Bariatric Triage, Care & Transport

PURPOSE: -

This policy provides guidance for providers concerning the triage, extrication, care and transport for bariatric patients. The CDAA EMS system strives to provide all patients, including bariatric patients, with timely and effective care that preserves the comfort, safety and dignity of the patients and ensures the safety of providers. At times, even a single patient can exceed the capacity of the immediately available resources. Like a multi-system trauma patient, a bariatric patient requires:

• Appropriate EMS resources to respond.
• Appropriate protocols and equipment for the provision of care.
• Specialized equipment for transfer to the ambulance and transport.
• Careful selection of the appropriate destination hospital.
• Pre-alerting of the ED to ensure adequate resources to manage the patient.
• On scene times that may be significantly extended for bariatric patients.

EQUIPMENT:

Deployment of equipment and procedures shall be done under local or regional operating guidelines.

DEFINITIONS:

A bariatric patient is a patient whose:

• Weight exceeds 400 pounds (181 kg) OR
• Weight, girth, body contours and/or co-morbidities challenge the ability of a two-person EMS crew to effectively manage.

DISPATCH

Bariatric Ambulance: If available, consider requesting a bariatric transport ambulance to respond to the scene. Resources should be requested as soon as it becomes clear that bariatric capabilities may be required. While standard ambulance stretchers can potentially handle some patients up to 750 pounds (340) kg or more, the use of a specialized bariatric stretcher increases the ability to provide effective care, is more comfortable for the patient and enhances provider safety.

Additional Personnel: Consider requesting additional responders. Bariatric patients may require additional personnel to participate in lifting and moving. For significant extrications, consider request assistance from civil defence team. It may be necessary to remove doors, walls or windows to carry out a safe extrication. The priorities are similar to extrication from a vehicle, although fixed property repair costs might be higher.

AEMT/Paramedic: Consider requesting a paramedic. Even BLS bariatric patients present unique treatment challenges which may benefit from a higher level of care.

MEDICAL CARE: Medical care must take into account the unique challenges presented by the bariatric patient as well as the likelihood of extended on-scene times. Providers should use appropriately sized equipment to the extent it is available or can be readily obtained. For example, an appropriately sized blood pressure cuff will need to be used and intramuscular injection will be given with a longer needle. If there are significant barriers to removing the patient from the structure in a timely manner (long narrow stairs, patient in the attic, etc.), there may be situations where EMS will provide extended care to the patient at the scene. In such cases, consult Medical Direction and consider use of the extended care protocols.

TRANSFER TO AMBULANCE: Specialized equipment will be needed to transfer the patient safely from the scene to the ambulance stretcher for transport. Many services utilize large transfer flats for moving bariatric patients. Be sure before you use any patient transfer device that you understand the procedure for using it safely and that you know the weight limits of the device.

HOSPITAL DESTINATION: Ensure that you select a destination hospital that has the capabilities to care for your patient. Bariatric patients may require specialized hospital stretchers, CT scanners, catheterization laboratory equipment, operating room equipment, etc. It may be appropriate to consider an alternate destination after consultation with Medical Direction. Pre-notification serves both to ensure that the hospital is capable of caring for the patient and allows hospital staff time for adequate preparation. Communication with the hospital shall be in a professional manner. Respect for the patient's privacy and feelings will match the respect for all EMS patients.

TRANSPORT TO THE HOSPITAL: A bariatric stretcher should be used to transport the patient to the hospital and equipment cache transfer devices may be utilized to facilitate transfer of the patient to the hospital stretcher. Be alert to ensure that the stretcher is adequately secured in the patient compartment. Transfer flats or other specialized transfer equipment may be left in place to facilitate the transfer of the patient to the hospital stretcher.

PEARLS

• It may be difficult to establish IV and IO access. Consider intramuscular or intranasal as alternatives for some medications. For IM, ensure that the needle used is sufficiently long.
• Weight-based calculations may yield inappropriately large doses in obese patients. Consult with Medical Direction when in doubt.
• Bariatric patients often have decreased functional residual capacity, and are at risk of rapid desaturation. Extremely obese individuals require more oxygen than non-obese individuals due to their diminished lung capacity. Pulse oximetry may not be reliable due to poor circulation. Even patients without respiratory distress may not tolerate the supine position.
• Bariatric patients may present with severe airway challenges. Carefully plan your approach to the airway, and be prepared with backup airway plans.
• If the patient has had recent bariatric surgery, possible complications may include anemia, dehydration, hypoglycemia, leakage, ulcers, localized infection, sepsis, etc.