About 15 years ago, a hospital asked Paul Fox, whose Jenkintown company sells medical furniture and equipment, if he could supply a chair for a 500-pound patient.
He was stunned.
"I had never sold a chair for somebody who weighed 500 pounds," he said.
It is a measure of how much Americans have grown that such requests are no longer unusual.
"We could sell 10 to 15 pieces a month today," Fox said.
The obesity epidemic means that more patients are maxing out equipment meant to safely hold people who weigh no more than, say, 250 to 350 pounds. As a result, hospitals are now peppering their waiting areas with tastefully understated "love seats" that can be used by the supersized, or two or three people of normal weight. They are buying overhead lifts that help nurses move patients who weigh up to 1,000 pounds and switching to stretchers safe for 750 pounds.
Hospitals are investing in MRI machines big enough to hold 550-pound patients. They are buying portable machines to extricate obese patients from their cars at the emergency department entrance. They are widening doors and switching from wall-mounted toilets, which support a mere 325 pounds, to sturdier floor-mounted models. They are buying longer needles and catheters and bigger patient gowns. They are renting or buying "big-boy" beds, commodes and walkers designed for the morbidly obese. Two Main Line Health hospitals have purchased extra-large hyperbaric chambers to aid wound healing for patients up to 550 pounds.
"Demand's been huge, I can tell you that, no pun intended," said Lauren Green-Caldwell, a spokeswoman for Hill-Rom, which makes medical equipment. The company's largest bed can support half a ton.
Stryker, another medical supply maker, estimates the U.S. bariatric market products made for the obese at $100 million a year, with 20 percent annual growth.
The larger patients are also driving changes in medical technology, particularly imaging equipment such as CT scanners and ultrasound, X-ray and MRI machines. In standard machines, several inches of fat can get in the way of a good picture or make it impossible. "We probably don't make anything that wouldn't be affected in one way or another by this epidemic," said Corey Miller, a GE Healthcare spokesman.
The extra steel reinforcement and design changes do not come cheap. Bariatric furniture costs 20 to 50 percent more than standard products, Green-Caldwell said. For example, a basic hospital bed might cost $6,000 to $8,000, but the extra-large model costs $10,000 to $12,000.
Hospitals say insurance companies do not pay more for care given to extra-big patients.
Fifteen million Americans are morbidly obese, or at least 100 pounds overweight, according to the American Society for Metabolic & Bariatric Surgery. A Rand Corp. study published last year found that the fastest growing group of the overweight is the fattest what it called the "super obese."
Scientists use the Body Mass Index, a measure of the relationship between height and weight, to classify obesity. With some exceptions such as professional athletes you're obese at a BMI of 30, morbidly obese at 40 and super obese at 50. For someone who stands 5-foot-9, that translates, respectively, to 203, 270 and 338 pounds. While the proportion of people who are super obese is still under 1 percent, it increased 75 percent between 2000 and 2005, according to the study.
Obese people tend to have more than their share of health problems, making them prime candidates for a hospital stay. And they are more likely to have complications when they are in the hospital. "From the beginning to the end, they're more likely to have a problem," said Fernando Bonanni, director of Abington Memorial Hospital's surgical weight-loss center.
"There's lots of patients that are between 250 and 400, more than you might think," said Richard Webster, vice president for musculoskeletal services at Thomas Jefferson University Hospital, which does not have a bariatric surgery program. "Your size and your health are directly related, which is why we see so many large patients."
When Bonanni came to Abington, he set about raising everyone's consciousness about comfortable equipment and humane treatment for his patients. Rudeness to obese people, he said, "is absolutely the only form of prejudice left in our society that's acceptable."
Hospitals quickly learn that it's not enough to set up special rooms for patients recovering from bariatric surgery. Severely obese patients need treatment for all kinds of reasons. Christiana Hospital, for example, cared for a 600-pound pregnant woman last summer.
Temple University Hospital is making changes that help its biggest patients whenever it renovates. "We just realized that bariatrics was not confined to four rooms on the ninth floor," said Terry McGoldrick, the hospital's chief nursing officer.
Hospitals everywhere are finding the changes expensive. Abington Memorial shared some prices: Stretchers that can hold 700 pounds cost $3,147, compared to $2,400 for the standard version. Wheelchairs with a 700-pound weight limit cost $1,300, more than five times the price of the standard size.
Outfitting a room with an overhead lift costs about $12,000, said Jan Nash, chief nursing officer for Paoli Memorial Hospital.
Jefferson Hospital now routinely buys beds that can support 500 pounds and stretchers strong enough for 700. The hospital says it still expects to spend more than $250,000 renting bariatric equipment this year. The extra-large furniture cannot fit in the city hospital's private rooms, so another cost is that morbidly obese patients often must be by themselves in rooms meant to hold two patients.
Harvard University radiologist Raul Uppot studied how patients' expanding waistlines are affecting medical imaging and found a growing number of fuzzy pictures. Some patients can't fit in the machines at all. Those who can are more likely than thin people to have "inconclusive" films. With CT scans and X-rays, doctors can improve the picture, but at a price: exposing patients to higher levels of radiation.
Patients too big for a hospital's imaging machines may face exploratory surgery or other less efficient diagnosis methods, Uppot said.
GE Healthcare recently started making a CT machine with an 80-centimeter opening. Siemens last year introduced an MRI machine with a 70-centimeter opening and an extra-powerful magnet meant for examining obese patients.
The Hospital of the University of Pennsylvania has an earlier incarnation of the large-bore MRI, which is 10 centimeters bigger than the standard model. Evan Siegelman, chief of body MRI at the hospital, said his department, which takes referrals from two sister hospitals, scans a patient every two days who could not fit in any other MRI. Siegelman hopes to have one of the more powerful open-bore machines when Penn's Perelman Center for Advanced Medicine opens next year.
Even getting patients to the hospital requires special equipment.
In the past, it could take six ambulance crews to get super-obese patients out of their houses, said Karen Kroon, general manager for American Medical Response, a Philadelphia ambulance company. And then they might have had to ride on the ambulance floor because stretchers were not strong enough.
In 2005, her company bought a stretcher that can support 1,000 pounds. It comes with a ramp and motorized winch. The company uses the equipment "fairly regularly," Kroon said.
The Philadelphia Fire Department has spent more than $200,000 over the last three years on patient carrying devices that can hold up to 1,600 pounds, stair chairs for people up to 500 pounds and stretchers that hold 650 pounds. Every ladder company has the jumbo equipment, said Daniel Williams, executive chief.
The special needs don't stop with a patient's last breath.
Hospitals are also buying lifts for their morgues.
The index measures the relationship of height and weight. People with a BMI over 30 are considered obese.
Normal weight: 18.5
Morbidly obese: 40
Super obese: 50