Glenda Cyr has been my patient for many years. She also follows with an endocrinologist in the city because of hypoparathyroid disease. She’s on varying doses of calcitrol and vitamin D and he follows her bloodwork regularly, even though he last saw her about two years ago. He works at the Catholic hospital across the city from the rival, bigger, Cityside hospital.
Back in March, Glenda became very ill very quickly and was first admitted to our local hospital and within 24 hours they transferred her to Cityside. She turned out to have abscesses threatening several of her vital organs. Some were drained and some were inaccessible so she was on complicated regimens of intravenous antibiotics over several weeks at the big hospital and then at a rehab facility closer to home.
Shortly after her admission, it was time for her regular blood draw, which Autumn usually does. But because she was at Cityside, we called the endocrinologist and left a message that she was there.
Maine has a health information exchange where most hospital systems upload their clinic notes, imaging and laboratory results. In our system, telephone notes, patient letters and office messages are not posted on the information exchange. Because the endocrinologist has treated her over the phone since he last saw her two years ago, I don’t know exactly what is going on with her care there.
Sometime in April, I got a message that he wanted me to evaluate Glenda, but the message didn’t say for what. I called the endocrinology office to ask what the issue was that they wanted me to look into but the office staff were unable to locate any such information. There were no recent notes in the health information exchange from the Catholic hospital system, but plenty of notes from Cityside and the rehabilitation hospital.
Finally, I got word that he wanted me to look into why her albumin was dropping so drastically. This is a big issue when you have a calcium level problem, because calcium is bound to albumin and you can ballpark the ratio, but it is often very helpful to check an ionized calcium. He was basically hoping that I could tease out why her albumin was dropping as this would make it more straightforward for him to control her calcium levels.
She has been home for two weeks now and I have seen her once in a hospital followup visit when I didn’t have the information about what I was supposed to look into. We had scheduled an appointment for today now that we know our assignment. Before I headed out, I logged into the health information exchange to see what her latest albumin level was. Lo and behold, it is now normal.
My instinct told me that the albumin must have dropped when she was so desperately ill and now normalized when she is relatively well. I googled albumin, infection, illness, and there it was: It often drops during infection or inflammation, and during the pandemic that was thought to be a marker for poor outcomes.
When I saw her today, she showed me a letter dated two weeks ago, describing his concern. He must have seen the chemistry profiles done at Cityside Hospital on the health information exchange so he must have known how desperately ill she had been. I did not know until today that hypoalbuminemia can be caused by illnesses such as severe infections and I suspect neither did the endocrinologist or he would not have asked me to look into this.
You can’t know everything and you’re never too old to learn.