You are called to a residence for a 22-year-old female patient who has just attempted suicide. You enter the residence to find an emaciated female lying on the bathroom floor with multiple lacerations to her anterior wrists and forearms. There is a man in the room who identifies himself as the patient’s father, and he is holding direct pressure on her wounds with bath towels. He tells you he found her like this and called 911 immediately.
She is very lethargic; however, she follows commands and is oriented. You and your partner lift her to the cot with a blanket and cover her up. As you continue your assessment, your partner bandages her lacerations with 4x4s, controlling the bleeding. She is pale and cool to the touch. On the monitor, she has a BP of 84/53, HR 47, and appears to have a prolonged QT, O2 sat of 98%, and her respiratory rate is 10 and shallow. As you’re loading her into the back of the ambulance, her father tells you that she was recently discharged from an inpatient facility that specializes in eating disorders for non-compliance.
How much do you know about eating disorders? Could this be what's causing the ECG changes?
The two central eating disorders that most people are aware of are Anorexia Nervosa and Bulimia Nervosa. More recently, Binge Eating Disorder and Avoidant/Restrictive Food Intake Disorder (ARFID) have been added as potential eating disorder diagnoses. Let’s do a little review of the differences in these disorders.
Anorexia Nervosa
Anorexia is a condition where the individual obsesses about food and weight. The person might have an intense fear of gaining weight or have body dysmorphia with disbelief that they are underweight. It is common for individuals with Anorexia to restrict food intake and exercise excessively.
Bulimia Nervosa is a condition where the individual obsesses over food and weight, and instead of restricting food intake, they will binge eat and then purge. Purging may consist of vomiting or the intake of laxatives or diuretics. In addition, following a binge, the individual may exercise for hours to negate the calories they ingest. The purging or excessive exercise is thought to be done out of guilt. This disorder is much more common among the population.
Binge Eating Disorder is a disorder where an individual eats an abnormally large amount of food without controlling themselves to stop, even if they are feeling full. The person may feel a loss of power and a sense of guilt or shame following the binge. How this is different from Bulimia is that an individual with this disorder doesn’t participate in purging, or if they do, it’s not consistent.
Avoidant/Restrictive Food Intake Disorder (ARFID) is more unique and was not added to the DSM-5 until 2013. The individual doesn’t obsess over weight or have a fear of gaining weight. The aversion to food is more of a sensory issue or a lack of interest in eating. People with these disorders can sometimes be labeled as “picky eaters” because they will only eat a limited selection of foods.
Fading Away
I want to be clear: all of these eating disorders are severe mental health conditions. The individuals experiencing and living with these disorders do not have control over them. They are not living with these disorders by any choice of their own. Eating disorders affect people of all genders and have one of the deadliest mental health consequences in the United States; 1 in 7 men and 1 in 5 women are affected, and morbidity and mortality are as high as 1 in 5. It was estimated in 2019 that there are approximately 30 million individuals living with an eating disorder in the United States. After COVID-19, this number has increased due to isolation and increased instances of mental health issues. In addition, eating-disordered patients have the highest rates of suicide out of all mental health conditions.
It has been found that many patients with an eating disorder also have an additional concurrent mental health condition. Some of these additional mental health disorders are anxiety, obsessive-compulsive disorder, substance abuse, major depression, personality disorders, and bipolar disorder. More interesting, a study conducted in 2019 found that eight different mental health disorders shared some of the same genetic areas; one of these disorders was Anorexia. Continued research in this area could lead to a better understanding of eating disorders and why individuals with these disorders also have additional mental health symptoms. This could open doors to further treatments and earlier recognition and diagnosis of eating disorders.
Manifestations
You might be asking yourself why I’m writing about eating disorders, considering the rarity of EMS responses to them. However, we might be responding to a patient with an underlying eating disorder, and we not even know it because we are being called for a manifestation of it.
While eating disorders don’t necessarily prompt a call or request for 911, complications from them can create the need for EMS assessment and intervention. Calls typically happen when medical complications arise, such as severe malnutrition, dehydration, electrolyte imbalances, heart arrhythmias, or loss of consciousness. A mental health crisis occurs, including suicide attempts or severe distress related to the eating disorder, or family/friends call for emergency intervention if a person with an eating disorder refuses medical care despite life-threatening symptoms.
Eating disorders can lead to severe malnutrition, but they typically result in different forms of nutritional deficiencies depending on the behaviors involved. Anorexia is more commonly associated with Marasmus, a severe form of malnutrition. This occurs due to prolonged calorie restriction, leading to extreme muscle and fat loss, weakness, and organ dysfunction. Bulimia and Binge Eating are less commonly linked to Marasmus because people with these disorders often maintain a more fluctuating weight. However, they are at high risk for electrolyte imbalances due to vomiting, laxative use, or diuretic abuse, which can lead to cardiac arrhythmias, dehydration, and sudden cardiac arrest.
Hyponatremia is found in approximately 7% of individuals with eating disorders. It is thought that one of the reasons for the low sodium level is that the patient drinks excessive amounts of water to satiate hunger or help reduce anxiety. Another potential reason for patients with eating disorders to have low sodium levels is a lack of sodium reabsorption in the kidneys secondary to tubulointerstitial disease. Depending on how severe the hyponatremia is, this can lead to altered mental status, delirium, and or seizure activity.
Hypokalemia is a common finding in patients with eating disorders. There is a higher chance of low potassium in patients who purge due to its loss through emesis, urine output from diuretics, or diarrhea secondary to laxative use. Patients who continue to purge will have increased volume loss, and as a result, the body will increase aldosterone secretion. This further potentiates the loss of potassium in the kidneys by more excretion. The continued loss of potassium causes the patient to become metabolically alkalotic and, in severe cases, can lead to QT prolongation, development of torsades de points, ventricular fibrillation, and sudden cardiac arrest.
Hypomagnesemia can be seen in patients with eating disorders secondary to malnutrition from restricting food. Up to a fourth of eating-disordered patients were found to have low magnesium. Another reason for the low magnesium level could be the use of laxatives or diuretics. It is also common for patients with eating disorders to experience low magnesium levels when they are going through the re-feeding process if they are in inpatient or outpatient programs. Magnesium tends to follow glucose into the cells, potentiating low magnesium levels. These low Magnesium levels can cause tetany, seizure activity, respiratory depression, and cardiac arrhythmias such as atrial fibrillation, ventricular tachycardia, or torsades de points.
Hypophosphatemia can be seen in up to 44% of patients with eating disorders. The leading cause for this is secondary to malnourishment. Also, like magnesium, the patient can experience even lower phosphate levels during refeeding due to extracellular phosphate following glucose into the cells. Phosphate plays a vital role in cellular energy and structure integrity. At low levels, cells can begin to lyse, more specifically, red blood cells and cells in the muscles, leading to rhabdomyolysis and acute renal failure.
What Can We Do?
As for any prehospital treatment, the priority is addressing any life threats, airway, breathing, and circulation. You may end up focusing on this for the majority of transport time, especially if the patient has attempted suicide, is experiencing seizure activity, has cardiac arrhythmias, or is in sudden cardiac arrest.
If you transfer the patient to a facility with specialty internal medicine services or other unavailable services, you will most likely continue any treatments initiated. These treatments will mostly be electrolyte infusions such as Magnesium and or Potassium to address acute life-threatening cardiac arrhythmias the patient could be experiencing. You may also see an attempt to correct a low sodium level if the patient has neurological symptoms or is experiencing seizure activity. If this is being done, please be careful not to raise the sodium level too quickly, which can cause Central Pontine Myelinolysis (Osmotic Demyelination Syndrome). If the patient is hyponatremic, it is best not to correct more than 6-8 meq/l over 24 hours. If you can reassess electrolyte levels during transport, I would encourage you. If the patient is not seizing or in a lethal arrhythmia, it is almost never a good idea to attempt and fix a low sodium level. It has likely been that way for a while and will need to be carefully elevated by a nephrologist.
It is imperative to recognize that these disorders are serious mental health disease processes. Continue to remain professional and ensure you don’t consciously or unconsciously allow bias to prevent you from doing what’s right for your patient. Unfortunately, you won’t be able to “fix” the patient when they are with you. Once they get to definitive care, the priority will be refeeding, addressing the severe malnourishment, and normalizing the metabolic derangements. Once that is complete, the focus will be placed on addressing the underlying mental health conditions and matching them with the inpatient or outpatient resources they need.
“The moral responsibility of the healer is to step inside the patients’ experiences and accompany them through the worst moments with empathy and expertise” –Dr. Paul Farmer
About the Author
Hanna Thompson is an experienced paramedic, educator, and flight crew member for Life Link III, who has also extended her expertise internationally by volunteering with Haiti Air Ambulance (HAA). Her contributions in Haiti, especially following the devastating earthquake in August 2021, were significant. During her time with HAA, Hanna participated in over 50 flights in just three weeks, helping provide critical medical support during a time of extreme need. This dedication not only underscores her commitment to medical service but also highlights the strong partnership between Life Link III and Haiti Air Ambulance, aimed at enhancing emergency medical response capabilities. Additionally, Hanna is a writer for FOAMfrat, where she contributes her valuable insights and experiences to enrich the educational content for emergency medical professionals. Her work is a testament to the collaborative efforts in providing life-saving medical interventions in both routine and crisis situations.
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