The tale of a pacemaker...

[Adam D. RN2005]

My life has been a blur over the past two months. Now that I am catching my breath, back from vacation, and slowing down slightly from the overtime, I now have more freetime.

From a nursing perpective after being 10.5 months in, I am really feeling comfortable with my job. About a month ago, I had a patient on my second day with them showed some dizziness when PT went to ambulate them. I checked their vitals, blood sugar, and did a full neuro and they were all WNL. Called the MD to let them know, we decided to interogate the pt's recently installed pacemaker. Comes back normal. Doesn't sit right with me. Something is just not right with the pt, I even tell the MD this. I report off at the end of the shift for any RN to look out for these symptoms.

Two days later, I am back on and have the pt with a nursing student now. Student reports to me that the heart rate is 41 with the auto cuff. Go in and assess the pt. They tell me that they feel dizzy and tired, the exact same as a few days earlier. Listen to the heart rate and I am counting 40 slow lub dubs per minute. BP is normal. Pt has a demand pacemaker set for a min of 75. This is before we move the pt from chair back to bed.

Have the student and tech return the pt to bed and I go and activate the Rapid Response Team and call the MD. By the time the team got to the room, after making the mistake of going to bed one who looked dead with a non-rebreather mask (actually normal for that pt), they assess the correct pt and now is normal again.

We call for EKG and remote tele hook up and then call for a interogation of the pacemaker again. Speak with the primary MD who decides to defer to the pacemaker MD. Fair enough.

About 30 minutes later the arrogant pacemaker MD comes and interogates the PM and he says all is normal. I said is it possible it may not be installed correctly. Get a nasty there is nothing wrong with the pacemaker, something must be wrong with your ears. At this point I decided that I no longer want this pt on this unit, they need to be on the tele unit. MD refuses at first, but I stuck to my guns and said that this patient is no longer safe under my care. They need to be on the tele unit. Finally after 10 minutes the arrogant MD relents. But goes you are wrong and don't know how to listin to a heart beat. I bite my tongue not to say anything, I don't want to stoop to his level.

Get the patient transfered, the Nurse who I reported off to calls up at one point to ask me a question on the pt and then states that I must not have been hearing the heart rate correctly and that I should have multiplied the 40 heart rate by two to get 80 and I will have a normal heart rate. Report this to my supervisor who called that RN's supervisor. We won't go there.

About a week later, I saw the primary MD for that patient and asked how they were doing. Well, they were D/C, but not before having another episode, this time caught on telemetry, a heart rate of 30, with the pacemaker failing to capture.

Turns out, that one of the leads of the pacemaker when the patient was sitting in a chair, was in the Superior Vena Cava. I saw the MD who said I did not know what I was talking about later in the week. I resisted the urge to tell him I told you so. It came back to me through my supervisor that the MD apoligized.

I felt vindicated, because I caught something wrong with a pacemaker, and even when the MD refused to believe me, I stuck to my guns to get the patient the treatment they needed.

I am loving this profession. And love everyday (even the rediculously hard ones where I get no break or lunch (which that shift and the next days shift was) and leaves me exhausted at the end of my shift.)

More later. Got to get ready for another awsome shift of nursing tomorrow. Can't wait!!!

Adam, RN

[Altra, BSN, RN]

Hats off to you, Adam.

How many times has it been drummed into our heads, "treat the patient, not the monitor" ? I guess that particular MD forgot that on that particular day ... nothing *seemed* to be wrong with the equipment, but the patient was obviously symptomatic. Something needed to be done.

[AmyB]

What luck that the patient was blessed with such an attentive nurse who was such a great advocate. It sounds like you really know your stuff and enjoy your profession. Good for you!

[UM Review RN, ASN, RN]

Adam, great job!

Especially in the face of the fact that the cardio MDs can really tick you off with those attitudes they have sometimes. But wait--he did the surgery too? Never mind, that explains it.

Most first-year nurses have to pretend to "be the duck"--let the arrogant Md 'tude roll right off your back and take care of your patient--seems like you've already got it, Adam.

[Abbies]

Adam, alias Guardian Angel, Good job advocating for the patient. I expecially liked the part where you stated "this patient is no longer safe under my care" and stuck to your guns when no one would listen to you.

[NRSKarenRN, BSN, RN]

Great story! Yep

a. Agree with Mlos: "treat the patient, not the monitor"

b. Trust your gut instincts.

c. Backbone develops after reading allnurses members advice.