I had an interesting scenario this weekend that I think could be a harbinger of things to come in EMS.
With the growing obesity in the population, ambulance companies have started putting bariatric ambulances on line. The ambulances come equipped with special wide load stretchers that more comfortably accommodate the larger patient.
Years ago before these ambulances came on line, we often had to move the stretcher mounts on the ambulance from the side to the center to enable the patient (bulging over the sides of the stretcher) to fit in the back of the ambulance provided the stretcher could bear the patient's weight. If the stretcher couldn't bear the weight we sometimes put the patient in a fire department Stokes basket or, in rare cases, the patient was transported to the ambulance on the back of a flatbed truck.
Now that these bariatric ambulances are out on the road, some interesting dilemmas have come up.
When I work in the city, our company has one bariatric ambulance that sometimes is out on a call and is not immediately available when I arrive on scene to find a larger patient. So what do I do? Delay transport until the big ambulance is available or follow the old stokes/flatbed routine? Obviously, it depends on the patient size and condition.
I described such a scenario back in 2005.
"You're Going to Need a Bigger Ambulance"
Now three days a week I am contracted to a suburban service that does not have a bariatric ambulance. What do we do? Again it depends on the patient condition.
Here's what happened this weekend.
We are called for chest pain. We arrive to find a large patient, estimated by the nursing home to be just under 400 pounds, who tells us he has been having chest pain for a week. The pain increases on palpation of his sternum. The patient appears quite stable, is in no distress, and is in fact, eating lunch when we arrive. I have had this patient before, so on seeing him, I know what to expect.
"I'm not getting on that stretcher," he says looking at our regular size stretcher.
"You are if you are having chest pain and want us to take you to the hospital," I say.
"I'm not getting on it. Bring the wide stretcher."
"This stretcher is certified for up to 500 pounds."
"I'm not getting on it."
To be fair to the patient, it is not just an issue of pounds, the patient is as wide as he is long. The stretcher appears to be easily less than a third of his width. More of him will hang off each side of the stretcher than be centered on it.
This is also my third encounter with this same patient. On one occasion, I was working for the suburban service. On the other, I was working for the commercial service. In both cases the patient was stable, and the call was more of a request for transportation for evaluation than an immediate need for treatment.
I go back and forth with the patient.
"You should buy a wide stretcher for patients like me."
"A point to be considered," I say, "But that doesn't change the fact that right now, we don't have a wider stretcher. This is it."
I again fully advise him of the dangers and consequences of his refusing to let us put him on our stretcher.
"I want the wide stretcher."
I finally tell him I will call the commercial service and see if they can send out their big ambulance with its wide stretcher for him.
"That's what you should have done in the first place instead of arguing with me," he says.
I go to the nurses's station and call the commercial service. I explain the situation("You need to understand -- he will not let us put him on our stretcher. He is alert, competent and refusing us.") They finally agree to send out the big ambulance. They add it will be about 90 minutes before they can get there.
After sharing this information with the patient, I again advise him to let us transport him on our stretcher.
"That's fine. I'll wait. I'm not getting on your stretcher."
We tell him and the staff to call back should he change his mind or if they feel his situation is deteriorating. He signs a refusal and goes back to eating his lunch.
This is just what happened when I worked for the suburban service the last time. In the one instance when I worked for the commercial service, I had to convince our dispatcher to send out the big ambulance because, despite the fact the patient was just under 400 pounds and did not meet the weight criteria mandating the larger ambulance, he simply would not get on our stretcher. In both cases, the big ambulance eventually came and the patient was transported non-priority.
Now as more and more large size patients become aware of the wider stretchers, similar scenarios can be expected to play out.
"I'm not getting on it. Bring the wide stretcher."
It is not too much of a stretch to imagine that all ambulance services, commercial and volunteer, large and small, will one day have to provide the wider stretcher due not just to the burgeoning size of the population but to the simple availability of a more comfortable, and in some cases, more humane, stretcher.
In the meantime, I just worry about the time when the patient is in true distress and still refuses to get on the stretcher.
