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Emergency Departments Shoulder Challenges of Providing Care, Preserving Dignity for the “Super Obese”

2007; Elsevier BV; Volume: 50; Issue: 4 Linguagem: Inglês

10.1016/j.annemergmed.2007.08.014

1097-6760

Ėric Berger,

Emergency and Acute Care Studies

Expanding American waistlines are presenting new challenges in emergency care, from burdening patient transport systems to complicating diagnosis and treatment.As more and more Americans become obese, a larger number tip the scales as “super obese,” straining hospital and emergency medical services. The word “bariatric” itself is only 40 years old—coined from the Greek word “baro” for weight. It made its way into the lexicon in tandem with the pathology it describes.Academic inquiry into this emerging field with regards to emergency medicine remains limited, but preliminary studies suggest treating super-obese patients has significantly taxed the financial and personnel resources of the emergency health care system. In one recent example, based on a survey of 1,356 members of the National Association of Emergency Medical Technicians, nearly one in 2 medics sustained a back injury while performing EMS duties. Most blamed lifting extremely heavy patients.Need for a Body of EvidenceAs Americans put on the pounds, some emergency physicians have begun calling for more rigorous study of these impacts, especially as the steady increase in obese and super-obese patients threatens, along with crowding, to deliver a double-punch to emergency departments (EDs).“The bariatric patient places unique issues before the emergency medicine services industry, and the issues are a mix across the entire spectrum of patient care,” said Dr. Raymond Fowler, an associate professor of emergency medicine at the University of Texas Southwestern Medical Center in Dallas, TX. “It behooves us to better understand how our community can cope with this.”In the last decade, obesity has steadily become an increasing threat to public health. In 2003, new research showed nearly two-thirds of the public had become overweight or obese, leading the head of the US Centers for Disease Control and Prevention (CDC), Dr. Julie Gerberding, to proclaim obesity the number one threat to public health in the United States.Ominously, the number of the very largest patients has grown even faster. A study in the Archives of Internal Medicine reviewed the rise in different classes of obesity between 1986 and 2000 using data from the CDC’s Behavioral Risk Factor Surveillance System.1Sturm R. Increases in clinically severe obesity in the United States, 1986-2000.Arch Intern Med. 2003; 163: 2146-2148Crossref PubMed Scopus (450) Google ScholarNumber of Super Obese QuintuplesThe prevalence of people with a body mass index exceeding 30, the lowest threshold for obesity, doubled from one in 10 to one in 5 during the 15-year span. The prevalence of severely obese patients—those with BMIs exceeding 40 (about 100 pounds overweight)—quadrupled from one in 200 to one in 50. And the prevalence of super-obese patients, those with a BMI above 50, whose size and weight raise both transportation and medical equipment issues, increased by a factor of 5, from one in 2,000 to one in 400.The first and most common category of obesity presents the better known challenges to the health care system including the ED. Obesity is strongly correlated with diabetes and heart disease, suggesting more acute ailments will occur related to these conditions, such as heart attacks.“Intuitively, whether it is an increased incidence of heart disease, hypertension or diabetes, more people will become sick and present themselves to the emergency department,” said Dr. Theodore Delbridge, professor and chairman of the Department of Emergency Medicine at the Brody School of Medicine at East Carolina University and chief of emergency medicine at Pitt County Memorial Hospital.“Clearly, the obesity epidemic is having an effect on emergency department care. It’s not so easy to point out on a patient to patient basis, but it’s much easier to reflect upon it from a global basis.”Super-obese patients, however, present a more individual problem.The difficulties begin with paramedics. A typical ambulance, with equipment and 2 paramedics, may have capacity for a 400-pound patient. A special bariatric ambulance, equipped with a winch at the front of the patient compartment, which pulls a stretcher up a ramp, can carry up to a 1,000-pound patient. This is an expensive solution and logistically challenging. When the number of the super obese in a community quadruples, the bariatric ambulance already may be in use when needed.Generally, EMS workers are not asked to lift more than 100 pounds, so lifting a very large person requires a large crew. With very large patients, toppling becomes an issue. Extreme cases—one example came in 2003 when 22 Cleveland firefighters and emergency workers spent 2 ½ hours removing a 772-pound woman from her townhouse through a too-narrow door—are becoming more common. EMS officials say it is clear that larger patients may see delays in their initial care and transport to hospitals.Dr. Stephen Schenkel, chairman of emergency medicine at Mercy Medical Center in Baltimore, MD, said some large patients have filed lawsuits regarding transportation issues such as a hospital refusing to transport a patient by helicopter, which often have stricter weight limits than ambulances.Heavy Duty EquipmentEquipment problems continue once large patients reach the hospital.Novation, a health care contracting services company of VHA Inc. and the University HealthSystem Consortium (UHC), has surveyed member hospitals for four years on how they respond to the care of obese patients. The survey has consistently found that EDs see the most obese patients (75% of respondents in 2006). Additionally, 78% of hospitals reported an increase in the admission of severely obese patients in the last year.“There seems to be no question that the emergency department has been the most affected area in hospitals by the growing population of obesity patients,” said Sandy Wise, a senior director at Novation.A standard bed might carry 500 pounds, so hospitals are investing in bariatric beds. Some also have opted for equipment such as the Titan X bariatric lifter, a transfer device that costs about $18,000.According to a recent analysis by MarketStrat, a Fremont, CA-based consulting firm, global sales of bariatric stretchers are expected to rise from $29.6 million in 2004 to $50.5 million in 2012. An even greater jump is anticipated for sales of special lift systems, from nearly $75 million to $193 million.In Novation’s survey, 49% of institutions had purchased new supplies, most notably beds and lifts, in the last year to accommodate obese patients. Two-thirds of respondents said they spent more on such items in 2006 than in 2005.Delbridge said ED staff members may delay moving or dealing with an obese patient because of the extra work, time and personnel required.“The morbidly obese patients represent the greatest challenge because hospital equipment might not readily accommodate them,” he said. “There may be an unconscious stigmatization by the staff, and that’s difficult to avoid.”The super obese face delays in diagnosis and treatment as well. It is often extremely difficult to draw blood from them, gain intravenous access, or perform a lumbar puncture. They often do not fit in computed tomographic scanners and magnetic resonance imaging machines, and conventional radiographs produce poor quality images in the obese.“When it comes to these difficult tasks that will tie up their time, nurses and physicians clear their other less time-consuming tasks off their radar screen, so the obese patient has to wait,” Delbridge said.Another treatment challenge is proper drug dosing—should physicians dose by ideal weight, actual weight, or something in between? For most drugs there simply aren’t good clinical studies that inform on proper dosing for very large patients.Super-obese body types can also raise the likelihood of secondary complications such as skin infections, said Dr. Sephora Morrison, a fellow in the ED at Children’s Memorial Hospital in Chicago, IL. With more body surface area, and more skin folds, maintaining adequate hygiene is more difficult. Poorer circulation can also hinder wound healing.Still, the detection of trends in this area remains more anecdotal than evidence based, and Morrison said considerably more study is required to understand the scope of the changes in larger patients.Evidence Cuts Both WaysThe evidence for obese patients unduly taxing the ED is not unequivocal, however.A study in Academic Emergency Medicine evaluated 98 obese and 176 non-obese patients presenting to an emergency department with abdominal pain.2Platts-Mills T.F. Burg M.D. Snowden B. Obese patients with abdominal pain presenting to the emergency department do not require more time or resources for evaluation than nonobese patients.Ann Emerg Med. 2005; 12: 778-781Google Scholar The authors, who anticipated they would find the larger patients consume more time and resources such as laboratory tests, instead found no difference between the groups.“We were surprised by the results,” said lead author Dr. Timothy Platts-Mills, assistant professor of emergency medicine at University of North Carolina-Chapel Hill.He noted the research had limitations, including the fact that none of the nearly 100 obese patients exceeded 400 pounds.“So, our findings may hold for obese patients but may not tell us about resource use for very large individuals,” he said. “Anecdotally, I can say that super-obese patients who present to the ED often require vast amounts of pre-hospital resources for transport and present significant logistical problems once they arrive at the ED.”Dr. Peter Grant, a senior emergency staff specialist based at St. George Hospital in Sydney who co-authored a 2004 review article in Emergency Medicine Australasia titled “Emergency Management of the Morbidly Obese,” has studied what might be done to address the logistical issues raised by large patients in the ED.3Grant P. Newcombe M. Emergency management of the morbidly obese.Emerg Med Australas. 2004; 16: 309-317Crossref PubMed Scopus (35) Google Scholar Some of Grant’s suggestions to optimize care are in the next section.A Systematic Approach•Out-of-hospital ambulance protocols should provide adequate notification to receiving hospitals, or bypass of patients to facilities adequately equipped to provide specialized care. This can be tricky, however. In Michigan, a community hospital transferred an obese patient with an orthopedic injury because it didn’t have an operating room to handle him. The patient died en route to an academic center hospital. The man’s family sued.•Hospitals should acquire specially designed heavy duty beds, or have processes in place for their timely delivery via hiring companies with 24-hour call centers. Patients will often need to be admitted to 2 bed spaces to accommodate them.•During their planning to accommodate larger patients, institutions should also develop a specific list of narrow doorways or corridors where access with heavy duty beds will be a problem. Hospitals should also educate staff to assist in preserving privacy and dignity for these patients.•As part of their care, bariatric patients should receive early multidisciplinary involvement from such areas as clinical nutrition, dermatology, and psychiatry. They should also receive early and aggressive deep venous thrombosis prophylaxis and pressure care.•Aggressive management decisions should be based on present illness and comorbidities rather than size alone. There is limited evidence to support the notion that patients will have prohibitively poor outcomes from major surgeries or ICU treatments.“There are no easy answers,” said Schenkel, from Baltimore’s Mercy Medical Center. “These are difficult challenges and hospitals must carefully consider where they spend their money to ensure the proper patients get proper care and equipment. A lot of what we’re talking about is the basic respect involved in ensuring people get taken care of in a respectable way.” Expanding American waistlines are presenting new challenges in emergency care, from burdening patient transport systems to complicating diagnosis and treatment. As more and more Americans become obese, a larger number tip the scales as “super obese,” straining hospital and emergency medical services. The word “bariatric” itself is only 40 years old—coined from the Greek word “baro” for weight. It made its way into the lexicon in tandem with the pathology it describes. Academic inquiry into this emerging field with regards to emergency medicine remains limited, but preliminary studies suggest treating super-obese patients has significantly taxed the financial and personnel resources of the emergency health care system. In one recent example, based on a survey of 1,356 members of the National Association of Emergency Medical Technicians, nearly one in 2 medics sustained a back injury while performing EMS duties. Most blamed lifting extremely heavy patients. Need for a Body of EvidenceAs Americans put on the pounds, some emergency physicians have begun calling for more rigorous study of these impacts, especially as the steady increase in obese and super-obese patients threatens, along with crowding, to deliver a double-punch to emergency departments (EDs).“The bariatric patient places unique issues before the emergency medicine services industry, and the issues are a mix across the entire spectrum of patient care,” said Dr. Raymond Fowler, an associate professor of emergency medicine at the University of Texas Southwestern Medical Center in Dallas, TX. “It behooves us to better understand how our community can cope with this.”In the last decade, obesity has steadily become an increasing threat to public health. In 2003, new research showed nearly two-thirds of the public had become overweight or obese, leading the head of the US Centers for Disease Control and Prevention (CDC), Dr. Julie Gerberding, to proclaim obesity the number one threat to public health in the United States.Ominously, the number of the very largest patients has grown even faster. A study in the Archives of Internal Medicine reviewed the rise in different classes of obesity between 1986 and 2000 using data from the CDC’s Behavioral Risk Factor Surveillance System.1Sturm R. Increases in clinically severe obesity in the United States, 1986-2000.Arch Intern Med. 2003; 163: 2146-2148Crossref PubMed Scopus (450) Google Scholar As Americans put on the pounds, some emergency physicians have begun calling for more rigorous study of these impacts, especially as the steady increase in obese and super-obese patients threatens, along with crowding, to deliver a double-punch to emergency departments (EDs). “The bariatric patient places unique issues before the emergency medicine services industry, and the issues are a mix across the entire spectrum of patient care,” said Dr. Raymond Fowler, an associate professor of emergency medicine at the University of Texas Southwestern Medical Center in Dallas, TX. “It behooves us to better understand how our community can cope with this.” In the last decade, obesity has steadily become an increasing threat to public health. In 2003, new research showed nearly two-thirds of the public had become overweight or obese, leading the head of the US Centers for Disease Control and Prevention (CDC), Dr. Julie Gerberding, to proclaim obesity the number one threat to public health in the United States. Ominously, the number of the very largest patients has grown even faster. A study in the Archives of Internal Medicine reviewed the rise in different classes of obesity between 1986 and 2000 using data from the CDC’s Behavioral Risk Factor Surveillance System.1Sturm R. Increases in clinically severe obesity in the United States, 1986-2000.Arch Intern Med. 2003; 163: 2146-2148Crossref PubMed Scopus (450) Google Scholar Number of Super Obese QuintuplesThe prevalence of people with a body mass index exceeding 30, the lowest threshold for obesity, doubled from one in 10 to one in 5 during the 15-year span. The prevalence of severely obese patients—those with BMIs exceeding 40 (about 100 pounds overweight)—quadrupled from one in 200 to one in 50. And the prevalence of super-obese patients, those with a BMI above 50, whose size and weight raise both transportation and medical equipment issues, increased by a factor of 5, from one in 2,000 to one in 400.The first and most common category of obesity presents the better known challenges to the health care system including the ED. Obesity is strongly correlated with diabetes and heart disease, suggesting more acute ailments will occur related to these conditions, such as heart attacks.“Intuitively, whether it is an increased incidence of heart disease, hypertension or diabetes, more people will become sick and present themselves to the emergency department,” said Dr. Theodore Delbridge, professor and chairman of the Department of Emergency Medicine at the Brody School of Medicine at East Carolina University and chief of emergency medicine at Pitt County Memorial Hospital.“Clearly, the obesity epidemic is having an effect on emergency department care. It’s not so easy to point out on a patient to patient basis, but it’s much easier to reflect upon it from a global basis.”Super-obese patients, however, present a more individual problem.The difficulties begin with paramedics. A typical ambulance, with equipment and 2 paramedics, may have capacity for a 400-pound patient. A special bariatric ambulance, equipped with a winch at the front of the patient compartment, which pulls a stretcher up a ramp, can carry up to a 1,000-pound patient. This is an expensive solution and logistically challenging. When the number of the super obese in a community quadruples, the bariatric ambulance already may be in use when needed.Generally, EMS workers are not asked to lift more than 100 pounds, so lifting a very large person requires a large crew. With very large patients, toppling becomes an issue. Extreme cases—one example came in 2003 when 22 Cleveland firefighters and emergency workers spent 2 ½ hours removing a 772-pound woman from her townhouse through a too-narrow door—are becoming more common. EMS officials say it is clear that larger patients may see delays in their initial care and transport to hospitals.Dr. Stephen Schenkel, chairman of emergency medicine at Mercy Medical Center in Baltimore, MD, said some large patients have filed lawsuits regarding transportation issues such as a hospital refusing to transport a patient by helicopter, which often have stricter weight limits than ambulances. The prevalence of people with a body mass index exceeding 30, the lowest threshold for obesity, doubled from one in 10 to one in 5 during the 15-year span. The prevalence of severely obese patients—those with BMIs exceeding 40 (about 100 pounds overweight)—quadrupled from one in 200 to one in 50. And the prevalence of super-obese patients, those with a BMI above 50, whose size and weight raise both transportation and medical equipment issues, increased by a factor of 5, from one in 2,000 to one in 400. The first and most common category of obesity presents the better known challenges to the health care system including the ED. Obesity is strongly correlated with diabetes and heart disease, suggesting more acute ailments will occur related to these conditions, such as heart attacks. “Intuitively, whether it is an increased incidence of heart disease, hypertension or diabetes, more people will become sick and present themselves to the emergency department,” said Dr. Theodore Delbridge, professor and chairman of the Department of Emergency Medicine at the Brody School of Medicine at East Carolina University and chief of emergency medicine at Pitt County Memorial Hospital. “Clearly, the obesity epidemic is having an effect on emergency department care. It’s not so easy to point out on a patient to patient basis, but it’s much easier to reflect upon it from a global basis.” Super-obese patients, however, present a more individual problem. The difficulties begin with paramedics. A typical ambulance, with equipment and 2 paramedics, may have capacity for a 400-pound patient. A special bariatric ambulance, equipped with a winch at the front of the patient compartment, which pulls a stretcher up a ramp, can carry up to a 1,000-pound patient. This is an expensive solution and logistically challenging. When the number of the super obese in a community quadruples, the bariatric ambulance already may be in use when needed. Generally, EMS workers are not asked to lift more than 100 pounds, so lifting a very large person requires a large crew. With very large patients, toppling becomes an issue. Extreme cases—one example came in 2003 when 22 Cleveland firefighters and emergency workers spent 2 ½ hours removing a 772-pound woman from her townhouse through a too-narrow door—are becoming more common. EMS officials say it is clear that larger patients may see delays in their initial care and transport to hospitals. Dr. Stephen Schenkel, chairman of emergency medicine at Mercy Medical Center in Baltimore, MD, said some large patients have filed lawsuits regarding transportation issues such as a hospital refusing to transport a patient by helicopter, which often have stricter weight limits than ambulances. Heavy Duty EquipmentEquipment problems continue once large patients reach the hospital.Novation, a health care contracting services company of VHA Inc. and the University HealthSystem Consortium (UHC), has surveyed member hospitals for four years on how they respond to the care of obese patients. The survey has consistently found that EDs see the most obese patients (75% of respondents in 2006). Additionally, 78% of hospitals reported an increase in the admission of severely obese patients in the last year.“There seems to be no question that the emergency department has been the most affected area in hospitals by the growing population of obesity patients,” said Sandy Wise, a senior director at Novation.A standard bed might carry 500 pounds, so hospitals are investing in bariatric beds. Some also have opted for equipment such as the Titan X bariatric lifter, a transfer device that costs about $18,000.According to a recent analysis by MarketStrat, a Fremont, CA-based consulting firm, global sales of bariatric stretchers are expected to rise from $29.6 million in 2004 to $50.5 million in 2012. An even greater jump is anticipated for sales of special lift systems, from nearly $75 million to $193 million.In Novation’s survey, 49% of institutions had purchased new supplies, most notably beds and lifts, in the last year to accommodate obese patients. Two-thirds of respondents said they spent more on such items in 2006 than in 2005.Delbridge said ED staff members may delay moving or dealing with an obese patient because of the extra work, time and personnel required.“The morbidly obese patients represent the greatest challenge because hospital equipment might not readily accommodate them,” he said. “There may be an unconscious stigmatization by the staff, and that’s difficult to avoid.”The super obese face delays in diagnosis and treatment as well. It is often extremely difficult to draw blood from them, gain intravenous access, or perform a lumbar puncture. They often do not fit in computed tomographic scanners and magnetic resonance imaging machines, and conventional radiographs produce poor quality images in the obese.“When it comes to these difficult tasks that will tie up their time, nurses and physicians clear their other less time-consuming tasks off their radar screen, so the obese patient has to wait,” Delbridge said.Another treatment challenge is proper drug dosing—should physicians dose by ideal weight, actual weight, or something in between? For most drugs there simply aren’t good clinical studies that inform on proper dosing for very large patients.Super-obese body types can also raise the likelihood of secondary complications such as skin infections, said Dr. Sephora Morrison, a fellow in the ED at Children’s Memorial Hospital in Chicago, IL. With more body surface area, and more skin folds, maintaining adequate hygiene is more difficult. Poorer circulation can also hinder wound healing.Still, the detection of trends in this area remains more anecdotal than evidence based, and Morrison said considerably more study is required to understand the scope of the changes in larger patients. Equipment problems continue once large patients reach the hospital. Novation, a health care contracting services company of VHA Inc. and the University HealthSystem Consortium (UHC), has surveyed member hospitals for four years on how they respond to the care of obese patients. The survey has consistently found that EDs see the most obese patients (75% of respondents in 2006). Additionally, 78% of hospitals reported an increase in the admission of severely obese patients in the last year. “There seems to be no question that the emergency department has been the most affected area in hospitals by the growing population of obesity patients,” said Sandy Wise, a senior director at Novation. A standard bed might carry 500 pounds, so hospitals are investing in bariatric beds. Some also have opted for equipment such as the Titan X bariatric lifter, a transfer device that costs about $18,000. According to a recent analysis by MarketStrat, a Fremont, CA-based consulting firm, global sales of bariatric stretchers are expected to rise from $29.6 million in 2004 to $50.5 million in 2012. An even greater jump is anticipated for sales of special lift systems, from nearly $75 million to $193 million. In Novation’s survey, 49% of institutions had purchased new supplies, most notably beds and lifts, in the last year to accommodate obese patients. Two-thirds of respondents said they spent more on such items in 2006 than in 2005. Delbridge said ED staff members may delay moving or dealing with an obese patient because of the extra work, time and personnel required. “The morbidly obese patients represent the greatest challenge because hospital equipment might not readily accommodate them,” he said. “There may be an unconscious stigmatization by the staff, and that’s difficult to avoid.” The super obese face delays in diagnosis and treatment as well. It is often extremely difficult to draw blood from them, gain intravenous access, or perform a lumbar puncture. They often do not fit in computed tomographic scanners and magnetic resonance imaging machines, and conventional radiographs produce poor quality images in the obese. “When it comes to these difficult tasks that will tie up their time, nurses and physicians clear their other less time-consuming tasks off their radar screen, so the obese patient has to wait,” Delbridge said. Another treatment challenge is proper drug dosing—should physicians dose by ideal weight, actual weight, or something in between? For most drugs there simply aren’t good clinical studies that inform on proper dosing for very large patients. Super-obese body types can also raise the likelihood of secondary complications such as skin infections, said Dr. Sephora Morrison, a fellow in the ED at Children’s Memorial Hospital in Chicago, IL. With more body surface area, and more skin folds, maintaining adequate hygiene is more difficult. Poorer circulation can also hinder wound healing. Still, the detection of trends in this area remains more anecdotal than evidence based, and Morrison said considerably more study is required to understand the scope of the changes in larger patients. Evidence Cuts Both WaysThe evidence for obese patients unduly taxing the ED is not unequivocal, however.A study in Academic Emergency Medicine evaluated 98 obese and 176 non-obese patients presenting to an emergency department with abdominal pain.2Platts-Mills T.F. Burg M.D. Snowden B. Obese patients with abdominal pain presenting to the emergency department do not require more time or resources for evaluation than nonobese patients.Ann Emerg Med. 2005; 12: 778-781Google Scholar The authors, who anticipated they would find the larger patients consume more time and resources such as laboratory tests, instead found no difference between the groups.“We were surprised by the results,” said lead author Dr. Timothy Platts-Mills, assistant professor of emergency medicine at University of North Carolina-Chapel Hill.He noted the research had limitations, including the fact that none of the nearly 100 obese patients exceeded 400 pounds.“So, our findings may hold for obese patients but may not tell us about resource use for very large individuals,” he said. “Anecdotally, I can say that super-obese patients who present to the ED often require vast amounts of pre-hospital resources for transport and present significant logistical problems once they arrive at the ED.”Dr. Peter Grant, a senior emergency staff specialist based at St. George Hospital in Sydney who co-authored a 2004 review article in Emergency Medicine Australasia titled “Emergency Management of the Morbidly Obese,” has studied what might be done to address the logistical issues raised by large patients in the ED.3Grant P. Newcombe M. Emergency management of the morbidly obese.Emerg Med Australas. 2004; 16: 309-317Crossref PubMed Scopus (35) Google Scholar Some of Grant’s suggestions to optimize care are in the next section. The evidence for obese patients unduly taxing the ED is not unequivocal, however. A study in Academic Emergency Medicine evaluated 98 obese and 176 non-obese patients presenting to an emergency department with abdominal pain.2Platts-Mills T.F. Burg M.D. Snowden B. Obese patients with abdominal pain presenting to the emergency department do not require more time or resources for evaluation than nonobese patients.Ann Emerg Med. 2005; 12: 778-781Google Scholar The authors, who anticipated they would find the larger patients consume more time and resources such as laboratory tests, instead found no difference between the groups. “We were surprised by the results,” said lead author Dr. Timothy Platts-Mills, assistant professor of emergency medicine at University of North Carolina-Chapel Hill. He noted the research had limitations, including the fact that none of the nearly 100 obese patients exceeded 400 pounds. “So, our findings may hold for obese patients but may not tell us about resource use for very large individuals,” he said. “Anecdotally, I can say that super-obese patients who present to the ED often require vast amounts of pre-hospital resources for transport and present significant logistical problems once they arrive at the ED.” Dr. Peter Grant, a senior emergency staff specialist based at St. George Hospital in Sydney who co-authored a 2004 review article in Emergency Medicine Australasia titled “Emergency Management of the Morbidly Obese,” has studied what might be done to address the logistical issues raised by large patients in the ED.3Grant P. Newcombe M. Emergency management of the morbidly obese.Emerg Med Australas. 2004; 16: 309-317Crossref PubMed Scopus (35) Google Scholar Some of Grant’s suggestions to optimize care are in the next section. A Systematic Approach•Out-of-hospital ambulance protocols should provide adequate notification to receiving hospitals, or bypass of patients to facilities adequately equipped to provide specialized care. This can be tricky, however. In Michigan, a community hospital transferred an obese patient with an orthopedic injury because it didn’t have an operating room to handle him. The patient died en route to an academic center hospital. The man’s family sued.•Hospitals should acquire specially designed heavy duty beds, or have processes in place for their timely delivery via hiring companies with 24-hour call centers. Patients will often need to be admitted to 2 bed spaces to accommodate them.•During their planning to accommodate larger patients, institutions should also develop a specific list of narrow doorways or corridors where access with heavy duty beds will be a problem. Hospitals should also educate staff to assist in preserving privacy and dignity for these patients.•As part of their care, bariatric patients should receive early multidisciplinary involvement from such areas as clinical nutrition, dermatology, and psychiatry. They should also receive early and aggressive deep venous thrombosis prophylaxis and pressure care.•Aggressive management decisions should be based on present illness and comorbidities rather than size alone. There is limited evidence to support the notion that patients will have prohibitively poor outcomes from major surgeries or ICU treatments.“There are no easy answers,” said Schenkel, from Baltimore’s Mercy Medical Center. “These are difficult challenges and hospitals must carefully consider where they spend their money to ensure the proper patients get proper care and equipment. A lot of what we’re talking about is the basic respect involved in ensuring people get taken care of in a respectable way.” •Out-of-hospital ambulance protocols should provide adequate notification to receiving hospitals, or bypass of patients to facilities adequately equipped to provide specialized care. This can be tricky, however. In Michigan, a community hospital transferred an obese patient with an orthopedic injury because it didn’t have an operating room to handle him. The patient died en route to an academic center hospital. The man’s family sued.•Hospitals should acquire specially designed heavy duty beds, or have processes in place for their timely delivery via hiring companies with 24-hour call centers. Patients will often need to be admitted to 2 bed spaces to accommodate them.•During their planning to accommodate larger patients, institutions should also develop a specific list of narrow doorways or corridors where access with heavy duty beds will be a problem. Hospitals should also educate staff to assist in preserving privacy and dignity for these patients.•As part of their care, bariatric patients should receive early multidisciplinary involvement from such areas as clinical nutrition, dermatology, and psychiatry. They should also receive early and aggressive deep venous thrombosis prophylaxis and pressure care.•Aggressive management decisions should be based on present illness and comorbidities rather than size alone. There is limited evidence to support the notion that patients will have prohibitively poor outcomes from major surgeries or ICU treatments. “There are no easy answers,” said Schenkel, from Baltimore’s Mercy Medical Center. “These are difficult challenges and hospitals must carefully consider where they spend their money to ensure the proper patients get proper care and equipment. A lot of what we’re talking about is the basic respect involved in ensuring people get taken care of in a respectable way.”