- Email: [email protected]
Transporting the morbidly obese patient: Framing an EMS challenge
EMS
Transporting the Morbidly Obese Patient: Framing an EMS Challenge Author: Jan R. Boatright, RN, CEN, New Orleans, La Section Editors: Jan R. Boatright, RN, CEN, and Kathy Robinson, RN, CEN, EMT-P
Jan R. Boatright, Louisiana Chapter, is Associate Director and CAO, Priority Mobile Health, New Orleans, La. For reprints, write: Jan R. Boatright, RN, CEN, Priority Mobile Health, PO Box 6379, New Orleans, LA 70174; E-mail: [email protected]. J Emerg Nurs 2002;28:326-9. Copyright © 2002 by the Emergency Nurses Association. 0099-1767/2002 $35.00 + 0 18/9/124409 doi:10.1067/men.2002.124409
T
he transportation of patients weighing in excess of 500 lb poses serious challenges to EMS crews, from the medical management of the vast array of health problems these patients present with to physically moving the person from one location to another. On occasion, most ambulance companies have been called upon to move patients weighing 500 to 800 lb or more. Transporting patients who are morbidly obese can overwhelm even the best-prepared EMS provider.1 Data from 20002001 at our ambulance service reveal that injuries related to transferring and handling of patients represented at least 50% of Workers’ Compensation annual costs. Unlike in the hospital setting, at the scene of an emergency often only 2 or 3 people are available to move a patient from one spot to another. Just one injury could literally mean the end to an EMT or paramedic’s career. It is important that EMS providers ensure that their personnel are transporting people in a manner that is as safe as possible both for the personnel and their patients, as well as in a respectful manner.
What is morbid obesity?
Approximately one third of all adults (or 58 million people in the United States) are estimated to be obese.2 Persons are considered morbidly obese when their weight is at least 100 pounds greater than their ideal weight. The prevalence of obesity seems to be increasing, and the potential for our EMS crews to need to transport a patient weighing in excess of 500 pounds is real. Health effects of morbid obesity
Severely obese people are approximately 6 times as likely as nonobese people to have heart disease and 10 times as likely 326
JOURNAL OF EMERGENCY NURSING
28:4 August 2002
EMS/Boatright
to have diabetes and kidney failure. Severely obese people have decreased lung capacity and their chest wall is very heavy and difficult to lift, yet their demand for oxygen is greater with any physical activity. This condition can be completely disabling and can prevent the patient from assisting with getting themselves into an ambulance at the time of an emergency. Experience tells us that EMS providers must conduct pre-planning exercises to prepare for attending to special situations. Experts advocate for the creation of policy and procedures, pre-training, continuing education, request for lift assistance, community involvement, and the use of equipment that helps patients without harming workers. Even with the best intentions, treating and transporting morbidly obese patients will take more time than almost any other type of call to which EMS responds.
Data from 2000-2001 at our ambulance service reveal that injuries related to transferring and handling of patients represented at least 50% of Workers’ Compensation annual costs. EMT and paramedic training curricula should cover obese patients by saying, at a minimum, that accommodations may be necessary, equipment may need to be obtained (eg, larger blood pressure cuffs), and that they may require additional assistance. Moving devices
In medical transportation circles, we have heard of patients being transferred in unusual ways. In one instance, when a man who weighed more than 1000 lb was experiencing severe respiratory distress, a crane reportedly was used to lift him from the third floor onto a waiting flat bed truck. Most providers can recall at least a few occasions when their crews had to call for assistance from the fire department and other agencies to move patients who were too big to fit on the stretcher or in the ambulance. Some have even had to use a rented U-Haul truck. Patients can be transferred via tarpaulins or huge straps used to drag the patient out of his or her house and into the back of a waiting vehicle.
August 2002 28:4
There is no real method of securing the patient for safe transportation except on a regular stretcher in a regular ambulance, and little can be done to arrange the patient in a therapeutic or comfortable position. A standard box-shaped ambulance has a 40- to 44-inch width inside of the patient compartment, with vans being about 4 to 8 inches smaller. A patient weighing 700 pounds can measure 50 to 55 inches wide or more. Most EMS vehicles are crash tested and rated for a payload maximum of 1600 pounds. Considering that the 2 or 3 health care providers needed to care for the patient could together weigh 600 pounds, little room is left for the equipment and supplies required. We have to wonder what liability exposure the provider has when transporting a morbidly obese patient in an ambulance that cannot secure the transporting device to the vehicle. In 1999, after meeting with a representative of one of our industry’s stretcher vendors, who subsequently discussed the issue with representatives from the National Highway Traffic Safety Administration (NHTSA) and General Services Administration, we found that there are many more questions than answers. Is there a demand for a stretcher that could carry persons in excess of 500 lb? Would a larger stretcher require a larger ambulance? Would a larger stretcher require a different securing/locking device? Would an ambulance with a new design stretcher require new dynamic crash testing? Would a larger ambulance stretcher allow enough room to provide patient care? Are there federal or state regulations requiring mandatory transport of the morbidly obese patient? NHTSA put that last question before Medicare and was told that Medicare did not require transport but would pay for “alternative” methods of transport if they were necessary. Clinical training and protocols
NHTSA officials, who are responsible for overseeing the creation of the National Standard Curriculums for EMTs, polled the state EMS offices a few years ago about state licensed EMS providers being required to transport patients who do not fit on the ambulance stretcher or in the ambulance. Out of the 12 states that responded, 5 said that providers are directed to “use common sense,” contact
JOURNAL OF EMERGENCY NURSING
327
EMS/Boatright
medical control, and meet the needs of the patient. None offered specifics of what “common sense” measures they had in mind. All of the State Directors who responded said their state had no rules, regulations, or requirements concerning the oversized patient who may not fit on a stretcher. Most said that they would not advise their medics to do unwise things. “We expect them to use judgement and not load someone who exceeds their and their equipment’s capacity…they are expected to call whatever help they deem necessary,” was one response. A “duty to act” clause found in most state regulations means that leaving a sick person at the scene because of their size would constitute abandonment in many cases and may be a violation of the American With Disabilities Act.3 The EMT Paramedic Curriculum minimally covers obese patients by teaching that accommodations may be necessary. It also includes the need to use appropriately sized diagnostic devices and to maintain professionalism, and it notes that the paramedic may require additional assistance.4 Most sample EMS protocols reviewed were basic and failed to address the issue in a definitive manner. Liability concerns
According to an Occupational Safety and Health Administration rule, every employer has a duty to provide safe working conditions. In this light, can we ask a provider to transport someone who is morbidly obese? Will the provider’s Workers’ Compensation carrier provide coverage to employees who lift far more than they should? Will the insurance company provide general and professional liability coverage for the transportation of a morbidly obese patient at all? Will the manufacturer of the stretcher assume “product liability” coverage when the provider exceeds the payload of the stretcher? What exposure does the provider have if a morbidly obese patient is transferred and the transporting device cannot be secured to the vehicle? Each EMS provider must answer all of these questions. It is my opinion, after many discussions about this issue, that if a provider decides to transport a morbidly obese patient by any other method than the use of standard EMS equipment, the provider should obtain “hold harmless” releases from all parties, including providers who are providing assistance. Under no circumstance should the
328
provider attempt to transport or move a morbidly obese patient without a “hold harmless” release from the patient and family members. The company’s legal counsel should develop this document.
“We expect them to use judgement and not load someone who exceeds their and their equipment’s capacity…they are expected to call whatever help they deem necessary.” Community-wide solutions
EMS crews are expected to call for whatever type of help may be needed. I am familiar with one provider who received assistance from the fire department and local Red Cross to successfully move a 750-lb patient. When it was determined that the patient would require frequent transports for renal dialysis, the EMS operations manager contacted Social Services. The ambulance supervisor thought that assistance with securing a hospital admission for longterm weight reduction and dialysis treatment would be most beneficial for the patient. It is important that EMS providers use a communitywide approach to identify potential patients, pre-plan responses, and consider sharing specialty equipment to address the issue of obese patients. On the basis of our program’s experience, I offer some suggestions: • Create company policy that addresses the concerns, identifies strategies, and sets limits on how few people may attempt to move a patient over a specified weight. • Ensure company policy that insists that personnel call for lift assistance whenever confronted with a patient who exceeds the logically identified lifting limits of the crew on scene. • Provide routine training that includes new strategies for morbidly obese patients in both emergency and nonemergency situations. • Obtain proper equipment that is reasonably priced. Such types of equipment may include the following:
JOURNAL OF EMERGENCY NURSING
28:4 August 2002
EMS/Boatright
–Heavy rated stokes baskets or scoop stretchers lined with layers of blankets to be used as cushion and additional padding to elevate the patient’s head as necessary to accommodate the patient’s condition and airway. –Expandable/connectable flats made from extra heavy-duty materials for the oversized patient. –High- or medium-pressure inflatable air bag sets or a patient-handling air cushion that assists in the lateral transferring of a patient. –Equipment for securing the (stokes basket) apparatus to the floor of the ambulance. –Ramps used to slide the patient, with the least amount of lifting, during egress from a building and/or loading into and out of the ambulance. • Ensure pre-planning among responders and the community and remind all persons involved to remain nonjudgmental and offer matter-of-fact, creative problem-solving suggestions for consideration.
Submissions to this column are welcomed and encouraged. Contributions should be sent to one of the following: Jan R. Boatright, RN, CEN Priority Mobile Health, PO Box 6379, New Orleans, LA 70174 504 263-7531 • [email protected] Kathy Robinson, RN, CEN, EMT-P 671 Eyersgrove Rd, Bloomsburg, PA 17815-9752 571 271-7956 • [email protected]
Conclusion
In the end, we can assume that it is every EMS provider’s intention to ensure prompt, efficient, safe treatment and transportation to their vast patient population, but we cannot wait until called upon to decide how to move severely obese persons. REFERENCES 1. Boatright JR. Transportation of the morbidly obese. Ambulance Industry J 1999;19:14-6. 2. Overweight and obesity threaten U.S. health gains. HHS News 2001 Dec 13) [cited 2002 Feb 2]. Available from: URL: http://www.hhs.gov/news/press/2001pres/20011213.html 3. National Association of EMS Physicians. NAEMSP database of rules and laws [cited 1999 Aug 8]. Available from: URL: http://emergency.ucdmc.ucdavis.edu/sweiss/state/index.html 4. Beebe R. Size matters. J Emerg Med Serv 2002;27:22-33.
August 2002 28:4
JOURNAL OF EMERGENCY NURSING
329
Transporting the Morbidly Obese Patient: Framing an EMS Challenge Author: Jan R. Boatright, RN, CEN, New Orleans, La Section Editors: Jan R. Boatright, RN, CEN, and Kathy Robinson, RN, CEN, EMT-P
Jan R. Boatright, Louisiana Chapter, is Associate Director and CAO, Priority Mobile Health, New Orleans, La. For reprints, write: Jan R. Boatright, RN, CEN, Priority Mobile Health, PO Box 6379, New Orleans, LA 70174; E-mail: [email protected]. J Emerg Nurs 2002;28:326-9. Copyright © 2002 by the Emergency Nurses Association. 0099-1767/2002 $35.00 + 0 18/9/124409 doi:10.1067/men.2002.124409
T
he transportation of patients weighing in excess of 500 lb poses serious challenges to EMS crews, from the medical management of the vast array of health problems these patients present with to physically moving the person from one location to another. On occasion, most ambulance companies have been called upon to move patients weighing 500 to 800 lb or more. Transporting patients who are morbidly obese can overwhelm even the best-prepared EMS provider.1 Data from 20002001 at our ambulance service reveal that injuries related to transferring and handling of patients represented at least 50% of Workers’ Compensation annual costs. Unlike in the hospital setting, at the scene of an emergency often only 2 or 3 people are available to move a patient from one spot to another. Just one injury could literally mean the end to an EMT or paramedic’s career. It is important that EMS providers ensure that their personnel are transporting people in a manner that is as safe as possible both for the personnel and their patients, as well as in a respectful manner.
What is morbid obesity?
Approximately one third of all adults (or 58 million people in the United States) are estimated to be obese.2 Persons are considered morbidly obese when their weight is at least 100 pounds greater than their ideal weight. The prevalence of obesity seems to be increasing, and the potential for our EMS crews to need to transport a patient weighing in excess of 500 pounds is real. Health effects of morbid obesity
Severely obese people are approximately 6 times as likely as nonobese people to have heart disease and 10 times as likely 326
JOURNAL OF EMERGENCY NURSING
28:4 August 2002
EMS/Boatright
to have diabetes and kidney failure. Severely obese people have decreased lung capacity and their chest wall is very heavy and difficult to lift, yet their demand for oxygen is greater with any physical activity. This condition can be completely disabling and can prevent the patient from assisting with getting themselves into an ambulance at the time of an emergency. Experience tells us that EMS providers must conduct pre-planning exercises to prepare for attending to special situations. Experts advocate for the creation of policy and procedures, pre-training, continuing education, request for lift assistance, community involvement, and the use of equipment that helps patients without harming workers. Even with the best intentions, treating and transporting morbidly obese patients will take more time than almost any other type of call to which EMS responds.
Data from 2000-2001 at our ambulance service reveal that injuries related to transferring and handling of patients represented at least 50% of Workers’ Compensation annual costs. EMT and paramedic training curricula should cover obese patients by saying, at a minimum, that accommodations may be necessary, equipment may need to be obtained (eg, larger blood pressure cuffs), and that they may require additional assistance. Moving devices
In medical transportation circles, we have heard of patients being transferred in unusual ways. In one instance, when a man who weighed more than 1000 lb was experiencing severe respiratory distress, a crane reportedly was used to lift him from the third floor onto a waiting flat bed truck. Most providers can recall at least a few occasions when their crews had to call for assistance from the fire department and other agencies to move patients who were too big to fit on the stretcher or in the ambulance. Some have even had to use a rented U-Haul truck. Patients can be transferred via tarpaulins or huge straps used to drag the patient out of his or her house and into the back of a waiting vehicle.
August 2002 28:4
There is no real method of securing the patient for safe transportation except on a regular stretcher in a regular ambulance, and little can be done to arrange the patient in a therapeutic or comfortable position. A standard box-shaped ambulance has a 40- to 44-inch width inside of the patient compartment, with vans being about 4 to 8 inches smaller. A patient weighing 700 pounds can measure 50 to 55 inches wide or more. Most EMS vehicles are crash tested and rated for a payload maximum of 1600 pounds. Considering that the 2 or 3 health care providers needed to care for the patient could together weigh 600 pounds, little room is left for the equipment and supplies required. We have to wonder what liability exposure the provider has when transporting a morbidly obese patient in an ambulance that cannot secure the transporting device to the vehicle. In 1999, after meeting with a representative of one of our industry’s stretcher vendors, who subsequently discussed the issue with representatives from the National Highway Traffic Safety Administration (NHTSA) and General Services Administration, we found that there are many more questions than answers. Is there a demand for a stretcher that could carry persons in excess of 500 lb? Would a larger stretcher require a larger ambulance? Would a larger stretcher require a different securing/locking device? Would an ambulance with a new design stretcher require new dynamic crash testing? Would a larger ambulance stretcher allow enough room to provide patient care? Are there federal or state regulations requiring mandatory transport of the morbidly obese patient? NHTSA put that last question before Medicare and was told that Medicare did not require transport but would pay for “alternative” methods of transport if they were necessary. Clinical training and protocols
NHTSA officials, who are responsible for overseeing the creation of the National Standard Curriculums for EMTs, polled the state EMS offices a few years ago about state licensed EMS providers being required to transport patients who do not fit on the ambulance stretcher or in the ambulance. Out of the 12 states that responded, 5 said that providers are directed to “use common sense,” contact
JOURNAL OF EMERGENCY NURSING
327
EMS/Boatright
medical control, and meet the needs of the patient. None offered specifics of what “common sense” measures they had in mind. All of the State Directors who responded said their state had no rules, regulations, or requirements concerning the oversized patient who may not fit on a stretcher. Most said that they would not advise their medics to do unwise things. “We expect them to use judgement and not load someone who exceeds their and their equipment’s capacity…they are expected to call whatever help they deem necessary,” was one response. A “duty to act” clause found in most state regulations means that leaving a sick person at the scene because of their size would constitute abandonment in many cases and may be a violation of the American With Disabilities Act.3 The EMT Paramedic Curriculum minimally covers obese patients by teaching that accommodations may be necessary. It also includes the need to use appropriately sized diagnostic devices and to maintain professionalism, and it notes that the paramedic may require additional assistance.4 Most sample EMS protocols reviewed were basic and failed to address the issue in a definitive manner. Liability concerns
According to an Occupational Safety and Health Administration rule, every employer has a duty to provide safe working conditions. In this light, can we ask a provider to transport someone who is morbidly obese? Will the provider’s Workers’ Compensation carrier provide coverage to employees who lift far more than they should? Will the insurance company provide general and professional liability coverage for the transportation of a morbidly obese patient at all? Will the manufacturer of the stretcher assume “product liability” coverage when the provider exceeds the payload of the stretcher? What exposure does the provider have if a morbidly obese patient is transferred and the transporting device cannot be secured to the vehicle? Each EMS provider must answer all of these questions. It is my opinion, after many discussions about this issue, that if a provider decides to transport a morbidly obese patient by any other method than the use of standard EMS equipment, the provider should obtain “hold harmless” releases from all parties, including providers who are providing assistance. Under no circumstance should the
328
provider attempt to transport or move a morbidly obese patient without a “hold harmless” release from the patient and family members. The company’s legal counsel should develop this document.
“We expect them to use judgement and not load someone who exceeds their and their equipment’s capacity…they are expected to call whatever help they deem necessary.” Community-wide solutions
EMS crews are expected to call for whatever type of help may be needed. I am familiar with one provider who received assistance from the fire department and local Red Cross to successfully move a 750-lb patient. When it was determined that the patient would require frequent transports for renal dialysis, the EMS operations manager contacted Social Services. The ambulance supervisor thought that assistance with securing a hospital admission for longterm weight reduction and dialysis treatment would be most beneficial for the patient. It is important that EMS providers use a communitywide approach to identify potential patients, pre-plan responses, and consider sharing specialty equipment to address the issue of obese patients. On the basis of our program’s experience, I offer some suggestions: • Create company policy that addresses the concerns, identifies strategies, and sets limits on how few people may attempt to move a patient over a specified weight. • Ensure company policy that insists that personnel call for lift assistance whenever confronted with a patient who exceeds the logically identified lifting limits of the crew on scene. • Provide routine training that includes new strategies for morbidly obese patients in both emergency and nonemergency situations. • Obtain proper equipment that is reasonably priced. Such types of equipment may include the following:
JOURNAL OF EMERGENCY NURSING
28:4 August 2002
EMS/Boatright
–Heavy rated stokes baskets or scoop stretchers lined with layers of blankets to be used as cushion and additional padding to elevate the patient’s head as necessary to accommodate the patient’s condition and airway. –Expandable/connectable flats made from extra heavy-duty materials for the oversized patient. –High- or medium-pressure inflatable air bag sets or a patient-handling air cushion that assists in the lateral transferring of a patient. –Equipment for securing the (stokes basket) apparatus to the floor of the ambulance. –Ramps used to slide the patient, with the least amount of lifting, during egress from a building and/or loading into and out of the ambulance. • Ensure pre-planning among responders and the community and remind all persons involved to remain nonjudgmental and offer matter-of-fact, creative problem-solving suggestions for consideration.
Submissions to this column are welcomed and encouraged. Contributions should be sent to one of the following: Jan R. Boatright, RN, CEN Priority Mobile Health, PO Box 6379, New Orleans, LA 70174 504 263-7531 • [email protected] Kathy Robinson, RN, CEN, EMT-P 671 Eyersgrove Rd, Bloomsburg, PA 17815-9752 571 271-7956 • [email protected]
Conclusion
In the end, we can assume that it is every EMS provider’s intention to ensure prompt, efficient, safe treatment and transportation to their vast patient population, but we cannot wait until called upon to decide how to move severely obese persons. REFERENCES 1. Boatright JR. Transportation of the morbidly obese. Ambulance Industry J 1999;19:14-6. 2. Overweight and obesity threaten U.S. health gains. HHS News 2001 Dec 13) [cited 2002 Feb 2]. Available from: URL: http://www.hhs.gov/news/press/2001pres/20011213.html 3. National Association of EMS Physicians. NAEMSP database of rules and laws [cited 1999 Aug 8]. Available from: URL: http://emergency.ucdmc.ucdavis.edu/sweiss/state/index.html 4. Beebe R. Size matters. J Emerg Med Serv 2002;27:22-33.
August 2002 28:4
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329