It has been said that no good conversation ever starts with the words, “Remember that patient you sent home?” The other one I hate is when your director approaches you and says, “Hey, I’ve got something I want to talk with you about.” These are rarely positive interactions, and you leave them wondering why you didn’t become a dermatologist or a plumber.

I’ve also learned that there are many signs that can portend a difficult patient encounter. This can happen when the patient says, “It all started when I slipped on the wet floor in Wal-Mart 9 months ago.” You know life will get exciting soon when the nurse tells you that the lady they just brought in to room 3 is crowning. And there is a more recent phenomenon of eight burly EMTs arriving to unload the patient who is overflowing their gurney.

I predict that the treatment of the superobese will be the next fertile ground for trial lawyers.

We’ve gotten used to the fact that about a third of the population is significantly overweight, and we see them with their orthopedic issues, metabolic syndrome, and sleep apnea. The hospitals have purchased bigger beds, and the nursing units have machines that help them to move the patients. Adjusting to the nation’s growing waistline has been relatively easy.

Dealing with patients with a BMI greater than 50 is another issue. It seems that the number of superobese patients we encounter is off the charts. Just like every other challenge we face, emergency physicians, nurses, and medical technicians adjust and make the best of it. In spite of our can-do approach, it is clear that in most hospitals we have limited resources for caring for those who weigh more than 400 pounds.

I recently cared for a woman who presented with altered mental status. She definitely needed a CT scan of her head, but it was clear that she weighed at least 500 pounds. I guessed 500. One of the nurses guessed 700. I felt like the carnival guy who guesses your age, weight, or birthday. I would have been closer on her birthday.

We finally got a bariatric bed with a scale and measured her at 625 pounds. This is 225 pounds over the limit for our CT, MRI, or angiography tables. I made some calls around the region and found that the biggest limit for CT scanners in our area was 500 pounds. It became clear that there was no easy or quick way to image the head of this woman. She was admitted in the middle of the night, and access to a CT became an issue for the inpatient service to resolve.