Saleh Aldasouqi, MD, FACE, ECNU, is professor of medicine and chief of the endocrinology division at Michigan State University College of Human Medicine in East Lansing. His writing combines insights from his years of caring for patients and training physicians in the U.S. and internationally.

“From the Doctor’s Bag” is a blog about topics at the intersection of humanities and medicine — topics without a P-value or area under the curve. It takes a mostly lighthearted view of issues that affect health care providers as professionals and members of society, parents, siblings, spouses, neighbors or friends.

BLOG: Christmas in the ER, myxedema and pomegranates

Most people spend Christmas with families. Some people still go to work — not only doctors, but all other people and professionals whose work does not stop on holidays.

So, although I enjoyed a short and interrupted Christmas week, I was on-call for hospital patients for the holiday.

The call was quiet on Christmas Eve, but around 9 p.m. Christmas Day, I was paged by the ER physician.

ER physician: “I have this sweet 80-year-old patient who has not been taking her levothyroxine for weeks, and she is here with AMS (that is, altered mental status). Her [thyroid-stimulating hormone] is about 100 mIU/L, and I am not sure if she is in myxedema or if she needs intravenous thyroxine.”

Me: “Did you get T4?”

ER physician: “Pending.”

Me: “Did you order cortisol?”

ER physician: “I will do that STAT.”

The ER physician did a wonderful job, evaluating the patient thoroughly, but extreme thyroid cases are challenging for ER physicians and most non-endocrinologists. I never get annoyed when colleagues ask for help to understand such cases. The doctor said she did not believe that the patient was in myxedema, but she was concerned about the altered mental status. She was admitting the patient for further evaluation and observation.

Hospitalized patient 2019 
Most people spend Christmas with families. Some people still go to work — not only doctors, but all other people and professionals whose work does not stop on holidays.
Source: Adobe Stock

I was leaning toward oral levothyroxine, after getting the rest of the labs.

However, I did not feel comfortable making the decision over the phone. I decided to go to the ER.

I was encouraged by the unseasonably warm weather (for Christmas, in Michigan). I had not gone out throughout most of my time off, so I did not mind going out in the evening on Christmas. I waited an hour or so, allowing the labs to be completed, and then I drove to the hospital.

I saw the patient and I had an enjoyable conversation with her. She did not appear to be in myxedema by appearance. Cognitively, she admitted to some memory slips lately, which was also confirmed by a family member. To test orientation, we ask patients questions about place, time, person. She was partially disoriented; she was not oriented to place. However, she was perfectly oriented to time (she guessed the approximate time, 11 p.m.). To person, she was partially oriented. She guessed who I would be:

“A surgeon,” she said.

“Close enough,” I said.

When asked about the current president of the United States, she knew the current president very well. We do not talk politics in medicine, but this is the traditional question that doctors ask patients to test if their orientation is intact to person. Her thyroid hormones were low, but not critical. Her cortisol was normal. So, I decided to go with oral levothyroxine, and I agreed with admission.