OP is a fag.

[–]msundi833678 points 8 months ago As an anesthesiologist this is the scariest patient population to be obese. So many people do not understand this either. A pregnant airway can be unexpectedly difficult in a normal sized patient. A large patient can be life-threatening.

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[–]321zzz1017 points 8 months ago Another anesthesiologist here. Totally agree with what you said, and as you well know, even in non-emergent situations just placing an epidural for labor or a spinal for a cesarean section can be a real chore.

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[–]mhc-ask318 points 8 months ago I had to do an LP on a morbidly obese patient, and I couldn't reach the dura with a 3.5 inch needle. I went about 6 inches in with the harpoon before I called it quits and paged IR.

Out of curiosity, what are your options for a patient in labor, who needs an epidural, and is so obese that you can't even reach the dura? Stat IR consult?

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[–]Levlove497 points 8 months ago "Hey, so this sucks, but you can't have an epidural.... sorry...."

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[–]TheOnionBlast178 points 8 months ago It's a reality. The harpoon is a real thing. The deepest I've ever placed an epidural was 10cm. In an emergency you don't want to have too rely on there being extra long equipment in order too get you anesthetized adequately for your labor, and or c section.

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[–]pf22645 points 8 months ago L&D nurse here. I had an obese patient (BMI >50 if I recall correctly) who wanted an epidural. They tried probably 4-5 times before saying no sorry you are too large for an epidural.

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[–]Throwawaychica21 points 8 months ago What was the patient's response?

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[–]BaggyKill373 points 8 months ago Name checks out

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[–]NukeNewbie987 points 8 months ago Surgery on obese patients is much harder as well Ive heard (Im sure you can correct me if im wrong) And the more obese the patient, the more likely of a complication during the operation or recovery.

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[–]msundi83855 points 8 months ago Absolutely. Honestly when I have a case and look up the patient for the first time... first thing I check is how big they are. Other things I personally don't worry about as much.

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[–]_just_a_dude_202 points 8 months ago How do you deal with really obese patients? I know there's definitely a science to what you do, but I feel like that's stacking so many variables on top of one another. Have you ever just felt like, "Yeah, not a good idea to put this one under." at any point?

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[–]powowie420 points 8 months ago We prepare to the extreme, I only do surgeries intr-aabdominally, so can't really speak for other people. So starting from the beginning. My consent process is different for surgeries for obese and especially once you cross BMI 50 (my own anecdotal experience). If it's an elective case, we try really hard to not go to the OR so that we will try medical management for the patient to more extremes that a more normal individual. Obviously for non-elective cases, you don't have that options. I explain risks for poor wound healing because of poor nutrition, increased risk of wound breakdown, increased risk of postoperative hernias, increased risk of converting from laparoscopic/robotic to open abdominal procedures, increased risk of anesthetic difficulty, increased risk of injury to general organs because a lot of fat can obscure organs and increases time the patient is under anesthesia. Postoperatively, they have increased risks of clots because they don't mobilize early. God forbid they require CPR intraoperatively, because no way you can compress the chest 2 inches on an obese patient. They have increased risk of pneumonia and atelectasis because the ventilator can't recruit as much lung. Obese patients also notoriously are slow to get up and get on postoperative goals like using those incentive spirometers for all the good they do.

Intraop, we position them differently. Sometimes, we use bed extenders to put another OR table together which kills the surgeons' backs. You have to pad them really well. Some patients are required to be in lithotomy position for procedures but even our biggest stirrups don't fit so some poor souls have to hold the legs. Patients are harder to transfer to and from their beds and sometimes we have the blowup pads under them, but sometimes they are broken, so this kills our backs and knees. Similar thing happens when you help them sit in chair, stand, or to a commode or bathroom. Multiple nursing staff members are needed so no one hurts themselves in trying to help the patient.

I'm not an anesthesiologist so can't really speak for them but often these patients have such a large buffalo hump that the neck is below the sternum and airway is mechanically blocked. So I have seen them put folded sheets under their necks to help stabilize the neck, especially since they can have heavy soft tissue on their necks. Then they have fiberoptic brochoscopes which help to visualize the cord. I don't know if their anesthetics are different but I know we dose differently. We give different doses of antibiotics.

Then you get to the surgery and your incisions have to be massive and your retractors have to be massive and everything is just more effort on your poor hands, shoulders, backs, and knees, especially the assistants'. Surgery takes longer becuase visualization is difficult. They bleed more and it's easier to underestimate volume replacement in a 400 lbs patient then in a 150 lbs patient. If you do laparoscopic, we use longer instruments. The obese patient is where robotic surgery is very helpful. However, sometimes, we have to put their pelvis slightly higher than their thorax and some patients can't tolerate that and you have to open the abdomen which sucks because it's like trench warfare.

I've seen baby being pulled out of a woman with BMI 87 in a cesarean. The surgeon had his full arms in the woman, and imaging the weight of the abdominal fat pad the surgeon had to fight against to deliver this baby!

Our anesthesologists will sometimes do different types of epidurals which can last many hours if they think general anesthesia is a terrible idea on somebody which can help, but with side effect that patient is awake and epidurals can be inferior to general anesthesia.

Then of course, you fear wound/incision complications.

All in all, BMI is often the single biggest determinant of how excited I am for a procedure.

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[–]Fizzlesplunk62 points 8 months ago Thank you for your insightful and fantastic comment. Reddit is a better place when people with your education and experience share their thoughts. Very interesting!

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[–]nuala-lala186 points 8 months ago Have you ever just felt like, "Yeah, not a good idea to put this one under."

That is not alway an option for some surgeries, so if, for example, your 4'10" 500lb patient needs a laparotomy due to a bowel obstruction, you have to make a plan to safely intubate and extubate them at the end of the case. Sometimes obese people have easy enough airways, because all their fat is waist down. Other times they look like this, which to be honest is easier to deal with than something like this or this. If you have to intubate awake, you intubate awake, but one way or another you get it done. If your plans (A, B, & C) don't work, you call ENT for a surgical airway. In very rare circumstances, you skip right to an ENT consult and use the airway they create to administer anesthesia.

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[–]Chillvab108 points 8 months ago Good lord those pictures

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[–]togno9973 points 8 months ago Your reply just made me lose interest in clicking those links. I'm very thankful.

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[–]Chillvab46 points 8 months ago I’m glad I could help. The first not bad at all but the other two...enter at your own risk

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[–]maxwellgriffith99 points 8 months ago As a nurse, putting people under isn’t hard, it’s the hemodynamics effects (hr, bp, cardiac output, etc) that can get compromised quickly. And that’s before you factor in a fetus whose blood supply depends on mom adequately pumping. Then you have to worry about safely waking them up, and what those drugs can do to a fetus.

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[–]welcometodumpsville44 points 8 months ago Not to mention nursing obese patients (bedpanning, showing keeping surgical wounds clean) post op.

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[–]htmwc98 points 8 months ago It sounds ridiculous but when cutting through subcutaneous fat at incision can lead to the fat melting in the surgical lamps and making holding onto scalpels extra hard...

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[–]velvetjones0142 points 8 months ago It’s actually quite hard on the OB. C-sections on obese patients are difficult and exhausting for the OB. I know at least two who go to PT for their shoulders because of injuries from delivering obese patients.

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[–]321zzz126 points 8 months ago Absolutely. One recent study in the American Journal of Perinatology of over 2400 cesarean sections showed that

there is a dose response with respect to increasing BMI and risk for wound complications, with the most severely obese women at greatest risk. We also found that as degree of obesity increases, differences in operative characteristics change as well. Our findings are important given the increasing rate of obesity and extreme obesity in obstetrics. Additionally, wound complications cause significant emotional and financial stress on patients and on the healthcare system as a whole. These complications can lead to increased recovery time and even re-hospitalization.

Source: Maternal Obesity and Risk of Post-Cesarean Wound Complications

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[–]tossmeawayagain48 points 8 months ago In my field we have pre-approved frameworks for wound healing - a best practice guide for how long various wounds take to heal. These guidelines frequently go right out the window with my obese and morbidly obese patients, as even uncomplicated wounds take much longer to heal. It's to the point that ticking the "obesity" box on one of those reports is an instant rejection of the framework, necessitating a custom built wound care plan.

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[–]Slamalama1832 points 8 months ago As a l&d rn obese patients are incredibly difficult. Not only for this reason but if an emergency happens and we need to quickly move mom and she already has an epidural it is incredibly difficult. Surgery is much harder to do. Recovery is a lot longer and there is a higher risk of your incision getting infected.

Gestational hypertension and preeclampsia is a huge huge problem as well. Just last night 4/5 patients on my team alone had pre-e. That’s insane

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[–]GoEagles2471752 points 8 months ago People also think they're supposed to gain way more weight during pregnancy than they really have to. I was shocked by how little the amount was when I took my maternity class in my undergraduate nursing program. Many think gaining 50-60 pounds is normal or even low when that number tops even the highest recommended weight gains.

I know this is about women entering pregnancy but I think it coincides with most Americans just being totally clueless when it comes to their own health. I see so many patients in the hospital who are morbidly obese and just think they're "chubby". It's mind blowing how distorted the reality of what is a healthy weight has become.

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[–]mutatron250 points 8 months ago My wife gained about 30 lbs, she's small and her pregnancy was small. One time we were at a party talking with another pregnant woman. She almost spit out her donut when my wife said she was 8 months pregnant "Your doctor must be wrong! You should look into that!"

But 8 months was correct, and the baby was normal size, like 7.5 lbs.

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[–]GoEagles247163 points 8 months ago Yea that sounds perfectly normal. People really think they know better than doctors. It's ridiculous.

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[–]I_Fart_On_Escalators35 points 8 months ago May I ask your wife's height? I'm 5'1 and small frame. Even though I gained the recommended 30 lbs (I started pregnancy at an average, healthy weight), I showed early, maybe around 5 months it was starting to be visibly obvious. I also had insane swelling during the last month. My baby was also average weight at birth. We all carry our pregnancies differently.

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[–]mutatron35 points 8 months ago 5'4"

How much you show depends on how the weight is distributed, and how your insides are built, I would think. There's a somewhat tall, somewhat thin woman at work who recently had a baby. She showed early, and also got a little bit of extra fat in the face. Now a few months post partum she's tall and thin again.

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[–]gotsnowart76 points 8 months ago I was violently ill my entire pregnancy and ended up actually losing weight throughout my pregnancy even though I looked like I was smuggling a beach ball under my shirt. It was a nightmare and even at a normal weight I still developed pre-eclampsia, hydramnios and anemia and myself and my daughter both nearly died during the emergency c-section when I went into labor 9 weeks early. I think some women just have this idea that pregnancy is 9 months of just getting fat then you shit out a kid. But in reality there are SO many things that can go wrong during a pregnancy and having poor health in the first place isn't really a good way to start one.

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[–]marianwebb188 points 8 months ago My mom was underweight when she got pregnant with me (5'8" ~105 lbs) they still only recommended she gain at most 35-40 pounds or so while pregnant.

I think the whole "eating for two" mantra doesn't do anyone any favors. You don't need to eat twice as much as you normally do, you need to eat an additional 300-500 calories primarily containing quality protein. YOU don't need to gain weight when you're pregnant (unless you were underweight to begin with). Your fetus needs to gain weight, and your total weight gain shouldn't be much higher than fetal + fluid + placental weight. Even if you're having twins, you don't need to gain 50-60 lbs.

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[–]SumOMG28 points 8 months ago So it’s just like bulking when bodybuilding

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[–]greysector218 points 8 months ago It is crazy how we have normalized fat. I was obese, coming in at 236 lbs, 6'0" male. I didn't have a big belly, I am a broad guy. I had no idea the danger I was putting myself in. I thought I could lose a couple of lbs but didn't realize I was 50 lbs overweight. 50 lbs! My doctor told me i would be dead by 65.

I am now down 32 lbs and still working on it.

Now you may hear the typical response of people that say that BMI is not a good indicator for individuals, so they justify their size just as I did. BMI is accurate for 90% of the population. Even naturally strong people and muscular people shouldn't be more than a few lbs over. Very rarely is someone at a healthy weight and 20 lbs outside their BMI.

We need to stop making excuses for ourselves and for others. Lose the weight!

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[–]ShredderIV81 points 8 months ago I was just about the same height/weight as you. Never had a doctor tell me my weight was a big issue. People called me skinny, because like you I'm broad and collected weight all over, not just in my belly.

I've lost 65 pounds now and am only 10 pounds under being considered overweight for my height. Everyone comments that I'm too thin / skinny now when the reality is that I could even still do to lost a few pounds and be more active.

People have a very skewed perspective of what is a healthy weight in America.

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[–]Marklar_the_Darklar91 points 8 months ago I definitely agree with the distortion of weight going on in America. People comment saying I'm "skinny" when at best I'm average, even slightly overweight. But because so many people are obese they start to think that's healthy cuz they see it everywhere.

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