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October 6, 2015

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At time of budget cuts, school nurses see more than skinned knees

More children are coming to class with medical needs that require monitoring, treatment


Steve Marcus

Clark County School District nurse Keri Mossel, center, feeds Chastity Ibarra, 12, as her mother looks on at Brinley Middle School. The girl must be fed through a tube in her stomach. School nurses handle more complicated ailments now than they did a generation ago.

In a big room with a kitchen at J. Harold Brinley Middle School, a girl in a wheelchair pushed by her mother waits to be fed through a plastic tube.

The feeding is tricky, but routine for Keri Mossel, 36, the school nurse. Mossel must insert the tube through a pea-sized hole in the abdomen of the wriggling girl, Chastity, 12.

Mossel then pours a milky white formula into her. It’s the only way Chastity can eat. Meningitis attacked Chastity’s brain and spinal cord when she was an infant, ravaging her body’s development. Swallowing would lodge food in her lungs. She cannot speak and she tires easily.

Chastity’s mother, Surrene Ibarra, 31, is glad to have a school nurse around. But there isn’t a nurse every day at Brinley, in Las Vegas, or the 350 or so schools spread over Clark County.

Paraprofessionals, with training in first aid and cardiopulmonary resuscitation, are at each school. But they aren’t nurses.

As Chastity’s case makes clear, the job of a school nurse is far more complicated than it was a generation ago. Food allergies, hyperactivity, autism, seizures, even heart attack and psychosis are some of the maladies increasingly affecting schoolchildren. They need nurses.

And although Clark County nurses contend they are adjusting their work practices to existing staffing — despite caseloads that are more than double recommended levels — they are spread thin. With more budget cuts looming, it might get thinner.

The sea change in school nursing can be seen in two large binders of student records that the nursing staff at Brinley keeps nearby. They are labeled “disability notebook” and “medication notebook.” Each is three inches thick.

“On a scale of difficulty, the nurse’s job was probably a 2” decades ago, said Diana Taylor, the district’s director of health services. She started as a nurse in the district in 1988. “Today, it can be a 10.”

For parents, how modern schools are staffed can be troubling. Ibarra, Chastity’s mother, worries that Brinley doesn’t have a full-time nurse. But she understands that Clark County is under enormous budget pressure.

Amy Garcia, executive director of the National Association of School Nurses in Silver Spring, Md., said, “Parents whose children have become quite ill at school, or, sadly, have been severely injured or died, sometimes don’t get it. They expect there to be a nurse at school because when they were children there was a nurse at school.”

In Clark County, the nursing budget has escaped the nearly $400 million in education funding cuts made in the past three years. The number of nurses has grown but hasn’t skyrocketed, officials say. The district has 184 school nurses today, up from 45 more than 30 years ago. The nurses, who look after more than 300,000 students, work in tightly organized teams to account for there not being enough for each school.

Like circuit-riding judges in the Old West, Mossel and other nurses shuttle from school to school, usually two, but sometimes three schools in a week.

“The team approach can work,” Garcia said.

“It’s not the most desirable, however, because children with asthma or diabetes or seizure disorders can’t be treated by one nurse if they get sick at the same time. She can’t be in three places at once.”

The school nurse association recommends at least one nurse for every 750 students, about the size of a small middle school.

In Clark County, however, there is one nurse per 1,825 students, or nearly two and a half times the recommended ratio. That’s equivalent to two Brinley schools. Nonetheless, nursing officials say they can cope. “We have to,” Taylor said.

Clark County and Nevada aren’t unusual, but there are states with higher staffing ratios.

At one nurse per 311 students, Vermont ranks highest in a recent survey of states by the school nurse association. Michigan, at one nurse per 4,836 students, ranks lowest.

Nevada largely reflects Clark County, where most students live. At one nurse per 1,882 students, Nevada ranks 36th among states, according to the survey.

Advances in medical technology are saving children who would have died in infancy or as toddlers. In a decades-long movement, “medically fragile” students who would have stayed home or been cared for in institutions are now encouraged to join students in public schools.

Those students, too, are sicker. Illnesses that interrupt education, such as asthma, are increasingly common. Just why is unknown, but one theory is that cleaner environments of modern cities and suburbs may be causing some children’s immune systems to not develop as robustly as in dirtier environments. The immune system is like memory, and if it isn’t acquainted with an environmental trigger for, say, asthma, it can’t learn to fight it. Such theories still require more research, Garcia said.

One indication of the occurrence of severe and chronic illness in the district is the number of student health care plans — detailed procedures and medications for students sick enough to need them. Each of 47,408 students has such a plan, or about 15 percent of district students, Taylor said.

Lynn Row is a health service coordinator who oversees 30 nurses, including Chastity’s nurse, spread over 90 schools. When one school needs more nurses, they can be reassigned from other schools, she said.

Officials try to hire nurses not only with experience in pediatrics but also such high-stress fields as intensive care, infectious diseases, and especially, trauma, such as gunshot wounds and car crashes.

Mossel, who is part of a team of 14 nurses, used to work full time as a trauma nurse and still works such cases a few times a month at University Medical Center.

She loves being a school nurse, she said, but even she is fazed sometimes. Recently, a student had to be evaluated for what seemed to be a psychotic outburst.

Mossel, who also works at Lilly & Wing Fong Elementary School in Las Vegas, said younger children need more time and patience.

“They need more TLC,” she said. “A high school student can act as his own historian. But a little one just knows his tummy aches and you have to ask a lot of questions.”

Mossel and Chastity’s mother share a private language of nods, smiles and cooing noises with Chastity.

Because of her disability, Chastity can’t talk but presses icons on a computer screen. That triggers a computer voice, such as that of the physicist Stephen Hawking, when she needs to go to the bathroom or wants water.

Feeding Chastity every day at school can take as long as a half-hour.

Chastity’s mother has two other school-age children without severe disabilities. So Ibarra worries about Chastity, who in a year will be going to high school.

Ibarra thinks nursing staffing is fine at the girl’s school now, but if it falls short, she may home-school Chastity as best she can, even though Ibarra works at night as a manager at Panda Express until 11 p.m.

Or Ibarra might volunteer at the high school somehow, anything to make sure she’s near her daughter.

“I have to make sure she’s safe,” Ibarra said.

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