Morbid Obesity

I took care of a 650 pound woman once. She had renal failure and needed dialysis when I met her. We admitted her to the hospital but probably for the last time. Due to her size, she was immobile. She basically had to have six firefighters lift her every time she went anywhere. When it comes to dialysis, that’s usually a three days per week event. Patients that have transportation issues can usually be set up with services to accommodate their schedule. However, that’s usually one driver of a handicap accessible van. That’s not six firefighters lifting her onto an ambulance gurney that is almost maxed out for weight and then picking her up to take her home.

And that’s just Monday. She would need this Monday, Wednesday, Friday. No medical insurance is going to pay six firefighters to be available with an ambulance to pick her up, wait for three to four hours, and bring her home and do that three days per week. As I understand it, after she was admitted, this was explained to her and she was made comfort care only.

I’ve had two similar experiences with morbidly obese patients that come to mind. I was working a night shift when a paramedic supervisor called for online medical direction. (That’s usually when EMS has a question that falls outside their usual protocols and guidelines.) He explained they were on scene at a cardiac arrest. They did not have IV access and were standing next to the patient doing CPR.

For those not familiar, you don’t typically stand next to a patient and do CPR, particularly prehospital. Most patients that need CPR are on the floor. Even if they are found in a bed, chair or on a couch, they are moved to the floor. So when he said “standing”, my ears perked up.

Turns out the woman was 800 pounds.

I told them to stop immediately. There is no effective CPR going on with a patient who weighs 800 pounds. This led me to have a conversation with my community paramedics at one of our weekly meetings. They were seeing a patient in his home regularly. The man had recently lost a family member and was depressed and morbidly obese. I explained that a hard conversation needed to be had with the patient about his code status.

CPR is largely ineffective in morbidly obese patients. In essence, they needed to have a “come to Jesus” talk with this guy because he was basically sentencing himself to death. He was not getting out of the house, going to appointments, exercising, eating better, or doing pretty much anything except eating terrible food and being sedentary. And the end game was that he would die in his apartment with no hope of resuscitation.

The automatic CPR machines have made transporting a patient in cardiac arrest a possibility while still allowing EMS to remain safely seatbelted in an ambulance. Prior to this, one of two things happened. Either the patient wasn’t transported if CPR was still needed or EMS put themselves at high risk by doing CPR in the back of a moving ambulance.

The Lucas (the most common automated CPR device) does not restrict based on weight. The website specifies a maximum sternum height and chest width which is more or less 12" x 18”. Depending on how a person carries their weight, this would not be the same for all patients. A very top heavy person with a wide and thick chest might not. fit despite weighing less than a patient with a small chest who carries their weight around their abdomen or hips and thighs.

That being said, there is a limit and for the most part, if you don’t fit, very few EMS agencies are risking their personnel to do CPR on you in a moving ambulance. The risk of injuries to EMS are too great and combined with the baseline poor outcomes for prehospital cardiac arrest, especially in morbidly obese patients, the juice just isn’t worth the squeeze.