4 Patient Mistakes I'll Never Forget - Bariatric RD Stories

Article By: Rachel Ignomirello, MS, RDN, CSOWM, LDN

Rachel Ignomirello is a Bariatric Dietitian and Board-Certified Specialist in Obesity and Weight Management.

Bariatric programs offer coaching, counseling, and education before surgery to teach patients what to do and not to do after surgery. All postoperative behavior recommendations are critical for safety and health. If patients only follow half of the guidelines, they will likely only be half as successful and at a higher risk of complications. Some patients feel like complications won’t happen to them or that they are somehow different from others. Sadly, many stories about noncompliance and the prices those patients paid. I wanted to share these examples to discuss the importance of behavior compliance following bariatric surgery – not to scare anyone. There’s that classic quote, “It’s good to learn from your mistakes. It’s better to learn from other people’s mistakes.” The following accounts did occur, but some minor details have been changed to protect identities.

Patient Story #1) A patient came in on a Monday with severe abdominal pain. After an assessment, the surgeon performed an endoscopy to examine the upper GI tract and found a stomach ulcer. We discovered that the patient had dental work the previous Friday, and her dentist prescribed ibuprofen to relieve dental pain. It only took THREE days for the stomach ulcer to present itself. Left untreated, that ulcer could have led to severe bleeding or perforation (hole). Bariatric patients have to avoid Non-steroidal Anti-Inflammatory Drugs (NSAIDs) for life. These are common medications such as ibuprofen, aspirin, Advil®, Aleve®, Motrin®, meloxicam, Celebrex®, etc. NSAIDs in bariatric patients increase the risk for gastric ulcers. Acetaminophen (Tylenol®) or prescription pain medications are often used in place of NSAIDs for pain relief in postoperative patients. It’s important to tell all healthcare providers about NSAID avoidance, even dentists.

Patient Story #2) In the same week, my hospital had two bariatric patients come in with burning stomach pain. One patient was 7-months out, and the other was 7-years out. It turns out that both patients restarted smoking cigarettes. When bariatric patients use tobacco or nicotine-containing products, it increases the risk of complications to 30%. The highest risk is ulcer formation, and that’s exactly what happened to these two patients. The patient who was further out from surgery came in right after the stomach pain started. They were able to receive emergency surgery and live. The other was not so lucky because they delayed their care out of guilt for smoking. The stomach ulcer was so advanced that it perforated the stomach, leading to spilled stomach contents in the abdomen. That caused an infection, which led to sepsis. Sepsis quickly leads to tissue damage, organ failure, and death. Restarting smoking cost that patient their life, so let their mistake remind you that tobacco/nicotine avoidance must be lifelong.

Patient Story #3) I probably have a story for every vitamin deficiency you can think of. They all relate to patients not taking their bariatric supplements or not taking the right ones. One patient was admitted to the orthopedic unit for a hip replacement because they had broken their hip from a light fall. Upon assessment, the patient reported having bariatric surgery years ago. Their calcium lab always looked fine on bloodwork, so they stopped taking the calcium supplement. They did not realize that their body was pulling calcium from their bones until it had none left to give. This patient developed osteoporosis, which is why a light fall caused such a severe break. Another patient came into the office complaining of extreme fatigue, hair loss, and odd cravings for things like dirt. When assessing their supplements, the patient took an over-the-counter gummy vitamin because it had the word “bariatric” on the label. Over-the-counter vitamins rarely meet bariatric guidelines, and certain formulations (gummies) cannot be made with iron. This is exactly what she was low in. This patient developed anemia and had to get several iron infusions. Patients must follow vitamin instructions from their bariatric team to help prevent deficiencies.

Patient Story #4) My last patient mistake story is a story that repeats itself over and over again. It’s about patients who did not follow their postoperative nutrition guidelines and hurt themselves. The first that comes to mind is a patient who was barely out from surgery. They were supposed to be on their liquid diet but were feeling hungry and desperate. This led to them doing an online search for bariatric diet advice. The internet told them that they could eat fish and soft-cooked vegetables. The patient did eat those things and ended up in the ER getting their stomach pumped later that day. The food caused an obstruction (blockage) in their new stomach pouch. It took weeks for their stomach to rest and recover before they could try advancing again. The postoperative diet is about healing and safety, so it’s imperative to follow it. Another patient story that comes to mind is when a patient ended up with a head injury because they passed out and hit their head on the sidewalk. When the patient got to the hospital, staff discovered that they were severely dehydrated. Dealing with dehydration can lead to low blood volume and blood pressure. This may cause someone to feel dizzy or even faint. Despite being educated to drink 4-8 ounces of fluid each hour, that patient ignored that guideline and even thought it was normal not to urinate for 12+ hours. Each eating and drinking guideline is meant to keep patients from hurting themselves.

For patients who take a wrong turn on their bariatric journey, I hope they have the option of making a U-turn to head back in the right direction. When we make mistakes, we must forgive ourselves and learn what not to do. If struggling, it’s always a good idea to get back on track with program guidelines and to reach out to the bariatric surgery team for additional support. Do not delay your care.

BariMelts provides general recommendations, not to be construed as medical advice. Please consult your doctor.

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