Managing the Morbidly Obese ED Perspective
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- John Thompson
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1 Managing the Morbidly Obese ED Perspective Dr Stuart Young Director of Emergency Medicine, Logan Hospital Currently on secondment to Retrieval Services Queensland
2 Acknowlegements: Justine Powell NUM, RFDS Brisbane Tony Hucker, QAS Paramedic Educator
3 Managing the morbidly obese in ED Access to ED Logistics Medical issues
4 Local Perspective Australian study 2007 (Kam and Taylor) 23.7% of patients attending ED obese (BMI 30-40) 4.1% morbidly obese (BMI>40) For Logan ED seeing 80,000 patients/yr (approx 60,000 adults) that would equate to: = 40+ obese patients/day = 7 morbidly obese patients/day
5 Access: Getting to ED
6 Getting out of the house
7 QAS: Standard Response Vehicles
8 Standard Stretcher
9 Routine Transport
10 Specialist Transport and Retrieval Unit
11 Bariatric Equipment
12 STRU Unit
13 Bariatric Equipment
14 Bariatric Equipment
15 Current Bariatric Unit Locations - Qld Metro North (Chermside) Metro South (Nathan) Toowoomba Townsville
16 Access: Rural and Regional Queensland
17 Retrieval Services Queensland Transports 20,000+ patients/yr Primary response Inter-hospital transfers 11 helicopter bases 7 fixed wing bases (RFDS)
18
19 RFDS Kingair (Lifeport) loading system Stretcher length 186cm Stretcher width 48cm Clearance to sidewall 8cm Door width 60.5cm Load system 180kg limit Note: attached equipment can weigh up to 22.5kg allows for patient wt 157.5kg
20 RFDS Kingair TAS loading Stretcher length 186cm Stretcher width 51cm Clearance to sidewall 8cm Cargo door width 130cm TAS loading: Patient only 247kg With equipment allows for patient weight of 222kg
21 Kingair TAS loading
22 What happens if the patient weighs over 247kg?
23 Road Options Can fly team out to patient who can provide critical care to patient Can drive bariatric ambulance out to patient Prolonged driving distances Longreach-Rockhampton 7 ½ hours (one way) Quilpie- Brisbane 12 hrs (one way) Physiologically demanding for patient and staff Fatigue considerations
24 ADF C130 Usually needs few days notice Ambulance can be carried in aircraft Very expensive
25 Example 200+ kg patient Regional hospital to tertiary centre Respiratory failure/pneumonia NIV with high O2 requirements C130 with military ambulance used Patient moved to ambulance (secured to mattress on floor) Intubated in ambulance Ambulance driven into aircraft Patient managed in ambulance Driven off and transferred at the other end Took 3 days to organise and cost approx $400,000
26 ED
27 Overview: What do we know about how we manage morbidly obese patients in ED? 1. Length of stay is longer 2. Increased CT usage (approx 10%) 3. Obese patients more likely to get IV and blood tests 4. Increased rates of intubation 5. Higher admission rates 6. Increased mortality rates 7. 50% more likely to suffer injury requiring medical attention
28 Logistical Issues in ED Ideally some forewarning of arrival with equipment immediately available and Direct unloading onto heavy duty bed or wheelchair Standard bed takes up to 200kg but limited by width Heavy duty bed can take up to 500kg Lifting device or hover mattress to assist with transfer Adequate staff available to assist
29
30 Where to manage the patient in ED?
31 Bariatric toilet
32 Medical Issues 1. Airway and ventilation Positioning the patient ramping and head of bed elevated Use apnoeic oxygenation/delayed sequence intubation strategies to maximise preoxygenation Weingart 2012 Better ventilators Availability of video laryngoscopes Use of NIV Nothing however replaces expertise and experience in the team
33 Medical Issues 2. Vascular Access Use of ultrasound becoming much more widespread Must be able to access longer cannulae Use of EZ-IO when time-critical vascular access required
34 Medical Issues 3. Diagnostic uncertainty/limits of clinical examination/plain imaging Increased use of CT (250kg limit) Diagnostic uncertainty makes it difficult to refer patients to inpatient teams
35 Medical Issues 4. Pharmacology Ideal body weight vs total body weight Suxamethonium TBW Vecuronium IBW Rocuronium TBW Ketamine TBW
36 Medical Issues 5. Paediatric patients Seeing 80kg 10yo and 35kg 4yo Medication dosing Use of Broselow tape to determining ideal body weight Worse outcome in Burns Asthma Injury Incidental findings: hypertension, NIDDM
37 ED Assessment and Management: Issues identified by staff Kam & Taylor 2010 Medical Staff Physical examination Finding anatomical landmarks Performing procedures Nursing Staff Positioning patient Mobilisation Assistance with clothes IV cannulation Radiographer Positioning patient Ability to get good images
38 Recommendations: Lifting equipment Other equipment (tourniquets, beds) Extra staff to assist
39 Summary 1. Delayed access to care 2. Delayed time to disposition once in ED 3. Increased CT usage 4. Need for specialised equipment/accommodation for patient (plus staff training) when the patient is in ED.
40 Thank you
41
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