Nachi: Nah! Just some definitions, nothing personal!

Jeff: Whatever, back to the article… Obesity is associated with an increased risk of hypertension, hyperlipidemia, and diabetes. Rising levels of obesity and associated co-morbidities also lead to an increase in bariatric procedures, and thereby ED visits!

Nachi: One study found a 30-day ED utilization rate of 11% for those undergoing bariatric surgery with an admission rate of 5%. Another study found a 1-year post Roux-en-y ED visit rate of 31% and yet another found that 25% of these patients will require admission within 2 years of surgery.

Jeff: Well that’s kind worrisome.

Nachi: It sure is, but maybe even more worrisome is the rising prevalence of obesity. While it was < 15% in 1990, by 2016 it reached 40%. That’s almost half of the population. Additionally, back in 2010, it was estimated that 6.6% of the US population had a BMI> 40 – approximately 15.5 million adults!!

Jeff: Admittedly, the US numbers look awful, and honestly are awful, but this is a global problem. From the 80’s to 2008, the worldwide prevalence of obesity nearly doubled!

Nachi: Luckily, bariatric surgical procedures were invented and honed to the point that they have really shown measurable achievements in sustained weight loss. Along with treating obesity, these procedures have also resulted in an improvement in associated comorbidities like hypertension, diabetes, NAFLD, and dyslipidemia.

Jeff: A 2014 study even showed an up to 80% reduction in the likelihood of developing DM2 postoperatively at the 7-year mark.

Nachi: Taken all together, the rising rates of obesity and the rising success and availability of bariatric procedures has led to an increased number of bariatric procedures, with 228,000 performed in the US in 2017.

Jeff: And while it’s not exactly core EM, we’re going to briefly discuss indications for bariatric surgery, as this is something we don’t often review even in academic training programs.

Nachi: According to joint guidelines from the American Society for Metabolic and Bariatric Surgery, the American Association of Clinical Endocrinologists, and The Obesity Society, there are three groups that meet indications for bariatric surgery. The first is patients with a BMI greater than or equal to 40 without coexisting medical problems. The second is patients with a BMI greater than or equal to 35 with at least one obesity related comorbidity such as hypertension, hyperlipidemia, or obstructive sleep apnea. And finally, the third is patient with a BMI of 30-35 with DM or metabolic syndrome though current evidence is limited for this group.

Jeff: Based on the obesity numbers, we just cited – it seems like a TON of people should be eligible for these procedures. Which again reiterates why this is such an important topic for us as EM clinicians to be well-versed in.

Nachi: As far as types of procedures go – while there are many, there are 3 major ones being done in the US and these are the lap sleeve gastrectomy, Roux-en-Y gastric bypass, and lap adjustable gastric banding. In 2017, these were performed 60%, 18%, and 3% of the time.

Jeff: And sadly, no two procedures were created alike and you must familiarize yourself with not only the procedure but also its associated complications.

Nachi: So we have a lot to cover! overall, these surgeries are relatively safe with one 2014 review publishing a 10-17% overall complication rate and a perioperative 30 day mortality of less than 1%.

Jeff: Before we get into the ED specific treatment guidelines, I think it’s worth discussing the procedures in more detail first. Understanding the surgeries will make understanding the workup, treatment, and disposition in the ED much easier.

Nachi: Bariatric procedures can be classified as either restrictive or malabsorptive, with restrictive procedures essentially limiting intake and malabsorptive procedures limiting nutrient absorption. Not surprisingly, combined restrictive and malabsorptive procedures like the Roux-en-y gastric bypass tend to be the most effective.

Jeff: Do note, however that 2013 guidelines do not recommend one procedure over another and leave that decision up to local surgical expertise, patient specific risk factors, and treatment goals.

Nachi: That’s certainly an important point for the candidate patient. Let’s start by discussing the lap gastric sleeve. In this restrictive procedure, 80% of the greater curvature of the stomach is excised producing early satiety and weight loss from decreased caloric intake. This has been shown to have both low mortality and a low overall rate of complications.

Jeff: Next we have the lap adjustable gastric band. This is also a restrictive procedure in which a plastic band is placed laparoscopically around the fundus leaving behind a small pouch that can change in size as the reservoir is inflated and deflated percutaneously.

Nachi: Unfortunately this procedure is associated with a relatively high re-operation rate – one study found 20% of patients required removal or revision.

Jeff: Even more shockingly, some series showed a 52% repeat operation rate.

Nachi: 20-50% chance of removal, revision, or other cause for return to ER - those are some high numbers. Finally, there is the roux-en-y gastric bypass. As we mentioned previously this is both a restrictive and a malabsorptive procedure. In this procedure, the duodenum is separated from the proximal jejunum, and the jejunum is connected to a small gastric pouch. Food therefore transits from a small stomach to the small bowel. This leads to decreased caloric intake and decreased digestion and absorption.

Jeff: Those are the main 3 procedures to know about. For the sake of completeness, just be aware that there is also the biliopancreatic diversion with or without a duodenal switch, as well as a vertical banded gastroplasty. The biliopancreatic diversion is used infrequently but is one of the most effective procedure in treating diabetes, though it does have an increased risk of complications. Expect to see this mostly in those with BMIs over 50.

Nachi: Now that you have a sense of the procedures, let’s talk complications, both general and specific.

Jeff: Of course, it should go without saying that this population is susceptive to all the typical post-operative complications such as venous thromboembolic disease, atelectasis, pneumonia, UTIs, and wound complications.

Nachi: Because of their typical comorbidities, CAD and PE are still the leading causes of mortality, especially within the perioperative period.

Jeff: Also, be on the lookout for self-harm emergencies as patients with known psychiatric disorders are at increased risk following bariatric surgery.

Nachi: Surgical complications are wide ranging and can be grouped into early and late complications. More on this later…

Jeff: Nutritional deficiencies are common enough to warrant pre and postoperative screening. Thiamine deficiency is one of the most common deficiencies. This can manifest within 1-3 months of surgery as beriberi or later as Wernicke encephalopathy. Symptoms of beriberi include peripheral neuropathy, ataxia, muscle weakness, high-output heart failure, LE edema, and respiratory distress.

Nachi: All of that being said, each specific procedure has it’s own unique set of complications that we should discuss. Let’s start with the sleeve gastrectomy.

Jeff: Early complications of sleeve gastrectomy include staple-line leaks, strictures, and hemorrhage. Leakage from the staple line typically presents within the first week, but can present up to 35 days, usually with fevers, tachycardia, abdominal pain, nausea, vomiting sepsis, or peritonitis. This is one of the most serious and dreaded early complications and represents an important cause of morbidity with an incidence of 3-7%.

Nachi: Strictures commonly occur at the incisura angularis of the remnant stomach and are usually due to ischemia, leaks, or twisting of the gastric pouch. Patients with strictures usually have n/v, reflux, and intolerance to oral intake.

Jeff: Hemorrhage occurs due to erosions at the staple line, resulting in peritonitis, hematemesis, or melena.

Nachi: Late complications of sleeve gastrectomies include reflux, which occurs in up to 25% of patients, and strictures, which lead to epigastric discomfort, nausea, and dysphagia.

Jeff: I’m getting reflux and massive heartburn just thinking about all of these complications, or the tacos i just ate…. Next we have the Roux-en-Y bypass.

Nachi: Early complications of the Roux-en-Y Gastric Bypass include anastomotic or staple line leaks, hemorrhage, early postoperative obstruction, and dumping syndrome.

Jeff: Leak incidence ranges from 1-6%, usually occurring at the gastro-jejunostomy site. Patients typically present within the first 10 days with abdominal pain, nausea, vomiting, and the feeling of impending doom. Some may present with isolated tachycardia while others may present with profound sepsis – tachycardia, hypotension, and fever.

Nachi: Similar to the sleeve, hemorrhage can occur both intraperitoneally or intraluminally. This may lead to hematemesis or melena depending on the location of bleeding.

Jeff: Early obstructions usually occur at either the gastro-jejunal or jejuno-jejunal junction. Depending on the location, patients typically present either within 2 days or in the first few weeks in the case of the gastro-jejunal site.

Nachi: If the obstruction occurs in the jejuno-jejunostomy site, this can cause subsequent dilatation of the excluded stomach and lead to perforation, which portends a very poor prognosis.

Jeff: Next, we have dumping syndrome. This has been seen in up to 50% of Roux-en-Y patients.

Nachi: Early dumping occurs within 10-30 minutes after ingestion. As food rapidly empties from the stomach, this leads to distention and increased contractility, leading to nausea, abdominal pain, bloating, and diarrhea. This usually resolves within 7-12 weeks.

Jeff: Moving on to late complications of the roux-en y - first we have marginal ulcers. Peptic ulcer disease and diabetes are risk factors and tobacco use and NSAIDs appear to increase your risk. In the worse case, they present with hematemesis or melena.

Nachi: Internal hernias, intussusception, and SBOs are also seen after Roux-en-y gastric bypass. Patients with internal hernias usually present late in the postoperative period following significant weight loss.

Jeff: Most studies cite a rate of 1-3% for internal hernias, with mortality up to 50% if there is strangulation.

Nachi: And unfortunately for us on the front lines, diagnosis can be challenging. Presenting symptoms may be vague and CT imaging may be negative when patients are pain free, thus laparoscopy may be needed to definitively exclude an internal hernia.

Jeff: Strictures may occur both during the early and late period. Most are minor, but significant strictures may result in obstruction.

Nachi: Trocar site hernias and ventral hernias are also late complications, usually found after significant weight loss.

Jeff: Cholelithiasis is another very common complication of bypass surgery, occurring in up to one third of patients, usually occurring during a peak incidence period between 6-18 months.

Nachi: For this reason, the current recommendation is that patients undergoing bypass be placed on ursodeoxycholic acid for 6 months preventatively.

Jeff: Some even go as far as to recommend prophylactic cholecystectomy to prevent complications, but as of 2013, the recommendation was only ‘to consider’ it.

Nachi: Nutritional deficiencies are also common complications. Vitamin D, B12, Calcium, foate, iron, and thiamine deficiencies are all well documented complications. Patients typically take vitamins postoperatively to prevent such complications.

Jeff: And next we have late dumping syndrome, which is far more rare than the last two complications. In late dumping syndrome, 1-3 hours after a meal, patients suffer hypoglycemia from excessive insulin release following the food bolus entering the GI tract. Symptoms are those typical of hypoglycemia.

Nachi: Lastly, let’s talk about complications of lap adjustable gastric band surgery. In the early post op period, you can have esophageal and gastric perforations, which typically occur during balloon placement. Patients present with abd pain, n/v, and peritonitis. These patients often require emergent operative intervention.

Jeff: The band can also be overtightened resulting in distention of the proximal gastric pouch. Presenting symptoms include abd pain with food and liquid intolerance and vomiting. Symptoms resolves once the balloon is deflated. The band can also slip, allowing the stomach to move upward and within the band. This occurs in up to 22% of patients and can cause strangulation. Presentation is similar to bowel ischemia.

Nachi: Later complications include port site infections due to repeated port access. The infection can spread into connector tubing and the peritoneal cavity causing systemic symptoms. Definitely start antibiotics and touch base with the bariatric surgeon.

Jeff: The connector can also dislodge or rupture with time. This can present as an arrest in weight loss. It’s diagnosed by contrast injection into the port. Of note, this complication is less common due to changes in the technique used.

Nachi: Much like early band slippage and prolapse, patients can also experience late band slippage and prolapse after weeks or months. In extreme cases, the patients can again have strangulation and symptoms of bowel ischemia. More mild cases will present with arrest in weight loss, reflux, and n/v.

Jeff: The band can also erode and migrate into the stomach cavity. If this occurs, it usually happens within 2 years of the initial procedure with an incidence of 4-11%. Presenting symptoms here include epigastric pain, bleeding, and infections. You’ll want to obtain emergent imaging if you are concerned.

Nachi: And lastly there are two rare complications worth mentioning from any gastric bypass surgery. These are nephrolithiasis, possibly due to increased urinary oxalate excretion or hypocitraturia, and rhabdomyloysis.

Jeff: That was a ton of information but certainly valuable as most EM clinicians, even ones in practice for decades, are unlikely to have that depth of knowledge on bariatric surgery.

Nachi: And truthfully these patients are complicated. Aside from the pathologies we just discussed, you also have to still bear in mind other abdominal conditions unrelated to their surgery like appendicitis, diverticulitis, pyelo, colitis, hepatitis, pancreatitis, mesenteric ischemia, and GI bleeds.

Jeff: Moving on to my favorite - prehospital care - as always, ABCs first. Consider IV access and early IV fluids in those at risk for dehydration and intra-abdominal infections. In terms of destination, if it’s feasible and the patient is stable consider transport directly to the nearest bariatric center - early efforts up front will really expedite patient care.

Nachi: Once in the ED, you will want to continue initial stabilization. Special considerations for the airway include a concern for a difficult airway due to body habitus. Make sure to position appropriately and preoxygenate the patients if time allows. Keep the patient upright for as long as possible as they may desaturate quickly when flat.

Jeff: We both routinely raise the head of the bed for all of our intubations. This is ever more important for your obese patients to help maximize your chance of first pass success without significant desaturation.

Nachi: And though I’m sure we all remember this from residency, it’s worth repeating: tidal volume settings on the ventilator should be based on ideal body weight, not actual body weight. At 6 to 8 mL/kg.

Jeff: Tachycardic patients should make you concerned for hypovolemia 2/2 dehydration, sepsis, leaks, and blood loss. Consider performing a RUSH exam (that is rapid ultrasound for shock and hypotension) to identify the cause. A HR > 120 with abdominal pain should make you concerned enough to discuss urgent ex-lap with the surgeon to evaluate for the post op complications we discussed earlier.

Nachi: If possible, obtain a view of the IVC also while doing your ultrasound to assess for volume status. But bear in mind that ultrasound will undoubtedly be more difficult if the patient has a large body habitus, so don’t be disappointed if you’re not getting the best views.

Jeff: Resuscitation should be aimed at early fluid replacement with IV crystalloids for hypovolemic patients and packed RBC transfusions for patients presumed to be unstable from hemorrhage. No real surprises there for our listeners.

Nachi: Once stabilized, gather a thorough history. In addition to the usual questions, ask about po intolerance, early satiety, hematemesis, and hematochezia. Definitely also gather a thorough surgical history including name of procedure, date, known complications post op, and name of the surgeon.

Jeff: You might also run into “medical tourism” or global bariatric care. Patients are traveling overseas to get their bariatric care more and more frequently. Accreditation and oversight is variable in different countries and there isn’t a worldwide standard of care. Just an important phenomenon to be aware of in this population.

Nachi: On physical exam, be sure to look directly at the belly, making note of any infections especially near a port-site. Given the reorganized anatomy and extent of soft tissue in obese patients, don’t be reassured by a benign exam. Something awful may be happening deeper.

Jeff: This naturally brings us into diagnostic testing. Not surprisingly, labs will be helpful in these patients. Make sure to check abdominal labs and a lipase. Abnormal LFTs or lipase may indicate obstruction of the biliopancreatic limb in bypass patients.

Nachi: A lactic acid level will help in suspected cases of hypoperfusion from sepsis or bowel ischemia.

Jeff: And as we mentioned earlier, these patients are often at risk for ACS given their comorbidities. Be sure to check a troponin if you suspect cardiac ischemia.

Nachi: If concerned for sepsis, draw blood cultures, and if concerned for hemorrhage, be sure to send a type and screen. Urinalysis and urine culture should be considered especially for early post op patients, symptomatic patients, or those with GU complaints.

Jeff: And don’t forget the urine pregnancy test for women of childbearing age, especially prior to imaging.

Nachi: Check an EKG immediately after arrival for any patient that may be concerning for ACS. A normal ekg of course does not rule out a cardiac cause of their presentation.

Jeff: As for imaging, plain radiographs certainly play a role here. For patients with respiratory complaints, check a CXR. In the early postoperative period, there is increased risk for pneumonia.

Nachi: Unstable patients with abdominal pain will benefit from an emergent abdominal series, which may show free air under the diaphragm, pneumatosis, air-fluid levels, or even dilated loops of bowel.

Jeff: Of course don’t forget that intra abd air may be seen after laparoscopic procedures depending on how recently the operation was performed.

Nachi: Plain x-ray can also help diagnose malpositioned or slipped gastric bands. But a negative study doesn’t rule out any of these pathologies definitively, given the generally limited sensitivity and specificity of x-ray.

Jeff: You might also consider an upper GI series. Emergent uses include diagnosis of slipped or prolapsed gastric bands as well as gastric or esophageal perforations. Urgent indications include diagnosis of strictures. These can also diagnose gastric band erosions and help identify staple-line or anastomotic leaks in stable patients.

Nachi: However, upper GI series might not be easy to obtain in the ED, so it’s often not the first test performed.

Jeff: This brings us to the workhorse for diagnostic evaluation. The CT. Depending on suspected pathology, oral and/or IV contrast will be helpful. Oral contrast can help identify gastric band erosions, staple-line leaks, and anastomotic leaks. Leaks can be identified in up 86% of cases with oral contrast.

Nachi: CT will also help diagnose internal hernias. You might see the swirl sign on CT, which represents swirling of the mesenteric vessels. This is highly predictive of an internal hernia, with a sensitivity of 78-100% and specificity of 80-90% according to at least two studies.

Jeff: While CT is extremely helpful in making this diagnosis, note that it may be falsely negative for internal hernias. A retrospective review showed a sensitivity of 76% and a specificity of 60%. It also showed that 22% of patients with an internal hernia on surgical exploration had a negative CT in the ED. Another study found a false negative rate of 32%. What does all this mean? It likely means that a negative study may still necessitate diagnostic laparoscopy to rule out an internal hernia.

Nachi: While talking about CT, we should definitely mention CTA for concern of pulmonary embolism. In order to limit contrast exposure, you might consider doing a CTA chest and CT of the abdomen simultaneously.

Jeff: Next up is ultrasound. Ultrasound is still the first-line imaging modality for assessing the gallbladder and for biliary tract disease. And as we mentioned previously, ultrasound should be considered for your RUSH exam and for assessing the IVC.

Nachi: We also should discuss endoscopy, which is the test of choice for diagnosing gastric band erosions. Endoscopy is also useful for evaluating marginal ulcers, strictures, leaks, and GI bleeds. Endoscopy additionally can be therapeutic for patients.

Jeff: When treating these patients, attempt to contact the bariatric surgeon for guidance as needed. This shouldn’t delay imaging however.

Nachi: For septic patients, make sure your choice of antibiotics covers intra-abdominal gram-negative and anaerobic organisms. Port-site infections require gram-positive coverage to cover skin flora. Additionally, give IV fluids, blood products, and antiemetics as appropriate.

Jeff: Alright, so this month, we also have 2 special populations to discuss. First up, the kids.

Nachi: Recent estimates from 2015-2016 put the prevalence of obesity of those 2 years old to 19 years old at about 19%. As obese children are at higher risk for comorbidities later in life and bariatric surgery remains one of the best modalities for sustained weight loss, these surgical procedures are also being done in children.

Jeff: Criteria for bariatric surgery in the adolescent population is similar to that of adults and includes a BMI of 35 and major comorbidities (like diabetes or moderate to severe sleep apnea) or patients with a BMI 40 with other comorbidities associated with long term risks like hypertension, dyslipidemia, insulin resistance and impaired quality of life.

Nachi: Despite many adolescents meeting criteria, they should be referred with caution as the long term effects are unclear and the adolescent experience is still in its infancy with few pediatric specific programs.

Jeff: Still, the complication rate is low - about 2.3% with generally good clinical outcomes including improved quality of life and reducing or staving off comorbidities.

Nachi: Women of childbearing age are the next special population. They are at particular risk because of the unique caloric and nutrient needs of a pregnant mother.

Jeff: Pregnant women who have had bariatric surgery have an increased risk of perinatal complications including prematurity, small for gestational age status, NICU admission and low Apgar scores. However, these risks come with benefits as other studies have shown reduced incidence of pre-eclampsia, large for gestational age neonates, and gestational diabetes.

Nachi: 2013 guidelines from various organizations recommend avoiding becoming pregnant for at least 12-18 months postoperatively, with ACOG recommending a minimum of 2 years. Bariatric surgery patients who do become pregnant require serial monitoring for fetal growth and higher doses of supplemental folate.

Jeff: We also have 2 pretty cool cutting edge techniques to mention this month before getting to disposition.

Nachi: Though these are certainly not going to be done in the ED, you should be aware of two new techniques. Recently, the FDA approved 3 new endoscopic gastric balloon procedures in which a balloon is inflated in the stomach as a means of simulating a restrictive procedure. Complications include perforation, ulceration, GI bleeding, and migration with obstruction. As of now, they are only approved as a temporary modality for up to 6 months.

Jeff: And we also have the AspireAssist siphon, which was approved in 2016. With the siphon, a g tube is placed in the stomach, and then ⅓ of the stomach contents is drained 20 minutes after meals, thus limiting overall digested intake.

Nachi: Pretty cool stuff...

Jeff: Yup - In terms of disposition, decisions should often be made in conjunction with the bariatric surgical team. Urgent and occasionally emergent surgery is required for those with hemodynamic instability, anastomotic or staple line leaks, SBO, acute band slippage with dilatation of the gastric pouch, tight gastric bands, and infected port sites with concurrent intra abdominal infections.

Nachi: And while general surgeons should be well-versed in these complications should the patient require an emergent surgery, it is often best to stabilize and consider transfer to your local bariatric specialty facility.

Jeff: In addition to the need for admission for surgical procedures, admission should also be considered in those with dehydration and electrolyte disturbances, those with persistent vomiting, those with GI bleeding requiring transfusions, those with acute cholecystitis or choledococholithiasis, and those with malnutrition.

Nachi: Finally, patients with chronic strictures, marginal ulcers, asymptomatic trocar or ventral hernias, and stable gastric band erosions can usually be safely discharged after an appropriate conversation with the patient’s bariatric surgeon.

Jeff: Definitely a great time to do some joint decision making with the patient and their surgeon.

Nachi: Exactly. Let’s close out with some Key points and clinical pearls.

Jeff: Bariatric surgeries are being performed more frequently due to both their success in sustained weight loss and improvements in associated comorbidities.

Nachi: There is an increased risk of postoperative myocardial infarction and pulmonary embolism after bariatric surgery. There is also an increased risk of self-harm emergencies after bariatric surgery, mostly in patients with known psychiatric co-morbidities.

Jeff: Nutritional deficiencies can occur following bariatric surgery, with thiamine deficiency being one of the most common. Look for signs of beriberi or even Wernicke encephalopathy.

Nachi: Staple-line leaks are an important cause of postoperative morbidity. Patients often present with abdominal pain, vomiting, sepsis, and peritonitis.

Jeff: Strictures can also present postoperatively and cause reflux, epigastric discomfort, and vomiting.

Nachi: Intraperitoneal or intraluminal hemorrhage is a known complication of bariatric surgery and may present as peritonitis or with hematemesis and melena.

Jeff: After significant weight loss, internal hernias with our without features of strangulation are a late complication.

Nachi: Late dumping syndrome is a rare complication following Roux-en-Y bypass occurring months to years postoperatively. It presents with hypoglycemia due to excessive insulin release.

Jeff: Esophageal or gastric perforation are early complications of adjustable gastric band surgery. These patients require emergent surgical intervention.

Nachi: Overtightening of the gastric band results in food and liquid intolerance. This resolves once the balloon is deflated.

Jeff: Late complications of gastric band surgery include port-site infections, connector tubing dislodgement or rupture, band slippage or prolapse, and band erosion with intragastric migration.

Nachi: Given the myriad of possible bariatric surgeries, emergency clinicians should be cognizant of procedure-specific complications.

Jeff: Consider obtaining a lactic acid level for cases of suspected bowel ischemia or sepsis.

Nachi: Endoscopy is the best method for diagnosing and treating gastric band erosions.

Jeff: Septic patients should be treated with antibiotics that cover gram-negative and anaerobic organisms. Suspected port site or wound infections require gram positive coverage.

Nachi: Pregnant patients who previously had bariatric surgery are at risk for complications from their prior surgery as well as pregnancy-related pathology.

Jeff: A plain radiograph may be useful in unstable patients to evaluate for free air under the diaphragm, pneumatosis, air-fluid levels, or dilated loops of bowel.

Nachi: CT of the abdomen and pelvis is the mainstay for evaluation. Oral and/or IV contrast should be considered depending on the suspected pathology.

Jeff: Have a low threshold for emergent surgical consultation for ill-appearing, unstable, or peritonitic patients.

Nachi: So that wraps up Episode 30!

Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%.

Nachi: And the address for this month’s cme credit is ebmedicine.net/E0719, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net with any comments or suggestions. Talk to you next month!