1. Socioeconomic Status (SES)
Defining Socioeconomic Status
Socioeconomic status (SES) is a measure of a person's social and economic position. It is not just about income but is a composite measure that encompasses:
- Income: Wages, salaries, government pensions, and other sources of economic resources.
- Education: A person's highest level of educational attainment.
- Employment & Occupation: Whether a person is employed and the status or skill level of their occupation.
In Australia, this is often measured by area using the Socio-Economic Indexes for Areas (SEIFA), which identifies areas of relative advantage and disadvantage. This is important, but paramedics must be careful not to misclassify an individual's SES based on their geographic location alone.
The Link Between Low SES, Poverty, and Health
Low SES is a key social determinant of health. People with lower SES face an increased risk of poor health and social isolation.
- Poverty: Refers to lacking the economic resources to meet basic needs and live within socially acceptable standards. The "poverty line" is the income level below which this occurs.
- Material Deprivation: Refers to the outcomes of poverty, such as being unable to afford essential goods and services (e.g., adequate food, heating, medications).
Impact on Health: A systematic review by Pathirana & Jackson (2018) found a strong, consistent association between low SES (especially low education and area deprivation) and multimorbidity.
Multimorbidity is the co-existence of two or more chronic health conditions (e.g., diabetes and heart disease). People in lower socioeconomic groups are at a much higher risk of developing multimorbidity, and it often occurs at a younger age.
Implications for Paramedic Practice
- Complex Presentations: Expect patients from low SES backgrounds to have a higher likelihood of multimorbidity. Their presentation may be complex, with multiple interacting chronic conditions.
- Social Determinants: Be aware that the patient's condition may be exacerbated by material deprivation (e.g., malnutrition, inability to afford medications, poor housing conditions).
- Barriers to Care: The patient may have delayed seeking help due to cost (e.g., of a GP visit), mistrust of the health system, or low health literacy.
- Referrals: Be mindful that follow-up instructions (e.g., "see your GP") may be difficult for the patient to follow due to cost, transport, or other barriers. Connect them with social support services or bulk-billing clinics where possible.
2. Patients with Bariatric Needs
Defining "Bariatric Needs"
This is not simply a measure of obesity but a practical definition based on patient and worker safety. A patient has bariatric needs when their weight, body size, or shape restricts their mobility, health, or access to standard equipment and care.
- NSW Health Definition: A patient with bariatric needs is often defined as being over 120kg or having a BMI >30, OR whose size restricts mobility and access to standard equipment.
- Equipment: All equipment has a Safe Working Load (SWL) which must be known and adhered to.
Health Profile and Barriers to Care
Patients with bariatric needs are at a significantly higher risk of chronic health conditions, including:
- Cardiovascular disease (hypertension, AMI)
- Type 2 Diabetes
- Pulmonary disease (e.g., hypoventilation)
- Osteoarthritis
Critically, these patients often delay seeking treatment due to embarrassment, fear of being judged ("obesity bias"), or previous negative experiences with healthcare providers. This can mean their presentation to paramedics is more urgent or advanced.
Key Paramedic Challenges and Management Strategies
Management is guided by two primary principles: patient dignity and clinician safety. Always communicate with the patient respectfully, explaining what you are doing and why.
| Challenge | Assessment & Management Considerations |
|---|---|
| Manual Handling & Transport |
1. Plan First: Before moving, assess the environment (doorways, corridors, stairs, access to vehicle) and the patient's mobility. Form a clear plan. 2. Resources: Call for additional resources early (e.g., Fire & Rescue, bariatric-capable ambulance/transport). 3. Equipment: Know the SWL of all equipment. Use specialized bariatric equipment (e.g., powered stretchers, air jacks, patient slides). Avoid using equipment that is not weight-rated for the patient. 4. Communicate: Pre-notify the receiving hospital with the patient's weight and measurements so they can prepare appropriate equipment (e.g., bariatric bed, hoist). |
| Airway Management |
High Risk: Bariatric patients often have a difficult airway due to thick necks, large tongues, and redundant tissue. "Ramping": This is the key technique. Position the patient with blankets/pillows under their head, shoulders, and torso to align the external auditory meatus (ear canal) with the sternal notch. This "ear-to-sternal-notch" position optimizes airway patency. Ventilation: Two-person BVM technique is often required. Decreased functional residual capacity and weight on the chest mean patients desaturate very rapidly. |
| Clinical Assessment |
Blood Pressure: Using a standard-sized cuff on a large arm will give a falsely high reading. Ensure an appropriately large bariatric cuff is used. Vascular Access: IV/IO access can be extremely difficult. Consider alternative sites or routes (e.g., intranasal, intramuscular) for medication if appropriate and time-critical. Auscultation: Breath sounds and heart sounds will be distant or muffled. Listen on the patient's back, medial to the scapulae, where there is less adipose tissue. Pulse Oximetry: Thick fingers may prevent an accurate reading. Use an alternative site like an earlobe or lip. BGL: If finger pads are too thick, an earlobe is an effective alternative site for a sample. |