Link:  http://www.washingtonpost.com/wp-dyn/content/article/2010/02/07/AR2010020702666.html?hpid=topnews

By Mary Pat Flaherty
Washington Post Staff Writer
Monday, February 8, 2010; B01

Local paramedics and firefighters don’t need to follow television shows about a half-ton teen or biggest losers to track the obesity trend.

They carry that knowledge with them.

Calls for patients weighing 350 pounds come daily in the District. A patient between 400 pounds and 600 pounds is part of every workweek for many crews throughout the region. Patients topping 600 pounds are transported by emergency teams every few months.

Girth is a separate challenge.

“I think everyone has struggled with this issue, and technology is just now coming to grips with it,” said Fairfax Deputy Fire Chief Christine Louder.

Across the Washington region and the country, departments have been adapting steadily to plus-size patients. They have added specialty equipment and training to reduce their back injuries and avoid the spectacle of moving a person on planks, tarps or the floor of an ambulance.

Nationwide a few communities, including some near Topeka, Kan., charge nearly double to transport patients over 350 pounds. There is no discussion locally on that front, said officials with the major agencies. But area departments are part of a buying trend expected to double sales of specialty equipment by 2012.

Sales of stretchers designed specifically for very large patients were expected to reach $50 million in 2012, up from $29.6 million in 2004, while sales of specialized lift systems were projected to rise from $75 million to $193 million. The projections were included in a 2007 article for EMS providers written by Raphael M. Barishansky, now chief of public health emergency preparedness for the Prince George’s County Health Department.

Reinforced brackets, hydraulic lifts, extensions for belts, harnesses and blood pressure cuffs, and equipment designed so as many as a dozen people at one time can lift a patient are in use in the District and Prince George’s, Montgomery and Fairfax counties, as well as many smaller departments. So, too, are cots widened to about 30 inches, which provide increased surface area while still being able to pass through most internal doors.

But those improvements are not enough once a patient reaches about 700 pounds, a group that has become a new focus.

Patients that large must be moved with extra staff and in specially rigged ambulances. Some have a ramp and winch that can pull in a 1,600-pound patient on a cot and is built with a chassis the size of a lumber truck.

Local EMS officials can recite the types of challenges driving their discussions:

The 1,300-pound patient in Prince George’s whose illnesses require regular trips to a skilled nursing facility.

Any of the patients topping 400 pounds who watch a typical crew of two or three people walk through their door, then another crew and then another.

The patient more than 600 pounds who hadn’t been off the third floor of his Montgomery townhouse in years. Before emergency crews could move him, they needed to check that the floors and stairs would hold up under him, the crew and its equipment. He had to be moved in a panel truck and taken through the wider doors of a nursing center’s laundry room entrance. The last firefighters knew, the patient returned home and was living on the second floor.

There is attention to “the logistics of all of this, and that’s important, but it’s a small component,” compared with safety or sensitivity, said Assistant Chief Michael McAdams of Montgomery County Fire and Rescue.

“The last thing you want is everyone surging to pull and pull, and you have someone fall off the cot or have something degrading happen,” McAdams said.

Among local departments, District crews have regular access to a winch-and-ramp ambulance under an agreement with Medstar, which runs a big unit out of Washington Hospital Center in Northwest. But the Northern Virginia EMS Council met last month to consider a plan to buy and share use of one of the high-end winch ambulances, which cost about $250,000.

“I wouldn’t want anyone to avoid calling 911 out of embarrassment that they may not fit,” said Capt. Greg Rauch, who manages the EMS program for the City of Fairfax Fire Department and is heading the council’s research into a shared ambulance for bariatric transports, as the moves of large patients are called. “In my view, these patients deserve the same specialized equipment as some other patients do for their particular needs. No one should be humiliated.”

Several Maryland departments have similar feelings and are exploring grants to cover a retrofit of some of the mass-casualty units already positioned throughout the region as part of homeland security plans. Most of the area’s fire departments also are incorporating specialty equipment for those patients as they replace aging ambulances.

The upgrades extend to training on medical aid and the adjustments needed for very large patients. But the talk about gear recognizes that to get patients to care they need, they have to be moved.

“Watching maybe a dozen people file in is enough to raise a patient’s anxiety all by itself. And many of these people start out by apologizing to us and asking us to be sure we don’t hurt ourselves or them,” said James Augustine, medical director for D.C. Fire and EMS until his recent resignation.

Given the hundreds of thousands of EMS calls annually across the D.C. area, very large patients account for a sliver of calls. Fairfax had 56 patients weighing more than 400 pounds last year among its roughly 63,000 calls. Montgomery fire officials estimated they moved a dozen patients in that weight range last year among 58,000 transports. Prince George’s handled about 100 among its roughly 100,000 EMS calls last year. “But while they’re a small portion, they require a lot of resources,” said Maj. Dennis Wood, who oversees paramedic operations for Prince George’s Fire and EMS department.

Between 2004 and 2007, obesity increased throughout the Washington region, according to statistics from the federal Centers for Disease Control and Prevention. One in five adults is obese in most local jurisdictions, although some pockets are higher.

The super-weight patients are rising even faster, national data show. The rate of morbidly obese patients who are at least 100 pounds overweight increased faster than obesity as whole, a 2007 Rand Corp. study found.

For now, Wood said the Prince George’s department uses a general rule — aimed at reducing back injuries — that “for every 50 to 100 pounds over 250, you need to add another set of hands on the call.” But in October, Wood told crews to systematically record patient weights to help the department plan and train.

“It’s a timely topic in our field, because this is a patient population that is increasing and not one we are well prepared for,” Wood said.