Editor's note: Cases are obfuscated and amalgamated to protect patient privacy and provider anonymity. While staying as true as possible to the actual event, creative license is used to better explain the lesson(s) in the case.
Our case this month takes us to the very edge of our limits, perhaps breaking them badly enough that a new operational model is needed to survive.
As EMS providers we are born and bred to push limits. We risk our own health and safety as we try to never refuse service. We respond rapidly and bravely in even the harshest of conditions. We push our vehicles, equipment, bodies and minds to perform in circumstances they were never designed for. This challenge extends to the most final of limits: death. We try to stave it off with every therapy at our disposal.
The patient in this case worked from home, successfully running a large business he built from scratch. His mild anxieties, agoraphobia and mysophobia, became manageable as he cut himself off from physical contact with other people. Food and other services were delivered to his home for years without him leaving.
It wasn't until Carl weighed more than 800 pounds and was confined to his second-floor bedroom that he needed to call 9-1-1 for the first time in his life. His body, unable to move well due to its size and lack of muscle, had become a breeding ground for infections. His open wounds wept pus as if trying to sweat off what could no longer be contained inside his skin.
The 9-1-1 call was actually placed by one of Carl's Facebook friends, who'd noticed he seemed despondent and feared for his well-being.
The first-arriving crews had difficulty entering, reaching and remaining in the same room as Carl. The house was filled with garbage and unbreathable air. Carl had devised ways to obtain food, but his cleaning person had quit several months ago.
It was first necessary for crews to rotate in and out of the scene. The crews tried to lift Carl on a tarp, hoping to drag him across the floor, but one paramedic injured his back as he tried to lift from an awkward position. Carl's skin sloughed off as they tried to lift and contain his folds inside the tarp.
It wasn't until a dozen or more responders were present that the full reality of this scene began to sink in: The crews would have to break walls and use industrial equipment—a tow truck at first and eventually a small crane from a nearby construction site—to get Carl to the hospital. The full response would include shutting down streets, handling news media, bringing in a structural engineer, and a fire department auxiliary setting up a rehab center, as the process would take hours.
The crews thought it best to lower the patient onto the stretcher in the position needed to load it into the ambulance. But once he was on the stretcher, which was rated to accept his weight, the frame began to bow, making the mechanisms to raise and lower fail. Carl was eventually transported on the floor of the ambulance after the stretcher and all its hardware were removed. A ramp and a complicated set of pulleys had to be built on site.
Caring for Carl
Sepsis was an obvious concern. Carl's open pressure sores were dressed with circumferential bandaging techniques, as no tape was sticking to his moist, waxy skin. Unable to breathe well in the supine position necessary to extricate him, he also required supplemental oxygen and the use of blankets to prop his torso up. Once he was semi-sitting, gravity helped alleviate the pressure his abdomen placed on his diaphragm and lungs.
No IV could be established, and intraosseous needles were deemed not long enough to try.
The behavioral component of this case was a significant obstacle to extrication and care. Carl's fear of leaving his home and contracting a disease, coupled with his depression and embarrassment, meant he was not only refusing care but also extremely belligerent. Occasional outbursts from the frustrated responders on scene only made him more angry and eventually aggressive. Without a good blood pressure (no cuff was large enough) or IV line, the paramedics on scene and online medical direction did not want to provide the standard benzodiazepine indicated for a behavioral emergency patient.
The difference in this case was one incredibly compassionate paramedic whom we'll call Betsy. Betsy found a way to set her own emotions and disgust aside and talk Carl through every step of the process.
Crews donned Tyvek suits, which not only bolstered their own safety but also helped Carl feel like there was less chance of the crews infecting him. A decontamination zone in the receiving hospital was set up with an engine company.
It's easy to sit back after the fact and consider how we might play things differently. The crews in this case made decisions based on their training, experience and available resources. No options appeared good, and picking the least-bad option seemed like the only path. But even in the face of those tough choices, their teamwork, creativity and adaptability ensured a good outcome.
In retrospect the system was not equipped or prepared for a patient of this size. "Proposing to plan for such an event seemed outrageous," said one deputy chief. "Now we know better. We are regrouping and thinking of news ways to tackle this kind of a response. We will not be caught by surprise again."
The system has since reconfigured an old unit to accommodate a winch and ramp system for bariatric patients.
Taking a cue from legendary Phoenix fire chief Alan Brunacini's "safe service with smiles" doctrine, the EMS crew followed up with Carl as he progressed through his hospitalization. Betsy led a group of volunteers to help rebuild parts of the house that had been destroyed in the extrication and build a ramp to ensure Carl's return home would go smoothly.
Perhaps most important, many of the responders took the case very personally. "I don't think I will look at my life quite the same way again," said one EMT who struggled with his own weight. "The only thing available at the rehab area was donuts and candy bars," said another. Working together, responders developed plans for a multidisciplinary exercise challenge and revamping the rehab menu.
When Carl was discharged, he was half his original weight. Betsy led a crew of her peers to bring him home. Carl was so touched, his business has now funded a wellness program for emergency services workers and new state-of-the-art specialized response equipment.
Low-frequency events with high acuity require specific preparation and response. A pediatric cardiac arrest, for example, happens rarely, but when it does our patient deserves to have the best care available. The bariatric patient is no different. Our response systems must prepare and practice for cases like these so safe and effective care can be delivered. The use of checklists, periodic skills practice with specialized equipment, and preplans with specialty resources (such a construction company) can ensure the next patient receives top-notch care.
Please help us identify errors and near-miss events that affect the safety of EMS providers and patients. Report events anonymously at: www.emseventreport.com.
E.V.E.N.T. is an anonymous tool designed to improve the safety, quality and consistent delivery of EMS. The data collected will be used to develop policies, procedures and training programs. A similar system used by airline pilots has led to important airline system improvements based upon pilot reported near-miss situations and errors.
David Page, MS, NRP, is director of the Prehospital Care Research Forum at UCLA. He is a senior lecturer and PhD candidate at Monash University. He has over 30 years of experience in EMS and continues to be active as a field paramedic for Allina Health EMS in the Minneapolis/St. Paul area.
Will Krost, MD, MBA, NRP, is a faculty member at the George Washington University School of Medicine and Health Sciences in the Departments of Clinical Research and Leadership and Health Sciences, as well as for the University of Findlay PA program. He has over 23 years of experience in EMS operations, critical care transport and hospital administration.