Dr. Resor was able to get the tap, but it was normal: The cerebrospinal fluid showed no evidence of infection. We exchanged baffled looks.
I went back to the mother empty-handed, and as if on cue, her daughter moaned again, “I feel so bad. So bad.”
Ms. Suarez’s mother read my worried look and compressed her lips. Suddenly I had no doubt: Something was very wrong, something we were still missing. There had to be a doctor in the hospital who could figure this out.
“We’ll move her to the intensive care unit and run more tests,” I explained. “They’ll watch her very carefully.”
The ICU resident, Dr. Martinez, was an old acquaintance, so I got right to the point. “Twenty-six-year-old. Type 1 diabetic. Altered mental status since this morning. Workup normal so far. I have no idea what’s wrong with her.”
Dr. Martinez smiled. “Let’s take a look.” After a brief exam, she turned to me. “Except for the heart rate’s being up, she doesn’t look too bad. I don’t think she needs to go to the ICU.”
I waited a beat, then tried to channel the mother’s raptor look. “She’s sick. She needs to be in the unit,” I said slowly. “The whole case needs rethinking.”
A few hours later I walked by the ICU to check on Ms. Suarez. Her mother sat in a far corner of the room. Monitors beeped. The heart tracing sped across the screen, clocking 120 beats per minute.
Dr. Martinez glided over. “Her heart rate won’t go down,” she said, worried. At that moment, the intern came charging in. “Her thyroid levels are way high,” he panted.
Resisting the urge to slap my forehead, I shuffled over to the mother. “I think we have an answer.”
Dr. Martinez had the same flash of understanding. “This is what we call thyroid storm,” she said. “We have work to do.”
A Life-Threatening Condition
The thyroid gland is the body’s gas pedal. Get too much of its hormone, a condition known as hyperthyroidism, and your metabolism revs up: You burn body mass, shake uncontrollably, and cannot tolerate heat. If the gland produces too little, all systems grind into low gear: You pack on the pounds, can barely get out of bed, and feel perpetually chilled.
Straddling the windpipe below the Adam’s apple, the gland got its name from the Greek word for “shield-shaped.” The thyroid is prey to myriad attacks, from autoimmune antibodies that can destroy it or stimulate it and from bacteria and viruses that can infect it. Thyroid disease is so common, and its symptoms so protean, that in Bellevue Hospital 20 years ago, we checked thyroid levels on all admitted patients.
Simpler, cheaper procedures have moved thyroid testing out of the hospital and into the doctor’s office, but thyroid disease still afflicts millions of Americans—many for months before they are accurately diagnosed.
Garden-variety hyperthyroidism causes symptoms that are unpleasant but hardly lethal: tremors, a fast heartbeat, weight loss, heat intolerance, and vomiting. Thyroid storm, usually marked by all the signs of high thyroid plus confusion or delirium, is a different and very rare beast. Hyperthyroidism affects about 1 percent of the population, and only 1 percent of those ever
suffer thyroid storm. During 25 years of practice, I’d seen only one prior case, and that patient not only had a history of hyperthyroidism but came in with a high fever and high blood pressure—symptoms
Ms. Suarez didn’t show.
Left untreated, thyroid storm precipitates convulsions and heart failure. It is deadly in 20 to 30 percent of cases and so requires aggressive, immediate control.
To treat Ms. Suarez, the ICU team set to work on every organ and cell that stores, releases, or is acted upon by the thyroid hormone. They administered beta-blockers to dampen the hormone’s effect on the heart, drugs called thionamides that block hormone synthesis at the gland, and steroids to block conversion of one type of thyroid hormone, T4, into the more potent T3. It was like stopping a runaway stagecoach at once by reining in the horses, braking the wheels, and padding the trail with straw.
With intensive monitoring and medication adjustments, the ICU team safely slowed Ms. Suarez’s system down. Four days later she was back to herself.
Oddly, thyroid storm is not just a function of too much of the hormone. Usually some other stressor—like infection, surgery, or childbirth—tips someone over, but none of these applied to Ms. Suarez. Even more puzzling, she had never had thyroid problems before.
Batteries of tests failed to uncover a trigger for her thyroid storm, but there was good news. Ms. Suarez could avoid future episodes by having the gland removed surgically and replacing the hormone with a once-a-day pill.
Relieved at the outcome, I tried to convince (and console) myself that good clinical judgment doesn’t mean always knowing the answer; sometimes, it just means knowing when to call for help.
Actually, there’s a simpler lesson: When mother hawks cry, listen.
Tony Dajer is chairman of emergency medicine at New York Downtown Hospital in Manhattan. The cases described in Vital Signs are real, but names and certain details have been changed.