Got potassium?

​Today we had a young lady with Type I diabetes who presented with blood glucose in the 300s, diffuse weakness or and 3 ketones in her urine. She also had diffuse abdominal tenderness but no distention or guarding or bleeding anywhere. Vitals rather stable. 

She had been off of her diabetes medication for a few months. She actually had received care at the local Thai hospital in the past and had been an oral medication only. 

There was some concern for DKA. 

Interestingly, the head medic pulled out their guidelines for chronic disease, and I peered over her shoulder while I worked on a quality measures project I’m doing. The DKA guidelines said to give 1 liter IVF per hour. That is all. Their only clue to potential acidosis was ketones in the urine. 


They can’t test metabolic panel, pH; don’t have insulin drip or potassium infusions. We have subQ insulin leftover from patients who have expired, and a bottle of insulin I bought at the local pharmacy just in case. We have potassium tablets, but the patient was vomiting up everything she swallowed 


I told her we have to think about potassium. She said their guideline doesn’t mention potassium because  they they have to hope the patient will be able to afford/opt for transfer to the Thai hospital. We are just not equipped to treat DKA. Still, I hand wrote “Check potassium” next to the DKA guidelines in the book. 


This is another reason I keep pushing for some way to get an on-site or quicker metabolic panel result. The current situation is any send-out labs have to be ready by 1pm. Anything else has to wait til tomorrow at 1pm. So fingers crossed for any critical cases. We have a fair number of DKA cases, and I think it’s bread-and-butter enough for us to get equipped to treat. 


The patient could not afford to transfer. So the medic called one of the non-profits that raises money to pay for certain imaging, procedures or treatments at the Thai hospital. In the meantime, she got 2-3 liters of IVF. Also in the meantime, I fretted about her potassium level. 


So I decided to do an ECG with our finicky ECG machine that only spits out 10 of 12 leads (it chooses which 10 it wants to produce each time LOL). There were no long PR segments, peaked T waves or QRS prolongation. There may have been u waves in 1 lead but honestly the ECG quality is terrible and I wouldn’t bet money on the lone u wave. In any case, I explained to the nurse that with DKA on the differential, and as we were dumping IVF into her, we have to consider low potassium. Her glucose improved some after the IVF. 

Our little old ECG machine


Has suction cup electrode like this 

There was also the abdominal pain to think about but mainly I wanted to process through the use of ECG as our only immediate evaluation of potassium. And no way to treat hypokalemia. I’m uncomfortable with that! 

Then we found out she did get approval to transfer to the Thai hospital, though she had already been with us 6 hours by the time I went home and she was still in bed. I hope she actually gets to go tonight. 


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