Teachers Often Left to Deal With Pupils’ Medical Needs

One of the boys in Michele Daly’s kindergarten class had diabetes, and several times a day she would prick his finger, squeeze out a few drops of blood and test his blood sugar to make sure it was at a safe level.

She was terrified of making a mistake.

“If I was wrong, he could go into a seizure or eventually suffer heart failure,” said Daly, who teaches in West Jordan, Utah. “I have no medical background. I shouldn’t have to do that.”

Her predicament is becoming increasingly common. Across the nation, teachers and other school personnel without medical training are being asked with growing frequency to perform medical duties for which they feel ill equipped and ill at ease.

These range from dispensing medication to more complicated procedures: administering finger-stick blood tests and insulin injections, performing breathing treatments, even feeding children through stomach tubes and changing catheters.

And some, like Daly, are called upon to make medical judgments for which they feel they lack expertise.

This situation has developed in recent years as more children with disabilities have, by federal law, been mainstreamed into regular classrooms. Although they are capable of learning alongside able-bodied children, many of them bring special medical needs with them.

“It’s not the past, when a kid came to school with measles and you just sent him home,” said Ruthmary Cordon Cradler, a special-education expert for the California Teachers Assn.

“In the old days, if a kid got a bloody nose, you gave him a tissue and threw it away,” she said. “Not today. You’ve got to put on your gloves, get a special box. . . . Everything involving health in the schools has grown in complexity.”

At the same time, dwindling school budgets have forced districts to make wrenching decisions about who and what to cut, with school nurses among the first on the hit list.

“Who would have thought 10 years ago that we’d have kids coming to school who needed to be tube-fed or catheterized?” asked Art Caplan, director of the center for bioethics at the University of Pennsylvania. “Are more coming? Yes. With technology and the push to mainstream, you’re going to see more of them coming to your schools.”

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Among other things, dramatic medical advances during the last decade “have allowed smaller and smaller newborn babies to be saved who otherwise would have died but who have more and more physical disabilities,” said Wanda Miller, a registered nurse who runs the student wellness programs for the St. Paul, Minn., school system. “By doing that, the number of children with special needs has increased immensely.”

The government estimates that 5.4 million children in the nation are classified as disabled. More than half are learning-disabled; most of the rest have physical or other health problems. In California, nearly 30,000 students have severe health problems, according to the state education department, and many thousands more have special needs.

Under a federal law enacted 20 years ago, all children with disabilities must be included in regular classrooms in public schools to the greatest extent possible. Many of these children need an adult to help them during the day with special health needs or to make medical decisions that affect them.

The 1976 Individuals With Disabilities Education Act does not specify which person--classroom aide, school nurse, teacher or some other staffer--must provide these services. More often than not, it is the child’s teacher who assumes the role.

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“It’s the desire of parents and teachers to have these kids in school--and have life be as normal as possible for them, which is the right thing to do,” said Tim Laatsch, executive director of the Assn. of Wisconsin School Administrators.

“But the majority of schools do not have a school nurse on duty,” Laatsch added. “So the responsibility most often falls upon the person the child comes into contact with first--the teacher.”

Bob Tate, a senior policy analyst in Washington for the National Education Assn., the professional organization for teachers, estimates that there are only 30,000 full-time nurses for about 85,000 public school buildings nationwide.

The NEA holds that “there should be a full-time nurse in every school--nurses, not teachers, should be doing these kinds of things,” Tate said.

More common than severely disabled children are those with such conditions as diabetes, asthma and severe allergies, which let children function normally most of the time. But they also require monitoring and medication, and they hold a potential for medical emergencies that would force teachers to make snap decisions.

“These children can be perfectly healthy and then suddenly become extremely ill,” said Miller, the St. Paul nurse. “Teachers are afraid of that--and they should be.”

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So are many parents. In Calvert County, Md., for example, one family brings their 5-year-old daughter home from school at 11:30 a.m., when the school nurse leaves. The daughter, who would otherwise be going to all-day kindergarten, has a life-threatening allergy to peanuts, and her parents are concerned because there is no one at the school during the afternoon trained to administer an EPI pen, a special injection.

Doug and Susan Pearson have a different solution. They send their 6-year-old daughter, Emily, who is diabetic, to first grade in Bethesda, Md.--and Doug Pearson goes there several more times each day to monitor her blood-sugar level. When Emily was diagnosed last year, Pearson quit his job and became a consultant with a home office and a cellular phone so that he would always be available.

“The bottom line is that we take the responsibility ourselves,” he said. “Teachers should not have to do this, although they should be aware of the condition and know what to do, just in case.”

Patty Arvin, who teaches severely disabled fourth-, fifth- and sixth-graders who attend classes with non-disabled children in Fairfield, Calif., says teachers who must tend to medical responsibilities have less time to do what they were hired to do: teach.

She said she and her teaching colleagues spend three or four hours every day performing medical procedures: removing fluid from a breathing tube, giving insulin injections, testing diabetics’ blood and changing a catheter, which is a device used to drain urine from the bladder.

“Doing these procedures takes my time away from other students,” Arvin said.

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But school boards, faced with tight budgets that frequently pit academics against extracurricular activities or nonteaching personnel, almost always favor academics.

“School boards are committed to keeping instruction as high as possible,” said Anne Bryant, executive director of the National School Boards Assn. “That means when you’re talking about choosing between a health care professional or a teacher, they’re going to go with the teacher.”

Although policies vary, most school districts carry liability insurance in the event that something goes wrong. The NEA urges teachers to be aware of their limits of coverage. Some insurers, for example, require that certain procedures be performed by licensed professionals. The NEA also offers supplemental liability insurance to its members.

No major tragedies are known to have occurred thus far. But critics, citing numerous close calls, say it is only a matter of time.

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In 1992, a school office clerk in Clark County, Nev., gave a second-grade boy five Ritalin tablets--a drug used to treat attention deficit disorder--instead of the five digestive tablets he was supposed to take.

She realized her mistake almost immediately and called for help. The boy’s stomach was pumped and he was fine, but the experience left the clerk traumatized.

“There is an increasing risk of something going wrong and not having someone there who knows what to do about it,” Tate said. “It’s a bad situation all the way around.”

Lynn Luking, who teaches at a public elementary school outside Louisville, Ky., refused an order last year to administer a Valium suppository to a child in her class who was prone to life-threatening seizures.

“The parents and the school district instructed my client: ‘If he starts writhing, your job is to pull down his pants, insert the suppository, then call the emergency folks,’ ” said Dennis Janes, her attorney. “She was not enthusiastic about this.”

As it turned out, the child did suffer an attack, but it was on a day when Luking was not there. The responsibility of administering the drug fell to the school principal, Janes said.

The principal “lost his nerve, called the mother and the emergency medical folks,” Janes said. “When the emergency team arrived, they refused to do it, saying they weren’t authorized to administer prescription medications. All they could do was take him to the hospital.”

They did, and the child survived, Janes said.

Under the threat of legal action, however, “the school district backed off” from forcing Luking to comply, Janes said. “They found several other employees, secretaries, who didn’t have the nerve to say no. Eventually the child moved on to another class. The problem went to somebody else. But it didn’t really go away.”

Kindergarten teacher Daly said that several years ago, she had to administer special breathing treatments to a child with serious respiratory problems. His episodes were unpredictable, and she had to decide when the treatments were necessary. When they were, she had to stop what she was doing with the other students and lug out a noisy portable machine.

The child ultimately choked to death in the care of a baby sitter while eating canned pasta.

“I kept thinking: ‘What if that’d happened in my class?’ ” Daly recalled. “I love kids. I’ve always wanted to teach. But I don’t know anything about medicine.”

Some school districts have had to confront “do not resuscitate” orders for children who could experience cardiac or respiratory arrest while in school. This means that the parents and their children’s physicians, in the belief that certain emergency procedures would worsen a child’s condition, have decided not to intervene.

Many teachers, however, have balked at the idea of standing by and allowing a child to die, especially with other children present.

The NEA has urged schools and teachers “to take steps to make sure it’s a valid order, that they hash out and discuss all the issues in advance so that people aren’t blindsided if and when something happens,” Tate said.

In some states, legislatures have responded to the growing anxiety of teachers by enacting laws that prevent them from being forced to comply with some of these orders.

Iowa, for example, passed a law in 1991 requiring teachers to receive training for medical procedures they might be asked to perform, but it stipulated that they had the right to refuse to do them.

California has no such law, according to Cradler of the California teacher group.

Bryant of the National School Boards Assn. recommends that, instead of imposing medical duties on teachers, districts should look to hospital emergency services, neighborhood clinics or local visiting nurse associations.

This is already happening in some places. In Montgomery County, Md., for example, the county health department--rather than the school district--pays the salaries of part-time school “health techs” who, although not nurses, have received special training in first aid, cardiopulmonary resuscitation and other medical procedures, such as administering blood tests and insulin injections.

Bryant said: “We need to get creative about finding the services that are going to keep kids in schools healthy.”