Sick Enough by Jennifer L. Gaudiani

Author:Jennifer L. Gaudiani
Language: eng
Format: epub
Publisher: Taylor and Francis

Case Resolution: Manuel

In the ICU, the doctors are familiar with eating disorder medicine and make the diagnosis of bulimia nervosa. The team assesses that Manuel has profound volume depletion, and they know about the risks of pseudo-Bartter syndrome. They begin normal saline that has a little potassium in it at 75 ml/hr and give Manuel 50 mg of spironolactone a day, starting that first day, even when he has low blood pressure. Manuel’s serum sodium is checked every four hours because they know it should not rise more than 4–6 mEq in 24 hours. The ICU team administers 60 mEq of oral potassium upon arrival, and then prescribes 40 mEq twice a day, knowing that more than that will just make his stomach ache. Intravenous magnesium is started, and this continues until his levels are consistently above 2 mEq/L. Two days later, Manuel has a normal serum sodium, normal potassium, normal bicarbonate, normal magnesium, normal vital signs, and his EKG QTc interval has normalized as well.

Manuel is transferred out of the ICU to the medical ward, and he feels absolutely miserable. His body looks and feels different to him because he is no longer dehydrated, even though he has no edema. Knowing that he has to make meaningful progress toward recovery, he eats the food the hospital brings him and does not purge, but it’s a huge struggle, especially without psychological support. The social worker offers to connect him with residential eating disorder programs, and he reluctantly accepts these referrals. His eating disorder tells him to refuse, that he can simply go home and “do this by himself,” but in his heart, he knows he needs a higher level of care. He worries that being in a larger body will mean that he’s not sick enough to enter residential care, but upon completing intakes, he learns that he does indeed meet the guidelines. He transfers from the hospital to residential programming and completes a full course of treatment. When it’s time for him to discharge from the facility, the staff members make sure that he has referrals to a terrific eating disorder therapist, dietitian, and doctor, upon return to school.

The Sponge Metaphor and Finding Self-Compassion

When discussing dehydration, rehydration, and edema, I tell patients the sponge story. There are three types of sponges. On one side of the spectrum, there’s the hard, dry sponge that’s been sitting on the counter for a week. On the other side of the spectrum, there’s the sopping, dripping sponge you get after running the sponge under the water. In between, there’s a soft, pliable sponge that doesn’t have an extra drop of water in it.

I tell my patients who purge that presently they are like the dry, hard sponge. I want to avoid making them like the sopping sponge. Instead, I want for them to be the middle sponge. To do this, we have to do the equivalent of putting the dry sponge in the sink and dripping water slowly onto it while checking it regularly … not flooding it with the faucet fully open.

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