Bariatric Handling - A case of understanding

Not all people are patients, but all patients are people, and they come in all shapes, sizes, and cultures, shades of skin, genders, preferences, attitudes, and beliefs. Some of them have impairments which occurred at birth or are acquired through age, disease, or accident. Moreover, some of them have attributes that lead to impairment, e.g. their physical size.

One of the biggest problems of the developed world is an abnormal approach to food, with a move from eating to live towards living to eat, surrounded by a society with conflicting values about body weight and appearance, especially where women are concerned. Food advertising is prevalent on television, with high-fat and high-sugar products being given peak airings during children’s programmes.

Food Focus
This ever-present food focus is enhanced by an increasingly sedentary lifestyle. Literature of the 18th and 19th century reflects the amount of walking being done, simply as a means of transport or as a leisure activity among those who did not work. People now do not walk as default and spend a great majority of their time in sitting.

So the advent of an increasing number of people in society whose body mass (weight) is extremely large is not surprising. The World Health Organisation defines a BMI (body mass index) of over 25 as being overweight, with a BMI in excess of 30 classed as obese. To simplify matters, large people who weigh more than 25 stone (148kg) are often placed in this category, as 25 stone is a common SWL (safe working load) for much of the standard care equipment in the UK.

‘Bariatrics’ is the term used to cover all aspects of care management for the obese. The term comes from the Greek ‘baros’ meaning ‘pressure’ – the mechanical basis of big people’s problems. And the Greeks were the first to recognise obesity as a medical disorder; Hippocrates wrote that ‘Corpulence is not only a disease itself, but the harbinger of others’.

Health concerns of obese patients
Big people have difficulties long before they begin to manifest the more severe medical problems that may eventually bring them to gastric surgery, as mechanically their excessive mass creates practical problems in all areas of day-to-day life. Large mass not only interferes with normal movement, it also puts disproportionate force through the weight-bearing joints, leading to pain and stiffness and contributing to even more limited mobility.        

Many big people suffer routinely from sleep deprivation caused by sleep apnoea, and skin conditions are prevalent due to their increased skin folds and large abdomens. They take extended time to heal from even minor injuries due to impaired circulation, and their weight inevitably induces different movement and gait patterns from smaller humans. As time goes on, their physiological problems will increase to include a raft of associated disorders-cardiac, endocrine, dermatological, neurological, urinary, respiratory, rheumatological, gastrointestinal, and oncological. Therefore, by the time big people reach hospital care, whether electively or not, they present complex cases for assisted movement.

Moving and handling big people
In common with other people with mobility problems, big people need help to move on many occasions whether they are in their own homes or in hospital. The handling of people is covered by the same basic legislation as the handling of loads 11 where a risk assessment becomes not only a legal requirement but a common sense approach. The factors that contribute to the risk in the existing situation are noted with a view to considering whether they are alterable in the short or long term, thus reducing the risk as far as reasonably practicable. 

This is of course an ergonomic assessment as it deals not only with system designs inherent in the physical environment and the organisational protocols and outcomes, but also with the intrinsic and inescapable human factors – either in the operator alone, or in the case of handling people, both the operator and the person being assisted.

Moving people in a community setting often presents a scenario where the risks are mostly unalterable (especially in the short term); people living in their own homes are not in a controlled environment but are used to their own individual methods, expectations and outcomes. Solving these handling problems requires firstly an empathetic assessment tailored to the individual and their needs, followed by consultation, communication, compromise, and problem-solving skills on the part of the handler, coupled with an appreciation of ‘positive risk’.

The UK government is very much in favour of people becoming independent with support within their own homes, bringing ethical, social and financial benefits, and many organisations are working to help people with problems to locate equipment that would assist them in their daily lives; for example the Disabled Living Foundation, an independent charity, with its award-winning website available free for all.

Moving big people as patients
Within the hospital scenario, the obese person is often of very limited mobility, as they either have significant medical problems and/or have had surgery. As with all immobile patients that need assistance, they require handling equipment that will move them safely, comfortably, and with the most dignity possible, whatever their destination. The advent of equipment that has a higher safe working load (SWL) and a bigger surface area has become necessary so that bigger people will be able to use it in safety and comfort, and there are many companies now manufacturing larger versions of assistive designs, including crutches, walking frames, beds, commodes, hoists, chairs, and trolleys.                 

It should be remembered that having these items increases the numbers of people that can be handled in safety; it does not preclude the equipment from being used by people of smaller dimensions.

However, the answers to successful moving and handling do not only lie in the use of equipment. In order to provide effective bariatric management, service providers need to link a number of associated components together. These include clear operational procedures, including identification of processes and responsibilities, and competent patient assessment with realistic outcomes.

Patient handling guidance for specific tasks need to encompass all possible situations, and thought also needs to be given to environmental considerations, such as physical space requirements, staff training, and service evaluation and development.

Training and education
The operation of specialised bariatric equipment can be easily learned and taught, but moving and handling people does not just involve techniques or manoeuvres; ergonomics is all about designing for comfort, whether it be physical or psychological, for all the humans involved.

In order to move people with safety, dignity and respect, carers need to have some understanding not only the physical problems but also the psychological problems that influence people. Nowhere is this more noticeable than in the handling and moving of big people. People hold very negative stereotypes about the obese and they are actively discriminated against, for example, in the employment market.

Training courses dealing with bariatric care therefore need to include understanding of the complex problems facing big people, including social, physiological, and psychological aspects, an appreciation of the vast importance of skin viability and pressure for these patients, and a working knowledge of the equipment involved, including ergonomic considerations of the concomitant space and personnel requirements.

One place to find such courses with these vital components is DLF Training, a nationally-recognised provider specialising in realistic and practically-orientated accredited training to assist those dealing with impairment and disability at all levels. Within their extensive programme, they provide a structured pathway of people-moving training and education from basic to advanced and including specialist workshops in paediatrics and bariatrics. All DLF moving and handling trainers are expert experienced personnel who are Registered Members of National Back Exchange.

Conclusion
The field of bariatric patient handling is moving at an increasing pace to keep up with the exponential increase of the numbers of big people that require care in the UK. As the population of obese people grows within all sections of society, education and training in how to understand and deal with their specific handling problems will become a necessary part of every carer’s skill base.

For more information
Philippa Bromley (prev. Leggett) MSC PGD PGC MCSP is Head of Independent Living at the Disabled Living Foundation, an independent London charity providing advice, help and information about equipment and assistive technology for people who experience and manage disability. She is an ergonomist, physiotherapist  and nationally and internationally known manual handling consultant. Further details of training courses can be found at www.dlf.org.uk/training or by calling DLF on 0207 432 8010.