Maria Niebrzydowska1, *Klaudiusz Nadolny1, 2, Robert Niebrzydowski1, Jerzy Robert Ladny1, Emilia Duchnowska1, Lukasz Szarpak3, Hady Razak Hady4
The specifics of dealing with an obese patient in the practice of emergency medical teams
Specyfika działania z otyłym pacjentem przez zespół ratownictwa medycznego
1Department of Emergency Medicine, Medical University of Bialystok, Poland
2College of Strategic Planning, Dabrowa Gornicza, Poland
3Lazarski University, Warsaw, Poland
41st Clinical Department of General and Endocrine Surgery, Medical University of Bialystok, Poland
Jednym z najpoważniejszych problemów zdrowotnych XXI wieku na świecie jest otyłość. Występowanie otyłości osiągnęło już rozmiar światowej epidemii i aktualnie jest najszybciej narastającym problemem nie tylko w aspekcie medycznym, ale także epidemiologicznym, społecznym i ekonomicznym.
Z uwagi na stale rosnącą ilość osób borykających się z nadmierną masą ciała, należy liczyć się z tym, że osoby otyłe będą pacjentami zespołów ratownictwa medycznego. Należy mieć świadomość, że ta grupa pacjentów jest specyficzna, a opieka nad nimi jest trudna i wymagająca, dlatego należy przygotować się na to wyzwanie technicznie oraz przystosować placówki ratownictwa medycznego i szpitale.
Otyłość stanowi obecnie jedno z największych wyzwań współczesnej medycyny, w tym także medycyny ratunkowej. Ze względu na stale rosnącą liczbę osób otyłych, ale i co za tym idzie, stale rosnącą ilość osób poddanych zabiegom bariatrycznym, należy przeanalizować, w jaki sposób ten trend przekłada się na pracę zespołów ratownictwa medycznego. Istotna jest prawidłowa i rzetelna opieka nad pacjentem otyłym w celu uniknięcia powikłań związanych bezpośrednio z nadmierną masą ciała i niedostosowaniem sprzętu do warunków, w jakich powinien być zaopatrywany pacjent otyły.
One of the most serious health problems of the 21st century in the world is obesity. The occurrence of obesity has already reached the size of the global epidemic and is currently the most rapidly growing problem not only in the medical aspect, but also in epidemiological, social and economic.
Due to the constantly growing number of people struggling with excessive body mass, one should reckon with the fact that obese people, will be patients of emergency medical teams. You should be aware that this group of patients is specific, and caring for them is difficult and demanding. That is why you should prepare for this challenge technically and adapt emergency medical facilities and hospitals.
Obesity is currently one of the greatest challenges of modern medicine, including emergency medicine. Due to the constantly growing number of obese people, but also the constantly increasing number of people undergoing bariatric procedures, it should be analyzed how this trend translates into the work of medical emergency teams. It is important to properly and reliably care for an obese patient in order to avoid complications related directly to excessive body weight and inadequate equipment to the conditions in which an obese patient should be supplied.
Obesity has become one of the most serious health problems of the 21st century in the world. The occurrence of obesity has already reached the size of the global epidemic and is currently the most rapidly growing problem not only in the medical, but also epidemiological, social and economic aspect (1). The most important reason for the rapid development of the obesity epidemic is the lifestyle characteristic for developed countries (1, 2). Interestingly, the number of obese people is growing rapidly, despite the steadily increasing number of health awareness among the population and easier access to healthy food, diets, nutritionists and fitness instructors as well as people promoting healthy and active lifestyle (2).
Obesity is defined, according to the WHO, as a condition in which excessive fat accumulating in the form of adipose tissue adversely affects health (3). Obesity development occurs when there is an excess of energy consumption in relation to its expenditure (3).
The body mass index (BMI), which is expressed as the ratio of body mass in kilograms to the square of the height expressed in meters, serves for the clinical classification of body weight for adults and children over two years old (tab. 1) (4).
Tab. 1. BMI Classification. According to (4)
|correct body mass ||18.5-24.9|
|III degree||> 40|
Among the causes of obesity, the most important are environmental factors, genetic predisposition, endocrine disorders and lifestyle.
Regarding to the causes of obesity associated with lifestyle, the most important is the lack of physical activity, the type of work undertaken (so-called sitting work), exposure to stress, food availability, the impact of culture, tradition and beliefs and the use of drugs and certain medications. Important factors contributing to the development of obesity include social factors such as low social class or poverty (5, 6).
The increase in the occurrence of obesity in the world is associated with the problem of increasing incidence of related diseases. The most important include type 2 diabetes, arterial hypertension, ischemic heart disease, increased risk of ischemic stroke, as well as osteoarthritis and sleep apnea syndrome. The huge importance is attached to the influence of obesity on the development of cancer (7, 8).
Obesity is strongly associated with high rates of cancer of the esophagus, large intestine, colon and rectum, gall bladder, pancreas, kidneys, and also increases the risk of death from stomach and prostate cancer in men and the nipple (after menopause), uterus, cervix and ovaries in women (7, 8). It should be remembered that obesity not only increases the risk of developing these cancers, but also increases the proportion of deaths due to these diseases 8.
Excessive body weight contributes to the development of many chronic diseases of the gastrointestinal tract, such as gastro-esophageal reflux, additionally increasing the risk of its complications (Barret’s esophagus, esophageal cancer), polyps and colorectal cancer and liver disease (non-alcoholic fatty liver, hepatic cirrhosis), hepatocellular carcinoma (9-11).
Extremely significant consequences obesity brings in female reproduction, starting with the problems of getting pregnant and maintaining it, ending with technical problems during surgery or even performing ultrasound examination, which is difficult due to excessive abdominal fat. The association of obesity with obstetric failure and the occurrence of polycystic ovary syndrome in women has been demonstrated (12). There is also a greater risk of complications during pregnancy in pregnant obese who are several times more likely to suffer miscarriage. In addition, the risk of pregnancy-induced hypertension and pre-eclampsia is significantly higher, which may be the reason for the intervention of emergency medicine teams (12).
Obesity is associated with an increased risk of death and a more severe course of chronic diseases – asthma, chronic obstructive pulmonary disease, psoriasis, rheumatoid arthritis. The treatment and healing process in obese people lasts longer and is associated with more complications and infections (9). Among the most serious metabolic complications of the obesity, the metabolic syndrome (10) should be mentioned.
Obesity is associated with a very negative impact on the quality of life as well as the frequent occurrence of depression and mood disorders, which may be related to excessive amount of leptin – a hormone of hunger, which is overproduced in obese people (13). Obesity is an important risk factor for developing venous thrombosis (14).
All diseases coexisting with obesity, or which develop more severely, due to the patient’s weight, may be the reason for the intervention of emergency medicine teams, that is why it is extremely important to prepare paramedics and emergency medicine team to work with an obese patient. Unfortunately, there is no data on how many patients using the services provided by emergency medicine teams is obese, but it can be assumed that it is similar to society in general.
Among methods of obesity treatment, pharmacological, dietetic and psychological as well as operational methods are distinguished. Currently, bariatric surgery, or obesity surgery, is the gold standard of its treatment and at the same time one of the most significantly growing areas of surgery, due to the huge demand. Regarding the indications for bariatric surgery, it should be considered in adults whose BMI index is above 40 or 35 kg/m2, along with co-morbidities in which the loss of body weight due to surgical treatment will cause improvement or complete cure. In addition, the indication for surgical treatment is to achieve weight loss as a result of conservative therapy, and then to increase it again (10). Among the available methods of surgical treatment, the sleeve gastrectomy, the adjustable gastric banding and gastric bypass are mentioned.
The contraindications to surgical treatment of obesity include contraindications to general anesthesia, as well as important contraindications from the cardiovascular system, which excludes the possibility of surgery, as well as cancers, inflammatory bowel diseases, significant coagulopathies and mental disorders (10).
Obesity is currently one of the greatest challenges of modern medicine, including emergency medicine. Due to the constantly growing number of obese people, but also the constantly increasing number of people undergoing bariatric procedures, it should be analyzed how this trend regard the work of emergency medicine teams. It is important to properly and reliably treat an obese patient in order to avoid complications related directly to excessive body weight and inadequate equipment in which an obese patient should be supplied.
Over past two decades, the occurrence of obesity in Europe has tripled. There are already over 1.5 million obese people in Poland, and this problem affects men to a slightly greater extent. It is estimated that over half of Polish population suffer from overweight and obesity. This problem affects 49% of women and 64% of men. Extremely dangerous is the increase of occurrence of obesity and overweight in school and middle school children, where this problem affects every 5th child.
Due to the constantly growing number of people struggling with excessive body mass, it should be assumed that obese people will be patients of emergency medical teams. It should also be assumed that this group of patients is specific, difficult for treatment and demanding, that is why the personnel should be prepared for this challenge technically and emergency medicine facilities and hospitals should be adapted for the situation. Basing on questionnaires with health care workers, the most frequent problems concerning medical proceedings for obese people have been indicated: inability to measure blood pressure, difficulties in establishing a peripheral intravenous line, difficulty in maintaining the airways and intubation, necessity to engage additional personnel during transport and transfer of the patient and lack of adaptation of the size of the equipment to the size of the patient (15). According to the study, the majority of paramedics and medical personnel notice an increase in the average body weight of the patient, and virtually everyone has declared that they have to deal with an obese patient. About 25% of calls to emergency medicine teams from obese people are mainly for help with transport and not to provide emergency medicine services. The most common reason for calling was breathlessness (16).
The transport of an obese patient appears to be particularly important and problematic. Many aspects have to be taken into consideration. One of them is the introduction to the practice two-person teams. Frequently, such a team includes a nurse or a female paramedic, which is associated with the need to call for assistance in the transport of an obese patient, another team of emergency medical services or fire department team. Usually, the help of witnesses of an event, family or nearby persons is insufficient or even impossible to obtain. During the transport of obese patients, members of emergency medicine teams are at risk of injury, in particular of the shoulder girdle, spine and upper limb joints, therefore, it seems important to identify risk factors and then to apply preventive measures (17). According to the results of the study in Australia published in 2011, the risk of injuries related to the transport of obese patients regards in particular paramedics and members of emergency medicine teams, nurses, firefighters and funeral homes workers. Interestingly, the latter introduced a whole range of necessary equipment to handle the oversize body of the deceased obese – larger body bags, transport trucks with increased load capacity, larger refrigerators, the dimensions of rooms and the width of the entrance door to larger sizes of bodies are also adapted (18). Employees and staff in the sector of forensic medicine as well as care for the deceased have applied many improvements to minimize lifting and manipulation of bodies.
Unfortunately, there are no standards and algorithms for dealing with obese patients in pre-hospital care in Poland. Another aspect is the technical capability of the equipment of an ambulance. It is intended that ambulance teams dispose the new, fully functional equipment, however, by definition, it is not a device adapted to transport a sick obese person. Due to the increasing number of obese patients, ambulances and emergency helicopters should be equipped with stretchers, chairs and lifts with increased load capacity. The stretcher on the ambulance’s equipment has a load capacity of 150-270 kg, which in case of super obese patients may turn out to be insufficient, considering, for example, that during transport, on the stretcher next to the patient a cardio monitor should be present, as well as oxygen bottle and other equipment.
An attempt to improve the care of an obese patient has been made in the United Kingdom, including identification of the risk associated with handling, transport and care of an obese patient. In the study, questionnaires have been applied, supplemented, among others, by members of the emergency medicine teams. Five topics have been analyzed – factors directly related to the patient, space and design of buildings and vehicles, equipment, communication as well as organizational and personnel issues. Almost 60% of the respondents admitted that there is no organization in the place of their work improving the care of a bariatric patient. Approximately 77% of respondents had access to specialistic equipment, but only 32% of them received specialistic training. In the study center, there were no formal communication systems between organizational units, which increased the need for manual transfer of obese patients. The study clearly showed that there is a need to design or adapt buildings, vehicles and equipment to reduce the risks associated with manual handling of bariatric patients (19).
In 2014, the only bariatric ambulance in Poland has a Krakow emergency department. However, it is a transport ambulance, which means that it does not serve the patients of the State Medical Rescue. In a bariatric ambulance, lifting a heavy patient by personnel has been replaced by a special lift. The patient is transported under the lift on a special stretcher, which can be widened, due to the fact that the obese patient has not only increased body mass, but also needs additional space. The load capacity of these stretchers is approximately 300 kilograms. In order to put the patient inside the ambulance, a special incline slides out of the vehicle. Then the stretcher attaches to the lift, which is in the ambulance. For each type of bariatric stretchers, there are special systems for loading the stretcher to the carriage, controlled by a remote control. Battery powered guarantee 77 up/down cycles at maximum stretcher load without the necessity to charge. Adapting the equipment to patients with excessive body mass reduces not only the risk of injury and overloading among medical personnel, but above all ensures greater safety and comfort for the patient.
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