Fire departments adapt to dilemma of transporting larger patients

Todd Stepp remembers an unusual call for help his family-owned towing company received more than a decade ago.

A 1,150-pound Tampa woman needed to get to a hospital, but there was no way she could fit in any ambulance.

"She was having cardiac arrest," recalled Stepp, 40, of Stepp's Towing Service.

With her size, she couldn't walk even when she was relatively healthy. And there was no single stretcher large or sturdy enough to handle her weight.

Tampa firefighters responded to the scene. A crew removed the exterior wall of the woman's bedroom in her first-floor apartment. Then a tow truck with a boom attached maneuvered and parked sideways as close as it could get to the woman, who was either in her late 30s or early 40s, as far as Stepp can recall.

Several men, including paramedics, emergency medical technicians and tow-truck staff, rolled the woman onto four stretchers they had fashioned together using heavy-duty straps.

Then came the boom that hovered over her bed and with the help of cabled winches, she was lifted up and carried outside. Her mattress was moved to the waiting flat-bed truck and she was gently placed on it and strapped down. Paramedics joined her and police escorts surrounded the truck for the 10 mph ride to St. Joseph's Hospital, where she died later that day.

There's nothing dignifying about being hoisted onto a flat-bed truck because you're too large to fit in an ambulance.

The fact is, though, it's been done for many years in emergency situations. But with obesity on the rise in this country, ambulance companies, both public and private, are catering to the needs of the morbidly obese or bariatric patients, as they are called in the industry.

Obesity affects more than one-third, or approximately 72 million, of the adult American population, according to The Obesity Society. In Florida, 24 percent of the adult population is obese, according to 2008 statistics. More than 60 percent of the U.S. population is considered overweight.

The obesity problem continues to grow and is considered an epidemic. In 1995, the Centers for Disease Control and Prevention reported that no more than 20 percent of the population in each of the 50 states was considered obese. In 2008, only one state - Colorado -- could make that claim.

In recent years, fire rescue departments and private medical transport companies have been addressing the needs of these patients.

Some are purchasing larger ambulances while others have been acquiring larger-capacity stretchers.

About five years ago, American Medical Response's west Florida division started turning its attention to bariatric patients. Of their 43 ambulances serving Hillsborough, Pasco, Hardee and Highland counties, four of them are larger bariatric units, said Tom Diaz, general manager for that division.

"We were looking for a safer and more dignified way of transporting bariatric patients," he said.

The bariatric units are outfitted with specialized equipment, such as larger blood-pressure cuffs, larger stretchers and winches to easily maneuver patients.

"It was a really tough challenge moving larger patients and we all have horror stories about it when time is of the essence," Diaz said, citing similar stories as Stepp's tale. "That's what drove us in this direction."

For several years, American Medical Response ambulances were called on from several Tampa Bay area counties when bariatric patients were in trouble. They still receive some calls but they're less frequent now that public ambulance services are getting their own equipment.

In 2008, they used their bariatric units 1,300 times. This year, the number has decreased, said Diaz, but they have been used more than 1,000 times. Many of those calls, however, aren't emergency situations.

"These patients have more medical concerns, so they get moved frequently," Diaz said.

Three years ago, Tampa Fire Rescue purchased a bariatric unit, now known as Rescue 20, based in Tampa Palms.

Since then, it's been requested 88 times -- 57 times in the city and 16 times in Hillsborough and 15 times by Plant City, said Capt. Bill Wade.

Before that, Tampa would call on American Medical Response's fleet but prior to that anyone more than 400 pounds would have to be transported on a flat-bed truck, Wade said, "providing no dignity for the patient and no safety for the paramedics."

"The flat bed was a poor option, but at the time it was the only option," he said.

Rescue 20 was purchased for about $200,000, about $30,000 more than a typical rescue unit, Wade said. The unit also has a bariatric stretcher which can hold about 400 pounds more than the standard 300-pound capacity gurney.

In Pasco County, fire rescue officials decided to go the more economical, but perhaps more readily available, route instead of purchasing a special transport unit. Pasco now has bariatric-capable stretchers on all 21 of its rescue units.

"We don't have to call private companies now," said Pasco Rescue Chief Duncan Hitchcock.

As part of a mutual-aid agreement, there wasn't a fee to the county for calling the private company, but it was an inconvenience.

Besides providing safety for the patients and the paramedics and emergency medical technicians, having bariatric stretchers in each ambulance speeds up those calls by eliminating the need to wait around for a specialized ambulances to arrive from other jurisdictions.

"The sooner we can get the patient to the hospital, the sooner we can get back in service for the next call," Hitchcock said.

In 2002, Pasco Fire Rescue started introducing the heavy-capacity stretchers to its fleet, easily lifting up to 650 pounds. Some of their stretchers will take as much as 1,000 pounds in their lowest position. The newer stretchers have wider bases, too.

"We started seeing more patients that were the bariatric type," Hitchcock said. "We just realized there was a need."

The cost difference between the regular stretchers and the bariatric-capacity ones is between $1,000 and $1,500, Hitchcock said. The ones Pasco Fire Rescue is standardizing cost about $5,000 apiece, he said. Some of the stretchers have been paid for by grants.

"With that cost, we're also investing in a quality stretcher that's going to last a little longer," Hitchcock said.

During his career, Hitchcock, who is a paramedic and a registered nurse, recalls working in St. Petersburg in the 1970s when on the rare occasion they had obese patients, they had to place them on ambulance floors and prop them up with blankets and pillows.

"Years ago, we would pretty much use a tarp or salvage cover to pick them up and put them in the ambulance," Hitchcock said.

In Pasco, the need wasn't as much as in Hillsborough County. Hitchcock estimates that they used to call for private transport about 10 times a year. Now that all of the ambulances have the stretchers, they don't track bariatric calls but they seem to have increased, he said.

"It seems to be more prevalent and instead of trying to make do with what you get, we're trying to make a concentrated effort that the patients are getting bigger so we've trying to get the stretchers that handle the weight," Hitchcock said. "Dignity issues are also something you consider."

Benefits of the specialized ambulances and stretchers extend to the paramedics and EMTs, too.
Before the bariatric equipment, several paramedics, EMTs and firefighters would be called to the scene to help move the patient. Typical crews on bariatric units in most jurisdictions are three people rather than the standard two-person crew. Still, more manpower is often required.

"You have to have more hands for the safety of the patients and the safety of the caregivers. You can't expect people to lift a patient of that size," Hitchcock said.

That takes a lot of people off the street for other emergency medical calls, Hitchcock said. Even though now there are less people required with the oversized stretchers and ambulances with ramp-and-winch systems, there are still more. It takes at least six people to lift 1,100 pounds when the special stretchers are in their lowest position, he said.

"The biggest injury to firefighters is back injuries," said Pasco Fire Rescue 9 firefighter-paramedic Justin Crook. "It actually takes some of the workload off of the paramedic-firefighter."

Of course, rescue workers say patients are the No. 1 concern, and paramedics say they like giving them back their dignity since switching to the bariatric equipment.

"We've actually had some patients who were like, "Oh, please don't drop me." And now they actually have more confidence in us," Crook said.

It's all about patient care, they say.

"Bariatric patients have special needs. We have to be able to meet their needs," Crook said. "There's a stigma attached to it and we want to make their ride to the hospital as comfortable as possible."