Paul J. Sobczyk graduated with honors from the Pittsburgh Institute of Mortuary Science and is the owner and operator of Kolodiy-Sobczyk Funeral Home, Cleveland, OH and the embalmer at National Mortuary Shipping. Paul has embalmed hundreds of bariatric cases and has established himself as a leader in this field. Paul has delivered many seminars explaining tips and techniques regarding this topic. He can be reached by phone at 1-800-321-0185 or by email at [email protected].
It is no hidden fact that America is one of the largest nations in the world. Unfortunately in the context of this article we refer to the waist size of its citizens and not its population or economic strength. America is known to have the largest number of morbidly obese or bariatric citizens per capita than anywhere on the globe. The number of obese citizens in the U.S. has doubled between 1990 and today and is estimated to cause 300,000 premature deaths a year from diseases associated with obesity. This is the second highest preventable cause of death. For the funeral professional, this has implications regarding the methods of removal and preparation as well as funeral goods and service.
As embalmers, we have all witnessed the shift in the size and weight of Americans first hand. When I first began embalming in 1976, it was a rarity to have an individual weighing 400 pounds or more. However, today this is not unusual and there are many times I am called to embalm a 500 to 900 plus pound decedent. In the number of cases I have embalmed, the heaviest was 1120 pounds. These cases require some special considerations in regard to the embalming process for both adequate preservation and disinfection of the deceased as well as the safety for the embalmer and support staff.
The process begins when the phone rings and we receive notification of a death. Often we know when a case is considered bariatric beforehand, but there are times this comes as a surprise. Regardless of firsthand knowledge, the removal must be done; that is a separate topic for another article. Once the deceased arrives at our facility, this is where my work begins. This is a detailed process, but I will share with you a general overview.
A case this large often does not fit well on a standard embalming table. The standard tables are approximately 28 to 30 inches in width and have a maximum load of 400-500 pounds. When the elbow-to-elbow or hip measurements of a deceased are 42 inches or greater, and the weight is over 500 pounds or more, problems occur. In addition, because of the flaccidity of the excess adipose tissue the body easily conforms to the contours of the table; blocking any drainage routes. You then need head blocks and body positioners to re-establish drainage on the table. To overcome this, NMS purchased a specially built table that measures 42 inches wide and has a maximum capacity of one ton. This helps ensure the embalmer has enough room to work, reduces the risks of damage to equipment or self, and ensures all drained fluids are appropriately disposed off.
The actual embalming process requires some unique techniques. I usually inject using the carotid artery as this is the easiest and most efficient route of entry into the circulatory system. However, like any other case, additional or alternative points of injection may be needed. Gaining access to the carotid artery may require cutting through the sternocleidomastoid muscle. Because of the added depth needed to gain access, raising the artery is normally accomplished by feel rather than sight. This added depth also means one will need to work within the incision. Trying to excise the artery outside the incision on these cases may be impossible. Because of the added tension and adaptation of the circulatory system as well as effects caused by diseases most often associated with being morbidly obese, these arteries are often narrower in diameter and more taunt. This combined with the added depth of the incision area makes excising the artery difficult, and it may break. I have found that when working in the confined area of the incision, the use of a tissue spreader is helpful. I also recommend using smaller 1 inch length arterial tubes or cannulas because they are the most maneuverable inside the incision.
Like any other case there is no magic formula for fluid dilution. Each case is unique, and the amount of fluid, index, and accessory chemicals used are determined at the time of analysis. I have found through experience it is not unusual for these cases to have high volumes of edema and circulation problems, anticoagulants and edema corrective solutions are often used. I have also found that 35 index fluid and a more penetrating arterial fluid work the best. Remember that your secondary dilution is increased because of the excess fluid in the adipose tissue. I also like to add a little more dye in my solution. This allows me to better observe the distribution of fluid to the extremities. Because the embalming solution may not reach all the outer layers of the body, it is important to have the ability to observe these areas and appropriately treat via hypodermic or topical treatments.
Another method I have utilized over time is to delay drainage. The reasoning behind this is that the external pressure created by the weight of the overlying tissue compresses the circulatory system and underlying organs. By delaying drainage until after the third or fourth gallon of fluid injected, the pressure of the fluid counteracts the external pressure and assists in opening up the arteries and creating equal distribution of embalming fluid throughout the body. However, it is important to keep an observant eye for any swelling in the neck or face. I then aspirate the thoracic, abdominal, and nasal cavity of the deceased. I recommend using 32 to 64 ounces of a 50 index cavity fluid works best on these cases to ensure proper treatment of the visceral organs.
One of the common problems with bariatric cases is purging because of the external pressure and weight caused by the overlying tissue on the abdominal and thoracic cavity. To help mitigate this, I have found that cutting and plugging the trachea helps. To do this I gain access through the carotid incision and bisect both the esophagus and trachea. I then make two plugs of three inch by six inch sheets of webril cotton and incision sealer. To make these I take the webril cotton and place some incision sealer in the middle of the cotton. I then roll the cotton into a small tube or plug. Using your index finger these can then be placed one in the bottom portion of the trachea, and one above. The cricoid cartilage will keep the foramen of the trachea open for this procedure. These same plugs can be made of two inch by four inch webril cotton and packed into the nasal cavity for added protection.
Some other common conditions in bariatric cases are decubitus ulcers. These must be treated, but extra caution should be taken. These ulcers often occur on the backside of the deceased and gaining access may require additional assistance to help move the deceased on his or her side. Diabetes is also a common condition in bariatric cases and this effects the circulation, most notably to the lower extremities. This lack of circulation, combined with the inability of embalming fluid to reach the outer layers of the adipose tissue, increase the chances of the deceased forming water blisters and skin slip on the lower extremities. The use of a topical treatment can help ensure preservation. I prefer to use some form of embalming gel and then wrap the legs in plastic wrap. Some plastic garments will not fit bariatric cases; to ensure a seal and prevent any leakage or damage to garments saran wrap can be utilized. I cut a roll of saran wrap in half making two 4 inch rolls; this is much easier to handle compared to the 8 inch roll. I can then use this saran wrap to wrap the treated arms or legs.
Once the deceased has been embalmed, dressing and casketing present unique challenges because of the size of the deceased, oversized caskets may be required. In these situations, I would never suggest casketing the deceased alone. It is always better to employ the help of others who have experience in moving a deceased. A good lift with a high enough weight capacity and long straps is also a necessity to ensure everyone’s safety and respect for the deceased. Care must also be taken in transportation of the casket. One must ensure the weight capacity of the casket bier is rated high enough to handle the weight of the deceased and casket. Finally, one must ensure that all routes of entry and exit, both inside the funeral home as well as areas outside, such as the church are wide enough for the casket to fit.
The care of the deceased, the reputation of the funeral homes we embalm for, and the safety of our staff is paramount. When working on all cases it is our responsibility as funeral professionals to ensure these needs are met in a dignified and respectful manner. FBA