The Patient Was…

The patient was a 60-plus-year-old male who was referred to me for control of hypertension (high blood pressure).  His degree of hypertension was only moderate, but even mildly elevated blood pressure, over a long period of time, can lead to stroke and other cardiovascular disorders.

His general doctor had started him on a drug called reserpine, which is one of the oldest drugs developed for treating high blood pressure. It has been supplanted by many newer, more effective, and safer drugs, and is, in fact, no longer available in the United States.

I had a particular interest in blood pressure and was active in the American Society of Hypertension. I had studied and done research with the founder of the organization and was on the Board of the society’s official journal, The American Journal of Hypertension.

The patient was a retired pharmacist, a point he made a few times even in our early conversation. I silently noted the repeated reference to his professional status, but I did not realize the importance it would play in what subsequently transpired.

As initial therapy for his moderately elevated blood pressure, I prescribed what is commonly known as a diuretic drug. Diuretics basically cause the body to eliminate more fluid through the kidneys, thereby producing more urine. But urine does not come out as pure water. Rather, as the body rids itself of excess fluid, it also excretes what are called electrolytes. 

Electrolytes are chemical particles that dissolve in fluid and carry electrical charges. Yes, electrolytes are  —  electrifying. Some carry positive charges and some carry negative charges. And these dissolved, charged, chemical particles (known as ions) are essential to normal body function, especially nerve and muscle function. They create and carry nerve impulses, and their movements generate muscle contractions.

The body tries to regulate the levels of electrolytes in the blood and in the lining and interior of the body’s cells. If there is too much or too little of one or more electrolytes, the consequences can be very serious, even fatal. Electrolytes can move in and out of cells, across cell linings, and their relative concentrations in the blood and various body tissues may determine if cells can perform their normal functions.

There are several electrolytes that are especially vital to health and safety.  Among the most well known are sodium (chemical symbol Na) and potassium (K). Both sodium and potassium carry positive electric charges and are usually designated, respectively, as Na+ and K+. In the body, their electric charges are usually balanced by other, negatively charged particles.

Now, when a diuretic drug is prescribed, the prescriber is usually well aware that when more water is excreted through the kidneys, dissolved electrolytes are also eliminated in the fluid. Since sodium is the electrolyte most associated with elevated blood pressure, its elimination is desirable. But other electrolytes are also excreted, important among them, potassium. Thus, when a diuretic is prescribed, potassium supplements are often prescribed as well.

The blood levels of the patient’s electrolytes were within the normal range when tested before any drug was prescribed.  But the level of potassium was below the middle of the normal range, so I prescribed a common potassium supplement in its usual liquid form.

The common dose was one or two tablespoons daily, and I so instructed the patient. We made an appointment for him to return in three weeks, to check his blood pressure response to the treatment and to recheck the levels of his electrolytes.

When he came back for his return appointment, he did not look well. And he seemed rather angry. So, before I examined him we sat in my consultation room and I inquired as to how he was feeling and what seemed to be troubling him.

He said that I had treated him as a “regular” patient and had not taken into account his status as a retired pharmacist who understood medications and their dosages, and who was accustomed to having his expertise recognized and being treated as a scientific professional. He resented, he said, my prescribing potassium supplementation in terms of “tablespoons” rather than in scientific terms like “milliliters” or “drams,” a unit of measurement used almost solely by pharmacists.

I was getting a bit fearful looking at his unwell appearance and asked how much potassium he had been taking. He said he had converted my prescription of tablespoons to his units of drams or something else and had calculated the amount he actually needed.

It was wildly excessive!

I took him at once into the examination room and quickly drew a blood sample to test for potassium levels. Although the result would not be immediately available, I wanted to document the level for what might need to be done later. I then lay him on the examination table and hooked him up to my EKG (electrocardiogram) machine. As the EKG tracing was being recorded, it showed classic signs of dangerous hyperkalemia (potassium excess).

And the patient died!

Right there, lying on my exam table, he went into cardiac arrest. I quickly started cardiac resuscitation, as my secretary called for an ambulance. I was able to restore a feeble heart beat although the patient was not responsive. The ambulance arrived and took him to the nearby Emergency Department (ED) of my hospital. He suffered another cardiac arrest in the ambulance and was again resuscitated. In the ED he once more went into cardiac arrest and this time could not be brought back to life.

Later on, when the result of the blood test was available, it revealed severe hyperkalemia, a potassium level usually associated with fatal abnormalities of the cardiac rhythm. The timing of the blood test was fortuitous because if the blood had been drawn after the cardiac arrest had occurred, the result would have been unreliable because dying cells release potassium into the blood stream and the elevated levels of potassium could have been an effect of the heart stoppage and not its cause.

Professional pride led the patient to make a mistake that cost him his life.

A “Greek Tragedy.”

A needless death!