The Endangered School Nurse

Six-year-old Owen chortled with glee as he flung a rubber chicken up into the air on a parachute, sending it to the ceiling. Gym class had gone inside on a rainy day. His round cheeks grew pink as he ran.

But a giddy romp before lunchtime can be dangerous for Owen, a diabetic first grader whose blood sugar can careen from too high to too low. Too low and he could fall into a coma; too high and he could damage his eyes and risk blindness later in life. Health technician Dee Cundiff has to sit him down during gym class for a juice box to keep him from crashing, has to eye exactly how many apple slices he eats at lunch.

It falls to nurse Cheri Amati to give him his insulin. All of this is scary enough for the people who love Owen. But his mom and dad were terrified when they heard that nurse could disappear next year.

“Who is supposed to take care of all this?” asked Dana McCarter, his mother.

Forced to figure out how to gut their own budgets to close an estimated $120 million deficit, principals across San Diego Unified planned to slash half of the nurses who are stationed at their schools and a fourth of the health technicians, who care for students but don’t have nursing degrees. Doing so would save roughly $3.8 million.

San Diego Unified tentatively plans to expand an existing pool of traveling nurses to cover more schools, but nobody is exactly sure how often those nurses will be able to stop by. More than 40 out of roughly 140 nurses in the school district could be warned this week that their jobs are on the line.

La Jolla Elementary currently has a nurse just two days a week and already relies heavily on traveling nurses to give Owen his insulin. Next year it will rely on them entirely, with no nurse on campus. The health technician could disappear too; Principal Donna Tripi hopes to get the school district to cover her.

Owen goes to school in a wealthy area with less dramatic needs than poorer neighborhoods across town. But even here, “they’re going to have their hands full,” said Cheri Amati, the school nurse.

Children can still get medical attention when there is no nurse on site. Health technicians like Cundiff who are trained in first aid and CPR can patch up scrapes, help diabetic kids count carbohydrates and carry out other everyday tasks. Traveling nurses can give insulin injections, conduct hearing and vision screenings and do other tasks. Someone will still come to give Owen his shot.

But nurses and parents fear the budget cuts will make schools slower to sniff out health problems and less nimble in treating them. Nurses say when they float, they find it harder to know the kids and detect problems before they explode. It will only get harder if they have to juggle more schools next year. Health technicians cannot perform all of the same tasks and duties — and they’re under the knife too.

“You can only spread us so thin,” said Jennifer Gorman, who oversees nursing in San Diego Unified. She added, “I don’t think it’s going to be as safe.”

During gym class, Owen throws a rubber chicken in the air with a colorful parachute. He loves playing, but it can push his sugar to dangerous levels and is monitored by the school’s health technician. | Photo by Sam Hodgson. Click on the image to enlarge.

The cuts would leave San Diego Unified with roughly one nurse for every 1,000 kids, according to Gorman’s estimates. The U.S. Department of Health and Human Services recommends one nurse for every 750 students — and that is just for children who are well. The teachers union is fighting the cuts, saying they run afoul of new rules in their contract that set minimum staffing for nurses.

Parents are already frustrated with dealing with different nurses on different days. Owen sees up to five nurses in a week. His father, John Reed, once left work to pick Owen up, panicked that a substitute nurse wanted to give him more insulin than usual. Reed loves all the nurses; he just wishes there weren’t so many.

“They say, ‘Hey, this is what the doctor’s orders say.’ Well, we get the orders changed all the time,” Reed said. (Nurse Amati said they had to communicate with Owen’s doctors six times in roughly three weeks.) “This disease is really slippery. It’s important to have people who are familiar with us.”

Traveling nurses such as Sue de Lira already hopscotch between up to six schools in a day, injecting insulin, screening kids for scoliosis, sitting in on meetings for students with disabilities, and anything else that pops up at schools without nurses. California courts are still battling over who can give insulin to schoolchildren; San Diego Unified only allows nurses to do so. So, much of her schedule is insulin.

After determining his blood sugar is low, the school’s health tech, Dee Cundiff, has him drink a fruit punch box. Her position is also in jeopardy with San Diego Unified’s budget cuts. | Photo by Sam Hodgson. Click on the image to enlarge.

“We’re in and out,” de Lira said. She stops by Silver Gate Elementary in Point Loma for just 15 minutes to help a little girl with insulin; later she comes back to give the same girl another shot.

The schedule is no less hectic for Kathy Ryan, an on-site nurse at Lincoln High School, who sees between 40 and 60 students every day with problems from headaches to severe issues like rape. But staying at one school means she can spot problems herself, instead of waiting for a school to call. She once sized up a girl who came to her office asking for a sanitary pad and realized the girl was actually giving birth.

Nurses argue that that particular skill — making a judgment call on a medical issue — is what separates school nurses from less expensive health technicians who don’t have nursing degrees. Those tough calls have become more important as schools enroll more students with severe medical problems. Children who once wouldn’t have survived past toddlerhood are now in classrooms and on the playground.

Owen licks a drop of blood off his finger after pricking it to test his blood sugar level. | Photo by Sam Hodgson. Click on the image to enlarge.

“I could teach you how to give an injection,” said Linda Davis-Alldritt, who handles nursing issues for the California Department of Education. “But I couldn’t teach you in a day how to assess that person to make sure they need that injection.”

Short on nurses, schools may be quicker to call 911 or send kids home when they don’t need to and slower to offer other help, Gorman said. Principals fear they could get sued if someone errs when giving a child medication, said Jeannie Steeg, executive director of the principals union.

On the flip side, advocates for diabetic students, who argue any trained staffer should be able to give insulin, fear schools will hold back care or make parents come give insulin when nurses aren’t around.

“There’s no way there’s sufficient nurses to do this alone,” said Robert Henry, a University of California, San Diego professor and president of medicine and science for the American Diabetes Association. Besides, he adds, “you can’t really schedule these things.”

Nursing has long been thin in California schools compared to other states: The state ranks 42nd in its student-to-nurse ratio, with more than 2,100 children per nurse, according to the National Association of School Nurses. The California Department of Education says almost half of California schools have no nurses at all.

The school board will vote Thursday on whether to send layoff warnings to nurses and other employees. Several school board members have said they don’t like the idea of paring back on nursing. But sparing the nurses would mean cutting something else.

Please contact Emily Alpert directly at emily.alpert@voiceofsandiego.org or 619.550.5665 and follow her on Twitter: twitter.com/emilyschoolsyou.