Podcast – Eating Disorders in the Emergency Department

I’m going to come in straight with my take-home message, which is eating disorders are deadly. Really sadly, there’s a lot of press lately, probably in the last five years, reporting really sad deaths of mainly young women, mainly at the transition age, and they’re eating disorders are deadly. We’re still quoting actually anorexia nervosa as being the most deadly of all psychiatric conditions, so it’s something like a 10% lifetime mortality risk if you have anorexia nervosa. The coroners here have reported failings, medical failings, lack of a woeful lack of knowledge.

And I guess that’s kind of understandable, there’s a BMJ report in 2018 looking at how much training we get as undergraduates and something like two hours in our five years of training in eating disorders and undergraduates. We also know that eating disorders are increasingly prevalent. There’s been a 90% increase in admissions through our ED department and through our PAU’s to our awards in the last five years. Just imagine if we’re seeing a 90% increase in things like TB or measles, what a forgery that would cause. They’re deadly, about one in five of deaths of eating disorders are from suicide, so if my maths is correct about four out of five of those deaths are from medical complications, so we need to know about this, it’s an epidemic we need to know about.

I’m going to try and take you through assessment and management of a eating disorder in your body, the medical complications and some top tips. So what are you going to see? You’re going to see patients presenting basically with the effects of starvation, with the effects of malnutrition and that affects pretty much every system. You’re going to see people who have not got enough nutrition and not got enough energy on board and essentially what happens then is everything slows down, pretty much every physiological system in your body slows down and some actually stop. So, for instance, if we take the gastric system, I would say that pretty much 100% of patients I see will have constipation. They’ll complain if abdominal pain or complain of bloating, can get a gastroparesis and that’s basically because if you haven’t got enough energy coming in, things are going to start slowing down aren’t they? So the peristalsis, the guts are going to become really sluggish, so it is going to feel like when they’re eating it’s just sitting there and it’s just not moving through and that’s going to cause tummy pain. And it’s also kind of makes sense doesn’t it? If you’re not eating very much then the gut needs as much time possible to extract all the nutrients out of that small amount of food which is going through. So constipation really common. Fertility obviously in the impact of fertility hopefully is going to be transient, and that’s going to be down to the secondary amenorrhea that we see. If you period, stop that’s a really clear sign that you’re not eating enough and your body is not happy. Again a really clever actually evolutionary adaptation amenorrhea. If we look at populations that have been plunged into famine, fertility generally drops across that whole population because what’s the point of bringing in another child into population where there’s not enough food to even make you healthy and to be able to support a baby?

Bones. So we know that young people would low weight from not eating enough are at increased risk of low bone mineral density and at increased risk of fracture later in life. And that’s because if they’re not having periods then they’ve got low estrogen levels, they’ve got low IGF1, they’ve got higher cortisol because it’s quite a stressful position and that all impacts on bone turnover. We quite often see sick euthyroid syndrome so we may see low T4 and T3 when we do bloods but a normal TSH, please don’t start them on thyroxine. They don’t need thyroxine, they just need food. Haematological, so we get the slowdown in bone marrow work, really effort of work and we often see a neutropenia. Neutropenia is really common in people who are underweight and it’s actually quite a good way of tracking their weight. You see the upwards flick when you begin to gain weight as well and a lot of them can be in the mech. We see impact on hair and skin, brain. So things begin to slow down and if you’ve only got a certain amount of energy your body tries to power the most important things which is essentially a heart and brain. So if you’re seeing symptoms which are both cardiac or the brain and when I talk about the brain I guess I’m talking about a slowing of cognition, poor concentration, then you know something’s really up.

So, we’re just going to talk a little bit more about the cardiovascular system. So, bradycardia is really obvious one that I’m sure you’re all aware of. We worry about a bradycardia under 40 and eating disorders, that’s a red flag. Please don’t give them an atropine, what they need is food. Commonly see signs bradycardia but we can see heart block and we can see things like a junctional modal escape rhythm. I’ve seen that a couple of times and looked at the ECG, technically freaked out, phone cardiology friends, luckily didn’t need anything other than admitting and feeding and nutrition. We often see the partial tachycardia and the changes in blood pressure but we also see pericardial effusion and actually papers and the poor pericardial effusion, asymptomatic pericardial effusion to be somewhere about a third of young adolescent girls with this. We’ve seen this fairly recently just in our hospital when we echoed a girl who presented with pitting oedema up to mid thigh with a refeeding. She got an echo and she had a really large pericardial effusion, three centimetres surrounding both venticles. Again that doesn’t need pericardia as an t-cif, it doesn’t need draining, it needs food and it will settle at a time. Left ventricular atch fee, again I guess quite understandable really if you’re losing muscle bulk from the rest of your body, you’re also losing muscle bulk from your biggest pumping organ and with that left ventricular atrophy you can see mitral valve prolapse. I’ve picked up a few new systolic murmurs and clinic who’ve gone on to have echoes and it has been mitral valve prolapse. It may be the reason that some people present with chest pain and dizziness and fatigue. Again it doesn’t need surgery, it needs food, that left ventricle with improved and hopefully the prolapse will improve too.

So the brain basically shrinks which is pretty significant isn’t it and quite often I will show these images if I’m seeing a patient in an outpatient setting and I’ve got the time just to show the impact of a malnutrition in the brain. So basically what you’re going to see in A&E is you’re going to see people presenting with signs and symptoms that are attributable to starvation so they’re going to come in with a whole range of symptoms. You’re either going to get a patient who’s got a no-needing disorder and that more likely to have been brought in actually probably by worried parents or you’re going to have a patient who don’t know necessarily is good at eating disorder and hopefully you’re going to pick it up on your screening whether that’s your head assessment or something called a scoff screening. What is your role as somebody who is working out of an emergency department? Your role is basically doing a risk assessment and this is what you guys are all really great at. What you’ve got to decide is is this young person well enough to go home and be discharged or do the needs be admitted and we’ve got these fantastic new guidance, mead guidance, managing medical emergencies and eating disorders which came out in about March 2022 to replace the Marzipan guidance and we can use these to try and help our risk assessment. The mead guidance gives us a lovely rag rating of red amber and green. Here are the red flags. What I find really useful is sharing the mead guidance and the rag screening with the young person with the family because what it does actually say is for those red flags it actually says impending risk to life and for the amber flag says alert to impending risk to life. So it really hammers home the importance of us doing a really thorough examination of this young person because this is serious, serious illness.

The main red flags that I tend to really focus on are the rapidity of the weight loss. Not necessarily the BMI although that is important but it’s the rapidity of the weight loss. The heart rate, the blood pressure, really useful. I talked a little bit about the postural tachycardia we see in the postural drop. That’s also really useful to track progress so when people are getting better usually within about six, seven days you see that improve. The other thing that’s really useful to try and do in your ED department is the soft test. So that’s the sit-up squat sound test, it’s essentially a test of their muscular function and how strong they are. Your department should have a mead performer. This is the one we’ve just started using just last week in Tornton. I borrowed it and been lent it from colleagues from out of Leicester Children’s Hospital. I really like it because it’s really simple, it’s really colourful. It basically takes the mead criteria and pops it into this flow chart for you with some hints of what to ask and why it’s important to ask those things.

I guess the things I just wanted to make you aware of is quite often young people will sit in front of you with a very normal heart rate. But when you’ve got somebody telling you that they’re only eating a lettuce or a cucumber each day, that’s not reassuring and it’s possibly because they’re sitting in an emergency department and if you get them onto an ECG machine and rest them, their blood pressure, sorry, the heart rate will probably drop so don’t be reassured by a normal heart rate. Risk assessments are always just for a guide and I would really want you to think about if you’re going to admit this young person and what mead suggest is if they’ve got one red flag or two am was the need of missing then it really ought to be a joint discussion with your CAMs colleagues if you’ve got them and ideally if they’re in the hospital have a chat with them because it may well be that they don’t take many reds on your physical criteria but if the parents are saying but if I take a home and push it to each is going to self harm or if I push it to each is throwing glasses I’m really worried about my safety then there may be a reason to admit that for more of a psychosocial reason as opposed to a pure physical reason.

So, I’ll put some communication, remember the bunch jump. And the young person has a plate of food put in front of them it is like asking them to step off a cliff every single time, three meals a day, three snacks a day, they are incredibly fearful, there’s terror there and they’re in that fight and flight mode the whole time. So just remember when you’re talking to these young people you know how difficult it is to communicate and to converse and to negotiate with somebody is in the fight and flight the whole time. You can often use all your skills to try and bring them out of that before you can connect them before you can have a good chat with them. Separate the care from the young person and separate the young person from the ED. What do I mean by this? I mean it’s always really good to see young people with their parents to get a history but very often what I see is the young person may be giving their history of this is how much I’m eating, no I’m not purging, I’m not so much exercise and I can see their adults sitting behind them going just cringing because they know that that’s not the truth but many parents are not going to want to jump in and challenge their adolescent for obvious reasons they don’t want them having an angry outburst they don’t feel like they’re undermining so it’s really important to try and talk to the parents alone too because you’re likely to get quite a different story.

We know that eating disorders can be really secretive, they can be deceitful, they can be dishonest. It’s the eating disorder that’s doing that and not the young person which is what I mean by separate the young person from the eating disorder. It can be really helpful to externalise the eating disorder and say I can see that the eating disorder is making you do this, I can see that the eating disorder is really challenging you here, really try and separate them. The young person on not manipulative is the eating disorder that’s making that happen. In pediatric I think we really really try to be this you know keep calm and carry on don’t we? We want to appear like we really know what’s going on which hopefully we do most of the time we want to keep the parents alone, we want to reduce the parents anxiety. We’ve got a little chap who comes in through it easy whether he’s got a group or whether he’s got a wheeze, we’re likely to say no problem we’re just going to pop you into recess, we’re just going to pop this adrenaline mask on your face, we’re just going to pop this candy ring, we’ve seen this before, we know what we’re doing, we’re just going to do some popping.

The difference with the eating disorder, the difference with an eating disorder is you’re very likely to have a young person who’s sitting in front of you who’s possibly been brought in by worried teacher or parent who’s saying there’s nothing wrong with me, I feel fine there’s nothing wrong with me, I’ve just been to the GP and they’ve told me me ECG is normal number, blood’s normal, I want to go home. What we need to be doing is sharing how can you say I’m really openly with this family and actually we’re almost trying to just raise the anxiety a little bit so we need to be explaining that normal ECG’s and normal bloods aren’t reassuring. Our bodies are really really good at keeping everything stable and keeping everything just right. So for instance looking at that boat I would say to you is that boat floating, most of you would go, but the only reason that boat’s floating is because you’ve got men and possibly women bailing out that water as fast as they can. I can’t tell you at what point those people’s arms are going to get tired and that boat is going to sink and that’s what I’d be saying to a young person, your blood may be okay at the moment, your blood pressure may be okay at the moment, but I can’t tell you how long it’s going to take for your body to suddenly crash and to suddenly fail because you’re not eating enough or you’re exercising too much.

You need to be steering away actually from minimizing or trivializing the illness because if you say something like, well your arms are okay today so you don’t need it missing, that’s going to go one of two ways and both ways are bad actually. That eating disorder is going to hear, you’re okay, you’re not unwell, you can go home and continue what you’re doing or even worse it’s going to hear that doctor has just said you’re well, that doctor has just said you’re fat, you’re not doing a good enough job with this, you need to try harder and they’re going to go home and restrict even more. So really, really think about your language if you’re going to be discharging someone from your department, you need to be saying your obziricate at the moment, this is not reassuring because of this, this, this, this, this, this, we’re going to keep a really close eye on you, we’re going to check, you know, hopefully check you again whether that’s in the community or the GP so that they’re not hearing that they’re okay. We really try and stay away from talking about weights and calories, you’re going to get into this vicious cycle of lots of battles and lots of negotiations.

Actually, when, when we admit people to our ward, I’m quite clear that we’re not admitting them to achieve weight gain, okay? What we want is we want a regular eating pattern, we want them to know how much they need to eat, we want to be able to keep them bed rested, we want to be able to help with their restricting their exercise, we want to give their parents a rest. Of course, if we get all that right weight gain will be the end result, but really try and steer away from talking about weight and calories. What we’re wanting to do is to improve their health, to improve their heart rate, to improve their blood pressure, to stop them from fainting. And we tend to try and blind way if we can. If they’re heading towards sort of 16, 17 years, then some people will want to know the weight and it’s important to give them that really, but always chat with the parents if, if you’re not sure, don’t just blood out a weight in front of them. And the last thing I just want to leave you with is steer away from any sort of blame, okay?

Eating disorders are not lifestyle choices. They are not a parenting failure. Time and time again, we hear young people and these families talk about shame and talk about guilt of having a mental diagnosis in their family. They feel shameful that they’re taking our time up. They repeatedly say, “I don’t know why you’ve admitted me, I don’t need to be here, there’s people who are far more worthy.” These kids are worthy of our time. These families are worthy of our time. They’re worthy of seats in our way to room and the worthy of beds in our wards. Please give eating disorders the same empathy and attention and compassion as you would give to any other young person, whether that’s admitted with leukaemia or pneumonia or DKA. Thanks.