Possible error in judgement?

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Hi. I was hoping to get other's perspectives on this clinical scenario. I assumed care of a pt from 3:30-7:30. During this time, I did a routine EKG on a pt. Pertinent background, the pt has a dx of A-fibb and is on Digoxin and Plavix. I initially conduct the EKG while the pt is sitting in her wheelchair as I thought it would be accurate as long as the leads had good contact w/ the skin. I do seperate EKG's which say the pt's heart rate is between 140 and 150 BPM. I take her pulse manually and it's 56 BPM and I wonder whether the EKG is accurate. Pt has no c/o at this time. I know A-fibb can be asymptomatic, but didnt expect a change in heart rate that quickly. I immediately take her vital signs w/ an automatic vitals sign machine and again her pulse is around 56. I repeat the EKG laying down and again her pulse is reading between 120 and 130 BPM. I decide the machine must be giving a faulty readout and ask night shift to retake her pulse in an hr. I did not hear anything from night shift, but today a nurse on day shift called to ask about the EKG in question.

Now I'm wondering if I should have notified the dr? I'm also thinking that the machine may have been correct and she was having paroxysmal episodes of A-fibb? Conidering she has already been diagnosed w/ A-fibb and being treated for it, should I have noticed the on-call dr anyway?

Thank you for taking the time to read and respond to my question.

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Did you look at the EKG?

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Yes. The one performed in the wheelchair had a lot of artifacts that made it difficult to read, so I redid the EKG while the pt was laying down. There were no ST elevations or other notable abnormalities beyond the heart rhythm, which the EKG read-out interpreted as A-fib. Manual pulse check did not confirm the BPM recorded on the EKG.

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When you looked at the rhythm was the patient in A-fib? You can't go by the machine interpretation.

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No, they did not appear to be

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But now I'm concerned that maybe my interpretation was wrong? Worst case scenario, if the pt was having paroxysmal a-fibb will the physician likely be upset that I didn't notify them (given that this is a known and treated condition)?

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They didn't appear to be because you know how to interpret EKG's or are you guessing? A-fib isn't really difficult to determine. Sorry I'm not meaning to bust your chops but it sounds like you are not that comfortable doing it and if that is the case your EKG's need to be reviewed by someone who is. An EKG done in a wheelchair isn't acceptable in any situation so not sure why you started there. What was the rest of the patient assessment?

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Yes, I am not super comfortable interpreting EKG's, but I can do basic interpretations. I had my charge nurse review the EKG as well, and he saw no outstanding abnormalities. No significant findings from pt assessment. O2 sat above 95% on RA, no c/o of fatigue, dizziness, SOB, chest pain, or palpitations. LOC x4. No abnormal breathing pattern or other signs of distress noted. Pt conversational throughout exam.

I did the EKG in the wheelchair to minimize the pt's discomfort (she was obese and had extreme difficulty changing positions); however, now I understand that the seated position is likely to give faulty readouts.

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Too bad you can't post the EKG. That would help immensely. It's hard to tell what was going on without it.

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.

It's generally best to alert the MD to any abnormal EKGs. The machine will spit out an analysis, and that may be wrong, but it should still be reported. If there was artifact on the EKG, was it not possible to repeat and get the patient to lie still? Was it due to tremoring? A span of 100 bpm between your pulse measurement and the EKG does not seem like a good test. What did you feel as a manual pulse? Automated readings should never be considered the gold standard because machines are more fallible than human assessment.

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The first EKG w/ the pt in the seated position had a significant number of artifacts due to tremoring and positioning, so I repeated the EKG laying and the reading did not have any significant artifacts. The manual pulse was 56. The automatic vitals sign machine also recorded a pulse of 56.

The day shift nurse got back to me and said they would have preferred to have been notified, but did not seem overly upset. She was also told to trust the EKG over a manual pulse when the pt has a dx of A-fibb. Moving forward, I will always alert the physician to an abnormal EKG, regardless of pt diagnosis/hx.

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When you are unsure or something just doesn't add up it's always best to contact the provider. Nobody should ever fault you for that.

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