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Caring for Morbidly Obese Patients

Not sure how I feel about this.

Boston Emergency Medical Services debuts an ambulance with a mini-crane and reinforced stretcher to transport patients weighing up to 850 pounds. It cost $12,000 to retrofit the ambulance.

My problem is this: I think we need to do our best to provide medical care to all patients. But patients need to take some basal level of responsibility for their own health. If you’re saying that you got to be 850 pounds due to a “glandular problem,” you’re blowing smoke. See this post (hat tip to MDOD) and then come talk to me.

Let’s say you want to go hiking in some secluded location or you want to go spelunking far beneath the surface of the earth. When you take those risks, you implicitly accept the chance that if something happens to you, there’s not going to be an acute care clinic at the 3,000 foot mark on the mountain you want to climb. If you get hurt, you aren’t going to have access to the medical care that might otherwise be available to you. You may take your cell phone with you and may make arrangements for air medical transport if needed, but even with those precautions, you just might die from your injuries based solely on the risks you took – and no one is to blame but you.

If alcoholic patients drink to the point that they develop liver failure and then they continue drinking alcohol, most hospitals will not perform liver transplants. You got yourself into that situation, you refuse to help yourself get out of that situation, the system isn’t going to invest massive amounts of resources into your care – and no one is to blame but you.

Should people who eat themselves to death be treated any differently?

Should it ever be right to tell patients that if they let themselves get so obese that traditional ambulances can’t carry them that dispatchers will tell refuse transport and they will be responsible for their own transportation to the hospital?

If we continue down the road that we must accommodate the medical needs of every morbidly obese patient, are we then going to require that all hospitals purchase CT scanners and MRI scanners to accommodate patients of all weights – if those scanners even exist? Will every hospital be required to maintain an additional set of beds, commodes, bathroom fixtures, blood pressure cuffs, and a plethora of other utilities solely to treat morbidly obese patients.

Or perhaps we create regional system of care for morbidly obese patients. One regional hospital gets all the necessary equipment to manage the medical needs of morbidly obese patients and any morbidly obese patient requiring testing or admission must be transported to one of these centers. Hospitals can transfer trauma patients if they don’t have a trauma surgeon, shouldn’t they also be able to transfer bariatric patients if they don’t have a bariatric specialist?

This post is not meant as an attack on morbidly obese people, but more intended as a reality check. What should be a rational method of dealing with morbidly obese patients? If we require EMS and hospitals to make all these expensive modifications for morbidly obese patients, where do the accommodations end for other patients with other medical conditions needing costly medical care?

And how long is it going to be before the Law Firm of Dewey, Cheatem, and Howe files a claim against a hospital when a patient dies because the hospital didn’t have those modifications?


  1. Nearly all emergency ambulances in the UK have hydraulic tail lifts – there is no lifting of the ambulance stretchers at any point (http://www.youtube.com/watch?v=slGxOztxadI). If they need to be raised/lowered, the stretchers have a foot pump (see the one my service uses: http://www.ferno.co.uk/product/pegasus). Staff in the UK would see it as archaic to have to lift the stretcher into the ambulance.

  2. Smokers can deny they are damaging their lungs and health and still get treated by medicine.

    My mother smokes and she covers up the warnings on the Canadian cigarette packages because she doesn`t like the way they look. She doesn’t want to see the damaged lungs or cancers on her pack of smokes when she goes to smoke.

    The same kind of mental illness in a smoker that can deny reality is in the Morbidly Obese.

    A smoker has to buy smokes though.

    Once a person is so obese they cant `move to buy groceries or feed themselves, who is feeding them?

    That person who feeds the obese , is like the barman who keeps selling alcohol to the drunk.

  3. Regional care for obese patients – that’s a good idea. Of course, if your hospital has a bariatrics program, many of the patients self select and request the ambulance come to you.

    I still remember the old days when we (as medical students) had to wheel patients to the loading dock to weight them to see if they’d exceed the limit of the CT/MRI table. And if they didn’t, making arrangements for transfer for an MRI at the zoo.

  4. William the Coroner

    There are MR/CT scanners that are designed for patients that weigh 1200-2400 pounds. Granted, they usually say “Moo” or “Neigh”. In Ohio, people who are that big end up going to the Vet school at OSU. And yes, if you are so big you need equipment designed for a cow, you need to lose weight.

  5. Two words: Work comp. $12000 investment will prob save the healthcare system moola overall.

    • Possibly true.
      But what about volunteer ambulance services on shoestring budgets? I’m sure that these rigs will cost more to upkeep than traditional rigs.
      What if more than one morbidly obese patient needs emergency transport at the same time?
      It would be interesting to see a projected cost/benefit analysis

  6. One of my least favorite super-morbidly obese patients:
    PEG dependent (?, yeah),
    indwelling foley,
    rectal-tube (?, yeah),
    decub-ridden d/t horrific malnutrition;
    septic approximately every other month.

    (yes, that means that she’s too lazy to eat, piss and even crap for herself….)

    Hasn’t walked or even sat upright in 4 years.

    Is one of the nastiest and most unpleasant people you’ve ever met.

    What are the medical bills we pay for this person?

  7. How can a morbidly obese person have malnutrition?

    And “horrific” malnutrition at that?

    With all the food intake ..wouldn’t they at least be getting nutrients to support their body?

    I have heard that morbidly obese people are malnourished ..but why and in what way?

    • Eg., junk food, chocolate, softdrink/pop/soda, MacDonald’s etc contains sugar and sodium…and that’s about it. No protein, no carbs, no calcium, potassium etc.

      Malnourishment isn’t really about not eating enough food/starvation, it’s about a lack of those things obtained through diet that are necessary to maintain homeostasis.

    • I thought I could remember something… actually, it’s not the diet that’s to blame in a case like this, I believe. From a journal:

      “Although morbidly obese patients have excess body fat stores, they are prone to develop protein malnutrition during metabolic stress (57). The elevated basal insulin level in obesity suppresses lipid mobilization from body stores, causing an accelerated breakdown of protein to fuel gluconeogenesis (58). The result is a rapid decrease in lean body mass and an increase in ureagenesis and urinary nitrogen losses.”

      Especially when they’re ill and under stress, their metabolism is messed up, so they’re not breaking down fat, as a shorthand version.

    • Yes, the mordibly obese and be malnourished just like skinny people. It’s the balance of good stuff vs. bad stuff that is consumed.

  8. Well, I’d guess that among all those piles of food they eat, there’s nary a vegetable in sight, at least not one that’s fresh and still has some nutrients in it.

    And I do agree with the liver transplant analogy… you did this to yourself, and if you refuse to help us help you, then we just won’t help you.

  9. We actually have bariatric sized rooms..two on each floor along with bariatric commodes, recliners and regular furniture like bedside chairs. I had a family chowing down on Mickey D’s request if I could locate some of our bariatric furniture since they couldn’t fit into our regular furniture.
    I say bariatrics is one of the worst applications of PC I’ve seen.
    And our ambulances have started charging a surcharge for transport if you weight more than 350 due to injury and increasing work comp claims.

  10. I agree that patients should have responsibility. But here is a story for you.
    I had a secretary in Germany…ahem. Socialized medicine. Her husband had a kidney transplant in his early twenties. He was an alcoholic who fell on and off the wagon, and had many rehabs.

    The social system of medicine sent him on “holidays” for Kidney dialysis as his first kidney began to fail because he continued to drink. Surprise– he got another freaking transplant.

    And,this time proceeded to drink himself to death.
    I could never support giving someone another kidney knowing they were simply going to abuse it.

    Just like any big business not being fiscally responsible will fail, if a patient cannot show due diligence in what the prescriptive for care is, they should be rewarded or penalized as opposed to taxing the rest of us who give a damn about our health and act accordingly.

  11. Would it be appropriate to withhold calories from patients this obese? Hydration only while in the hospital? If the disease is due to too many calories, do healthcare providers not have a responsibility to limit those calories when they are able?

    • Um. Morbidly obese people can also starve to death if you completely withhold calories from them for any length of time and these guys are ALWAYS the ones that languish on the ward for weeks. Duh.

    • Hannah is right that the stress of disease and starvation can be detrimental to these patients, but that doesn’t mean that they can’t be fed low-calorie diets.
      Can someone who is more knowledgeable about nutrition give us an answer? Is a 1200 calorie balanced diet detrimental to a hospitalized patient?

      • Come on, lets push it down to a three figure number to balance out the Micheal Phelps like five figure numbers they peak out at.

      • Yes, it’s detrimental.
        The deficit in energy balance needs to be proportionate.
        BMR needs to be calculated based on lean body mass / “lipid partition,” and the reduction should not place the patient into a state of starvation. In situations when the patient has a decubitus ulcer, cellulitis, etc., this kind of dietary “punishment” is especially damaging.
        In addition, many of these patients have binge eating disorders. Putting them on a starvation type diet – the equivalent of a 400-calorie/day diet for you or me (assuming a few things, sorry)- will promote binging the second they get out, and will lead to a rather dramatic weight bounce-back and increase. The treatment team gets to feel smug during the inpatient phase, and then gets to feel even more smug when the patient comes back with weight gain.
        It’s more rational to drop the patient’s intake by about 500-750 calories from BMR – again, considering things such as wound healing – while maintaining adequate protein intake, limiting simple carbohydrates, etc., and for goodness’ sake get the consult psychiatry team involved and the dietitians involved on DAY 1 on every single admission.
        If you can get an eating disorders specialist… bitter laughter… then do it.
        I like to let my patients “free feed” and order as they wish for the first day or two, and that lets me start to do some teaching and modification, because if you don’t know where the patient is starting from, then how can you change things?

  12. At what BMI/weight would you draw the line, though? Would a BMI 44 patient get transported, but not a 45 BMI?

    How would the EMTs judge when a person was ‘too fat to save’? When they couldn’t lift the patient? Maybe a family will sue because 911 sent Susie Milquetoast instead of Hans Schwarzenegger to transport their willpower-challenged auntie.

    • Sarah:

      Its easy to determine. We had a trauma alert cancelled when the patient was too heavy for the helo to take off!

    • This is a good point, but I don’t think it is necessarily a good idea to say that difficulty in establishing a starting point should be sufficient to scrap a policy that may have a profound effect on public health as a whole.
      Perhaps it should be a judgment call. It should be pre-determined how much weight a given paramedic can safely lift. If a patient is close to exceeding the lifting weights of all paramedics involved, they either call for more assistance or make the patient/family responsible for getting the patient to the ambulance where hydraulics can do the lifting.

  13. I thought there really was a glandular problem for 0.5% of US people. But that doesn’t account for 60% of us being overweight or obese. Is it a problem with the adrenal gland?

  14. Can you say corn syrup? it’s added to almost everything we eat. In and of itself it’s no different than any other simple glucose. But we ingest so much of it our insulin production is constantly in overdrive with huge fluctuations of blood sugar. Blood sugar is meant to rise and drop gradually.
    It’s these wild swings that cause weight gain.
    You may add splenda to your cereal and coffee but unknowingly ingest way too much simple sugars in your other foods.
    Honestly in this day of so much food available to eat here how we have managed to contanimate it with hormones, antibiotics and unecessary sugars is beyond me.
    >stepping off of soap box now<

  15. The liver transplant analogy is not sound. Livers aren’t denied to people because “they did this to themselves” and thus don’t deserve it. They’re denied because it’s not a wise allocation of a scarce commodity — better to give the liver to someone who has demonstrated sobriety for some time, so that the liver may last longer.

    It may seem like a subtle distinction, but it’s important. Most of medicine and mortality is from preventable diseases. To a large extent, most patients can be said to have “done this to themselves” … are we going to refuse to care for all of them?

    • In the case of organ transplants, absolutely deny the chronic abuser of alcohol a second kidney.

      And if any organ recipient has a condition that is self-inflicted (read drug abuse, alcoholism, smoker, obesity not related to a medical condition) Why should they be afforded a perfectly good and functioning organ that could be rejected because of said conditions?

      You don’t deny them care, but you give them an opportunity to change the outcome before you waste the organ on someone who takes it for granted.

      In my comment above, N* should never have been given a second kidney over someone else who had taken care of himself.

  16. Some of the comments here really break my heart. I hope all of you aren’t in the medical field. If so, please stay the hell away from me.

    Bariatric care is no more of a one-size-fits-all [no pun intended] than care for any other group of people. I am 5’3″ and weigh 400 lbs. In one hospital visit it was insisted that I was required to use a “bariatric bed” because I weighed more than 350 lbs. These beds the hospital owned were designed such that they folded into a chair shape, you sat down and then it flattened back out. Unfortunately, a) you had to step up to sit in the chair, and I have a very weak leg, and b) the seat was about at the point of my mid-back. Despite having the help of two people, the first attempt to get me into the bed wound up with me falling onto the floor and hurting myself. No, I did not sue. I did, however, get a regular hospital bed to stay in.

    That said, it is trivially easy for a person my size to get malnutrition from regular every day foods. I spent a year with a food budget of, at most, $150/month. I ate one meal every other day, because that’s all I could afford. Fresh fruits and most vegetables were a rare treat – cheap frozen ones were sometimes possible, as was meat, bread . Cheese, pasta, rice, dried beans, and potatoes made up the bulk of my intake, with added frozen spinach and yogurt, when on sale. Junk food? Fast food? No money for anything like that. Fortunately the health clinic I went to gave me multivitamins to take.

    In the end I did not lose any weight. People who believe that weight is simply about “calories in + energy expended” need to go back and take a nutrition class. Caloric burn and the nutrition gained is far, far more complicated, especially for anyone over the age of 30.

    Obesity is also not a simple thing. In part there is more of it because of more ‘office’ jobs, but it’s also from the fact that people are living longer and having more children, which means the genes that affect weight, such as the ‘thrifty’ gene (that changes your metabolism when your food intake drops so that you survive, then puts on weight when your food intake goes up again as a famine prevention) are being passed along.

    (FWIW my food budget has gone up some, so there is more fresh vegetables in my life and occasionally I can splurge on some nice, lean meat. But I still take a multivitamin. As for junk food, I broke down and got some low-fat microwave popcorn. Not so great for salt, though.)

    • I don’t know that I agree that weight loss is far more complicated that intake < output. I do agree that there are other issues involved, but believe that those issues are in a tiny minority of the cases and/or have a minor effect on ability to lose weight. Prader Willi Syndrome is one example. How do you explain the tremendous weight loss feats of the contestants on "The Biggest Loser"?

      • Thank you for reminding me YET AGAIN that medical professionals are not hard scientists.

        First of all, the idea of “The Biggest Loser” is astoundingly horrific, and I’m surprised that more people haven’t sued that show and it’s producers off the planet. But there are people who can force themselves to lose weight by doing drastic things like that awful show. Worse, drastic and fast weight loss is not only not sustainable [you’re basically informing your body you’re in a famine which can trigger a “must store food” mechanism], but can be dangerous. There have been class-action lawsuits for diet companies that have pushed quick weight loss that literally killed people. It’s a major stress to your heart, your liver and your gallbladder, at the least.

        Second, the fact that weight loss is more complicated than intake & output has been proven by science for, oh, I dunno, about 80 years. In the 1950s, when they could still do so, they did an experiment with prisoners. They took a pile who were all thin. One half had a family history of obesity. The other half did not. Then they fed them a high calorie diet for some months, and also discouraged them from most exercise. After the months were up, they all gained weight. Simple, right?

        Well then they put them back on standard food and got them all exercising again. Guess what happened? All the people who had a family history of obesity stayed fat. The rest all naturally shed the pounds.

        Try reading a book called, “Big Fat Lies” by Dr Glenn Gaesser. Dr Gaesser is a Ph.D. who studies the relationship of exercise to health and obesity. The book is full of references to actual scientific studies backing his information. As a matter of fact, one of his big points is that people’s obsessions with dieting is likely more damaging to them, long term, than their actual weight, and that exercise, not body size, is the key to health. And this has been proven and re-proven in many studies done by others (including some pretty amazing studies done at Duke).

        Lastly, let me tell you something, something that has been echoed by other groups of people (like gay people) for just as long: Do you really think that someone would choose to weigh 400 lbs? Do you really think it’s enjoyable? Do you think that people who weigh so much sit around thinking, “Gee, it’s easier being this big than trying to lose weight. Losing weight is SOOO HARRRD. It’s so much easier to just not fit into standard-sized clothing, chairs, or other places. I’m so much happier in my life this way!”


      • actually, let me add to that.

        It’s not even just “Why would you want to be someone who doesn’t fit into everyday life”
        “Why would you want to be someone who is publicly scorned and laughed at — and that is considered socially acceptable?

        Why would you want to be someone who gets inferior health care, because it’s blindly assumed that your problems are just from your weight (personally, that’s nearly killed me once and nearly cost me a leg that’s now permanently damaged)?

        Why would someone CHOOSE to be someone who is perceived as lazy and stupid with no “will power”?”

      • Honey, you got put in a bariatric bed at 400 lbs because the equipment isn’t rated to take care of your fat self. Calories in does equal weight gain, though immobility creates a tremendously low BMR, which means that you can maintain your immobile self on very few calories. 2000 calories of mashed potatoes is one hell of alot of food, dear, at 100cal/1/2 cup.

        Now, as to why healthcare workers aren’t sympathetic? Because we’re tired of getting hurt. We can’t pick you up, pull you up, roll you over…and your fat butt won’t fit on a standard bedpan, which means that it is all hands on deck every time we have to move you. That’s most of the staff on our floor, which isn’t safe for anyone else involved.

        Stop eating and start moving. Get some willpower—alcoholics can’t drink booze, you can’t eat so much……

    • If I have to more you in any bed at any hospital, then I will be protecting my back before I consider your care. It is survival instinct!

  17. The slippery slope problem will be: At what BMI do you stop considering treatments? If 45 is too heavy then the 44.99 is not? Knowing that obesity contributes to poor health overall, why shouldn’t the cutoff be 30?

    These are the ethical issues society refuses to wrestle with.

    • Maybe we don’t define a strict BMI, but a percentile rank. If your BMI is in the top 5%, treatment options become more limited.
      I foresee the government addressing this ethical barrier in the near future. Isn’t one of the requirements for “meaningful use” of EMRs a need to be able to record a patient’s BMI?

  18. Ademola Adewale wrote a succinct summary on this topic ~4 years ago in EP Monthly (http://www.epmonthly.com/the-literature/evidence-based-medicine/the-obese-patient-confronting-the-epidemic/). Interestingly, Dr. Adewale and I have repeatedly asked EM Clinics of North America to devote an issue to the topic of “Obesity and Emergency Medicine”, but we have been repeatedly refused. The most common argument against such an issue is that there is insufficient research data to report. EM in the early 21st Century will have to address the obesity epidemic as a genuine and long-term challenge to our specialty with practical and academic solutions to succeed.

  19. And if any organ recipient has a condition that is self-inflicted (read drug abuse, alcoholism, smoker, obesity not related to a medical condition) Why should they be afforded a perfectly good and functioning organ that could be rejected because of said conditions?

  20. But I just can’t lose weight, I’ve tried everything and I just can’t lose weight! I can’t. I’ve tried and I can’t.

    Oh this? Well, I get dizzy and confused when my blood sugar’s low.

    Oh, that? Well, I like to save money by bringing my lunch, and Hungry Man is tasty. But one’s not really enough, you know?

    Well, of course I get dinner at the drive-through on the way home, I don’t have time to cook!

    Walk? No, honey, I’ve got foot problems, also fibromyalgia and chronic fatigue syndrome.

    I just don’t know why I’m so heavy, though. I think it’s something they’re putting in the food. Yeah, it’s that corn syrup stuff, I mean I don’t eat that much, right?

  21. First, saying morbidly obese for 400lb+ patients may be technically correct (I’m not sure, is super obese an accepted term now?), but a little misleading when the majority of morbidly obese people are going to be much smaller than that. We’re really talking about a pretty tiny percentage of the population here (even if that tiny percentage has grown). I suspect most people don’t even have the genetic capacity to get to the size range described in the ambulance article.

    Second, I just can’t see how this is a bad thing. As an ED volunteer I was on occasion asked to move 300+lb patients because the nurses and techs were too terrified of career-ending back injuries (I’m not saying it was right, I’m just saying it happened). If people are that worried — rightly, IMO — why *not* invest in career-saving technology? It will probably even provide some value with much smaller and/or fitter patients.

  22. “Should people who eat themselves to death be treated any differently?”

    White Coat: I appreciate the point you are making here and ultimately I agree with you regarding the need for personal accountability.

    However, I believe you are comparing Apples and Oranges.

    First off, we are not talking about an organ transplant here, we’re talking a simple ride to the hospital albeit one with that requires more rubust gurneys, cranes and ambulances.

    Secondly, an ambulance provider’s choice to invest in a bariatric setup will no doubt reduce the chance of injuries to EMT’s and Paramedics (which makes great business sense) AND the patient benefits from said equipment as well.

    The bottom line of this is that it is NEVER okay to judge people for their personal choices.

    The hospitals all over the world have scores of people who have made poor choices and now suffer because of them. Then there are folks who made “all the right choices” and suffer also. It makes no difference.

    As healthcare providers, we will sleep easier at night if we know that we were compassionate to ALL of our patients regardless of the “How’s and Why’s.”


  23. Lil Suthern Medic

    For anyone curious about the EMS side of things…our non-bariatic stretchers are weighted for 500 lbs. That is pretty standard across the board.

    I have seen a few people in five years sustain back injuries from lifting patients. Let me be clear about this: back injuries can occur at anytime while lifting a patient, no matter the weight. Does a heavier patient increase the risk? Yes. But it is a risk you take with any patient, even with proper techniques. Things happen.

    We have a lady that we take in every so often. Never an emergency. She is 400+ lbs. So why does she call us? Because she can no longer fit in a conventional vehicle. We are the only way she can get to the hospital. And that breaks my heart.

    • I’ve seen Strykers rated up to 650 for non-bariatric versions.

      Even if every EMS system could afford the super-awesome bariatric equipment, there’s always the issue of getting the patient from wherever they are to your cot, and then there’s getting the cot out of the house, which is complicated by steps and sharp turns and the fact that many houses are not EMS-friendly, in fact they’re a living nightmare to move patients in and out of.

      Moving mordbidly obese patients can be a tricky, time-consuming business, and that’s why so many EMTs/medics bitch about it…

  24. The liver transplant example is a good one. The inherent underlying problems here are societal – people/patients are not expected to assume any responsibility for themselves, are rewarded for being leeches on society. Also we have to be honest and admit that very few docs (and administrators) – if any- ever have the “balls” to tell the patient the truth. We as providers are prostituting ourselves to Press-Ganey and PC (and job security) by just going along with it all.

  25. There is no good solution to this problem that will appease everyone – but I think that regional centres a good idea. Morbidly obese people could be transferred for admission and services that will better serve them.

  26. Wow, I am embarrassed to be a health care worker after reading some of these comments. All patients deserve our best efforts at caring for them, regardless of their weight or whether your opinion is that they “had it coming.” It may not be possible to accommodate every patient fully…the appropriate equipment may just not be available. But the right thing to do is to try to figure out the best course of action, not sit around making fun of people. It’s a shame to find such highly educated people acting like kindergarteners.

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