Thank you. Good morning. Thank you for giving me the opportunity to discuss this topic. So despite the World Health Organization recognizing that morbid obesity is a global public health issue, when the panel has done their research on finding about mobility interventions and outcomes in the medical setting for this population, there is an amazing lack of evidence to point to. So we will draw hopefully a little bit on my 35 years of experience as a physical therapist to help you along with figuring out how best to mobilize these patients. And it's crucially important that we mobilize these patients as soon as you possibly can in the ICU setting. So my one disclosure is I've been a consultant for the Arjo Huntley Equipment Company. My objectives are to help you appreciate the strengths and limitations of ICU early mobility research to define some of the considerations for mobilizing the obese ICU patient. So let's look at what evidence base there is. Now the evidence base surrounding early mobility tends to be a bit controversial these days. And the reason for it to be controversial is it's not telling us directly very much to go by. And that's because there's such a heterogeneity of population in our ICU settings. There are no good descriptions of interventions in the studies. There are a multitude of outcome measures that are utilized in ICU early mobility studies. And there's a lot of gray, messy, ill-defined outcomes from the randomized control trials. But what we have in the trauma setting is we do have a retrospective analysis of a QI project. And this tends to be where a lot of the best information comes from is honestly it's not RCTs. A lot of it is about QI projects. And in that, after they introduced an ICU mobility protocol to their trauma ICU, this group at the top, Coles, basically showed that there was a benefit of early mobility with less mortality in their patient population. I think one of the most striking things about trying to look at the evidence base for ICU early mobility, particularly in an obese population, is for reasons no one seems to really fully understand yet, folks with a higher BMI tend to have a survival benefit with longer mechanical ventilation and ICU hospital time as a side effect. But they don't die, basically. And therefore, they will spend a lot of time in your hospital setting, particularly if you can't get them moving. So let's think about what it is to be a patient with a high BMI. We hold biases. And I honestly believe that a lot of the lack of research is related to the fact that we all carry biases against the morbidly obese. They hold stigma. They don't live in a vacuum. They understand the biases towards them. There is shame, anxiety, and depression very often as a baseline component of the psychology of a morbidly obese person. Research demonstrates that body composition, however, and we know this in the exercise physiology world, body composition can change at any point in time in your lifetime with the right diet, the right psychological and behavioral interventions, and the right exercise. The important thing to understand also about your high BMI patients is they will spend a long time in your hospital. So they all have longer lengths of stay. If they end up in the ICU, they all have a longer time on mechanical ventilation. And a lot of the reason has to do with there are limited equipment, limited facilities, and limited staff training to help mobilize this patient population. We also don't really have much to help measure the outcomes and the functional progress of our morbidly obese ICU population. So we typically use things such as a timed up and go or a PFID or we have a six-minute walk test. We have all these functional outcome measures, a Berg Balance Test that they don't really have the body habitus to do well with. So there's literally one outcome measure specific to the morbidly obese population and that's from the Italian Obesity Society. It's the ICFOB. What we do also know about the baseline metabolic activity of our morbidly obese patient population is they all have endocrine disruption. They're all in a metabolically unusual state, usually essentially a diabetic metabolic state. They have a lot of comorbidities, particularly a lot of arthritic and joint pain. I'm going to get to why that's really important to consider when you're looking at mobilizing your patients, especially if it's a vented ICU patient. So here is some compelling case study information. I didn't cherry pick this. I think there literally are like two published case studies on mobilizing morbidly obese patients in a hospital setting. So I couldn't really even do much more than find the one case study from Johns Hopkins in the published information about this patient population. But it's super compelling because if you look at the top study, which came out of Australia, you have two patients that they describe and their mobility intervention. So look at that. These patients are lying in bed for about a month prior to starting their mobility intervention. Okay. So then what happens after these patients lie in bed for a month and you try to get them moving, as it shows on the slide, you now need four or five staff people to try to hoist someone with a ceiling lift and a lot of very complicated equipment. And they're delirious and they're profoundly weak. And moving them is going to take months and months and months before they restore any independent function. Versus, let's look at the case study from Johns Hopkins. So we have a morbidly obese, body mass index of 69. It's a very large person. Woman presented to the medical ICU with septic shock, multi-organ failure requiring mechanical ventilation, vasopressors, hemodialysis. Before that admission, the patient reported being able to walk about three meters with a walker. Intensive physical therapy for this patient in their recognition of this patient is going to deteriorate profoundly but not die and spend a long, long time just living in our hospital or some other institutional setting unless we get them up moving. So on ICU day number two, we got this patient up out of bed. So after only nine days stay with a lot of intensive physical therapy, and here's drilling down into the details of this study. Day two, they sat on the edge of the bed. Here they are in the vent. Assist control, PIPA 15, FIO2 60%, respiratory rate set at 30. So this is a sick person, right? This is not someone who's just hanging out in your ICU on a little bit of high flow oxygen. This person is really sick. They're critically ill, but they're also morbidly obese. They're also getting up sitting on the edge of the bed, hospital day two. Is that important? Yes. Because when you're there on hospital day four, the patient now has the capability of getting to the chair. The other aspect of doing all this is you can't sedate these folks. You can't sedate these folks. You can't sedate these folks. The propofol just hangs out in their adipose tissue and you'll never get rid of it. So hospital day five, she's taking steps in the room, right? Hospital day six, she's extubated. So a faster extubation thanks to the mobility. She's going to take, she's going to be dialed up on CPAP. Hospital day nine, she goes home walking. She is now able to walk farther than she was when she entered the hospital, which is another experience I personally have with intensive physical therapy. You can help these patients actually improve their function despite their critical illness. So now I'm going to really try to dive into discussing equipment. There's two things about equipment with this patient population. One, as we just saw in the Hopkins case study, you don't want the typical life-sustaining, life-supporting ICU equipment to prohibit your ability to move the patient. Patients can move on all kinds of equipment. So here's a case study from my own institution. A 57-year-old came in from an outside hospital after a 10-day admission there. She has end-stage liver disease due to cirrhosis. She's septic. She has acute kidney injury, history of breast cancer, and she is obese. So she has her physical therapy evaluation on hospital day three. UCSF is where I work. And her APACHE score is 25. So she's sick, right? She's a critically ill person in our ICU. She is not on continuous renal replacement therapy at that point in time of my initial evaluation. But on hospital day four, she did need to start continuous renal replacement therapy. So on the subsequent PT sessions, what we now do with her on her continuous renal replacement therapy is we disconnect it for two hours to allow her to get up out of bed and start walking. Because walking is the most important intervention we can provide to her to, again, help her go home, help her return back to a normal life, right? Not a passive mobility process. So this is what that looks like to disconnect her, right? Not a big deal. Our nurses do it all the time. And there she is now able to walk down the hall. So I want to use this as an example. And I want you to see that she progressed in her capability. She progressed in her ambulation ability because we went ahead and did this intervention of taking the ICU equipment out of the way to allow her to mobilize. So what we want to do is get the ICU equipment out of the way so these patients can mobilize. The other thing, so here's another example. Here's a vented patient. He is disconnected from the continuous renal replacement therapy. He's got an ET tube ventilation you can see. So he's disconnected from the ventilator. He's placed on a transport ventilator. Now he's walking down the hall as well. Again, improving his strength and mobility despite critical illness. So the ICU equipment should not be a barrier. The other thing to keep in mind with the morbidly obese patient population, and I've seen this over and over and over again in a somewhat surprising way, patients who are very large, especially when they have a very large panus, have developed over time unique mobility strategies. It's not good body mechanics. It looks kind of ugly. But think about it. They need to use momentum to get from point A to point B and to reposition themselves. They need to use the force of gravity and momentum. Very often that involves sidelining and proning. So when you come to the bedside of a morbidly obese patient and they're on the vent and they can't talk to you and they're like thrashing in bed, please don't turn on the sedation. They're not necessarily getting agitated, but very often they're reacting to their back pain and their knee pain and their arthritic pain that they have at baseline. And they're trying to get into what's their more normal comfortable lying position, which is never supine. It's never supine. They're sidelined. They're somewhat halfway sidelined, halfway prone. Just let them do it. And these are the mobility strategies we have to allow them to employ. So I allow them to teach me how they move. I don't even bother to try with like, here's what good body mechanics are, or here's how, like I literally walk in the room and say, show me how you do this. So here we have a demonstration of when a patient is not strong enough to get up out of bed. When we have really deconditioned patients, we need, now we need special equipment. And so this is another way we don't want equipment to be a barrier. Now for this patient population, we need some special equipment, right? We need to be able to have a bed that they can exercise and grow stronger in. Because remember my other point being that patients can improve their physiology at any age and at any size. But you need to give them the tools and the opportunity to do that. And it has to happen before they become so weak and deconditioned they can't any longer. So I don't have this bed at my facility. I wish I had this bed at my facility. But out of all the various standing beds and bariatric beds I've ever looked at, and I feel like I've looked at all of them, I wish I had this bed at my facility. Because it has the right place of the center of gravity that standing is comfortable for a large patient. It has the handrails on the bedside. The straps are easy to place. This is the type of thing we need to create now in our ICUs. Every ICU is going to need a bariatric suite. Because this patient population, it's a global public health problem. This patient population is not going away. And just ignoring them isn't going to help. So we know it helps with their overall physiology, their skin, their ability to breathe well, their ability to get off the ventilator in a timely fashion. And what I also always dream of is that all the equipment we get and put in a room for this patient population or any patient population in regards to mobility for that matter, that it could be compatible would be great. Because I have equipment typically in my ICU that's made by two or three different companies, and lo and behold, it doesn't fit together when I need it to. This is a great example of, again, how this bed has been designed to allow the TOLOS, which is an aid that's used to help people get from sitting to standing who are quite weak and obese, that it's compatible and fits together. It's an important consideration to understand. So ceiling slings, again, in your ICU suite, when you're looking for equipment that facilitates mobility, this is a lifesaver, the ceiling slings. The ceiling slings now should not be your mobility intervention, but they help you transition to your mobility interventions. Again, we don't want to train the mobility strategies of momentum that these folks have developed out of them. And we don't want it to be a passive mobility session. We want to help them do what we want to help all our ICU patients do, which is breathe better, have better vascular circulation and functioning, have better skin, have better mentation. And that's going to require them to have their own ability and power, empowerment, to do the movement. So this is just a little list of the things that I think are really crucial to have in a bariatric suite in your ICU. And the big take-home message for how to approach mobilizing these patients is they do have strengths. As I've said before, they definitely have developed over time their own momentum mobility strategies. Use those to your benefit. So I'll tell a quick little story. We once had a six-foot-two, six-foot-three gentleman who was morbidly obese. He was ginormous. And even though he was in a bariatric bed, he was overflowing the bariatric bed. And I was not in the ICU. He was in. I was in a different ICU. But he was assigned a physical therapy consult, and somehow no one in our department picked it up. So people paged me and said, please come and see this man. Please come and see this man. Please come and see this man. So I got to him in the afternoon. And I went into this room. And he looked at me and said, are you the therapist? And I said, yes. And he said, thank God. I've been needing to get up out of bed all day to use the bathroom. And all the nurses have told me, I can't move. I shouldn't move. Please don't move. It won't be safe for me to move. You're the one who's going to do it? I was really hoping for a bigger guy. And I said, no, I'm cool. You just show me how you do this. And I'll stand over here. And tell me what you need. Tell me where I should put the commode. Tell me where I should put the bed rail. Tell me how high to lift the head of the bed. I need him to tell me how he's doing this. Because each individual person of size is going to have their own strategies they've already worked out. And I don't want him to lose those strategies. Please show me how you do it. And then I stand back. And they do what they do. And I go, great. Didn't hurt my back at all. So they do also often have incredible upper body strength. They have been at home pulling themselves back and forth on their arms a lot. Go ahead and let them do that in your ICU. Draw upon what are their strengths, which is typically arm strength, an understanding of the physics of momentum, and a great desire to get up. I also really appreciate an EVA support walker as one of the best walkers to help this population walk. Including, as you can see, this woman is not morbidly obese, but she is walking down the hall in her EVA support walker with a portable vent. And I thank you for your time. Your patients really do want to get up out of bed and move. And in case anyone wants to see those slides again, if you're coming in later. Can we get the video to go again? If you hit the, there you go. Thank you. So I'll take questions at the end. And I actually really enjoy working with this patient population. I really do. They often have such a strong desire to be mobile and to be more independent and to be empowered. And you just have to draw upon that. Thank you.

early mobilization

morbidly obese patients

barrier to mobility

specialized equipment

improve function