Sometimes there's a satisfying feeling knowing you helped save someone's life. It's a quiet gratification; no one comes up to you to pat you on the back, or gives you a hug, or says "Good Job!". And so, since this is my blog I'll just blow my own trumpet here.
I was paged to see Mr. J emergently. He was post-op day 12 for CABG, with no previous history of glucose lowering medications. That morning, he was unresponsive, and was found to have a glucose of 19 mg/dL. After an amp of Dextrose, his sugars were better, but he remained hypotensive and tachycardic. He was pale, oxygen sats running at the mid 80s on 4 liters. He did not look well.
Now, obviously, the differential diagnosis at this point is pretty wide, most likely from a non-insulin mediated etiology like sepsis, MI etc etc. Basically any sick enough patient can become hypoglycemic; you don't even have to go into the rare (but the Boards love these questions don't they? insulinomas. However I looked at his chart, and something jumps out at me: His past medical history includes POEMS Syndrome, which in his case includes hypothyroidism.
I had the lab perform a stat cortrosyn stimulation test. After the 60 min labs were drawn, I immediately started him on IV Hydrocortisone even before results are back. 2 hours later, his glucose, blood pressure and HR are improved. Thus, I wasn't too surprised when I saw his cortisol levels: baseline 3.2, 30 min 8, 60 mins 11. Adrenal insufficiency, a known association to his exceedingly rare disorder. Seen in about a fifth of patients with endocrinopathies (the 'E' of POEMS). And if severe enough and undiagnosed and untreated, invariably leads to death. The way Mr. J was looking, I doubt he would have lasted another day without the steroids.
Last I saw him, he was sitting up, having Jello. He was off his oxygen cannula, with his systolics running in the 130s, and looked great. I gloated to myself, and said no more to anyone. That sight of him in itself, is reward enough.