A Mystery for Dr Holmes

One of the occasionally frustrating aspects of being a prehospital provider is that you have to hand over your patient to other caregivers.  We try to do our best to relay our specific concerns and findings, but sometimes it can feel like something was missed in the handoff.  On occasion, it feels like the hospital doesn’t take your patient as seriously as you did.  Sometimes it feels like the receiving providers don’t see what you found compelling about your patient.

            “Hi.  What did you find about that woman with the Sick Sinus Syndrome?”

            “Huh? Which?”

            “The woman I brought to room three, three hours ago with tachycardia, bradycardia, sinus pauses, and so on.  It looked like SSS to me.  But she had no history.  What did you find out?”

            Shrug.  “She didn’t do that for us.  Completely normal rate the whole time.  So we discharged her and told her to see her doctor.”

            “Uh, thanks.”

Sometimes, though, they do get as interested in a patient's presentation as you are.*  Which is awesome.

I once responded to a high-end shopping district for a syncope.  We arrived to a home furnishing shop (which I could never buy anything from) to find a pale, diaphoretic, and supine woman in her fifties who had been shopping with a friend when she began to “act funny” and fell to the ground.  I found the patient to be generally atraumatic, but altered and difficult to arouse.  She was tachycardic, normotensive, and appeared to my eye to be hypoglycemic.  Her blood sugar, when checked, was 15 mg/dL.  I found it impressive that she was responsive at all. 

Rather than work her up and treat her in the store in front of everyone, we lifted her onto the pram and moved her to the ambulance.  A quick line was stabbed into her arm and 25 grams of dextrose woke her right up.  Simple hypoglycemic wake-up, right?  So now is where it gets a little weird. 

The patient had no history of diabetes.  As a matter of fact, the only medical history she had was a touch of hypothyroidism.  She was prescribed Synthroid for that and has not experienced other medical problems.  She reported no recent trauma or illness, nor did she report any kind of increased workload or changed exercise routine (e.g. she didn’t just run a marathon or just start trying out for Olympic weightlifting).  She had picked her friend up that morning, they went to an overpriced trendy lunch, and this all happened about two hours after that. 

It was weird to me that she was so hypoglycemic without a history of DM.  It was weird to me that she was so hypoglycemic within a few hours of lunch.  The whole deal was weird.  So I convinced her to go to the nearest ED to get checked out.  It took about 15 minutes of verbal convincing, but she agreed to go with me.  I was specifically worried about something like a pancreatic tumor that would cause blood sugar derangement, but I didn’t tell the patient that.  I could have told her to eat a full meal and call her doctor, but I thought her problem was more interesting than a “normal” diabetic wake-up.

We got to the hospital and I handed the patient off to the staff there.  The verbal handoff included a nurse and the physician, and on my way out I chatted with the doctor more specifically about my findings and my concerns.  We talked about mechanisms of hypoglycemia and worked through her history as it related to that.  She was on the same page as me, and seemed engaged in the patient’s mystery.  I gave her a card with my cell phone number on it and asked her to text me when she had any ideas about the patient’s diagnosis.  I left to run some more calls.

A few hours later I got a text from the physician asking me to call her, so I did.  The doctor explained that the abdominal CT, blood tests, and all other findings were normal.  It took hours of picking at the mystery to figure it out.  Eventually they figured out that the patient refilled her Synthroid two days before.  The doctor asked the patient’s husband to go home and bring the thyroid medication back to the ED.  They looked at the “Synthroid”:

Source

Yeah, that’s actually a 10mg tablet of glipizide.

Mystery solved.  The pharmacy had filled her thyroid prescription with glipizide.  The patient was lucky that she took the medication right after lunch.  Imagine if she took it right before bed. 

I have so much respect for that doctor and the rest of the ED staff that it is difficult for me to explain.  Think about how easy it would have been to monitor the patient for a few hours and release her to home with instructions to follow up.  Instead, the doctor and the rest of the ED staff worked the problem until they had an answer.

Awesome.

*None of that means that I am always interested in my patients' stories, or always catch when a case is interesting. I'm sure that the reverse complaint is true: "Prehospital providers never pick up on really interesting cases..."