Safer Surgeries for All: Expert Tips on Anesthesia and Obesity with Dr. Sarah Bodin

If you are overweight or obese and planning to have surgery, it's important to understand how excess weight can put you at risk for certain side effects and complications, whether from the surgery itself or the anesthesia you need.

To help me explore the unique challenges people with obesity face when undergoing surgery, I invited Dr. Sarah Bodin, a double board-certified physician in obesity medicine and anesthesia, to join me for this week’s episode.

Together, we delve into the complexities of anesthesia, and discuss the impact of medications like GLP-1 and the importance of screening for conditions such as sleep apnea. Join us now as we navigate the path to safer and more inclusive surgical experiences for all patients.


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Audio Stamps

01:30 - Dr. Bodin shares her professional background.

02:10 - Dr. Bodin discusses the importance of holding GLP-1 medications before surgery due to their effects on gastric emptying.

08:35 - Dr. Rentea asks about the clinical challenges posed by obesity, such as obstructive sleep apnea, hypertension, diabetes, and difficulties with IV access.

10:22 - Dr. Rentea and Dr. Bodin discuss the necessity of screening for sleep apnea in weight management patients due to its impact on both weight and overall health.

11:50 - We learn about the safety considerations regarding weight limits for outpatient versus hospital-based surgical settings.

15:25 - We hear the proactive measures overweight and obese people can take to prepare for surgery to reduce the likelihood of complications and promote successful outcomes.

20:13 - We find out about the risks associated with skin removal surgery for people who have lost significant amounts of weight.

22:44 - Dr. Bodin shares her tips for other physicians that might not have had as much training in this area, including how to be mindful of language and biases.


Quotes

“None of us want to have problems surgically because of our weight.” - Matthea Rentea MD

“My recommendation would be that if you're taking a weekly injectable, you hold it for a solid two weeks prior to your surgery.” - Dr. Bodin

“It is super, super common for me to see obstructive sleep apnea. Some of which has been diagnosed and some of which people do not know about.” - Dr. Bodin

“If you have obesity, you're more likely to have sleep apnea. If you have sleep apnea, it can potentially cause worsened weight gain. So yes, that is built into my screening tools for my practice.” - Dr. Bodin

“High blood sugars are associated with a number of different problems around surgery.” - Dr. Bodin

“If your cardiovascular system, your heart, your blood vessels, and your respiratory system are all a little bit tolerant of exercise, you're going to better be able to tolerate the stress that a surgery and an anesthetic bring.” - Dr. Bodin

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Transcript

0:56

Welcome back to the podcast. I am super excited today to have on Dr. Bowden. Now I want to give you a little bit of background here. So she's double board certified in obesity medicine and also anesthesia. I met her because she is a colleague like me. She has her own clinic and we were talking about different anesthesia risk for things. And one of the things that I like to highlight on this podcast is that I'm not just about shape shifting. I'm really about your metabolic health and you getting into a better place with things like that. And so we were just talking about some of the logistical challenges that if we have overweight or obesity, that it will bring to having anesthesia if you're getting a surgery. And so today I'm going to have her introduce herself and just tell us a little bit about who she is and where she practices, but we're going to talk about things today, such as. If you're on a GLP 1, how does this affect if you're going to get a surgery? How far in advance do you have to hold it? What kind of risks does it pose? And then other things related to weight. So Dr. Bowden, can you just start out introducing yourself a little bit and just tell us a little bit about you? Sure. Thank you very much for having me. I really appreciate it and glad we've connected like you said, I am double board certified in anesthesiology and obesity medicine. I've been practicing anesthesia for almost 25 years now. And got drawn to taking care of the disease of obesity through that practice. Of course. I practice in, North Florida. I live in St. Augustine and have a telehealth based obesity medicine practice. In addition to my anesthesia practice. So tell, let's start out. I know there's so much that we can talk about. I know we kind of brainstormed before. Hey, what, what do we think people really want to hear about? And I think that, One of the challenges when you're on these amazing GLP 1 medications, so if anyone's newer, that would be any of the injection anti obesity medications. There are always warnings as far as how long before surgery to hold it, so can you go over a little bit, what are the newest guidelines with that, and kind of what do we worry about with the medications, like why do we have to hold it at all? Yeah, great question. And really, really, really important. And obviously it's becoming, it's a daily occurrence for me now that I take care of somebody who's taking, a GLP one medication, whether it's for diabetes control or for weight management, both of which are perfectly legitimate reasons to take them. And they're great drugs. We do have to be very careful with them around surgery and anesthesia because of one of the mechanisms that's desirable for them for weight loss and for diabetes control, which is. slowing gastric emptying, slowing down how fast food transits through the stomach and the small intestine. So, that is why we have people prior to anesthesia hold food and liquids, so that the stomach is relatively empty. When we, render folks unconscious with anesthesia, they stop being able to control swallowing, coughing, coughing things away from the airway. And it puts them at risk for what we call aspiration, where stomach contents of any sort, whether it's food, secretions, acid, whatever, can make it from the stomach up into the mouth, into the oropharynx, and then down into the lungs. And that is potentially deadly. So of course, if you're taking a GLP 1, you know that you're full longer. Your stuff, the food simply doesn't leave your stomach as quickly. So we have found that folks. who are taking especially the longer acting injectables like Ozempic, Wegovy, Monjoro, and ZepBound, and the other ones, there are some other weekly injectables too, those are the ones we're seeing the most of, more likely to have retained stomach contents even when they have followed those fasting guidelines and putting them at higher risk for an aspiration event. So the American society of anesthesiologists came up with some guidelines about six months ago, I think, recommending holding these medications for about a half life of the drug. So they're kind of, in my opinion, wimpy, wimpy, and we're probably going to see some, changes to these recommendations, but as it stands, if you're taking a weekly injectable, like terzepatide or semaglutide, otherwise known as Wegovy. Ozympic, Manjaro, or ZepBound, you need to hold it for a solid seven days at the minimum. My feeling is people need to hold it for longer, more like two weeks, probably even three weeks. And my guess is we'll start seeing some changes in fasting times as well as we collect more data about how quickly stomach's emptying and what the risks are. My recommendation would be that if you're taking a weekly injectable, you hold it for a solid two weeks prior to your surgery. And that's any kind of surgery and any kind of anesthesia. If you're going for an endoscopy, if you're going for, you know, dental work and where you're going to get sedation, if you're going for a major surgery, any of them, hold it for a full two weeks. If you're taking a daily injectable, well as the oral semaglutide, which is ribelsis for diabetes. I don't know how many people you'll have taking that. There are a few people taking it. Those are daily dosers. You can take those. You should hold those. The recommendation is 24 hours. Again, I would double it to be safe. Because we we know this is getting a little nitty gritty issue. We know the elimination half life for these drugs and that's what the hold time recommendations are, but that doesn't necessarily correspond exactly with the clinical half lives. So it may be that many people. Even if they hold it for a full elimination half life still have a lot of contents left in their stomachs Yes So practically for people that are listening. I mean, I don't think that they write I think gosh I was looking this up for for semi glutide. I think it's seven days is the half life And so keep in mind people like let's just give an example of let's say you took two milligrams that was your weekly dose So then one week later, you still have one milligram around and then Let's say you stop taking it. You still have half a milligram after that, right? So it's like, things keep breaking down. That's the definition of half life, but people will tell me, like, let's say they're holding their medication for, I don't know, they stop it because they don't feel good. And it will actually be weeks until it's fully out of their system. And I think people think, oh, I held it that week. I'm good. And it's like, no, you actually still have a lot of it around. So I'm really glad that you kind of hammered home. And of course, everyone's going to listen to what their doctor says, but it's incredible that you're still seeing so much retained content in there, how long after, and it's really a safety thing. So I think that's really good for people to hear because I think people get stuff done more than they realize between like colonoscopies and, you know, kind of other different types of procedures. I think that stuff is happening just very often. Yes, and unfortunately, you know, many, most places, most places where I'm working now have really good protocols for making sure that that those medications are screened for and the patients are given instructions to hold. But of course, people make it through the cracks or, you know, I had a patient the other day who had forgotten to tell the screener that he was taking Ozempic and. And then, then they show up and we, you've come in on the day of surgery and you've taken your, your GLP one that week and, and what do we do now? Right? Do we post surgery? That's probably the safest thing to do. And there's gonna be an increase in people who are good at doing what we call gastric ultrasound, which is using an ultrasound tool to look at the contents of the stomach, and look more objectively and be able to tell how much. is in the patient's stomach and we can make a better judgment rather than okay well you took it a week ago but some people still have a full stomach at a week and some people don't we don't know unfortunately that's not completely widespread yet but it's my guess is it's going to become much more widespread. Ultrasound's pretty readily available and people are getting better at using it. We'll get there. That is fascinating. Kind of the bedside ultrasound to be able to do that for gastric stuff. I wouldn't have occurred to me. It makes complete sense though, that you would have much more of an accurate picture right at that moment. Oh, I always love that. Whenever I talk to a physician, there's always something I don't know. And I love learning. That's so fascinating. And I wonder, I wonder, I know that I see all the consequences that can come from long term overweight or obesity. And I'm wondering, what are some of the common things. That you see clinically that sort of have the most impact or need to be managed kind of as far as like anesthesia with this. Well, of course there are many, many of course, diseases that are associated with obesity that have a high impact. The most, frequent one that I see is obstructive sleep apnea. I want to come back to that. I want to list a couple of other, a couple of other things that are common, of course, hypertension, high blood pressure, heart disease, more likely to have heart disease, of course, diabetes, mellitus type two, usually, and managing blood sugar and potential risks with diabetes. Difficulty obtaining IV access and folks with severe obesity, just because the veins are a little bit harder to see. So sometimes that's a problem for us perioperatively. Airway management becomes a little bit more complicated and that links along with obstructive sleep apnea. But the reason I say obstructive sleep apnea is because, folks with obstructive sleep apnea who tend to have upper airway or central Obstruction to their breathing as they get sleepy at night. We will bring that out very readily with sedation, and with opioids, and certainly with general anesthesia. And I do, part of my practice is a pain practice where I do a lot of sedations for pain procedures, and we're not putting breathing tubes in for many of those cases. It is super, super common for me to see obstructive sleep apnea. Some of which has been diagnosed and some of which people do not know about, it's It's pretty easy to predict folks based on physical exam and, body mass index, who are the higher likelihood folks. So in those folks, I've got to be pretty careful about positioning and careful with, medications that are, more likely to cause obstruction of the airway. Yeah. So that's a, that's an everyday problem. Was this interesting? Do you, as part of your obesity medicine practice, I mean I think that this is pretty standard where we're screening everyone like with something called like a stop bang criteria or in some capacity we're screening people for sleep apnea and we might do it because it's quality of life or helps with weight management, but is this something that you're really on your patients in the weight management practice to get screened for that? Like, I feel like do you have like a heightened awareness of this? Yes, definitely. Yes, absolutely. Well, not only because it's, it's, you know, it's drilled into me because I'm an anesthesiologist and I see it in action every day. But because like you said, it does have impact on, on weight itself and weight, you know, they're, they're like a feedback loop. If you have obesity, you're more likely to have sleep apnea. If you have sleep apnea, it can potentially cause worse, worsened weight gain. So yes, that is built into my, for my, my screening, tools for, for my practice. And something that I will make referrals for for sleep testing on patients who screen positive. And there's like you mentioned the Stop Bang screening, screening questionnaire. And that is used very commonly in perioperative settings as well, preparing patients for anesthesia for surgery. It takes, you know, seconds to do it. And we're able to identify people who are, of high likelihood, low, moderate or high probability of having obstructive sleep apnea. And it's a good place to, to identify folks and send them for screening and testing to potentially get treatment. Yeah. Yeah. It's so, okay. So you were mentioning things that you're looking out for things that might be more present and something that we talked about before, which was actually something that I always experienced when I was in primary care. There would be different weight limits to like an outpatient setting versus a hospital based surgical setting. And so I'm wondering if you can talk a little bit about that because I don't know that people understand what settings are safe for them, given what's going on for them. Great, great question. So if you're a hospital setting where there is, you know, everything is available that all all types of people and equipment for resuscitation for treatment, if a critical event occurs, an ICU is present, then you can feel pretty comfortable that if something unexpected comes up or something that's a higher risk event, there's immediately An area to treat it. If we're talking about an outpatient, I work mostly in outpatient centers now, and they're freestanding. They're not attached to hospitals. And if we have a major event like a heart attack or, a respiratory failure or a critical airway event, we have to call an ambulance and get a patient transferred to that higher level of care, to the hospital, to an emergency room. So that's extra delay in treatment and in level of care. So because of that, and because there are bigger risks with taking care of folks with severe obesity and severe medical problems, that is why these folks, we just kind of as a, as a blanket rule, say over a certain weight limit or certain, usually we use body mass index. We know that's an imperfect measure, but it's an easy screening tool. And it's actually pretty well correlated with complications in terms of higher, higher body mass index. I believe both of the surgery centers where I work now where you use 50 as our cut off for no, no go, got to go to the hospital or got to go to a higher, higher acuity setting, body mass index of 50, and the biggest thing that I would worry about is again, respiratory events apnea or airway, losing airway, heart attacks and things like that, cardiac events become more likely, but respiratory is the main thing. Yeah, I, I know that some of my patients would be frustrated because they wanted the convenience of, I'll give you an example where I had my primary care practice literally on the other side of the hall, like down the hall was where they could do colonoscopies and things like that. So they were used to coming there. They were used to parking. It was like, Oh, this is all convenient. And I said, listen, if something happens, like it's, it's not often that it happens, you know, knock on wood for everyone involved. But if something happens, I want to be right there where you immediately can take care of me. I don't want to be somewhere where you have to get me in a, in a, In a, ambulance and get me somewhere else. So that's just something that although it seems like we're, you know, taking, it, it can not feel great to be told, Hey, you can't have the surgery here and you have to go somewhere else. But in the long run, I think that it's incredibly helpful. And I know when I was going through internal medicine during training, when I was doing the hospitalist service, one of the most common admissions that we would have is really a slow inability to wake up from anesthesia. The blood gases doing things where we knew, hey, there's something going on here beyond a regular waking up and we can't just send this person home right away. Right. And so that would be an observation for a day or whatever it is post surgical. And it's, it's, yeah, it's fascinating kind of on the other side of things, seeing that quite often. I remember it's always the end of the day admission because they would have had the surgery. Yes. They might watch them in the recovery room for however many hours of life they take. Come on in. But are there things that I really like, we went over lots of scary things right now. But I'm wondering, are there any things that you see that people can do? I mean, we just talked about, holding your medication appropriately. Are there any sort of empowered things that we can tell people that no matter where they're at? Wait, why is. things that they can do if they're, if they're prepping for an elective surgery, things that they could do. Sure. Absolutely. Some small things you can do if you, you know, we're talking about folks who, you know, people who have diabetes, if you can do the best you can do to help. control your blood sugar, make sure that's as well controlled as you can get it before surgery. High blood sugars are associated with a number of different problems around surgery. infections are one, urinary tract infections, pulmonary infections, kidney, kidney dysfunction and cardiovascular events. So controlling the blood sugar is real and wound healing. So if you keep your blood sugar controlled and It's, we really aim around surgery if it's an inpatient surgery to keep, her sugars under 200, maybe ideally under 180. So, but good blood sugar control, good nutrition, which goes along with that, of course. Making sure that you're eating lots of protein, plenty of protein, or at least adequate protein. You don't want to overdo it. There's no need to. Overdo it, but making sure that there's plenty of protein reserves for healing. Because of course, if you're healing a big incision or even a small incision, but you know, you're not moving around as much, your body goes into what we call a a catabolic state where it's breaking down, potentially breaking down muscle in order to, to achieve healing. So making sure that your nutrition is optimized. Blood pressure control, if you have high blood pressure as well. Making sure you're staying on your medications. Getting some exercise. Now, getting some exercise is actually kind of the concept of what we call prehabilitation. And making sure that folks who are maybe inactive are beginning to build up strength and endurance a little bit. Because having surgery and anesthesia is, you know, is a physiologic stress. It's a little bit like, exercise. So if your body is your cardiovascular system, your heart and your blood vessels and your respiratory system are all a little bit tolerant of exercise, you're going to better be able to tolerate the stress that a surgery and an anesthetic bring as well. So just basically all the principles of taking good medical care of yourself. All together, eating well, probably staying hydrated, definitely staying hydrated, making sure you're drinking plenty of fluids. Don't come into the hospital dehydrated to start with. Your strength is up, your endurance is up a little bit. If you happen to be a smoker, that's a really big one. And we didn't really, it doesn't really relate to necessarily to nutrition, but that is an overall concept that's really important. If you are a smoker, and you're having an elective surgery, stopping smoking ahead of time would be ideal. That's easier said than done. But even if you can withhold the cigarettes for 24 hours prior to the surgery, it actually enhances, it drops what we call the carboxy hemoglobin levels in the blood. The hemoglobin molecule, which carries oxygen in the blood can carry it more efficiently, even after 24 hours of, of, Abstaining from cigarettes. So even that small amount helps you, helps you carry, start, start the wound healing process better. Even if you need to quit for longer, two weeks or more would be preferable, but that's, you know, that's kind of, that's kind of pie in the sky. Yeah. What else? Folks with obesity tend to have a higher thrombotic risk, higher blood clotting risk. So that's something that, we try to be very aware of around anesthesia and surgery, particularly if you're having general anesthesia because of some of the blood flow changes that occur under general anesthesia. We make sure to put on what we call sequential compression devices on the lower extremities during it before, before we. start the general anesthetic to keep that blood flow in the lower extremities flowing and decrease the risk of blood clots. If you have obesity, depending on the size of the surgery and the risk with that, your doctor may prescribe a blood thinner, to take temporarily around surgery to decrease that risk of blood clots because blood clots in the legs and blood clots in the lungs can be, can be deadly. They are higher risk around surgery and they're higher risk for people with obesity. Yeah, you just mentioned a lot of things. I mean, it's fascinating. It's basically like, well, you doing all these things beforehand, it's really going to greatly increase the chance of something not occurring during surgery, which is like, we all want that, right? We don't want something to happen. And then also the big thing I keep hearing here is look, if you can exercise afterward, you'll, you'll have better outcomes during the surgery. You'll have better outcomes, eating enough protein wound healing afterward, All these things matter, right? It's so interesting when we think about it. It's not just, it's, it's like, hey, I want to, I want to not only make it through this surgery, but I want the outcome to be really good. A lot of the time, you know, what I think about is, a lot of people are getting skin removal surgeries because they've done great on the GLP ones or whatever intervention, whether it's bariatric surgery, whatever it's looked like, and now it's time for them to get it. Skin removal surgery. And I think they're still thinking, and this is my question to you, they're still kind of viewing themselves with that same risk that they did when the weight was up. But if their weight is in an area that is considered healthy for them, they're in a great spot and they're qualifying even to get that skin removal surgery. Do you see typically the same challenges arise or are they sort of equaling what their, counterparts are that never had weight to begin with? That is a really good question. And I actually do a lot of folks in that position because I do a lot of anesthesia for plastic surgery. So if, if people have lost weight to the point where their weight is much healthier, they're at a relatively normal body mass index, their blood pressure is controlled or normal without medications. If they have diabetes, you know, the blood sugar is better controlled. Perhaps they're off medications, you know, many times after. After surgeries, people, of course, come off of their antidiabetic medications, which is great. Most you know, if most of the health concerns have reversed with the significant weight loss, their risks really go back down. To really relatively close to normal. Again, the biggest thing to keep an eye on for me, if somebody who's lost a significant amount of weight as the folks that say I was being treated for sleep apnea, I no longer need my BiPAP or my CPAP. That's great, but I still consider them a little bit higher risk than somebody who never had it to begin with. Keep an eye on, but I have found that most folks that have lost a significant amount of weight, they're come for skin removal surgery. They essentially behave physiologically like they're normal. That's so good to hear, right? Like that's. It's, it's nice because I feel like it's that sometimes at the end, you know, people have lost all this weight, but they're still getting yeast infections or, it's just really the extra skin is getting in the way. And so if they decide to make that a thing that they want to do, then it's nice to know that, Hey, you're not going in there with the same risk that you did before. So that, I think that's incredibly positive. Yeah, definitely. It's a great, I think that's a great surgery. That's a lot of times what we're seeing is that, that not only for cosmetic reasons, but because that skin is, it's interfering with exercise and took care of a patient a couple of weeks ago, couldn't ride her bike or walk because of the excess skin. It was very uncomfortable. She's in great shape. She wants to keep exercising, let's, let's take care of her. So we do. Yeah. Yeah. Love that. And I wonder, do you have any tips for other physicians that might not have had as much training in this area? Like let's talk, let's pretend like we're talking to new anesthesia residents that are day one coming in. Are there any type of things that you've developed with time that you feel really helped as far as like a compassionate approach in this area? Because I have to tell you, like I've had surgery before and it was incredibly vulnerable. This is when I had a C section with my son and I just remember thinking, Oh my gosh, I'm in the OR, like who's going to see, like, it was just so much was going on. And I'm just thinking like, are there any ways that you go about it where you feel like maybe. If other physicians knew this, it can help put the patients more at ease that you've experienced in your career. I don't have a specific, that's a really, really good question. I need to think more about that because I think about it more every day. Once I started studying and learning I became very acutely aware of how much, how much bias is just openly voiced in the operating room. Yeah. And calling people obese rather than people with, not using first person, first person, first language. And even that's fascinating, right? And I became aware of my own biases and wow, I mean, they were there, they're there. And I had to start really examining that. And now I'm acutely aware of it everywhere. And it, you know, that the whole GLP thing for a while, every, you know, people were rolling their eyes saying, Oh my God, they're using these drugs off label. Like, no, they're not. That is on label. That is an on label use of this medication. When I overhear kind of, misinformation or misunderstandings among people, I try myself to speak up in as tactful a way as possible to clear up those biases. I become aware when I'm changing a blood pressure cuff saying I need to get another size rather than saying, Oh, that cuff is too small for you. Let's go say that it is factual, but you can say it in a way that sounds critical versus. Um, so I'm trying to be more aware of that. It's hard. It's really hard. I think, and especially when people are under anesthesia, the commentary, and when I hear it again, I speak up as much as I can, but it's just it's so rampant. I think it's, it's shifting in the right direction. I think people are becoming More aware, but especially because, you know, like in centers where there are bariatric centers of excellence, people are better trained in making sure they're kind to the, to kind and understanding. And as you know, a lot of the healthcare force has the disease as well. And, I think having it obviously makes people a lot more attuned to how they speak around other folks and commiserating and saying this is a difficult disease process and we want to be sensitive to you. Yeah, I like that we're having this conversation because I think it's It's fascinating that we need additional training and understanding and what we're looking out for and thinking, Oh my gosh, I maybe said that all the time. I didn't even realize how it was perceived and that there's really always work to do in this area. Not, not only with weight, but race and, and health disparity, just all of it. It's really all, honestly, it's all related. And it's fascinating that we really, there's no like getting this right. It's that we need to keep, we need to keep looking at what, how are we acting as this, you know, kind of looking at it from all the different angles. Yeah. It's definitely a hard conversation. It is. Everyone's much more aware of gender and race discrimination now, but, obesity bias is alive and well, and it's just not as, it's not as scrutinized yet. That's getting there. Good. Yeah, I feel we will get there. Exactly. I feel like we, I can't believe we don't have laws for these things. It will come people. So tell, tell everybody, how can they find you? Tell us what the name of your clinic is. Like, how can people find your clinic? Tell us a little bit more about that. Awesome. Yes. So I'm my, you can find me on my website, which is www. qualityoflifemd. com. And that's the name of the business is quality of life physician weight management. It's a little bit of a mouthful, but I really. Wanted to focus on helping people achieve their quality of life and their goals. It's so descriptive. I feel like it's literally a hundred percent what it is. What a great name. Yeah. And I've had people say, Oh, maybe you should shorten the name. Yeah. But I like it. It tells you what I want to, I want you to know about it. And that is my goal is for people to, like I said, to achieve that quality of life and to live with the best way they can not live with carrying around, poor health that that's dragging them down literally. And I'm sorry. No, go ahead. That's that's about it. I'm thanks to Dr. Dr. Matea. I am now on TikTok as well. I'm being dragged kicking and screaming into the 21st century and my daughter helps me a little bit with that and gotten back on Instagram. And I do have a Facebook page as well, which I am intermittently on. So I'm on all those things. But my website is the best way to find me. I am licensed in Florida so anyone who lives in Florida, I can work with you via telehealth. Telehealth is a great way to see people though, so, and it's very convenient for patients. I really love, you know, something I wanted to bring up that we had talked about. This was before, like when we had talked other times. Just the heart that you've gone into this with where you saw things that problems that had occurred from this, but how you really wanted to help people before they had to face stuff like that. Right. And I think that none of us want to have problems surgically because of our weight. And if we're able to work on things prior, like quality of our life to go up, things like that. I would love to not worry that if I get in a car accident that I'm not going to be an anesthesia problem. Right. Like that, I would like that to not be a concern that I have. And so it's, it's just incredible. I, I really think that your heart is in such a good place. And I'm so glad that you're on here. And hopefully if anyone is in Florida, you know, a great physician to contact. Yeah. Thank you. I appreciate that. Yeah. It's about, yeah. Trying to keep, worked in hospitals for a long time, just like you did. And they are, imperfect institutions. I'll just leave it at that. Anything you can do to support. stay out of the hospital will benefit you. One of my other goals is to help people stay out of the hospital. So you don't need to go in for heart care. You don't need to go in for, complications of diabetes or complications of kidney disease or any of those things that are, or cancer, you know, cancer is related to obesity. You don't even have to go in for cancer care. If you can stay in the hospital, it's a good thing. Thank you so much for coming on today. And. teaching us all so much and just thanks again. Thank you. It was really fun. I, I really appreciate the opportunity to come on. I love to try to help educate people and help people. So thank you very much.