17 July 2008


If you're going to pick a place to croak, the triage desk of a major ER is a good place to do it. That's what my patient the other afternoon decided to do. He walked in, told the nurse he was feeling short of breath, then promptly keeled over, stone cold dead.

Well, for a few minutes, anyway. We pulled him onto a gurney and rolled him back, bagging him and doing CPR. He was a skinny guy in his early forties, and I didn't know a damn thing about him, not even his name. We threw on the patches and the presenting rhythm was V-Fib; we promptly shocked him into this:

About this time I noticed the dialysis fistula in his arm. He was still pulseless, and as we were getting a line in him and intubating, his rhythm degenerated into this:

It didn't take a genius to figure out he was hyperkalemic. Another shock, speedballed with Calcium and Bicarb brought back a pulse and a nice tight complex ECG:

Someone had performed a wallet biopsy on him and gotten a name and some records; I got his nephrologist on the phone, stat:

-- Hi, Chris, I've got your patient Billy here in the ER.
-- Oh, yeah. I said hi to him about twenty minutes ago as I was walking through the waiting room. He looked fine then.
-- Nice timing! He coded about five minutes later.
-- I'm not surprised. He mentioned he hadn't been in to dialysis in a while. What's his potassium?
-- Just above ten.
-- Hmph. It was over eleven last time. Does he have a pulse?
-- Yeah, we've got him resuscitated and tubed.
-- Okay, well, I guess we'll have to take care of him again. This is probably the sixth time this year alone. Send him up to the ICU and I'll have them ready for him. You did give him calcium, I hope?
-- C'mon, man, who're you talking to? I'm no rookie.
-- All right, all right. But don't screw around too long down there -- just send him right upstairs, OK?

Later that night, as I was driving home, I reflected on the case. It's classic ER medicine: exciting to be sure, and fun, but demanding -- I had to figure out the potassium knowing nothing about the patient, quickly, and with no room for error or hesitation. This is what it's all about for an ER doc, and in the past I have taken great satisfaction in such cases.

But not today. Rather, this case felt incredibly hollow, that it had been another exercise in futility. This patient's persistent and severe self-destructive behavior was the sole cause of this and his many other critical presentations, and I felt like we were just enabling him by repeatedly rescuing him. Not that we had any choice in the matter. But there was a bitter taste left in my mouth. I happened to catch the nephrologist on my way out, and I asked him how Billy had done.

-- Oh, great, he says. We got his potassium right down and he's fine now, watching TV and eating dinner. Fantastic job -- you really saved his life.
-- Or at least delayed the inevitable for a bit longer, I responded.


  1. So many people give a lot of bicarb, but forget about the potassium, or they decide to wait for labs to come back, or spend so much time making a decision without labs, that they might as well wait for them. It is important for people to realize that a dead dialysis patient is hyperkalemic until proven otherwise.

  2. Or at least delayed the inevitable for a bit longer, I responded

    But... that's all you ever do.


  3. Matt Dick wrote:

    "'Or at least delayed the inevitable for a bit longer, I responded'"

    "But... that's all you ever do."

    But for this guy it has been about as regular as menses - "probably the sixth time this year alone." Not that he has ever menstruated. At this rate he is not going to make it in to the hospital, or he will be misdiagnosed, or he will just be down for too long without compressions.

    Dropping dead this often cannot be good for your health.

    BTW, what is that nice dark looking beverage that appears to be out of an Anchor Steam-type of bottle, even a similar label, but with a tree instead of an anchor?

  4. I gotta agree with Matt...ventolin and ABX to the 4 ppd smokers, metformin or insulin to the 300lb diabetics, IV ABX to the IVDU's,...we take out joints and replace them, remove cancers...all in the hopes that we'll delay the inevitable for a bit longer.

    Dude! That's our job! :)

    Just take pride in the fact that you are a smart practitioner who can think on his feet. Small victories...small victories.

  5. Hey, we're all going to kick it. The precious time you give back to him is valuable even if he squanders it.
    Good job.

  6. @ rougemedic:

    Anchor Our Special Ale, their Christmas-time beer. Should be tons of info about it on their site. Man I guess I drink too much!

  7. Anonymous/Matt Dick,

    It looks great. I lived in San Francisco for a while and I forgot all about that. They do make a wonderful holiday ale. I could never decide which I preferred, Samuel Smith's or Anchor. I guess I will have to start investigating that again - and Sam Adams and Sierra Nevada, . . . . :-)

  8. "In the long run, we're all dead."-- John Maynard Keynes, economist.

  9. Ahh yes. I have Our Special Ale from about 4 or 5 of the last 15 years. I seem to have a lot of the 1993, which that is, I think.

    2003 is also excellent.

    If you drink enough to know an Anchor product that you've never personally see, I would say that you drink just enough.


  10. If we ever want this utopia of universal socialized healthcare then we have to halt all of this stupid futility. This mans care is costs 6-7 figures annually. This would fund the healthcare of hundreds of families or that of a small country.

  11. Anonymous,

    I agree that universal health care will require a lot of rationing. Doing something, just because we are able to do something - advances in medical science are continually expanding what falls into this category - and deciding it is the right thing to do for any particular patient, are very different decisions. We will not be able to do everything for everybody.

    I do not think that you can decide that a patient, who arrests in the ED waiting room, should not be treated. There would not be the time to gather information in the emergency setting. Once he is stabilized, that is a different story. How the rationing is accomplished so that people do not feel that care is being rationed is also another question.

    Yes, it probably does cost well over a million dollars a year to help this guy ignore the medical care that would keep him out of the hospital, the treatment that would keep the costs of care to a minimum.

    If it is any consolation, he will probably not survive the year, unless he changes his approach to taking care of himself. At some point he will drop dead in a place that does not have someone able to treat hyperkalemia as well as Dr. Shadowfax demonstrated here. Makes me wonder if the patient's name is Felix. :-)

    Resuscitation is often of those who do not take care of themselves and those who are a financial drain on society. These are not the only patients resuscitated. There are plenty of patients who experience cardiac arrest for reasons other than self destructive behaviors.

    Other "positives" are the great post about hyperkalemia, with ECGs. This is something that is hard to explain to some people. This is an excellent real patient resource to use to show changes in rhythm, especially the link to The Wrong Juice and the dramatic and immediate response to calcium in that patient.

    I will also have to see if the local distributor can get Anchor products. :-)


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