Beyond the Basics: Bariatric Emergencies

CEU Review Form Bariatric Emergencies (PDF)Valid until October 5, 2007

Case Study
     You are finishing an uneventful 12-hour shift with your local EMS company. So far, you've only had two BLS transports to the emergency department. As you watch TV, the radio squelches out, "Medic 12, respond to 1020 Elm St. for a 32-year-old male with difficulty breathing." While responding, you begin to contemplate potential etiologies for respiratory distress in a 32-year-old. Being it's mid-summer, you consider seasonal causes like anaphylaxis, extrinsic asthma or exacerbation of congestive heart failure due to the increased humidity and temperature. As you arrive in a seemingly safe middle-class neighborhood and exit the squad, a female approaches the ambulance from the house, frantically waving her arms and yelling, "I don't think he's breathing." At the patient's side, your initial assessment yields a 32-year-old male in obvious respiratory distress, with shallow irregular respirations at 14 per minute. It is readily evident that his breathing is inadequate, as there are no vesicular breath sounds, his skin is dusky blue, and the pulse oximeter yields 84% on room air. Your partner begins assisting the patient's breathing with a bag-valve mask attached to 100% oxygen as you continue your assessment. After completing the initial assessment and a rapid medical assessment, you obtain vitals: BP 130/68, pulse 104 and regular, and a modest elevation in the pulse oximeter reading.

     You ask the family about the SAMPLE history and learn that the patient was released from the hospital four days ago after bariatric surgery. He is also an insulin-dependent diabetic with hypertension. Ongoing ventilatory assistance only produces breath sounds in the upper lobes, with minimal to absent breath sounds in the middle and lower lung fields. A blood glucose level obtained after the IV start is 44 mg/dl. Per protocol, you administer 25 grams of dextrose and continue assisting the patient's respirations while preparing to transport to the local hospital.

     With a short transport time of only two minutes and backup not yet on scene, you decide to depart the scene while you continue BVM assistance and radio your report to the receiving facility. The physician and staff are ready when you wheel the patient into the emergency department. After assuming care from you, they begin to assess the patient, whose vitals are now: BP 132/88; pulse rate 104 and irregular; pulse ox 92%. The cardiac monitor shows sinus tachycardia with occasional premature atrial contractions, and the patient's temperature is noted as 101.3°F.

     The physician prepares intubation equipment while the respiratory therapist places a Bi-PAP face mask on the patient, draws an ABG and orders a portable chest x-ray. The x-ray is displayed on the digital monitor in the room. Looking at the film you wonder how and why a 32-year- old is in heart failure, as evidenced by bronchial congestion and what appears to be pulmonary edema in the lower lung fields extending into the midvesicular region. Before you can ask the doc any questions about the patient and your interpretation of his chest film, your portable alerts you to another Code 3 call.

The Obesity Imperative
     The U.S. Department of Health and Human Services has recognized obesity as a "neglected health problem." Obesity is defined by body mass index (BMI) of 30 kg/meter2. BMI is a calculation that takes into account the patient's height and weight, which allows for fluctuations due to the patient's body size instead of establishing a one size/weight formula to fit all. According to this formula, a person is overweight if his/her BMI is between 25 and 29.9 kg/meter². There is also a BMI scale for adolescents and pediatrics, taking into account their physical stature.