Core Bariatrics
Episode 21: How Sleep Affects Weight with Dr. Ethan Emmons
Unlock the secrets of a good night's sleep and its profound impact on weight management with sleep medicine wizard Dr. Ethan Emmons. Our latest episode traverses the shadowy links between sleep disorders like apnea and weight gain, especially in the bariatric world. Dr. Emmonss, with his rich background in pulmonary and critical care, decodes the body's adrenaline-laced response to sleep interruptions, illuminating how they can sabotage blood sugar and fat regulation. Whether you're a health aficionado or a medical professional, this conversation packs a wealth of insights, demystifying the complexities of sleep and weight for a healthier you.
Discover the transformative power of sleep hygiene and its pivotal role in prepping patients for bariatric surgery in our compelling dialogue. Dr. Emmons dissects the nuts and bolts of at-home sleep apnea testing, providing reassurance with non-invasive techniques that pave the way for better health. We lay out a practical blueprint for enhancing sleep quality, from screen-time curfews to curbing caffeine, guided by recommendations from the American Academy of Sleep Medicine. These nuggets of wisdom aren't just theoretical; they're life-changing rituals that could lead to sweet dreams and even sweeter health outcomes.
Unlock the secrets of a good night's sleep and its profound impact on weight management with sleep medicine wizard Dr. Ethan Emmons. Our latest episode traverses the shadowy links between sleep disorders like apnea and weight gain, especially in the bariatric world. Dr. Emmonss, with his rich background in pulmonary and critical care, decodes the body's adrenaline-laced response to sleep interruptions, illuminating how they can sabotage blood sugar and fat regulation. Whether you're a health aficionado or a medical professional, this conversation packs a wealth of insights, demystifying the complexities of sleep and weight for a healthier you.
Discover the transformative power of sleep hygiene and its pivotal role in prepping patients for bariatric surgery in our compelling dialogue. Dr. Emmons dissects the nuts and bolts of at-home sleep apnea testing, providing reassurance with non-invasive techniques that pave the way for better health. We lay out a practical blueprint for enhancing sleep quality, from screen-time curfews to curbing caffeine, guided by recommendations from the American Academy of Sleep Medicine. These nuggets of wisdom aren't just theoretical; they're life-changing rituals that could lead to sweet dreams and even sweeter health outcomes.
Welcome to Core Bariatrics podcast hosted by Bariatric surgeon Dr Maria Iliakova and TMA LaCose, bariatric coordinator and the patient herself. Our goal is building and elevating our community. The Core Bariatric podcast does not offer medical advice, diagnosis or treatment. On this podcast, we aim to share stories, support and insight into the world beyond the clinic. Let's get into it.
Speaker 2:Today we have with us an excellent medicine specialist from Iowa City originally, and he has over 31 years of experience in the medical field as a sleep doctor. He graduated from Uniform Services University of the Health Sciences in Bethesda, maryland. We met working together on Bariatric patients in Iowa City and he currently leads a sleep program at Bell and Health in Green Bay, wisconsin. I'd really like to welcome you to Dr Ethan Emmits.
Speaker 3:Yes, thank you. I appreciate it. I know both of you fairly well. Yeah, I'm excited.
Speaker 1:I'm going to be telling the audience that you had bossed me around for a solid I think it was two years or so while I worked in the clinic there, but I loved working with you and learned a lot.
Speaker 3:Thank, you, I will mirror that.
Speaker 2:I didn't get to work with you for as long, but I really admire how much you helped guide people through the process that was otherwise really intimidating. So I'm really grateful and excited that you're with us today to talk about sleep and how it affects everything. Well, tell us first how did you even get involved in sleep medicine? What was the draw for you?
Speaker 3:Actually my specialty was pulmonary and critical care, icu medicine, and I have to throw a shout out to one of my someone who was a fellow with me at the time, chris Fry, and we were at a critical care fellowship and he was going to go out and do sleep as well and I was, ah, I don't want to do sleep. We're young, we're all about the ICU, and I'm like, why would I want to do sleep? And at the time I didn't know much about it. So I'm like, oh, it's probably going to be boring. But he made a very good point to me. He actually said to me he goes, when you're 50 years old, you want to be up all night in the ICU, and that, right, there was it.
Speaker 3:So that's what got me started in sleep. And then, once I got into it, you realize it's actually really interesting and there's a lot of misconception in sleep Folks. They read a lot on the internet, which is necessarily true. Once you get into it, it's really interesting. I continue to do pulmonary up to about 2018. And then my sleep practice there in Iowa City had gotten so busy, went to sleep only, and I have to admit it is an excellent job for later in your career. It's important in the bariatric population to know about sleep because it has such a significant impact on things and a lot of times patients are like, hey, if I have sleep apnea and I have bariatric surgery, what's going to happen? And things like that. So that's what I spent a lot of time talking to people about.
Speaker 2:So let's dive into that a little bit. Sleep apnea is something that I think a lot of people have heard the term but may not really know what that is. Can you start off by telling us what is sleep apnea?
Speaker 3:Yeah, I'm going to give it a very specific term. This is the way I talk to patients. I've always my dad had a sixth grade education, so that's the level I generally try to explain things and basically sleep apnea is a mechanical problem. So it really is how much room back here do you have in the back of your throat? Now, some of that is genetic, some of that is as a weight component.
Speaker 3:Sleep apnea is at night. You're sleeping and because of relaxation and the muscles in the back of our throat, the back of your throat again deep down, closes and it obstructs and you're choking, literally choking. And as I say to patients, if you're choking and sitting there in front of me in my office, you're gonna panic. Right, it does the same thing. Brain says while you're sleeping, brain says I'm choking. Your brain turns on awake for two seconds, just enough time to open things up so you can begin, and then your brain goes right back to sleep A little while later. 30 seconds, one minute, five minutes, whatever it is, do it again. You choke, panics. Brain wakes up, opens things up, go back to sleep. So basically, people sleep apnea at the brain level. They're doing this kind of awake asleep. Awake asleep. If you're not enough, they're not getting restful sleep.
Speaker 3:And then there's the all sorts of the physiologic things that happen, because when you're choking it's a panic reaction, so you actually have a release of something called adrenaline, epinephrine, so people spike their blood pressure. That can cause high blood pressure, higher risk of stroke, heart problems, makes reflux worse. It also contributes to wake because when you have Drenaline surge you also actually spike cortisol and so what happens is having a spike of your blood sugars. And Whenever you take adrenaline and people have heard of the fight or flight response and you combine that with extra blood blood glucose, blood sugar the body turns it into fat. People are just making fat and I saw it all the time. People come in frustrated. I Work out, I do all this stuff not losing any weight, but you can do all the right things all day, but if you're choking all night and making fat all night, not gonna have any and you're not gonna make any progress.
Speaker 3:So that's one of the things about sleep apnea is it actually can cause weight gain and then the vicious circle the more weight you gain, the worse you sleep apnea, the more weight you're gonna gain. So it plays a role in that and even just disrupted sleep in general. Aside from sleep, apnea plays a role the hormones that regulate our appetite Grayland and leptin or what their names are. They're basically disrupted when people are sleep deprived and it actually Triggers people's appetite. So that's why during the night, when people have trouble sleeping, if they get up during the night they want to eat. It's because there's a disruption in that and Unfortunately it's the also. Not only do they what, do they want to eat, that sweet, high, sweet, salty, high-carb foods. So all sorts of things and I don't want to get into much into the, the technical, but there's sleep plays a huge role and just weight in general, certainly in the bariatric population.
Speaker 1:But also when you are getting that in interrupted sleep, your body is waking up a little bit, so you get tired throughout the day, which is going to cause you to not want to work out. Not want to, you know, do much, or you're drinking all the caffeine to try to stay awake. But sleepiness during the day is another thing. With sleep apnea, that is another thing that's gonna hinder losing weight.
Speaker 3:It's been study. We know that people who have sleep apnea or have disruptive sleep for other reasons actually exercise less. So that's actually been looked at. So you're a hundred percent.
Speaker 2:That's pretty fascinating because I don't think a lot of people know that sleep apnea or disruptive sleep can actually cause Weight gain. I think people realize that it may stop people from being able to lose weight, but that's pretty fascinating that you can actually even cause weight gain and, like you said, be put on this cycle as a result.
Speaker 3:Yes, absolutely can gain weight. Now Maybe I'm jumping ahead a little. You know I get the question all the time. Is okay, I sleep and I'm getting bariatric surgery as I Fafnina go away.
Speaker 1:No, I am proof of that. No, because my anatomy it does not yep. So I am getting my teeth fixed to hopefully widen my palate, and all of that because, yes, I know I still have sleep apnea. I'm one of the unlucky ones.
Speaker 3:Yeah, it's about anatomy. So this is what I tell folks because they'll ask. First thing They'll ask is how does weight gain playing the sleep apnea? As I said before, sleep apnea is mechanical tongue size, tongue position. How much room did mom and dad give you back there? And so some, no matter what they weigh, they got bad anatomy, they're gonna have sleep apnea, it doesn't matter. But there's other people who might one way Okay, they don't have a lot of extra room, but they're actually okay. But what happens when we gain weight? Our tongues actually get bigger. Our tongue become infiltrated with fat. They get bigger. There are fat pads in the back of the throat. That actually expands. The folks, the unlucky ones, I think, where it's about hey, use, got bad anatomy, it's not gonna matter what you weigh yeah they're still gonna have sleep apnea, even after their.
Speaker 2:So it sounds like, basically, the less space there is in your mouth and your palate, their higher risk for sleep apnea.
Speaker 3:Absolutely.
Speaker 2:Yeah, and whether that less space comes from anatomy, comes from being overweight and all the contributing factors or a combination Depends on the person, but that the extra weight is typically not helping the situation. Would that be the right assessment?
Speaker 3:Oh, yeah, absolutely my rule of thumb. I would tell the patients certainly the patients that you all were sending me would be, if you, if they had mild, the moderate sleep apnea, it's probably gonna go away. It really is going away. But if they came with very severe sleep apnea from the get-go, I tell him he'll get better. It may not be a severe that needs seep again. Maybe you could use something like a mouthpiece, but it's unlikely that it will resolve totally.
Speaker 1:So for our patients you always recommended, after they probably level out with their weight loss, to get retested.
Speaker 3:But it would depend on how severe their sleep apnea was now mild sleep apnea, 5 to 15 times an hour you're choking. Moderate, 15 to 30. Over 30 severe my rule of thumb, and the rule of thumb that the American Academy of Medicine uses, is if it's a 10 to 12 and above, I would retest. If it was 10 or under and and they had a significant amount of weight loss, it's gonna be gone. We could tell when I did tell the patients who just wanted to know, which is fine, but if you're really From the start, it's gonna go away. If you have significant weight loss, anyone who started with kind of that mild in the moderate range plus, I would retest them. And even if they were severe, I retest them because if they're severe and then now they're mild, that may change the treatment options.
Speaker 2:So we've talked a little bit about testing, but I'm actually really curious how testing works, because there have been such massive improvements in how we test. Can you talk a little bit about how that's changed over time and how that looks in your process?
Speaker 3:A lot of people heard of the traditional sleep study, which really hasn't changed, and since I've been doing With 40 years, you go there, stickies and wires everywhere and belts around your chest and we have audio and video and it sounds horrible and guess what it is? It is, but now we do home testing. Now the thing about a home sleep that people need to realize is it only tells me about one and that is sleep. There's a whole lot of other sleep disorders out there and that home test doesn't really help me with those. They need that overnight test.
Speaker 3:But if I'm looking just for sleep certainly bariatric problems that are being referring me to screening I just do a simple home test. You take it home, you wear it, bring it back the next day and they're actually pretty darn accurate. The home test is, that said, they are considered a screening test, so what does that mean? It means if it's positive, that helps me, I can believe that result. But if it's quote negative, there really is no such thing as a negative home test. The home test is that the tried and true, really the standard now for initial screening, and it's what insurance companies want us to do.
Speaker 2:And that just sounds so much more convenient for people, because I think a lot of people are intimidated as they go through the process of being evaluated for bariatric surgery and a lot of people used to. In practice, when I was a fellow, for instance, I just saw a lot of people's jaws or like their heart would sink. You could see it on their face. Oh no, I have to do this. And then in your program, I was so shocked because literally not a single person ever complained about the process, which was incredible.
Speaker 3:Part of it is I mostly being. My entire appointments are nothing but education. So education, non sleep, apnea, what's called sleep hygiene. But when I started to talk about testing, the very first thing I would say to them is so, just so you know, we're gonna start with a home test, but let me tell you about all the testing options and you could just see them. The relief. Frankly, it's because there's a lot of misinformation to the internet, a lot of preconceived misconceptions. The days of the alien mask long gone.
Speaker 1:Yes, that's how I got a lot of women to you would order their CPAP and they're just like I really don't think I can do this. I taught you. You were right across the hall from me and I did many times talk to women about. It. Is not this big barbaric mask anymore, it is as small as a little nasal cannula at that point. But you were talking about sleep hygiene and you are so into this, so talk about that, because, especially for people that can't get to sleep, yeah, it is one of my soapbox items is because I'm a firm believer and you gotta help yourself.
Speaker 3:And so the biggest is coming to the big keys when people come in and say, hey, I have insomnia, I can't sleep, and there's a couple keys that you gotta be sleepy before you even try to get into bed. The other one is the electronics, and this is what Tamia, I know, is alluding to on militants about the whole electronics. Yeah, you are, and what we're talking about is anything with a screen TV, phone, ipad, computer. These screens do a lot of things and, in the most simplistic terms, as they basically turn your brain on wide awake Power for your brain to go to sleep as you've turned off your TV or phone, and what happens is People, they turn everything off up, and then that they do.
Speaker 3:They later takes up to an hour for the brain to wind down, even if their circadian rhythm was trying to make him go to sleep and 10. And then again, as I said, with a warning, and they're, and so they start to get spun up. But then the people who say, oh, I have to have the TV on to fall, but they don't realize, even though the body can go to sleep eyes close. Nor and everybody knows them says they're sleeping. Their brain actually still paying off up to an hour as well. It's still awake, essentially.
Speaker 3:And so for those folks it's lost time, as I like to call it, and when someone comes in tells me how sleepy they are in the morning, while I'm getting six, seven hours of sleep. But if you lose it an hour because you're watching TV up to the point you go to bed, you're not getting six or seven hours of sleep.
Speaker 3:You're getting an hour less. And so bottom line is the official recommendations, american Academy sleep medicine is a one hour break from all electronic screens before going to bed. That's what it is. That is the official recommendation and there's real science behind that, as I talked about. And again, folks who say, hey, I got to have the TV on the fall, sleep this or that, that's great for you, but we're just recognize you're losing about an hour of sleep time at the brain level. The other one I always you guys are always are in tune with this caffeine we recommend no caffeine after two o'clock. Caffeine last ten hours. People don't realize how long caffeine hangs around. They don't realize that. And the other issue is that folks don't realize that caffeine actually suppresses your deep sleep, makes it harder to get into deep sleep and you need deep sleep to feel rested. All this light sleep we get during the night doesn't do anything to make you feel rested. You gotta get the good deep sleep and some dreaming sleep. And so I always get people and very proud of themselves, I took three red bulls to go right to sleep and Michael G. That's great, but it's impacting your sleep quality as well.
Speaker 3:Nicotine we say one hour break before going to bed is a stimulant. Alcohol is its own separate discussion we can have about that. The bottom short version is alcohol is a depressant initially. But the breakdown products of alcohol the liver breaks it down are very powerful stimulants. And so I get people say, yeah, I had to. I have a few drinks before bed, I go to sleep, fine, but boy, three, four, five hours later I'm flopping like a fish. Why?
Speaker 3:is that it's the breakdown products of the alcohol. Those are the some of the basic sleep hygiene things we talk about caffeine and none after two o'clock. Nicotine, an hour break, alcohol, certainly, as I talked about it, and really the one hour break from electronic screens. That's the big one, and it's always amazing how many people come back and say, yeah, I turned off the TV and it really made a difference. I'm like, yeah, it really does.
Speaker 2:Yeah, I'm not surprised, because I think that's the sleep hygiene is something we really struggle with because I think, especially in younger generations, we're so used to having the phone with us all the time to work for our families, for our friends, for all kinds of different connections. It's so common to just to scroll until you fall asleep, essentially. So it's a really it's in our patient population, even in the general public. I just really think that's a. That's tough to hear that you need an hour, yeah, yeah, yeah, and some people just ignore me and that's fine.
Speaker 3:They can do it they want. But yeah, there's plenty of people ignore me and again, I've been doing a long time. I am a little cranky and little and understand yeah sometimes they'll come back and keep complaining to me about how they can't fall asleep and I'm like did you turn your TV or put your phone down? No, and I can't help you.
Speaker 3:Yeah, you just stick to your guns, which I think in sleep medicine is a good thing, yeah, I'm just hey, I can't help you till you help yourself, yeah.
Speaker 3:So that's the one thing. One thing I did want to bring up real quick is because I know that you guys know I've put this out there before is patients who have sleep apnea, who are on CPAP and are getting bariatric surgery. The question comes up is hey, I've had my surgery, I've started to lose weight. Do I need to stay on my CPAP or can I just stop it? And there is, as you guys know, because I've mentioned it before, there is that one study out there that does show pretty convincingly that patients who have sleep apnea, who are on CPAP and stay on their CPAP for one year after they've had their surgery, actually lose more weight and have less weight gain back than those who stopped their CPAP early after their surgery prematurely. And it makes perfect physiologic sense because you have sleep apnea even if you've had bariatric surgery and you aren't getting treated. Guess what your body is going to be doing. You're going to be working all day to lose weight and then you're going to be making fat all night, just like before you had surgery.
Speaker 1:That's a good recommendation, yeah.
Speaker 3:So I'm looking. Yeah. So I tell folks hey, yeah, you're on CPAP. I know you don't, maybe your sleep apnea will go away Ultimately. Stay on the CPAP. And then down the road will test you six, nine, twelve months, depending on how fast your weight loss Journey. So that's one thing I do like to tell folks is Stay on that CPAP, because it actually probably helps you lose more weight versus those who don't.
Speaker 2:So that's a very important one for people to hear, I think, because a lot of folks Well don't really know what to expect in terms of timing, and so setting that one year expectation, I think, really puts people at ease, because it's not arbitrary, it's not oh, we want a torture, you want to stay on something just for the fun of it for a year, but it's quite literally to help you get the most out of the tool that you've decided to you.
Speaker 3:Exactly, if you're gonna go through having surgery because that's not anything anybody does lightly and and there's a whole bunch of other issues that come up with having bariatric surgery If you're gonna go through that, set yourself up for success, set yourself up to have the best possible outcome you can. And so I push people hey, just stay on the CPAP. Yep, nine, twelve months, I'll retest you and we'll see where you're at.
Speaker 2:So that's awesome. Yeah, I think that's a really good expectation to be setting for people. That's one of the most common questions we get, so Glad you're addressing it. On and in terms of the treatment options, actually, since you've been, you've mentioned a couple of times that the days of the alien mask are gone, where, yeah, yeah, the Darth Vader voice overnight or something. Yeah, what does that look like now for people and does it vary by severity? What does what kind of determines what treatment options are available?
Speaker 3:Yeah, if you have moderate to severe sleep apnea, your initial treatment is still CPAP. It really you've seen these things on TV and spire, which is not new and spire has been around probably 10 years Things like inspire and some of these other surgical implants that they talk about doing. Now those are second line. Those are for people who've tried CPAP the mask and machine and they struggled or it just didn't work for them. It wasn't effective for them. Then that can make them candidates for some of these implantable devices like inspire. Now everyone wants to know inspire is what is inspire? It's a pacemaker that's implanted surgically. Their wires are run to the back of the throat and at night you have a remote and you turn the Space maker on and you get electrical stimulation to the back, your throat turning. That helps keep the muscles activated to keep things open so you can breathe. Actually works pretty well. But again, it's a second line type thing after CPAP. So moderate, severe yeah, you're gonna end up on CPAP initially Mild is where you really have a lot of options. Some people still do CPAP, machine mask and I'll talk a little bit about that in a second.
Speaker 3:I'm a huge fan of these mouthpieces. They're called oral appliances, dental orthotics they have different names. They're actually a medical device there, so people think it's covered by dental insurance. No, it's covered by your medical insurance, including Medicare. But these are mouthpieces. They they fill your mouth pretty good, as I like to show people. But it's an upper. It's an upper and a lower. They're custom made to you by someone who does it, usually a dentist. They're custom made and what they do is they actually move your lower jaw a little bit forward. I'm talking millimeters here and and you guys have done CPR it's just like doing a chin lift.
Speaker 3:We do a chin lift to pull the jaw a little forward to open up the airway. When we're doing CPR. That's what these oral appliances do. They just move your lower jaw a little bit forward.
Speaker 3:Super effective and mild sleep apnea. I'm a huge fan of those. For mild sleep apnea. Occasionally positional therapy.
Speaker 3:Some people only have their sleep apnea usually on their back only and on their side. They're fine. And I got ways to keep you off your back. In the old days, 30 years ago, we'd say you go buy a tennis, tennis balls, take three tennis balls it's so many aligned on the back of a t-shirt. And guess what? Nobody sleeps with three, ten on three tennis balls. But it can be very effective for people who have no other reason to sleep on their backs. Some dude they have whatever hip pain, whatever it is. But positional therapy alone it can be beneficial. Sometimes weight loss alone, other than bariatric surgery. Isef sent a number of people to the medical weight loss program where we were at. So medical weight loss and people have mild sleep apnea is can be very effective. So not having to go through to the end of getting bariatric surgery.
Speaker 3:And now one of the interesting things, or exciting things, coming out there's been studies now about a pill to treat mild sleep apnea. It's in studies. It's gonna start its phase three study and I won't get into what that means, but it's been proven to be safe and effective and now they're doing large studies on this. It's a couple different medicines. I won't get into the details, but this will probably be on the market the next three to five years, a pill that has shown to be pretty effective for mild sleep apnea. So there's options and there's even more options coming. Again, I'm getting towards the end of my career. A lot of these things I won't probably deal with, but there's gonna be more options. In regards to CPAP the alien mass they had talked about the machines nowadays they're small, yeah, big, they are small. If you hear your machine is broken, everybody's worried about compressor sounds.
Speaker 3:I'm telling you, you hear your machine. You better take it back because it's broken. And as far as masks, yeah, there are still some that cover the nose and the mouth are like this there's some people that need that. There's someone cover the nose, there's some that just sit under the nose and, as Tammy mentioned, some that just go into the nose, and I don't have any sitting here in my home office, but that's actually shocking yeah yeah, I would think you have an armament of them in the back, but you know, yeah so, yeah, no, I have a, but they're in a box.
Speaker 3:I actually should have pulled them out. I just didn't think about it because, yes, tammy, I took them all when I left. Oh, that's funny. So that's why I had acquired them. I took them with me. But the point being is, yeah, the days of the alien mass, the compressor sounding machine, all those things are just long, long gone and, as Tammy knows, when I start somebody on CPAP, I would have a whole appointment where I would do nothing but go over, sleep CPAP with them, show them mass, showing them machine, tell them the key to doing it.
Speaker 3:And I'll tell you right now the key to doing well with CPAP. You have got to put it on every night and I could care less if it's an hour or two hours or three hours. You've put it on every night because it is as much a habit as it is anything else and it takes two weeks to develop a habit and I just can't tell you the number of patients would be like, yeah, I just put it on every night was only for a couple hours, but I put it on every night. And they'll tell me, yeah, after two, three weeks, suddenly I just got it and it started to stay on more and more. I tell folks I can help anybody it puts it on every night Can't help the person who tries twice a week.
Speaker 2:That's a powerful message to hear, because I do think a lot of the things that we do, we're offering tools and we're offering support and we're offering knowledge and expertise, but ultimately we can't be there 24 seven with people and it does require putting it in action. Do you find, when you have folks maybe that are struggling with compliance or strut, they're just struggling with getting it to done in their life, what kinds of things can help with that? I don't know if you've ever had people come to you and say this works, this doesn't.
Speaker 3:As far as CPAP, yeah, yeah, yeah, a lot of it is figuring out what works best for you. I'll tell you, one of the big messages is everybody knows the guy who says, oh, I use this mask and you should use this mask. No, you've got to find what works best for you. And the thing I tell folks is you got the two keys, you got to put it on every night and you've got to work the company you get the machine from to find the right mask for you. And it is common for people to go through two, three, four masks in the first couple of months before they figure out the one that's the one for them.
Speaker 3:And I tell them you've got to do two things. You got to put it on, but you've got to work with that company to get into the mask that you're comfortable with and what I like to wear, because I have CPAP, I have sleep apnea. Then we're in it 20, what? Four years? People always want to. They always ask me what do you use? And I'm like it doesn't matter what I use.
Speaker 1:You've got to find.
Speaker 3:You've got to find the mask that works for you, and so the big key is putting it on every night and finding the right mask. And I will tell you, if someone puts it on every night and they work to find the right mask, 98% of them do great they just do.
Speaker 1:Most of your parents or parents could gravy.
Speaker 2:Most of your patients were very compliant, for sure, because they got that education from you and they got that role and that approach of find the right fit for you, I think, really resonates with our audience, with our folks, because there is no one one size fits all strategy for any of this. So making sure that you take what you can into your own hands and you get help when you need it, I think that's a really powerful message coming from you.
Speaker 3:Oh yeah, like I said, everybody's different and so I tell that to folks. You've got to find your way in all this because everybody's different, and certainly with CPAP or any sleep problem you've got to put the work in. And I've often tell patients I'm there to guide you, I'm there to be your cheerleader when you come back to see me, but I can't come to your house and put your CPAP on you.
Speaker 2:And I used to tell folks all the time.
Speaker 3:You know what I said. Hey, I stopped going to people's houses and moving their TVs out of the bedroom a few years ago. I can't help you if you don't help yourself.
Speaker 2:That's fair, that's fair and, on that note, I think that's probably a great note for us to wrap up the episode. But yeah, dr Emons, I'm just so grateful to you because such incredible care of the patients that we got to work on together I thought that was super remarkable. You were such a great communicator, not just with your patients but also with us, and I just really want to commend you for the kind of care and the kind of compassion that you show, because it really makes a tremendous difference and even for me who's a younger surgeon, and I just I'm so grateful for working with you.
Speaker 1:Yes, I appreciate that. I am too, even though if you were cranky and mad at me sometimes, I learned so much from you and take some of the things that you taught me into my career going forward, so we do thank you for being here.
Speaker 3:I appreciate that. Thank you, I appreciate it.
Speaker 1:Thank you, everybody.
Speaker 3:Yeah, anytime. So I'll come back anytime you want. Sounds good, love that.
Speaker 2:Bye guys With that. Thank you so much.
Speaker 3:All right, take care.