A 91-year-old gentleman with coronary disease, an ischemic cardiomyopathy, chronic atrial flutter and a dual-chamber pacemaker was admitted through Urgent Care for symptomatic orthostatic hypotension and what was reported to be a 2 minute run of monomorphic ventricular tachycardia at a rate of 110 bpm recorded while this veteran was in Urgent Care. I came to ACU this morning to do a consult on this gentleman, looked at the recordings, concluded that it was indeed a slow monomorphic ventricular tachycardia and planned to treat him with amiodarone. I interrogated the pacemaker, it appeared to be working appropriately, and I planned to write orders to start the amiodarone loading.
At this point Evan took me aside and showed me an episode recorded on telemetry on ACU where the pacemaker was pacing the ventricle at a rate around 110 bpm. I explained that the pacemaker was inappropriately tracking atrial flutter, "thinking" it was sinus tachycardia that needed ventricular pacing at the same rate. Evan then explained to me that he believed that the episode in Urgent Care was the same phenomenon, representing ventricular pacing rather than ventricular tachycardia. I pointed out the complete absence of pacemaker spikes in front of the QRS complexes on the run recorded in Urgent Care, versus the clear presence of pacemaker spikes on the runs recorded on ACU. Evan then explained to me that the telemetry in Urgent Care did not have the pacemaker detection function activated, which clearly explained why it wouldn't have put a pacemaker spike in front of the QRS complexes. He then went to the telemetry memory to printed up both tachycardias in multiple leads and we compared these with the 12-lead ECG previously recorded with ventricular pacing. Sure enough the QRS morphologies mapped out virtually perfectly. In retrospect it became quite clear that the episode in Urgent Care was not asymptomatic sustained ventricular tachycardia; it was simply inappropriate ventricular pacing. I was then able to reprogram the pacemaker so it wouldn't do this.
Evan's intelligence, attention to detail and persistence saved this man an inappropriate diagnosis of ventricular tachycardia, inappropriate use of a potent antidysrhythmic medication that would have exacerbated his symptomatic orthostatic hypotension, and lead to appropriate safe pacemaker reprogramming. I have to admit I would not have caught this without Evan's work.
Evan is always a great nurse and it doesn't surprise me that he would put something like this together this morning. Evan has outstanding patient care.