Almost time for shift change, I admitted a very young male who was very confused but pleasant. Hooked him on tele and noticed his heart rate was very irregular it would be as low as 50s to SR to as high as 120s-150s at rest. EKG was done and was uremarkable. No cardiology consult was put in the order. No H&P was documented since he was very out of it when brought to the ED the night before. BMP was also unremarkable except for k of 3.0 and ammonia level of 48umol (which in our hospital is considered critical value). Looked at the ED documentation and pt was given 4 doses of Latulose and no repeat ammonia level was done and also no documented repletion of K was done. I tried paging the doctor who admitted the pt but I already know he won't be calling me back since it was already past 1900 and I also called the on call MD for that night but I know I won't be hearing any call back anytime soon. So the best I could do at that time was document all my findings and my attempt on calling both the hospitalist and the on call. I also told the night nurse to page the on call again if she doesn't get any call back within the hour.
I came back the next day, and the nurse reported to me that his heart rate went as low as the 30s and his lactulose level was still 48 after giving one dose last night. K was also still at 3.0.
I text paged the MD of the situation. No call back after 30 mins. I call paged the MD 2x since I thought that it was critical that the MD be notified of the pt's heart rate dropping to the 30s.
MD finally called me back and told me that he will be discharging the pt today to the psych facility and almost hung up on me as soon as he finished his sentence. I told the MD of what happened last night and that his K and ammonia are still abnormal. He told me he's not at all concerned about it. At first I thought I was imagining things. I mean yes I only have 2 years of nursing experience vs. how ever many years he's been practicing, and the thought of questioning him I thought was insane! But it still bugged the crap out of me. At that time I was very nervous and braced myself for whatever's about to happen. I repeated myself and told him that maybe his heart rate was all over the place because his K was low. He said "well he can just get K supplement at the psych facility", I told him, I don't think the pt was safe to be DC with such erratic heart rate and maybe the pt will benefit for a cardiology consult. I also told him maybe his high ammonia is contributing to him having altered mental status. I can already tell he was very pissed and annoyed. He told me well go ahead and and put the consult in but want him DC today!
To make my story short. Cardiologist saw the pt and told me that the pt was not safe to be discharged and was glad I insisted on consulting him. Turned out the pt was in junctional bradycardia and that if the pt was DC'ed at the psych facility, there was a big change he'd code and be sent back here or the ICU.
My question now is, why was the primary physician angry at me? I feel like I did the right thing. I did not disrespect him or was aggressive in anyway.
