Doctors followed tangled trail to cyanide diagnosis
By Margaret Harding
Published: Thursday, Aug. 1, 2013, 12:01 a.m.
UPMC Presbyterian doctors desperate for answers used a machine to pump oxygenated blood into their dying colleague's body as they ruled out potential causes for her collapse, investigative records show.
Dr. Autumn Marie Klein, 41, was “morbidly ill” and unable to speak when an ambulance took her to the hospital after her husband, Robert Ferrante, 64, called 911 and said his wife might be having a stroke.
Pittsburgh police on July 24 charged Ferrante, a University of Pittsburgh professor of neurological surgery, with using cyanide to poison Klein. He purchased cyanide with a Pitt credit card on April 15 and had it shipped overnight to his laboratory, police said. On April 17, Klein collapsed in the Schenley Farms home they shared with their daughter, Cianna, 6.
Doctors noted Klein's “agonal respirations” when she was in the emergency department, according to medical records the Tribune-Review obtained.
“That means you are barely breathing, sort of like a guppy out of water,” said Dr. Bruce Wapen, an emergency physician at Mills-Peninsula Medical Center in Burlingame, Calif., and an emergency medicine consultant. “That means her brain might have already been dead. You're seeing the last gasps from the lungs as the message from her brain telling her to breathe fades.”
Cyanide stops the body's cells from getting oxygen, effectively suffocating them, said Dr. Christopher Holstege, chief of the medical toxicology division and an associate professor of emergency medicine at the University of Virginia.
“There's no energy for the cells, so they die,” Holstege said. “The brain first, then your heart, then your other cells.”
A victim of cyanide poisoning may gasp because “your brain is starving for oxygen and can't use it. It's not truly suffocating, but it is somewhat like that,” Holstege said.
Doctors gave Klein medical stimulants to try to get her heart pumping and raise her blood pressure, putting her on a system that functions as an artificial heart and lung before moving her to the cardiothoracic intensive care unit early on April 18. A scan of Klein's brain and body to check for bleeding, aneurysms and other medical reasons for her collapse turned up nothing.
“They're scurrying around, getting further and further down the list of the differential diagnoses,” Wapen said. “When a person comes in with a presenting complaint, you make up a list in your head of the things that are most likely to cause this presenting complaint. You prioritize it so the most common and/or the most deadly are at the top.”
A consulting doctor who reviewed Klein's case noted she had a bicarbonate of 6, records show. A normal bicarbonate level is in the 20s, Wapen said. It drops if the body is trying to balance out something acidic, he said.
“It may be something you were given, a poison, or just the fact that you aren't breathing makes you acidotic.” Wapen said. “Cells produce carbon dioxide. If you're not breathing it accumulates. ... That makes you progressively acidotic.”
That, coupled with the increasing level of lactate in her body, could have been the clues that pushed the doctor to order a cyanide test. The body produces lactate, or lactic acid, when oxygen levels drop.
“Cyanide is not something you think about,” Holstege said. “But if you're really perplexed, and they're acidotic and you can't find anything else, you'll see that that's on the differential.
“These are not easy diagnoses to make.”
Dr. Karl Williams, the Allegheny County medical examiner, described the doctors as “ordering everything and the kitchen sink” out of desperation.
“It's them searching for anything to explain what they're seeing,” Williams said. “She was extraordinarily close to death without them knowing why.”
The consulting doctor, at the end of his report, notes that because of Klein's “profound acidosis,” he ordered a “toxicology screen along with serum alcohols and cyanide (although this is unlikely)” on April 18.
Test results on April 23 showed a lethal level of cyanide, Williams said, and his office called Pittsburgh police.
Margaret Harding is a Trib Total Media staff writer. Reach her at 412-380-8519 or firstname.lastname@example.org.
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