The memory still bothers Ken Keller: A panicked ambulance crew had a critically ill patient, but the man weighed more than 1,000 pounds and could not fit inside the vehicle. And the stretcher wasn't sturdy enough to hold him.

The crew offered an idea to Keller, who was then an investigator with the Kansas Board of Emergency Medical Services. Could they use a forklift to load the man — bed and all — onto a flatbed truck? Keller agreed: There was no other choice.

"I'm sure it was terribly embarrassing to be in his own bed, riding on the back of a flatbed with straps tying him down, going to the hospital, and then have a forklift at the hospital unload him," Keller said.

As the nation battles the obesity crisis, ambulance crews are trying to improve how they transport extremely heavy patients, who become significantly more difficult to move as they surpass 350 pounds. And caring for such patients is expensive, requiring costly equipment and extra workers, so some ambulance companies have started charging higher fees for especially overweight people.

The move to modify ambulances is just the latest effort to accommodate plus-sized patients. Some hospitals already offer specially designed beds, wheelchairs, walkers and even commodes.

Ambulance companies say it's time for insurance providers, Medicaid and Medicare, or patients themselves to begin paying the added costs, which are cutting into their razor-thin profit margins.

In the past, ambulance companies often absorbed the extra expense of serving the obese. Now they are adding charges similar to those already imposed on intensive-care patients, people requiring multiple medications and patients on ventilators.

"In order for these systems to survive and continue to provide their service, there has to be some way to recover those costs," said Jim Buell, a director at the American Ambulance Association.

Transporting extremely heavy people costs about 2 1/2 times as much as normal-weight patients. It takes more time to move them and requires three to four times more crew members, who often must use expensive specialty equipment, Buell said.

Keller, now an operations manager for the American Medical Response unit in Topeka, successfully petitioned the Shawnee County Commission last summer to raise ambulance fees from $629 to $1,172 for critical-care patients and people who are 500 pounds or heavier.

In Colorado Springs, Colo., and the Nebraska cities of Omaha and Lincoln, the fees are $1,421 for an extremely obese patient, compared with $758 for a typical patient.

Before those ambulances had heavy-duty equipment, crews just had to make do, often calling in burly firefighters to help lift patients.

"I've heard stories of people moved by U-Haul trucks and sides of mobile homes having to be removed to move patients out, things of that nature," said Ted Sayer, a general manager for the American Medical Response unit.

The Centers for Disease Control and Prevention has long said that nearly a third of Americans are obese. About 5 percent of the population is morbidly obese, meaning they are more than 100 pounds heavier than their ideal weight.

Some critics say the higher fees are a form of discrimination.

"Ambulance services are a critical public service and should accommodate the needs of all of those who require them at a fair cost," said Joseph Nadglowski, president of the Obesity Action Coalition, a group that advocates for the obese.

Higher payments for heavy patients are commonplace in Oregon and Washington because the insurance industry there acknowledges the additional costs, said Liz Merritt, a spokeswoman for Scottsdale, Ariz.-based Rural/Metro Corporation, an ambulance provider.

Ambulance companies say the insurance industry is their best hope for closing the financial gap.

As with any medical service, ambulance companies bill private insurers or government health care programs. Medicare and Medicaid do not pay extra for transporting the extremely obese, although that's something the ambulance industry wants to change. The uninsured are charged directly, but many of them cannot pay.

"It's really an emerging area," said Susan Pisano, a spokeswoman for the America's Health Insurance Plans, an insurance industry trade group. "It is one more way that obesity is contributing to health costs."

Proponents of the extra fees say obese patients are grateful for equipment that eliminates the need for flatbed trucks and forklifts.

"We've noticed that people who are heavy know that they are heavy, and they don't want to impose on others, and they don't want someone injured while moving them," Sayer said.

Like many ambulance companies, Keller's unit in Topeka recently spent about $10,000 to retrofit an ambulance with equipment that accommodates patients weighing up to 1,600 pounds. Ambulance services with helicopters also are creating larger patient compartments and adding stronger gurneys.

Sales of specialized lift systems nationwide are expected to reach $193 million by 2012, up from $75 million in 2004, according to EMS Insider, an industry newsletter. The sale of specialized stretchers is expected to nearly double to $50 million in 2012.

Keller is hopeful more companies add the equipment so the very obese will receive better care. He recently went out on a call involving a severely overweight woman.

"The family was there, and we brought the cot in and helped her onto the cot. And she said, 'I appreciate it so much, you looking out for our needs,"' Keller said. "And I thought that was pretty cool."