UPMC Presbyterian found clues in cyanide poisoning puzzle
August 1, 2013 12:00 PM
Autumn Marie Klein
By Paula Reed Ward and Liz Navratil Pittsburgh Post-Gazette
An extraordinary confluence of circumstances allowed UPMC Presbyterian hospital staff to figure out that Autumn Klein may have been suffering from cyanide poisoning the night she was raced into their emergency room April 17.
First, city paramedics took Klein to the Oakland hospital over the requests of her husband, Robert Ferrante, 64, a University of Pittsburgh medical researcher who is now charged with criminal homicide in her death. He told a 911 call taker that he wanted his wife to go to UPMC Shadyside -- saying falsely, according to an affidavit of probable cause, that his wife's parents were there -- even though Shadyside was farther away from the couple's Oakland home and is not classified as a trauma center.
Second, Klein survived for a much longer time than is typical in acute cyanide poisonings. A person who has ingested cyanide will die within two to three minutes, an expert said. Instead, in the case of Klein, the ER staff at Presby kept her alive -- at least in part by using a blood circulation system that supplies oxygen to the blood called extracorporeal membrane oxygenation.
UPMC Shadyside does not have that technology in its emergency department.
Third, the staff at Presby was able to link together a number of symptoms Klein was experiencing that, individually, could have been indicative of any number of medical conditions, but taken together could point to cyanide poisoning.
"If the patient had died in the emergency department, it is likely the diagnosis of cyanide poisoning would not have been made," said Angela Gardner, a former president of the American College of Emergency Physicians who works at the University of Texas Southwestern Medical Center in Dallas. "It is not on the average ER physician's first line of thought when a patient comes in."
And, it is not a standard test conducted by the Allegheny County medical examiner's office at autopsy.
"It's very, very rare," Dr. Gardner said.
What hospital a patient is transported to is generally left to the individual, or, when that person is unconscious, a family member.
"We don't direct patient flow," said Pittsburgh EMS acting Chief Mark Bocian. "We basically let the patient tell us where they think they need to go, and that's based on a number of factors. ... It really is relatively important that they're at the right facility."
A number of factors are considered in that decision, including where the patient's treating physician practices and which facilities take a person's insurance.
If the preferred hospital is within a reasonable distance, paramedics generally will take the patient there, the chief said.
In Klein's case, according to the affidavit, UPMC Shadyside was 1.4 miles away from her home, while UPMC Presbyterian, where both she and Mr. Ferrante worked, was just four-tenths of a mile away.
In rare circumstances in which a patient requires specialized treatment, such as at a burn center or a trauma center, paramedics will overrule the personal preference, Chief Bocian said.
He declined to comment on why paramedics took Klein, who was head of women's neurology at UPMC, to Presby and said he was not involved in that decision.
Cyanide is fast-acting
One of the reasons why diagnosing cyanide poisoning can be so difficult is that the chemical works quickly.
"Cyanide poisoning is rapidly fatal," Dr. Gardner said. "By the time you get to the ER, they're usually dead."
And in cases where cyanide is involved -- for example, a person is exposed to it in a fire or in an industrial setting -- that information is normally provided by a third party who accompanies the patient to the ER.
Cyanide tends to affect the heart and brain first, toxicologists said, and works by blocking the spot where oxygen needs to bind to produce energy. The result is a "cascade effect where basically you suffocate," said Brian Logue, a South Dakota State University professor who has studied cyanide extensively.
Cyanide poisoning can cause coughing and convulsions, and it has been reported there can be an uncontrolled scream caused by muscle contraction.
"Sounds of respiratory distress can be heard in the background during the call," according to the affidavit of probable cause against Mr. Ferrante, which noted that the 911 call taker could hear Klein groan in the background.
Only a few hundred milligrams of cyanide -- an amount that could fit inside a pill capsule -- can cause death.
Police said Mr. Ferrante asked a person who works in his lab to purchase a 250-gram container of potassium cyanide and have it shipped overnight two days before his wife collapsed.
When the Allegheny County medical examiner's office weighed the container during its investigation, the affidavit said, about 8.3 grams of cyanide was missing from the bottle.
A woman who weighs about 120 pounds could die with 168 milligrams of cyanide in her body, Mr. Logue said.
"Therefore, the 8.3 grams that is missing would be about 50 times the lethal concentration," he said.
'Somebody has to be looking'
The symptoms of cyanide poisoning range widely, including a rapid heart rate followed by a slow heart rate, a lowering of the blood pressure, headache, seizures and coma.
The underlying symptoms Klein exhibited that night could have been a stroke, Dr. Gardner said, but when that was ruled out by a CT scan, doctors would start broadening the possibilities.
Sepsis likely would have been considered, she continued, which would have prompted ER doctors to run a serum lactate level test. Depending on the results, they could be associated with cyanide poisoning, Dr. Gardner said.
Considering that, along with Klein's respiratory distress and the description by hospital staff that her blood was bright red -- indicating high levels of oxygen -- the chances that cyanide was involved were even greater.
The team that treated Klein requested a cyanide test but noted it was "unlikely," police said.
Although it takes days to get cyanide results back from blood work, samples drawn from Klein three times over about 10 hours at the hospital were positive.
"Obviously, it came to somebody's mind," Dr. Gardner said. "Somebody has to be looking for cyanide to find it."