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.
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.
I also had an interactive and mutually educational conversation with the ER physician. I shared more in-depth information about myxedema from personal experience. Likewise, I learned from her about recent updates in the management plans for the patient’s other comorbidities. I felt humbled to share some of the thyroid pearls that endocrinologists learn over the years.
Earlier, as I was browsing social media on Christmas, I came across an ad for the new edition of the Williams Textbook of Endocrinology. This is the standard endocrine textbook around the world. I could not initially tell what the pathology picture on the cover page was. A lump, a nodule, a gland? I thought it was a 3D restructured pathology section from a site in the body that is endocrine-related somehow.
To me, it looked like a pomegranate! Small, pearl-looking balls that are so red and so crisp!
I consulted with my friend and classmate, Dr. Essam Raweily, who is a pathologist in Wales.
He said: “Dear Saleh, this is a cut in the thyroid, and it is not 3D, but 2D!”
I hope everyone who reads this post had a joyful holiday. Happy new year to all!