I think I just ended someone's career

[Asystole RN]

Long story short, I had to report a registery LPN who was seen crushing, cutting, snorting, and then rubbing the residual powder on her gums by nearly an entire med floor. Most of her narc cards are missing several pills each. She was so intoxicated she could not stand at the cart and nearly fell over several times. She was escorted out and made the statement that she was already being investigated and was about to finish RN school. While waiting for the bosses to arrive some of the staff made it a game to shoot staples at her face and throw cups and tape at her, she was so impaired she didn't notice and just continued to look around the room we had her sit in. Her eyes were half closed and she would constantly fall asleep, while talking in a very slow and slurred speach! She couldn't even dial her phone to call her husband, someone had to dial for her...made we want to cry. I have never seen someone so completely intoxicated.

I feel bad that this nurse's promising career was cut short, I feel worse about her patients.

Sad day for nursing.

[GHGoonette, BSN, RN]

But would there be as much forgiveness for the drunk driver as for the nurse? We are quick to ostracize an impaired driver no matter the circumstances involved. You never hear people say "oh poor guy, he clearly needs help, we shouldn't blame him, remember he has a disease" as has been shown to the nurse in the original scenario.

Meanwhile he risks all who happen to cross his path, as did the nurse. But why the double standard?

foraneman has made some excellent points regarding the nature of addiction. Let's take the worst case scenario; we'll assume that the alcoholic driver is involved in an accident that costs innocent lives, is arrested and thrown into jail. At the trial it emerges that this person is addicted to alcohol. Which would be the right decision for the judge to make under the circumstances? Further jail, or revoking the accused's driver's license and ordering that this person be placed in an appropriate facility for treatment?

Same case scenario for the nurse. While under the influence of whichever poison she's taking, she makes a mistake with drug dosages and a patient dies. She may be guilty of culpable homicide, but to what extent is she responsible for it?

I think in both cases there will be a public outcry and condemnation of their acts, but amongst those who know what addiction is and what kind of stranglehold it places on its victims, there should at least be some measure of understanding and pity.

[diane227, LPN, RN]

It is not your job to worry about her career. There are options out there for nurses who are impaired. You have the responsibility to the patient to assure safe care.

Now, I also hope that these insensitive co-workers were taken to task as well. Their behavior was totally inappropriate and they should be disciplined for what they did.

One question I have however is why was she not removed from the floor and taken to the supervisors office or some other private area? Why was she allowed to remain in a public area? When I have had to deal with matters such as these, the staff member in question was immediately removed from the work environment and placed with the supervisor or at least in a private area until I could arrive at the hospital. Sure, what she did was not good in any respect. But she is a person and she deserves the same consideration and respect that we would want to receive if we were in a similar situation.

[Scrubby]

It is not your job to worry about her career. There are options out there for nurses who are impaired. You have the responsibility to the patient to assure safe care.

Now, I also hope that these insensitive co-workers were taken to task as well. Their behavior was totally inappropriate and they should be disciplined for what they did.

One question I have however is why was she not removed from the floor and taken to the supervisors office or some other private area? Why was she allowed to remain in a public area? When I have had to deal with matters such as these, the staff member in question was immediately removed from the work environment and placed with the supervisor or at least in a private area until I could arrive at the hospital. Sure, what she did was not good in any respect. But she is a person and she deserves the same consideration and respect that we would want to receive if we were in a similar situation.

Imagine if a patient or a relative happened to walk past and seen this happening. It wouldn't really inspire much confidence in the health care system.

[diane227, LPN, RN]

It appears that this facility had a very poor system for dealing with such matters. Very unprofessional. You CAN take action. Calling the police is the very last thing that you want to do unless you are sure that she is walking to her car and going to attempt to drive. Although you may not believe this, you have a DUTY to also assure her safety when you know she is impaired. Calling her husband is certainly one option. But you have to assure that HE is also capable of assuring her safety (that he is not also too impaired to drive). Secondly, I believe that you also have a duty to assess her. Even though she did not want to go to the ED, I would have taken her vitals and documented them along with a mental status exam. I guarantee you that if she leaves that facility and she dies you will be held liable for that event and I can tell you that a jury will not be sympathetic.

When an employee has a substance abuse issue, it is best to deal with that issue head on and in a direct manner, first assuring patient safety and then the safety of the employee involved. For some reason we can deal with patients who have this issue but we cannot deal with our own co-workers. It makes us uncomfortable and we often feel anger toward them for what they have done. It is fine to feel that way but you have to keep your feelings in check. If she is impaired, her husband could provide consent for her ED treatment. We are not talking psychiatric care here. We are talking about assuring that she has not taken so much medication that she will die. I would have insisted that she be seen in the ED and I would have had her husband and her if possible sign a refusal of care before I allowed her to leave. She sounds like she was very impaired and I personally would not have felt comfortable allowing her to leave the facility without medical clearance.

[foraneman]

foraneman has made some excellent points regarding the nature of addiction. Let's take the worst case scenario; we'll assume that the alcoholic driver is involved in an accident that costs innocent lives, is arrested and thrown into jail. At the trial it emerges that this person is addicted to alcohol. Which would be the right decision for the judge to make under the circumstances? Further jail, or revoking the accused's driver's license and ordering that this person be placed in an appropriate facility for treatment?

Same case scenario for the nurse. While under the influence of whichever poison she's taking, she makes a mistake with drug dosages and a patient dies. She may be guilty of culpable homicide, but to what extent is she responsible for it?

I think in both cases there will be a public outcry and condemnation of their acts, but amongst those who know what addiction is and what kind of stranglehold it places on its victims, there should at least be some measure of understanding and pity.

Excellent questions. Intoxication is never a defense to a crime (except for involuntary intoxication where someone slips you a mickey for example). In both the drunk driving and impaired practice scenarios you suggest where someone has died, the individual is usually charged with homicide. Vehicular manslaughter in the first case and usually manslaughter in the second. While such outcomes are VERY rare, there ARE nurses who are in jail for manslaughter for just such occurrences. Intoxication CAN be a mitigating factor. Since a nurse who is impaired and makes a fatal mistake did not form the INTENT to kill a patient they cannot be charged with murder. But they are ALWAYS responsible.

However, the current scenario is much different. Drug diversion is a felony. Reporting the diversion is not mandatory beleive it or not. No law ever compels anyone to report a crime. We are not the police. No DEA regulation mandates such reporting. So, if a facility chooses to engage law enforcement, they should be very clear exactly what the ramifications are, and the reasons they are choosing this course. Arguments that they are 'protecting' the facility or 'covering their ass' are without basis. Such reporting does neither. Absolutely NO evidence exists that jail is a beneficial 'therapy' which will 'snap' someone out of their addiction. Look through the headlines which are full of people of privilege in and out of jail yet still on drugs. Nor is it a deterrent.

Model Drug Free Workplace programs NEVER emphasize a punitive approach but are specifically designed to facilitate, at least for the first occurrence, appropriate medical care and treatment. The guidelines are created by the U.S. department of labor and have been adopted by the states....not created by bleeding heart do-gooder addiction treatment advocates in case you are wondering.

[unbecominganurse]

Drug diversion results in the surrender of THOUSANDS of nurses licenses each year in the U.S. If you are a nurse who may want coverage for vacation and holidays, every nurses' career is at least of some concern, if only from a self-serving standpoint.

NURSYS database statistics between 1996 and 2006 noted 16,010 violations specifically coded as drug diversion by a nurse for their own use. There is strong evidence to support that this is an extremely low estimate of the actual rate of occurence as only 44 of 60 jurisdictions were included in this statistic and some nurses are not identified in the workplace.

However, in my professional experience, the significant level of impairment noted in this nurse on her last day of work did not just happen overnight, without many telltale signs along the way; signs that were either ignored or covered up for by colleagues prior to this point. Such actions further implicate the unethical and unprofessional conduct by colleagues who did not protect patients or the nurse, who by the way, could have been added to the long list of nurses who die each year due to substance use disorders. Paula Davies Scimeca, RN, MS

[subtleinnuendo]

Imagine what kind of hell it must be to live for addiction, whether it's for drugs or alcohol. It's very sad. I would have wanted to hug that woman and walked her to the rehab, not treat her like an animal in a cage. Shame on those allegedly compassionate co-workers.

Still, you did not end her career, she did, or rather, her disease did. Maybe she can get some help.

[OttawaRPN]

foraneman has made some excellent points regarding the nature of addiction. Let's take the worst case scenario; we'll assume that the alcoholic driver is involved in an accident that costs innocent lives, is arrested and thrown into jail. At the trial it emerges that this person is addicted to alcohol. Which would be the right decision for the judge to make under the circumstances? Further jail, or revoking the accused's driver's license and ordering that this person be placed in an appropriate facility for treatment?

Same case scenario for the nurse. While under the influence of whichever poison she's taking, she makes a mistake with drug dosages and a patient dies. She may be guilty of culpable homicide, but to what extent is she responsible for it?

I think in both cases there will be a public outcry and condemnation of their acts, but amongst those who know what addiction is and what kind of stranglehold it places on its victims, there should at least be some measure of understanding and pity.

I do see your point and understand the whole premise behind culpability and responsibility, but I suppose the point I was trying to make is that much compassion has been shown to this nurse in her near-miss situation that I doubt would have been shown to another addict in a similar situation but different context ie) drunk driver.

Her situation was fortunately only a near-miss, it could have panned out much worse. By the same analogy the drunk driver's near miss could have been being pulled over before he had the opportunity to run someone over. When we read in the news "drunk driver clocked going 120/km in 60/km zone" nobody is going to feel sympathy for the guy, give him a hug and pat on the shoulder, instead likely public outrage that he dare do such a thing and knowingly get behind the wheel drunk endangering innocent lives, yadda yadda; however this lynch mob mentality is the polar opposite of what has been shown to the addict nurse. That, in a nutshell, was really the point I was trying to make.

[Neveranurseagain, RN]

Kudos to you, Asystole, for this blog. You opened up a topic that is not talked about out in the open like it should be. Impaired nurses and doctors have been around as long as the medical profession has, yet addiction/diversion is not openly discussed. And many of us have not worked around a nurse that was impaired. At least everyone on this blog is more aware of addictions, and learned how "the pack" mentality can turn on a co-worker.

I for for one, now know to be a little more alert as to addiction in health care professional, and have mentally worked out a plan on what should be done and what shouldn't be done if a situation like this occurs at work.

Thank you for posting this blog.

[unbecominganurse]

While you are right that the drunk driver is met with much public outcry, all the compassion shown this nurse will not outweigh the shame and stigma, loss of income, or probable loss of health benefits to get the treatment needed. Nor will any amount of support prevent the imminent surrender of professional license to practice nursing for an indefinite, if not permanent, period of time.

What we do need to wrap our arms around as a profession is the fact that we have not done due diligence regarding nurse safety and wellness. We call ourselves professionals; yet we do not even reach a par with the electrical trades and law enforcement officers who receive extensive and ongoing safety training on safest handling of their potentially lethal tools of the trade: electrical current and handguns.

Add to this the fact that we use the term "waste" in reference to medication that is non-administered, spilled, expired, etc., perpetuating a mindset far from the truth: that those doses are "up for grabs." Some nurses are tempted by this notion, especially those with genetic predisposition to addiction or history of prior use of a mood-altering substance for legitimate medical reasons or recreationally. Given that one in five high school students admit use of prescription medication to get high prior to graduation, the boundary of the medicine cabinet has already been breached by a growing number prior to nursing school.

Until we embrace, wholeheartedly, that we have a significant issue that will afflict thousands of our peers in the coming years, if not ourselves, and commit resources of time, energy and money to initiatives that promote nurse safety and wellness, we will remain, at least in my humble opinion, much less deserving of the title "professional" than the electrical trades and law enforcement. Paula Davies Scimeca, RN, MS

[foraneman]

I do see your point and understand the whole premise behind culpability and responsibility, but I suppose the point I was trying to make is that much compassion has been shown to this nurse in her near-miss situation that I doubt would have been shown to another addict in a similar situation but different context ie) drunk driver.

Her situation was fortunately only a near-miss, it could have panned out much worse. By the same analogy the drunk driver's near miss could have been being pulled over before he had the opportunity to run someone over. When we read in the news "drunk driver clocked going 120/km in 60/km zone" nobody is going to feel sympathy for the guy, give him a hug and pat on the shoulder, instead likely public outrage that he dare do such a thing and knowingly get behind the wheel drunk endangering innocent lives, yadda yadda; however this lynch mob mentality is the polar opposite of what has been shown to the addict nurse. That, in a nutshell, was really the point I was trying to make.

Actually it was pretty much the exact mentality which was shown to this nurse. But I do understand what you are trying to say....though when it comes down to it, what point is there to be made here? Some will say it is that we should throw nurses in jail....while others will say it is that we need to focus on medical treatment of addicition, since it is an epidemic. The number of incarcerated drug offenders has increased twelvefold since 1980. 1 in 18 males in the US are in jail, or monitored on probation, parole, etc. The United States has less than 5% of the world's population and 23.4% of the world's prison population. Jail is not just a bad answer...it is a wrong and failed answer.

[sarasidnic]

I'm glad to hear you did feel bad doing what you know you had to do and that you made sure she did not get behind the wheel of a car. I'm not happy that it made you cry to see that but i'm happy that your the type of person who feels the whole situation and did not shoot things at her or laugh because it is not a happy sight or something to ever be laughed at. You sound like a very caring person who did the right thing but didn't enjoy doing it. I'm not trying to sound corny but, thank you for being the way you are!!

CAT