DENVER >> After collapsing in the street across from her Kansas City, Missouri, home, 43-year-old Hallie Smith showed up at a hospital emergency room bleeding badly from a gash above her eye. But she heard a more dire diagnosis when the attending physician examined her gaunt physique: You’re going to die within 30 days if you don’t get help.
At that point, she was an emaciated 5-foot-7, growing weaker and missing work to the point she lost her job as an exercise instructor. People warned her she had gotten dangerously thin. She looked in the mirror and saw a fat person, reported the Denver Post (http://dpo.st/29L4aIV).
The trip to the ER provided a wake-up call to Smith, who had never been treated for anorexia nervosa, the psychiatric disorder she traces to the trauma of watching her mother, tall and beautiful, gain considerable weight after going on medication for bipolar disorder and eventually commit suicide.
When nearby eating disorder treatment centers balked at accepting Smith in such precarious condition — or voiced concerns about insurance coverage — she was pointed to Colorado for specialized medical stabilization she regards as life-saving.
“I was dying, and I didn’t know it,” Smith says. “I was caught between a rock and a hard place — but really, between a rock and death.”
She spent about three weeks occupying one of the 15 beds at the ACUTE Center for Eating Disorders at Denver Health Medical Center, the first and only facility in the country that offers medical stabilization for people with eating disorders. Like others in the unit, she aimed to transition to an inpatient or residential program that treats the psychiatric roots of her illness once the physical problems were resolved.
Anorexia, which has the highest mortality rate — up to 30 percent — among psychiatric disorders, as well as bulimia and other malnutrition-related eating disorders, can trigger a unique set of life-threatening physical complications. Malnourished patients also remain at high risk from “refeeding syndrome,” which can wreak havoc on metabolism with sometimes fatal consequences once they begin eating again.
“You can be a robustly healthy schizophrenic,” says Dr. Philip Mehler, founder and executive medical director of ACUTE. “But you can’t be a severe anorexic or bulimic and not have a litany of medical complications. I was struck by the paucity of medical resources for people with eating disorders.”
As eating disorders became more prevalent in the 1980s and ’90s, Mehler began seeing more and more patients show up at Denver Health close to death. In 2008, he launched the ACUTE Center with two beds to deal with those cases, ultimately forming a multi-disciplinary team that includes dieticians, psychologists and psychiatrists, nurses, social workers and physical and occupational therapists.
Patients live on the same floor, but their care remains very individualized, in part because people with eating disorders tend to compare and compete. Doctors might discuss calorie intake or trends of weight gain or loss, but they avoid talking in terms of specific weights.
“A typical doctor might see one or two cases like this in 30 years,” Mehler says. “Ours see hundreds every year. To do this well, you have to see a lot of it. It’s clear that in certain things, volume does equal quality. There are very few people who understand this from the medical side.”
The ACUTE Center took off, growing from two beds to four to its current 15, with plans to expand to possibly 20 to 30 beds in the next two years.
Dr. Margherita Mascolo, ACUTE’s medical director, calls the fifth-floor facility “an ICU for the medical complications of eating disorders.” Because it’s attached to Denver Health, patients can have quick access to expertise and equipment to deal with a broad range of medical complications.
“We’re a 500-bed safety-net hospital,” she says. “Anything is available.”
Still, the center faces barriers to serving patients. Mehler says some medical facilities insist on treating eating disorder patients themselves rather than referring them to a specialized center. Education and outreach have become a key part of ACUTE’s mission.
More than 90 percent of patients come from outside Colorado and some other candidates may be constricted by travel. Insurance plans may also have travel restrictions, though ACUTE more recently has cultivated strong relationships with major health care providers. The center’s services generally fall under an insurer’s medical benefits, leaving mental health coverage to pick up the more traditional inpatient or residential treatment once a patient has been stabilized.
“There are treatment centers all over the country, but once patients hit a certain threshold, they’re too sick for behavioral health or psychiatric programs,” says Rachael Harriman, ACUTE’s administrative director. “When they need to be medically hospitalized to deal with the effects of malnutrition or starvation, that’s where we step in.”
Criteria for admission vary on a case-by-case basis, but generally low weight — below 70 percent of ideal body weight — can be a strong indicator, and the center has seen patients as low as 45 percent. Extreme behaviors, such as purging or abusing laxatives, also can trigger medical complications even if low weight isn’t a factor.
“The biggest barrier,” Harriman says, “is to get people to know we’re here.”
Three weeks into treatment, Smith busied herself with books, her computer and practicing her French language skills. She doesn’t remember her first week in the unit — something she attributes to “starvation brain” that affected her short-term memory. She adjusted to the strict rules, including the initial round-the-clock presence of a certified nursing assistant to guard against some patients’ tendency to purge.
The physical weakness from her anorexia scared her the most, she says. When she taught her exercise classes, she had plenty of energy. But that dissipated, and along with it her core strength and concentration. With so much lost muscle mass, patients often are at risk of falling and breaking bones weakened by conditions like osteoporosis.
“It’s this force inside of you that is stronger than you are,” Smith says, describing her eating disorder. “It starts out with trauma, and it’s how you cope with anxiety and it becomes like your best friend. It makes you feel powerful and strong, even though you’re getting weaker. It’s a total paradoxical disease.
“I’m still not cured, but I’m getting healthier.”
Recently, she progressed to another inpatient program.
ACUTE treats patients 17 and older, with nearly one-third of those admitted being over 35, reinforcing the truth that eating disorders can be chronic conditions and not just a young girl’s disease. About 15 percent of patients are men, who tend not to seek treatment as early but develop serious complications more quickly.
Just down the hall from Smith, 20-year-old Dante Rana, who arrived about a week earlier from North Carolina, battled the debilitating effects of another eating disorder that falls under a new classification called ARFID — Avoidant/Restrictive Food Intake Disorder.
Rana, who worked part-time at a movie theater, wasn’t intentionally rejecting food. But he would forget to eat, or simply skip meals. He didn’t realize he had a problem until last September, when he and his doctor realized the medication he took for depression wasn’t working and he had dropped a concerning amount of weight in just a few months.
After stops at two different eating disorder clinics couldn’t halt the decline, the second one referred him to ACUTE.
“I was a very different case,” he says. “I didn’t have anxiety based around food. I’m just indifferent about it. That can change with structure and with a program about getting into the habit of eating, getting a meal plan. I know I can reach a place where I’ll be able to eat on my own.”
When he arrived in Denver, his heart was laboring because it had been weakened by malnutrition. Resting, it pounded at 100 beats per minute, well above the normal rate of between 60 and 90. Just walking to the restroom would cause it to spike to 140.
He wears a monitor that relays his heart rate to the nurses’ station. Three times a day he can walk two laps around the fifth-floor hallway. Twice during the week and three times on weekends he can be wheeled outside for some fresh air.
“I don’t know how long I’ll be here,” Rana says. “I’m in no rush to leave. I’m here to get better.”
On average, patients stay from two to three weeks, though each case is different. Generally, the medical staff looks at criteria like calorie intake of at least 2,000 per day, minimum weight requirements, stable lab results, an absence of cardiac issues and evidence that the gastrointestinal tract has recovered. Additionally, patients must be physically strong enough to participate in normal life activities.
“This is the necessary first step so they can engage at treatment and hit the ground running,” medical director Mascolo says.
Betty Lyttle, 46, traveled from Orange County, California, in 2014 to find help at ACUTE that eventually helped her continue the recovery in other programs both in Denver and back home. Her obsession with weight loss happened gradually from the time she was in college, starting with diet and exercise as a coping mechanism and escalating to include severe laxative abuse.
Her eating disorder, a type of anorexia nervosa that includes purging, became like a voice in her head that drowned out everything.
Over time, her behaviors worsened — she added alcohol abuse to the list — until her husband, Billy, led an intervention to get his wife into treatment. He called all over the country, but was told Betty was too much of a risk in traditional programs because of her dwindling body mass index and her laxative abuse. Finally, one of those programs directed him to ACUTE.
During her 17-day stay, Betty says, “something clicked.” She overcame multiple challenges, including refeeding syndrome, gastrointestinal blockages and osteoporosis, and after further treatment at traditional eating disorder facilities her life has gotten back on track. She still believes her time in Denver saved her life.
“It sounds corny,” she says, “but as soon as the doors closed behind me, the voice in my head was gone.”
Information from: The Denver Post, http://www.denverpost.com