“Hmmm,” Colleen said. “I think you’re right. What on earth could be causing that?” Both women straightened up and looked across the divide into the open door of Jack’s cubicle. All was quiet. Aliyah wasn’t to be seen although not all the cubicle’s interior was visible. To see better, Colleen took a few steps along the desk counter but immediately returned. “I don’t think anybody is in there. Any further changes in the ECG?”
“The T waves are gradually getting taller and steeper,” Laurie said. “It seems to be progressive.” In the back of her mind, she was trying to remember what she knew about T waves, but it was all a hazy, distant memory, and under the stress of the moment her mind wasn’t working well. She looked up at Colleen, whom she knew was an expert since watching and monitoring ECGs was part and parcel of her daily job.
“It could be an early sign of ST elevation,” Colleen said, but she clearly wasn’t convinced. “But that is hardly the case. If anything, the ST segment seems to be going down. Hmmm. I’ll head in there and see if anything has changed with the ECG leads.”
“Wait!” Laurie said, her heart beginning to race. She had the premonition something was wrong, something major. “The ECG is changing. Now it looks like the P wave is flattening. What on earth could that mean?”
“That happens in atrial flutter or atrial fibrillation, but the pulse seems to be slowing slightly, which doesn’t make sense. Yikes! What the hell is going on? I’m going in there and I’ll let Patti know. We need a cardiologist ASAP.”
With her eyes riveted to the monitor, Laurie watched as Jack’s heart rate slowed further until the entire ECG complex began to spread out. Then, to her horror, it degraded into a chicken scratch sine wave and the alarm went off, indicating a cardiac arrest.
The entire SICU erupted in response, with everyone not necessary to keep someone else alive rushing into Jack’s cubicle, while Patti placed an emergency code call to bring the circulating cardiac resuscitation team on the run.
With great restraint, Laurie kept her seat. She wanted to rush into Jack’s cubicle as well, but she knew she wasn’t supposed to leave the central desk. She also knew she wasn’t as prepared or as knowledgeable as the nurses and doctors who were already there, so it wasn’t as if she could really help, and might be in the way. As she sat there with her heart racing, she had the crushing feeling that she had failed Jack. Her whole effort had been to watch over him, but somehow she’d fallen short with no idea how. This thinking reminded her of Lou’s request to call him if anything untoward happened. Although there couldn’t be anything more untoward than what was occurring at the moment with Jack’s heart in arrest, she wasn’t going to call him, since there was nothing Lou could do. But thinking of Lou reminded her again of Jasmine Rakoczi and how she had tried to kill Laurie when Laurie had been a patient.
“My God!” Laurie shouted. Instantly all sorts of connections and associations coalesced in her brain. After the Rakoczi event, she had read a lot about the forensics of potassium chloride poisoning and how it was a near-perfect way for a medical serial killer to carry out their gruesome goals. After death, all the body’s cells that had been hoarding potassium in life let it out, so the dead body was essentially flooded with potassium, making the detection of an externally lethal dose having been administered impossible. Part of that reading was about the physiology of sudden high potassium and what it did to the ECG.
With sudden comprehension of what was happening, Laurie leaped up so fast her chair careened across the central desk area on its casters to crash into the counter on the opposite side. Laurie ran toward the opening out onto the main part of the unit. Almost simultaneous with her emergence, the swinging doors into the unit burst open and the resuscitation team came rushing in, pushing the crash cart with a defibrillator, medications, and supplies needed to treat a cardiac arrest.
Laurie and the resuscitation team arrived simultaneously at Jack’s cubicle, which was nearly filled with various personnel. The team surged ahead, pushing people aside. Laurie, who desperately wanted to get to Colleen, saw that she was on top of the bed kneeling alongside Jack’s right side and doing chest compressions. On the opposite side, Aliyah was using an ambu bag to respire Jack in concert with Colleen’s efforts. As the resuscitation team quickly and wordlessly took over both the chest compressions and the respiration efforts while also preparing the defibrillator, Patti, who had seen Laurie arrive, forced her way through the throng to get to Laurie’s side. For her part, Laurie was trying to reach Colleen while desperately calling out her name over the raucous sound of the monitor’s alarm.
“Dr. Montgomery!” Patti yelled sternly while grabbing Laurie’s arm and pulling her to a halt. “You can’t be here. You must leave this instant!”
Laurie knocked Patti’s arm to the side with shocking force, catching Patti completely by surprise. Laurie then barreled through two intensive care nurses who were talking while looking at the monitor. Laurie reached Colleen and forcibly yanked her wrist to get her attention.
“I know what it is!” Laurie yelled, catching Colleen by surprise. Colleen was watching the placement of the defibrillator paddles.
“Clear!” the leader of the resuscitation team yelled before discharging the machine. Jack’s body lurched from the shock. Everyone including Colleen turned their attention to the monitor, hoping the ECG cursor, when it reappeared, would show a heartbeat.
“Colleen!” Laurie yelled in frustration. “It’s potassium chloride!”
Colleen turned to her. “What?”
“Restart the compressions!” the team leader shouted when the cursor popped back onto the screen and traced a straight line. Now Jack’s heart was no longer fibrillating. It was at a standstill with no electrical activity whatsoever.
“I remembered those specific ECG changes!” Laurie yelled to Colleen. “The peaking of the T waves and the disappearance of the P wave is diagnostic. It’s the first signs of hyperkalemia! Jack’s been poisoned with potassium chloride. Tell them to start treatment for hyperkalemia immediately! Please! Every second counts.”
Frantically Colleen looked from Laurie’s tortured face to Patti, who had come up behind Laurie and was trying to pull Laurie from the cubicle. Colleen then looked back at the resident who was doing the chest compressions. She was torn with indecision. Laurie was making a certain amount of sense, but hyperkalemia was a rare problem causing cardiac arrest and mostly seen with serious kidney disorders, not healthy men.
“Tell them to use bicarbonate and whatever else helps!” Laurie shrieked, again knocking Patti’s arm away. At that point, Laurie noted the intravenous was going full tilt into Jack. Breaking off from both Colleen and Patti, she pushed her way up to the head of the bed and stopped the IV using the flow controller. Patti had pushed after her and roughly grabbed Laurie’s arm, angrily ordering her to leave at once and threatening to call security. But Colleen, who’d recovered from her sensory overload, came up behind Patti and intervened. “Hold on, Patti! I think Laurie has a point. The ECG changes we witnessed are pathognomonic of hyperkalemia. I think she’s right!”
“Could someone turn off that freaking alarm!” the resuscitation team leader yelled over the sound, as he prepared for a second defibrillation attempt. A second later, the cubicle fell into comparative silence as Jack’s body again heaved in response to the second shock.
“All right, Bruce, listen up,” Colleen yelled out to the team leader when the cursor continued to trace a flat line on the monitor. “We are going to treat this case as severe hyperkalemia. I want you to use sodium bicarbonate, along with calcium gluconate, and at least twenty units of regular insulin along with a fifty-gram dose of glucose. Also let’s get a stat electrolyte study. And somebody take down those two IV bottles and replace them with saline. Any questions?”