese? Sternal IO capability?

IO is ALS (MICA) only, for no real reason other than the IO gear is expensive. There has been talk of Ez-IO for our basic ambulance providers in the national journal of late. I'm not sure of the sternal IO capabilities.

Blood pressure cuffs or where would be the best location to take a BP?

Not addressed so far in my degree, but the trucks don't seem to carry a range of cuffs as a rule. I'm quite certain that a 500 pound man would stump a few of us over here.

Difficult airway scoring considerations? What airway would you choose? Considerations for each device?

I've read that Vt should be calculated on ideal body weight rather than actual body weight, which makes sense seeing as though the lungs don't get any bigger when your belly does. Also, shallow, fast resps are the norm for obese patients for obvious reasons, so I would imagine that they have a reduced capacity to compensate for a traumatic condition that causes further reduced ventilation or chest expansion (ie #rib). Other than that, we don't have a lot of airway devices to play with - LMA if possible, if not OPA and wait for MICA.

Any other medical considerations that might complicate a "trauma" on a patient this size?

Morbid obesity is considered a 'complicating medical condition' in the state trauma triage guidelines and as such patients like this would be on their way to a level one trauma centre, where an equally injured person of lower weight may not be. They could have any number of other problems (metabolic conditions etc), I've yet to do the subject that covers the bariatric patient specifically.

We've not discussed this specifically, although as I say, that class is probably yet to come. We don't have any bariatric spinal immobilisation gear.

There are a number of Complex Patient Ambulance Vehicles (CPAV, aka, "the fat truck" <_< ) with all the appropriate gear for bariatric patients and bypass/ECMO CCT, but they have a limited emergency response capability.

All in all, our state service would have significant trouble dealing with a situation like this I think, especially outside of the metro areas, both in terms of the education of its paramedics and the equipment that it provides. Extrication is not my business, but it wouldn't matter terribly because we couldn't do much with a 500 pound man after they got him out anyway, I'm afraid.

Interesting and pertinent issue.

 

[VentMedic]

I would think size would be more of an issue than actual weight.

Some medical helicopters have a total weight limit of 1300 to 1500 pounds which includes 3 crew (max 200 - 220 pounds each) and all the equipment. It would also depend on the length of the flight as well as the configuration of entry. Fixed wing would be easier to adapt with wider stretchers provided there was adequate crew to load and unload. Pilots don't always lift.


A Chinook?

http://www.telegraph.co.uk/health/h...pital-bosses-consider-helicopter-airlift.html

 

[lightsandsirens5]

A Chinook?

Not a bad idea. Although the Super Stallion that the airforce uses for CSAR might be better.

That could happen eventually you know. I know most air ambs are struggling to survive and can't have an extra bird sitting around right now, but you never know. Somday they might just have to........"Highway command this is MedStar Heavy 1, we have you in sight, three out."

Vent, what would you do with a 500 lb pt that needed c-spine. I guess I have never even thought about it.

 

[MusicMedic]

AS a new Emt, i can say we havnt really talked much about Bariatric Patients, other than the fact that they tend to be on the very top floors of apartments with no elevator -_- and always the last calls of the night (In class joke)

But I would use a Thigh Sized Blood Pressure Cuff on their arm, if they arm is any bigger than id stick with cap refill, since i believe there isn't any bigger size on the truck.

and another question kinda an addon to Lightsandsirens question: Would the patient fit on a Spine Board? as well as a C-spine Collar?

 

[Aidey]

I'm going to mention I work for a private service that transports for the area FDs, most of which are also ALS.

But, what about moving a large patient from inside a wrecked vehicle safely? The word "safely" applies to the patient, EMT(P)s and the FFs.

For me specifically lifting is my biggest safety concern. Usually there are more than enough people on scene to make this work. I do not have anything to do with the actual extrication, nor do I have the proper PPE to be in the "hot zone" so I don't have any say on what happens there.

From experience though in a patient that large I can think of several safety issues. First off, with a patient that large not as much damage is needed to trap them in the car. To extricate them more of the car would have to be removed also. This would extend extrication time, compromise the remaining integrity of the car, expose the patient to the elements longer etc.

It also complicates moving the patient if they are down an embankment, or there is rough terrain, or even ice.

What's the load limit for your local HEMS? Do you know this in advance or do you let them make the decision?

I do not know. My private service is not allowed to activate them, the request has to go through the fire department or police officers on scene.

What about IV access or IO on the very obese? Sternal IO capability?

We have the EZ-IO and are supposed to be getting the LD needles soon.

Blood pressure cuffs or where would be the best location to take a BP?

The largest cuff we have is the "large thigh cuff", which I haven't had to use, but I would guess is at least 20 inches?

Difficult airway scoring considerations? What airway would you choose? Considerations for each device?

It would depend on the situation, aside from OPA/NPA we have ETI and the King airway.

Considerations for decreased sensation and peripheral neuropathy? Diabetes? Chest pain or lack of?

Those conditions, and others commonly seen in the bariatric population are going to complicate your assessment and possibly your treatment.

Any other medical considerations that might complicate a "trauma" on a patient this size?

Difficulty in palpating anything. Difficulty in assessing lung sounds, heart sounds and bowel sounds. Difficulty or even inability to perform interventions that require going through the adipose layer, so needle chest decompression, surgical airways, IVs/IOs, IM injections.

For the hospital, there could be issues with the imaging equipment. X-rays may not be as clear, and MRIs and CAT scanners both have weight/size limits.

BTW, there are few thing more difficult than being a quadriplegic or even a paraplegic for a patient of this size and for the health care providers caring for them both short and long term.

We have a semi-quad* here who is 700lbs. He/his family/the state has done a lot to ensure we have great access into his place and to his bed, but it is never easy for anyone to move him.

*He has limited ROM in his shoulder, but none distal to that.

 

[Melclin]

I spoke to a paramedic on placement yesterday who has worked some shifts on our Complex Patient Ambulance Vehicle, and who has recently had to call them out on another job. The response time was almost two hours, let alone the extra scene time due to bariatric transport issues (but I spose the later can't be helped). Apparently our service only has one CPAV, I had thought there were more, on account of having read the original "promises" - evidently the other trucks got lost along the way. Not exactly top notch care.

Also I checked the "large size" BP cuffs we have on our standard trucks and they don't seem terribly large. It was fairly hard to tell without having a gigantic patient to try it out on. I would wager that there would be a few potential pts out there for whom it would be too small.

What complicating issues would you expect with auscultating the pressure of a bariatric pt? It would be harder to hear through the fat I'm thinking? Does is reduce the accuracy in the same way as taking a pressure over a thick jumper might?

 

[Aidey]

I forgot to mention that no one in the area as bariatric backboards, so even at a basic equipment level we don't have everything we need.

Melclin, what other types of patients is your CPAV designed for?

I bet for the BPs that the sound travels though adipose tissue better than a thick jumper, but that the sounds would be muffled like you said. It also wouldn't be as easy to palpate the pulse in order to find the best place to auscultate over.

Now that I'm thinking about it, arm shape is a problem too. Some overweight people have a lot of extra tissue around the top of their arm, and then the arm narrows quite at bit at the elbow. The cuff just doesn't fit right. I've also run into this problem in really buff guys who have large biceps and narrow elbows.

 

[MrBrown]

Metro Auckland has a bariatric ambo but other areas do not.

In all honesty the capability of our service to deal with this patient would be extremely limited or non existant. I think the maximum our standard stretcher is designed for is 150kg.

Cases of extremely obsese patients on a tarp being lifted into the back where the stretcher has been taken out is not unheard of.

I guess that'd probably be the only way we could handle this patient.

 

[Melclin]

I forgot to mention that no one in the area as bariatric backboards, so even at a basic equipment level we don't have everything we need.

Melclin, what other types of patients is your CPAV designed for?

I bet for the BPs that the sound travels though adipose tissue better than a thick jumper, but that the sounds would be muffled like you said. It also wouldn't be as easy to palpate the pulse in order to find the best place to auscultate over.

Now that I'm thinking about it, arm shape is a problem too. Some overweight people have a lot of extra tissue around the top of their arm, and then the arm narrows quite at bit at the elbow. The cuff just doesn't fit right. I've also run into this problem in really buff guys who have large biceps and narrow elbows.

The CPAV is also for complex Crit Care transport (pts on CP bypass, ECMO, intraortic baloon pumps etc. - but we don't do a lot of CC transports here)

This is an excellent summary complete with pretty pictures of the hydraulic stretchers and inflatable lifting mattresses etc:
http://www.anfvic.asn.au/multiversions/18198/FileName/Ambulance_Vic_Nolift_expo.pdf

I now understand that there may be some CPAV capability in the private sector, so the state on the whole may have more than one truck, but not much more.

Cases of extremely obsese patients on a tarp being lifted into the back where the stretcher has been taken out is not unheard of.

I guess that'd probably be the only way we could handle this patient.

I'm fairly certain I've heard of that happening here too, and from memory there was a bit of a stink about it...infringement on dignity and so on.

 

[Akulahawk]

Great discussion! It's been a while since I've even had to think about these patients... (not by choice, mind you...)

500 Pound Man Involved in Head On Collision

http://www.emsresponder.com/article/article.jsp?id=11742&siteSection=1

This was a recent headline and it would be interesting to know what are the capabilities of your EMS and FD for vehicular extrication of a patient weighing 500 or even 350+ pounds? We know that IFT of bariatric patients has improved greatly provided the facilities have nice beds and Hoyer lifts to assist in getting the patient moved to the much improved EMS stretchers. But, what about moving a large patient from inside a wrecked vehicle safely? The word "safely" applies to the patient, EMT(P)s and the FFs.

What's the load limit for your local HEMS? Do you know this in advance or do you let them make the decision?
Depends upon the service. Some make their load limit known, others will need to make that determination when they get on-scene.
What about IV access or IO on the very obese? Sternal IO capability?
I've rarely had problems getting a line on the obese, but I've never had to do one on the very obese. I don't think that any of the services I worked for ever had anything specific for the bariatric patient.
Blood pressure cuffs or where would be the best location to take a BP?
That would be wherever I can get a BP. The values themselves may be off, but I'd be more concerned about the trend...
Difficult airway scoring considerations? What airway would you choose? Considerations for each device?

Considerations for decreased sensation and peripheral neuropathy? Diabetes? Chest pain or lack of?
It's sometimes been difficult to figure out if their sensorimotor status is normal for them or something new...
Any other medical considerations that might complicate a "trauma" on a patient this size?
Sure. Right off the top of my head, their vital organs may have a decreased abilty to function as it is... due to being compressed by the extra mass surrounding them. Add some good impact trauma, and I can see the bariatric patient decompensating pretty quickly.
BTW, there are few thing more difficult than being a quadriplegic or even a paraplegic for a patient of this size and for the health care providers caring for them both short and long term.
The morbidly obese patients I've had were definitely difficult to manage... even if only for their physical size! Add in the medical problems (never had a bariatric patient that didn't have many pre-existing issues...) and it's just :wacko: sometimes.
New EMTs: Was the bariatric patient discussed at length in your EMT class? Has your agency discussed this patient with you as a safety issue?