Caring for Patients With High BMIs

For Mandy Pate, RN, CBN, everything about the sleeve gastrectomy was familiar. She knew every square inch of the operating room at the University of Michigan Health System in Ann Arbor where it would be performed. She knew every staff member milling around the table preparing to start the case. They were following pre-op protocols she could recite in her sleep. But there was one major difference this time around. Ms. Pate was lying on the table, the patient during a procedure she had helped perform countless times before.

From the perspective of a patient, Ms. Pate observed some inherent biases even her most well-intentioned colleagues had toward high-BMI patients. "After my surgery, I wanted to get up and use the bathroom, and the nurses didn't want me to," she says. "I couldn't understand why." Her confusion was certainly justified. After all, Ms. Pate wasn't on a bed restriction, and she wasn't hypotensive or dizzy.

Didn't that mean she should be up and moving as soon as possible? A nurse's offhanded comment provided some context for the staff's overly cautious approach to her care.

"I remember one nurse saying, "You're really mobile,' like she was surprised," says Ms. Pate. "I think sometimes people make assumptions because of your weight that you can't do something, that you can't get up, or you can't walk, or you can't move."

If colleagues of Ms. Pate, an OR nurse who routinely logged 12-hour shifts, held misguided assumptions about her lack of mobility, imagine what they think of unfamiliar patients with high BMIs.

I think for a lot of people, even some within the medical community, obesity is still seen as a character flaw.
- Mandy Pate, RN, CBN

Ms. Pate, who weighed 330 pounds at her heaviest, is down to 165 pounds. Her journey from nurse to patient to advocate has inspired her to challenge facilities' approaches to treating high-BMI patients, especially as the nation's obesity epidemic is increasing the number of heavier individuals undergoing procedures in outpatient ORs. She believes it's time to change outdated mindsets and protocols in order to provide safe and satisfying care for this growing patient population.

When it comes to operating on high-BMI patients, a common question is, "Where should we draw the line?" Some facilities won't schedule surgeries for patients with BMIs above 35, but perhaps there's more to consider.

"You can't get caught up on the number alone," says Ashish C. Sinha, MD, PhD, DABA, MBA, professor and vice chairman of the department of anesthesiology at Temple University Lewis Katz School of Medicine in Philadelphia, Pa. "What's more important to me are the other comorbidities. Does the patient have diabetes? High blood pressure? Sleep apnea?"

He's most concerned with sleep apnea, especially if patients are non-compliant with their CPAP machines, will be alone at home after surgery or are given narcotics to manage post-op pain. These are all signs the patient might not be suitable for undergoing surgery in an outpatient setting.

Of course, the majority of high-BMI patients are candidates for same-day surgery, as long as your facility knows how to properly manage their care during all phases of the surgical episode. Everyone involved in the procedure — surgeons, anesthesiologists, administration and nursing staff — must collaborate to create guidelines for handling high BMI patients. "You never want to call them rules," says Dr. Sinha.

"You call them guidelines because you have the ability to be discretionary."

Your facility's guidelines should include understanding and managing the clinical challenges of caring for obese patients.

• Difficult airways. While patients with high — even extremely high — BMIs can successfully undergo most outpatient procedures, "Airways are always a big concern," says Ms. Pate. "Managing the airway is a major part of our educational efforts."

Obesity increases the difficulties of mask ventilation and intubation. The challenge is that high-BMI individuals generally have a high metabolic demand, and their oxygen reserves are low. "The scales are swinging in the wrong direction with both of these," says Dr. Sinha.

"Patients have less reserves, and they consume it faster. That means they desaturate very quickly."

If your facility is serious about giving high-BMI patients the best care possible, reevaluate your staff's attitudes and preconceptions about these patients. Surgery is scary under even the most ideal circumstances. For patients with high BMIs, not only are the circumstances often far from ideal, but there are also usually other anxieties at work.

For starters, there's the tangible fears patients have based on a life filled with embarrassing incidents. "A lot of patients are afraid of not fitting on OR beds, of falling off the table or of the table breaking," says Ms. Pate.

She also says obese patients worry about whether their caregivers will make snide comments about them when they're under anesthesia, because they've been dealing with unkind looks and jeers from strangers their whole lives.

"I think for a lot of people, even some within the medical community, obesity is still seen as a character flaw, a decision to not do the things you should be doing [to lead a healthy lifestyle]," says Ms. Pate.

Education can help eliminate the prejudices, subconscious or expressed, some surgical professionals still have against overweight patients. After Ms. Pate was discouraged from getting up on her own following surgery, her facility conducted educational sessions to reset internal expectations of what high-BMI patients are capable of doing — and what they should be expected to do — after surgery.

Even changing outdated terminology — saying a patient with obesity as opposed to an obese patient — can go a long way toward making patients feel comfortable, at-ease and ultimately satisfied with the care you provide. Obesity isn't a character flaw, it's a disease. Make sure your staff always treats it that way.

Your entire care team should understand the stigma that's involved in being an overweight patient — and why this stigma can prevent people from getting the life-changing care they need. Sensitivity training is one option. Making sure your facility is outfitted to make high-BMI patients comfortable — oversized chairs in the waiting room, adequately sized gowns and blood pressure cuffs, and surgical tables designed to hold larger patients — is another. But even the smallest gestures can do wonders, so encourage your staff to look at the surgical experience through the patient's eyes.

Ms. Pate now appreciates that expression on a literal level. "One of the last things I remembered before the anesthesia took effect was a nurse holding my hand and rubbing my arm," Ms. Pate says.

"That's why I always make it a point to hold my patients' hands when they're drifting off to sleep." OSM