A Homeless Mom Suddenly Ate 40 Cookies. This Is What Happened To Her Heart.
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A Homeless Mom Suddenly Ate 40 Cookies. This Is What Happened To Her Heart.

October 6, 2019


A starving mom suddenly ate 40 cookies, this is what happened to her heart. MJ is a 35 year old woman, presenting to the emergency room delirious, the paramedics found her on the street lying on the ground, shaking with several
empty boxes of cookies and her children. You see, MJ was a homeless woman who
had been starving for more than a year, she had no legal spouse, didn’t eat very
often, and when she did have food, she’d give it to her kids. A few months ago, she made it to a major city, around this time, she had become
accustomed to not eating much. In fact, the few times she did eat, she would feel dizzy and thirsty afterwards,
her heart rate would increase, she would feel uncomfortable, so she opted
to not eat much; if at all on most days. During this time, MJ had lost a
significant portion of her body weight, at 5′ 5″ tall, she weighed a total of 75 pounds, that’s nearly half of her ideal body weight. Finally, one hot summer day, MJ felt exhausted, she received a few boxes of
cookies late at night from a local bakery, they had past their sell-by date, so it was
typical for the bakery to give the food away. In a strange deviation from her
recent behavior of not eating much, she had a taste of one of the cookies, she enjoyed it, then she had a taste of another,
and another, and another. She looked away, kept eating and
without paying attention in 30 minutes, she had finished a total of 30 cookies by herself. It’s an hour later, her kids are asleep and MJ
feeling lethargic, her vision is blurred, she thinks she feels a little dizzy, but is unsure, she feels that she’s just tired and now that
she’s eating well for the first time in years, she can finally have a good sleep. It’s morning now, MJ wakes up, she didn’t sleep well, she eats 10 more cookies for breakfast. As she walks on the street throughout the day, she feels her heart fluttered, she has a headache, her field of vision
starts to blur and warp, she’s dizzy, collapses on the street and starts seizing. Her kids cry out for help and an ambulance is called where she’s brought to the
emergency room where we are now. Given this past medical history, there’s a few glaring clues as to what’s happening: most immediately, MJ is suffering
from Refeeding Syndrome. The name is intuitive, there’s 40 cookies that she ate, and they’re a form of refeeding, this is the first time, that she’s had a
major oral intake of calories in over a year. “Syndrome” refers to the grouping of symptoms that she’s having related to this refeeding. But how could this be? Even if it was just cookies, eating something
should be better than nothing, right? Well, not quite, and it’s less the fact that cookies are unhealthy for you and more so the changes in MJ’s
physiology since she is gone in starvation. Let’s look at this clinically, first: her body has been malnourished
for a long period of time and this is physically evident. At 5′ 5″ tall, her ideal body weight is 125 pounds, that number is calculated and standardized in humans and we used this in clinic to assess
status and to dose drugs. She weighs 75 pounds 60% of her ideal and this is a problem,
because under 70% is the threshold, where someone would be
at risk for Refeeding Syndrome, and she’s there. On presentation to the emergency
room, she’s hypothermic, meaning her body temperature is
low as she was found shivering, her blood indicates that her liver enzymes are elevated and her kidney function is abnormal, these are typical symptoms for presentation
of a chronically starving patient. She has to some extent compensated
for these losses over time; her baseline heart rate before
refeeding was 35 beats per minute, that could be normal for a well-trained athlete,
but MJ certainly isn’t one at the moment. She should be somewhere between 60 to 100 beats per minute, like most people and at presentation,
she has 70 beats per minute, so she should be okay, right? Actually, no. For patients in starvation,
whether it’s rooted in eating disorder, “dysphagia,” known as an inability to
eat due to difficulty swallowing, or rooted in a different etiology, bradycardia is very typical in patients like MJ. “Brady” meaning slow
and “cardia” referring to heart rate, slow heart rate typically
defined as under 60 beats per minute, in extreme starvation, it can dip
to below 30 beats per minute, meaning one beat every two seconds or longer. Baseline heart rate of 35 now up
to 70 with a sudden refeeding is an extreme change in a short amount of time, educating a major cardiovascular complication, her heart EKG shows that her heart is beating irregularly. But why is this happening? We can start to explain it through
the delirium and the seizure that she suffered when she
arrived to the emergency room, Because she’s been in starvation, she has vitamin deficiencies, the important
one here being thiamine or vitamin B1. Thiamine isn’t produced endogenously, meaning that your body doesn’t produce it by itself, we need to source it from your dietary intake. It’s important in cells, it helps promote the breakdown of sugars and plays a central role in cerebral energy utilization Its deficiency initiates the injury of
brain cells by inhibiting metabolism, causing MJ’s delirium and her seizures. But thiamine isn’t active by itself, it’s usable in your cells in a form known
as thiamine pyrophosphate. Phosphate, that is the root of the problem here, MJ is suffering from hypophosphatemia. “Hypo” meaning low, “phosphate” referring to the important
anion that exists mainly inside of your cells, and “emia” meaning presence in blood. Low phosphate presence in blood. This has severe consequences in
multiple aspects of MJ’s biology, one major contribution to her physical
decay from malnutrition is muscle atrophy. “A” meaning without,
and “trophy” referring to nourishment, her muscles have broken down over
time because she hasn’t been eating. But this isn’t just limited to the muscles
we can see just by looking at her though, what we would call skeletal muscle, the smooth muscle of her stomach and
intestines have atrophied and most importantly, her heart muscle has atrophied. What does this have to do with phosphate? Well, muscle tissue is the prime utilizer of it, in the blood, there’s a few important
electrolytes involved in muscle contraction: sodium and potassium signal for a contraction, calcium commits to a contraction, and phosphate provides the energy for the contraction. You may have heard of it, it’s called ATP, adenosine triphosphate. Adenosine being an adenine molecule,
that’s the a in your genetic information attached to a ribose sugar and triphosphate, three phosphates. That energy provided by ATP is responsible
for almost all movement in your body, whether it’s food through your stomach, blood pumped to your brain,
or you walking on the street. But have you noticed when you walk faster on the street that you start to breathe heavier and deeper? In a state of activity, your muscles need more oxygen to produce
more ATP to meet energy demand and in order to provide that oxygen, the body uses another phosphate-containing compound known as 2,3-Diphosphoglycerate, the name tells you exactly what it is. Glycerate, with two phosphates on
carbons number two and three. 2,3-DPG, in red blood cells
potentiates oxygen dissociation, increasing availability of oxygen to
tissues like the muscle from the blood, that oxygen is used to create more ATP. So all kinds of muscle are very dependent on phosphate to provide energy for contraction. But let’s go back to the name
of MJ’s condition: hypophosphatemia low phosphate presence in blood. Why is the phosphate low? She just ate 40 cookies, so everything in terms of electrolytes and
nutrients should be high in her blood, right? Actually, no. The cookies MJ ate were high in sugar sugar mainly glucose strongly stimulates the pancreas to release a hormone known as insulin, that decreases blood glucose by shifting
it into the body cells from the blood. In a healthy person, insulin release
is highly regulated in very precise, you get exactly what you need. But MJ isn’t healthy, she’s malnourished, 40 cookies totaling 1200 grams
of sugar within 12 hours is a huge shock to her system, her body is sensitive to insulin, meaning small amounts of it will have a greater impact on her
body than if she were healthy. This happened over a long period
of time, as MJ ate less and less, she felt dizzy after eating those cookies, because her blood sugar became
lower than before she ate them, due to this massive insulin response. But it’s not just glucose shifting into her cells, the electrolytes in her blood: sodium, potassium,
calcium, magnesium, and phosphate, they’re all shifting out of the blood and into her cells. Most of these nutrients are literally
getting sucked out of her blood and shoved into her cells, this signals the beginning of MJ’s heart problems. Because the time scale is short, the movement of sodium into all cells of the body, not just the muscle gets detected by the kidney, they respond by reabsorbing the sodium
that would have shown up in the urine, a constant of this is that waterfall
of sodium and is retained in the body. This begins a process of volume overload inside MJ, as more and more fluid begins
to accumulate in her body. Fluid that should have been urinated out, her heart is starting to have difficulty handling it, she exhibited signs of this when her
heart was fluttering in the morning, there’s congestion in her heart. That extra fluid accumulating in her body is more than her heart can handle, and she’s starting to show signs of
acute decompensated heart failure. “Decompensated” means that the heart hasn’t had enough time to adapt to the changes in her body and “acute” meaning an underlying
physiologic change was recent due to an event, in this case, the eating of 40 cookies in
a person who was previously starving. This isn’t a one-dimensional problem,
because her heart muscle has atrophied, it’s not as strong as it would be if she were well fed, because phosphorous is shifting
intracellularly due to high insulin response, the heart muscle has less phosphate
available to it from the blood, meaning less production of ATP for energy and less 2,3-DPG for oxygen
dissociation to produce that ATP. Her heart muscle has a higher workload through an overload in fluid and less energy to provide work to that load, this still isn’t the end of the story. the muscle that draws air into the lungs the diaphragm in MJ’s case, it too has atrophied in her starvation and with less phosphorous
available to it means she has dyspnea. “Dys” meaning abnormal and “pnea” meaning breath, it’s not only harder for her to
provide energy to her muscles, but she also can’t breathe in enough
oxygen with those muscles. This could have been avoided, if MJ ate slowly and didn’t succumb to her appetite. Refeeding Syndrome isn’t new to humans, in 100 A.D., the Jewish Roman scholar, Flavius Josephus, described an epidemic of deaths among Jews who had been entrapped and starved by the Romans, he wrote that those who engorge themselves died, but the ones who restrained their appetite in the face of abundant food were able to survive. In 600 A.D. China, Sun Si Miao, the most influential physician
in East Asia for a thousand years, wrote about Refeeding Syndrome in context of beriberi. The symptoms caused by thiamine deficiency, it was a problem in rural China at the time as peasants were often only allowed to eat white rice and the removal of its husk depleted
its primary source thiamine. And when there wasn’t enough food
due to natural disaster, people starved and faced Refeeding
Syndrome when food was available again. In World War II, prisoners of war were liberated in 1945 and those who were fed paradoxically died after eating. And this was the first modern
description of Refeeding Syndrome, even today, Refeeding Syndrome isn’t well known outside of nutritional support circles in sight clinic. Cancer patients commonly have dysphagia or difficulty swallowing due to their treatments, or stomatitis, a mouth sore and
common side effect of treatment. They typically don’t eat much and
in effect they become malnourished, when hospitalized, they’re typically fed entirely through a tube or parenterally through their veins and
they get a sudden bolus of nutrients that their body isn’t used to, causing insulin response, the intracellular
shift of electrolytes and glucose, causing Refeeding Syndrome. If a person who is previously
starving, refeeds too suddenly, they’re put at an incredible risk of dying inside a decayed form of their own body. For MJ, we treat her underlying
conditions namely her hypophosphatemia, this is easier said than done. Since her levels are extremely low
due to the nature of her Refeeding, we give her intravenous phosphate,
but only up to a limit, because she’s delirious,
oral intake is likely unreliable for her, but IV administration is only for a short amount of time. The reason being is that IV phosphate is very dangerous, as it can form solid salts with the calcium in the blood, which can damage the kidneys causing
renal failure and hypocalcemia, or low calcium presence in blood. Since muscle cells use calcium to commit to a contraction, when it’s low in blood that too can
cause problems in MJ’s heart, we switch to oral repletion of phosphate
when the levels begin to increase. For potassium and magnesium, we replace those intravenously as well, but we do it in a saline solution without dextrose, in some cases, students and residents will want to replete the electrolytes in a 5% dextrose solution, but it’s contraindicated in this case. Dextrose is the D-isomer of glucose, presence of dextrose will stimulate insulin release, which got MJ into the trouble that she’s in right now, by treating the underlying electrolyte
abnormalities and later, thiamine deficiency, MJ was able to resolve her feeding syndrome and subsequent cardiac
dysfunction and encephalopathy. What happened to her and her kids afterwards? Well, that’s a part of the story that you can help write. Thanks so much for watching. Take care of yourself and be well. English CC by Charles Baluyot

Only registered users can comment.

  1. A Grandpa Ate 50 Muffins. This Is How His Heart Shut Down.

    MJ is a 45 year old man, presenting to the emergency room, with emesis, nausea, and chest pain. His son, Alister tells the admitting nurse that MJ defacated and vomited 10 times over the past few hours. With social support from the ICU, a strong lesson learned, and an event that will never be lived amongst his family and an event that he will want to erase from his memory for the rest of his life. MJ was able to make a full cardiovascular recovery and was able to live his life to the fullest after years without food and shelter, with his heart fully functional again.

  2. I actually thought this was amusing until I clicked and realized they were homeless, which is in no way, shape, or form, any laughing matter. I sometimes eat cookies on an empty stomach, but not homeless at present. We never can predict anything.

  3. Perfect example of how our society fails people who need help. This woman never would have eaten that many cookies if she had access to a somewhat regular supply of food from a food bank or homeless shelter, fucking something. It's pathetic that we send billions of dollars away to other countries every month, but our own citizens are starving in the streets. What a joke.

  4. Real facts TOTALLY REAL FACTS:
    Fact 1:You can live with only half of your brain
    Fact 2:You can live without your appendix
    Fact 3:You can live with only one kidney
    Fact 4:You can live without nose sinuses

    THIS IS ALL REAL FACTS NO FAKE NO HATES THIS IS ALL REAL FACES

  5. Oh my god thank you so much. I felt a seizure as I fasted for 40 days doctors did not know of this condition and I felt like I was slowly dying until I drank milk which has phosphate and watched your video and now I know why. You saved me when a hospital could not. God help and protect you.

  6. I Just Wanna Know How She Got Like 4000000 Containers Of Cookies And How Her Kids Called 911 And Got A Phone

  7. Wonder why she didnt give some cookies to her kids? That's what I would have done.
    I would have sought after old bread instead of cookies to eat. Also some restaurants give away old food too and its still good. I shamelessly get free food that way and its a lot, feeds me for a few days if I keep it in the freezer and the fridge. Good way to save some money for clothes and other materials for the kids.

  8. The most interesting case of refeeding that I have read about was when the Germans were surrounded and cut off by the Soviets in Stalingrad.
    They were fed a fatty paste by surgeons and sanitaters. It caused Wehrmacht troops to die faster than when they were starving to death.

  9. Pancreas: “Ooh, sugar! Time to crank out some insulin to slurp it out of the blood! …Along with phosphates but that should be fine, right?”
    Kidneys: “Oh shit, we're losing phosphates! We need those to live! Hold on to your fluids, people!”
    Heart: lacks phosphates, suddenly has a higher workload because of all the fluids
    Heart: G U E S S I ' L L D I E

  10. Excellent as always. Minor nitpick: The prefix brady- is pronounced with a short "a", as in "sad", not a long "a" as in, well, "The Brady Bunch." Many feel that this saccharine 60's sitcom was responsible for the subsequent wholesale mispronunciation of bradycardia, bradykinin, bradykinesia, bradyarrhythmia, bradydiastalsis, bradyphagia, bradyacusia, bradyauxesis, bradypragia, bradyphemia and others even more abstruse. All you medical students and interns out there: it is this kind of etymologic pearl which, if dropped strategically during Attending Rounds will mark the beginning of your rise to the status of mythologic legend.

  11. When would americans understand that processed and packaged food is not supposed to substitute for a daily balanced diet? Whenever I hear what they eat as a meal, I feel disgusted.

  12. The comments are full of people saying how they couldn't eat more than 2 or 3 cookies. Lol, this woman has been malnourished for a long time, obviously your system does not work the same as her malnourished system.

  13. Refeeding syndrome is no joke. If you’re depressed or don’t have an appetite, please at least try. This is more common than you think.

  14. A girl here has been watching Chubbyemu for a year now.

    This is what happened to her foot
    Also, I noticed that all of the names have only 2 digits
    For example:
    AJ
    MJ
    PJ
    DJ
    CJ
    … is this real? Most of the diseases
    These people get have hyper-something-emia.

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