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.

I recall that 20 years ago the limit on our scanner at Ohio State was 300 pounds. We rarely encountered someone too heavy for it. When we did, the patient took a quick trip to the veterinary school to be scanned on their large animal machine. (No, they didn’t return with hay sticking out of their ears.) Now we are happy when the patient weighs ONLY 300 pounds. We’ve come a long way.

This raises an ethical question. At what upper weight limit must a hospital’s advanced technology accommodate obese patients? Should table limits be 600? 800? 1,000? One might argue that, while it may not be intentional, hospitals discriminate against the superobese when these services are not available to them. The same could be said of movie theaters, restaurants, and airlines that fail to provide “big boy” seating.

The other side of the argument would be that the expenditure to accommodate a relatively few number of people is overly burdensome to hospitals. Try that argument on any business or municipality that has had to make changes to their sidewalks or entrances to accommodate those with physical disabilities. The Americans With Disabilities Act (ADA) of 1990 is far-reaching legislation that resulted in significant expenditures to benefit a relative few.

Agree with this type of legislation or not, the government has a long history of mandating action that is burdensome (see EMTALA).

In my mind, the question is not if, but when. I predict that the treatment of the superobese will be the next fertile ground for trial lawyers. There will be lawsuits based on discrimination and failure to provide proper equipment and testing facilities.

Some hospitals will make adjustments voluntarily. This could be done out of fear of litigation or the realization that there is money to be made.

Some hospitals might want to avoid the distinction of being the bariatric hospital for the region, which would require them to take transfers on every 401-pound patient who might need a CAT scan.

Eventually, this question will be tackled on a legislative level. It seems likely that someone will propose adding the superobese to the list of people covered by the ADA. The act does not currently apply generally to the obese as it does to someone who is blind or wheelchair bound. If the superobese gain this status, then hospitals would be mandated to make necessary changes.

It would be nice if this problem could be settled without government intervention. It may be that hospitals will need to specialize in the treatment of the superobese just as they do for pediatrics and trauma. This could be done on a regional basis. I have no doubt that much will be learned and outcomes will improve if physicians, nurses, and administrators concentrate their efforts on this population.

Certainly, market forces would move this along if insurance companies, Medicare, and Medicaid would provide extra compensation to hospitals that are willing to take on the designation of being a bariatric hospital.

The superobese present significant challenges for us in the ED, and these patients can monopolize the resources of any department. I encourage every emergency physician to provide the same top-notch care to these patients as is done for everyone else.

Until the equipment and institutional approaches catch up to the problem, the patients may not have access to every service in the hospital.

A tactful explanation of the situation will go a long way to prevent misunderstandings and help the patient to understand that you are doing your best for them. n

Dr. Baehren lives in Ottawa Hills, Ohio. He practices emergency medicine and is an assistant professor at the University of Toledo Medical Center. Your feedback is welcomed at David.Baehren@utoledo.edu.