“Notification!” Brenda shouted as she hung up the red phone. “Eighty-year-old, altered mental status, no palpable blood pressure. Three minutes out.”
While nurses gathered IV equipment and an EKG machine, two paramedics rolled in a stretcher bearing a small, moaning, barely conscious Asian woman.
“Couldn’t get a blood pressure,” the chief medic said, panting. “Pulse 30 on arrival.” That meant her ventricle had stopped responding to her pacemaker, so they jolted her heart with a shot of atropine, which bumped her heart rate to 60.
"Her medical history is renal failure, dialysis three times a week, hypertension, and a history of stroke,” the medic added. “Son says she woke up confused, saying her legs hurt. Couldn’t walk. Fine the night before. We gave her D-50 [a glucose solution that reverses hypoglycemia]. Didn’t help.”
The prickly durian fruit has an odor like strong
cheese and plenty of vitamins and minerals,
including potassium. Durian is a delicacy in
many parts of Southeast Asia.
Thin and wiry, Mrs. Chee looked awful. Brenda hooked her up to the EKG machine. Out came one scary electrocardiogram. Instead of intermittent, tightly spaced spikes and valleys, there were broad, sickening drops followed by abrupt peaks—a paper roller coaster. When the queasiness in my own stomach settled, I said: “This is hyperkalemia [high potassium]—it has to be. She needs calcium now.”
Giving it would counterbalance the excess potassium. I turned to Mrs. Chee’s son, who had remained calm and attentive at her side.
“Has she ever gotten hyperkalemia before? You know, high potassium?”
He shook his head. “Never. I’m an ER doc like you. She’s been on dialysis for 10 years. Very compliant. No hyper-k ever.”
I showed him the EKG result. His eyes widened.
“I’m going with calcium,” I said.
“Whatever you think. And feel free to kick me out.”
I looked at Mrs. Chee’s bony forearm and checked her IV. Calcium chloride, the emergency treatment we would give for her dangerously high potassium, can kill tissues if it leaches out of a vein.
Brenda handed me the 10-milliliter vial of calcium chloride.
“IV’s flowing well, right?”
“Saline went through fine.”
I hooked up the plunger and, with an eagle eye on the IV, pushed slowly. The monitor overhead beeped at the pacemaker minimum of 60 beats per minute. Mrs. Chee’s heart couldn’t beat on its own. The loopy EKG rolled across the screen.
Six minutes after the calcium went in, the EKG pattern contracted like an accordion. Mrs. Chee’s heart rate jumped to 88 and the roller-coaster pattern morphed into properly spaced spikes and dips.
“Wow,” her son exclaimed.
Fifteen minutes later his mother opened her eyes, announced she was better, and wanted to go home.
The calcium treatment would work for only an hour, so we finished up by infusing insulin and more glucose. These substances drive potassium out of the bloodstream and into the cells. There it would stay until a resin called Kayexalate, which Mrs. Chee began to drink, pulled the excess potassium into her gut and eventually out of her body.
