Mitt quickly saw someone whom he recognized: Madison Baker. She was intently watching the monitor over the senior medical resident’s shoulder. Relieved to see his surgical backup was already there, meaning he wouldn’t have to call her if he was asked to do something he wasn’t capable of, which was just about anything at all, he moved over behind her. “Hello, Madison,” Mitt said to get her attention.
Madison turned around upon hearing her name. “Mitt,” she said, acting surprised. “What are you doing here? I was hoping you were in never-never land.”
“I was but I got a call saying my patient had an arrest. I got here as soon as I could.” Mitt was aware of being less than truthful, but hallucinations were the last thing he’d be willing to admit to Madison.
“Oh, for goodness’ sake,” Madison complained. “I told the nurses specifically not to call you because I was already here. Well, I was not exactly here in this room, just a couple of doors down with one of my patients. The nurse who’d been assigned to Ms. Walker ran in and got me. It’s a strange story. She said the patient had been perfectly stable all evening, even ate a full liquid diet, and had only been using her PRN IV analgesic sparingly. The next thing she knew, the patient had no heartbeat. None. Zero. It’s weird. And the resuscitation team can’t figure it out, either. They’ve tried multiple shocks and even an external pacer and can’t get any electrical response. I know you scrubbed on the case this morning. Was there any problem with the anesthesia that you remember? Anything at all?”
“No,” Mitt said. “The anesthesia went perfectly fine. It was the earlier case where there was a problem with anesthesia.”
“Oh, yeah, I heard about that one. She’s in the ICU, correct?”
“Correct. The name is Elena Aguilar.”
“I looked in on her earlier in the evening. That’s another weird situation. I understand she never started breathing after her succinylcholine was stopped.”
“Unfortunately, that’s true. And then later on, she even stopped fighting the ventilator.”
“What did the anesthesiologist think was going on?”
“I asked but didn’t really get an answer. Later it was discovered her electrolytes were abnormal, and she started having cardiac issues as well.”
“You mean the electrolytes became abnormal while she was in the PACU?”
“Apparently. That’s what the nurse suggested to Dr. Singleton and me.”
“Somebody mustn’t have been watching the IV,” Madison hypothesized with a disapproving shake of her head. “That’s even stranger, because the PACU nurses are a terrific bunch and extraordinarily competent.”
“I got the impression the PACU nurse herself was confused.”
“Well, enough about Aguilar. What’s the story with this patient? I haven’t had an opportunity to check the EHR. Any personal history of cardiac issues that might explain this episode?”
“There wasn’t,” Mitt said. “None at all. No family history, either.”
At that moment a nurse pushed by Mitt and Madison, forcing them to step out of the way. The nurse handed the medical resident in charge of the resuscitation a slip of paper.
“Holy shit!” the medical resident exclaimed the second she glanced at what the nurse had handed her. “The freakin’ potassium’s 14.95! I’ve never heard of that. That’s impossible! My God! No wonder there’s no electrical activity.” She then barked a series of orders to the male resident to prepare bicarbonate, calcium gluconate, hypertonic glucose, and insulin, all of which she immediately began to administer as soon as it was available. While she was busy doing so, she asked Madison over her shoulder if the patient had a history of kidney failure, adrenal insufficiency, diabetes, or HIV, all of which can be associated with high blood potassium.
Madison looked at Mitt, and Mitt responded with a definitive no.
“This is ridiculous,” the resident complained to no one in particular. “A 14.95 potassium level has to be a world’s record, and if we don’t get it down ASAP, there’s no chance of success here.” She then turned to the nurse who’d handed her the slip of paper. “Call the medical resident on call and say we need emergency dialysis stat!” Then she turned to Madison. “Since you surgery guys are here, can we get you to insert a tunneled dialysis catheter for us? I’m sure you’re better at it than we are.”
“That’s to be debated,” Madison said. “But sure. We’re happy to help.”
At that point things moved into high gear, and in the rush of activity, Mitt was even able to forget about his recent hallucination and his fatigue. With Latonya Walker’s right groin prepped, Madison insisted that Mitt insert the dialysis catheter at her direction while she held back the abdominal adipose tissue with a small retractor. The catheter itself was sizable, containing a double lumen, one for the blood to be taken from the vein to be processed in the dialysis machine and another for the cleansed blood to be returned to the patient’s circulation.
“You remember the inguinal canal anatomy, I presume?” Madison asked in a joking fashion. It was an area of the body all medical students remembered from a popular mnemonic device, NAVEL, meaning nerve, artery, vein, and empty space with lymphatics.
“I do,” Mitt replied. He could feel the pulsating femoral artery and knew that the femoral vein, his target, was immediately adjacent medially. Taking in his breath and holding it, he plunged the pointed catheter tip through the skin, angled upward toward the patient’s head.
“Great,” Madison encouraged. “Now, advance it slowly until you feel it break through the vein wall.”
As a medical student, Mitt had become relatively proficient at drawing blood, and what he was currently doing was similar, just in a unique anatomical location and under far different circumstances. As Madison suggested, he felt the catheter break through an unseen boundary as he advanced the tip. When he drew back on the attached syringe, it filled with blood.
“Perfect,” Madison said. Then after instructing Mitt to thread the catheter up into the vein a short distance and tape it securely to the skin, she called out to the dialysis team that the catheter was good to go.
Mitt enjoyed a rare feeling of accomplishment after he’d stepped back to give the newly arrived on-call medical residents room to attach the catheter to their dialysis machine.
For the next hour and fifteen minutes, the resuscitation team kept up their frantic activities with the person doing the closed-chest massage changing every five to ten minutes. The group of people observing thinned considerably, although Mitt and Madison stayed. After about an hour, the medical resident in charge ordered a repeat potassium level, and when it returned at still over ten, she’d become discouraged, admitting that despite all that had been done, the potassium level remained much too high to expect a return of the heart’s electrical function.
“Okay,” the senior medical resident of the resuscitation team called out. “We gave it our best shot. The key point here is that the patient’s pupils, which were widely dilatated when we first arrived, have never come down. I’m afraid this is a lost cause. Let’s stop.”
As the resuscitation group began to dismantle all their equipment, Mitt and Madison walked back toward the nurses’ station.
“Well, at least that was a good effort,” Madison said. “I was impressed. They pulled out all the stops, but it’s still a mystery to me what the hell could have happened to make the patient’s potassium level go through the roof. I’ve never seen or heard anything like it.”