The woman who nearly ate herself to death: Conclusion

We did what most of you recommended: Reduce the calorie intake, maintain the infusions (they were already going at the maximum rate recommended by the BNF) and discuss the platelet scenario with the haematologist.

Reducing the calorie intake is recommended if electrolytes get deranged in refeeding syndrome, as reducing the insulin surges should help prevent the intracellular shift.

Although the electrolytes were low, one concept I have come to appreciate is that you can do more harm by correcting electrolytes too rapidly than leaving the original imbalance. For example, magnesium infusions cause flushing, hypotension and potentially respiratory paralysis. You would certainly want to spot these problems early and stop the infusion if necessary. Testing the patellar reflex is a quick way of screening for magnesium toxicity (reflex absent in toxicity). I would still err on correcting the electrolytes at the maximum recommended rate, even at these levels.

I was actually on another ward when I got a bleep about this patient. I was told she had fainted whilst on the toilet, passing a PV clot. When I returned, her BP was fine and I had requested a repeat ECG and FBC, U&E, Bone Profile and Coagulation. The ECG showed sinus tachy at 120. She felt a little dizzy. I told her to lie on the bed and gave Hartmann’s 500ml over 20 mins as a fluid challenge to see the response.

The consultant haematologist was at a golf club when I rang. I explained about her bleeding episodes, and that this was a presumed new platelet problem. I gave him the obs and the latest Hb (10.1, from 10.7 the day before). He was not concerned, and asked me to ring if the patient bled again. I have since looked at the guidelines and could not classify where exactly my patient would fit – can you?

The next morning (Sunday), the patient became very confused and paranoid. She insisted that we were holding her against her will. She refused all IV medication and would only take tablets.

I politely asked her if she would be happy to take some extra vitamins. I gave her an extra 200mg of thiamine and asked the nurses to avoid feeding her until she seems calmer, or until lunch, whichever is the earlier. Looking back, this may have been an alcohol withdrawal episode. I suspect she was drinking more than a bottle of vodka a week prior to admission. Delirium tremens is not all about Liliputian hallucinations. It is a hyperadrenergic states, with sweating, tachycardia and cardiovascular collapse. My patient had many of these signs. Whilst gradually realising this and writing up a chlordiazepoxide regime, I was tapped on the shoulder by a concerned nurse.

“She’s just made a 999 call that we are holding her against her will.”

30 minutes later, she self discharged.

This was probably an acute confusional state. She was so grateful for our care the night before. Medico-lego-ethico wise, were we right to just let her go?

(In case you are worried, I have liased with her GP, and found out she has visited him since and that her bloods have improved markedly).

The woman who nearly ate herself to death

A woman in her early 40s is referred by her GP to the Acute Medical Unit feeling generally unwell.

“What’s the main problem?”

“I’m depressed.”

Me too, I thought.

“I’m sorry to hear that. Why do you think you are depressed?”

“My fiancé broke up with me a year to the day last week, and I lost my job yesterday (details slightly changed)”

Adjustment disorder then. I had 7 patients to clerk, and it was only 10:30am. A part of me wanted to simply screen for serious problems and discharge if possible. However, I had a feeling that quite a few more open questions would be needed to ensure we get the full history in a patient in this frame of mind. I also needed to make sure she did not get the feeling of time pressure to ensure she really spoke her mind.

“I’m sorry to hear that. How have you been since?”

“I’ve not eaten for the past 7 days. And for the last 5 days, every time I eat, it comes back up. Dark brown with black specks.”

Hold on. Poor appetite goes with depression, but possible coffee ground vomit? I had another look at her obs:

  • Pulse 103
  • BP 130/70
  • RR 18
  • Sats 100 on air
  • Temp 36.4

The tachycardia concerned me in light of her possible GI bleed. I decided to get some IV access and take some bloods while taking the rest of the history. There were no other abdominal signs, other evidence of a GI bleed or risk factors apart from the alcohol use described later. She also reported heavy periods recently, but no other coagulation deficit symptoms. She had been suffering with extreme fatigue, poor motivation and poor sleep as well as low mood. She had no suicide ideation. Her past medical history was remarkable for a period a year ago where she would drink 1 bottle of vodka a day. She said she only drank a bottle a week now. No other drug use.

I was still thinking depression/adjustment, but wanted reassurance from the bloods that there was no evidence of a bleed.

I sent FBC, U&E, Clotting, TSH, LFT and Bone Profile, including Magnesium. I gave 1L  Hartmann’s over 8 hours whilst I awaited her results.

I was phoned by the lab regarding the following results. The rest of the bloods were normal, including LFTs and coagulation. (Although BMJ learning has produced an excellent e-learning module highlighting that in alcoholic liver disease, the main problem is synthetic function, and it is not unusual for LFTs to be entirely normal).

  • Hb 10.7
  • WCC 8.4
  • Plt 20
  • Na 128
  • K 2.3
  • Urea 1.8
  • Creatinine 34
  • eGRF >90

I switched her fluids to 1L N Saline with 40mmol KCl over 4 hours, then 8 hours, and informed my registrar. An ECG showed no changes.

Hypokalemia could be explained by her vomiting, which would also explain her hyponatremia (1L of gastric fluid contains 20-80 mmol Na and 5-20 mmol K according to the BNF). I thought back to her history and realised something else may be going on.

To reiterate the risk factors for this condition:

Very poor intake for 7 days

Previous alcohol misuse

What I was thinking of was Refeeding Syndrome.

I recently prepared a brief presentation on this case. To cut to the essentials, the longer the patient has been starved and the worse the patient’s pre-existing glycogen/lipid stores, the more the patient will switch to using proteins and ketones.

When you reintroduce glucose to a patient who has primed their body to preserve glucose at every possible opportunity, there is a massive surge of insulin.

This insulin shifts the intracellular electrolytes even more intracellularly. In particular, phosphate, potassium and magnesium levels drop alarmingly. In addition, insulin stimulates glycogen, fat, and protein synthesis. This requires phosphate, magnesium and thiamine.

Our patient was given 200mg thiamine and 2 Vitamin B Strong tablets before anything else. This is because when we do refeed her, the surge of glucose will deplete the thiamine reserves. (Or so we are taught, and NICE guidelines suggest. Have a look at the flip side). Whether or not this is actually true, 200mg of thiamine doesn’t do harm.

I advised her to avoid high glucose foods, and to eat about 50% of her normal amount of food per day. I informed the nurses of this plan.

The next day, her electrolytes came back as:

  • Na 131
  • K 2.7
  • Ca 2.0 (adj)
  • Mg 0.31
  • Phosphate 0.33

This was getting quite serious. Magnesium deficiency causes torsades de pointes and seizures. Phosphate deficiency causes weakness and dysphagia, which is the last thing you need in a starved patient.

We had to now prioritise the IV fluids. We could only get two cannulas in. Hypomangesia in itself leads to hypokalemia through a renal mechanism and causes torsades as described. Hypokalemia causes many arrhythmias. These two needed to be corrected first. We also started cardiac telemetry.

We started a 20mmol phosphate infusion after 30mmol of magnesium had been given. We infused these electrolytes at the maximum recommended rates in the BNF. A repeat electrolyte count later in the day showed similar results, despite the IV fluids. She seemed to be in normal fluid balance, with an improving urine output and stable obs. The nurse did mention visible haematuria (plts = 20, Hb 10.1).

Our management plan, and what happened next, will be revealed in the next post.

The unsung hero of Littletown

4pm.  The fag end of a long day. I was tidying up the loose ends, when I noticed an old lady visiting one of the siderooms. The patient in there was in his late 30s with end stage multiple sclerosis, who presented with multiple seizures. A CT head had shown no new problems, just long standing hydrocephalus which is a possible late sequelae of MS. Incidentally, there is some controversy as to whether the apparent hydrocephalus on imaging in MS is a true communicating hydrocephalus or just the appearance caused by periventricular white matter loss with disease progression.

I remembered this was a patient who was a potential discharge. I had seen him myself earlier, and remembered that he did not respond to direct questions but seemed alert. We did not know his baseline status nor his care package, so I hoped that this woman would be able to shed some light.

“Hello. My name is Viral, one of the doctors. May I ask how you know Mark?” (not his real name)

“I’m his mother.”

I thought this was a possibility, but I had assumed she was too old to be the mother of a 38 year old.

“Would it be OK to ask you a few details about your son to help us plan his return to home?”

I took a social history, and established that this man was entirely dependent on his live-in carers for 24 hours of the day. He relied on them for eating (via his PEG), toileting, moving, cleaning, financial work…virtually everything I could think of.

I thought how terrible it must be for a mother to see her son like this. The she said something which stunned me.

“It’s just him and me. My husband died four years ago, and we only had one child. I had no brothers or sisters, so it’s just us.”

There I was, planning a discharge and checking the obs were stable and feeling like I had it tough when I was face to face with a woman who knew she was the only person in the entire world who would ever really care for this man properly. If she was not there, this man would have no one.

The fragility of the situation struck me.

She told me how every time he is in hospital, she lives alongside him during every visitor hour possible. She spoke directly to her son, and for the first time since his admission three days ago, I witnessed this man speaking and replying to questions. She told me about the foods he liked before the PEG, and the way he used to charm the nurses into giving him his favourite foods. She smiled fleetingly at this memory, before her concerned expression took hold of her face again.

“He’s all I’ve got.”

This man clearly needed his mother. However, the mother also needed her son. He was all she had in this world, and his dependency on her seemed to give her a strong sense of purpose. She understood the medical background to MS very well, and taught me a few things about the various treatments in end stage MS. She prided herself on the level of care she gave her son, and I was very impressed by the depth with which she had researched the condition and sought out the very best treatment.

I shuddered to think what would happen when one of them passed away, leaving the other. I realised that this situation was inevitable. There was the here and now, these fleeting moments when one human can care for another and the other human is reassured knowing they are loved before one of them will be utterly alone with just fading memories to keep them company.

None of the care we give in medicine can compare to a mother whose very life is caring for her son. The son was clearly happiest when the mother was around, as evidenced by his improvement in interactions and communication, and by restricting these times to visiting hours only we could only be causing them anguish. I realised then that sometimes our duty as doctors was to get patients back to their status quo as soon as possible, perhaps more than trying to fix every last medical detail.