Low HR

[joe007]

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.

[Esme12, ASN, BSN, RN]

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.

Why was your abdominal pain on a monitor? Do you monitor all of your patients? Was this a "sinus brady"? Smoker or not...did this guy exercise? How old was this patient? What was the previous history and were they on any meds?

Wile your preceptor was inappropriate...abusive? I guess by some standards. I don't let people who act inappropriately get under my skin...I ignore them and consider the source.

[Caffeinated RN]

In my case, I spoke with the charge RN who hooked me up with the right person. As it was stated earlier, you would want to seek out your own facility's chain of command, as this could vary. I am very fortunate in that I work in a very positive, supportive environment. My preceptor would have never dreamed of saying such things to me (unless he was playing around)!

I suggested the apical HR because the patient may have been experiencing some non-perfused PVCs, or even runs of v-tach, especially if s/he had electrolyte abnormalities related to pancreatitis (nausea/vomiting/poor intake). Of course, if he was on tele, you would know this, so forgive me if I'm missing the mark here (I wasn't sure if by monitor, you meant pulse ox monitor or telemetry).

I wouldn't think twice about a patient who was asymptomatic in the 40s, but the 30s would make me nervous, too! Then again, I personally haven't seen a patient with a HR in the high 30s in sinus brady. The last patient I had with a HR in the 30s was in a junctional rhythm....and coded shortly thereafter

I am sorry you have to deal with your work's unsupportive environment.

[wooh, BSN, RN]

He's been back and isn't dead because you discharged him? Knowing nothing else about the situation, I wouldn't worry further about it. In the future, if you're concerned, you can always ask something along the lines of, "Why are you not concerned?" in a tone that shows a genuine interest in learning.

Well, I wouldn't have done the EKG without direction from the doc... though I would take a gander at the monitor to see if it was sinus brady or heart block.

been upfront and in his face questioning his decision

Not good advice... few docs respond well to nurses getting in their face and questioning their decision...

Better to go and say, "This guy is making me nervous... could you take a quick peek just to make sure?"

Preceptor... well, to a degree, I think I'm with you... the preceptor bears more responsibility but I would not have let him walk off to discuss it with the doc by himself...

An HR in the 30's *must* be explained before the pt is discharged... even if they're asymptomatic... it is possible to have intermittent 3rd degree blocks and the patient can sometimes tolerate it... until they can't... and then they code... just that quick.

Let it be a lesson learned... from this day forth, do not let anybody, including your preceptor, speak to the doc about your patient without you there. You are the nurse and you owe it to both yourself and the patient to ensure that things are appropriately considered.

Don't get in a doc's face, though... probably won't end well for you.

[joe007]

Silver... in the ER you always start assessing and doing things w/out a doctor's order... they're called standing orders.

[LoveNeverDies]

If I was in a situation where I felt uncomfortable I would question it, at least that way you can understand the Doctor/Preceptors point of view. However, I have a resting heart rate of high 30s-40s, bp of around 90/70 occasionally 80/60. NO symptoms at all. When I am initially in the hospital it is usually up in a more "Normal" range, so I will continuously have to explain as it goes down that I am fine, feel fine. There are a lot of factors involved and they may have just been more familiar with the history.

[Anna Flaxis, BSN, RN]

Asymptomatic bradycardia I would report to the physician, but I certainly wouldn't do so in a confrontational manner. Just more of an FYI, here is a situation I thought you'd like to know about. It might not result in further workup, and you may end up DCing the patient anyway, but you have done your due diligence to assess, inform the MD, and document your assessment findings and resulting actions.

As has already been mentioned, this guy might live like this, and is suffering no acute adverse effects from it, and discharging him while advising him to follow up on it with his primary would be reasonable.

Now, a 3rd degree block, you would have been able to see on the monitor. No EKG needed. This would be much more concerning than sinus brady. In this instance, I would print out a rhythm strip to show the MD.

[nurseprnRN, BSN, RN]

Asymptomatic lying on the bed, or asymptomatic up and ambulatory? Did you take postural signs? I don't see that mentioned.

Although I agree that something like vomiting/Valsalva/pain can make someone vagal-ish and brady down and it might be harmless, I surely wouldn't let someone with no prior experience of this being harmless get up and walk out my door without a better answer.

And don't diagnose those docs so definitively. You, with your vast experience, have no basis for doing so, and if you learned about it via gossip from your coworkers, the answer is a noncommittal, "Mmm-hmmm," and to ignore it. You have no idea what their days are like. If you want to learn more about them, starting with an appeal to learn more about their decision-making processes ("Can you tell me why this isn't of concern?") might be a good place to start.

"Can you tell me why this isn't of concern?"

Five years and three jobs into nursing and I've yet to have a doc respond with anything but positively to this approach. Sometimes I walk away and disagree but at least I know that they've thought about it and made a decision... which is *their* role. A quick note of "MD consulted and aware, no new orders" and I'm off to the next patient.