Preceptor said..."You could have lost your license!"

PMFB-RN, RN · Nov 8, 2012

I have a question, this happened on my last shift.
I am a new nurse and this is my 4th week in the Emergency. I have had a full load since i started. My preceptor will go help in the Trauma rooms when an ambulance comes in or help the female nurses he has a crush on and usually i'm by myself.
A pt comes in through triage with numbness/tingling in his right hand has a hx of a TIA a month ago, no c/o pain and the triage nurse brings him to the room. I hook him up to the cardiac monitor, do a NIH stroke scale and swallow screen (no signs of a stroke and he passed the swallow screen) and do an EKG. I walk the EKG to the Dr.'s ask which one has this pt one of them took the EKG (which showed a 1st degree AV block) and signed it and gave it back to me. The Dr. (another Dr. not the one that signed the EKG) took an hour to come assess the pt. Then he calls a code stroke and i get questioned about the pt by my preceptor because he hasn't been around and he didn't know anything. He says i should have made the Dr. come sooner. He then says you better be glad the pt did not have a stroke (it was another TIA) or you would have been in trouble. Was i at fault? If so, how?

*** Your preceptor sounds like a drama king/queen and is makig a much bigger deal out of it than it was. You should have made sure your preceptor or charge nurse and the physician was aware of your assessmet findings but sounds like you did just fine to me.

FWIW you didn't do anything that would put your lisense at risk. There are some very misinformed nurses out there who think every time a medication is given late their lisense is at risk.

camiluvsNURSING · Nov 8, 2012

You may be right, his secret lover (seriously) got fired a couple of weeks ago because it took her 4 hours to do a EKG and every since all he talks about is making sure you cover yourself...trust no one. Then he told me by next year he is leaving before they fire him. Sometimes it's just too much, he worries about keeping a job more than he precepts!

PMFB-RN, RN · Nov 8, 2012

You may be right, his secret lover (seriously) got fired a couple of weeks ago because it took her 4 hours to do a EKG and every since all he talks about is making sure you cover yourself...trust no one. Then he told me by next year he is leaving before they fire him. Sometimes it's just too much, he worries about keeping a job more than he precepts!

*** That such a nurse is allowed to precept new nurses is beyond beliefe to me.. It would make me seriously question the hospital and I would start looking for a different job. The best time to find a job is when you already have one.

tri-rn · Nov 8, 2012

Wondering why the Doc found it necessary to call a code Stroke if the pt's NIH was negative?

camiluvsNURSING · Nov 9, 2012

The Dr. that had that pt was fairly new to our hospital. He over reacts alot, the pt questioned him several times as to why he did that. What didn't sit well with me is my preceptor went to talk to the Dr. trying to save face and told him "I want to apologize for the new nurse i'm working with." As if i did something wrong, if that pt was that critical it should have been caught during triage!

NurseKatie08, MSN · Nov 9, 2012

Time for a new preceptor.

fiveofpeep · Nov 9, 2012

A better preceptor would have explained that stroke response time is kept track of and published and also factors in to the hospital's ability to be stroke certified and be a stroke receiving center. For example, a patient needs to be called a code stroke within a certain amount of time, get a CT in x amt of time, and start TPA within a specified time from the ER door to injection.

Given that you have only been there four weeks, I would be peeved that you didnt come get me straight away or get someone to double check because even if you're NIH certified, I wouldn't necessarily trust it. I worked in a neuro ICU and now I work in a mixed medical surgical ICU and you'd be surprised how completely different one person's NIH score compared to the other (for the same patient).

It's not something you lose a license over but it's something to learn a lesson over. Make sure you are familiar with the policies of your facility, like how soon should a patient who could potentially be a code stroke be seen by the ER MD. They also follow MI to cath lab response time closely as well so you may want to check that out. There are also some key sepsis core measures that need to be followed too (like BCx in ER, ABX started in ER after cultures sent.)

Good luck to you.

georgiasteve · Nov 9, 2012

Doesn't sound like a very supportive preceptor, but stroke times are very important given the window of time TPA can be given. The sooner a CT can be completed, and hemorrhagic stroke ruled out, the sooner TPA can be considered if appropriate. There are several factors that affect if you can give TPA such as ...did the person wake with the symptoms, have they ever had brain surgery (with clips I think), age, and time (say the symptoms started 4 days ago-TPA no go). But we all live and learn.

AP0525 · Nov 9, 2012

The biggest thing here is when did her symptoms start? ( as others have said) If she is out of the window to be called a "code stroke", her vitals were stable, she was awake and alert, etc., then she was fine to wait for the doctor for a bit. If she were in the window, then you should have notified the dr and activated the code stroke system (however your hospital does it). However, if you are only 4 weeks in, you shouldn't be left alone and expected to know those things and your preceptor is the one who is ultimately responsible for the group of patients since he is supposed to be precepting you.

one__speed · Nov 9, 2012

I have a question, this happened on my last shift.
I am a new nurse and this is my 4th week in the Emergency. I have had a full load since i started. My preceptor will go help in the Trauma rooms when an ambulance comes in or help the female nurses he has a crush on and usually i'm by myself.
A pt comes in through triage with numbness/tingling in his right hand has a hx of a TIA a month ago, no c/o pain and the triage nurse brings him to the room. I hook him up to the cardiac monitor, do a NIH stroke scale and swallow screen (no signs of a stroke and he passed the swallow screen) and do an EKG. I walk the EKG to the Dr.'s ask which one has this pt one of them took the EKG (which showed a 1st degree AV block) and signed it and gave it back to me. The Dr. (another Dr. not the one that signed the EKG) took an hour to come assess the pt. Then he calls a code stroke and i get questioned about the pt by my preceptor because he hasn't been around and he didn't know anything. He says i should have made the Dr. come sooner. He then says you better be glad the pt did not have a stroke (it was another TIA) or you would have been in trouble. Was i at fault? If so, how?

Whay was the patient triaged as. CTAS 2 ( or emergent) and the patient should have been seen by the ER Doc a hll of a lot sooner than an hour later.

Having been both the preceptor and the preceptee (you get it... both sides of the table) this guys sounds like a bit of a lame ass preceptor. Sounds like he isn't doing his job and is trying to cover his ass by laying blame on you.

From the sounds of it, the doc decided to assess further for stroke, but from you description of minimal "defecits" TPA woudn't be in the patients near future unless they had deteriorated in that hour.

Our version of "code stroke" order set covers all of hte bases (labs, CT, consults, etc.), but doesn't immediately indicate the patient is up for thrombolytics.

Cheers.