Renal here. This patient should have been admitted. K 2.5 indicates a chronic issue with malnutrition, and therefore a high risk of refeeding syndrome. She needed labs checked at least daily and an evaluation into the underlying cause of the hypokalemia. Throwing more ORAL potassium at a patient with abdominal pain and nausea after it already didn’t work the first time? What was the thought process here? There was a thought process right? Right?
They actually went even less aggressive at the ER visit. She was prescribed supplemental K by the pediatrician, ER just said to eat potassium-rich foods. The refeeding syndrome idea is interesting, some others have raised the possibility of anorexia although it wasn't mentioned anywhere in the court records and obituary didn't give any clues either. Sad case.
I'm curious what Neil has to say but I don't personally have a hard cutoff in my mind. There's an interesting discussion on Reddit that basically seems like the generalists (EM, peds, hospitalists...) are all saying if they can tolerate PO fine and don't have any other serious symptoms, ok to send home. Whereas the specialists, seems like mostly nephrologists, are saying definitely admit even if their other issues seem minor. Very interesting to realize that there is not a lot of consensus here and seems to be MASSIVE practice variation.
Yeah I'm not aware of any studies on this issue. I'm an ER doc and I think anything below 2.5 I would wanna admit even if tolerating PO. The lab calls me with a critical result if it's 2.8 or below but anything 2.7 and above I don't get too excited about although I guess that's arbitrary. Also there's a good chance that the Mag at that point would be low and would have to be repleted also. Now that I think about it, was a Mag level checked in this case?
Mag should have been given with hypoK, but a Mag level likely wouldn't have been helpful. 98% of mag is intracellular, so the small extracellular mag you're checking when you order a level isn't accurate.
Sorry! They didn't disclose the pathologist's actual opinion. The attorney had submitted a filing that listed all of the plaintiff witness and a brief summary of what they would say. I edited the case to include the summary of the pathologist's opinion, only additional info it has it that an autopsy was done.
Now that I've actually read what you added, I'll say that translates to "the autopsy was completely unremarkable with no obvious cause of death; therefore, given the documented hypokalemia, the most likely cause of death is hypokalemic arrhythmia."
Yeah that was kind of the vibe I got from reading between the lines. I think there are more questions than answers about the actual cause of death in this case.
Agree, definitely could have made a case. I feel like a potassium in this range usually comes down to the surrounding context. If they're feeling ok and can tolerate PO, otherwise healthy, probably discharge. More complicating issues = admit.
I think the most damning part is that they recognized the issue in the last ER visit, they tried to give supplementation and kept patient there for hours, all for the K to remain very low on re-evaluation. That alone would make me offer admission since she failed outpatient therapy and in hospital supplementation (assuming ER gave her potassium and Mg). Whether this caused her death directly is unclear, but given her social situation and multiple visits, admission would be the most logical choice or 24-48 hour follow up.
The “expert opinion” was so obviously not written by a doctor. It’s all vague language about failing to “care” for the patient, whatever that means. I feel like there should be some law or regulation against having a doctor simply slap their name on a document written by a med mal attorney. The only part of the care that I’m not sure if I agree with was discharging the pt when her K+ was 2.5, that’s pretty low. I guess it did go up to 2.7 though. And they probably didn’t know that she was already taking potassium supplementation. I guess idk what I would’ve done if I were the doc in that situation.
Edit: and I forgot, what the hell was that last point by the plaintiff about not treating “circulatory insufficiency?” Wtf?
Yeah I'm pretty sure the doc just signed this and it was written by the plaintiffs attorney. Not sure how much true collaboration there was. The circulatory insufficiency comment is so clearly written by someone with zero medical training or understanding.
Regarding special defense point #2 -3: what instructions or follow-up did the patient miss? If she was prescribed KCl x 14 days on Dec 10 and told to follow up after the treatment, then she would have finished it on Dec 23-24 depending on what day she started it, and she presented to emerge on Dec 24.
She was supposed to follow-up with the pediatrician as an outpatient. I suppose you could make the argument that the ED visit was the equivalent of a pediatrician follow-up because they checked the potassium, but the ED visit was focused on her abdominal issues with the K only being (what was perceived to be) an incidental finding. Follow-up with the pediatrician would have provided more focused review of her hypokalemia rather than being just one of several factors in the ED.
Renal here. This patient should have been admitted. K 2.5 indicates a chronic issue with malnutrition, and therefore a high risk of refeeding syndrome. She needed labs checked at least daily and an evaluation into the underlying cause of the hypokalemia. Throwing more ORAL potassium at a patient with abdominal pain and nausea after it already didn’t work the first time? What was the thought process here? There was a thought process right? Right?
They actually went even less aggressive at the ER visit. She was prescribed supplemental K by the pediatrician, ER just said to eat potassium-rich foods. The refeeding syndrome idea is interesting, some others have raised the possibility of anorexia although it wasn't mentioned anywhere in the court records and obituary didn't give any clues either. Sad case.
I also thought of an ED, given the electrolyte imbalance, diarrhea (from laxatives??), and implied psychosocial stress. Agreed, a sad case.
Ah good eye, I hadn't thought about the diarrhea --> laxatives connection.
Out of curiosity, is there usually a certain cut off in regards to potassium level at which you recommend admission?
I'm curious what Neil has to say but I don't personally have a hard cutoff in my mind. There's an interesting discussion on Reddit that basically seems like the generalists (EM, peds, hospitalists...) are all saying if they can tolerate PO fine and don't have any other serious symptoms, ok to send home. Whereas the specialists, seems like mostly nephrologists, are saying definitely admit even if their other issues seem minor. Very interesting to realize that there is not a lot of consensus here and seems to be MASSIVE practice variation.
Yeah I'm not aware of any studies on this issue. I'm an ER doc and I think anything below 2.5 I would wanna admit even if tolerating PO. The lab calls me with a critical result if it's 2.8 or below but anything 2.7 and above I don't get too excited about although I guess that's arbitrary. Also there's a good chance that the Mag at that point would be low and would have to be repleted also. Now that I think about it, was a Mag level checked in this case?
Mag should have been given with hypoK, but a Mag level likely wouldn't have been helpful. 98% of mag is intracellular, so the small extracellular mag you're checking when you order a level isn't accurate.
There's finally a pathologist expert witness and I don't get to read anything from them!?
Sorry! They didn't disclose the pathologist's actual opinion. The attorney had submitted a filing that listed all of the plaintiff witness and a brief summary of what they would say. I edited the case to include the summary of the pathologist's opinion, only additional info it has it that an autopsy was done.
No worries, I was just joking
Now that I've actually read what you added, I'll say that translates to "the autopsy was completely unremarkable with no obvious cause of death; therefore, given the documented hypokalemia, the most likely cause of death is hypokalemic arrhythmia."
Yeah that was kind of the vibe I got from reading between the lines. I think there are more questions than answers about the actual cause of death in this case.
Excellent post! I think a strong case could be made for admitting a patient with a K+ of 2.5.
Agree, definitely could have made a case. I feel like a potassium in this range usually comes down to the surrounding context. If they're feeling ok and can tolerate PO, otherwise healthy, probably discharge. More complicating issues = admit.
I think the most damning part is that they recognized the issue in the last ER visit, they tried to give supplementation and kept patient there for hours, all for the K to remain very low on re-evaluation. That alone would make me offer admission since she failed outpatient therapy and in hospital supplementation (assuming ER gave her potassium and Mg). Whether this caused her death directly is unclear, but given her social situation and multiple visits, admission would be the most logical choice or 24-48 hour follow up.
It did go up slightly in the ER, but not a lot and she was just told to eat potassium-rich foods at home, not given an Rx.
Interesting case. I am curious if an EKG was done looking at the QTc interval?
Doesn't appear to have been.
The “expert opinion” was so obviously not written by a doctor. It’s all vague language about failing to “care” for the patient, whatever that means. I feel like there should be some law or regulation against having a doctor simply slap their name on a document written by a med mal attorney. The only part of the care that I’m not sure if I agree with was discharging the pt when her K+ was 2.5, that’s pretty low. I guess it did go up to 2.7 though. And they probably didn’t know that she was already taking potassium supplementation. I guess idk what I would’ve done if I were the doc in that situation.
Edit: and I forgot, what the hell was that last point by the plaintiff about not treating “circulatory insufficiency?” Wtf?
Yeah I'm pretty sure the doc just signed this and it was written by the plaintiffs attorney. Not sure how much true collaboration there was. The circulatory insufficiency comment is so clearly written by someone with zero medical training or understanding.
Regarding special defense point #2 -3: what instructions or follow-up did the patient miss? If she was prescribed KCl x 14 days on Dec 10 and told to follow up after the treatment, then she would have finished it on Dec 23-24 depending on what day she started it, and she presented to emerge on Dec 24.
She was supposed to follow-up with the pediatrician as an outpatient. I suppose you could make the argument that the ED visit was the equivalent of a pediatrician follow-up because they checked the potassium, but the ED visit was focused on her abdominal issues with the K only being (what was perceived to be) an incidental finding. Follow-up with the pediatrician would have provided more focused review of her hypokalemia rather than being just one of several factors in the ED.