Tales from the ER #6

“Just a heads up – room 9’s family is a little difficult.”

“What are they here for?”

“Teenage daughter was supposed to be a direct admit to the eating disorder unit, but bed board screwed it up and there’s no bed for her until the morning, so they got sent here.”

“Why didn’t they just send them home?”

“Primary doc was worried about bradycardia and electrolyte imbalances. Primary doc also apparently said family is in denial about the anorexia diagnosis.”

“Ah, gotcha. I’ll see them next.”

Eating disorders are sad cases. Anorexic patients are usually Type A, white, female teenagers from well-off families that end up in a downward spiral of feeding off perfectionism and control rather than actual food. The families aren’t “difficult” per se, they’re just tired and scared of the fact that the constant cycle of therapy and hospitalizations doesn’t lead to any meaningful progress. In my experience, those families aren’t in denial about what’s wrong. They see a 90-pound teenage girl refusing to eat and withering away and they know it’s abnormal.

I walked in and indeed it was a white, well-dressed family, looking quite distinct from our usual ER clientele. Dad appeared angry with his cell phone in hand. Mom had tears in her eyes and so did her daughter, the patient. The patient was 16 years old and had that “ana” look: sharp cheekbones, sunken dark eyes, thin dull hair, and protruding collar bones visible from underneath the flimsy hospital gown.

In these tense situations I just start from square one. It risks the ire of families and patients who expect perfect communication between primary doctors and ER doctors, but at the same time it lets them know I haven’t pre-judged the situation. I introduced myself and asked what had brought them into the ER tonight. Dad must’ve been a businessman used to the efficiency of the private sector because he immediately launched into a tirade about the dysfunctional direct admissions process that had sent them to the dingy ER instead of straight to the hotel-like eating disorders unit. I was halfway through the robotic apology they make us repeat during annual patient relations training when the mom interjected:

“My daughter doesn’t have an eating disorder! This is a huge mistake. Sweetie, please tell them you actually want to eat.”

I turned to the girl who looked terrified. By this point in my career I’d become fairly jaded and cynical, but I’d seen enough anorexic patients to sense something was off. Usually at this point anorexic patients are pitching fits because they know they’re about to lose control and be force fed. If anything, anorexics get angry rather than scared. I resigned myself to the fact that my efficiency metrics for this shift were going to suck. I had to get the full story, so I sat down.

“Let’s back all the way up, how did this start?”

About six months ago this girl was having the time of her life – a great summer break spent upstate working as a summer camp counselor. Then school started and she said it was impossible to eat or drink. That’s weird - anorexic girls love to drink tons of water.

“It was hard to drink water?”

Yes, she said, at first it felt like burning, and then eventually swallowing anything caused a searing pain in her chest, throat, and mouth. The patient and her mom kept going on and on about how the primary doctor never took it seriously. While that was likely true, I could sense the other patients piling up in the waiting room, so I directed them back to the actual story.

“What were you doing right before this all started? Any colds, coughs, stomach bugs, fevers, anything?”

“Well, I did get Lyme disease while I was at camp.”

Mom interjected again, “That’s the other thing – this primary doc heard us say Lyme and instantly blew us all off!”

I shuddered. I’m a total hypochondriac when it comes to tick-borne illnesses like Lyme and Rocky Mountain Spotted Fever. Those bugs are real and everywhere and do the most bizarre things to people.

“Did you get treatment for Lyme?”

“Yes, I took two weeks of doxycycline.”

Somewhere in the deep recesses of my mind I remembered a med school lecture on how certain pills like doxycycline can cause esophagitis, a horrible erosion and ulceration of the lining of the esophagus.

“How did you take it?”

“What do you mean? I swallowed the pills.”

“Did anyone ever tell you you’re supposed to take the pills with a full glass of water and stay upright for at least an hour afterwards?”

“No, I took them all right before bed.”

The whole room fell silent for a moment. I couldn’t believe what was happening, it seemed too much like a TV show.

“Alright here’s what we’re going to do. We’re going to get some blood work and an EKG, but I’m also going to call the GI docs to come see you, because you might have an injury to your esophagus from the doxycycline pills.”

Now the dad started crying.

GI arrived a couple hours later and shared my suspicion. The patient didn’t get admitted to the eating disorders unit, she went to a regular pediatric ward and had an endoscopy the next morning. I got an email from the GI attending later that day:

“Multiple erosions and ulcers on endoscopy with some bleeding and tissue friability. The lumen is narrowed. We’re starting her on sucralfate and will follow as an outpatient. Family is very grateful. Thank you for the consultation.”