Winter humbles the leaves 

By Marquis Berrey, MD, PhD, Johns Hopkins Medicine 

The autumn view across the distant water is spectacular. Colors pop from every branch—reds, the maples; browns and oranges, the oaks; bright yellow, the stately poplars; the evergreens true to their name. The scene delights both the eye and the mind’s eye. There’s the surface appearance of color, beauty, variation. And there’s also another pleasure in understanding the reality beneath the color in nature and the life cycle of different kinds of trees. 

Intellectual joy is one of the pleasures of practicing medicine. One of my faculty declared that medical education needs to promote eureka moments—the joy of discovery, the excitement of insight, the pleasure of recognizing the unifying pattern that underlies a variegated world. 

Trees have their seasons—so do we. Emergency services brought Violet in from home hospice. In the autumn of her life, a series of strokes, combined with dementia, had previously limited her mental status to turning her head to her name and smiling in recognition at family. Now she didn’t respond at all, her large prominent eyes rolling back in her head. Her hands, legs, and face were swollen and puffy. Her tongue seemed large. She grimaced and groaned in pain when we pushed on her belly. As we settled her into the intensive care unit, the monitors went on—oxygen saturation monitor on her ear, the heart monitors across her chest. A peripheral IV was already running antibiotics. I cannulated the right radial artery and inserted an arterial line under the supervision of the fellow. Then the active heating blanket covered her. 

The vitals didn’t quite match septic shock. Blood pressure was low, urine output almost nothing, and body temperature dangerously low in the low 80s Fahrenheit. But her heart rate was slowed as low as 32 beats per minute, not tachycardic, and her breathing was slow, with cyclic periods of increasing and decreasing volume, then periods of not breathing (known as Cheyne-Stokes breathing), rather than the expected tachypnea. Some of her labs from the emergency department had resulted in low sodium and low glucose. 

Eureka! This was myxedema coma, a life-threatening presentation of severely depressed thyroid function. Resulting lab values confirmed our suspicions: First, the hormone that stimulates the thyroid was extremely high, then the two forms of the peripheral thyroid hormones were abnormally low. Investigation showed the other hormonal axes were intact; only the thyroid axis was impaired. Myxedema coma is rare: where I work in the Baltimore metro area of nearly three million people, there might be five per year. The endocrinology fellow on call had never seen it. Despite its rarity, medical education trains us to recognize the only endocrine emergency. Intellectual pattern recognition for something so uncommon produces a kind of strange pleasure and wonder. So this is real, what’s written in the books. And then comes a rushed sensation of daring and power: I can treat this. 

Yet pleasure soon mixed with grief. For successful treatment doesn’t always follow correct diagnosis. Mortality in myxedema coma is high. If intellectual joy is one of the pleasures of medicine, checking therapeutic hybris by personal grief is one of its emotional challenges. That was myxedema coma; this was Violet. Violet’s breathing worsened after she failed to prevent saliva from entering her lungs and, with family consent, she was intubated. In succeeding days, high doses of thyroid hormone improved Violet’s temperature and heart rate. Urine output gradually returned. The low sodium and glucose corrected, too. But whenever I spoke to Violet, she didn’t respond to her name. She didn’t recognize family. When the ventilator was temporarily paused, she didn’t trigger her own breaths. At last, Violet’s family made the painful decision to compassionately liberate her from the ventilator. 

Winter, we know, humbles the leaves. 

Click here to read more about the author.

This piece originally in the Johns Hopkins publication, “Biomedical odyssey.” 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.