the bariatric patient the world is growing dixie lee davenport, rn, cen, cct-rn, phrn ems outreach...

The Bariatric Patient The World is Growing Dixie Lee Davenport, RN, CEN, CCT-RN, PHRN EMS Outreach Manager Riverside Methodist Hospital OhioHealth

Disclosure The author/speaker has no actual or potential conflict of interest in relation to this presentation The author/speaker has no actual or potential conflict of interest in relation to this presentation Vendor products mentioned and/or shown as examples Vendor products mentioned and/or shown as examples No unapproved or off-label usages will be discussed No unapproved or off-label usages will be discussed

Objectives Define obesityDefine obesity Review American and world statistics regarding the prevalence of obesityReview American and world statistics regarding the prevalence of obesity Review of the pathophysiology of obesityReview of the pathophysiology of obesity Identify co-morbidities associated with obesityIdentify co-morbidities associated with obesity Identify special considerations related to trauma in the obese patientIdentify special considerations related to trauma in the obese patient Discuss challenges to prehospital and hospital providers in ergonomicsDiscuss challenges to prehospital and hospital providers in ergonomics Discuss sizism, social stigma & sensitivity in dealing with the obese patientDiscuss sizism, social stigma & sensitivity in dealing with the obese patient

Obesity Defined Condition of an excessive proportion of adipose tissue to total body weight that may lead to an unhealthy state.

Obesity Defined Definitions for Adults For adults, overweight and obesity ranges are determined by using weight and height to calculate a number called the "body mass index" (BMI)*. BMI is used because, for most people, it correlates with their amount of body fat. An adult who has a BMI between 25 and 29.9 is considered overweight.An adult who has a BMI between 25 and 29.9 is considered overweight. An adult who has a BMI of 30 or higher is considered obese.An adult who has a BMI of 30 or higher is considered obese.

Obesity Statistics - World Obesity is a modern problem - statistics for it didObesity is a modern problem - statistics for it did not even exist 50 years ago. not even exist 50 years ago. Worldwide, obesity has more than doubled since 1980Worldwide, obesity has more than doubled since 1980 In 2008, more than 1.6 billion adults were overweight*In 2008, more than 1.6 billion adults were overweight* In 2010 more than 40 million children under theIn 2010 more than 40 million children under the age of 5 were overweight age of 5 were overweight 65% of the world's population live in countries where overweight and obesity kills more people than being underweight65% of the world's population live in countries where overweight and obesity kills more people than being underweight Overweight / obesity are the 5th leading risk in global deaths**Overweight / obesity are the 5th leading risk in global deaths**

Obesity Statistics - World

Obesity Statistics U.S. A third of American adults are overweightA third of American adults are overweight More than one-third of adults (35.7%) are obeseMore than one-third of adults (35.7%) are obese Combined, 68.8% of Americans are either overweight or obeseCombined, 68.8% of Americans are either overweight or obese The CDC estimates 42% of Americans will be obese by the year 2030The CDC estimates 42% of Americans will be obese by the year 2030 After smoking, obesity is America's biggest preventable cause of premature death At the current rates of increase, obesity related health care costs are expected to exceed $300 billion by 2018 more than double the $147 billion reported in 2008At the current rates of increase, obesity related health care costs are expected to exceed $300 billion by 2018 more than double the $147 billion reported in 2008

Obesity Statistics U.S.

In 2001, no state had an obesity prevalence of 30% or more.)In 2001 the initiative Healthy People 2010 was introduced to spearhead lowering obesity rates to below 15% (In 2001, no state had an obesity prevalence of 30% or more.) No state met the nation's Healthy People 2010 goal.No state met the nation's Healthy People 2010 goal. Healthy People 2010 Healthy People 2010 Rather, in 2010, there were 12 states with an obesity increase of over 30%.Rather, in 2010, there were 12 states with an obesity increase of over 30%.

Pathophysiology Why Are We Bigger?

Pathophysiology

Pathophysiology High caloric intakeHigh caloric intake Low level of physical activityLow level of physical activity Low level of metabolismLow level of metabolism High insulin sensitivity?High insulin sensitivity? Lack of anti-obesity hormone?Lack of anti-obesity hormone? Why Are We Bigger?

Role of Brain Neurotransmitters Neurotransmitters govern the bodys response to starvation and dietary intakeNeurotransmitters govern the bodys response to starvation and dietary intake Decreases in serotonin and increases in neuropeptide Y are associated with an increase in carbohydrate appetiteDecreases in serotonin and increases in neuropeptide Y are associated with an increase in carbohydrate appetite Neuropeptide Y increases during deprivation; may account for increase in appetite after dietingNeuropeptide Y increases during deprivation; may account for increase in appetite after dieting Cravings for sweet, high-fat foods among obese and bulimic patients may involve the endorphin systemCravings for sweet, high-fat foods among obese and bulimic patients may involve the endorphin system

Obesity: A Higher Risk Heart diseaseHeart disease DiabetesDiabetes HypertensionHypertension StrokeStroke OsteoarthritisOsteoarthritis Kidney disease/stonesKidney disease/stones Psychiatric issuesPsychiatric issues Impaired body imageImpaired body image DepressionDepression Loss of self esteemLoss of self esteem

Obesity: A Higher Risk Heart Disease Overall increase in both morbidity and mortality Coronary artery disease Atherosclerosis and hyperlipidemia Hypertension CHF Sudden cardiac death Peripheral vascular disease As weight increases risks get higher

Obesity: A Higher Risk The Diabetes Epidemic The prevalence of Type 2 diabetes worldwide has more than doubled since 1980The prevalence of Type 2 diabetes worldwide has more than doubled since 1980 Estimated 153 million three decades agoEstimated 153 million three decades ago 347 million in 2008347 million in 2008 2 biggest risk factors for Type 2 (NIDDM) diabetes are heredity and weight2 biggest risk factors for Type 2 (NIDDM) diabetes are heredity and weight Over 80% of type 2 diabetic patients are overweightOver 80% of type 2 diabetic patients are overweight

Obesity: A Higher Risk Effect of Obesity on Diabetes In normal food metabolism, glucose enters the bloodstream.In normal food metabolism, glucose enters the bloodstream. Glucose is the primary source of fuel for the bodyGlucose is the primary source of fuel for the body Pancreas secretes insulinPancreas secretes insulin Insulin moves glucose from the bloodstream into muscle, fat, and liver cells, where it can be used as fuelInsulin moves glucose from the bloodstream into muscle, fat, and liver cells, where it can be used as fuel

Obesity: A Higher Risk Effect of Obesity on Diabetes In the obese, food metabolism is slowed down because of lack of exercise. This causes the glucose level to exceed what the body can handle.In the obese, food metabolism is slowed down because of lack of exercise. This causes the glucose level to exceed what the body can handle. Excessive levels of glucose make it difficult for the pancreas to regulate, leading to insulin resistance which results in type II diabetes.Excessive levels of glucose make it difficult for the pancreas to regulate, leading to insulin resistance which results in type II diabetes. THE MORE OVERWEIGHT OR OBESE YOU ARE, THE GREATER YOUR RISK OF DIABETES!!

Obesity: A Higher Risk Mean age: 12-14 years oldMean age: 12-14 years old Girls > BoysGirls > Boys 94% are in minority groups94% are in minority groups 74-100% have a strong family history74-100% have a strong family history 70% of overweight children become overweight adults70% of overweight children become overweight adults Children and Obesity + Diabetes

Obesity: A Higher Risk Pulmonary Problems Decrease in lung volume Increased work of breathing Higher airway resistanceHigher airway resistance Higher chest wallHigher chest wall Decreased complianceDecreased compliance Flattened diaphragmsFlattened diaphragms Altered lung volumesAltered lung volumes About 70% of people with OSA are obeseAbout 70% of people with OSA are obese

Obesity: A Higher Risk Pulmonary Problems Pulmonary hypertension secondary to:Pulmonary hypertension secondary to: HypoxiaHypoxia Pulmonary vasoconstrictionPulmonary vasoconstriction Depressed heart functionDepressed heart function

Obesity: A Higher Risk Pickwickian Syndrome Obesity-hypoventilation syndrome Obesity-hypoventilation syndrome 5% -- 10% of morbidly obese5% -- 10% of morbidly obese Left and right sided heart failure commonLeft and right sided heart failure common Obstructive sleep apneaObstructive sleep apnea HypoxiaHypoxia HypercapniaHypercapnia Marked daytime somnolenceMarked daytime somnolence Chronic respiratory acidosisChronic respiratory acidosis

Obesity: A Higher Risk Cancer Mortality Men:Men: StomachStomach ProstateProstate Women:Women: BreastBreast UterusUterus CervixCervix OvaryOvary

Obesity: A Higher Risk Obstetrics and Gynecology Female infertilityFemale infertility Disrupted menstruation and ovulationDisrupted menstruation and ovulation Early menstruationEarly menstruation Urinary incontinenceUrinary incontinence Abnormal laborAbnormal labor Increased progression to Cesarean sectionIncreased progression to Cesarean section Increased fetal sizeIncreased fetal size Pre-eclampsia and eclampsiaPre-eclampsia and eclampsia Gestational diabetesGestational diabetes

Obesity: A Higher Risk Obesity and Trauma Displaced ankle and elbow fractures w/ minimal traumaDisplaced ankle and elbow fractures w/ minimal trauma Higher incidence chest injuriesHigher incidence chest injuries Physiologic airbagPhysiologic airbag Rib fracturesRib fractures Pulmonary contusionsPulmonary contusions Higher mortality d/tHigher mortality d/t respiratory causes respiratory causes

Obesity: A Higher Risk Obesity and Trauma Higher incidence of pelvic fracturesHigher incidence of pelvic fractures Less likely to wear seat beltsLess likely to wear seat belts Subcutaneous fat hides physical findingsSubcutaneous fat hides physical findings

Obesity: A Higher Risk Obesity and Trauma Obese patients with critical injuries from blunt trauma have worse outcomes than do leaner patients*Obese patients with critical injuries from blunt trauma have worse outcomes than do leaner patients* Patients with higher BMIs had longer stays in both the intensive care unit and the hospitalPatients with higher BMIs had longer stays in both the intensive care unit and the hospital Required more days of ventilator supportRequired more days of ventilator support Significantly increased risk for acute respiratory failure, pneumonia, and urinary tract infectionSignificantly increased risk for acute respiratory failure, pneumonia, and urinary tract infection

Obesity Challenges Prehospital Delays due to problems in moving and transportDelays due to problems in moving and transport Appropriate sized gurneysAppropriate sized gurneys Excessive tissue impeding access for IV fluids, taking BPExcessive tissue impeding access for IV fluids, taking BP Mobilization of manpowerMobilization of manpower Managing airwaysManaging airways Pulse oximetryPulse oximetry

Obesity Challenges Airway Difficulties with intubation and BVMDifficulties with intubation and BVM Preoxygenation is criticalPreoxygenation is critical Desaturation is quickerDesaturation is quicker Sit upright or semi recumbentSit upright or semi recumbent as long as possible as long as possible Reduced pulmonary complianceReduced pulmonary compliance Higher ventilatory pressuresHigher ventilatory pressures May need to occlude pop-offMay need to occlude pop-off valve to ventilate valve to ventilate

Obesity Challenges Rolled towels or blanketsRolled towels or blankets Between scapula Displaces breast tissue Chest wall can obstruct handle Under the occiput Allows for sniffing position Creates more space for the handle Shorter than average handleShorter than average handle Adjustable angle laryngoscopeAdjustable angle laryngoscope Airway Techniques

Obesity Challenges Alternate Airways Awake oral intubationAwake oral intubation Nasotracheal intubationNasotracheal intubation LMALMA King AirwayKing Airway CombitubeCombitube CricothyrotomyCricothyrotomy

Obesity Challenges Anticipate a Difficult Airway Awake techniques if possibleAwake techniques if possible Pre oxygenate in reverse TrendelenburgPre oxygenate in reverse Trendelenburg For RSI consider increased dose of medsFor RSI consider increased dose of meds LMA has increased risk for aspirationLMA has increased risk for aspiration Neck anatomy distorted due to excess tissueNeck anatomy distorted due to excess tissue

Obesity Challenges Sphygmomanometry Inadequate width and circumference can artificially elevate blood pressureInadequate width and circumference can artificially elevate blood pressure Cuff width to arm circumferenceCuff width to arm circumference Ratio of 2 : 5Ratio of 2 : 5 Bladder length 80% arm circumferenceBladder length 80% arm circumference Important to have variety of cuffsImportant to have variety of cuffs May need to use thigh cuff in the morbidly obeseMay need to use thigh cuff in the morbidly obese

Obesity Challenges Pulse Oximetry Tissue thickness impedes light wave transmissionTissue thickness impedes light wave transmission Other areas of placement:Other areas of placement: EarlobeEarlobe Fifth digit of hand or footFifth digit of hand or foot NoseNose LipLip Temporal arteryTemporal artery

Obesity Challenges Intravascular Access Landmark vessels not visualized or palpatedLandmark vessels not visualized or palpated Multiple attempts, delayed accessMultiple attempts, delayed access Higher complication ratesHigher complication rates Secondary to multiple sticksSecondary to multiple sticks Wound infectionsWound infections PhlebitisPhlebitis ThrombosisThrombosis Standard 1.5-in needles not long enoughStandard 1.5-in needles not long enough 3-4 in needles and catheters preferred3-4 in needles and catheters preferred

Obesity Challenges Improving Success for IV Access Apply heatApply heat Light tapping over vesselsLight tapping over vessels Active pumping of extremityActive pumping of extremity UltrasoundUltrasound Topical nitroglycerin*Topical nitroglycerin* IntraosseousIntraosseous Reactive HyperemiaReactive Hyperemia Occlude with BP cuff 3-4 minutesOcclude with BP cuff 3-4 minutes Release 10-15 mmHg below diastolicRelease 10-15 mmHg below diastolic

Obesity Challenges ECG Difficulties Difficult landmarks for lead placementDifficult landmarks for lead placement Decreased or inconsistent voltageDecreased or inconsistent voltage Increased fat deposits around the heartIncreased fat deposits around the heart Flat/inverted T waves inferior leadsFlat/inverted T waves inferior leads Consistent change in obesityConsistent change in obesity Non-specificNon-specific

Obesity Challenges ECG Differences P, QRS, and T wave axes were more leftwardP, QRS, and T wave axes were more leftward More LVHMore LVH Left atrial abnormalityLeft atrial abnormality T wave flattening in the inferior and lateral leadsT wave flattening in the inferior and lateral leads Prolonged QT intervalProlonged QT interval

Obesity Challenges Hospital Equipment Costs

Obesity Challenges EMS Challenges Transporting people in a manner that is as safe as possible both for the personnel and their patients, as well as in a respectful mannerTransporting people in a manner that is as safe as possible both for the personnel and their patients, as well as in a respectful manner 2000-2001 injuries related to transferring and handling of patients represented greater than 50% of Workers Compensation annual costs.2000-2001 injuries related to transferring and handling of patients represented greater than 50% of Workers Compensation annual costs. Usually only 2 or 3 people are available to move a patient from one spot to anotherUsually only 2 or 3 people are available to move a patient from one spot to another Just one injury could mean the end to an EMT or paramedics careerJust one injury could mean the end to an EMT or paramedics career

Obesity Challenges Meeting the Challenge EMS providers must conduct pre- planning exercises to prepare for attending to special situations.EMS providers must conduct pre- planning exercises to prepare for attending to special situations. Experts advocate for the following:Experts advocate for the following: creation of policy and procedurescreation of policy and procedures pre-trainingpre-training continuing educationcontinuing education request for lift assistancerequest for lift assistance community involvementcommunity involvement use of bariatric equipmentuse of bariatric equipment 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

Obesity Challenges Obstacles to Removal Removal considerations:Removal considerations: How to be packagedHow to be packaged Stokes stretcherStokes stretcher Body bagBody bag MethodMethod Carry dragCarry drag LowerLower Ropes or slingsRopes or slings Removal route to ambulanceRemoval route to ambulance Need for additional resourcesNeed for additional resources Collapse unitCollapse unit ForkliftForklift Flatbed truckFlatbed truck

Obesity Challenges Obstacles to Removal Non-mobile patientsNon-mobile patients Patients unable to fit through doorwayPatients unable to fit through doorway Solution can be in removal of walls or windowsSolution can be in removal of walls or windows Requires heavy rescue equipmentRequires heavy rescue equipment Rescuers with engineering/construction experienceRescuers with engineering/construction experience Can lead to building collapseCan lead to building collapse Risk of injury to patient and crewRisk of injury to patient and crew

Obesity Challenges Obstacles to Transport Removing patient from sceneRemoving patient from scene Packaging and transferringPackaging and transferring Moving to the ambulanceMoving to the ambulance TransportationTransportation

Obesity Challenges Transferring Standard backboardStandard backboard Patient may not fitPatient may not fit Board unable to support weightBoard unable to support weight Rescuers must grasp and maintain board, lift carry and maneuver in syncRescuers must grasp and maintain board, lift carry and maneuver in sync Must lift from ground level to waistMust lift from ground level to waist Restricts breathing from prolonged period of lying flatRestricts breathing from prolonged period of lying flat

Obesity Challenges

Transferring Options to the standard backboardOptions to the standard backboard Specialized backboardsSpecialized backboards Basket stretchersBasket stretchers Reeves stretchersReeves stretchers Warehouse style cartsWarehouse style carts

Obesity Challenges Various Response Methods used by EMS agencies Patients that are too heavy for a 2-person medic unit can request fire departmentPatients that are too heavy for a 2-person medic unit can request fire department MAN-S.A.C. rated at 1600 lbs.MAN-S.A.C. rated at 1600 lbs. Heavy duty collapsible litters rated at 600 lbs.Heavy duty collapsible litters rated at 600 lbs. Dispatching trucks with additional personnel for liftingDispatching trucks with additional personnel for lifting Flagged address so initial responses include extra crews if availableFlagged address so initial responses include extra crews if available Hold-harmless contracts if patient exceeds rated capacity of the stretcherHold-harmless contracts if patient exceeds rated capacity of the stretcher

Obesity Challenges More Questions than Answers Is there a demand for a stretcher that could carry persons in excess of 500 lb?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 larger ambulance? Would a larger stretcher require a different locking device?Would a larger stretcher require a different locking device? Would a larger ambulance stretcher allow enough room to provide patient care?Would a larger ambulance stretcher allow enough room to provide patient care?

Obesity Challenges More Questions than Answers Are there federal or state regulations requiring mandatory transport of the morbidly obese patient?Are there federal or state regulations requiring mandatory transport of the morbidly obese patient? What liability exposure the provider has when transporting a morbidly obese patient in an ambulance that cannot secure the transporting device to the vehicle?What liability exposure the provider has when transporting a morbidly obese patient in an ambulance that cannot secure the transporting device to the vehicle?

Obesity Challenges Some Helpful Pointers Size-up building, check stairs, other escape routesSize-up building, check stairs, other escape routes Think outside the boxThink outside the box Dont exceed equipment ratings!Dont exceed equipment ratings! Know cot capacity and weight limitsKnow cot capacity and weight limits Appoint safety officer not working on the rescue to oversee health and safety issuesAppoint safety officer not working on the rescue to oversee health and safety issues

Obesity Challenges Some Helpful Pointers Size up the sceneSize up the scene Know patients weightKnow patients weight Match crew capability with taskMatch crew capability with task Call for assistance before neededCall for assistance before needed

Obesity Challenges Some Helpful Pointers Locate obese patients, preplan for future runs to each patients houseLocate obese patients, preplan for future runs to each patients house Evaluate patient mobility prior to transportEvaluate patient mobility prior to transport Scene assessmentScene assessment Door widthDoor width StepsSteps Vehicle placement so terrain works in your favorVehicle placement so terrain works in your favor PersonnelPersonnel Have a back-up planHave a back-up plan

Obesity Challenges In the Hospital Setting TransportationTransportation ParkingParking Waiting Room (space and chairs size)Waiting Room (space and chairs size) Restroom / stall sizeRestroom / stall size Weighing in privacyWeighing in privacy Small BP CuffsSmall BP Cuffs CT - MRI table sizeCT - MRI table size Scales with wide base and appropriate weight limitsScales with wide base and appropriate weight limits Narrow doors & hallwaysNarrow doors & hallways Size of examination tablesSize of examination tables Assistance getting on and off table.Assistance getting on and off table. Small paper exam gownsSmall paper exam gowns Reaction of other patientsReaction of other patients Reactions of staffReactions of staff

Obesity Sensitivity Sizism: A form of size (weight) prejudiceA form of size (weight) prejudice It is a form of discrimination against obese individuals.It is a form of discrimination against obese individuals.

Obesity Sensitivity Social Stigma Stereotypes: lazy, stupid, dishonest, lacking in self control & ambitionStereotypes: lazy, stupid, dishonest, lacking in self control & ambition Obese persons make less money than non-obese for same jobsObese persons make less money than non-obese for same jobs Frequent stigma exposure is associated with psychological distress, coping efforts, more severe obesityFrequent stigma exposure is associated with psychological distress, coping efforts, more severe obesity Often subjected to negative public responseOften subjected to negative public response

Obesity Sensitivity Societal Views of the Obese Emotionally ImpairedEmotionally Impaired Weak willedWeak willed Socially Incompetent and IsolatedSocially Incompetent and Isolated LazyLazy Dirty and unkemptDirty and unkempt Intellectually impairedIntellectually impaired WorthlessWorthless

Obesity Sensitivity Culture Behaviors- Attitudes- Beliefs Behaviors- Attitudes- Beliefs Culture influences all aspect of ones life.Culture influences all aspect of ones life. Culture is a learned system of beliefs, values, and rules that people use to guide their activitiesCulture is a learned system of beliefs, values, and rules that people use to guide their activities Culture shapes behaviors attitudes and beliefs about: fatness, thinness, eating, food, nutrition, activity and exercise.Culture shapes behaviors attitudes and beliefs about: fatness, thinness, eating, food, nutrition, activity and exercise.

Obesity Sensitivity Culture and Body Weight Culture provides the foundation for how you view the human body (your body and others)Culture provides the foundation for how you view the human body (your body and others) What is considered fat is influenced by culture.What is considered fat is influenced by culture. Body weight values and beliefs varies from one culture or ethnic group to another.Body weight values and beliefs varies from one culture or ethnic group to another.

Obesity Sensitivity Attitudes of Health Professionals Negative bias from healthcare professionals towards the obese patient can result in: The patients perception of these negative attitudes and the related rejection.The patients perception of these negative attitudes and the related rejection. Reluctance of the obese patient to seek medical assistanceReluctance of the obese patient to seek medical assistance

Obesity Sensitivity Language - Terms Non-threatening Accepting BariatricsObeseOverweight Dignified Care Offensive and Undignified Fatso/ChubbyPlump/TubbyStocky/Corpulent Stout/Big or Large Frame Rotund/Heavy Set Bulky/ Well Fed

Obesity Sensitivity Terminology - Used by the Mayo Clinic - Used by the Mayo Clinic Use of initials EC (Expanded Capacity) to describe specific bariatric equipmentUse of initials EC (Expanded Capacity) to describe specific bariatric equipment Equipment is marked with initials EC in the back right hand corner followed by weight capacityEquipment is marked with initials EC in the back right hand corner followed by weight capacity

Obesity Sensitivity Terminology Identifying equipment with EC avoids the offensive maximum weight or Big Boy labels.Identifying equipment with EC avoids the offensive maximum weight or Big Boy labels. EC equipment is identified at a glance with its weight capacityEC equipment is identified at a glance with its weight capacity The EC identifier and weight cap. ensures safe and appropriate use of equipment.The EC identifier and weight cap. ensures safe and appropriate use of equipment. - Used by the Mayo Clinic

Obesity Sensitivity See the Person Not the Size Sensitive treatment of obese patients involves attending to their needs of comfort, safety, and self-esteemSensitive treatment of obese patients involves attending to their needs of comfort, safety, and self-esteem The person, not the obesity, should be the focus of treatmentThe person, not the obesity, should be the focus of treatment Ensures that care is provided in a manner that enhances dignity, acceptance and a sense of worthEnsures that care is provided in a manner that enhances dignity, acceptance and a sense of worth

Obesity Sensitivity See the Person Not the Size ..obesity does not create a psychological burden. Obesity is a physical state. People make it a psychological burden. Stunkard and Sobal

References and Resources BBC News www.bbc.co.uk/www.bbc.co.uk/ World Health Organization National Institutes of Health Centers for Disease Control and Prevention. MSNBC - Obesity - The 21st Century Epidemic PBS - Obesity in America http://www.pbs.org/newshour/rundown/2012/05/obesity-in-america-by-the-numbers-1.html Transporting the Morbidly Obese Patient: Framing an EMS Challenge Journal of Emergency Nursing August 2002 Allison & Saunder, 2000 Sargent & Blancheflower, 1994 Myers & Rosen, 1999 The Bariatric Population: A New Challenge in Patient Care Ergonomics VISN 8 Patient Safety Center Hill-Rom Epidemiologists Majid Ezzati of the School of Public Health at Imperial College London and Dr. Goodarz Danaei of the Harvard School of Public Health in Boston American College of Emergency Physicians, Study Shows Obesity Worsens Trauma Complications

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the bariatric patient the world is growing dixie lee davenport, rn, cen, cct-rn, phrn ems outreach...

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