How to make some difficult decisions

Here is a rather tragic story about a school nurse who would not let a student having an asthma arrack use his inhaler because he did not have an updated medical release form in his file. The school called the mother to come but by the time she did the student had collapsed on the floor.

Clearly the school district and the nurse thought that it was better to abide by the letter of the law and rules and regulations than respond to an immediate medical need.

It is often the case that people are faced with difficult choices. In many such situations that I personally have been in, rather than ask which decision will likely give better results, I find it helpful to pose to myself the following question: Which decision, if it turns out to be the wrong one, will I likely regret more?

In this case, if the inhaler and the need were genuine but I mistakenly did not allow the inhaler and the student suffered a major attack or even died, that would be really bad. If I allowed the inhaler and it turned out that the student was using the inhaler to get another dose of illegal drugs (which is likely the fear that the school district has in these ‘zero tolerance’ days) that would not be good but not disastrous. So I would have allowed it.

I have found that decision rule to be extremely useful in some situations.


  1. jamessweet says

    I was appalled at the comments from school officials that “it was the parents’ fault” because they hadn’t sent in the proper form on time. Yes, having your son suffer a serious and life-threatening medical event seems like a perfectly proportionate punishment for being behind on fucking paperwork.

    I understand that the district feels they need to defend the nurse’s decision, since he/she was after all perfectly in compliance with the rules. But attempting to shovel blame onto the parents is unconscionable. The best possible spin you can put on this is that it was a highly unfortunate situation where no individual did anything wrong, but that bureaucratic complications led to a regrettable outcome. (And I personally agree with you, that the nurse should have gone ahead and let him have the inhaler.)

  2. Matt Penfold says

    The student was 17, well old enough be responsible for carrying the inhaler himself and deciding when he needs to use it.

  3. Matt Penfold says

    I would also question the school’s understanding of the law. It surely cannot be an offence in Florida to provide medical treatment to a minor in an emergency without parental consent.

  4. Scott says

    Not allowing someone needed medicine in an emergency because a form wasn’t filled out seems like an egregious ethical lapse on the part of the nurse.

  5. ischemgeek says

    Speaking as someone who had to put up with similar treatment of my asthma as a kid, this is a farcical arrangement.

    1) Life saving medications should never be left in the office. Why? Because, if they’re in the office, there’s a delay in getting to the medication that could be life-or-death in the case of a number of medical conditions.

    2) What nurse worth their credentials would sit back and watch as a kid collapses from hypoxia? I’ve had asthma attacks that bad. It’s terrifying. If you have never experienced the immediate, overwhelming terror of slow suffocation, I can’t describe it for you, but this video might be of some help (warning: the video is graphic and disturbing). It’s pure, instinctual panic. That someone could watch another person go through that and not do a damn thing leaves me cold. That she did it to a kid under her care only makes it worse. Okay, fine, you want to be obtuse about the regulation? Nothing says you can’t call a fucking ambulance for the kid!

    3) From what I know of American law (though I’m no lawyer), there’s nothing in the law that states that schools have to restrict access to medication that has been prescribed for the person in question and that belongs to the person in question. In fact, every law out there has been trying to increase the rights these kids have to get their medication because the schools themselves refuse to do so and without legislative pressure, will refuse any access to medication unless the parent jumps through a zillion hoops. Why? I have no idea.

    It is sheer luck this kid did not die or suffer permanent brain or lung damage from this incident.

    Sadly, this sort of neglect by school officials in my experience as a kid with severe asthma is not at all unusual. I could tell stories all day of the poor handling of my condition by school officials, but it’d be off topic. Suffice to say that several times, my fingernails and lips were blue before they even let me use my inhaler. This sort of neglect in life-threatening situations by school officials is not unique in the US, not unique to the US, and often has tragic consequences.

  6. dianne says

    Why didn’t they just call 911 and have the problem and its legal consequences be taken off their hands altogether? It sounds like the principle promoted a culture of rule following above all else, the dangers of which can be clearly seen in this story.

  7. Kevin says

    Does anyone else see a problem with a policy that forces someone to become separated from a device that is meant to be carried at all times and can result in death when not applied in a timely manner?

    I don’t even see how allowing it would somehow aid someone in drug trafficking or something of that nature. If they use it to conceal drugs, they could easily use another container. If they use it to ingest drugs, they would be busted immediately by the effects and its not like a supervisor would have stopped them ingesting a pill had it not been taken via an inhaler. Apparently being hard on medically necessary drugs that don’t have any negative side effects is necessary to maintain a tough persona in the war on drugs? I don’t see any semblance of reason behind the policy.

  8. mnb0 says

    I completely agree with MS’ decision rule. It’s consistent with the old Roman principle that someone is innocent until proven guilty.
    What kind of country do you live in when you have to call 911 to avoid such a responsibility?
    As the school called the mother another question arises. Apparently the school knew the student needed the inhaler, at least after the call and possibly before. Still the school thought following the rule strictly more important?!
    Sounds like the Wehrmacht defeated the US Army after all in 1945. Yes, that’s a Godwin. It’s the same despicable Befehl ist Befehl attitude that was condemned during the Nürnberg Trials.

  9. Frank says

    From the Code of Ethics for Nurses, on the website of the American Nurses Association:

    “Provision 2. The nurse’s primary commitment is to the patient…”

    Was it not the ethical duty of the nurse, as a medical Professional, to allow the use of the inhaler, school policy notwithstanding? Given the current budgetary pressure on public schools, it’s possible that school nurses could be scared of losing their jobs for any rule infraction, no matter how minor. But even if this were the case here, Mano’s criterion for making tough decisions seems apt.

  10. sailor1031 says

    I’m sorry but, as the school nurse isn’t he/she there to handle health emergencies if they arrive? There isn’t paperwork filed in advance to cover every possibility is there? Am I not getting something here? And WTF ever happened to common sense and good judgment?

  11. James says

    It is so easy to make Monday morning quarterback calls on what this nurse should or should not have done. It is in fact largely the fault of the parents for not insuring that the proper paperwork was in place so that their son’s medical condition could be managed efficiently. If you are even partially involved in your child’s education you understand this set of rules. My girls are in elementary school and medication criteria was given to us on parent night before the school year started, e-mailed to us prior to school starting and sent home with both my daughters the first day of school.

    Had the nurse allowed administration of the medication without following school policy (State law?) she could face loss of her license and therefor the loss of her ability to provide for her own family. The ironic thing is, if the nurse had allowed administration of the medication the boy would have likely been fine and the Monday morning quarterbacks would not be defending her saying “that nurse saved his life by breaching policy”. In fact, she likely would be facing a sanction by her employer and possible reporting to her state board of nursing. Since the boy would likely have been fine, those looking back would have been able to say that it wasn’t necessary and that he could have waited. Also, in terms of delivering “emergency care” – often for that to be allowed the individual affected has to be in arrest, not just distress. Once arrest occurs the nurse would be able to deliver CPR.

  12. Brea Plum says

    Excuse me, but how in the unholy fuck is this a “difficult” decision? Asthma attack = inhaler.

    This is not in any way a difficult decision, indeed, there is no decision required. Not by the average joe on the street and sure as hell not be a trained health provider.

    The school and the nurse shouldn’t be sued, they should be prosecuted for neglect and endangerment of a child.

  13. jamessweet says

    . It is in fact largely the fault of the parents for not insuring that the proper paperwork was in place so that their son’s medical condition could be managed efficiently.

    As I said before: Insinuating that having your son suffer a serious medical condition is a proportionate punishment for being behind on some stupid fucking paperwork is just sick. It literally disgusts me (yes, literally; I feel a twinge of nausea right now) that some people have such a hard-on for paperwork that they would even imply this. As someone who is a totally reasonable person, but who has a tendency to space out on things like filing paperwork in a timely fashion, I find it personally threatening to suggest such a thing.

    So you know, screw you.

  14. jamessweet says

    As to the rest of your post, I have no comment either way. I understand that the nurse was in a difficult position, even though I maintain that the right thing to do would have been to provide the inhaler. But I also don’t entirely condemn the nurse.

    However, trying to act like the parents deserved this because they weren’t johnny-on-the-spot with the paperwork… that’s just fucked up and, as I say, I find it personally threatening.

  15. Brea Plum says

    I simply can not wrap my brain around any of you people defending the nurse.

    A NURSE who withheld life-saving medication during a medical emergency. The reason why is irrelevant – she withheld life-saving medication during a medical emergency.

    What the hell is wrong with you people? The nurse should (and, if she were employed in a healthcare facility, most definitely would) be hauled in front of the licensing board for a hearing and possibly suspension or revocation. This is what the law calls “malpractice”.

  16. Stacy says

    Had the nurse allowed administration of the medication without following school policy (State law?) she could face loss of her license

    Bullshit. Unless you can cite a nurse’s licensing board that privileges administrative rules over using standard treatment during a medical emergency, the most she could possibly have faced was loss of her job with that particular school district.

    Job vs. kid’s health and possibly his life: hmmm…decisions, decisions.

  17. Stacy says

    Once arrest occurs the nurse would be able to deliver CPR

    CPR is next to useless during an asthma attack.

  18. James says

    @jamesweet… sorry if I nauseate you. I don’t feel nausea, only discouragement that so many are so quick to judge that the nurse is at fault here. The interesting thing about healthcare is that the nurse doesn’t get to tell her side of the story unless she is willing to breach HIPAA and risk all the sanctions that come with that action. She essentially has a gag order until her day in court, if that day ever comes. Hospital’s and healthcare worker’s endure this all the time. A patient has a complaint and runs to a reporter about the lousy care they received… how they were ignored, not cared for properly, etc… and because of HIPAA and guidance their councel the hospital and its professionals are forced to remain silent and seek justice in the legal system. All the while their reputations are smeared by the media and people who know nothing more of the situation than what they read in some article that is sparse on facts and full of opinion. The truth is we don’t know whether or not she conducted the appropriate and timely assessment on the boy and just how bad his condition really was. Just because a person “collapses” does not mean that they are in respiratory failure. I worked 5 years in an emergency department that serviced over 80,000 patients a year. I cannot tell you how many times I witnessed people putting on a show “collapsing in agony” or feigning chest pains only to be worked up and found to be having anything but an acute life threatening situation. What we don’t know is the history of this child’s behavior and the history of the interactions the school has had with the parents. Unfortunately we may never hear the nurse’s side to this. I am glad that a few of you at least have it figured out.

    “However, trying to act like the parents deserved this because they weren’t johnny-on-the-spot with the paperwork…” Please clarify where in my comment that I wrote that the “parents deserved this…” I don’t think that anybody deserves to have a sick child. Fault or accountability doesn’t necessarily correlate with one’s deserving of an outcome and I made no attempt make that link here. I do believe that had the parents followed the school’s protocols and had the proper documentation turned in that this would not have been an issue. Do you see it as otherwise? So I do assign a large portion of fault for this event occuring to the parents because “but for” their lack of following procedures this event would not have escalated to this level.

    I also find it interesting that the nurse was locked in the office. Again, the nurse is the one who is restricted as to what she can say. Did she feel threatened? I know many great nurses. I don’t know any that would lock themselves away from their patient unless they felt that they were at risk of being harmed. To me this indicates a big portion of the story is untold.

    Forgive me, I thought we were skeptics here.

  19. James says

    Lol, I am sure you are right Stacy…

    Doesn’t it make you wonder though that a nurse, a superintendent, and all the other office staff in the area watched this distressed young man struggle for air, suffer and nearly die without calling 911. Clearly these people are evil and just to be sadistic they are willing to risk their jobs and the possibility of his life as you mentioned…

    …Or, just a thought, I am going to go out on a limb here… maybe he wasn’t in distress? Maybe he was a troubled kid, or someone who frequently cried wolf, and the nurse determined, using good sound clinical judgement, that delivering this medication wasn’t a matter of life and death and since it wasn’t a matter of life and death in her professional opinion administration of the medication outside of the protocols would put her in violation of Florida’s guidelines for delivery of school health services.

    No, that is silly. Let us just assume that the nurse, the superintendent and all the other office staff are evil or morons or evil morons.

  20. MomRN says

    I read this story and I wanted to puke. What a bunch of garbage. Do you expect me to believe that a nurse and the superintendent and any other teachers that witnessed this kid just ignored him as he turned blue?! There is more to this than meets the eye. Odd that the kids inhaler was found during a backpack search and soon after he has a severe asthmatic attack. Odd that once it was found it was confiscated… I mean with the kid’s lips and nails blue and all that…

    I’m lucky that I work in a hospital. My husbands sister works part time as a school nurse. Not because she wants part time hours (she is a widow mom with 2 early teenage kids), but because that is all the school district can afford. She says that 1 or 2% of the parents never follow through with paperwork for medications but these same parents are the ones that threaten to call a lawyer the moment something happens.

    This nurse was screwed either way that day. If she gave the medication without the parents permission the parents would have bitched to the school district and maybe reported her to the nursing board. If she used her assessment skills and evaluated the kids ABCs (airway, breathing, circulation) and made the call that the kid was okay – well we see what happens in that scenario.

  21. Brea Plum says

    Of for chrissake, if they had given the inhaler without the paper work the LAST thing the parents would have done was sue. Leaving the kid gasping for breath, after not allowing the kid to keep the inhaler on him at all times as prescribed, GUARANTEES a nasty lawsuit that is well-deserved. The same for diabetic kids who need immediate insulin in case of emergency, and allergic kids with their epipens.

    What’s making me sick is the great length you people are going to absolve the nurse of blame for failing to act as a nurse, and to absolve the district for any blame for failing to act like they had two brain cells to rub together.

  22. Lisa Nason says

    As a person who has received training in CPR/AED, it surprised me that no one even bothered to address the “Good Samaritan Law.” One of the first things discussed during my training was that there is a law called the “Good Samaritan Law,” which protects an individual undertaking life-saving measures from being sued. Laws such as these were put into place to eliminate the fear of getting sued while trying to help someone in need.

    When I first read of this story, I was horrified by how this whole situation was handled-and then even more so by the comments submitted by some readers regarding how this should have been handled, and even worse, placing blame NOT on the idiot nurse who should have had her license revoked, but on the parents instead. Regardless of whether the paperwork was delayed, not submitted, unsigned, etc., it doesn’t erase the fact that this student has a history of severe asthmatic attacks. To blatantly withhold any potentially life-saving medications from someone in the throws of a severe asthmatic attack while suffocating himself into unconsciousness is absolutely unconscionable.

    The sad thing is that this kind of warped mentality-where people can actually witness something terribly wrong happen and then choose to take absolutely no action-seems to prevail in today’s society. If this is happening today, what is society going to be like years from now?

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