Four-hundred-, 600- and even 800-pound patients are presenting ambulance crews with some big challenges.

As obesity rates rise, paramedics in Nebraska and Iowa are faced with carrying more obese patients. In turn, paramedics find creative ways to move them, and some fire departments are looking to borrow or buy specialized equipment.

Lincoln Fire & Rescue, for example, is considering putting a construction crane and a forklift on call for patients who are too big to get out a door or down steps. Firefighters had to use a tarp to haul an 800-pound patient a few years ago.

It's another example of how obesity can strain the health care system, whether that's hospitals or ambulance crews. The Nebraska Medical Center in Omaha in recent years has purchased heavy-duty beds and wheelchairs for obese patients.

Adult obesity rates in Nebraska and Iowa have been rising.

In 2008, about 27 percent of the population in the two states was obese. That’s up from 23 percent in Nebraska and 24 percent in Iowa in 2005, according to a report by Trust for America's Health, a nonprofit group that focuses on preventive health.

Lloyd Rupp, a battalion chief in the Omaha Fire Department, said his crews encounter a 400-pound-plus patient every several days. Five to 10 years ago, crews would run into such patients every couple of weeks.

Paramedics in Omaha, Sioux City, Iowa, and elsewhere occasionally must call in an extra crew to help carry big patients, particularly up or down steps.

Fire departments emphasized that even though large patients can be tougher to move, they are treated with the same respect as other patients.

When paramedics don't have specialized equipment, they have to improvise.

"That is the trademark of firefighters," said Pat Borer, deputy chief of the Lincoln department. "They are resourceful."

Bill Lundy, volunteer captain with the York (Neb.) Fire Department, remembers a call several years ago involving a man who had suffered a heart attack in his basement apartment. The man weighed more than 350 pounds, and there wasn't enough room to get him and the stretcher up the basement stairs. There was also concern about whether the staircase could support the man and the firefighters carrying him.

Firefighters unhinged an interior door, put the man on it and slid it through a basement window.

Wendee Brown, an Omaha fire captain, said big patients often apologize for their size.

"They are embarrassed," she said. "You feel bad for them."

Moving big patients is tricky, she said. It's hard to get your arms around an obese patient, making it difficult to get leverage. If a patient is weak or unconscious, it's even harder.

A few years ago, a woman weighing more than 600 pounds who was dehydrated and weak had fallen out of a chair. Firefighters couldn't lift her onto a stretcher, so they used a backboard, which is normally used for people with neck or spine injuries.

Brown said firefighters rolled the woman onto her side and slid the board under her. They lifted the board onto the stretcher, then slid the board out.

Borer, the Lincoln fire official, said that several years ago crews used a 16-by-16-foot canvas tarp from a firetruck to move a patient who weighed more than 800 pounds.

Firefighters rolled up the tarp edges to create handles and slid the tarp under the person. An extra crew was called in to help, and it took about 10 firefighters to carry the person to the ambulance.

Standard response in Omaha for a medical call is an ambulance and a firetruck, with a combined crew of six members. Rupp said that a couple of times a year an additional truck with four firefighters will be called to help when a patient weighs more than 500 pounds and must be carried up or down steps.

Omaha might purchase a special ambulance to make it easier to transport obese patients. The ambulance would be used for all patients, not just those who are obese.

A standard ambulance costs $190,000 to $200,000. Omaha is considering paying $15,000 to $20,000 more for one that comes with, along with a winch, a reinforced floor and a bigger patient compartment. Rupp said the ambulance would be purchased when an existing ambulance must be replaced.

Some fire departments are considering purchasing heavy-duty stretchers, which can come with hydraulic lifts.

The Council Bluffs Fire Department purchased one four years ago. The stretcher can hold up to 1,600 pounds, compared with the standard 700 pounds, and is 29 inches wide instead of 23 inches.

The department uses it for patients who are 400-pounds-plus, and it's getting more use lately--once or twice per month instead of every other month, said Rick Benson, a division chief in the department.