Low HR

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Ethical dilemma.

I work at a hospital in the south east of the US. About 2-3 months ago I had an experience that made me feel uncomfortable. I was working a section with preceptor oversight when I noticed during discharge one of my pt's HRs had dropped into the high 30s. The man's initial complaint on arrival was abdominal pain and he had a history of pancreatitis. He was also a smoker. I took his radial pulse to make sure his HR was indeed low, asked the pt. if he was having any symptoms (which he was not) and then decided my next step would be an EKG to show the doctor. I put all the stickies on and started to hook up the EKG leads when my preceptor walked by the room. The pt. was up for discharge so he questioned what I was doing and why I was doing it. I explained that the pt's HR was in the high 30s (my preceptor could see the monitor) and previously had been normal and at the time and that I was getting an EKG so the doc could see what was going on and make a determination on what to do next.

At this time, my preceptor told me to hold off on the EKG and he would go talk to the doc and they would decide what to do. I waited in the room just talking to the pt. and his wife for about 2-3 min gathering history on any cardiac issues. My preceptor returned and told me that because the pt. was asymptomatic that the doctor said I should discharge him. So, I did what my preceptor and the doctor told me to do and discharged him, though I felt uncomfortable about this. I documented doctor aware of low HR and to discharge because asymptomatic.

Anyhow, I just finished a class on heart strips, R on T phenom, etc. and told the tele-floor nurse educator who ran the class (our ER nurse educator is worthless) about what happened and what I should have done. She told me I should have personally went to the doctor and pretty much been upfront and in his face questioning his decision about discharging the guy and that I didn't do my job. I feel that though this may be a text book answer, that it is unreasonable because I am a new nurse feeling out my place and may not understand all reason for discharging someone with a low HR who is asymptomatic and the doctor would feel I was challenging his authority. I don't have enough experience to really question my preceptor (10 yrs exp.) and the doc (25 yrs exp.) and have to trust that they are making the right medical decisions.

I feel like I should have been the person to go to the doc in the first place and my preceptor may have presented the information in an unjust manor. I have seen the pt. on our campus since this time and he seems to be doing well. I kind of feel that the nurse educator was being ridiculous putting all the responsibility on me (a new grad and new hire with 3-4 months exp.) for the discharge when I was doing the right thing by further assessing the situation and was actively told to stop doing this by my preceptor who you don't want to **** off because they will mark you as being a trouble maker and report you to management for insubordination etc. which will end in termination.

If I was confronted with this issue currently, I would probably confront the doctor personally since I am more confident in understanding what is going on.

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Specializes in Critical Care.

Did you notice that the HR was low on a cardiac monitor, or was it an O2 sat monitor pulse?

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It was low on both, plus verified by radial pulse.

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My personal feeling is that this person was discharged because the doctors like to have high turnover and they tell me that we should only really assess and treat problems that the person comes in complaining of -- AKA only treat people's symptoms. I philosophically disagree with this, but understand where they are coming from. You can't have an ED that focuses on everything a pt. has because it may not be emergent, there are tons of people waiting, and there are a ton of potential problems a person may have that would take much longer than it is necessary to treat everything. But alternatively, if you are not thorough and address multiple issues, you are neglecting the person's health. Often, this is countered with the idea that we are an emergency dept., not primary care. I have run into many varying attitudes and ideas on who should get what type of treatment. I just feel that blaming the newest and least experienced person who was trying to investigate further is unfair and feel that I was doing the right thing, and was actively commanded to stop because they wanted to get turnover because the guy had already been occupying the bed for 4 hrs and essentially I was opening a pandora's box. That's the general attitude in my ER. Street them ASAP because there are 70 people in the waiting room and house census is only 170, but we have 200+ pts in house somehow and need to get people out.

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What kind of cardiac history (if any) did this patient have? In that situation, I would have gotten an apical pulse and a full set of vitals, in addition to your assessment. I think an EKG was the proper thing to do, as well (though I probably would have ran it by the provider first....it depends, of course). I've seen this happen before, but only in patients whose histories have been well elucidated, there is a pacemaker in place, and the vitals (and patient) were stable. Did they give any other reason besides the fact that they were asymptomatic?

That is very frustrating. I'm a pretty new nurse, and I have already had some "What the hell are you thinking!" moments with providers, which has taught me to continue advocating, especially if your gut is screaming at you. In those cases where I went around providers using our chain of command, I was right. A doctor once personally thanked me for being so persistent. But it can be tough!

Keep on persevering!

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How do you go "around your chain of command"? I did take a full set of vitals. It is standard w/ all of our discharges. That is how I found out he had a HR so low. I figured if I had 3 sources telling me his HR was low, it probably was. He did not have a pacemaker. Thanks for the encouragement Caffein... I need to learn the boundaries of the nurse/pt. relationship. Many of the ER docs in my hospital are kinda angry/hate their life so they aren't the most approachable even if you do it in a non-threatening way. Some of them also have psychiatric issues like bipolar and depression and you never know if they're going to be "in one of their moods" or not. I guess my ER is probably not the healthiest climate. I was called a "worthless piece of ****" by my preceptor once for suggesting our secretary fax a document to a doctor's office.

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Specializes in Critical Care.

What was their rhythm?

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Specializes in Post Anesthesia.

Asymptomatic bradycardia that returned to a normal HR without intervention wouldn't have worried me if I knew the patient had been having GI upset and was likely to be vagal, or had normal kidney function and was eating well enough to have his electrolytes in normal range, just had d/c IV, d/c foley, blood draw, or something that could cause a sensitive person to feel "faint". The important thing was he had no symptoms and returned quickly without intervention. I think it would be a topic of discussion on follow up ip the office, but I can see discharging the patient.

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.

Your preceptor calls you names? When you're off orientation and not having to kiss everyone's butt you can decide how you want to handle that. It sounds to me like you're handling everything very well, considering the situation you're in. It's never easy to be a student or a new grad and you seem to be on the right track.

About your bradycardic person, I suppose all you could do was suggest he take his pulse periodically and if it doesn't stay above 50 he should get it checked out by his own doctor. Good luck.

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Specializes in LTC Rehab Med/Surg.

Our MDs don't get excited about HRs in the 30s-40s. If they're asymptomatic.

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Muno. Bradycardia on the monitor. I wanted to take EKG to get different views, but was stopped by preceptor. Suanna, HR was still low on discharge. Tricia -- if it weren't for my military background it would be hard to stay at this job, but pretty much the hazing one gets in the military has prepared me for this type of abuse.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
How do you go "around your chain of command"? I did take a full set of vitals. It is standard w/ all of our discharges. That is how I found out he had a HR so low. I figured if I had 3 sources telling me his HR was low, it probably was. He did not have a pacemaker. Thanks for the encouragement Caffein... I need to learn the boundaries of the nurse/pt. relationship. Many of the ER docs in my hospital are kinda angry/hate their life so they aren't the most approachable even if you do it in a non-threatening way. Some of them also have psychiatric issues like bipolar and depression and you never know if they're going to be "in one of their moods" or not. I guess my ER is probably not the healthiest climate. I was called a "worthless piece of ****" by my preceptor once for suggesting our secretary fax a document to a doctor's office.
I think if your preceptor is calling you worthless...you need to find another job.

I am confused however by your assumptions that

Many of the ER docs in my hospital are kinda angry/hate their life
and have mental illness
Some of them also have psychiatric issues like bipolar and depression and you never know if they're going to be "in one of their moods" or not.
that affect their decision making process. Your body language and non verbal communication may reflect your inner thoughts which doesn't help the environment.

I think YOU AND YOUR PRECEPTOR should have spoken to the EDMD so you can learn how to communicate effectively.

Several questions come to mind..what meds was the patient on? What is he full medical history? What meds did the patient receive while in the ED? Was there an old record? Was the discharge sheet modified to include follow up with PCP/cardiology re: heart rate?

Your department/facility should have the process laid out for circumventing chain of command. Do you have an ethics committee? Report it to the Medical director as a case review. Make a call to risk management.

I probably would have discharged the patient if asymptomatic after I did orthostatic vitals.

Have I gone toe to toe with an MD and gone around them? You bettcha. But I KNEW I was right and it was the right thing to do. Have I had a MD discharge their own patient or give med I didn't agree with?...yes.

When you stick your neck out you better bet right. I would however, learn how to communicate in a effective non confrontational manner

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