1. health and fitness
2. disease
3. diabetes

Bariatric Patients
A WEIGHTY PROBLEM FOR PARAMEDICS
Our Ancestors Greatest Dreams
Fulfilled!
Food production and starvation has always been
the #1 problem throughout human history
Human biology has adapted over thousands of
years to survive famine
The 21st century has brought the world (especially
developed countries) the greatest quantity and
quality of foods at the lowest cost in all recorded
history
 Mechanized farming
 Fertilizer technology
 Pesticides
 Efficient transportation to consumer
 Watermelons available at Christmas!
HOW BIG IS THE
PROBLEM?
AMERICA GROWS UP
Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1986
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1987
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4”
person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1988
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1989
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1994
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1996
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 1998
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2002
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2003
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2004
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2009
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
The Basic Human Physiological
Equation:
• Ratio of calories consumed to calories used
• Consumed vs Used
• Eat more than activity uses? = weight increase
• Activity uses more than consumed? = weight decrease
• There is no magic!
• There are no secrets
SO WHY PEOPLE ARE OBESE?
ADDITIONAL FACTORS
So Why People Are Obese?
Increased energy intake
 Foods are cheaper than decades
ago
 Bigger portions
 Due to cheaper costs
 Bigger crop yields
 Easier for food industry to ‘supersize’ you
 Bigger sizes
 Fruits are larger in size
 McDonalds Soft drinks sizes 1974
 8, 12 & 16 ounce
 21st century foods are more nutritious
than even 50 years ago
 Comparable foods might have more
nutrition per volume
 Better apples, rice, beef, etc.
So Why People Are Obese?
Decrease in Physical
Activity
 Physical activity was MUCH greater
in a horse drawn world
 Labor Saving devices require less
human caloric use
Fear of activity
 “Children cant walk to school, they
might be kidnapped”
 “I don’t want my child to get hurt
on the playground”
 “I cant exercise because I have;
asthma, autism, ADD, etc, etc, etc .
. . .”
 Is there a safe place to be active?
 Adults or children
So Why People Are Obese?
Genetics
You are alive today
because your
ancestors SURVIVED …
 Disease
 Disasters
 FAMINE!
Does your body hold on to
consumed calories better
than a genetic line that
never experienced
famine?
Were you raised in a family
that eats heavily?
 Adopted children can
become obese
So Why People Are Obese?
Ethnic & Socioeconomic
factors
 Food quality and portion size in
the old country
 Ethnic adaptations to new food
items
 How does a body change from
eating rice to potatoes?
 Foods available in different
parts of town
 Quality of fruits & vegetables
 Items stocked at ‘local market’
 Is local market a grocery store?
Or a liquor store?
 Most protein foods are
expensive
 Greater number of calories from
fats & carbohydrates
 Working a 12 hour day?
 Fast food more likely than a
prepared meal
 Fast food can change the ratio of
calories
 Fats, carbohydrates, proteins
So Why People Are Obese?
Stress
 Boredom?
 Anger?
 Depression/sadness?
Comfort food
seeking
 Greater volume of food
intake
 Comfort food high in
fats & carbohydrates
So Why People Are Obese?
Hormones
 Hypo-Thyroid
 Slowed metabolism
 Feeling weak & tired
 Cushing's
disease/syndrome
 High levels of Cortisol
 “I have a glandular
problem”
 polycystic ovarian
syndrome
 High levels of androgens
CNS Damage
 Pituitary imbalances
So Why People Are Obese?
Drugs - Pharmacology
 Glucocorticoids (dexamethasone)
 Antidepressants
 Phenothiazines (antipsychotic)
 Some beta-blockers
Less likely to lead to obesity . . .
Age
 Age slows activity
 Need to reduce caloric intake
 Menopause
 Weight gain
Quantifying Fat and Obesity?
BMI: Body Mass Index
 A weight-to-height ratio, calculated by dividing one's
weight in kilograms by the square of one's height in meters
and used as an indicator of obesity and underweight.
Quantifying Fat and Obesity?
Underweight: <18.5
Normal Weight: 18.5 24.9
Overweight: 25 - 29.9
Obesity: 30 - 34.9 (I)
Obesity: 35 - 39.9 (II)
Extreme Obesity: >40
(III)
 10-15% reduction in weight
has significant positive
effects on health
Save the Children
1 in 5 obese (6 to 17 years
of age)
More than doubled in the
last 30 years
Decreased physical
activity
Increased soda, junk food,
video games, TV
Increased chronic disease
onset
The Statistical Mystery
• Obesity = health problems?
• YES!
• BMI of 27 or higher = increased morbidity and mortality
• However as America’s weight increases, so does it’s life
expectancy . . . . ?
Obesity Complications
Increased likelihood of:
NIDDM or Type 2 DM
HTN
CAD, heart disease, hypertriglyceridemia
CVA
CA (prostate, colon, breast)
Sleep Apnea
Osteoarthritis
Fatty liver disease
Metabolic Syndrome
People who have 3 out of 5:
 Abdominal obesity
 Men > 40 inches
 Women > 35 inches
 HTN
 High fasting BG
 Low levels of HDL
 High serum triglycerides
Increases their risk for:
 Heart disease
 Stroke
 Diabetes
Sleep Apnea
Higher BMI correlated with sleep apnea
Use of adjuncts at home and on the job
 O2
 Bipap
 CPAP
Increased risk of hypoxia, CHF, Motor Vehicle Crashes
Medical Specialty
• Bariatricians and the Journal of Bariatric Medicine:
“Obesity is a chronic, debilitating and potentially fatal disease
that requires the treatment by a physician trained in
bariatric medicine
Treatment of Obesity
Exercise
Psychological Intervention
Diet and Very Low Calorie Diet
Hormone Therapy
Drugs
Surgery
Treatment of Obesity
Exercise
• Increased activity affects basic
physiological ratios
• Does intake = outgo?
• However . . .
• Lifestyle is a learned behavior
• Can people make meaningful
sustainable changes?
• Sedentary Occupation?
• Preferred recreation?
• Social Structure?
Treatment of Obesity
Psychological Intervention
• “Why do you overeat?”
• Depression?
• Stress?
• Lack of nutritional knowledge . . . . ?
• Possibility for some behavioral changes
• Overeaters anonymous – 12 steps to weight control
Treatment of Obesity
Diet and Very Low Calorie Diet
• Reduce general food intake? Excellent
strategy . . .
• However you cant starve your way to health
• Are sustainable behavioral changes
realistic?
• Severe dieting needs medical supervision
Complications of VLCD
 Nutritional Deficiencies
 Consumed food must be nutritionally balanced
 Fats, carbs, proteins, vitamins, minerals . . . .
 Increased risk of gallstones
 Greater than 10 lb weight cycle (chronic dieters)
= higher risk for gallstones
Gallstones
Classical Gallstones
URQ pain
Right shoulder, shoulder blade pain
N/V
Dyspepsia after desert, fish and chips
Dieter’s Gallstones
Weight loss > 3 lbs per week = higher incidence
VLCD: 1/3 of dieters developed gallstones
Shift in bile salts and cholesterol
Cholesterol increased
Bile salts decreased
Skipping meals may decrease gallbladder contractions
Stagnation = coagulation or gallstone formation
Treatment of Obesity
Pharmacological Treatment
 Amphetamines
 Amphetamine, dextroamphetamine, methamphetamine
Appetite Suppressants
 Phentermine (Adipex, Fastin, Banobese, Obenix, Zantryl)
Orlistat (Xenical): lipase inhibitor
 Requires vitamin supplement (A,D,E,K and beta carotene)
Leptin: hormone that may suppress appetite
Treatment of Obesity
Hormone Therapy?
• Possible future treatment - Needs greater research
• Treatment for known disorders?
• Thyroid
• Direct supplementation?
• Gut hormones
• Might modify hunger impulse . . . .
Treatment of Obesity
Surgical Treatment of Obesity
From Peptic Ulcers to the Lap Band
First Gastric Bypass 40 years ago
Risks:
 Surgical experience
 Sleep apnea
 DM
How it works:
 Food Restriction
 Malabsorption
The Stomach Is Made Smaller
• Laparoscopic surgeries
• Lap Band
The Stomach Is Made Smaller
• Gastric Bypass
• Duodenal bypass
• Roux and Y
• And many more! (depends
on local physician/surgeon
education/training)
The Stomach Is Made Smaller
• Gastric Bypass
• Duodenal bypass
• Stapling and excision
Possible Complications Bariatric
Surgery
•
•
•
•
•
•
•
•
•
•
•
•
•
Pouch Stretching
Band Erosion
Breakdown of Staple Lines
Perforation aka “leakage”
Venous thromboembolism (VTE)
Vomiting
“Dumping Syndrome”
Diarrhea
Abdominal hernias
Gallstones
Anemia, osteoporosis
Bloating, excessive gas, sweating, dizziness
Neuropathies
Malabsorption of:
Calcium
Iron
B12 (delayed)
Copper (delayed)
Thiamine (acute)
 Wernicke’s Encephalopathy







Acute confusion and ALOC
Ataxia
Nystagamus
Hypothermia
Hypotension (SNS disturbance)
Memory disturbance
Rx: Thiamine!
Dumping Syndrome
Undigested food enters the intestine too soon
 N/V, W/D, fatigue, shakiness
 Diarrhea
 Abdominal pain, cramps
 Bloating, belching, flatulence
 Anxiety, nervousness, fainting
 Palpitations, rapid heart rate
 Sweating
 Mental confusion
Why Even Do Surgery?
• Surgery more effective than other weight loss
programs
Obesity and Prehospital Care
• Fact: There exist a universal
prejudice against bariatric
patients in occupations
that are responsible for
lifting and carrying them
• Fact: The (unaided)
movement of a bariatric
patient can result in a
career ending injury
• Just as pediatric patients
are not little adults,
bariatric patients have their
own special needs and
medical complications.
Psychosocial Considerations
Both You and the Patient!
• Bariatric patients have
both a physical AND
mental problem
• They know they are ‘FAT’
• They are addicted to food
• You cannot cure them!
(think of them as an
alcoholic)
• The person who has not
been out of their house
for years has a (codependent) family or
friend who brings them
food
Psychosocial Considerations
Both You and the Patient!
• Acknowledge the stereotypes
• Acknowledge YOUR feelings
• They are still human
• Use dignity and compassion
• However - Don’t them end your career
Prehospital Bariatric Assessment
• Keep patient upright
• Easier breathing
• Sample lung sounds near scapula
• Decreased Adipose tissue
• Pulse oximeter
• Earlobe, little finger, nose
• Cyanosis
• Lips and eyelids
• Proper sized B/P cuff?
• EKG leads - avoid anterior
abdomen
• Lateral aspect of abdomen
Bariatric Airway
• High risk for aspiration
• Large stomach size
• Decreased gastric pH
• Need EXCELLENT oxygenation
• Decreased O2 reserves
• No toleration for apnea
• BVM is a 2 person job
• Additional tissue weight must be displaced
• Elevate head to 25 degrees (towels
under back)
• Towel between scapula can displace
breasts
• CPAP – BiPAP can be effective
• Set to at least 10 cm H2O to improve
effectiveness
Bariatric IV Access
• Landmarks are difficult to find
• Multiple sticks common – are the
complications worth it?
• Consider deferring in field
• Catheters longer that 1.5 inches?
• Consider earlier IO access
• Longer IO needles exist
• Medications
• Renal problems may cause blood levels to
be higher or lower than expected
• Lipophilic drugs may result in lower serum
levels and slower elimination
• Fentanyl - benzodiazepines
Obesity and Trauma
4-6 L of blood per person
Larger size does not equal larger blood supply
Increased metabolic demand from more cells
May have worse response to trauma
Spinal Stabilization
• Even normal people don’t fit on backboards!
• Complete immobilization is unrealistic
• Minimize ‘excessive movement’
• Cervical collar may affect airway
• Monitor carefully
• Field spinal clearance?
Logistics
• Proper sized stretchers
• Weight capacity
• WIDTH also!
• Can (interfacility) bariatric
equipment be brought to a 911
call?
• Patient safety may be worth the
wait
• Have adequate staff for lifting
4? 6?
• Ensure/survey a clear path to
ambulance
• Bariatric tarps
Final Thoughts
• Man’s 1000 year progress in fighting starvation has
resulted in an obesity situation in the modern world
• It is not going to be changed anytime soon
• You cannot cure a bariatric patient!!
• They require specialized equipment and
procedures
• Whatever you do, whatever treatment you provide,
they are always at higher risk for death
• Follow standardized procedures and don’t allow a
bariatric situation to end your career
Resources
• http://www.emedicine.com/EMERG/topic642.htm
• http://www.nlm.nih.gov/medlineplus/weightlosssurgery.html
• http://www.clevelandclinic.org/health/healthinfo/docs/2400/2451.asp?index=9472
• http://win.niddk.nih.gov/publications/gallstones.htm
• http://www.mayoclinic.com/print/dumpingsyndrome/DS00715/DSECTION=all&METHOD=print
• http://www.medem.com/medlb/article_detaillb.cfm?article_ID=ZZZD
2N03RFD&sub_cat=651
• http://www.neurology.org/cgi/content/full/68/21/E36
• http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=17
86
• http://digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis/index.htm
• http://digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis/index.htm
• http://www.emsresponder.com/print/Emergency--MedicalServices/Beyond-the-Basics--Bariatric-Emergencies/1$6008