A 55-year married woman and mother of adult children was brought to the hospital by ambulance in the early morning hours. She had a history of Type 2 diabetes. In the Emergency Room she was diagnosed with ketoacidosis (DKA) and hypokalemia (low potassium).
The patient was subsequently admitted to the hospital where she first came under the care of the nocturnalist, and then the day hospitalist.
At the time of the patient’s admission, her potassium level was 1.9. This level was not just low, it was critically low – and the laboratory reports were labeled accordingly. Very low potassium can lead to cardiac arrhythmias and death.
The standard of care (both as shown by experts and extensive medical literature) mandates that potassium be replenished aggressively before giving insulin. Insulin has the effect of lowering the potassium level in the blood, which is why the sequence of administration matters so much.
Both hospitalists, however, failed utterly to appreciate the patient’s life-threatening hypokalemia. Instead, they treated her as if she were an ordinary diabetic patient who presented in DKA. Inexplicably, there was no apparent appreciation of her low potassium. Both hospitalists administered insulin but provided woefully inadequate potassium resuscitation.
Neither hospitalist ever actually examined the patient.
The patient’s potassium level dropped through the day. Shortly before she coded in the early evening, her potassium level was 1.0 – a level incompatible with life. Indeed, it was. The code was unsuccessful, and the patient died less than 12 hours after she was admitted to the hospital.
Had the patient’s potassium levels been brought up, her DKA could have been treated effectively. The arrest would have been prevented and she would have survived.