Emergency Department Intervention for Dangerously Low Electrolytes

3/24/19

As many of us have learned, unless you live in a city or area that offers a hospital with an up-to-date eating disorders treatment facility, when your family member's [FM] electrolytes are found by lab work to be dangerously low or his/her behavior indicates something is awry, the place to go for help is the nearby hospital emergency department [ED].  There one can obtain a lab order for blood work and, if necessary, electrolyte replacement and professional attention as well as admission to the hospital.  This important visit can be life saving.   A process to streamline this is needed.  Better yet, would be a clinic or hospital wing with staff trained to provide immediate care.

However, since the ED often has a line of people waiting for care ranging from things (observed this most recent visit) like uncontrolled vomiting, pain from kidney stones, high fever and coughing to broken limbs, heart attacks and concussions, the practice is to triage each patient.  This process evaluates the person and the immediacy of his/her need for attention.  In other words, just because you came in before the next person does not mean you'll be seen before that later arrival.  Then the person is seen usually by a nurse practitioner or doctor who places orders for procedures.  These first two steps can sometimes consume at least an hour or more of time.   The lab order needed requires a ready phlebotomist to draw blood and the lab analysis can take an additional 30 minutes or more.  Next steps can be delayed even further if the ED doctor(s) have many patients and have not been alerted to the results.

As those of us have learned as we support our FM, many times there's nothing "visible"
during triage to evaluate their place in line unless our FM has collapsed and been taken to the ED by ambulance.  Even then, as I have again recently been reminded, that method of transportation does not guarantee immediate action because there's still the question, "why are you here"?  In one instance, for example, FM was slurring her words and the ED doctors accused her of drinking alcohol when in fact her sodium level was 119.  Fortunately FM was alert enough to strongly object to the incorrect diagnosis and knowledgeable enough to demand a blood draw because FM knew what likely was wrong.  Perhaps a medical ID bracelet would be a good idea?

Having observed all of this many times, I have made certain that we have information in hand that can potentially speed up the process from triage to electrolyte replacement.  The most recent visit still took more than 3 hours from triage to set up, a time delay which could mean the difference between life and death for someone whose system cannot tolerate dangerously low levels.

Following is a suggested process that could be implemented at a hospital ED.  I have found it helpful to bring along a copy of the Academy of Eating Disorders Guide to Medical Care that provides critical points for early recognition and medical risk management in the care of individuals with eating disorders.  You can access this guide here, download it and print it or you can order copies from the AED (see the website for more information).

(1) your family member with an active eating disorder, for example anorexia subtype bulimia involving starvation combined with binging and purging or water loading (meaning drinking water prior to being weighed to increase his/her weight or even drinking water to feel full), needs to have a standing lab order in place from his/her PCP for at a minimum a Basic Metabolic Panel taken at least every two weeks and perhaps more often.

(2)  The laboratory that receives the standing order must provide you or if an adult, your family member, as well as your doctor with the results immediately if a dangerously low reading is obtained.  Be aware of what low levels are.  This report needs to be available electronically, if possible, so you can download and print the results to take to the hospital ED.  Time can be of the essence.  The report may indicate "LL" for very low level.  Often the report will highlight low level items in a separate list on the report.

(3) if you/your family member are alerted that the levels indicate immediate electrolyte replacement, upon arrival at the hospital ED, during triage provide the lab report and highlight the low electrolyte information.  Often I have learned the low numbers do not trigger the response you hope for so if I am present (and if not my FM knows to say) I call attention to the number and now state, "I need a phlebotomist to perform a blood draw and electrolyte replacement as soon as possible, please."

(4) Next step is with the medical professional who orders the necessary lab draw and any other tests or alerts deemed necessary.  Often, because ED's are usually very busy, FM will be told to go back out into the emergency area to wait rather than taken to a room.  If so, please encourage FM to stay put and within earshot to hear his/her name.

(5) FM is taken to a room or bay area and preparations are made to draw blood and to have an IV port inserted for administration of fluids with electrolytes.  The blood draw specimen goes to the lab.  Expect an additional wait of 30-40 minutes at this point.

(6) if the levels of both sodium and potassium are unsafely low (my FM once had a low of 115 for sodium (Na) and the hospital called me and prepared me for her possible death before I got there) your FM will receive the necessary electrolytes by IV.  It's extremely important that the sodium level be increased slowly and carefully (this information is explained in the above booklet).  In my FM's case, she is unable to tolerate the pain caused by IV administration of a potassium solution and demands an oral solution instead.  NB - if your FM is known to self-sabotage by purging whatever s/he is given or  drinking water from the faucet in the bathroom, alert the staff and request a commode in the room.  Ditto if the FM requests food once food and drink are permitted.  Your FM may be attached to a heart monitor especially if the potassium reading is dangerously low.   Years ago (2011) FM was mistakenly given a sodium solution for several hours and her levels went far above normal.  Fortunately there were no side effects possibly because FM's system was accustomed to these huge swings.  You can learn more about this at the link eating disorders and central pontine myelinosis.

(7) if the level of eg potassium was found upon admission to the ED to be 2.5 or less, the ED personnel should request a followup blood draw before discharge from the ED or admission.  I now always ask for this blood draw especially because our FM gets the solution orally and if the ED is inclined to discharge him/her directly home rather than admit her/him to the hospital.

(8) if levels were found to be very low, best practice would be admission to the hospital floor and oversight administered by a hospitalist who is well-versed in the care of someone with an eating disorder.  Most recently my FM was very fortunate to have a hospital floor nurse who knew immediately that another blood draw was needed to establish next steps.  Again, the booklet will prove very helpful.  The goal at this point will be to stabilize your FM and increase his/her electrolyte levels to the minimums and develop a plan for discharge and follow up with his/her PCP.

I also recommend (and have been distributing) the recently released (Routledge, 2019) book Sick Enough - A Guide to the Medical Complications of Eating Disorders by Jennifer L. Gaudiani MD, CEDS, FAED.  This has been at considerable expense to me but I believe that in addition to possibly saving the life of my family member, the book just might educate other medical professionals who have the curiosity to learn more about eating disorders.   I have learned here in Tucson that many doctors, even those attending in local psychiatric hospitals, have received minimal training in the medical aspects of eating disorders, nor have they a reasonable understanding of what goes on in the mind of someone fighting an eating disorder.