"Old Lady With The Low Heart Rate"

I think this one is one for "the books". Y'know? The 'stash' of interesting patients/encounters that you file away some place?

Last week I was assigned to one of our two "Acute side" pods [2 nurses to deal with a theoretical 8 beds.] Naturally, given the state of Emergency Departments these days, those "8 beds" can 'stretch' to 12, 14 or 16 (this is the "acute side", mind you) depending on how many patients you can cram in before you're 'forced' to go on Divert... and of course, you don't get any additional "help" when you're over loaded. Management seems to think that it's ok to staff 2 nurses to 8 beds even when 6 of those patients are on vents...

... but I digress.

Anyway, my partner and I are already dealing with 13 patients (6 in rooms, 7 in hallway stretchers - some "sharing" hallway assignments) when we're curtly informed by the charge nurse that one of our room patients needs to come out because there's a lady out in triage with a "low heart rate and no discernible BP".

My partner and I look at each other and practically play 'Rock, Paper, Scissors' to decide which one of our "critical patients" in our rooms has instantly become 'less critical' so that they can sit out in the hallway while we treat this new patient emergency....

Ok, Ok. Just kidding. We pulled one of our semi-stable chest pain patients (the one we deemed to be at the lowest risk of all our patients) out of his room to open up a spot for our new patient (but we DID play rock-paper-scissors to decide who would pick up the new patient and I DID lose...)

So I walk into the room as the triage nurse and a tech assist the patient to the stretcher. I introduce myself to the patient and her husband (they're both about 90+ years old) and I note that the patient can still walk, albeit with assistance... and that she's still talking.

Triage had told me that the patient's HR was about 30 bpm and she couldn't get a BP.

Not the kind of behavior I'd expect from someone with such a low HR and no BP!, I thought to myself.

As she was settling in, getting undressed and hooked onto the bedside monitor; I asked my questions while surreptitiously assessing the pt. Radial pulse indicated a HR of 28. To confirm, I checked a carotid... also about 28-30 (with super-long pauses between beats). I used my stethoscope to check out her lungs and heart sounds - nothing exceptional other than her irregular bradycardia, with long pauses.

I did a manual BP - she was 55/20!

But she's sitting up and talking to me! Her only complaint is "feeling a little dizzy, like I've been feeling off and on this week except tonight it got worse".

Well, I'll say!

Of course, while this was going on; other things were stepping into high gear. Someone showed up with the EKG machine, someone else started hooking her up to the bedside transcutaneous pacer and a paramedic student started looking for a vein for an IV in her arm. I requested that he get an 18 gauge in her Right A/C and to come grab me if he had any trouble.

The patient shoo'ed all us 'men' outside (especially her husband) as we were trying to get her undressed for the EKG/monitor. She managed a wry smile and said "even after all these years, I'm still modest about myself around him". That elicited a chuckle from the two female techs and a grin from me.

"Well, you got nothing to worry about from us M'am. We'll make sure he doesn't catch a sneak peak", I said with a grin; which elicited a good belly laugh from her.

I figured it was time for me to step outside and talk to the husband.

"Hi Mr. Smith. While we're getting your wife settled in, I'd like to tell you what we're planning to do. First we'll hook her up the the bedside monitor so that I can keep an eye on her heart and other important signs even if I'm not in the room. Some of my colleagues are going to do an EKG, a simple electrical "picture" of her heart to see if there is any abnormality. Other colleagues are going to start an IV on her and draw some blood at the same time to test and see if she is or has suffered heart damage in the near past.

Do you have any questions so far?"

"No, I don't", said Mr. Smith.

"What I'd like to ask you though is your perception on things", I continued; "What made you bring her to the ER tonight. Has anything changed over the past week or was it something that happened tonight? Were you engaged in any activity which is not the norm for the two of you? Any strange/different food or drink? Medications?"

When I mentioned medications, Mr. Smith calmly tells me, "I think she took one too many of her BP meds. That explains her symptoms and her bradycardia. I don't think it's anything serious but given her bradycardia, I thought it best to get it checked out".

Now, normally, I don't have 90+ year old gentlemen use the words "symptoms, bradycardia and BP meds" in the same sentence... much less articulate them in a manner as to suggest a medical diagnosis!

Before I could ask the husband where he learned them neat words, out comes the paramedic student with a grin on his face as he hands me a bunch of vaccutainers containing blood samples. "Here you go Spook! 18G in the Right A/C, just like you requested".

As I was thanking him, the student turned around to face the husband and exclaimed, "Mr. Smith! Say, you wouldn't be the same Mr. Smith who was head of cardio-thoracic surgery at Sprawling Metropolis Trauma Center, would you?! I've heard so much about you! My Dad was a paramedic and he used to talk about you all the time!"

I swear I saw the old gentleman in front of me *blush* and mumble, "Yes. I was. But that was a long time ago".

Well, that probably explains him knowing all them words, eh?

Right when I was about to say something, the tech walked out with the 12-lead EKG report. I quietly stopped her and took the paper copy of the EKG to show it to Mr. Smith. I let him take a quick look at it, before I hurried over to the ER doc to show it to him.

Both the ER doc and I now approached the patient and her husband, to explain things as to where we stood. The ER doc was convinced that while her condition was serious, it didn't warrant an immediate pacemaker implant or surgery. Her lab work seemed to indicate no emergent abnormalities and he was inclined to agree with the husband that the pt. had probably taken one too many pills by accident.


The plan was to admit her to remote telemetry overnight - just in case.
While the ER doc was talking with the admitting consultant over the phone, I saw Mr. Smith quietly sneak into his wife's room.

They held hands for a while. Looking into each others eyes. Saying nothing... and yet 'speaking' all that need to be 'said'.

A little while later, I saw him get up, gently lean over and give his wife a heartfelt kiss. He brushed her hair off her face, while they were still holding hands. Then they said something that I couldn't hear and her bent over to kiss her again.

The look they had on their faces was just... well, indescribable.

[I did feel guilty that I witnessed what was obviously meant to be a tender, intimate, private moment between the two of 'em].

Mr. Smith slowly shuffled out of the room, taking care to close the curtains and shut the sliding door. He ambled over to me and said "Thank you for all your help today son. I'm loathe to leave but she insists I do. She says that I need my rest and that the dogs would get antsy without us."

He paused.... and looked down...

"Trust her to be more worried about me and the dogs even as she's lined up in a hospital!"


I walked over to Mr. Smith and bent down on my knees so that his eyes could see mine. I took his hands in mine.

"Mr. Smith, you're wife is as concerned about you as you are about her. But at this point in time, there's not a whole lot else you can do for her. I won't dare to presume to tell you how how things ought to be, but Sir; this hospital has strict visiting hours. As much as I'd love to bend the rules, you and I both know I can't."

He looked up slightly. A striking face; worn by the ravages of time, worry and care. A mist occluded his bright grey eyes.

"I've never been away from her. Ever. She'll be terrified. I know she will!"
That last response sounded less like a statement and more like a plea...

It nearly broke my heart.
"Hold on Mr. Smith. Let me see what I can do to..."

Just like that, I saw him shake his head. Take a few deep breaths in. Then he looked down to meet my eyes - his steel grey fiercely boring into my liquid brown.

"You take good care of her. She's all I have left!" I felt his hands clench mine, as if reinforcing his desperate plea.

"We will, Mr. Smith", I mumbled; "I promise".

He nodded assent, and then slowly shuffled off.


Leaving me all alone, to contemplate the loving bond that is shared between a man and his beloved wife....

Be careful when taking walks

One of our ER docs told me this story:

Many years ago, when I was doing my residency near The Other Big City, police brought this elderly gentleman in to the ER. They said that they'd found him wandering around and when they stopped to question him, he responded with incoherent words and neither one of the officers could figure out what the man was saying.

And neither could we. His vitals weren't normal but they weren't off the wall either. One of the nurses thought she detected some AoB (Alcohol on Breath) but for the most part this guy appeared benign. Lungs clear, good heart sounds, no apparent signs of trauma.

Then, one of the cardiology residents who happened to be down on a consult happened to pass by the ER room while we were trying to figure out what the hell to do. He stopped, poked his head in and asked one of the nurses what was going on. Upon being told the gist of the story; the resident shook his head and said: "He's not mentally confused or unstable. He's speaking a different language. I don't know what it is but I know it's not gibberish." Apparently this cardiology resident was of Indian extraction and had heard it before.

This set of a flurry of activity... and before long, they managed to find an Indian-American nurse who was called down to help translate.

Apparently, this gentleman had recently arrived in country; visiting his son's family for the holidays. He'd had a glass or two of wine in the afternoon and had decided to stretch his legs with a walk and take in some fresh air. That was when the police found him and the poor man spoke not a syllable of English. Fearing that he'd been injured/lost and wanting to make sure he was ok health-wise, the police brought him in and that's where all the fun started.

The "Nursing School" Car

I worked two jobs during nursing school. I bought a beat up 1995 Plymouth Neon - stick shift and a pretty decent radio. It had 2/40 air conditioning (2 windows rolled down driving at 40 mph). The only thing I cared about was the heater, since I lived in Buffalo.

The gauges worked when they felt like it. I once drove an entire stretch from Ohio through Illinois with a non-working instrument panel - I had no idea how much gas I had left or if the engine was overheating etc. The only thing that worked faithfully was the tachometer - so I used to guesstimate my speed based on engine revs and which gear I was in (e.g.: 1800-2000 rpm in 5th gear was roughly 35 mph).

Since the instrument panel worked erratically, the odometer didn't always run either. I had no idea about the true mileage of the car. These things sorta start to matter because you start to imagine scenarios like where your pistons ram through the camshaft because of a timing belt that wasn't replaced at the 'appropriate mileage' or busting a strut because of not having a safety inspection done at the 'appropriate mileage' so on and so forth...

It took me on several 1000 mile trips (and helped me move between two apartments. How I managed to cram my clothes, utensils, computer, stereo system and books and transport them thousands of miles, I alone know). It lasted through some of the worst winters Buffalo threw at us. It saved my ass during a real bad 75 mph spin out on the I-55.

That piece of junk lasted till 2007. I was driving home after my 4th 12 hour night shift in a row. I entered a school zone and with kids around, hit the brakes to slow down. Pedal went all the way to the floor but the car kept going. I used the gearbox to slow down to the point where I could yank the emergency brake. Thankfully, it worked and I was able to stop the car. By then I was wide awake and terrified.

I upgraded to a Honda within 2 weeks after that incident.

So, that was my "school car". What was yours?