So I got fired...

[JPINFV]

Shakes tiny fists of anger over being late to the "standing orders are standing orders, protocols are standing orders" comment. I'll also like to add that outside a handful of systems that have started to develop patient specific protocols to address specific community members with special medical needs, RNs can get additional PRN orders specific to their patient while paramedics are limited to just the standing orders.

 

[Level1pedstech]

... from an ER Tech position for allegedly being "in the process" of starting an IV (I'm an EMT-B but we have advanced skills training through the hospital).

Here's what happened:

A patient came in c/o weakness/fatigue. He was brady into the 40's with an A/V block on his EKG- Dr ordered an iStat (quick blood test in the ED for electrolytes and the like) and a line/labs. I took the pt back to a monitored bed from our "fast track" area, got him hooked up and went to prepare him for an IV since the MD ordered it. I simply put a tourniquet on to look for veins (and start it if the nurse would let me) since the RN wasn't there yet. I didn't even clean the skin, nor did I take out a needle. Finally the RN walked in, I asked if I could do it; he said no and took over (He's very egotistical and doesn't like Tech's starting lines or doing anything but bedpan duty. We have never gotten along and I always felt like he was analyzing everything I did to find every little mistake). I left thinking nothing of it, but apparently he told my manager that I was "in the process of starting an IV" that was not delegated to me (an RN must delegate, not a physician), which resulted in my termination.

This was a complete shock to me. I had been warned previously regarding IVs: once I got in trouble for switching EMS IV tubing to a Saline lock- (I was unaware we couldn't do that) and another time for looking for veins and offering to start an IV on a patient who was coding on one of the Med/Surg floors (it wasn't specified that our skills were only good in the ED).

Just wanted to get everyone's opinion on this and see if I'm the only one who thinks this is complete bull....

Thanks!

Over the years I have seen people struggle in the ER both as RN's and as techs. Usually a person will have difficulty when they come into the ER with no previous experience working in a busy fast moving atmosphere. But another bigger and somewhat over looked problem is people that just don't fit the culture in the ER,I like the previously mentioned square peg round hole analogy its a good way to describe people who don't fit in the ER.

Unless you have spent some paid time working in the ER its hard for people to understand the dynamic present and how one person can really make things difficult for everyone else. I may not be crazy about everyone I work with on every shift but I always try to maintain a certain level of respect and trust. I think there might be more to your story,I just don't see an RN writing up a tech for looking for veins or putting on a lock,this is another time where the trust and respect thing comes into play. It may not be in your job description but an RN to tech warning seems to be more appropriate in this situation at least the first time then maybe a written warning and maybe a suspension followed by termination. Every employer has their own unique system of discipline and yours just might be extra tough.

Part of being a competent tech is being able to respect that fine line and always stay within your scope of practice. Yes we do often find ourselves involved in procedures that are way above our scope of practice but usually its in the role of "assistant" with an RN,PA or MD at your side or at least close by. I wont go any further with that because your already in enough trouble and encouraging you or anyone else to venture over the line would be irresponsible. Every situation is different and you need to know and respect your boundaries. Having the complete trust of your fellow staff members is crucial and that seems to be missing in your case.

It sounds to me like somewhere along the line you became a thorn in the butt of your manager or director as well as at least one of your team members and lost that trust and respect. If that's the case your done and should just move on,if you have the union you may be able to get back in but would you really want to go back and work in what would probably be a hostile environment knowing you will be scrutinized every time you make a move? Also why should they give you another chance when there are probably a hundred or more people waiting in line to grab that job.

I don't mean to be cruel but it sounds like you really screwed up a good thing, now you need to learn from your mistakes and move on. It wont be easy especially if your in an area where such news travels like wildfire,your reputation will follow you in this business so you may need to do some big time damage control. Good luck!

 

[Veneficus]

Just wanted to get everyone's opinion on this and see if I'm the only one who thinks this is complete bull....

Thanks!

Nope, not bull.

One of the most important aspects in finding a job is to find one where the workplace culture fits in with your personality.

For example, if you are a very liberal person, working for a conservative organization or an organization where conservative people prevail is not going to go well.

Perhaps one of the most important things in healthcare is knowing what you can and cannot do, when you need to ask permission before, or when you can get "permission" after. This can also apply to where you are at and when you have multiple roles. Just because you know how to do something doesn't grant you some pseudopermission to do it.

From your narative, and I imagine also it is not the whole story, you have absolutely no idea what your boundries are. At the very least you are on your third strike.

I do not think unions should protect such people ever. In fact one of my biggest problems with them is they protect the most useless people from being rightfully terminated for failing to meet organizational standards, most often out of apathy or outright laziness.

Again from your description, it sounds like you can anticipate the needs of various situations. Which is a positive virtue. But it also seems like you are working in a place that doesn't really want that.

Some bosses are strict, some more leanient. But they are still the boss, and what one lets you do doesn't automatically translate to what another has or wants you to do.

Could I just point out:

In your story about changing IV fluid to a lock, was there an order to administer fluid or discontinue it for that patient at that time or were you basing the decison off of what is usually done?

I imagine you were on a floor because you were transferring a patient when you happened across a code?

It may surprise you to learn this, but many departments don't exactly "look up to" the ED staff. Usually, random providers from other departments are not really appreciated. it is your responsibility to kow where you are permitted to function, how and when. "you had no idea" doesn't exactly paint a shiney picture of your knowledge of your responsibilities. Your prolonged absence could als have been holding up patient flow in the ED, so you department may have been uffering while you were out freelancing around.

If somebody put a constricting band on a patient, and was "looking for a vein" as far as I am concerned, they are starting an IV. If they have no ability to properly clean the site, or are not set up prior to with their equipment, it looks to me like they are doing a poor job of it.

I have never known anyone who could start IV therapy or place a catheter who needed somebody to find a vein for them. The very argument sounds crazy.

For a moment, let's pretend you are working with me. (not really realistic because I don't really care who starts an IV as long as it is done in a acceptable way, but lets consider) If you put a TK on a patients right side, and showed me where a vein was, etc, you may have wasted your time. I am left handed, so whenever possible I like to work from the patients left side. Not that I can't work on the right side, but I usually like to choose my ground and when possible be in a position of strength.

Perhaps I need a more proximal or distal site? Perhaps I was a site away from a joint, I never like to use the hands. (too small of facial compartments in life altering area) But sometimes I cannot be so picky. (those times are rare) So really your impression of help is no help at all.

If you knew this nurse was exceptionally tyranical and didn't like you, why would you give him any reason to report anything you did? I would steer well clear and let him sink o his own. Infact I'd find a friendlier person to make sure I was already "busy" for them, just to get away from him.

Consider it a learning experience, and move on. It may suck, but if you are in RN school, go flip burgers till you are finished and can choose your job instead of lamenting a tech postion.


The nurse vs medic argument is old and tired and utterly pointless. Neither side can claim "victory."

 

[feldy]

while i worked as a volunteer in the ED this summer, essentially I had a very similar role as a tech. However, while i knew and had practiced certain things that were out of my scope as an EMT and especially as a volunteer, I always aired on the side of caution. I think there was one thing where I was told after the fact that next time let one of the techs do that, but that was because I was never told that I was not allowed to do that.

After that point, I would be asked by certain nurses who did not really know the scope of my postion to do things like splint, take out this person's IV or what not, but i just told them that the hospital does not allow me to do that, I would if i could but i shouldnt.

I think in the situation of the op and my situation, especially with such a limited scope, always aire on the side of caution, unless you are 100% sure that you are allowed to do something, then be honest and ask someone else to do it.

 

[Jeremy89]

Wow, Thanks for the replies everyone!!

I would like to encourage everyone to re-read my original post just for clarification.

I just wanted to specify a few things:

1. For everyone who suggested that I appeal it, well I met with the head of HR shortly after and let him know what was going on. He looked into it and wasn't able to offer my job back but he did say that no one is ever ineligible for rehire with the company (who happens to own half the hospitals in Phoenix).

2. There is nothing wrong with "looking for veins". That doesn't mean that I was "in the process of starting an IV"- I could have drawn the blood without RN delegation, or I could have been looking for veins, in the event that the patient goes downhill quickly, I could say "hey, his R AC feels great". The physician DID order it so I knew either way it was getting started, either by me or the RN.

My job as an ED tech was to anticipate what was going to happen and to prepare items for procedures or whatnot- if a patient is short of breath and their Sats are dropping, I'll grab the code cart just as a precaution, should we need to RSI. If a nurse gets Propofol out of the Pyxis, I need to make sure a pump is in the room. If we're taking a vented pt up to the unit, I need to ensure there is adequate O2 and a BVM on the bed. I knew this specific patient was getting an IV so I chose to prepare all the items for whomever was to start it.

3. With regards to my training, it was very very vague- we discussed general IV insertion and put a 22ga in a fake arm and we were done. They didn't specify anything except we could only draw blood from the line when it was started and that we would not be giving any fluids other than the NS pre-filled flush at the time of insertion. The instructor said "Any RN can sign you off", thus explaining my previous warning. The other time when the RN asked me to switch over the line, I obviously said yes. I figured if the RN was asking me then it was within my scope.

4. For everyone saying there's more to the story, there really isn't. There were the more reserved techs that worked there who just did what they were told, nothing more. As a nursing major, I couldn't stand working as a "dumbed down" tech who wasn't allowed to share and utilize what I knew. I was warned previously about IVs because no one specified anything about our scope of practice. Seriously- none of the other techs knew what we were specifically allowed to do. Once I had an MD put a syringe of Viscous Lidocaine on the table while I put a foley in. I didn't think twice about it- I mean its just lidocaine, right? I asked my Senior Clinical Manager (the one who fired me) and she referred me to our clinical educator and even he said it was "in the grey area". I've had nurses ask me to get Epi out of the code cart and pop the cap to prepare the pre-filled syringe. Again, a nurse asked me to so I assumed it was within my scope. Maybe its my fault for not knowing my scope, but if my educator can't even specify it, I don't know who can.

5. Finally, the date of my second warning was in April. I wasn't fired until July. This should tell you that I was able to improve my behavior and that all was good for over 3 months (and wasn't even "bad" when I got fired- I didn't do anything out of my scope).

 

[Jeremy89]

Again from your description, it sounds like you can anticipate the needs of various situations. Which is a positive virtue. But it also seems like you are working in a place that doesn't really want that.

This is true

In your story about changing IV fluid to a lock, was there an order to administer fluid or discontinue it for that patient at that time or were you basing the decison off of what is usually done?

See my above post- it was delegated by the RN.

I imagine you were on a floor because you were transferring a patient when you happened across a code?

It may surprise you to learn this, but many departments don't exactly "look up to" the ED staff. Usually, random providers from other departments are not really appreciated. it is your responsibility to kow where you are permitted to function, how and when. "you had no idea" doesn't exactly paint a shiney picture of your knowledge of your responsibilities. Your prolonged absence could als have been holding up patient flow in the ED, so you department may have been uffering while you were out freelancing around.

If somebody put a constricting band on a patient, and was "looking for a vein" as far as I am concerned, they are starting an IV. If they have no ability to properly clean the site, or are not set up prior to with their equipment, it looks to me like they are doing a poor job of it.

I have never known anyone who could start IV therapy or place a catheter who needed somebody to find a vein for them. The very argument sounds crazy.

Obviously you don't work in an ED. Its all about anticipation- the guy had symptomatic bradycardia. Who knows if or when is AV node would stop firing? Like I said, the RN was busy with his other 2 pt's (since he didn't let techs help him out- the whole purpose of our extended skills). I wanted to stay with the patient until the RN came in, should anything happen. But I wasn't just going to stand there when I could be doing something productive.

For a moment, let's pretend you are working with me. (not really realistic because I don't really care who starts an IV as long as it is done in a acceptable way, but lets consider) If you put a TK on a patients right side, and showed me where a vein was, etc, you may have wasted your time. I am left handed, so whenever possible I like to work from the patients left side. Not that I can't work on the right side, but I usually like to choose my ground and when possible be in a position of strength.

Perhaps I need a more proximal or distal site? Perhaps I was a site away from a joint, I never like to use the hands. (too small of facial compartments in life altering area) But sometimes I cannot be so picky. (those times are rare) So really your impression of help is no help at all.

Exactly, but it couldn't hurt to look in the rare case that RN would let me start one (he did once- I was shocked). I have learned to anticipate the size and location of the IV- this guy very well could get a CT Angio Chest so he'd need an 18+ in the AC.

If you knew this nurse was exceptionally tyranical and didn't like you, why would you give him any reason to report anything you did? I would steer well clear and let him sink o his own. Infact I'd find a friendlier person to make sure I was already "busy" for them, just to get away from him.

Consider it a learning experience, and move on. It may suck, but if you are in RN school, go flip burgers till you are finished and can choose your job instead of lamenting a tech postion.

Touché- Most likely I'll head back to Target where I worked before. Not my first choice, but as I mentioned, I can't stand working under my education level.

 

[Jeremy89]

RE: Working the code

I was picking up hours in the EKG department and got called up for a Rapid Response. When the patient coded I wasn't just gonna sit there and watch these MedSurg nurses fumble around the code cart when I know it inside and out. Besides, its not like the patient needed an EKG while he was coding!! Might as well make myself useful.

 

[JPINFV]

2. There is nothing wrong with "looking for veins". That doesn't mean that I was "in the process of starting an IV"- I could have drawn the blood without RN delegation, or I could have been looking for veins, in the event that the patient goes downhill quickly, I could say "hey, his R AC feels great". The physician DID order it so I knew either way it was getting started, either by me or the RN.

I don't think anyone is buying this. If it walks like a duck and quacks like a duck, it's a duck.

I go trap shooting (shotgun shooting) every week or two. At the range I go to, if an employee is in the trap house they put an orange traffic cone on top as a warning that someone is downrange on that range. If I'm at a station with my shotgun pointed down range, then I'm preparing to take a target and a danger to the technician, regardless of if my shotgun is loaded and the action closed or if I'm just getting a feel for shouldering my firearm.

Similarly, if you have a tourniquet on the patient and looking for a vein, you are preparing to start an IV, regardless of whether you mean to or not.

My job as ... I knew this specific patient was getting an IV so I chose to prepare all the items for whomever was to start it.

You went past preparing the items to initiating the initial steps of the intervention.

 

[JPINFV]

Obviously you don't work in an ED. Its all about anticipation- the guy had symptomatic bradycardia. Who knows if or when is AV node would stop firing? Like I said, the RN was busy with his other 2 pt's (since he didn't let techs help him out- the whole purpose of our extended skills). I wanted to stay with the patient until the RN came in, should anything happen. But I wasn't just going to stand there when I could be doing something productive.

Let's assume that the patient goes into a 3rd degree AV block and becomes unstable. The first line tx isn't an IV medication. So if you were so concerned that you were futzing around with an IV, were you also prepared to futz around with the defibrillator?

 

[Hockey]

Reason #294458486471.9 why I refuse to work in an ER. Too much BS. Too much drama

 

[Shishkabob]

RNs can get additional PRN orders specific to their patient while paramedics are limited to just the standing orders.

Well that's just not true either.


I can call my med control, or the receiving hospital, and speak and consult with the receiving physician and deviate from protocols... all PRN. Kinda the point of On-Line Medical Control, is it not?

 

[JPINFV]

Well that's just not true either.


I can call my med control, or the receiving hospital, and speak and consult with the receiving physician and deviate from protocols... all PRN. Kinda the point of On-Line Medical Control, is it not?

I'd argue calling in and asking for an order isn't all that PRN'ish. However, it's true that online control can always go, "administer X and if it doesn't resolve administer X more." Of course the unsaid difference is EMS is all of what, less than an hour normally from patient contact to hand off? However the physician doesn't want to get a call at O'dark 30 that the patient has a fever and needs Tylenol, which could easily be resolved by a PRN order.

 

[JJR512]

Similarly, if you have a tourniquet on the patient and looking for a vein, you are preparing to start an IV, regardless of whether you mean to or not.

Preparing to start an IV is not the same as starting an IV. The OP was fired for doing something that he was only preparing to do, not actually doing.

If I'm putting toothpaste on my toothbrush, I'm preparing to brush my teeth, but I'm not brushing my teeth. If I'm getting in a car, putting on my seatbelt, and getting out my keys, I'm preparing to drive the car, but I'm not driving the car.

I'm re-taking an EMT-B course now because my original certification expired last year, and I did not renew it then (that's a story for another time/place). It's early in the course, and at this time, we are not allowed to have patient contact. We are allowed to go out on the ambulance as an observer, and as observers, we are allowed to get out the O2, get out a nasal cannula, set it all up and get it ready, but we are not allowed to actually place the cannula on the patient. The instructor has explained that at this point in our training, patient contact is practicing medicine without a license, which is, if I recall correctly, a Class D Felony. But by your logic, setting up the O2 and the cannula is the same as placing the patient on oxygen, so I'm already guilty of a felony.

The State's Attorney's Office for Howard County, Maryland, can be reached at 410-313-3100, if you'd like to report me.

 

[feldy]

Preparing to start an IV is not the same as starting an IV. The OP was fired for doing something that he was only preparing to do, not actually doing.

If I'm putting toothpaste on my toothbrush, I'm preparing to brush my teeth, but I'm not brushing my teeth. If I'm getting in a car, putting on my seatbelt, and getting out my keys, I'm preparing to drive the car, but I'm not driving the car.

I'm re-taking an EMT-B course now because my original certification expired last year, and I did not renew it then (that's a story for another time/place). It's early in the course, and at this time, we are not allowed to have patient contact. We are allowed to go out on the ambulance as an observer, and as observers, we are allowed to get out the O2, get out a nasal cannula, set it all up and get it ready, but we are not allowed to actually place the cannula on the patient. The instructor has explained that at this point in our training, patient contact is practicing medicine without a license, which is, if I recall correctly, a Class D Felony. But by your logic, setting up the O2 and the cannula is the same as placing the patient on oxygen, so I'm already guilty of a felony.

The State's Attorney's Office for Howard County, Maryland, can be reached at 410-313-3100, if you'd like to report me.

The difference is here that you did not have pt contact while the op did.

mistakes are made and we learn. Just some quicker than others.

 

[JJR512]

The difference is here that you did not have pt contact while the op did.

mistakes are made and we learn. Just some quicker than others.

The point is not whether or not patient contact occurred. The point is whether or not the line that separates what one is and is not allowed to do is crossed. The point is also that doing something in preparation for an action on the wrong side of that line does not equal doing something on the wrong side of that line.

It's easy for me because my line is clearly defined. Judging by some of the things the OP has said, that line is not so clearly defined for him.

 

[JPINFV]

If I'm getting in a car, putting on my seatbelt, and getting out my keys, I'm preparing to drive the car, but I'm not driving the car.

That's sufficient action to get a drunk driving charge if you're drunk. Also, try loading a firearm at a range at someplace other than the firing line. Sure, you are just preparing to shoot it, but don't be surprised if people treat you like you just discharged it off the firing line.

I'm re-taking an EMT-B course now because my original certification expired last year, and I did not renew it then (that's a story for another time/place). It's early in the course, and at this time, we are not allowed to have patient contact. We are allowed to go out on the ambulance as an observer, and as observers, we are allowed to get out the O2, get out a nasal cannula, set it all up and get it ready, but we are not allowed to actually place the cannula on the patient. The instructor has explained that at this point in our training, patient contact is practicing medicine without a license, which is, if I recall correctly, a Class D Felony. But by your logic, setting up the O2 and the cannula is the same as placing the patient on oxygen, so I'm already guilty of a felony.

Emphasis added.

First, Maryland State law is a pain to go through. However, in general states create a licensure exemption for students in training programs. California's Code of Regulations, for example, explicitly gives supervised EMS students the same scope of practice as the level they are training towards*. A much looser clause is included in the Business and Professions code covering medical students (essentially medical students don't have to be directly supervised).

Second, what would the paramedics response be if you were alone with a patient for a few minutes while he went and did something (put something away outside, talk to a family member, what ever) and he came back to find you with an IV kit, a tourniquet around a patient's arm and palpating for a vein. After all, it's not illegal to assist with an IV, tie a tourniquet around the patient's arm, or feel for a vein.

The State's Attorney's Office for Howard County, Maryland, can be reached at 410-313-3100, if you'd like to report me.

It really is possible to break company policy resulting in termination without breaking the law.




*

§ 100063. Scope of Practice of Emergency Medical Technician.
(a) During training, while at the scene of an emergency, during transport of the sick or injured, or during interfacility transfer, a certified EMT or supervised EMT student is authorized to do any of the following:

Emphasis added.
http://www.emsa.ca.gov/laws/files/ch2_emtI.pdf

 

[JPINFV]

The point is also that doing something in preparation for an action on the wrong side of that line does not equal doing something on the wrong side of that line.

Are you suggesting that if someone is preparing to do something bad they shouldn't be stopped until they've actually completed the action?

 

[Shishkabob]

Are you suggesting that if someone is preparing to do something bad they shouldn't be stopped until they've actually completed the action?

Meh, depends.


Whilst there's "conspiracy" to commit a crime, there are also other crimes that don't actually happen until you commit it, regardless of intent. (Shoplifting isn't shoplifting till you exit the store... you can hid all the merchandise in your clothing you want, but not illegal till you step past the last register, regardless if you walk around telling all the employees you're planning on stealing stuff.)

 

[JPINFV]

Meh, depends.


Whilst there's "conspiracy" to commit a crime, there are also other crimes that don't actually happen until you commit it, regardless of intent. (Shoplifting isn't shoplifting till you exit the store... you can hid all the merchandise in your clothing you want, but not illegal till you step past the last register, regardless if you walk around telling all the employees you're planning on stealing stuff.)

True, but you don't have to do anything illegal for the store to ask you to leave either.

 

[Shishkabob]

True.


But for the sake of this thread, let's separate "legal" from "against a private employers policies".