by Barbara Ebel
“About eight months ago. That’s when she was perfectly normal.”
“Do you know what she weighed?”
“Sure. She was 125 pounds. She lost five pounds and said she looked ‘better,’ but if she lost a few more, then she’d be ‘perfect.’ She started eating less and less. Recently I saw her count out the number of cheerios she put in a cereal bowl and, of course, she wouldn’t put any milk on them. If that isn’t extreme enough, she exercises all the time.”
Annabel never heard of such harmful dieting behavior. Here she was standing by the door hoarding a cookie in her pocket; one-hundred-eighty degrees opposite this teenager’s actions. The young girl looked emaciated. Was there even a drug that could make a person eat? She had no idea what Dr. Keeton was going to do with her.
Selina opened up the chart she’d placed before her and shook her head. “Your daughter is 5 ft. 6 in. tall and now weighs 83 pounds,” she said and then calculated something on a nearby pad. “She is 65% the normal weight for a girl her age and height.”
Mrs. Carter gasped. “Oh my God,” she said. “I had no idea. She’s going to disappear.”
“She’s headed that way. Another thing … do you ever see her binge eat?”
“No. She restricts everything; she never overeats.”
“She meets every criterion for anorexia nervosa,” Dr. Keeton said.
Mrs. Carter stared at Selina. “That’s why she doesn’t have her periods any more, isn’t it?”
“That’s correct. She is extremely cachectic. Her condition right now is serious. I am suggesting hospitalization, a workup, and internal medicine to be involved. She should be treated for dehydration, starvation, and electrolyte imbalances.”
“This is incomprehensible in an affluent country like this why someone would starve themself. And my own daughter!” The woman looked back at Annabel and back to Selina with pleading eyes. “But she won’t be admitted, she said so herself.”
“Mrs. Carter, because of Lillie’s age, you can sign her into the hospital without her consent. I also have the power to admit people in a legal manner but, in this case, I don’t need to. You should work out fine.”
Lillie’s mother put her hands to her face and rubbed her eyes. “Did I tell you that her grades have slipped? The way she’s going, she will need to repeat the school year. Can you imagine? Being left back in high school? It’s embarrassing and unheard of.”
“I understand,” Selina said. “When a growing teenager is depriving their brain of nourishment, in fact, starving it, they cannot be thinking clearly nor processing new information. Lillie is going to need a lot of therapy, Mrs. Carter. This is just the beginning of trying to turn her around.”
Mrs. Carter rummaged in her bag on the floor and pulled out a tissue. “This is all my fault. Or perhaps my husband’s.” She rubbed the corner of her eye.
Selina kept quiet but knew she needed to start making arrangements for Lillie’s admission and begin seeing more patients stacking up in the waiting room. Annabel shifted her weight to the other leg.
Mrs. Carter again turned to Annabel. “You’re young. Can you help take care of her because maybe she’d listen to someone her age … that she must eat to stay alive?”
“I can help while I’m on this service,” Annabel said. “I’ll make an extra point of it.”
Selina stood up. “Come,” she said, “let’s go definitively talk to Lillie and you must sign the admission forms.”
Mrs. Carter tapped Selina’s sleeve as she passed. “Did I tell you? My husband and I even hear Lillie running in place in her room as we’re trying to go to sleep at night?”
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A lab tech walked down the hallway with his supplies as they went back into Lillie’s room. Selina stopped her.
“I will write the order, but please come in and take my patient’s blood work for electrolytes, CBC, LFTs, and an extra vial if internal medicine is going to need anything further.”
The tech nodded. “Happy to,” he said.
“Lillie,” Selina said, “we’re going to admit you and this young man is going to take some blood.”
“Can you roll up your sleeve?” he asked, standing next to her.
She dangled her feet from the examining table and inched her blouse up her arm. The young man flashed a look at Selina. Lillie’s veins were visible right under the skin of her scrawny arm.
He began filling the vials in a minute as Lillie voiced her displeasure.
“I can’t go to the hospital. I’m sure there’s nothing there that I can eat like the stuff I have at home. Mom, you can bring me some cheerios and an apple for each day. But never mind because I’m not going.”
“Lillie,” Selina said, “we’re not giving you a choice in the matter. You are on a path of self-destruction if you continue losing any more weight. You are also in a medical crisis right now with your current weight. My team and some other doctors are going to institute an initial and long term treatment for you. Let’s get you healthy and happy and back on an educational path like this young lady here.” Dr. Keeton pointed to Annabel.
“Lillie,” Annabel said, “you can trust what Dr. Keeton says more than the idiot eight months ago who told you that you were chunky.”
Chapter 14
The team finished their work behind schedule in the outpatient clinic and then breezed through the pedway over to the hospital. Everyone wanted to call it quits before rounds except Dr. Keeton who thrived with enthusiasm the closer they approached the wards.
“Dr. Tilson and I admitted a young patient today to our service who needs immediate help. Internal medicine will be lending a heavy hand to Lillie Carter’s care so she’s not staying on our ward. Let’s go to the medicine floor first to see her.
“Dr. Tilson,” she said as they went up the elevator, “you have the additional task before going home of writing her H&P and I’d like you to present her case to your colleagues now … the best you can with current information.”
Annabel shifted her weight from one foot to the other.
“This is good to put you on the spot … to think on your feet before you write your H&P. Dr. Washington will be appreciative too, since he still needs to see her.”
Annabel began to relax; Dr. Keeton would never throw a student to the wolves. She was sure her attending would fill in whatever she neglected.
They walked down the corridor of the medical floor and stopped at the nurses’ station. Karla Weaver noticed them from behind the desk.
“Looking for this?” Karla asked, pointing to Lillie’s chart.
“We are,” Annabel said.
“Are you the med student assigned to her?” Dr. Keeton asked.
“Yes. I’m Karla Weaver and I shared a lunch with your group this afternoon.”
“Good. With the hours they’re pulling today, that buffet is tiding them over.”
Karla closed the binder and handed it to Selina.
“Dr. Tilson is going to tell us about Lillie Carter right now. You are welcome to hear her on-the-spot H&P from our psychiatry standpoint.”
Karla shot Bob a glance. “I would like that.”
All eyes turned on Annabel and she realized she didn’t feel nervous in the least. Being a third year medical student and standing up in front of her peers to talk about patients was getting easier.
“Lillie Carter is a sixteen-year-old who was brought into clinic today unwillingly by her mother. The patient’s mother is concerned about her weight loss, skimpy eating habits, and excessive exercising.
“On physical exam,” Annabel went on, “the patient’s height is 5’6” but her weight is only 83 pounds. I did not do a proper mental status exam yet but she denied hallucinations, delusions, and suicidal ideation when questioned by Dr. Keeton.”
“Lillie’s blood pressure,” Dr. Keeton interjected, “is only 96/64, her lungs were clear but her heart rate was slightly tachycardic.” She looked at Dr. Weaver. “With what you know about her already, what’s you first guess about tho
se vital signs?”
Karla smiled. “She’s dehydrated. Since cardiac output is heart rate times stroke volume, her heart rate is high to compensate for the lower volume of blood pumped per beat.”
“Very nice, correct,” Dr. Keeton said. “Her intravascular space is low on total blood volume which is needed to pump oxygen into all her tissues so her body is compensating. But I diverge outside of my own specialty.” She smiled at them all. “You must experience all these rotations because before you go into one field, you must understand everything you can about the anatomy and physiology of the human body.”
Selina turned to Annabel. “Now that I interrupted you, please go ahead.”
“The patient has no known medical allergies, no past medical or surgical history. Lab work and admission testing were ordered and probably not ready but our impression, or most likely diagnosis, is anorexia nervosa. The plan is to begin psychiatric treatment but her medical condition needs to be corrected by treating her malnourishment and secondary effects of starvation. So she will be a dual-specialty, joint effort until she is physically stabilized.”
“Dr. Tilson, nice job,” Selina said. “Now I will add to what you all heard. Lillie’s type of anorexia is called ‘restrictive’ as opposed to the patients who don’t restrict themselves but rather binge eat and then induce vomiting. Others use laxatives or even enemas to try and remove the food they do eat.
“Next, there are four criteria to this disorder and Lillie has every one of them. Dr. Washington, it’s your turn to tell them.”
Joshua nodded. “As you must gather, Dr. Weaver, I’m the psychiatry resident. This very question was on my last exam. Remember that an anorexia nervosa patient will not maintain their body weight above the normal range for their age and they perceive their body image to be too fat despite being wallpaper-thin like our new patient. These patients are scared to death of gaining weight. And the last one? If the patient is female, which is normally the case, she becomes amenorrheic or her periods stop.”
Clearly pleased with her resident, Dr. Keeton patted him on the back.
“I understand,” Bob said, “the medicine service can intervene with her physical status right now but that’s temporary. I just don’t understand how we can change her for good.”
“Dr. Palmer,” Selina said, “like many psychiatric illnesses, the patient doesn’t recognize their problem. It’s not easy cracking that egg shell. She will need individual psychotherapy, group therapy, and behavioral management. On top of it all, since she still lives at home, the family also needs to be educated.
“A big question is also why did Lillie Carter develop this disorder to begin with? Yes, someone called her ‘chunky,’ but not every teenager who is told that ends up starving themselves to resemble a bony child with a parasitic disease in a third-world country. We must also focus on our patient’s dynamics within her family. Is there something there which helped catalyze her overboard reaction? You may all be long gone from my rotation by the time I have answers but you stumbled on an excellent example of anorexia nervosa that you will not forget.”
A silence enveloped the group and then Karla Weaver spoke up. “Thank you so much for letting me listen in. Hearing your discussion gives me a clearer picture of my patient and now I’ll look forward to psychiatry even more.”
She took a step and added, “We started an IV and fluids and we’re waiting on the labs drawn in your outpatient clinic.”
“Glad you could join us,” Dr. Keeton said. “I presume your resident has ordered Ms. Carter to be weighed daily. Your service also needs to monitor and fix her daily diet as well as her fluid intake and output.”
“Yes, Dr. Keeton,” she said. “We talked about that. Thanks again.” She darted her eyes towards Bob and after he smiled at her, he watched her go back to the desk.
“We’re finished,” Dr. Keeton said. “We have many more patients to discuss, so let’s go in and see Lillie.”
When the team walked in on Lillie, her bony legs were flexed as she leaned back on the bed with a distant stare.
“Stupid fluid going into my arm,” she said when Joshua stood next to her. “It’s a good thing there are no calories. At least that’s what they told me.”
“Lillie,” Dr. Washington said, “you are a pretty girl but you will be so much prettier once you put some weight on.”
“Ha! You’re just saying that.”
“I am very careful what I tell young ladies and patients and I only speak the truth.”
“In two or three days, we’ll start some therapy,” Dr. Keeton said from the bottom of the bed “Do you mind if Dr. Washington and Dr. Tilson are also there?”
“Whatever,” she said.
“We’ll be in tomorrow,” Selina said.
Back in the psychiatry ward, Selina stopped. “I think it’s Dr. Palmer’s turn to tell us about his new patient. Why don’t you give us a quick overview? Dr. Washington and I discussed her briefly.”
Bob cleared his throat. “I’d be happy to. Our patient’s name is Jamie Harris. She’s a forty-year-old female with a history of bipolar disorder who takes lithium and denied missing any doses. She works at a restaurant-like pizza place and her co-worker and friend insisted she make an appointment with her doctor. Apparently Ms. Harris’ mood is elated and she was handing out free pizzas to the customers the other night much to the chagrin of the manager.
“She has no prior medical or surgical history except for an appendectomy. On physical exam, her vital signs were normal and lungs and heart sounded fine. Her mental status exam revealed a woman who appeared her age, was dressed appropriately, and had a friendly attitude toward us. She spoke fast and denied delusions, hallucinations, and suicidal tendencies.
“Her diagnosis is chronic bipolar disorder and Dr. Washington and I believe her lithium level is not therapeutic. She was seen last time by another psychiatrist and her level was barely squeaking the low normal range. So we’ve admitted her because she is symptomatic and we don’t want her to escalate while we check her blood lithium and perhaps make adjustments to her dose.”
Dr. Keeton beamed. “Very nice. Is her blood sample in the lab yet?”
“Yes,” Bob said.
“Let’s see her,” she said as she turned.
Inside her room, Ms. Harris flashed a smile of big teeth from the window ledge where she sat with her feet on a chair. “I know the drill,” she said. “This is the whole team and the experienced ones are teaching the novices and I’m the subject of intense scrutiny and you’ll pick me apart, talk about me, figure out what I dream about, give me pills, take my blood, feed me for a few days and stick me in therapy, and what else did I forget?”
“Lovely,” Dr. Keeton said and laughed. “You’re a frequent flyer and I don’t need to explain anything.”
Ms. Harris also laughed. “I don’t want to be on this plane right now, doc, because I’ll miss work and maybe some pay. It’s too bad because, as far as I know, I did not miss a day of my medicine. Only when doses are skipped do I become worse and can’t figure stuff out and then I miss more doses and then I don’t feed my cat and I don’t want that to happen and then she slinks out the door because I’m not careful and then I must search for her. Well, you know how it is.”
Selina chuckled again. “We understand what you go through with your disorder, Ms. Harris. We’ll get you back on track and we’re hoping it doesn’t take too long. Okay?”
“All right. If you get me fixed up, make me go back to the clinic to see you next time. I had appointments with two other doctors there and they’re cool but I like you the best already. And these two guys with you aren’t too bad, either. Even though they are young pups, they’re easy on the eyes if you know what I mean.”
Selina looked at Bob and Joshua. “She’s finished complimenting you gentlemen for the day. Don’t acquire delusions of grandeur,” she smiled. “See you tomorrow, Ms. Harris, when we know your lithium level.” She whisked her team out of the room and stopped fu
rther away from the doorway.
“You should have picked up on the difference between Jamie Harris and our med student, Noah Goodman, who came in with a flagrant, acute and untreated bipolar episode. They both have the same disorder and exemplify different stages of treatment.”
Annabel and Bob nodded and then followed Selina and Joshua to finish rounds.
“I’m glad you can now help manage a bipolar patient like I do,” Annabel said to Bob.
“With the two of them, it’s like Dr. Keeton said. We get the full picture.”
“But Noah Goodman doesn’t compliment me,” Annabel said, “like Jamie Harris made a fuss at you.”
“What do you mean? Your patient has made overt passes at you.”
“That’s only because his self-esteem was sky high. He’s getting better so he hasn’t continued making passes at me. Heck, do men have to be in the throes of a psychotic illness to be attracted to me?”
“I’m not psychotic,” he said with a smile.
She swiped his upper arm. “I could swear I saw a twinkle in your eye for that medicine student back there. She gave you a double look, too.”
“I guess I like smart, beautiful women.”
“Aha, so you’re not denying it!”
“That you’re smart and beautiful?”
“I didn’t mean me. I meant the spark between you and her.”
“I know what you meant. I’m pulling your chain. Here,” he said, and pulled out his box of chocolate espresso beans. He handed her two and popped one in his mouth as well.
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Annabel lacked the energy to go for a run when she got home, not even a short one. She put on music while she rummaged through the refrigerator for something small to eat. The pickings were slim, a far cry from the diversity of her lunch, so she took out a yogurt, sprinkled it with wheat germ, and then sliced a banana on top.
She gave herself the liberty of eating while not multi-tasking and, when she finished, she looked at Findar for her last contact, Tristan.
I like your profile, he wrote. You and I would be a match because you said you study the medical field and I plan to switch careers soon and become a physician’s assistant. Being a basketball coach is getting old.