Posts Tagged ‘TSH’

When good algorithms fail

June 7, 2017

The thyroid’s a wonderful gland

And if everything goes just as planned

When we get the right number

With good conscience we slumber

But there’s another approach to be scanned.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

I do a lot of lab tests and x-rays, and I interpret results in the human context. Every result pertains to a person in a psycho-social environment, a factor in a complex system where everything is related to everything, and you can’t change one thing without having an effect on everything else.  Thus the popular medical saying, “We don’t treat lab tests, we treat people.”

Hypothyroidism, where the disease stems from an underactive thyroid, a very important H-shaped gland that sits at the base of the front of the neck, stands as an exception to that truism. We treat numbers.  If we get a high thyroid stimulating hormone (TSH) value, we give a small dose of levothyroxine, T4, the same as thyroid hormone, escalating the dose by six week intervals until reaching a normal value two tests in a row.

(The higher the TSH, the more the patient needs thyroid replacement; it represents the brain’s plea to the thyroid gland for more hormone.)

The approach works well for more than 95% of the people with hypothyroidism.

The problem arises in that small segment of the population that doesn’t convert levothyroxine (a core with 4 iodines attached) to its more active degradation product, triidothyronine or T3 (the same core but with only 3 iodines). Because each T3 is worth 6 T4s.

I explained all this to a patient two days ago, who gave me permission to write what I have.

Most people with lazy thyroid glands have symptoms that can include fatigue, depression, constipation, aching muscles, cold intolerance, mental slowing, and difficulty losing weight. And the vast majority feel normal when the TSH creeps under 3.5.

But a very few patients still don’t feel right, and microscopic doses of Cytomel (the trade name for T3) can make some, not all, feel much better.

I wouldn’t know about this if my sister’s very good endocrinologist hadn’t inspired me to read further.

The problem arises that such methodology verges on what many mainstream doctors call “fringe medicine,” because of the actions of a very small number of unscrupulous doctors. I try to keep a low profile, and I ran the case by two of my colleagues.  One expressed mild surprise, the other, as it turns out, uses the same approach


Three Community Health Clinic Doctors in an Evening Colloquium

October 5, 2012

It turns out my daughter’s a doc,

So’s her fiancee, no shock

At Community Health

You get lots, but not wealth.

Last night we sat down to talk.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

Our oldest daughter, Jesse, finished her Family Practice residency in July.  Bethany and I came to visit her and her fiancee, Winfred, also a family practitioner, in Tacoma.  Jesse represents the third generation in her family in medicine; Winfred the second.  Both grew up with medicine discussed at the dinner table.

All three of us currently work in Community Health Centers; my position permanent part-time, theirs full-time locum tenens.  We had a great colloquium last night.

Patient falling with urinary incontinence and memory loss?  “Normal pressure hydrocephalus,” Jesse said, even before I got to memory loss, and we talked about the handful of cases we’ve seen between the three of us.  The discussion included the human drama of the cases along with a recounting of the physical exam and the MRI.

The question of “What’s your personal best TSH?” came up.  Jesse had a patient with a 56, but once I saw a lab slip come in with “>105.”  The TSH remains the most important thyroid test; the higher the number, the more desperately the body screams for thyroid hormone.  My case dates from the last century, and I told the story, including pseudofractures, hyperparathyroidism, hypercalcemia, familial dysfunction, and bad physician communications.

All three of us serve underserved populations, which in this country means that our patients have very little money.  For a variety of reasons, poverty and diabetes go hand in hand.  Long a staple of therapy, insulin comes in a variety of strengths and costs, but none are cheap and we talked about the high cost of essential medications.  I recounted my experience bringing insulin to Cuba on a medical humanitarian aid mission.  In a small town, word spread quickly that I had brought a refrigerated package with me.  A young woman, a prostitute who worked the hotel where I stayed, approached me. Her younger brother had diabetes and couldn’t get insulin because of the inefficiencies of Castro’s system.  She made it clear she’d do whatever it took to save his life, ignoring my teenage daughter standing beside me.  It broke my heart to tell her I’d turned the insulin over to the Red Cross the day before.  Twenty years ago, $200 only bought 4 vials of an injectable medication that made the difference between life and death.

What beta blocker do you use?  Jesse knows generic propranolol rates as one of my favorite drugs, but I prescribe it mostly off label, for migraines, panic attacks, blushing, and performance anxiety.  Labetalol, which should be cheap because it’s been generic for so long, turns out to be very expensive; but the least costly one in my clinic, carvedilol, only lost its patent four years ago, and has a lots of good qualities.  All three of us use a lot metoprolol.  None of us start patients on atenolol, though we’ll keep people on it if they’re doing well.

None of us like prescribing narcotics or tranquilizers; Jesse and Winfred won’t prescribe sleeping pills at all.  Not even trazodone?  I asked, naming an antidepressant with good effects on sleep and chronic pain.  Well, they said, maybe trazodone.  How about Rozerem?  I asked.  It’s effective, minimal interactions, and no potential for abuse.  But it’s so expensive, and insurance won’t cover it.  I paused and thought and then admitted I’d given out samples but never written a prescription for it.

Blog end: I’ve reintegrated

January 16, 2012

I had a great time, it’s a fact

My life had been so out of whack

I flew cross the sea

From Barrow to Leigh

Now I’m home and it’s good to be back.

I received an email from a doc who went walkabout to New Zealand for a good deal longer than I had, and asked me questions about my reintegration.  I asked for permission to post the original missive, but three weeks later haven’t heard back.

I replied: 

It’s interesting that you emailed me six months to the day after I started back into work here in the States, and if it’s OK with you I’ll use your email and this return as a post.

I’ve enjoyed reintegrating to US society and the medical care system.  I’m back doing hospital work, which, strangely, I really enjoy.   I know my consultants on a first-name basis and I like the camaraderie in the hospital.

It helps that I’m working for a Community Health Center.  For a lot of reasons, our patient population gets sicker earlier.  The pathology load weighs heavy on them.  At any one time, half of our twenty to thirty hospital patients also appear on the nephrologists’ list because of chronic renal failure and dialysis.  Usually we have three people in active DT’s and three others in liver failure. 

I have had to get used to the paranoid reality of defensive medicine.  Our patient population has made the transition easier because many have no money and no insurance and hence can’t pay for procedures that probably weren’t needed in the first place.

For those with insurance, I worry that I overuse medical technology.

Getting labs back the same day, like glycohemoglobin and TSH, makes patient management easier, as does having in-house x-ray.  

I liked MedTech32, the electronic medical record (EMR) system that makes documentation so easy throughout New Zealand, and the hardest part of coming home has been dealing with Centricity, whose software engineers remain isolated from any contact with this particular end user; for example, I have to click through five data fields to make a back to work/school slip and I have no way to fix it.  My productivity has gone way down; eleven patients in a morning or afternoon taxes my resources; not that I spend more time with each patient but I spend more time fighting the computer to enter data.  And about half the problems could be fixed easily.

I miss the way I always started on time in New Zealand because I brought my own patients back from the waiting room, and I miss the way the patients (mostly) respected my time.  In my current situation I limit the patients to three problems per visit.

Narcotics seeking remains a problem here as well as everywhere.  I’m building up a reputation in the street-drug community here, just like I did in the South Island, as parsimonious with opiates and benzodiazepines. 

Still, my practice swells with new patients every day.  I like pediatrics, and I find that a new practice attracts young people and young families, even with an old practitioner.

In the long run, most people either fit into the category of wanderers or homebodies, and I am definitely a homebody. 

But man, did I have a great time.

My patient might have the same disease I did, but not the same symptoms

November 1, 2010

Last week, during a check

Of the thyroid, I said, “What the heck?”

     To me it seemed much

     On the basis of touch,

To find a lump in the neck.

The patient gave me permission to write the following information.

A nurse came to see me last week in follow-up for pneumonia.  She felt, more or less, back to normal.  I whizzed through the exam till I got to her neck.

Back in the physical exam course of medical school, they said, “If you want to learn to palpate, start with a watermelon under a blanket and work up to a dime under a phone book.” Perhaps because Saginaw, Michigan’s phone book lacked epic thickness, in short order I could, indeed, find the dime under it.  Whether from training or talent, I have sensitive fingers. 

In one case, I found a thyroid tumor the size of a Milk Dud.  Oftentimes, though, I feel things that lack reality, and I’ve gotten used to sending people for imaging studies which find nothing.

I make a habit of checking a patient’s neck by running my fingers over the entire area, finishing up with the thyroid. 

The thyroid gland sits just above the sternal notch, that finger-sized depression between the base of the throat and the top of the breastbone.  Enlargement of the thyroid is synonymous with goiter.  The thyroid gland functions much like the factory’s time clock’s mainspring, setting the pace for the whole plant.

When I ran my fingers over the patient’s thyroid, a large, woody-feeling gland stopped me abruptly. 

I asked the patient if she had symptoms of thyroid dysfunction: weight gain or loss, sleep disturbance, trouble with heat or cold.  No, she replied, she felt just about usual.

Of course I got blood tests; the results and the patient came back today.

In the normal course of events, the brain sends signals to the thyroid in the form of TSH, or thyroid stimulating hormone.  The thyroid then makes T4 with four iodine atoms, sends it into the body, where the muscles and the liver rip an iodine off to make T3, with six times the potency of T4.  Sometimes the thyroid gland makes the hormone without command from the brain.  In those cases the brain stops sending signals to the thyroid, the TSH level falls, and the T4 and T3 levels skyrocket.

I had to explain that information to the patient, along with the fact that she made an antibody aimed at thyroid destruction.  Then I thought back to the time my own thyroid went berserk and I remembered how I felt when I could, and did, walk barefoot in the snow leaving puddles.  Did the patient have heat intolerance, weight loss, tremor, an irrationally large appetite, a bounding pulse, and no inner peace?

No, she told me, none of those symptoms.  Yet her TSH came in as undetectable, with her T4 and T3 running twice the upper limit of normal. 

I prescribed propranonlol and arranged for an endocrinology referral. 

I marvel at how different two people with the same disease can feel.

The sea ice broke up, the eczema responded to propranolol, the young respect the elders. And don’t use possessives when you talk about whales.

June 25, 2010

I’m learning the Inuit tongue,

Enjoying respect from the young.

     It’s a terrible loss

     To get hurt blanket tossed

These are wonderful folk I’m among

I have permission to give the following information.

A teenaged patient with eczema, severe to the point of disability, came in a couple of weeks ago.  For reasons clear to me only at the time I did a thyroid test and his TSH was slightly low, indicating an overactive thyroid (the current primary thyroid test, the TSH or thyroid stimulating hormone, measures the brain’s demand for thyroid hormone; low levels indicate excessive circulating thyroid hormone).   A week or so ago I prescribed propranolol.  The eczema is markedly better today; the patient looks happier and is sleeping better. 

Next time I have a patient with poorly controlled eczema, I hope I remember the patient who had been to multiple dermatologists for years and got better with propranolol.

The patient was happy, the relative was happy; I could see things had turned out well, and I came away with job satisfaction. 

The young people treat me with great respect.  I commented on that to a knot of early twenty somethings.  They smiled at me with grandchild-like love and talked about how reverence for elders is part of the culture.

I got to talk to two people with critically low vitamin D levels, in the single digits, today.  Both have diffuse bone pain.  I explained how calcium doesn’t get absorbed or used properly without vitamin D, and in compensation the calcium in the bones gets mobilized.  Which keeps the circulating calcium up at the expense of skeletal strength.

Alas, one of the two uses narcotics recreationally; I hold confidence that I’ll make the bones better but I harbor no illusions that the narcotics seeking behavior will stop.  I hope I’m wrong.

The sea ice broke up in the early hours today.  This morning, working on the elliptical, I watched white ice flows on blue water floating slowly south, pushed by the winds. 

We’ve seen the first Nalukataaq injuries.  I’m a person with enough sense to say that blanket tossing looks like fun for the young but not for me.  Not everyone agrees with me.

My Inupiak language acquisition program is progressing.  I’m in the stage of echolalia, where I can repeat short sentences but I don’t know what they mean.  I was able to say “Good morning.  How are you?  I’m fine.  My name is Dr. Gordon.”  But my head is not in the language and the language has not taken root in my head.  I am, however, working on it.

Seeking to get a better handle on the grammar, I asked one of my informants how possessives are handled.  I got a blank stare.  I have a limited number of nouns in my vocabulary, so I started with whale, agvik.  “How would you say my whale?” I asked.  I got another blank stare.  Finally the informant said, “You wouldn’t say that.  You never say my whale or your whale or even our whale.  You just say whale, ahagvik.