SURPRISE ECG AND MRS. T

Mrs. T was a 95-year-old woman who until two years before lived independently. While in her apartment she fell breaking her left hip. This incident decreased her ability to take care of herself. Her daughters and son were very involved in her care but could not take care of her in their homes due to busy schedules. All thought it would be best to admit Mrs. T. to the nursing home where she could get the care she needed on a regular basis. Her family visited her often.

Mrs. T had a medical history of osteoporosis, osteoarthritis, hypertension, and cataracts. She needed help to go to the dining room to eat her meals but otherwise her mind was intact. She was complete care except she did eat for herself. One day the nurse came into the room I was charting because she had just taken Mrs. T’s vital signs.  

“Hi there. I just took Mrs. T’s vitals and her blood pressure is 185/96,” said Terri. I looked up at her.

“What does it normally run?” I asked her putting down my pen on the table.

“Looks like she usually runs lower than 140 according to her vitals sheet,” said Terri flipping through the chart. She had the vitals written down on a piece of paper and handed it to me. I looked at the pulse rate.

“Does she usually have a slow pulse?” I asked. Terri flipped through the chart to get back to the monthly vitals sheet. She set the chart down on the table. I saw over the past four months her pulse rate was lower than her normal 74. I flipped to her medical diagnosis page and saw there was no cardiac history except hypertension.

“The Verapamil could lower her pulse rate but why all of a sudden? She has been on this for a while,” I said to Terri and the chart. My mind was thinking of what the next step should be. The nursing home population could be tricky. With that I mean most are do not resuscitate (DNR) but some have a mix of checking on the advanced directive that they want to go to the hospital if became ill; want pain medications; want antibiotics; and want a feeding tube if unable to eat normally. At any time their minds could change and want everything done for their loved one. That is their right. But my job is to give them options.

“Well let’s take care of the BP by giving her Clonidine and checking it in an hour,” I told Terri. Terri wrote my order down on a piece of paper. I also wrote an order to discontinue the Verapamil and to start Lisinopril for her BP.

“Ok. I will give it to her now,” she said as she walked out of the room down the hallway. I started to think about the pulse rate. I looked at my watch and saw it was already 1600. I had the nurse recheck Mrs. T’s vitals in an hour.

An hour passed and Terri called me on my cell phone.

“Hi, it’s Terri. Mrs. T’s BP is down to 138/72,” she said.

“What is her pulse rate?” I asked. There was a slight pause.

“It was 48. Why is her pulse so low?” she asked.

“You know, get an ECG in the morning. I wonder what her rhythm is,” I told Terri.

“Ok,” she said.

The following day the ECG technician came in about 1100. I had not heard from anybody so I walked down to the nurse’s station to see what Mrs. T’s heart rhythm was. Judy was sitting at the desk.

“Hi. Do you have Mrs. T’s ECG?” I asked her. She flipped through a pile of papers on the desk and found what it and handed it to me. I said thank you and walked back to the room I charted in.

I sat down to look at the ECG. What was obvious when I first looked at it was Mrs. T was bradycardic. That I already knew so I started to systematically find my P waves, QRS, and T waves. After only about 30 seconds I knew what heart rhythm Mrs. T was in. She was in complete heart block also called 3 degree heart block. This rhythm was treated with a pacemaker. But with Mrs. T being 95-years-old she was not a surgical candidate. I needed to call the family to discuss my findings and see what they wanted to do. I felt Mrs. T had been in this rhythm for a while and was tolerating it. Usually when somebody is in complete heart block it is found after they passed out. Their BP is usually also low which was not true in this case.

I called the son which was also the power of attorney (POA) and told him my findings and what the options were. The options I gave him were to get a cardiologist consult to discuss risk/benefits of getting a pacemaker or leaving things alone. When a family member is given sudden news about their mother/father…etc. they never expect it even though their parents are advancing in age. Mrs. T had been healthy except for a fractured hip. The news I gave him left him speechless.

After discussing the options the son opted to take his mother to a cardiologist to discuss the risk/benefits of getting a pacemaker. He was leaning more towards just getting the information and not putting his mother through surgery. He needed to discuss the news with his sisters.

Mrs. T went to the cardiologist’s office where they discussed the risk/benefits of getting a pacemaker. The cardiologist told the family she was not a surgical candidate and since Mrs. T was not ambulatory and in a wheelchair most of the time he was not concerned. This news was satisfactory to the family and they would follow-up in a month.

Mrs. T did well after her high BP incident and the news her heart was not beating normally. She ate her meals and smiled as she got wheeled down to and from the dining room. Her son and daughters were happy with their decision and visited their mother often. They were going to enjoy having their mother with them until it was time to say good-bye. This could be next week or in ten years. Nobody knew that answer.