Robert Cima is holding up a thick metal paddle, a device bigger than a spatula. It’s gray and shiny, and he’s showing how he maneuvers it into place. “To get the leverage, you need a wider area,” he says, tapping the bulbous end. “We need to keep more tissue away from the wound. The little one doesn’t work.”

Cima, a surgeon at the Mayo Clinic, is explaining how he needs bigger equipment these days to cope with an increasingly obese patient population. The old, smaller retractor clamp in his other hand isn’t sturdy enough for patients who are 800, 900 or 1,000 pounds.

“It’s not like their organs get bigger,” he says. “It’s the distance from their organs to where we are that is getting bigger. Instruments are becoming longer because you want to keep the focal distance to the patient the same.”

The general public struggles to comprehend the scope of the obesity epidemic, but at hospitals like Mayo it’s made real everyday. They see it in new OR equipment, in the larger beds, wheelchairs, and MRI machines, and in the new ceiling lifts. Whole hospitals are having to be redesigned and remodeled to meet the needs of larger people (in some cases, much larger people).

“You can’t just redesign a wing. You have to redesign a whole hospital, because you never know when someone might come in,” Cima says.

The costs of all this are enormous. Aside from new equipment and facilities, there are also longer recovery times, less-than-optimal surgical results, and injuries to staff from having to move heavier people. Working in a hospital now gives you a greater chance of injury than working in construction, according to the Bureau of Labor Statistics.

Cima doesn’t see much hope in national obesity trends, which keep getting worse. Last year, 38% of Americans were classified as obese, with a BMI of more than 30, and about 10% of those had a BMI above 35. Many of these people will eventually need care, with the added burden this implies. Obese patients cost 42% more to the health system than normal weight patients.