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EMS speculation
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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
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