Diversion

RocketMedic

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Recently, I was very disappointed to see a familiar name on the Texas DSHS enforcement site:

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This person was, in many ways, a kindred spirit in that we both shared progressive ideals of EMS care, were passionate about the field and helping people, and worked in similar environments. I do truly believe that he is a good, compassionate provider at heart, and that he started into and worked in this field with the most noble of goals in mind, but somewhere, the disease of addiction seems to have claimed him and cost him his profession and his reputation. This is a tragedy. From Facebook groups to EMTLife, I always respected his opinion and ideas, even if we disagreed. I will not identify this member's username, but as the DSHS site is public domain, I think that it is important that we see the real-world consequences of these decisions. Diversion is a career killer, and that's absolutely appropriate IMO. We need to be trusted, and tolerating diversion is an unacceptable solution. It eventually gets necessary drugs pulled off of trucks, and that's not a great solution for our patients.

As a management student though, this is a learning experience for me. First, the narcotics-accountability system cannot rely on trust or assumptions, it needs to be as foolproof as possible. Patients were harmed in this event, and that is unacceptable. Although any system can be penetrated, I think that a lot of complications can be avoided if a rigorous, appropriate system of securing narcotics, ensuring that they are given appropriately, and disposed of appropriately is implemented- no matter who is doing the administration. Second, I wonder what (if anything) could be done to catch these employees before they get to this point- and save both them and our agencies from diversion. I sense that more-secure and sensitive processes could have alleviated this. Third, and hardest, I reckon that we have a responsibility as professionals and leaders to recognize that diversion is a problem, and need to both guard against it and positively teach our new providers why it isn't acceptable. I know that if I could go back in time and tell this member what would happen to him, he would likely have not listened- but if there had been better options available, or if his addiction could have been treated, a talented paramedic could be rehabilitated. Should this even be an option?

This is also making me reflect upon how, as a future leader, I would identify diversion should it occur. It's pretty well known that I'm pretty aggressive and liberal with appropriate pain management as a paramedic, especially in comparison to the "sucks to be you LOL I don't medicate fakers" crowd that a certain Middle-of-America EMS service accumulated when I was there- but I am also now seeing the other side of that, especially from the perspective of a system beyond a realistic span of control. What's the difference between appropriate use of narcotics and excessive use, and at what point does it start to concern a leader? What steps can we take to balance appropriate pain management for patients and appropriate safeguards on narcotics use? What systems do we currently use, and what can we do better?

@NomadicMedic @TransportJockey @TXmed
 
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VentMonkey

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//sighs// ya’ know...this is a tough one. I may not have been on here as long as the rest of you, but I know who it is you’re referring to, @RocketMedic. He’s a bright guy, and gave me some good pearls in the PM. Truly shocking and disheartening to me.

To the thread topic—I don’t know that there is a whole lot that can be done from people inevitably falling through the cracks of their own demons. Just look above and below him and we can clearly see how common this infraction appears to be. It’s, sadly, by no means uncommon. It’s happened at my service before, and during my tenure.

I mean, sure you can have tighter restrictions, or have your service be potentially placed between a rock and a hard place with things of this nature. Offering more than just EAP programs even before an addictive pattern presents is certainly a start, as is a very well-known zero tolerance policy even in the pre-hire setting. This can easily be achieved internally then work its way out to potential external candidates via “word of mouth”.

Should it affect the populations we serve because an individual clearly cannot control what it is that has a hold of them? Absolutely not.

That’s all I got, Rocket.
 
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RocketMedic

RocketMedic

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My thoughts in brief:

A lot of places are still going with keys, paper and non-timestamped use. It's 2018 and hotel safes are better than we have on most trucks. At a minimum, timestamps and ID pins can help.

For waste: I think that every employee, at every level, should have the authority to demand to see a narcotic be wasted, to the point that it should be an expectation. This is something I have my partner do- even if they 'trust' me, I ensure I waste everything appropriately in front of them, to their satisfaction. It's not foolproof, but it's a start.

One of my favorite FB friends is a recovered addict who left the field, got clean, and came back. Never diverted, and is completely honest about his struggle and his work. He's an inspiration and I respect the heck out of him. I don't think that addiction is necessarily a career-ender, but diversion is if that makes any sense.
 

EpiEMS

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For waste: I think that every employee, at every level, should have the authority to demand to see a narcotic be wasted, to the point that it should be an expectation. This is something I have my partner do- even if they 'trust' me, I ensure I waste everything appropriately in front of them, to their satisfaction. It's not foolproof, but it's a start.

Dual verification coupled with electronic locks and a good audit trail is definitely the bare minimum.
 

Carlos Danger

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Wow. Very disheartening indeed. I hope he gets whatever help he needs.
 

DrParasite

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As a management student though, this is a learning experience for me. First, the narcotics-accountability system cannot rely on trust or assumptions, it needs to be as foolproof as possible. Patients were harmed in this event, and that is unacceptable. Although any system can be penetrated, I think that a lot of complications can be avoided if a rigorous, appropriate system of securing narcotics, ensuring that they are given appropriately, and disposed of appropriately is implemented- no matter who is doing the administration.
The most secure way to deal with narcs is to leave them locked in a safe where no one has access to them. This way no one can inappropriately get them. This is, of course, absurd; there needs to be some way to balance the need to secure narcs while allowing them to be available enough to be administered to patients. And you need to have trust. If you don't trust your staff, than they shouldn't be working for you.

Should there be oversight? absolutely, but you should account for all equipment you use. If you have an employee that is stealing 4x4s, is that a problem? any inappropriate use of company equipment should be an issue. But we also work in an environment when you don't have a boss looking over your shoulder at all times, so you need to trust that 99% of your employees are going do the right thing.
Second, I wonder what (if anything) could be done to catch these employees before they get to this point- and save both them and our agencies from diversion. I sense that more-secure and sensitive processes could have alleviated this.
So when you made the topic of this thread diversion, I thought you meant being diverted from the ER. Never heard of the word being used to explain diverting meds from the patient to the provider.

And I doubt you could. Assuming the EMT is driving, what's to stop the paramedic from giving half a dose to the patient, and then pocketing the rest and giving it to himself, while documenting that he gave him the full dose? Unless someone makes a complaint, or witnesses the inappropriate activities, it's tough. I mean, you can record the trip, but do you really want to be the guy who has to review 100 tapes, for the 1 where something wrong might be happening????
Third, and hardest, I reckon that we have a responsibility as professionals and leaders to recognize that diversion is a problem, and need to both guard against it and positively teach our new providers why it isn't acceptable. I know that if I could go back in time and tell this member what would happen to him, he would likely have not listened- but if there had been better options available, or if his addiction could have been treated, a talented paramedic could be rehabilitated. Should this even be an option?
If you need to TELL a new provider that taking drugs is not acceptable, especially drugs that you are telling your employer that you gave to the patient, than we have bigger issues. Seriously. That's like saying you need to tell people to not hop on the ambulance if you have been drinking. It's one of those things that should be obvious from day 1, and shouldn't need to be told to people

That all being said, addiction is a problem. While I don't know who this particular person is, I do know that many addicts are good at what they do, and will do less than legal things in order to sustain their habit. But it's not an issue isolated to EMS; doctors, nurses, pharmacists, and anyone who has easy access to them can be a risk. The biggest thing I can say is, if you see something, say something. too often we look back on incidents like this and people suspected, or there were many clear warning signs that were missed.

I hope he gets the help me needs.
 

chriscemt

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If you need to TELL a new provider that taking drugs is not acceptable, especially drugs that you are telling your employer that you gave to the patient, than we have bigger issues. Seriously. That's like saying you need to tell people to not hop on the ambulance if you have been drinking.

Your point stands, but it's often that moment when the addict is told they are not allowed to hop on your ambulance if they have been drinking for that addict to finally come to some sort of sense.

Maybe it's not often.

Also, isn't the term diversion a type of administrative penalty? I hear it used like this, "I got a speeding ticket but I went on diversion so it's okay." I'm not from KS (or TX) originally, so it's still an unfamiliar term to me...
 

MSDeltaFlt

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I see the day when all medications, especially controlled substances, will use a Pyxis type system like hospitals use but made smaller for the mobile environment of ambulances. When I started flying my educator had recently lost one of his colleagues/partners/friends from suicide due to the aforementioned drug abuse and stealing narcotics. He was adamant about making sure ALL NARCS' TOPS CAN SPIN. A couple of years later in another state another flight nurse made the same choice after showing the same behavior.
 

EpiEMS

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That's like saying you need to tell people to not hop on the ambulance if you have been drinking. It's one of those things that should be obvious from day 1, and shouldn't need to be told to people

Eh, from a "You didn't tell me I couldn't!" you kinda have to - it's a policy thing.

Assuming the EMT is driving, what's to stop the paramedic from giving half a dose to the patient, and then pocketing the rest and giving it to himself, while documenting that he gave him the full dose?

Fair point. Not sure what the solution would be for this...
 

VentMonkey

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Again, this remains an individuals problem only corrected by their own accountability. It happens in hospitals and out of them.

EMS managers, and nursing managers should not be made to felt obligated when it comes to cutting much off at the pass of a pattern that was more than likely something already intrinsically there, or even precipitated by an individual’s lifestyle choices.

Preventative strategies and olive branches are about all that we should be obligated to implement; the rest is solely on the person themselves to own what it is that may eventually, and unfortunately beget their demise.

This is the sad, harsh reality of things. I do believe at the upper-management level there’s certainly opportunities to effect change within a respective service or department, but we can’t 100% stop everyone’s decisions. Period, point blank.

And I think any, and all destructive addictions and habits are indeed career-enders; tragically, they can also be life-enders.
 

VFlutter

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Eh, from a "You didn't tell me I couldn't!" you kinda have to - it's a policy thing.

If it is not explicitly forbidden then it is good to go!

I have definitely changed my practices over the years. When I was a new nurse in the ICU it was totally common for someone to say "Hey can you waste with me, i'm giving 50mcg of this 100mcg Fentanyl" and just swipe your finger at the Pyxis and get back to your patient. No one watched each other waste medications and definitely never watched them give it to the patient. Never would have thought anyone was doing something wrong. Unfortunately had a co-worker that got caught diverting and it changes everything.

You can do a lot of things to help prevent diversion however in EMS/ER/ICU it will always be a challenge because the critical nature makes people more liberal and trusting. And unless you watch a provider draw up a med and push it you really can't stop someone from diverting from the patient.
 

TransportJockey

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This post actually makes me very sad. This guy is a great guy and I considered, and still do consider him a great friend who I wish reached out before it got to this point. We had someone here right after I started get busted using Etomidate in the bathroom at work (got busted cause he had seizure like activity and made a crap ton of noise) and it was a big wake up call to all of us here. Since then it's something we harp on that if you have a problem, you need to talk to someone about it before it gets to the point of ruining your career and life.
 
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RocketMedic

RocketMedic

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Indeed. Diversion gets a lot of good people in this field.
 

MonkeyArrow

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I don’t explicitly know who this is on this forum (although I think I can hazard a pretty good guess), but I wonder if the tone here is different because some of the regulars “knew”/knew him. I’m not necessarily implying anything, but if this same story about Joe Blow was posted on here, I think a lot of y’all would strike a much different, harsher tone. Seems like a lot of apologizing and reminiscing over a career that could’ve been, when the tone about similar topics not centered around familiar faces hasn’t been so kind. Just something to think about.

And on the regulatory side, I second a lot of what @VFlutter said. In the ED, you’re supposed to get a second nurse to waste narcotics with you and swipe it into the Pyxis. But overhwlemingly, you never see the medication being drawn up/administered, just the vial with some fluid left. Often times, it’s nothing but a formality as people just sign off saying they saw a waste when they may have never even seen the vial. Eventually, though, people will get caught; a few nurses have gotten caught where I used to work diverting or digging through sharps containers or shooting up in bathrooms.
 

Carlos Danger

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Diversion of narcotics for personal abuse is a really big issue in my field (anesthesia), so it's something I hear about and read about quite a bit.

Drug abuse, broadly speaking, is a very complex issue, and a huge problem to which there is no simple solution. Making it more onerous to access and waste narcotics is no more than a tiny part of the solution. Most diversions in healthcare are committed by individuals who have already developed a substance abuse problem elsewhere, and many of these addicts, when in recovery and able to talk candidly about their problem, will tell you that you could put in place whatever safeguards you want and they would have found a way around them. They need the drug, and as their addiction worsens they worry less and less about getting caught. So let's not waste a lot of time worrying about how if we just put fancier lockboxes in the ambulance or stricter policies about witnessing waste in the ED that we could fix the problem. Those actions would do very little.

The very best way to prevent problems with diversion in the healthcare setting is to intercept developing substance abuse problems before they reach the point of people putting their careers at risk by stealing drugs from work, and getting those people into treatment. Think about it: We are very limited in our ability to prevent people from engaging in risky substance-abuse behaviors off-duty. Once a full-blown addiction has begun, we are also very limited in our ability to keep addicts from finding ways to access the drugs that they need. But if we can make opportunities for treatment available to people who have developed a problem but haven't yet taken it to the level of stealing from work - and just as importantly, make people feel truly safe seeking that help, then we could probably prevent many of these sad stories.
 

StCEMT

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We can put rules in place, but there is always some degree of trust that will have to be put in us. I have multiple layers of signatures, wasting, and pharmacy steps I have to follow with narcs and it still isn't fail proof.
 
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RocketMedic

RocketMedic

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While this is a problem and I hope he gets the help he needs and deserves, I think outing him here is a d!ck move.

Sorry. Maybe you don’t feel that way, but he is a good guy who had a promising career destroyed.

Texas DSHS "outed" him. Its a shame, but those are the consequences.

The guy who came back from addiction I follow is who I'm thinking of. Someone who can be rehabilitated. So how do we do that?
 
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