The title of his presentation was "Transfer and Mobility of the Obese Patient," a fascinating topic that provided a great degree of information and insight in an area that is the nightmare of many fat people: what will happen to me if I had an accident and they have to move me to a hospital? How will they treat me there? Will they be able to accommodate me? The problem, Dr. Dionne pointed out, is that many hospitals and facilities simply don't have facilities and equipment necessary for very large person. And they have no expertise and experience in trauma treatment of large people. As a result, Dionne is often called in on behalf of very large patients who simply cannot be moved with conventional methods.

He explained that in many cases and whenever possible, movement needs to be planned ahead of time. This is because many people who haven't moved in a long time need to be prepared, physically and mentally. In addition, most medical personnel usually doesn't know what sort of lifts, wheel chairs, and other equipment is available. Dr. Dionne explained some of the problems that occur when housebound and practically immobile need to be moved. And also why any degree of movement is always a good thing. One such problem is muscle atrophy, the permanent loss of muscle tissue that can occur when certain muscles simply are not used. Once those muscles are gone, they are gone forever. Preventative movement therapy can go a long way to keep that from happening.

Dr. Dionne presented a number of case studies. One example was an 800 pound man he helped in the early 1990s. The patient was married to a thin woman, they had a great marriage, he was a business owner, and a very, very intelligent and motivated man. Dionne said this positive experience, helped him as much as it helped his patient who engaged in a very productive dialog about his physical problems and the problems of people of size in general. Some of this dialog became the foundation of Dionne's work and expertise, and also the foundation of his educational programs that he is presenting all over the country.

Dr. Dionne then talked about different bariatric body types, which very much affect how a large patient is being treated and moved. In fact, recognition of body type and fat distribution are crucial in determining the proper equipment, both at home and in medical care. At this point, Dr. Dionne brought up another key point when it comes to moving a very large patient. It's anasarca, "the congested state," which is an acute care phenomena. It is a generalized swelling (edema) of the body, especially in the legs and abdomen. It results from the accumulation of fluid in body tissues. In very fat patients, the lack of mobility and movement results in water in lungs and other places. As a result of this, sudden movement can be very dangerous or deadly. Constant monitoring of the heart rate and oxygen may be required. Dionne pointed out that anasarca is not a condition unique to obese patients. It can also happen to anorexics. The presence of anasarca requires special attention to cardiac telemetry, edema, skin damage, deformities, bowel/bladder issues, anxiety. Unless all those are addressed, a patient can die or get hurt badly before they even receive care at a facility.

Once moved out of a house and to the hospital, standard beds are just not going to work. Dionne pointed out that there IS equipment out there but that many hospitals simply don't know where to find it and buy it. There presence of wider beds, beds with extensions for the legs, special air mattresses, air mattress overlays, etc., can be a literal life saver. If all of the above has been successfully negotiated, and once the danger of heart failure phase has been addressed and negotiated and the phase of critical care is over, movement often becomes very much easier. Then it becomes an issue of recognizing the proper bariatric body type for proper treatment.

Dionne identified five different basic types. They apple ascites, apple pannus, pear with LE abduction, pear with LE adduction, and pear with bulbose gluteal region. Each body type needs different treatment. However, even then different people may need different treatment because no two people are alike, like no two pregnant women are alike. Issues that may come into play for every different body type are the tolerance or intolerance to the movement of certain body parts, the ability to breathe in different position, mobile or immobile belly button/umbilicus. Even people of the same height and weight may be very different in the way they can be moved.

Dr. Dionne then showed slides of a number of different cases and discussed how the patients' body types affected treatment, and the methods he used to move them. An often overlooked, yet vitally important, tidbit of information is that very large people who lose a lot of weight may continue to have problems because vital parts of their bodies have not changed back. As a result of drastic changes in body weight of structure, muscles may become too long or improperly located, resulting in dangerous and at times deadly conditions. Somebody with an apple shape and hard round belly again requires very different treatment from someone with a soft tummy. Apple-shaped people often cannot lie on their stomachs while people with much larger but softer bellies can do that. This can also affect the way people can or cannot use wheelchairs or walkers. Some very large people have great endurance and can push a wheelchair for miles. Some people with tummies hanging very low have great problems with back muscles, both in standing upright and also when turning. They may be taught to lean back when turning and also in general to achieve a balance. Such a person may stand leaning backwards to be energy-efficient and not using the muscles, all putting it on the bones.

Also very important is to listen to the people affected. They know their bodies and they know what comes easiest for them. Sometimes complementing such natural movements and abilities works very well. "Pear shaped abducted" people have a body type that forces the legs are out to the side. They can't move their knees together. "Pear shape adducted" can put their knees together. They are rare. Both types have their own problems. Urinary tract infections and skin irritations are common in those types.

Dr. Dionne also teaches sensitivity training. He thinks it is very important to not just concentrate on a person's large size, disability, or large features. He suggests to also look at smiles, charm, hair, anything else that makes a person special. He showed a slide of a very large woman and said all the medical personnel always only looked at her size when, in fact, she had one of the sweetest smiles he had ever seen. A problem above and beyond the movement of very large patients is that some health care providers do not understand that some people simply cannot and will not lose weight no matter what program they are put on, be it for genetic or medical reasons. The obvious answer is that it doesn't matter what gave people their body types, what matters is to help those people.

Another interesting thing, Dr. Dionne pointed out, is that he's seeing many more very large old patients. This, he feels, indicates significant advances in medicine. Before, many of those people may not have survived to an old age either due to insufficient treatment or the lack of proper medication. Now they can be saved and they can be given quality of life and the proper tools and equipment.

One area Dr. Dionne is dealing with is safety, both as in keeping fat people safe, and in teaching medical personnel how to handle fat patients so that accidents do not occur. He talked about some basic issues that most people are not aware of. For example, fat people fall very differently from average-sized people. And not only do they fall differently, the resulting injuries are different and often entirely unexpected. Joints and limbs move in different directions, thus potentially tearing muscles and tissue in ways different from that observed in thin patients. One of the most common times problems occur is the first time people go to the bathroom after an operation. In such cases, Dionne suggests an egress test: Three repetitions of sit to stand. Three steps of marching in place. Advance step and return twice each foot. Successfully negotiating those exercises can greatly reduce falling. Before leaving the hospital it is important to try things out and see what will be needed at home.

Dionne showed a number of video clips that demonstrated different techniques of getting up from a chair or bed, and sitting down into a chair or a bed. Depending on the shape, size, and physical condition of a patient, there are many different ways, and many ways to assist and make it easier. All of this needs to be observed and analyzed, with the goal of making is as easy as possible for the patient to have movement. The proper equipment may include rails, or strategically placed handles at different heights. Dionne often provides expert opinions and analysis in cases where accidents involving fat patients occur. When he does deposition reviews he looks at what was actually done and what warning sins were missed. Examples of such warning signs are if someone cannot lift their trunk, if they cannot move arms or legs, if they cannot sit, or if they cannot move up or down in bed. All of those are signs that a safe and appropriate transport is needed and that such people cannot simply be asked to get up. Ignoring those warning signs can be very dangerous for all involved. Medical personnel need guidelines when to stop and ask for help, use a lift, or other means. Education is also needed in describing such conditions scientifically and accurately. Other red flags are less obvious: a patient's frequent calls for help, fear, anxiety, a lack of history on the patient, elevated pain level, or insufficient staffing. In addition, there is a need for a general inventory and assessment of a medical facility. This includes many areas. Pathways must be identified and measured to see if they are wide enough for extra-wide beds. Equipment motors must be strong enough to handle fat patients. Vendors of special equipment must provide appropriate education. Project Managers must be assigned to oversee the entire process.

Overall, Dr. Dionne gave us a passionate, knowledgeable, common sense presentation about a field that almost no one knows anything about. Throughout the speech, we learned of a large number of special, entirely new terms that the medical establishment needs to become familiar with. Dionne pointed out that until two or three years ago his services were not much in demand, but now all of a sudden he is getting calls for programs and advice all the time. Obviously, the medical establishment is beginning to realize that providing proper care to large patients is a winning proposition for both sides.

Conrad H. Blickenstorfer

Copyright 2002 NAAFA, Inc. - No reproduction in any form without permission from NAAFA, Inc.