Diabetic student - What would you do??

[photomom]

I had a situation yesterday that I'm personally frustrated about. I had a student who brought her insulin pen to school, and her brand new meter, and left them with me. I thought everything she needed was in the case she brought, but I didn't check it right away. Later, I realized there were no needles for her insulin pen and figured I would ask her about it when she came to check her sugar before lunch.

The problem is that we're a new school and I *don't* have all the paperwork I need on this girl! I sent home paperwork to mom, and called her to make her aware I was sending home and how important it is to get back to me, but it didn't come back. My supervisor said that I can keep the pen in the office and she can check her sugar here, but that she has to self-administer since we have no authorization or order.

So she comes back to check her sugar and it's over 200! She has her insulin pen and I ask what her regular dose is since her sugar is so high - 13 units! It's apparent to me that her diabetes is not well-controlled. Unfortunately, she also states that she forgot her needles at home. Now, what do I do?? She obviously needs insulin but is not likely in immediate danger. I try to contact mom to no avail - she's working and the kid doesn't know a work # or even where she works, but cell (only phone) is turned off. Other #s I have for anyone are no longer working (I work inner city, so no surprise). She is completely asymptomatic. I did receive an order sheet from her diabetes clinic for insulin in school, but it did not have a specific dose/time on it. It did, however, have a signature with parent's authorization for school nurse to contact the clinic, so I did. They stated that she's been without a meter until they just gave her one the other day and that based on her A1C, she probably runs 300's, which didn't surprise me.

The girl, meanwhile, is upset because she doesn't understand what the big deal is - after all, she's gone without her shot before and been fine. Attempted to educate her, and she rolled her eyes and turned away.

I ended up calling 911 for an ambulance to come get her so she could be treated since even if I had regular insulin needles, I had no order for how much to administer. I just feel so silly for doing so, and such a waste of resources, when she had no symptoms and seems to run high in general (although I had no official documentation of such and it was an educator I spoke with at the clinic). My supervisor and the principal agreed we had no other option in this case but it frustrates me!!! I guess I did the *right* thing, but surely there's an alternative, right?? Could I have asked to speak with her physician and taken an order over the phone to administer the insulin (if we had a needle)? Does EMS carry insulin syringes? At least then we could have avoided leaving school and avoided an unnecessary ER visit... Would love your thoughts on the matter. Thanks!

[Flare, ASN, BSN]

I probably would have called home right away when i noticed there were no orders or needles to have a parent bring me the right order and supplies right away. With a blood sugar of 200 i wouldn't have bothered with ems - in my state they can't administer the insulin anyhow - though i suppose paramedics could. If i did have insulin needles, however, I would have called the doctor's office right then and there to get a telephone order and request that an order be sent over via fax or email immediately. No needles? Would have still called the MD for the order then would have called parent and requested that he/she come in to medicate their child and bring me a supply.

This student and her family sounds like they have the potential to be problematic - i suggest playing hardball in the beginning with them to set the tone that they need to be responsible for their child's disease so that you can do your job!

[schooldistrictnurse]

Be aware of your state laws regarding phone orders, any orders in my state must be written, which might be why Flare added the fax comment. Otherwise, yes, you were in a really bad place with no direction. Did you have the ability to test for ketones? I might have had her sit tight in the office under your supervision until a parent could be reached and encouraged water if the ketones were small or moderate. My district policy is that kids automatically go home with moderate or large ketones. Good luck! And keep us informed on your saga!

[Jolie, BSN]

Under the circumstances, I believe you did what you could.

Buckle up for a rocky year.....

Is there any way you could schedule a joint meeting with the student, parents and representative from the physician's office? I have a sick feeling that may be your only hope of receiving all the necessary information, authorizations and supplies. Otherwise you will be chasing this family all year.

[photomom]

Unfortunately, there was only one number for mom (a cell) and it was turned off because she was at work and the child didn't know where her mom worked (it was fast food, but she didn't know which location and there were plenty to choose from). I did call the clinic she sees and they faxed a new order, but unfortunately the fax machine in our school was still out of order (nothing apparently works there, it's insane) so I had it faxed to my supervisor's office, but she wasn't physically there because she was elsewhere in the district and then was coming to my school and her office wasn't close. But even having the order does nothing for us if we don't have needles to administer the right amount of insulin.

No, I was not able to test ketones. The student stated she does test ketones at home (not sure if that's even true, she's very noncompliant) but didn't bring her supplies. I am amazed at this whole situation, especially since when I found out about her on the 3rd day of school (still missing records on most kids!) I was told that she controls it well herself and that last year, at her regular school, they didn't have a school nurse (district was trying to get rid of having nurses) so she kept it on her and just did everything herself! Well it's no wonder she's so poorly controlled!

I sent her to the ER about 2:30pm and heard that parents could not be reached until 7pm! I am just amazed. And like I said, maybe it's a culture/whatever thing because it's inner city, but it seems like nobody cares at all about the health of the kids! The office doesn't even have backup contact persons in case parents cannot be reached, so it's no wonder they're so hard to reach. I had called mom the day before when I found out about this girl and let her know what I needed and that it needed to happen or she can't get insulin at school. She was very agreeable and said she would be sure to fill it out and send it back the next day. The student didn't show up to school at all on Friday (day after ER incident), so I guess we'll find out next week what's going on. But at least we now have the order they faxed to my supervisor!

As far as sending kids home per policy, what do you do when you can't REACH the parent to send them home?! Just keep them in the office all day??

[Jolie, BSN]

Add your principal to the list of people who need to be involved with this student.

I was fortunate to have the full faith and backing of the building principals. If a parent or other emergency contact could not be reached for a student with an urgent health need, I kept the child in my office for observation and notified the principal.

While not always able to make immediate contact with parents, either, they definitely had access to more resources than I did. And once found, they made it very clear to parents that their students would not be allowed back in the building until we had the necessary information, authorization and supplies to properly attend to their children.

[photomom]

I like the idea of telling parents (backed by the principal) that they must have the authorization in place to come to school, but what if the parents just don't care that much about whether they're in school or not? It's an alternative HS - last chance at staying in school for students with behavioral issues. Many have attendance problems as it is - after all, only about 1/3 of the total enrolled actually showed up each day, and they weren't always the same students every day. In your experience, would this type of threat help encourage the paperwork to be returned? Or would it simply be another excuse that the student doesn't need to come to school??

And the principal nor the office had any other contact info and were also busy dealing with their own issues (constant behavior problems all day), so they didn't have much time to help me out, either.

Thanks for all the advice - it's nice to see how things work at other schools as well!

[Nurse ABC]

I would've done with Flare said. I always check diabetic supplies/orders immediately upon arrival at the beginning of the year to make sure we have what we need. I would've started working on the problem as soon as I realized there were no needles or orders. Since you couldn't reach the parents at all, I would've then made sure she didn't eat carbs at lunch (even if I had to have her eat in front of me), drink lot of water and walk around so her sugar would start coming down. BS's in the 200's are high but not emergent. I probably would not have called the EMS unless her sugar was at least over 350. I would then send a note home with the child if they rode the bus and called and left a message on the cell phone or went out and talked to whoever picked her up to tell them she could not return until we had all the proper supplies and orders. I've called and had orders faxed many times but if your fax machine isn't working then you will have to rely on the parent. If the parents don't care whether their child is in school or not then it becomes a social worker/truant officer problem. I would not risk the health of the child and school liability by not having what we needed on hand to effectively treat her when she's at school so although I would hope it wouldn't deter them from getting her to school it wouldn't stop me from having what I needed to effectively do my job. You didn't do the wrong thing at all. It didn't hurt to call for the EMS to pick her up to treat her and maybe that will get through to the parents how seriously you take her diabetes. Sounds like a difficult school but I would put my foot down from the beginning and demand proper supplies, orders, and a few phone numbers where someone can be reached. Good luck!!!