by Robert J. Lanz, LCSW
At one point in time she had been the embodiment of the California Dream. Lustrous blonde hair and sparkling blue eyes. Golden tanned skin and perfect white teeth forming a movie star smile. She had the robust body of a cheerleader, and on one New Year’s Day, she waved and posed in that famous parade as millions of people looked on in adoration of her physical perfection. And in all likelihood, since it never seems to rain on Southern California parades, those millions idealized the climate, too. Everything in the young princess’s world was perfect.
I imagine things would be different now, but in those days, knowledge of the behavioral manifestations resulting from some parent/child conflict, some genetic predisposition or twisted addiction were less well understood. What I understood was that, at some point, the princess’s fortunes had changed markedly. The patient was no longer on her way to fame and success and all the things everyone imagined for her when her carriage passed before them on that January morning.
Nope. Now she was “upstairs” dying and someone called down to the ER for me to come up and take part in the process. The intensive care unit, on the second floor, was a long way from that flowered float that carried her down Main Street. Whatever was going on in her mind was a long way from all those California dreams that come from having a centerfold-quality body. I’d seen centerfolds. And yes, I’d seen plenty of dreamy California girls at the beach. I was also familiar with the literature on eating disorders and seen some of the photos of extreme cases. But the women who suffered from them seldom came through the ER. When they were hospitalized, their doctors usually arranged for direct admission, so it was rare for us to ever see them in person.
I can keep a game face better than most, and in thirty years of delivering the worst kinds of news to some of the best kinds of people, it wasn’t hard for me to mask my feelings. In my job, that’s a good skill to have. People are always aware of my concern, but uncovering the depth and exact nature of my emotions involves more of a cognitive process. Most of the time the people I’m working with can’t tell when I’m incensed or disgusted or terrified, so sad I want to lay down on the floor and cry or fall into the arms of the ICU charge nurse to be held and comforted like a child.
That’s about the way I felt when I came into the intensive care room where the patient, her doctor and family were all waiting for me. The sight of the princess, all hooked up to machines and IV’s caused me to catch my breath, a very rare occurrence. I could probably remember another such occasion if I searched the darkest part of my brain where horror is safely tucked away beneath multiple layers of something else. But why would I want to go there and revive those memories? Remember when you walked in and saw your parents having sex? Yeah, I don’t either, and there’s a reason for that: psychological self-preservation.
But self-preservation was totally absent there in the ICU. As I rocked onto the balls of my feet, tried breathing like a normal person and got my bearings, I saw that there was nothing normal about that room. The multiple IV bags with tubes going into arm veins and neck veins and back of the hand veins. Veins that were so prominent that even the most inexperienced phlebotomist could hit them on the first try. All skin and bones, making for very prominent veins.
More tubes. Some in and some out. A decent-sized nasogastric tube went up her nose and down her esophagus for “feeding” the princess who had long ago decided that food was off her list of things to do. She may have had a more discrete feeding tube sewn into her stomach. I don’t know, as that part of her, what there was left of her, was under the sheet. Looking under the sheet might prompt more thoughts I didn’t want to entertain. The last tube was the ever-present urine catheter used to measure fluid output. Everything coming in gets measured. Everything going out does, too.
The concerned parents were at the bedside. One of the brightest doctors in the hospital was at the bedside. Some of the most skillful nurses in the hospital were at the bedside, and now one of the most experienced social workers in the hospital was in the queue. All of us stared at the patient in disbelief.
“What happened to our daughter?” the parents were likely wondering. “Is there anything else we can do?”
The normally objective nurses might have thought, “She used to be the girl I once fantasized about being.”
The doctor was probably thinking, “How did we lose control of this situation? There’s nothing left to do but call in the social worker.”
I was thinking, “I wonder what they expect me to do?”
When doctors and nurses and families are about to enter the totally helpless zone, the zone where no one is quite sure what to do, they call in the social worker. It’s one of those times when everyone knows what is going to happen, but no one knows what to do about it. The family looks at the doctor. The doctor looks at the patient. The nurses adjust the tubes. The patient now weighs sixty-two pounds and her bones stick out like those of the women in documentaries about German death camps during World War II. The once sparkling eyes are sunken deep into her face, colorless, barely there. A fine dusting of delicate little hairs called lanugo covers her face and body, a product of her whacked-out starvation body chemistry.
She’s slipping away right in front of us despite all the IV’s containing whatever is running into her body. As with any other grave illness, sometimes you can only watch as the patient slowly loses her heartbeat and fades from existence. A key component in that fading process is denial. For the princess, it most likely began about sixty pounds ago, when she stood naked in front of a big mirror looking on in disgust at a body she perceived as overweight rather than as the slender one she really had. If she were asked to hold her hands out to demonstrate the size of her hips, she would probably be off by at least fifty percent. A very strange disease indeed.
But none of that mattered. With all of our rebalancing interventions we could slow the death process, but not stop it, because the damage had been done. The princess was now on the death list, one of the ten percent of anorexic patients who would lose the battle.
I got beeped back to the ER before it was over. The lost battle against electrolyte imbalance, infection, hypotension and inevitable cardiogenic shock was in its final moments. It was all going wrong, from the perfect life to this almost perfect death, ebbing away as we all watched in excruciating pain of our own.
Back in the ER, I had other serious matters to attend to, so I put the sad princess’s death in my store room for dreams that have died. I needed to make room for the dreams that were still living, but it was also important for me to keep that kind of sadness out of the house where most of my life was lived.