Thursday, April 06, 2017

Out of Rhythm

Well, I caught another Rhythm interpretation screw-up and it's a doozy. From what I can see, nobody really cares, but I have fun doing the research and exposing the fraud.

Betty Lou, age 85, admitted to the hospital with nausea and vomiting. She's in mild Renal failure and her potassium really low (which got corrected). She had a history of A. Fib (paroxysmal) but was only on Coreg at home, and in Sinus Rhythm on admission. About 12 hours after admit, her heart starts to have 3 second pauses, and her heart rate drops into the 40's. Several 12-Leads were obtained, but the quality was horrid, such that neither the machine nor a person would be able to make any good call on the rhythm. Neither the RN nor the Monitor Tech (Cardiac Tele) could figure out the strip, and the nurse actually writes that in the record, along with stating that the EKG 12-lead reads "undetermined rhythm". When the patient drops to 35 and a pause, Nurse calls Hospitalist...........he says, don't give Beta blocker. When the HR dropped to 22, the Nurse charted, "Patient Asymptomatic". Finally, after a call to the Cardiologist, there is an order for Bedside Pacer Zoll, and Atropine prn. As this was Cardiac Tele, and presumably they are required to have ACLS, I would have thought the Nurse would have gotten the Zoll into the room already, without waiting for doctor's order.

Ok, so I take a look at the strips from Tele. They were monitoring Lead 2, and V3. In Lead 2, there was a broad stubby T-wave, followed by a prominent U-wave and a little pointy P-wave. So, with this heart rate of about 45, the Monitor tech, was interpreting those lumps as flutter waves, although that would have placed them at a rate of about 90, which I've never seen, no matter how many heart meds a person has been on. Now, in V3, amplitude was quite low, but there certainly was a P-wave, with a PRI first degree block of about, .38 seconds. Sometimes it even looked like there was some 2nd degree block, but all of the EKG's and strips were crappy. Over the course of about 12 hours, the strips were labeled "Undetermined, or A. Fib, or A. Flutter. The Cardiologist came in, identified the real problem as advanced Heart block, with a slow escape rhythm, and Betty Lou is getting a pacemaker today.

I am sorry to say, that the ICU nurses were calling it A. Fib too...............

Here's my report:

It bothers me
When I do see,
A misinterpreted
I can give a pass
To untrained Docs,
Who specialize
In Chicken Pox,
But Cardiac nurses
And their monitor crew,
Should nail every rhythm
In their purview,
Because that is a skill
Required of them,
And when they blow the rhythm
I say, "Ahem"!

How could you call that strip
Atrial Flutter,
When there is a "P"
"T" and "U" wave
You're some kind of nutter,
A rhythm so slow
With a triplicate block,
'Twas not even A. Fib
You got your head in a sock.

Ah, woe is me
And Auntie Em,
Under the watchful eyes
Of the likes of them.


Old FoolRN said...

Sounds like knowledge of the patient's history obscured interpretation. Reminds me of all the incidental appendectomies that I scrubbed on 40+ years ago because appendicitis was on the surgeon's mind even if there was no sign of inflammation.

Fibril_late said...

So true