Nurse to 16,500 Kids

By TINA NGUYEN

March 2, 1998 12 AM PT

TIMES STAFF WRITER

MISSION VIEJO —

School nurse Marilyn Ashwell gulps the last of her tea, glances at her watch and springs to her feet. She has four minutes to make it from her office to La Tierra Elementary for an 11 a.m. routine with third-grader Andrea Santos.

Walking briskly into the Mission Viejo school’s health office, Ashwell greets the waiting 9-year-old: “Good morning, Andrea. Can we do it in eight minutes today?”

Andrea smiles doubtfully, then nods.

Paralyzed from the waist down by a car crash that killed her mother last May, Andrea wheels herself to the bathroom sink, washes her hands and prepares to insert a catheter--a tube she uses to drain her bladder.

The once simple task of going to the bathroom and dressing herself now takes her as long as 45 minutes. Ashwell wants to shorten that time, so she visits Andrea almost daily, teaching her how to care for herself.

“This is her life now,” Ashwell says. “We want to make sure she grows to become independent.”

Helping children achieve self-sufficiency and maintain good health is Ashwell’s quest. Her role has become increasingly critical as more children with complicated and life-threatening conditions enter public schools under the mandates of a new federal law.

Some students need to be tube fed. Others breathe with respirators. Potentially fatal cases of asthma and allergies are up among children, doctors say. And a rapidly rising number of youngsters are relying on medications such as Ritalin, Prozac, anti-psychotic and narcotic drugs to get through the day.

Despite those increases, school districts have dramatically slashed their nursing staffs over the past two decades because of budget constraints, administrators say.

Only 150 full-time nurses serve Orange County’s 460,000 students. That’s about one nurse for every 3,000 students--surpassing the state’s ratio of 1 to 2,700, and even Los Angeles Unified’s figure of 1 to 1,360.

In the Saddleback Valley Unified School District, where Ashwell is one of only two nurses, the ratio is even more dire: one nurse for every 16,500 students.

During Ashwell’s 22 years at Saddleback Valley, she has watched the nursing staff dwindle from nine to one, as the student population has grown.

For 15 of those years, she was the district’s only nurse. Last year, administrators hired a second nurse after receiving a grant from Saddleback Memorial Medical Center in Laguna Hills. The one-year contract ends in June. District officials say they may not have the money to pay for a second nursing position, meaning Ashwell may work solo again.

“You can have all the money in the world, the best technology in schools,” Ashwell says, “but if children don’t have their health, they cannot learn.”

Even with additional help, Ashwell plays a multitude of roles as emergency medic, parent confidant, student counselor and health educator. Some days she zigzags among half a dozen schools to check on chronically ill students, counsel teenage mothers, train school employees in first aid and map out accommodations for disabled children.

Other days she works in her office at the Esperanza Special Education School in Mission Viejo soliciting charities to pay for hearing aids and eyeglasses for poor students, referring low-income families to free clinics, calling parents to remind them of their children’s doctor appointments, and seeking grants and medical expertise from local hospitals.

“You learn to be resourceful in this position,” Ashwell says.

She finds herself being the sole health-care provider for some families. That is not unusual among school nurses because about 25% of students in the United States have no health insurance, health officials say.

For example, Linda Vista Elementary fifth-grader Irais Rojas’ parents say they cannot afford to take her to the dentist regularly. The 10-year-old has been to the dentist only three times in her life. Her teeth have developed so poorly that she speaks with a heavy lisp.

Her teacher calls Ashwell, and two days later the nurse meets the girl. For privacy, they go into a classroom storage room to chat. Ashwell discovers that Irais has a severe underbite, several missing teeth and trouble pronouncing certain words such as “thermometer.”

Irais tells Ashwell that, as a toddler, she wore a brace on her gums.

Ashwell speculates that the brace stunted some teeth growth and contributed to the underbite.

“Can I look in your mouth?” Ashwell asks gently.

Irais opens wide and nervously grips her shirttail as the nurse uses two tongue depressors to examine her teeth.

“You have beautiful teeth,” Ashwell says reassuringly. “They are like little pearls inside your mouth.”

Ashwell has been unable to verify her speculation about how Irais’ teeth developed because the girl’s parents, who do not speak English, have not returned the nurse’s phone calls.

Such obstacles are not uncommon and are frustrating because follow-up is essential to good health care, Ashwell says. Her heavy workload makes it difficult for her to provide personal care.

“You’re doing everything by telephone,” she says. “You’re not getting to know the child and the parent. It’s not the kind of dynamic in which you can personally walk people through the process and build trust.”

The number of school nurses began to shrink in the late 1970s after Proposition 13 rolled back property taxes in California. One result was less money available for public schools. Nurses, along with guidance counselors, art and music teachers, were among the first targeted during budget cuts. Since then, growing demands for smaller class sizes, new textbooks and computers have prevented districts from restoring those cutbacks, school officials say.

“Our budget is barely balanced for this year and next year,” Saddleback Valley Supt. Peter Hartman says. “I’m very well aware of children’s health needs. But there are a lot of things we’d like to fund but we can’t.”

To get the most for their money, school districts increasingly are hiring health assistants--who work for less pay but are not required to hold a state license--to make up for the shortage of nurses.

For what it would cost to employ two full-time registered nurses, Saddleback Valley hired 14 part-time health aides this year. Health aides are certified in cardiopulmonary resuscitation and first aid, but a professional health background is not required.

The major duty of such health aides, who typically work only part of the week, is dispensing medications to children. When they are not on campus, school principals and secretaries end up filling in.

That trend of relying on aides and office staff to dispense medicines poses major risks, some health officials contend.

“If you took your child to the hospital, would it be OK if the lady at the switchboard gave your child the medicine?” asks Beverly Bradley, president of the American School Health Assn., a professional group based in Kent, Ohio. “I understand the strain on public schools, but the child has the right to be in an environment that is safe.”

At any given school, scores of children might file into the school health office at lunchtime for their medications. Many require daily treatments for chronic illnesses such as cancer, epilepsy, asthma, and attention deficit and hyperactivity disorders. In Orange County, more than 13,200 types of medications were dispensed last year in public schools, according to data from the county Department of Education.

“Kids these days are on some very serious chemical medications,” says nurse Patti Hachiya, Placentia-Yorba Linda’s supervisor of health services. “These are medications with serious side effects.”

Across California, the medication situation has become so overwhelming in some districts that school officials are allowing students to dispense medications, state education officials say.

Other reports of lax practices in some school health offices have prompted action.

State Supt. of Public Instruction Delaine Eastin sent a memo to all districts last fall outlining requirements mandated by California law. The letter included specific instructions on how to dispense medications safely and emphasized that only trained personnel should do so.

The state also hired registered nurse Pat Michael in January as a mentor for school nurses.

“Daily, we’re dealing with things we have never dealt with before,” Michael says. “Our professional abilities are being challenged tremendously.”

One of the toughest issues Ashwell faces in Saddleback Valley is a growing number of students with life-threatening allergies and asthma, which often are related.

Since last year, Ashwell has been working with Laguna Hills first-grader Ariella Rams, who is severely allergic to eggs and nuts, particularly peanuts. Even a trace of peanuts on another student’s hand or a tabletop could cause her airways to swell and suffocate her.

So Ashwell has worked diligently to turn Ariella’s classroom at Lomarena Elementary into a peanut-free zone. She showed students a video and read them books about the lethal effect that peanuts can have on some children. She wrote to parents, explaining Ariella’s condition, and asked them not to pack foods with peanuts in their children’s lunches.

School employees, including the custodian, were trained in how to inject the drug epinephrine, which would arrest the allergic reaction if Ariella should have an attack. Ashwell even made sure the school’s earthquake emergency kits were free of peanut butter.

Now, not a single child brings in foods containing peanut butter, peanut oil, peanut anything. Ariella’s teacher stocks the classroom with wet wipes and requires that every student clean his or her hands in the morning.

Gay Rams, Ariella’s mother, says Ashwell’s dedication is invaluable.

“Marilyn is spread very, very thin, but she still does such a comprehensive job,” she says. “She does it because she cares. She has helped our family live a normal life.”

The rise in life-threatening allergies and asthma among schoolchildren is alarming, doctors said. The reasons for the increase are unclear, but researchers attribute it in part to environmental and genetic factors.

Asthma is the leading cause of absenteeism from schools nationwide. The number of asthma cases among children and adults in the United States has jumped from an estimated 3% a decade ago to 10% now, said Dr. Stanley Galant, an allergy and asthma researcher at UC Irvine.

Because of that trend, doctors are urging schools to provide more nurses to help diagnose and treat young asthmatics.

“The problem is big and getting bigger,” Galant says. “Schools definitely can help in bringing it under control.”

Ashwell is combating the problem in her district by developing an asthma education program with Mission Hospital Regional Medical Center in Mission Viejo. Asthma experts now visit Saddleback Valley schools, informing teachers, administrators and parents about symptoms and treatments of the disease.

The program aims to prevent tragedies such as the case of a Mission Viejo fourth-grade boy who died from a severe asthma attack at school several years ago.

Besides treating chronically ill students, school nurses also see a growing number of children with severe disabilities.

Under a 20-year-old federal law that was revised in 1997, public schools must accommodate all children. In California, that includes about 610,000 students with physical and learning disabilities, according to state officials.

In some of those cases, disabled students must have adult help full time to get through the school day. While a nurse can train a staffer--whether a teacher or classroom aide--on how to care for a disabled child, making medical decisions and responding to crises demand the expertise of a trained professional.

“Parents who have totally healthy children don’t know how blessed they are,” Ashwell says. “They do not need to depend on others to make sure their children are safe at school.”

Some members of the California Parent Teacher Assn. say they are not comfortable with policies that allow unlicensed school staff to care for their children. That is why veteran Orange County PTA member Pat Klotz drafted a resolution last year calling for a cap on the nurse-to-student ratio.

That resolution, later approved by the state PTA council, will be used to lobby for laws like those in 16 states, including Pennsylvania and West Virginia, that mandate ratios as low as one nurse for every 1,000 children.

“There are so many places in Orange County that have incredibly poor nurse-to-student ratios,” Klotz says. “We have to improve the ratios, to make them safer ratios.”

Until that happens, Ashwell will continue to juggle a daunting workload.

An energetic woman, Ashwell seems well-suited for her hectic job. She goes far beyond the call of duty, often working through lunch and making home visits after hours.

Though she has two grown daughters, Ashwell also is “mother” to many students.

One student, whom Ashwell diagnosed with scoliosis, moved to Chicago. When Ashwell was vacationing in Illinois, she tracked down that student’s family to make sure that the youngster was getting treatment for her curved spine.

And then there’s Andrea Santos, a paraplegic whose mother is dead and who lives with her aunt and three siblings in Mission Viejo. Ashwell has helped Andrea look for affordable skirts and elastic-waist pants that are easy for the student to slip on and off when she changes her catheter.

On a recent Friday, Ashwell even travels 50 miles to Los Angeles to consult with Andrea’s doctor and physical therapist on her rehabilitation. Ashwell arrives at the Downey hospital at 7 a.m.--two hours before Andrea’s appointments--to give herself plenty of time to find the offices.

Equipped with a legal pad, pen and patience, Ashwell sits through the two-hour visit, asking the doctor about Andrea’s condition, measures to prevent infections and other steps to help the girl feel comfortable at school.

Ashwell, known as la enfermera to Andrea’s Spanish-speaking family, arranges for a new wheelchair for the child and works out busing arrangements for Andrea so her elderly aunt does not have to lift the girl in and out of the car.

As a nurse for Orange County’s fourth-largest school district, Ashwell says, her job is always demanding, often draining. What keeps her going is the personal reward that comes from helping frail children develop strength and hope.

“There isn’t a night that goes by when I don’t wake up thinking about something I need to accomplish--no matter how minuscule or pressing,” she says. “I need to think, at the end of the day, I’ve accomplished something for a child or a parent.

“It’s about doing my small part of bridging the gap between family and school.”

Tina Nguyen can be reached at (714) 966-5673. Her e-mail address is tina.nguyen@latimes.com

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A Heavy Caseload

Just 150 full-time nurses care for Orange County’s 460,000 students, or about one for every 3,000 kids. That’s a heavier load than the statewide ratio of 1 to 2,700 and more than twice as high as Los Angeles Unified’s 1-to-1,360 figure. Within individual Orange County districts the ratios of students per registered nurse vary wildly, from Capistrano Unified’s 1 to 20,000 to Laguna Beach Unified’s 1 to 250. Students-per-nurse data, for 1997:

District: Students per nurse

Anaheim City: 2,750

Anaheim Union: 9,300

Brea Olinda Unified: 7,000

Buena Park: 5,625

Capistrano Unified: 20,000

Centralia: 5,000

Cypress: 4,700

Fountain Valley: 1,000

Fullerton (Elementary): 3,000

Fullerton Joint Union: 13,500

Garden Grove Unified: 3,000