T waves

Last month I had a patient with a potassium level of 5.5 when I checked his labs in the morning.  5.5 is slightly elevated.  Slightly elevated potassium scares interns (me).  Slightly elevated potassium can turn into really elevated potassium which can turn into an arrhythmia which can turn into death.  Death is bad - I catch on quickly.  So I did what any good intern would do....rechecked the potassium level and got an EKG.  Sure enough, potassium was still high on the recheck, and the EKG.....well....I'm only on chapter 3 of Dubin's Rapid Interpretation of EKGs, but it looked to me like the T waves might be peaked.  They were certainly tall.  But I wasn't sure.  This is the part where the intern (me) freaks out a little bit.  Peaked T waves can be the first sign that the elevated potassium is affecting the patient's heart.  It was certainly affecting the intern's (my) heart....as it began beating more rapidly. 

Are these T waves peaked?  Well heck....they look a little peaked....maybe they're just tall....tall but not peaked.....or maybe they're just peaked and the patient is going to die in 5 seconds because you don't know the difference between peaked and tall.  Maybe you should just call your senior....or maybe you should sit down with your head between your legs.  Or maybe you should go get a doughnut. 

Just then, a senior resident, who I'd never spoken to before in my life, started walking down the corridor toward me.  I lurched out from behind the patient's chart, clutching the EKG in my hands, knuckles white, thrusted it out in front of me and said, "ARE THESE T WAVES PEAKED!?!?!?!"  My heart was beating 500 times a minute....I was about to call a Rapid Response on myself.  He looked at me like I was crazed....which was an accurate evaluation, but he took a quick glance at the EKG and said, "No....just a little tall.  Give him some calcium gluconate, D50 and insulin, and a little kayexalate." 

Yeah....that's what I thought......

So now I'm much more comfortable managing hyperkalemia. 

Next time....managing an upper GI bleed.