So, What Do I Do Now? Tips for Managing a Patient with an Eating Disorder in Your Office

AUTHORS:

D. Paul Robinson, MD, FAAP1,2; Meera Beharry, MD, FAAP3,4; Sydney Ward, PsyD5; James J. Burns, MD, FAAP6
1Tallahassee Memorial Healthcare Family Medicine Residency
2Florida State University College of Medicine
3Department of Clinical Medicine, CUNY School of Medicine at the City College of New York
4Texas A&M University School of Medicine
5Johns Hopkins All Children’s Hospital
6Florida State University College of Medicine

REVIEW ARTICLE | PUBLISHED SUMMER 2025 | Volume 45, Issue 3

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Introduction

There are numerous excellent reviews on eating disorders in the literature, including Dr. Burns’ review article in this issue.1, 2 However, few of these reviews give a step-by-step guide to help the pediatrician faced with a patient with an eating disorder in their office. Recent reviews that do this well are those by Hornberger3 and Golden.4 This article serves as a guide for general pediatricians to manage patients with eating disorders in the office setting. It represents the authors’ 90 years of combined experience and, we hope, will help you feel more comfortable with these patients in your office.

The Set-up

You are working in your office when you see a patient for a check-up. You note that the patient, age 13 years, has lost 20 pounds since her last visit. In taking the history, it appears she has an eating disorder (for this review, we will assume your patient is a female since 90% of patients with eating disorders are3). She is talking about feeling fat, constantly “body checking” and looking in the mirror, weighing herself several times a day, reading recipe books, cooking but not eating the food she cooks, and exercising more than she should. Now what?

The History

Take a good history of her symptoms. Having the parent present during the history-taking is helpful for these disorders, at least during the initial visit. The patient often denies behaviors or symptoms while her parent nods vigorously about them. We usually ask some of the following questions, including a full review of systems (ROS) and menstrual history. The full ROS is helpful because it helps tweak the patient’s and parents’ memory about symptoms she may have had but not considered to be an issue:

  • When did you start having concerns about your body size or shape?
  • With what part(s) of your body are you uncomfortable?
  • When did you make changes to your diet and lifestyle? Often, the person has had eating-disordered thoughts for months to years before they change their diet.
  • Are you exercising? How much? What time of day? (One of the authors once had a male patient who ran wind sprints in his yard every morning at 5 a.m.)
  • Are you using any other methods to lose weight? Vomiting? Laxatives? Diuretics?
  • Some of my patients tell me they have a little voice in their heads that is telling them to lose weight. Some have even named the voice! Are either of these things true for you?
  • What is your goal weight? Have you had other “goal weights” you have already passed? One of the things that distinguishes a patient with an eating disorder from a person without such a disorder is the fact that they are never comfortable once they get to a goal weight. Hence, they keep losing. The thoughts often get stronger as their weight decreases.
  • What was the first day of your last menstrual period? Have you lost your period? Are you having intermittent heavy bleeding? If so, for how long?
  • Are you cold all the time, even when others are comfortable?
  • Have you almost fainted or fainted?
  • Are there any times you feel your heart beating fast or slow?
  • Do you feel dizzy or lightheaded at times?
  • Are you constipated?
  • If purging, have you had blood in your vomitus? If using stimulant laxatives, are you increasingly constipated? Are you having recurrent abdominal pain?
  • Are you having headaches, particularly in the morning?
  • Are there any vision changes?Seeing spots or stars? Any times when things fade to black?
  • Are there any changes to your strength?
  • Are there any muscle cramps? Any chest pains? Shortness of breath? This is a concerning sign and warrants laboratory and electrocardiogram (EKG) evaluation.

The Physical Examination

  • We all know how to perform an excellent physical examination, but it is essential to understand a few unique issues in examining patients with an eating disorder.
  • Obtaining the patient’s weight: Patients with eating disorders should not be weighed in their clothes or with shoes on. They should, almost universally, be weighed in a gown with their backs to the scale so they cannot see their weight. If we have a new patient whose parent is concerned about an eating disorder, we always weigh the patient as noted above—more about this in the following section.
  • Calculating the percent of expected body weight: Many centers have started looking at an adolescent’s historical growth curve (before they became sick) to determine a target weight for treatment. If your patient presents with a body mass index (BMI) at the 3rd percentile (%ile) and was at the 35th percentile BMI before becoming ill, it is easy to calculate a reasonable goal weight if it were at the 35th %ile for BMI. The same would be true if her premorbid weight were at the 85th %ile. You can calculate it the old-fashioned way: BMI at her x%ile for age = kg/height (m)2. Solve for kg. Then, you can calculate your patient’s percentage of premorbid BMI. The Baylor College of Medicine Children’s Nutrition Center has a nifty calculator one can use to find this information.5 If her weight is less than 75% of the median BMI, most centers would recommend admission for medical stabilization (see article by Drs. Feldman and Ward in this issue).
    • Other physical changes to look for include:
    • Bradycardia (resting heart rate <60 beats per minute [bpm])
    • Orthostatic hypotension (an increase in pulse from lying to standing of 20 bpm or a decrease in systolic blood pressure by 20 mmHg and/or diastolic blood pressure by 10 mmHg)6
    • Russell’s sign (calluses on the dorsum of the 2nd and 3rd phalanges associated with self-induced vomiting)
    • Parotid enlargement (associated with purging behaviors)
    • The examiner notes chewing gum in the patient’s mouth during the examination
    • Red, chapped hands
    • Lanugo (if her weight is very low)
    • Low body temperature

Laboratory Studies

If your patient’s weight is very low and you feel you need to draw labs, it is crucial to let the patient know that you are drawing labs because her weight is low, but that you “expect them to be normal, but that does not mean you are ok!” If you act very concerned about your patient’s weight and draw labs and then call her to tell her they are normal, it will play right into her eating-disordered thinking that she is “fine and everyone else is worrying for nothing.” We have seen several adolescents, over the years, who are close to death from their anorexia nervosa, whose labs are normal or minimally abnormal. The body maintains normalcy until it can no longer do so! We inform our patients of this when we draw their labs.

Laboratory studies that may be useful include:

  • Complete blood count with platelets and differential
  • Serum electrolytes
  • Liver function tests
  • Lipid panel (not fasting, please!)
  • Serum phosphorus, magnesium, and calcium
  • Thyroid studies (note the presence of sick-euthyroid syndrome, which is common).
  • Other laboratory studies, as indicated.

For example, inflammatory markers or a celiac panel, and a stool calprotectin in patients with abdominal pain; a pregnancy test, and serum gonadotropins in an amenorrheic patient (more than 6 months without a menstrual cycle) or an amylase in a person suffering from bulimia nervosa (frequent vomiting causes increased salivary amylase levels) or epigastric abdominal tenderness.

If her weight is less than 80% of her expected body weight or her examination shows significant bradycardia, orthostatic hypotension, or an irregular pulse, we also obtain an EKG. The most common abnormality seen on the EKG is bradycardia; however, it is also essential to check for other abnormalities, such as junctional rhythms, dropped beats, and arrhythmias. In the past, we have also examined the corrected QT interval (QTc), but, as noted in Dr. Burns’ article, a prolonged QTc is no longer considered to be associated with eating disorders.7

A baseline DEXA scan is also helpful in amenorrheic patients, allowing for the monitoring of their bone density throughout treatment. Most of us repeat them annually until the patient’s periods return.

In-Office Treatment

We spend a lot of time educating the patient and her family about eating disorders. They are not, as some still teach, an attempt to control something in one’s life when all else is out of control. An over-involved mother and a distant, rigid father do not cause them. They likely relate to all the factors Dr. Burns’ article discusses, which we will not repeat here.

Do not immediately send your patient to a psychologist for counseling early in treatment, at least without addressing the malnutrition.8 People who are starving cannot think of anything but food. Therefore, they cannot derive anything from counseling. We have seen many adolescents sent to us after unsuccessful counseling whose weights are even lower than they would have been if sent immediately. As Dr. Reese’s article states, counseling should begin after meaningful weight restoration.9, 10

Educate the patient about Family-Based Therapy (FBT)11 and, when possible, refer the patient to someone who can help initiate this approach. When used successfully, this treatment method has been a game-changer (see article by Reese et al.), yielding quicker and more effective recovery rates compared to older treatment methods. Be aware, however, that it does not work on everyone, particularly when there is significant family dysfunction or very busy parents who do not have time to stay with their child when she is eating.

Give a handout with information the parent can look up if no local resources are available. An example of one is in the appendix of this article, which readers are welcome to use. And follow your patient. Don’t underestimate what a vital resource you are as your patient’s physician. In many instances, if you treat them with caring and gentle firmness, you can help them turn their lives around, even if there is no specialist in your area.

As noted in the physical examination section, when you see your patient for follow-up, weigh her in a gown with her back to the scale. We have had many patients come into the office with rocks in their pockets! Take care that they do not peak at their weight. Our nurses ensure the patient has no weights taped to her body every visit. Finally, a urinalysis should be randomly checked for specific gravity to ensure she is not water-loading before the appointment.

In our offices, we use blind weights until she has made some real progress in her mind with the eating-disordered thoughts. However, some FBT programs use open weights early on. At this point, it is unclear which method has the best outcome12, 13, but our perception is that patients become very upset in treatment if told their weights, at least until they are well on the way to recovery.

Compliments about progress need to be very specific. For example, “Your color is better.” “You appear to be able to talk without the pauses I heard before when your brain wasn’t getting enough nutrition,” or “You seem to be smiling more; that is nice.” One of the authors once made the mistake of telling a patient that she “looks great” in a follow-up. When the patient returned two weeks later, she admitted to the doctor that she had been restricting more since her last visit. “I knew if you told me I looked great, it meant I had gained weight.”

Initial follow-up in your office should occur every 1-2 weeks, allowing you to emphasize the importance of improvement in eating habits. At these follow-up visits, you can ensure your patient’s “medical stability” and address any questions your patient or her parents may have. You will likely find yourself repeating important talking points about the effects of eating disorders on your patient and family:

  • The body is smart if you don’t eat enough protein. It takes protein from the muscles. But it is also dumb because it does not know the difference between the biceps and the heart!
  • The fact that you do not have periods hurts your bones (and if you have gotten a DEXA scan that shows that, you can point it out).
  • Your eating-disordered thoughts are not telling you the truth about your weight.
  • Your body does not have the cushioning it needs. In a motor vehicle accident, your heart and organs will hit bone instead of cushioning tissues, causing even more damage than might have occurred.
  • If these behaviors persist long enough, they can permanently change your body’s metabolism, eventually leading to weight gain when you finally do begin to eat (think of the show The Biggest Loser and what happened to those contestants when they stopped restricting their diets).
  • You should not be driving if you have an active eating disorder. The eating disorder increases the risk of your being in a motor vehicle accident.

Many patients, especially if they present to you in the 85% of their premorbid BMI range, will eventually respond to this type of outpatient treatment in your office, especially if there is a local outpatient treatment facility for eating disorders or online treatment (available at https://equip.health/or https://withinhealth.com) and/or a dietitian in your area.

Sadly, it is our experience that adolescents who present at £75-85% of their premorbid BMI do not tend to respond as well to outpatient follow-up and need a higher level of outpatient care to help them move forward with their eating-disordered thinking. These might include intensive outpatient programs (IOPs), partial hospitalization programs (PHPs), residential treatment, or medical hospitalization for metabolic stabilization (see below for further discussion).

It is important to note that all of us are seeing more patients classified as “atypical anorexia nervosa” in the DSM-5, which is under the Other Specified Feeding or Eating Disorders category.14 These patients begin losing weight when classified as overweight or obese and present at a normal weight for their height. Unfortunately, they are just as ill, in their minds, as the patients who present to you at low BMIs. So, it is essential to remember the adage, “An adolescent female losing weight has an eating disorder until proven otherwise.” We will see our share of children losing weight from inflammatory bowel disease, malignancy, renal disease, etc. Still, an adolescent girl is most likely to have an eating disorder when losing weight.

Medications

In patients with anorexia nervosa- Restricting (AN-R) or anorexia nervosa- Binge Purge (AN-BP) subtypes, no medication is helpful in management. It is our experience that many of these patients present to your office appearing very depressed and/or anxious, in addition to their weight loss. It is logical for us to consider starting a selective serotonin reuptake inhibitor (SSRI) medication to help their mood. Unfortunately, no study has shown that these make any difference early on. Once some weight restoration has occurred, they might help with comorbid conditions, like depression or anxiety, that preceded the onset of the eating disorder.1, 15 But they will not help any of the eating-disordered thoughts.

There is evidence that SSRIs can help people who suffer from bulimia nervosa.16-18 The medication most studied is fluoxetine, and the recommendation is to work up the dose to 60 mg daily in these patients. Still, other SSRIs and norepinephrine-serotonin reuptake inhibitors (NSRIs) might also be helpful in certain patients who do not respond to fluoxetine.17

Avoidant Restrictive Food Intake Disorder (ARFID)

ARFID is a new diagnosis in the DSM-5. The patient will present to you at a very low weight or having lost weight. However, they will have no body image issues. This is an important distinction from anorexia nervosa or bulimia nervosa. The person with ARFID typically has one of three reasons for not eating enough food:

  • They do not like the texture of certain foods and will, therefore, not eat them.
  • They fear certain foods might make them ill or cause a physical reaction.
  • They are simply not hungry.

Due to the newness of this diagnosis, medical researchers are just beginning to learn how to manage patients who suffer from it.19, 20 However, we believe one should try to focus on getting the patient to eat more of the foods they are comfortable eating, along with recommending a multivitamin. Also, cyproheptadine has been used off-label to increase appetite. Please realize that patients with ARFID can become just as ill, including being at risk for refeeding syndrome, as people with anorexia nervosa. According to one study, 5- 14% of people in residential eating disorder treatment facilities have ARFID.21

Deciding on a Goal for Weight Restoration

If you have known your patient for a long time, you undoubtedly have a growth curve for them. In that case, a reasonable first goal for weight restoration would be her premorbid BMI. So, if your patient was in the 25th percentile for BMI pre-morbidly, that is a reasonable initial goal. If a patient is new to you, it is best to set a goal of 50th percentile BMI, at least until you know where their weight was before they became ill from old growth curves. You can use the following webpage to help make these decisions:

http://www.bcm.edu/bodycomplab/BMIapp/BMI-calculator-kids.html5

Sadly, there is data that some people with atypical anorexia nervosa may need to gain at least close to their premorbid weight, which could be a BMI in the higher percentiles, to make progress with their abnormal thoughts. A patient’s goal weight will be a moving target, as the normative BMI increases with age on the growth chart, even after menarche.

Higher Levels of Care

  • Intensive Outpatient Programs (IOPs)
    IOPs provide a flexible yet organized treatment alternative for youth requiring more support than a traditional weekly outpatient therapy plan. IOPs include individual treatment, group therapy, and nutritional counseling to address persistent emotional and behavioral issues associated with eating disorders. Patients often meet for several hours, three to five times a week. Dietitians offer advice on meal planning and cultivating a positive connection with food, while therapy concentrates on controlling triggers, enhancing body image, and creating coping mechanisms.
  • Partial Hospitalization Programs (PHPs)
    PHPs provide a structured and more intensive environment than IOPs by offering intensive day treatment that allows patients to remain home in the evenings. Still, they also offer meal support and supervision throughout the day. Time at home in the evenings can provide patients with the opportunity to practice independence with snacks, allowing them to focus on recovery while still spending time with family and friends. PHPs can vary in terms of duration and frequency. These programs include supervised meals, nutritional counseling, group therapy, and individual treatment. PHPs offer rigorous therapy with the goal of being able to step patients down to less intensive services as they build skills to manage their eating disorders.
  • Residential Treatment Centers
    Consider sending a patient to residential treatment when they are medically and psychiatrically stable, but when outpatient or PHP are insufficient to ensure stability, nutritional progress, or psychological well-being. Residential admissions are typically 30, 60, or >90 days or longer and require the patient to reside in the treatment setting. Residential programs offer 24/7 supervision and support, focusing on comprehensive treatment approaches that include meal support, medical monitoring, individual and group therapy, and family involvement. Programs often utilize evidence-based modalities, including dialectical behavior therapy (DBT) and cognitive behavioral therapy (CBT), and many programs offer family-based therapy (FBT) to educate caregivers and strengthen familial support. Residential treatment programs often recommend a step-down level of care to continue supporting the patient’s recovery journey, such as stepping down to a PHP or intensive outpatient program (IOP).
  • Hospitalization in a Medical Unit
    Hospitalization for medical stabilization will be discussed in detail in Feldman and Ward’s article. The American Psychiatric Association recommends inpatient admission for the following criteria:1
    • BMI is less than 75% of the median BMI, or when a premorbid growth chart is available, it is less than 75% of the patient’s premorbid BMI.
    • Rapidity of weight loss: >10% in 6 months, >20% in 1 year
    • Severe bradycardia (pulse <50 bpm during the day, <45 bpm at night) or arrhythmia
    • Prolonged QTc >450 mm or other significant EKG findings
    • Blood pressure (BP) <90/45 mmHg
    • Orthostatic drop in systolic BP of >20 mmHg or drop in diastolic BP of >10 mmHg
    • Orthostatic change in heart rate >40
    • Electrolyte disturbance, including hypokalemic alkalosis (more common in people with purging), hyponatremia, hypophosphatemia, hypomagnesemia, and acidosis (seen in laxative use)
    • Glucose <60 mg/dL
    • Acute food refusal
    • Psychosis
    • Frequent dangerous compensatory behaviors
    • Other medical complications: seizures, syncope, cardiac failure, pancreatitis, arrested growth and development
    • Hypothermia <36 degrees Centigrade (<96.8° Fahrenheit)

Conclusion

We hope that this paper will help increase your comfort level in caring for adolescents with eating disorders. Our experience with these patients is that, despite the time and effort involved in helping them, they are, as a group, wonderful individuals who will make significant contributions to their communities once they are in recovery from their illness.

Thank you for treating them and allowing them to do that.

References

  1. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Eating Disorders. Fourth Edition ed. Washington DC: American Psychiatric Association; 2023.
  2. Golden NH, Katzman DK, Rome E, Gaete V, Nagata J, Ornstein R, et al. Medical management of restrictive eating disorders in adolescents and young adults. J Adolesc Health. 2022;71(5):648-654.
  3. Hornberger LL, Lane MA, Hornberger LL, Lane M, Breuner CC, Alderman EM, et al. Identification and management of eating disorders in children and adolescents. Pediatrics. 2021;147(1):e2020040279.
  4. Golden NH, Katzman DK, Sawyer SM, Ornstein RM, Rome ES, Garber AK, et al. Update on the medical management of eating disorders in adolescents. J Adolesc Health. 2015;56(4):370-375.
  5. Shypailo RJ (2020)Age-based Pediatric Growth Reference Charts.Retrieved4/25/2025 from the Baylor College of Medicine, Children’s Nutrition Research Center, Body Composition Laboratory Web Site:http://www.bcm.edu/bodycomplab/BMIapp/BMI-calculator-kids.html. Published 2020. Accessed 04/25, 2025.
  6. Freeman R, Wieling W, Axelrod FB, Benditt DG, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011;21(2):69-72.
  7. Janzen ML, Malhi N, Laksman ZWM, Puyat J, Krahn AD, Hawkins NM. The QT Interval in anorexia nervosa: a meta-analysis. JACC Clin Electrophysiol. 2018;4(6):839-841.
  8. Lock J, La Via MC. Practice parameter for the assessment and treatment of children and adolescents with eating disorders. J Am Acad Child Adolesc Psychiatry. 2015;54(5):412-425.
  9. Hughes EK, Le Grange D, Court A, Yeo M, Campbell S, Whitelaw M, et al. Implementation of family-based treatment for adolescents with anorexia nervosa. J Pediatr Health Care. 2014;28(4):322-330.
  10. Rienecke RD. Family-based treatment of eating disorders in adolescents: current insights. Adolesc Health Med Ther. 2017;8:69-79.
  11. Lock J, Le Grange D. Help Your Teenager Beat an Eating Disorder. New York, NY: The Guilford Press; 2015.
  12. Froreich FV, Ratcliffe SE, Vartanian LR. Blind versus open weighing from an eating disorder patient perspective. J Eat Disord. 2020;8:39.
  13. Murray SB, Levinson CA, Farrell NR, Nagata JM, et al. The open versus blind weight conundrum: A multisite randomized controlled trial across multiple levels of patient care for anorexia nervosa. Int J Eat Disord. 2020;53(12):2079-2085.
  14. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
  15. Hilbert A, Hoek HW, Schmidt R. Evidence-based clinical guidelines for eating disorders: international comparison. Curr Opin Psychiatry. 2017. p. 423-437.
  16. Walsh B, WS A, Devlin MJ, et al. Fluoxetine for bulimia nervosa following poor response to psychotherapy. Am J Psychiatry. 2000;157(8):1332-1334.
  17. Crow SJ. Pharmacologic treatment of eating disorders. Psychiatr Clin North Am. 2019;42(2):253-262.
  18. Voderholzer U, Haas V, Correll CU, Körner T. Medical management of eating disorders: an update. Curr Opin Psychiatry. 2020;33(6):542-553.
  19. Brigham KS, Manzo LD, Eddy KT, Thomas JJ. Evaluation and treatment of avoidant/restrictive food intake disorder (ARFID) in adolescents. Curr Pediatr Reports. 2018;6(2):107-113.
  20. Katzman DK, Norris ML, Zucker N. Avoidant restrictive food intake disorder. Psychiatr Clin North Am. 2019;42(1):45-57.
  21. Seetharaman S, Fields EL. Avoidant/restrictive food intake disorder. Pediatr Rev. 2020;41(12):613-622.

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Appendix

Recommendations for Home Care of Children with Eating Disorders

  1. Remove any scales from the home where the child can weigh herself. We will weigh the child in the office and decide when to let her know her weight.
  2. Watch your talk about weight, diet, etc. Please don’t talk about your needing to lose weight.
  3. Do not allow the child to watch cooking shows, read cooking magazines, etc.
  4. Watch her internet usage. Some sites are “pro-anna” to which she can go, which are very destructive toward recovery.
  5. Get rid of clothes that fit her well when she was very thin. If she tries to wear them now and they do not fit, it will cause distress.
  6. It is easiest to think of the eating disorder as a “demon” that has taken over your child. When she acts up around food (and she will), keep cool, don’t melt down, and talk to your child. If you must get angry, tell your child you are angry at the anorexia, not at her, because it is continuing to make her do things that harm her.
  7. YOU should be deciding on the foods your child eats and YOU should be measuring and plating them. Do not give in to your child and allow her to do it at this point. You will be able to give that task back to her when she is better. But at this point she is not strong enough to fight the anorexic thoughts and she WILL sabotage the amount she gets somehow. You have successfully fed her for her entire life. You can do it now.
  8. Until told otherwise, you need to sit with your child for every meal. If she is in school, sometimes I allow her to eat lunch at school without you as a test, but I will let you know.
  9. Be prepared to take things she enjoys away to get her to eat. Cell phones, driving privileges, and time with friends. Also, be prepared for some very long meals. In hospital we only give them 30 minutes, but we have more power in hospital and it always feels safer to eat in the hospital than it does at home.
  10. She will try to bargain with you. As one former parent said, “We don’t negotiate with terrorists!”
  11. You should be on the lookout for her exercising when she shouldn’t. If she is in her room by herself, it makes sense to take her pulse when she comes out to make sure it is not elevated. I have seen kids doing crunches in bed, running in place in the shower or bathroom, sneaking out, and doing wind sprints. These patients can be very sneaky, so you must be sneakier at times.
  12. Helpful books:
    • How to Nourish Your Child through an Eating Disorder: A Simple Plate by Plate Approach to Rebuilding
      a Healthy Relationship with Food       by Casie Crosby and Wendy Sterling
    • Eating with your Anorexic by Laura Collins
    • NEDA Parent Toolkit https://www.nationaleatingdisorders.org/parent-toolkit
    • Help Your Teenager Beat an Eating Disorder, Second Edition, by James Lock and Daniel Le Grange
  13. A few helpful websites:
  14. It is fine to connect with a therapist once her weight has had a reasonable recovery. Going to a psychologist when she is still very thin is a waste of money and time. She cannot get anything out of it. If she has been hospitalized feel free to establish with a therapist when she is discharged. If she is being treated as an outpatient, I will let you know when I think it is a good time to establish with someone.
  15. Remember that nothing works for every patient. Sometimes we are forced to change the plan, as necessary, until your daughter moves forward. However, family-based therapies, as recommended above, is the best method for most patients.
  16. I can be reached, if needed, during the day at ___________. For after-hours, if urgent _______