Big  Challenges  in  EMS      

Jeff  Beeson  

Obesity    

•  Excessive  propor;on  of  adipose  ;ssue  •  Increasing  prevalence    •  Worldwide  1.1  billion  •  Body  mass  index  (BMI)  

United  States  Epidemic  

•  Percentages  – Men  doubled  – Women  increase  50%  – 31%  of  adults  are  obese  – 64%  of  Americans  are  overweight  

Pathophysiology  

•  Caloric  intake  •  Physical  ac;vity  •  Metabolism  •  Insulin  sensi;vity  

Body  Mass  Index  

•  Overweight    25-­‐29  kg/m2  •  Class  1    30  -­‐  34.9    kg/m2  •  Class  2    35  -­‐  39.9  kg/m2  •  Class  3    40  –  49.9  kg/m2  •  Class  4    >50    kg/m2  

Co-­‐Morbid  Condi;ons  

•  Heart  Disease  •  Pulmonary  Disease  •  Neurological  •  Renal  Disease  •  Psychiatric  •  Immune  •  Arthri;s  

Heart  Disease  

•  Increased  – Atherosclerosis  – Hyperlipidemia  – CAD  – Hypertension  – CHF  – Sudden  cardiac  death  

Pulmonary  Disease  

•  Decreased  volumes  •  Increase  work  of  breathing  – Higher  resistance  – Chest  wall  mass  – Decreased  compliance  – Diaphragm  pressure  

Pulmonary  Disease  

•  Pulmonary  Hypertension  •  Hypoxia  •  Pulmonary  Embolism  

Pickwickian  Syndrome  

•  10%  of  morbidly  obese  •  Heart  failure  •  OSA  •  Hypoxia  •  Hypercapnea  •  Day;me  somnolence  •  Respiratory  acidosis  

Neuroligical  

•  Stroke  – SAH  –  IVH  – Embolic  

•  Psuedotumor  

Renal  Disease  

•  Renal  blood  flow  – Renal  insufficiency  – Diabe;c  Nephropathy  

•  Kidney  stones  •  Post-­‐obstruc;ve  nephropathy  

Psychiatric  

•  Depression  •  Suicide  

Immune  System  

•  Immunocomprimised  

Musculoskeletal  

•  Degenera;ve  joint  disease  •  Complicated  cases  

Cancers  

•  Men  – Stomach  – Prostate  

•  Women  – Breast  – Uterus/Cervical  – Ovarian  

Trauma  

•  Premorbid  condi;ons  •  Interference  with  ADL  •  Ankle/Elbow  injuries  •  Seatbelts/Restraints  •  SubQ  hides  injuries  

Trauma  

•  Head  protec;on  •  Chest  Injuries  •  Pelvic  fractures  

EMS  Challenges  

•  Educa;on  •  Equipment  – Stretchers  – BP  monitoring  – Spinal  precau;ons  – Airway  equipment  

Airway  Management  

•  Difficul;es  •  Oxygen  curve  •  Posi;oning  

Posi;oning  

•  Rolled  towels  •  Sieng  up  •  Short  handle  •  Blade  adjustment  •  Bougie  •  Video  

Airway  Management  

•  Direct  •  Indirect  •  Alterna;ves  

Blood  Pressure  

•  Appropriate  size  cuff  •  Ra;o  2:5  •  Bladder  80%  of  arm  circumference  •  Arm/Leg/Ankle  

Pulse  Oximetry  

•  Tissue  thickness  •  Alterna;ves  – Earlobe  – Other  digits  – Nose  – Lip  – Temporal  artery  

Venous  Access  

•  Landmarks  not  visualized  •  Mul;ple  aiempts  •  Delays  •  Complica;ons  •  Needle  length  •  Intra-­‐Osseous    

Electrocardiogram  

•  Landmarks  •  Leads  •  Voltage  •  Flat/Inverted  T  waves  inferior  •  Increased  LVH  •  Prolonged  QT  

EMS  Educa;on  

•  EMT  curriculum  – Basic  introduc;on  – Accommoda;ons  – Appropriate  size  diagnos;cs  – Professionalism  

•  Most  providers  need  more  

Challenges  

•  Logis;cs  – Labor  intensive  – Equipment  – Antler  – Ambulance  floor  

•  Medica;ons  •  Personal  bias  

Ambulance  Design  

Moving  Obese  Pa;ents  

•  Access  •  Door  widths  •  To  ambulance  •  From  ambulance  •  Hospital  

Policy  

•  Bariatric  equipment  •  When  to  use  •  Automa;c  Dispatch  •  CAD  marking  

Equipment  

Conclusions  

•  Safety  •  Understanding  •  Planning