At A Quandry

[fire911medic]

I've been in the EMS game for quite a while now, and been an instructor around the same, but I've reached a situation with which I'm not quite sure how to proceed and though I know I get good and bad feedback off here I'm going to bounce it off anyway because I've been running it through my mind and unsure what to do.

Situation : Student (whom I happen to know well) is addicted to painkillers. No, at this point in their training, they have not been required to take a drug test yet - will be required prior to initiation of clinicals. This student states they will be going into rehab at a later date, and has shown up on a few occasions where they have been questionably high - student does have a legitimate reason that they could require prescription pain medication.

Here's my issue :

1. Am I overstepping my bounds as an instructor to a) request a drug test on reasonable suspicion same as I would an employee even though my other students are not subjected to one and this is not a stated option in their orientation packet (needless to say that is changing next class) ?

2. I am not comfortable with this student potentially working on painkillers and most services which I have been affiliated with follow the rule of prescription pain meds and you are off direct patient care and driving. I have already confronted the student with concerns of this and the patient provided me with a doctor's statement clearing them medically to perform EMS (which I am suprised, but I'm not their doctor and the statement signed is requried of all students and specifically states what is expected of an EMS students duties), but also cleared them to work on prescription pain meds.

3. Do I run the risk of suit if I defer the student's enrollement in class until off pain meds and rehab is completed (note the student has come forward with an addiction issue and volunteered the rehab information because it would have required being gone over 3 class periods)?

Here is my choice action and tell me if you believe this is within reasonable action or have a suggestion : Defer the student's enrollement with full refund ensuring place in next available class post completion of rehab with updated medical clearance without needing prescription pain meds allowing them to get the treatment they need without subjecting them to questions from other students during absence and also protecting potential patients. I don't want to jeapordize this student's future by turning them into the EMS board if they are able to function acceptably, however I have made it clear to this student that if I am aware of any abuse during clinical time they will be submitted. I am not reacting this way simply because I am familiar with the student and their situation, I would be sensitive to anyone, but on same token, patient safety is of utmost importance and I will NOT graduate a student that I deem to be a risk.

Any input is appreciated.

[Arctickat]

Does your school require the students to partake in a field practicum? If so, subject all the students to a mandatory drug test, don't single out this one student. If, and when this student fails, make sure he is aware that even though he has a prescription for these pain killers, he can not work while under the influence of such. Until such time as he is able to perform his duties without the need for painkillers he will not be able to complete his practicum and will be required to provide samples during the training period.

If he is using the pain killers for legitimate pain, then he shouldn't be working at all, he needs to heal first so he doesn't injure himself further. If he is abusing them, then he will not be able to complete his training until his rehab is complete.

Most of all, be supportive. Give him an opportunity to sort himself out and return. I know a few great medics who have had to shrug that monkey off their backs....there are even some on this forum.

Finally, none of us are lawyers. Get legal advice from one of them, not from me. My idea sounds good in my head, but I have no idea if it's legal where you are.

[DFIB]

I agree with ArticKat only you may loose more than just the one student if you drug screen everyone which is not a bad thing, right.

[DwayneEMTP]

What level of education is this student attempting to achieve?

Doesn't the students statement that they will go to rehab at a later date illuminate the fact that this is an adiction "only" and not a medical need?

I'm afraid that I have no opinion on whether or not you have the right to request a drug screen in an educational environment, though my guess would be that you certainly would based on suspicion, assuming that you can justify your suspicion.

I would not allow them to continue for several reasons, and non of which is me trying to be a hardass. There needs to be some baseline standard for education and entry into EMS, wouldn't you agree? Though the student, and perhaps you, believe that no one else is aware of this issue, I can promise you that that is not the case. Knowingly allowing this student to continue lowers the expected standards of your program to an unacceptably low point, in my opinion. You not only show the respect that you hold for your program, but define it for those that follow as well.

Also, this seems like a really big liability to me. If you believe that this person has such a significant need for narcotics then they certainly don't belong in the physical world of EMS. Also, and this would be pretty big for me, when they become injured, or further their injury, they will always have the ability to say, "But, I told F9m and she allowed me to continue so I assumed that it would be safe for me..." Doc's note or not, it seems that it puts you and your institution at a significantly increased unnecessary liability, doesn't it? And I'd be curious to know if the doctor's permission was verified. My guess would be that it wasn't, and even more so that it was never given.

Though we're not supposed to say such things in our politically correct world, they've admitted that this is an unhealthy issue and yet have chosen to continue it until 'some other day.' This shows an unhealthy, and immature personality and neither of those should be encouraged to enter the EMS family.

And lastly, and I promise that no offense is intended, but more than likely the last thing that this person needs is another enabler in their lives. It's time for them to make some hard choices, and helping them to postpone those choices is feeding their pathology...again, in my opinion.

Good to have you back!!!

Dwayne

[emtdennis]

There is a whole lot more at stake if this person is allowed to continue in training.

Besides putting you at risk, because you know of of this person's condition, other students, patients (in the future) will also be at risk. If there is injury or further damage to a patient, it will come back to you. We do live in a lawsuit happy society.

As others have posted, this person really needs to step back and get themselves together first.

I don't think you are overstepping your bounds as an instructor as far as bringing it up to higher authority in the school and hopefully they will act on it. You are looking out for this person, (and the school), maybe by some chance they will take the proactive step in the right direction.

Sometimes not an easy call..

Just an opinion, hope all goes well

[Just Plain Ruff]

I don't think you have much choice other than to take it to those in higher authority than you. Let them make the decisions as to whether to require further action.

If they choose to take further action or to sit on their hands is their decision.

But you did say that there is a drug test later down the road right? Before clinicals? That's a good place for the test to be. As this is your friend the best you can do is to warn your friend that the tests are coming and that if he fails the test that he is going to be out.

But then you have that note that he produced. I would definately do some vetting of that note. You have to know how crafty drug addicts can be and I'm not casting aspersions that your friend, but if he's/she's proactive enough to provide you with a note from a doctor then I'd be concerned. YOu need to contact the doctor in question and discuss the note and make sure that the doctor understands exactly what the student will be doing in clinicals.

Plus, your school does owe its clinical sites a bit of extra dliigence (which I am sure and am positive you already know this) and if you send them a stoned student, they will more than likely drop your school like a hot potato especially if that student harms one of their patients in any way so there is that liability that you have to look at as well.

Good luck, I do not wish to be in your shoes but this really needs to be in your administrations hands and not yours. It went out of your hands the minute the relationship was revealed that it was between you and your friend. That should have been "your" red flag that this should have been moved up to your Boss'es office. You are too close to the situation and the problem should be handled by someone other than you. Not saying you aren't doing a good job of it but your handling of it is clouded by your friendship and that's muddying the waters.

[Bieber]

There've been some good replies here, so I'll just add one small thought:

"In other news, an EMS instructor has been placed on administrative leave today pending an investigation into allegations that she allowed a student into an EMS program knowing that the student had an addiction to pain medications. Other department staff state that EMS students must perform clinical rotations as part of their education and that they routinely have access to narcotic medications. They also state that it is against their policy to allow students into the program who have a current ongoing issue with drug abuse. If found guilty of these allegations, the EMS instructor in question could be terminated and have her instructor license pulled by the state board of EMS."

"In other news today, a local EMS program was criticized today by a student hopeful who was denied entry into the program. The EMS instructor for the program stated that the student in question has been fighting an ongoing battle with drug addiction and explained that she elected to defer the student's enrollment into the program until the student had been through a drug rehabilitation program and medically cleared. Other department staff state that it is the department's policy to refuse entrance to any student who currently abuses drugs, and note that students must complete clinical rotations as part of their education during time which they may have access to narcotic analgesics. More on this story later."

Which headline can you live with? Furthermore, which path has the consequences you can live with? I can pretty much guarantee you that it will be easier to publicly defend yourself for erring on the side of patient safety than it would be to defend why you let someone you're familiar with--and who you know has a problem with drug addiction--into a situation where he could further abuse drugs and possibly harm patients.

Take care.

[fire911medic]

Thanks for the feedback few things though to clarify

1. This is an applying student - has not entered the program yet this is something I am addressing PRIOR to starting class - Lord knows I don't want to get into this situation in the middle of class

2. I would not consider this person a "friend". I am familiar with them as I know them and various people within the circles they travel, so I am objective with this in mind. I have absolutely no desire to be an enabler, and while they do have legitimate issues that MAY require pain medication (which as I said I am hesitant to believe they are physically capable of handling the physical stress of the job thus why all students are required to submit a clearance from a physician), I am unaware of any service that will allow a someone to perform patient care while under the influence essentially. Medically cleared or not. Do not want to elaborate on physical issues here due to it being a possible identifying factor.

3. The later date issue was confirmed today by the fact the student wanted to start class and planned to get off medication to see if they could do the job off it or not. The facility they planned to go to for dealing with the acute withdrawl has a waiting list - any other option would be a 30 day rehab and this facility specializes in people with physical issues potentially requiring pain medication.

I did address this with the director of the facility and it was basically put back into my hands. I want to give the person every chance as I do know more than one medic that's had to deal with this demon, turned their life around and came back successfully. I want to give this person and any potential student this chance. This is my first encounter with this (knowingly) and I do commend this person for trusting me enough to come forward with the information which makes me want even more to make sure I handle this with respect and fairly. At this point they are applying for a first responder license so we are at the lowest level, but regardless, it is potential patient care.

Thanks.

[mikeymedic1984]

I am not sure that you have the legal standing to force an early drug screen, unless your school mandates a drug screen for all students, or has a policy that mandates drug screening upon suspicion of drug use (Come'on, which student isnt high or drunk every Saturday night on your campus). The good news is that once they get this sloppy, they are usually on multiple meds, and will fail the drug screen that you have coming up. The bad news is that if they have a prescription for the meds, they have not violated any rule or law. Should you try to ruin their potential career through your fears and actions, you may face a lawsuit from the student (their Dr. says its OK, who are you to question the Dr. and violate HIPAA possibly -- that's what a lawyer would ask). So be careful. As others suggested, bump it up the line to a supervisor and let them decide whats the next best solution.

And I wouldnt worry too much, most reputable employers will do a drug screen before hiring.

[croaker260]

After some time dealing with issues like this as a former supervisor and current instructor. .....

1. The first question is : What does your POLICY state? Both your department policy and your school policy. I can pretty much guarantee you that if you don't have one now, you should write one.
   
2. The second question is; What have "we" done before? How has your department handled this situation before. Why? How did it turn out? If your department does not currently have a policy or prior precident, I would strongly suggest an informal conversation with the heads of the other allied health departments (i.e. Nursing) to see what they do in this situation. I promise you it has come up before. See what the prior precedent is.
   
3. The third question is: What does our Human Rescources / Dean of admissions say? This is what they get paid to do, solve problems like this. Use them.
   
4. The fourth question is: What is the right thing to do? When in doubt the best policy is honesty and transparency, avoid the temptation of simply "losing their application" or "not returning their phone call". And though we would all like to "give someone the chance", we need to make this decision on objective criteria. And that decision needs to be the same as if we had never spoken to the person and are simply looking at the case on paper, instead of looking across our desk at the student in person.
   

My advice (after doing all of the above)....... Simply sit down with the student and tell him/her that until the issues are resolved, you cannot allow them into clinicals. Explain that clinicals are an essential portion of passing the class (or at least the NREMT). Offer to let them audit the course now for credit only (without clinicals) or to let them take it at a later date when the issues are resolved. Let the student decide weather to withdraw or not, your not denying admission.

Finally, DONT DISCUSS THIS WITH ANY OTHER STUDENTS. Only your fellow instructors and your chain of command on a need to know basis. If they audit your course, treat them like any other student. Keep their secret like a professorial unless required ethically or by law to do otherwise.

And I wouldnt worry too much, most reputable employers will do a drug screen before hiring.

I couldnt disagree more. I would absolutely worry. At the local college where I teach , we have an ongoing problem with a local hospital because of another allied health programs student showed up high. Now we have a 100% drug testing policy prior to clinical. Take it form my personal experience.... The last thing you want to have to deal with is the lost of a clinical site(s) because a student showed up high, or at least "glazed", much less actually succumbing to temptation and stealing meds. I am not saying people with addiction issues cant be in EMS, but I am saying that people who have a self admitted problem and haven't completes rehab or other program shouldn't be until they resolve their issues.

And I am sure that any addiction/recovery specialist would probably advise against entering such a high stress /high risk for relapse course of study/career until they are well into recovery...at least a year, if not 5.

Addendum, I just saw this is for the First Responder License. Do you require clinical time for this? We dont locally.

If not, then it may not be as much of an issue as you may think, unless they come back for EMT or another course where clinical are required. All in all I still stand by my earlier post.