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 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 in May, Andrea wheels 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 up to 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 slashed 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 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.
For 15 of the 22 years she has worked in Saddleback Valley, she was the district's only full-time nurse. Last year, administrators hired a second full-time 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.
"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, officials say.
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 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, 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 hire 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.
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 the county Department of Education.
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 some action.
State Supt. of Public Instruction Delaine Eastin sent a memo to all districts last fall outlining requirements mandated by California laws. The letter included specific instructions on how to dispense medications safely and emphasized that only trained personnel should do so.
One of the toughest issues that Ashwell faces in Saddleback Valley is a growing number of students with life-threatening allergies and asthma, which often are related.
Ashwell is combating the problem of rising life-threatening asthma cases 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 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 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.
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.
Until that happens, Ashwell will continue to juggle a daunting workload.
An energetic woman, Ashwell 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.
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."