“There are certain physical characteristics to the anorexia diagnosis,” Dr. Harris said. “The number of months without a period, a weight below a certain BMI percentage . . . And the fact is, the parameters don’t do all that good a job of guiding us here. Anorexia nervosa, bulimia nervosa, they were established back before psychiatrists realized that many eating disorders aren’t that clear-cut. Let’s say you have a patient who primarily restricts, but also purges. And what about bulimics who also spend weeks fasting? Ultimately, I think we’ll see the diagnostic guidelines reworked to do a better job here.”
“I see,” I said. But I wasn’t entirely sure that I did.
“It’s all tied in to body image, too,” he went on. “How the patient sees himself or herself—most of my patients are female. Do you know, I had three different anorexic patients who decided to go to work as strippers in order to tackle their negative body image. I thought that was a fascinating approach to the problem! It seemed to help them, too.”
I puzzled over this. It hadn’t occurred to me before that Elena might have body-image issues. Why should she? Everywhere she went, she got compliments. It just didn’t compute.
“And then there’s the overlap between obsessive-compulsive disorder and eating disorder,” Dr. Harris went on. “Elena has OCD. It’s not unusual to find them together.”
“Oh. She does?”
This was something else I hadn’t thought about before, much less learned anything about. I tried to recall the tiny bit I knew about OCD, and my imagination presented me with a hypothetical Elena, stuck washing her hands for hours.
“Yes,” confirmed Dr. Harris. “You could say that, in a lot of ways, eating disorder is very much the condition of obsessive-compulsive disorder centered on food. When anxiety increases, the compulsions increase. In this case, they’re compulsions to restrict and diet.”
“I guess . . . I can understand that,” I said. “Yes, Elena does have trouble eating when she’s upset.” I paused. “But what about her seizures?”
“I’m sure they were brought on by the forced hospitalization,” Dr. Harris said.
Now, here was something definite and also, finally, something that I could understand. It seemed to be something that clicked with Joe, too. He said, “Then, since Elena’s not in the hospital anymore, will the seizures go away?”
“It all depends,” Dr. Harris said. “It depends on whatever stress she may be under later.”
Joe and I exchanged glances, uncertain again. “Does that mean they’re deliberate?” I asked. “Does she do them on purpose to control stress?”
“Well, define on purpose.” And Dr. Harris smiled, the wistful smile of a gentle soul. “I have one patient who had dissociation seizures all the time. Right in the supermarket, down she’d fall. She goes to my church, and there she’d be, on the floor right down in the middle of service. There didn’t seem to be anything she could do about them; they came on completely without warning. So I said to her, ‘You’re having these seizures so frequently, I’m afraid we’re going to have to talk about taking your driver’s license away.’” Dr. Harris’s gentle smile grew broader. “And, do you know, her seizures got a lot better.”
He lapsed into silence, but I could think of nothing to say. My horrified imagination had locked onto the image of Elena, tumbling over in a produce department and mindlessly circling right next to the stands of apples and pears.
There was a pause.
“Where do we go from here?” Joe asked.
“I’d go home, if I were you,” Dr. Harris said. “It seems as if you all could use a rest. And the Germans are doing excellent work in the area of eating disorder. I see no reason why Elena can’t get fine treatment right where you live.”
“So, no need for six months in a psychiatric institution,” I said bitterly, remembering Dr. Petras and his threats.
“I do think some time in an eating disorder treatment center would probably be good for Elena,” Dr. Harris said. “Six months, that’s probably too long, and anyway, I’m sure your insurance wouldn’t cover it. They’re very bad about covering eating disorder stays. I’ll give you a piece of advice: never let them hang up the phone.”
“I—what?”
My mind was still grappling with the statement Some time in a treatment center would probably be good. That statement wouldn’t fit into place for me. I had such feelings of pain and hostility against Drew Center that my brain was refusing to consider it.
“Never let them hang up,” he repeated. “An insurance company gets monitored for that. They’re not allowed to hang up on clients. So, you get on the phone with them, and you stay there. You keep going up the line, one supervisor after another, until you can make someone listen.”
Elena came back in from the waiting room, and the three of us shook Dr. Harris’s hand good-bye. My respect for him had done nothing but grow during the week Elena had worked with him, and I made a mental note to steer her toward college in our home city so she could continue to work with him when we came home next year.
Then we went back to the motel, collected our luggage and our various medical statements, test results, and receipts, said good-bye to our motel family for the last time, and crammed ourselves into the tiny car to drive back across the country.
My mood was no longer euphoric.
“Mom, it’s my business!” Elena snapped at dinner that night.
“I know. I’m just saying that Dr. Harris said a food diary is very important.”
“So fine, I’ll do one! You know, just because you had one little meeting about me doesn’t mean you’re an expert on me now.”
It didn’t make sense, that anger. It wasn’t part of the pattern of Elena. Was this hostile, closed-off person really the same girl who had snuggled down next to me and shared her chocolate pudding?
“Of course not,” I said. “All I wanted to say is: Why wait? Why not start it now? We could stop by Walmart and get a—”
“Leave it, Mom! Just drop it!”
And the fury in Elena’s voice left me stunned.
By the time we flew back home to Germany, it was late August, and Elena’s senior year was set to start in little over a week. The Summer from Hell had eaten almost every bit of her vacation. And the Summer from Hell was still gobbling up my time.
Insurance forms had poured in during the weeks I was gone. More were showing up every day: benefits statements for each doctor, each psychiatrist, each blood test, and each lab, not to mention the lengthy statements concerning the four different hospital stays. Even though by this time I was a veteran of insurance billing problems, this batch of forms still brought surprises.
I was sitting at the desk in the office one afternoon that week, talking on the phone and working through the stack of problems. “On the claim dated August third,” I said, “the visit to the ER, I need to know why you kicked it back as not a preferred provider. That hospital was on your preferred provider list.”
“Yes,” said a polite female voice in my ear. “But the doctor your daughter saw there is not.”
“Wait—You’re telling me that you told us to use that hospital, but then we’re not supposed to use the doctor who works there?”
“He isn’t in our network, ma’am.”
“But he works for the hospital. He works in the emergency room! So far as I know, he was the only doctor there.”
“Yes, but we don’t have him listed on our list of preferred providers—”
“The same list where you have the hospital listed.”
“Yes, ma’am.”
I gave up this particular fight with good grace. I knew when I was beaten, and I knew better than to take my problems out on the phone representative. Oh, well, I thought as I thanked her for her time, this isn’t so tragic.
It certainly wasn’t the worst problem I’d faced that day.
“What are you having for breakfast?” I had asked Elena that morning.
“Chill out, Mom.”
�
�I can make you something. Eggs and toast, biscuits . . . I can heat up last night’s spaghetti . . .”
“Chill out, Mom!”
Now, as I hung up the phone and wrote a note on the insurance form, I thought again about that baffling hostility. Elena wasn’t a nervous eater anymore, I admitted to myself. No, she was a downright hostile eater.
Elena heard me put down the phone and came to the doorway.
“So, we’re going to base after I shower, right?” she said. “I haven’t finished my school shopping.”
“I need to have lunch first,” I said. “Did you have lunch?”
“Yeah . . .”
But her face didn’t convince me.
These days, whenever Elena and I were together, she always seemed to wear the same expression: eyes slightly narrowed, mouth in a line, as if she were constantly bored. No longer did I get to watch that vivid parade of feelings I had loved since her earliest childhood.
It was just one more loss to grieve.
Now, as I watched her remote expression settle into place, I debated what to do. No, Elena hadn’t had lunch, and she hadn’t had breakfast, either. And now she wanted to get out of the house and run errands. Would she eat at the food court? Not anymore. Too much noise. Too many eyes.
Whether Elena and I liked it or not, we were inseparable at that point. Without a stateside license, Elena couldn’t drive in Europe. It was a bargaining chip I couldn’t resist.
“Okay. I’ll take you,” I said. “If you eat lunch with me.”
“Mom! ”
After Elena stalked away to take her shower, I sat there and argued with myself. Did I really want to do this? Should I really bargain and bribe? Elena was an independent, almost-grown woman. This wasn’t appropriate parenting.
But what was I supposed to do—just watch my daughter starve?
She still hasn’t put back on the weight she lost in those hospitals, I reminded myself. Her weight is still lower than it was at the beginning of July—not to mention what it was in June.
And at the thought of early summer, I felt a rush of fond nostalgia.
Just imagine! Only two months ago, we were all relaxed and content. Elena was telling me about her summer reading. She and Barbara were working on their tans . . .
June—so recent, but already softly blurred, like the memories of vacations long past. And was I only imagining the sparkling sunlight that lit those memories, as if I were seeing the scenes through a glass of champagne?
June—happy, golden June. The brief, bright pause before the Summer from Hell.
It felt like a lifetime ago.
CHAPTER TWENTY
The next day, I took Elena to the big military hospital for her first medical appointment since we had reached home. The lanky young doctor was new to us both, of course. The pediatrician who had worked with her in July was already gone, cycled downrange or cycled back to his home in the States. But this new doctor seemed thoughtful, friendly, and interested.
I had brought with us all the test results and discharge forms from the various hospitals so that he could review them, and he spent quite a bit of time familiarizing himself with their contents. Elena’s discharge form from the children’s hospital showed that she needed a follow-up cardiac echo exam and an endocrine consult, as well as more blood work to check on her new thyroid medication.
“I’ll get these referrals into the system this afternoon,” he said. “It’ll take a day or two before they’re picked up, though, so I’d wait until Monday to call for the appointment and lab times. And I’ll see you back here with the results of the blood work next Wednesday.”
That afternoon, I drove Elena to the high school so she could attend senior-class orientation. I was supposed to be working on a sequel to the book about Martin and his computerized dog, but for weeks, I’d done no writing because of all the hospital time. Now I was playing soccer mom.
Poor Martin! I thought while I sat in the car, and in my mind, I could see him standing there, waiting for me to join him on an adventure. His scowl was a good match for Elena’s hostile expression. Thirteen-year-old boys don’t like to wait.
I’m coming, Martin! I promised in a rush of guilt. Next week, I promise! I could have spent a few minutes working with him while I was waiting for Elena’s meeting to finish, but the car got hot, so I left it and wandered inside.
Mr. Temple, the school psychologist, spotted me in the main hallway and came over. “Mrs. Dunkle!” he said, sounding surprised to see me. “How’s Elena?”
“She’s fine, more or less,” I said.
Mr. Temple was a very nice man. He looked more like a professor than a therapist. It took me a minute to remember that he was the person who had referred Elena to Dr. Petras last spring in order to help deal with Valerie’s running away. That was where all this had started: with Valerie.
“I don’t think that grief therapy worked out the way we all thought it would,” I added bitterly.
“Why don’t you come into the office and tell me about it?”
In Mr. Temple’s office, I poured out the story of Elena’s enforced hospitalization and the bullying behavior I had seen from Dr. Petras.
“I’ve lost all respect for the man,” I said. “The final verdict from an eating disorder specialist is that, yes, Elena does have an eating disorder, but calling it anorexia nervosa goes too far. What’s more, he concluded that it was Dr. Petras’s heavy-handed treatment that caused Elena to go into that cycle of blackouts.”
“I’m sorry to hear this,” Mr. Temple said. “Dr. Petras’s specialty is child psychiatry. He has the degree as well as experience. I had no reason to believe he wouldn’t do her good.”
“I’m not blaming you,” I said. “How could anyone know what he was going to do? But I know what I saw, and it wasn’t professional behavior. He forced Elena into a hospital that wasn’t set up to treat her, and he triggered a dangerous drop in her weight. She still hasn’t regained the weight he made her lose.” And I’m beginning to worry now whether she ever will, I thought. But I didn’t say that out loud.
Mr. Temple looked upset.
“I hardly know what to say,” he said. “It’s shocking. Really shocking.”
“Yes,” I said grimly. “It was.”
The week passed in a rush of back-to-school shopping and reunions with friends. By the time Elena had her next appointment with the lanky young doctor at the military hospital, classes had already begun. I drove to the school and signed Elena out, and we headed to the hospital—that one-stop-shopping medical center away from home for thousands of Americans overseas.
“This time, we need to tell him about the episode of chest tightness you had,” I said as I parked the car. “That pain you’re having in your chest now—he needs to hear about it. I’ve never heard you mention chest pain before.”
“Mm-hmm,” Elena said. She had that expression on her face again—cool, distant, and wary.
The lanky young doctor came into his office and greeted Elena first, which I liked. In fact, I liked a lot of things about this doctor.
“Your blood work looked good,” he told her. “Of course, I didn’t run the thyroid tests. So,” he continued to me, “did you get her appointment set up with Endocrinology?”
“I tried,” I said. “But your referrals didn’t seem to be in the system. I couldn’t make the appointment with Cardiology, either. Something must have gone wrong with the paperwork.”
“Well, strictly speaking, it isn’t paperwork,” he said, smiling. “It all stays right here in the computer system. Hold on a minute while I take a look, and we’ll get it straightened out.”
He sat down at his messy desk and tapped on the keyboard for a minute. Then his brow furrowed, and he cocked his head sideways.
“Oka-a-ay,” he said slowly. “This is odd.”
The thing about axes falling again and again is that you get to be good at detecting them. I heard him say this, and I held my breath. I told myself that this was going to
be a good kind of odd, but that old familiar tension climbed up my spine and knotted the muscles in my shoulders.
The doctor did some more tapping. Then he stopped and rubbed his chin for a minute.
“There’s a note in here,” he said. “It says that you’re to be denied care. That’s why my referrals got kicked out of the system.”
I could feel my head swivel sideways, too, just like the doctor’s had done. Elena was staring, baffled. We must have looked like a roomful of golden retrievers listening to a dog whistle.
“I—excuse me, what?” I said. “Denied care? Is there some kind of insurance problem?” And my mind flashed to the stacks of forms still waiting to be straightened out. No, I couldn’t recall a problem that would affect us receiving care.
The doctor answered my question with a question of his own:
“Do you know a Dr. Petras?”
Elena started to laugh.
I didn’t.
“What does Dr. Petras have to do with Elena’s care?” I asked. “He’s a doctor who hasn’t seen her in months.”
“Well, he put a note in the system that tells every department to deny this patient care. He put it in . . . last Thursday.”
Last Thursday. The day of the school orientation. The same day I had told Mr. Temple how unprofessional he had been.
Elena asked, “What does the note say?”
“It’s . . . confidential,” the young doctor said. But his tone wasn’t formal. It was amazed.
Anger is a furnace. I could feel myself heating up. I could feel boiling blood mount into my face and course down my arms into my hands. I clenched those hands together and tried to stay calm. Logic and reason. Against a world gone crazy, that was all I had.
“Are you telling me,” I said, “that some doctor Elena hasn’t seen in months has put a secret note into her file?”
“Yes,” the doctor said, with the air of someone having a pleasantly interesting adventure. Clearly, his work didn’t bring him this kind of diversion every day. “Yes, in fact, that’s exactly what’s happened.”
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