School Nurses Dispense a Healthy Dose of Social Work : Health: An increasing number of students are showing up with serious illnesses but no insurance to pay for treatment.

It’s 9:30 a.m. on a sunny Wednesday at Wilson Middle School, and the folding chairs and Naugahyde-covered cots that crowd Sue MacLaughlin’s health office are full. LeShay has a fever, DeJuan was hit on the head by a door, Jorge doesn’t feel like going to second-period class and Princess has a cat scratch that’s started to swell.

But MacLaughlin must deal first with the problem faced by a 12-year-old sixth-grader newly arrived from Mexico who’s been avoiding gym. The boy, she explains, stepped on a nail in Mexico when he was 7. He never received treatment for the wound. He can stand and walk on the foot, but running creates pain and swelling. The family’s solution is to take him out of gym.

MacLaughlin, the school’s full-time registered nurse, has another idea.

Throwing an arm casually around the boy’s shoulder, MacLaughlin explains through an interpreter that until help can be found he must at least suit up; he has missed weeks of gym. Just do the exercises that won’t hurt your foot, she tells the plump, wide-eyed boy, and sends him off to class.

“I want him to get moving, and gym could be good for him,” she said with a sigh, making a note on his chart. “We need to have someone look at his foot, in case there’s still a shred of nail in there.”

There was a time when a school nurse would simply have written a note to his parents, advising them to take him to the family doctor. But things have changed. More and more children who show up at MacLaughlin’s office have no family doctor.

This sixth-grader has never had a checkup, never had a dental examination, never been tested for hearing or vision problems. Like an estimated 28% of the children in Pasadena schools, he comes from a family without health insurance.

The uninsured children generally are from families in which one or both parents work, but in jobs that carry no benefits. Poorer families are eligible for MediCal.

At MacLaughlin’s crowded school, the crisis is even more dire than in other parts of the city: She and her principal estimate that two of three children who enter her door are uninsured, often leaving her with a room full of very sick children and virtually nowhere to refer them.

At the request of school officials, students named in this article are identified only by first name or by age or grade.

In the case of the sixth-grader who stepped on the nail, MacLaughlin has to go a little bit further than just sending a note home.

She looks up the names of two low-cost clinics, then has a translator write down the information in Spanish for the boy’s parents. But she knows that they will face a long wait even if they can find a way to get off work to take their son to one of them. His father has already tried to take him to a Los Angeles County clinic, but the first available appointment was two months later.

If they can’t afford the clinics she suggested, she’ll make more calls, as she has dozens of times before, ferreting out a medical office here, a specialist there, someone who will treat just one more child who cannot pay.

Skinned knees and tummy aches once constituted the business of the school nurse. These days, MacLaughlin sees plenty of scrapes among the 800 to 1,000 incidents she encounters each month, but also examines broken bones that haven’t healed and serious skin infections that started out as simple patches of eczema.

As a school nurse, she cannot by law give out any medication--not even an aspirin--recommend an over-the-counter allergy medicine or even take out a splinter.

Yet she represents nurse, doctor, dentist and social worker to many of the 1,475 children who attend Wilson Middle School on South Madre Street in Pasadena. Children with seizures. Children with strep throat. Children like the boy with a badly abscessed tooth whose mother tried to remove it with pliers because the family could not afford a dentist.

“I had one kid who fell down running and split his head to the point where I could see bone,” MacLaughlin recalled. “I called the mom and told her to come immediately, but she said: ‘I can’t. I don’t have a car.’ When she finally got here, she just stood by him crying. Another one of her kids told me she was not crying because he was hurt, but because she couldn’t afford to take him for help. She had no health insurance.”

On an average day, MacLaughlin sees between 30 and 40 children with problems ranging from head lice to influenza to bruises from child abuse. Mixed in are the adolescents who just need someone to talk to and will feign an illness to get into the gentle oasis of MacLaughlin’s poster-covered office.

At Wilson Middle School, they all have to await their turn.

By 10:15 on Wednesday, two girls want the nurse to check the results of their tuberculosis tests so they can get clearance to work in the cafeteria. Another needs a sanitary napkin. One frightened seventh-grader clutches her books to her chest and whispers that she needs a pass to go home; she has been threatened and doesn’t want to fight. MacLaughlin calls a counselor to intervene. She calls for a parent to come and pick up Gavin; his temperature is 100 and his chest hurts when he breathes. She shows Thuan how to clean his scraped leg. Did Kenneth eat breakfast? No? Maybe that’s why his stomach hurts.

“First aid is part of what I’m supposed to do,” said MacLaughlin, a warm, outgoing woman who speaks with a hint of an accent from her native Canada. “But I’m also required to do health and development histories, vision, hearing and scoliosis screenings and IEP (individualized special education plans) evaluations. You get to feel like you’re drowning after awhile.”

Fortunately for MacLaughlin, there may be a life raft on its way.

Pasadena is not an anomaly when it comes to uninsured children: One in seven from working American families has no access to reimbursed health care. But the problem here is worse--twice as high as the national average, by some estimates--partly because of the large influx of immigrant families. So local activists have launched a campaign to do something about it.

The Health Coalition for Children and Youth, coordinated out of All Saints Episcopal Church by Lorna Miller, is currently trying to recruit Pasadena doctors who will provide six free office visits a year to children who are sick or injured, but uninsured.

In preparing a report on the needs of Pasadena children for the United Way two years ago, Miller spent months in school nurses’ offices, watching a parade of children in need and nurses with no resources to help them.

“People who are a phone call away from their doctors don’t realize these problems exist,” said Miller. “What was overwhelming to me was seeing nurses send home children who were very sick, saying, ‘Take them to a doctor,’ and knowing that nurse would not have the time or assistance to do the hand-holding to make sure that decision got followed through.

“We wanted to organize resources for these poor school nurses so that help can be a phone call away.”

The coalition chairman, Dr. Don Thomas, director of emergency services at Huntington Memorial Hospital, admits that early committee meetings were spent “lamenting about what the government was not doing and looking at things that would not work.”

But ultimately, Thomas said, the coalition came up with a plan, Project Young and Healthy, that will appeal to existing agencies and practicing local physicians to “open their doors a little wider to take in our children who don’t have insurance.”

It has been an uphill fight, waged in an environment where hospitals and clinics are being squeezed by unreimbursed cases, and most doctors won’t even take patients with MediCal. Miller said she surveyed pediatricians in Pasadena, and found that only four said they accept new MediCal patients, for whose care they are minimally reimbursed.

Details are still being worked out. As it stands now, the plan would:

* Raise $80,000 a year for three years to launch a pilot version of Project Young and Healthy, to be staffed by volunteers, a part-time clerk and a full-time volunteer coordinator.

* Send volunteers into the schools to help school nurses with paper work, so they can devote more time to the needs of children.

* Identify children without health insurance and make certain they have received basic preventive care and screenings.

* Weave a human safety net of physicians who will volunteer their services for six office visits a year from children who are in immediate need of care, or who will agree to consult with school nurses over the phone about difficult cases.

* Match up existing school crisis teams with professional social workers or psychologists who would serve as consultants to help with the more serious psychological problems found among schoolchildren.

Roughly a dozen physicians have expressed a willingness to help, and more are at least interested, said Miller. “We desperately need them, and want to appeal to their goodwill,” she said.

Thomas said three city schools, Madison Elementary School, Longfellow Elementary School and Washington Middle School, will be the first to implement Project Young and Healthy, beginning in the fall.

Evelyn Allen, the school nurse at Madison, said more than 75% of the children she sees are uninsured, from families without money, without basic health education, without transportation and often without baby-sitters to stay home with the children when they are sick. Some are homeless; many are from broken homes.

So Allen sees children who are sent to school with temperatures as high as 104 degrees. She sees them with untreated ringworm, conjunctivitis and head lice. She sees disintegrating teeth in children who don’t know how to brush, or have no toothbrushes. One student came to school with hepatitis. The nurse drove another child home herself and implored the family to take him to an emergency room because of complications that could develop from the tennis ball-sized swelling on his head.

Meanwhile, back at Wilson School, Thomas has been jabbed with a pencil, and the graphite has broken into pieces under the skin. It needs to be excised by a doctor, MacLaughlin explains, but he just smiles.

This one, he said, displaying a black mark deep in the skin of his other hand, is from last year.

UNINSURED CHILDREN

Estimates of how many children under 18 come from uninsured families In Pasadena: 28% In Los Angeles: 30% In California: 22.5% In the United States: 14%

Pasadena and U.S. estimates are from 1988; Los Angeles and California statistics are from 1986.

Sources: Pasadena figures are from the Pasadena Coalition for Children and Youth; Los Angeles and California figures from the UCLA School of Public Health; United States statistics from the Children’s Defense Fund.