Background: patient in for a pacemaker. He has complete heart block as well. Elderly, in his 90's (that's all I knew). I work in a telemetry unit.
It wasn't my patient but I was by the monitors when I noticed a patient's HR in the 40s. It was heart block, as we knew already from the ED report (he had just arrived on unit). As I watched a moment longer, it dropped into the 30s, and then it was 28. I quickly walked into the room where I saw a conscious man sitting up in bed, in no apparent distress getting his vitals taken by another nurse. I asked, "are you feeling okay?". He told me yes. I said, "nothing is bothering you at all?" He said he was fine. I just couldn't believe that a man with a HR in 20's felt "fine". I verified the HR (now in 30's) by taking his pulse.
There was a doctor in the room at this point. I stepped outside to the hallway monitor again and saw a QRS complex with a period of v-fib looking activity before the next QRS. It was not artifact, because it was very clearly defined. Was it a-fib? Below is a google image search of the closest thing I could find:
I'm used to very high ventricular rates in a-fib. A-flutter, then? Sorry if it's a dumb question. I'm still learning the difference between textbook and real life for many concepts.
I now very quickly returned to the room. He was still alert and conversing. A rapid had been called by this point, but I was just baffled by how he presented given his vital signs/heart rhythm.
Any ideas? Have you seen a patient with a HR so low that was asymptomatic? I'm a new nurse 5 months into my first job, so I haven't gained enough experience to know these things. He was sent to CCU externally paced before he could get his implanted.