The Paramedic's Brother-In-Law

Chapter Forty-Nine

It took a couple of days for Mitch to get Meghan’s bloodwork back. He had expected to maybe see signs of a possible infection or some anemia, but he wasn’t as prepared to see how off her metabolic panel was. He sat, looking at the computer screen, his hands held together, thinking. Finally, he reached for the telephone and dialed a friend.

Ward Scott speaking.

“Hey, Ward, It’s Mitch Branston.”

Mitch, my man! What’s up? What’s the latest on Kelsey?

Mitch smiled. “Kelsey’s doing good, returning to light duty this week in the Education Department. I need to pick your brain. Got a few minutes?”

The voice on the other end became more serious. I’m off today and putzing around the house. I have all the time you need.

“Well, I need a good diagnostician to help me work through a patient case. Want to come over? I’ll provide the coffee.”

Sure thing! I can be there in 15 minutes.

“I’ll put the pot on,” Mitch promised, and the call ended.

Mitch left his office and headed for the kitchen. He put on a new pot of coffee to brew, and pulled out some brownies Kelsey had made.

Leaving the coffee to brew, Mitch returned to his office and pulled up Meghan’s hospital chart, his personal chart on her, and her labwork results. He locked his computer and returned to the living room just in time to hear a car pulling into the drive. The doorbell rang, and Mitch opened the door, ushering Ward inside.

“Thanks for coming,” Mitch said, shutting the door. “I brewed a fresh pot, and Kelsey has brownies on hand, if you’re interested.”

“Just the coffee at the moment, thanks.” Ward looked around the living room and kitchen as Mitch poured hot coffee into mugs.

“You have a really nice house, man. Married life has certainly agreed with you!” Ward took a sip of his coffee and smiled.

“Yes, it has. Kelsey has a good eye for making the house into a home.”

“So, you said you needed a diagnostician. What’s up?” Ward asked.

“Let me show you my medical suite first, and then we’ll go into my office and discuss a patient,” Mitch offered.

“Medical suite? You mean to tell me you actually have an in-home office?! I wanna see this!” Ward set his coffee down, but Mitch gestured for him to bring it with him.

“You can bring your coffee with you. This way!” Mitch led Ward back into the medical suite. “I kept a separate entrance from the rest of the house, and this is a small waiting area. The hall leads down to the rooms. My office is the first door, here. The middle is the exam room, and the last one is a patient room, in case of an overnight patient or recovery for a few hours. Let me show you that first.”

Mitch opened the door, showing the room Meghan had stayed in the few months she had stayed after her accident. Ward nodded in thought. “The bathroom from this room connects with the exam room.” Mitch shut the patient room and opened the exam room door, turning on the lights. He stepped aside so Ward could enter.

“Now this is a home office!” Ward exclaimed. Mitch grinned. “You’ve definitely got the setup to not only do exams, but minor procedures here if you needed?” Mitch nodded. Ward walked around, opening a few cabinets and drawers, nodding to himself. He returned to Mitch after a few minutes. “Okay, man, I’m officially jealous.”

Mitch laughed. “I wanted a home office, and I built what I wanted. It’s been really helpful.” He ushered Ward out of the room and into the hall before heading towards his office. “Let’s go to my office.”

Mitch settled at his desk and motioned for Ward to pull up a chair. “So aside from showing off, there, buddy, what did you need from me?”

Mitch rested his hands on the desk. “I don’t know if you remember my sister-in-law, Meghan. She was a patient of yours for overnight observation a few months ago.”

Ward thought for a moment. “I don’t remember her well, but I think she was in sometime around when Kelsey had her accident, right? Yes, because you wanted to do that MRI. Okay. What about her?”

“Well, she has me concerned. She’s been passing out occasionally over the last several months, and I’ve noticed a trend of abnormally low blood pressures that are corresponding to the syncopal episodes.”

“How low are we talking about?” Ward asked.

“She had an episode a few weeks ago where her blood pressure was 78 systolic,” Mitch replied.

Ward whistled. “That would be an issue. Are you able to get it raised with fluids, or are you having to pharmacologically intervene?”

“So far, fluids eventually will raise her blood pressure. She and I have discussed this, and she’s concerned about it. I did a thorough physical and some lab work.”

“Let me guess: she’s anemic,” Ward asked.

“Yes, but it’s not just anemia.” Mitch pulled up the lab results. “Her sodium levels are low, and her potassium is just barely on the high end of normal. Fasting glucose levels were a little low, but still within the normal range.”

Ward rubbed his chin thoughtfully. “Is the syncope the only symptom she’s complaining of, or is there anything else?”

Mitch double-checked his notes. “She’s complaining of long-term fatigue, some nausea without vomiting, frequent feelings of lightheadedness. And she’s lost weight again, about 10 pounds in the last couple of months.”

“Have you checked any cortisol levels?” Ward asked.

“No,” Mitch said slowly, shaking his head. “Why? What are you thinking?”

“I’m wondering if it could be an adrenal issue. If her lab values were a little more off, or if you had mentioned metabolic acidosis, I would be saying Addison’s disease. I would suggest a random cortisol level first, and if that comes back low, you need to get her scheduled for an ACTH stimulation study. It could be mild adrenal insufficiency at this stage, but that’s where I’d start.”

“Hmmm. You could be right. I’ll see about getting her cortisol levels checked. Thanks.” Mitch stood, holding his hand out to Ward.

Ward stood and shook it. “More than welcome, my friend. I’d also suggest talking with someone in Endocrinology about this. Maybe Mark Woodruff? I’ve worked with him before, and he seems to be a knowledgeable dude.”

“I’ll reach out to him and run this by him for his opinion,” Mitch agreed.

**********

Mitch called Dr. Woodruff a couple hours later. “Mark? This is Mitch Branston. Have a few minutes?”

Sure thing, Mitch. I’d welcome the break in paperwork, Dr. Woodruff chuckled.

“Great. I have a patient that I’d like to discuss with you, get your take on things.” Mitch pulled up Meghan’s chart and lab work again.

Sure thing. What have you got?

Mitch gave Dr. Woodruff a run-down of Meghan’s symptoms and labwork. “I spoke earlier today with Ward Scott, and he recommended I speak with you. He thinks it could be early Addison’s disease.”

There was a pause on the other end. Well, it’s possible. Have you done a cortisol level?

“No, not yet, but Ward recommended that, as well as an ACTH stimulation study. I’m going to see if I can get her in to have those done in the next couple of days.”

Go ahead and get the cortisone levels. I’d advise getting an 8 am cortisol level for the most accurate results. If that’s low, then call me and I’ll get your patient in for the ACTH stimulation study within a week.

“Thanks, Mark. I’d appreciate that.” Mitch sighed and made a note in Meghan’s file. “If this does turn out to be Addison’s, how could this potentially affect her lifestyle?”

Well, with Addison’s, we give corticosteroids to increase cortisol levels. It’d be something she’d be on for the rest of her life, but as long as we monitor the labs and dosages, she should be okay. Why?

“Well, the patient is my sister-in-law, so I’m curious in that regard. The biggest concern is that she is a paramedic, and I know it would be very hard for her to accept that she wouldn’t be able to work in the field anymore.” Mitch ran his hands through his hair.

Ah, yeah, that would be difficult. I think it might take some closer monitoring at the beginning of treatment, but I don’t see why that would be an issue with her work. I assume she’s been working without issue during this time?

“For the most part. We’ve noticed 3 episodes of syncope, which we determined was from a hypotensive event, but she says that she has periods of lightheadedness off and on. I’m not sure, but I think those syncopal episodes followed a significant critical call.”

Hmmm. Well, it could be an increased demand on cortisol by her body that she just doesn’t have, or it could be an idiopathic thing. What does she normally do with these kinds of events?

“Code Red Mountain Dew.” Mitch replied, making a face.

Dr. Woodruff laughed. That’s awful stuff! However, I can understand that someone with some of the issues you’re telling me about would be looking for caffeine or similar stimulants to try to recover from a major adrenaline dump to the system. Does she regularly consume a lot of caffeine?

“She is a self-professed coffee junkie,” Mitch confirmed.

That might be something to look into reducing, but let’s take one thing at a time. Go ahead and get that cortisol level, and give me a call. If it’s normal, we’ll brainstorm what avenue to go down.

“Thanks, Mark, I appreciate it.” Mitch thought a bit more about Meghan’s chemistry panel. “Should I be doing something to help with the sodium and potassium levels?”

I’d suggest maybe more salt in her diet, within reason, of course, but unless the potassium levels are heading towards critical, leave those alone for the moment until we have a better idea what we’re looking at. I’d have another chem panel drawn while doing the cortisol, just to keep an eye on it.

“Sounds like a plan, then. Thanks for your time, Mark. I’ll be calling you back when I get these lab results.”

You’re welcome. Keep me informed, and I’ll let my staff know that I might have an emergent patient consultation within the week. We’ll get her in as soon as possible if needed.

“Awesome! Thanks again!” Mitch ended the phone call and added a few more notes to Meghan’s chart. He thought for a few more minutes before picking up his phone and tried to get ahold of Meghan, but the call went straight through to her voicemail. He left a message and hung up. Then it dawned on him that tonight was a class night. Glancing at the clock, he confirmed the time; sure enough, class was in session.

Chuckling to himself, Mitch sent Meghan a text. When you get a chance, I need to speak with you tonight. Call me when you get a free minute.