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How to treat obese firefighters in rehab

Obesity in fire departments is a growing problem and can be divided into three categories – prevention, rehab and injuries

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Upated June 5, 2015

We have all heard the jokes, maybe even some of us have made them, about the number of Nomex cows needed to make some firefighters’ bunker gear.

Obesity is a major health care issue in this country. Defined as a Body Mass Index of over 30 (less than 25 is normal), obesity is approximately 220 pounds or more on a 6-foot-tall person.

More than 30 percent of the nation is obese (not just overweight) and this percentage has increased dramatically in the past 20 years. And firefighters aren’t exempt from this trend.

What does this mean for those of us responsible for the medical care of firefighters?

Let’s break the discussion into three categories: prevention, rehab and injuries.

Prevention
Prevention encompasses activities designed to improve the fitness of all firefighters and reduce the weight of our overweight colleagues.

In many ways, the work environment of emergency services does not lend itself to a good diet and opportunities for exercise. Too many meals are grabbed on the go between calls.

The images of the kitchen at Squad 51 where meals could be cooked from scratch and eaten leisurely are not realistic in many of our districts. Although, we sometimes are creating this problem ourselves by sending an engine company to every sprained ankle, but that is a topic for another day.

It takes work to eat a well-balanced and low-calorie meal while on duty.

In Philadelphia, a recent law requires chain restaurants and take-out locations to list the calories right on the menu. I was quite surprised at certain sandwiches and menu items that have many more calories than I had thought.

Take the time to become informed and find meals that satisfy your hunger and help you watch your waistline. I have found that a salad with chicken at a popular fast-food restaurant actually tastes good and is filling, at a third of the calories.

Bringing lunch with you is an option as well. If you bring food from home, bring enough so you are not tempted to buy a second lunch a few hours later.

I also find that bringing a sandwich that can be wrapped up when the tones go off is much better than having to eat a cold cheesesteak later.

Many fire stations have an exercise room or workout area, but in my opinion, too often weight training is a primary focus instead of cardio and fat burning. Treadmills, elliptical machines and stationary bikes would be much more helpful to have for this purpose.

Put a TV in the room and tune it to a sports channel. Make it a place firefighters want to go to.

If you are an officer, set an example and schedule time for exercise and use the room yourself.

I understand that some departments are concerned about the liability if a firefighter gets hurt using the equipment.

Really? Would administrators prefer they sit on a recliner all day? I believe the benefits outweigh the small risks.

Rehab
When an overweight firefighter enters the rehab area, we do need to have a somewhat higher index of suspicion for medical problems.

Anybody who is overweight has an increased risk of several chronic diseases, including hypertension, diabetes and sleep apnea which can cause the individual to have a higher carbon dioxide level than a non-overweight person.

Be sure not to blow off minor complaints in these colleagues — pay attention and assess them a bit more carefully.

They may require more time for their vitals to normalize, and remember that their baseline blood pressure and heart rate may be higher than those in better shape.

It also may take longer for them the dissipate heat. Make sure they get their gear off to help this process.

Use the appropriately sized blood pressure cuff, as a wrong size can significantly change the values we get.

Injuries
Patients who are overweight are inherently more difficult to assess and evaluate than a thinner person. In medicine, much of our assessment is based on the physical exam.

For example, consider a firefighter who fell from the apparatus and is complaining of pelvis and abdominal pain. In a thin individual, the abdominal exam can tell us quite a bit about whether there is a serious internal injury or not.

We look for rigidity and guarding (as the abdominal muscles tense up in response to free blood in the area from an injured organ) as well as the specific location of the pain. A soft abdomen with no or mild pain is unlikely to be harboring a serious injury.

However, in an obese patient, these physical signs may not be present, or they may be delayed. Thus, we are more likely to use a CT scan to evaluate their status.

Overweight patients are also quite difficult to place spinal motion restriction, or cervical spine immobilization. In many cases, an obese person has significant difficulty lying flat because their abdominal girth can rise a bit and impede their ability to breath.

They also may require a significant amount of padding under their head even if they are able to tolerate the supine position.

In the event of an increased risk of a spinal injury, you may need to think outside the box and perhaps only use a half spine board with the patient sitting up somewhat. That’s not ideal, but if the patient refuses to lie flat you may have to do what you have to do.

Finally, moving a large patient can be a challenge.

Whether this is the rescuing a firefighter down in the basement or on an upper floor of a fire building, or moving an immobilized patient on a long board, make sure you have enough staff to move the firefighter without anyone else getting injured.

Take an active role in improving the fitness of all of our fellow firefighters, and be prepared to treat them if the situation warrants. And maybe lay off the jokes.

Obese people know they are overweight, they don’t need us to point it out in a way that makes fun of them.

The Rehab Zone. Kenneth G. Lavelle, MD, FACEP, FF/NREMT-P, is Clinical Instructor of Emergency Medicine at Jefferson Medical College, Philadelphia, and Attending Physician at CapitalHealth, Trenton, N.J. He was previously an attending physician at Albert Einstein Medical Center, and previously spent 14 years working as a firefighter and EMS provider.

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