The other night, I was charge nurse on a telemetry unit with a couple of LPN's and an agency RN. The agency nurse had a patient who had been on this floor for several weeks now with GI problems. The pt has a mild cardiac history, but no active problems. Anyway, in the middle of the night, with no known precipitating factors, she goes into SVT. Her rate starts at 140's, drops back to SR, then goes up to 150's, SR, 160's, SR, and so on until she has rates over 200. Each time she goes into SVT she stays in it longer and longer (3 - 5 minutes of SVT with 15-20 seconds of SR in between). I din't worry about the pt too much to start with because her nurse has more experience than I, and she works in ICU a lot. I saw her calling the MD and knew that she would get an order to bring this woman down.
A little later I noticed that the woman was still having SVT on the monitor. I asked the nurse what the MD ordered, and she said that he had ordered no drugs, just to arrange a cadiology consult (her admitting physician was GI specialty). So she called the cardiologist on call who had never seen the woman before (but she is known by her cardiologist in that practice), and he told the nurse that he would be in to see the woman in a couple of hours when he made rounds. He made this decision because the woman's BP was stable and O2 sats were okay. He ordered no drugs or anything.
When the nurse told me this, I was flabbergasted. How long can a person sustain rates near or above 200? I offered to call the MD back and ask him to order something, but the nurse became offended and told me that because the woman was stable, she would be okay for the next 2 hours until the MD came to see her. I went to her room and talked with the woman. I had taken care of her myself 6 days earlier, and the woman that was lying in the bed now was not the same woman. She was pale and weak, not exactly diaphoretic, and feeling really bad. All systems might have been stable, but the pt herself was in bad shape.
Can anyone tell me if I was right to be concerned? I still believe that something should have been done, but the woman's GI MD, the cardiologist, and the agency RN (who also has ICU experience) all seemed to think that this was no big deal. I felt that adenosine should have been given as per ACLS algorithm, at the very least. That is why we take the ACLS course, isn't it, so that we can act in the absence of the docs if they have not seen a patient (with his order, of course).
What is the consensus out there?
ps- by the way, the woman came out of this situation ok. The agency RN had been attempting to use vagal maneuvers to bring her out of it, and I was aware of that, but it wasn't initially successful. She either spontaneously converted back into SR or the vagal maneuver finally worked, I am not sure which.
Oct 24, '01
From your description of the patient she was indeed symptomatic with her SVT. After the second or third episode she should have been treated by a physician. If the Cardiologist would not give an order for treatment I would have demanded he come in an see the patient immediately. Althought this patients outcome was good, it does not always work that way. You may want to give Rick Management a heads up on this one because I am sure the patient wasn't thrilled about the delay either.
Nov 1, '01
I agree with debbyed
I have worked both tele and ER. If indeed the patient was stable she could possibly wait for the MD to come in in 2 hours but I would have been concerned and definately keeping a close watch on her. BUT by your descripition the pt was not stable and at least needed a stat EKG and adenosine. I would also have done Q15 BPs until the MD arrived. An yes I would have put the code cart outside of her door or at least nearby. At the first sign of further deterioration of her condition I'd have been on the phone with the MD and if he still did not give an order then I would have contacted the house supervisor. Its better to error on the side of caution and have a live patient and pissed MD than a dead pt and be able to say I told you so. BE ASSERTIVE.