16.4 Bariatric Patients, Limited Mobility & Patients With Different Abilities

16.4 Bariatric Patients, Limited Mobility & Patients With Different Abilities

CPCF Appendix A foundational knowledge #13 names, as a single examinable body of knowledge, the unique needs of neonatal, pediatric, geriatric, bariatric patients, and patients with different abilities, mental health, addictions, and/or psychiatric conditions, and requires paramedics to know the anatomical and physiological differences and the modifications in approaches to assessment, treatment, communication, and use of equipment. The neonatal, paediatric, and geriatric populations are covered in Sections 15.3, 16.1, and 16.2. This section covers the two groups most often omitted from paramedic education entirely — and it also carries a competency obligation, because inequitable service delivery to these patients is exactly what indicator F3.2 asks paramedics to reduce.

Bariatric Patients: Physiology First, Logistics Second

"Bariatric" in a paramedic context describes patients whose body habitus requires modified assessment technique, equipment, or handling. The clinically important point is that the modifications are physiological, not just logistical.

Respiratory

• Reduced functional residual capacity and chest wall compliance. Adipose tissue on the chest wall and abdominal contents pressing on the diaphragm reduce lung volumes, particularly when supine.
• Rapid desaturation. A smaller oxygen reservoir plus higher metabolic demand means the safe apnoea time is dramatically shortened. Pre-oxygenate thoroughly and avoid unnecessary apnoeic periods.
• Position matters enormously. Supine positioning can precipitate respiratory failure. Sit the patient up wherever the clinical situation permits; the ramped position — shoulders and head elevated so that the external auditory meatus is level with the sternal notch — improves both ventilation and airway visualization.
• Obstructive sleep apnoea and obesity hypoventilation are common, meaning baseline CO2 retention and sensitivity to sedatives and opioids.

Cardiovascular

• Blood pressure measurement fails with the wrong cuff. A cuff that is too small reads falsely high. The bladder should encircle roughly 80% of the arm circumference; use a large or thigh cuff on the upper arm, or the forearm with the arm supported at heart level if no cuff fits.
• Higher circulating volume and cardiac output at rest, with limited reserve; concurrent hypertension, left ventricular hypertrophy, and heart failure are common.
• Peripheral venous access is harder. Anticipate needing a longer catheter, ultrasound-guided access at hospital, or an intraosseous route where authorized and indicated.

Assessment

• Landmarks are obscured. Palpating a femoral pulse, identifying the xiphoid, locating the cricothyroid membrane, or auscultating breath sounds all require more care and often repositioning of tissue.
• Auscultation is muffled; use the trends in respiratory rate, work of breathing, capnography, and oximetry rather than relying on breath sounds alone.
• ECG electrode placement must still be anatomically correct; displaced precordial leads produce false ST changes. Reposition tissue to place leads correctly rather than placing them where they happen to stick.
• Abdominal examination is limited — a rigid abdomen may be impossible to detect, so weight the mechanism and the vital-sign trends more heavily.
• Medication dosing is complicated by the distinction between total body weight and lean body weight for different drug classes; follow local directives and consult medical direction rather than estimating.

Equipment and Handling

• Know your equipment's rated capacity — stretcher, stair chair, scoop, backboard, and the ambulance loading system each have a stated safe working load. Exceeding it endangers the patient and the crew.
• Request bariatric-capable resources early. A bariatric stretcher, lifting equipment, additional crews, or fire service assistance takes time to arrive; requesting it at the point of recognition rather than at the point of failure is the marker of competence (skill #14, indicator G2.2).
• Plan the extrication route before moving the patient, including door widths, stair turns, and landing space.
• Never improvise a lift. Most paramedic back injuries occur during unplanned lifts of heavier patients; this connects directly to Section 5.2 and competency E4.

Dignity

Bariatric patients report high rates of humiliating experiences in healthcare. This is both an F1.2 obligation (practise self-awareness to minimize personal bias and inequitable behaviour) and a practical one, because patients who anticipate judgement delay calling. Concrete behaviours: discuss equipment needs matter-of-factly and out of earshot of bystanders where possible; never discuss weight over the patient; ask before repositioning tissue and explain why; avoid audible strain and commentary during lifts; and use the patient's stated preferences about how they are moved.

Patients With Different Abilities

Mobility Devices Are Part of the Patient

A wheelchair, walker, prosthesis, or communication device is not luggage. Practical rules:

• Transport the device with the patient wherever possible; separating a person from their wheelchair can leave them immobilized for days.
• Ask the patient how they transfer. They have done it thousands of times and usually know the safest method; this is shared decision-making (B5) applied to a physical task.
• Custom seating and pressure-relieving cushions exist for a reason. Patients with spinal cord injury develop pressure injuries within hours on a hard surface — pad the stretcher and offload pressure points.
• Do not push a wheelchair without asking, and never grab the chair — it is experienced as grabbing the person.

Spinal Cord Injury: Altered Baseline Physiology

Patients with established spinal cord injury have physiology that will mislead you if you assume a normal baseline:

• Autonomic dysreflexia occurs with injuries at or above roughly T6. A noxious stimulus below the level of injury — most commonly a blocked urinary catheter, constipation, or a pressure injury — triggers uncontrolled sympathetic outflow below the lesion with reflex parasympathetic response above it. The presentation is severe hypertension with bradycardia, pounding headache, flushing and sweating above the lesion, pallor and piloerection below it. It is a hypertensive emergency and a genuine cause of stroke and death. Management is immediate: sit the patient upright, loosen tight clothing and abdominal binders, and look for and relieve the trigger — most often by checking the catheter for kinks or blockage. A blood pressure of 130/80 may represent severe hypertension in a patient whose baseline is 90/60.
• Impaired thermoregulation below the lesion means these patients become hypothermic or hyperthermic easily.
• Absent or altered pain sensation means significant injury or infection may present only as autonomic dysreflexia, spasticity change, or vague unwellness.
• Respiratory reserve is reduced in higher cervical and thoracic injuries; a chest infection that another patient would tolerate can cause failure.

Communication and Sensory Differences

• Deaf and hard-of-hearing patients: face the patient in good light, do not cover your mouth, do not shout, offer writing or a phone screen, and use a professional interpreter rather than a family member for anything consequential.
• Blind and low-vision patients: identify yourself by name and role, describe what you are about to do before you touch, offer your arm rather than taking theirs, and tell the patient when you are leaving the room.
• Patients who use augmentative and alternative communication: bring the device, allow time, and do not finish sentences. Slow communication is not impaired cognition.
• Autistic patients and patients with sensory processing differences: reduce sirens, lights, and noise where possible, minimize unnecessary touch, explain each step before it happens, allow a familiar support person and comfort object, and accept that limited eye contact is not evasion or altered level of consciousness.
• Patients with intellectual or developmental disability: address the patient first, not the caregiver. Use plain language and check understanding. Presume capacity — capacity is decision-specific, and a diagnosis does not remove the right to make decisions.
• Diagnostic overshadowing is the documented error of attributing new symptoms to a patient's known disability rather than investigating them. A patient with cerebral palsy who becomes more distressed may have a fracture, a urinary tract infection, or an acute abdomen — and their caregiver's report that "this is not like him" is high-quality clinical data.

[!TIP] The single most useful question in this whole section is: "What do you normally do, and what usually works?" Patients with long-term conditions and their regular caregivers are experts in their own care, and their answer will be better than your improvisation almost every time.