The patient who healed me

Successful treatment of an unsuspected illness eased the author's grief over her grandmother's death.

By Angela D. Sellers, MD
Family Physiciam/Baxley, GA

During my first years as a doctor, I was in anguish over my grandmother's death.

I was 16 when she died, but I remembered her well. She was a happy spirit with a full-bodied laugh and a deep well of love for her grandchildren.

She had only a sixth-grade education, but she was the smartest woman I knew. She'd taught herself piano, and she played well. When she was more than 50 years old, she took the high school equivalency exam and got one of the highest scores possible in algebra, which she'd never studied in school.

My grandmother had suffered much hardship. She lost her firstborn to sudden infant death syndrome. She'd then raised four children during the Depression. After my grandfather was drafted during World War II, she raised them alone. She brought my mother, then a toddler, through a bout with polio, and my uncle through a case of nephritis that cost him a kidney.

When my grandmother reached her late 50s, she began to slow down: Her speech, her thoughts, her movements became less fluid than in years past. Her decline was gradual, but relentless. Eventually, she neither spoke nor rose from her bed. Lying in a nursing home bed with a nasogastric tube providing her nutrition, she was a shell of the woman I remembered.

The doctor said it was Alzheimer's disease, though my grandmother didn't fit the pattern of dementia.

No one noticed the scar on her neck where a goiter had been removed more than 30 years earlier. She'd had hormone replacement therapy for only a few weeks, and her thyroid levels were never checked again.

It was only when I began studying endocrine systems in medical school that I realized that my grandmother had died of severe hypothyroidism ending in coma. It was this knowledge that plagued me. I would daydream of going back in time to tell her physician to test her thyroid function. I checked for symptoms of thyroid dysfunction in almost every patient.

One night during my last year of residency, a critical patient was admitted by transfer from an outlying ER. She'd suffered a myocardial infarction, I was told, and needed a tertiary care center. She was hypotensive. She'd gone into respiratory arrest, so she was on a ventilator.

Her ECG and blood tests didn't point to a clear-cut diagnosis. Her pulse was 45 beats per minute. Her face and abdomen were doughy. Her lower legs were edematous, without pitting—a sign of hypothyroidism. Her family said she looked swollen compared to her usual appearance. They said she'd become increasingly tired and slower-moving over the past few months, and she complained she was always cold.

I ordered a test of the patient's TSH level and ran to the library. I read that the mortality for untreated myxedema coma was about 50 percent. While I was at the library, the unit called to tell me that the patient was deteriorating, and that the test results did indeed suggest thyroid trouble.

My attending suggested that I continue treating her as an MI, but my instincts told me I would lose her if I did. I discussed the risks of thyroid treatment with her family. They gave the go-ahead for treatment, which my attending and I agreed to start slowly.

I stayed with the patient all night, gradually increasing her dosage of synthetic thyroid hormone, which she was tolerating well, and adding hydrocortisone to prevent adrenal crisis.

The next morning, one of my fellow residents took over the patient's care. Her ECG and echocardiogram showed no evidence of ischemic heart damage. My colleague told me I had saved her life.

The patient was discharged a few days later. The family was grateful to have their wife, mother, and grandmother back. And I could think only that my prayers had been heard. I helped this woman survive the illness that had killed my grandmother. She probably doesn't know me, but I will be forever grateful to her for bringing me that measure of peace.

 

Carol Pincus, ed. Angela Sellers. The patient who healed me. Medical Economics 2000;9:173.