School nurse Michelle Marra slowly discusses with Takirah Sleet, 7, everything left on her blue lunch tray to calculate just how much she has eaten. The process is necessary to determine how much insulin Takirah will need to get safely through the rest of the day.
The effort is part health lesson as Marra helps Takirah learn about carbs and calculating the insulin correctly, part check-up to see how the first grader is feeling that day, and part office visit as Takirah gets her injection.
On a recent weekday, Marra is busy seeing students like Takirah who come into her office with ailments that range from serious conditions such as asthma and diabetes to bumps and bruises.
How Takirah and other Fayette County public school children are cared for will change next year. The Lexington Fayette County Health department, facing budget cuts and layoffs, has announced a plan to scale back its school nursing program. Officials are working out the specifics.
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The nature of health care in schools has been changing for decades. Laura Proctor, who has been a school nurse for 21 years, said better health care allows some kids with serious conditions to attend school, and medical technology advances including portable oxygen tanks and rescue inhalers allow those with chronic conditions to stay in the classroom.
In April, according to local health department statistics, school nurses provided 2,586 scheduled treatments that included catheterization and feedings by gastrostomy tubes. At Yates Elementary, one of the schools Proctor serves, 130 of the 400 students deal with chronic conditions, including allergies and seizures.
While on campus, nurses also perform vision and scoliosis screenings, review immunization records and physical exams, provide care in emergency situations and see students with minor health complaints.
"We are the first line of defense for a lot of these kids," she said.
It's the same across the state. And more students with greater medical needs are appearing in classrooms as schools search for ways to save money, said Mary Burch, president of the Kentucky School Nurse Association.
"In order to be educated, a student has to be healthy. How do you make that happen?" Burch said.
Providing a nurse in schools is not mandated in Kentucky, Burch said, and the level of care varies widely from district to district. Some districts hire only a nurse consultant to provide training to school staff, who then manage medical needs.
Burch, who works with the Erlanger/Elsmere public schools, said Fayette County has provided a better program than many districts because health department-financed school nurses and school officials made it a priority.
"It's unique for the health department to fund school nurses," she said.
In Fayette County, the health department's public school nurse program, which started 30 years ago, has grown in five years from 16 full-time positions to 24, Marra said.
There are now eight Fayette County public elementary schools with health clinics. Clinics at Arlington, Harrison, Tates Creek and William Wells Brown elementary are run by the local public health clinic, HealthFirst Bluegrass, and not by the county health department. Changes are not planned at those clinics, said William North, HealthFirst executive director.
Cardinal Valley, Millcreek and Mary Todd elementary schools have less comprehensive clinics that will face changes. Middle schools generally have nurses who serve several schools. The five Fayette County high schools each have a full-time nurse, but that is not likely to continue, said Marra, a team leader for the health department nurses.
High schools have full-time nurses because they have thousands of students and because teens can face adult health concerns such as hypertension, Marra said. At all the schools, she said, nurses can make referrals if specialized care is needed.
Some nurses, including Proctor, who serves two schools, will probably be stretched further to serve more schools.
The district was moving in the right direction by expanding school health, Marra said, but with 40,000 students, the district still fell short of meeting the level of care suggested by the National Association of School Nurses: one school nurse for every 750 students.
Health department officials are waiting to learn the extent of state budget cuts before devising their new plan. Health Commissioner Dr. Rice Leach announced last week that 25 health department employees are likely to be laid off in coming months. What specific jobs will be cut has not been determined. Leach said that because school nurses are not a state-mandated requirement of the health department, they will not be a priority.
Leach's mantra in recent month, as the severity of budget cuts becomes clear, has been that the health department needs to stop funding non-mandated services but help ensure that the care can be provided elsewhere.
Jack Hayes, director of student achievement support for Fayette public schools, said the school board hopes to increase funding for nursing. The health department now provides services worth about $1 million to the schools, he said. The school system provides $800,000 for school nurses. About $600,000 could be reallocated and added to the school health budget to cope with any changes, Hayes said. He also has asked to add a school health coordinator to the district staff to develop partnerships with the University of Kentucky and other local health providers to serve students. Those requests must be approved by the school board, he said.
The biggest difference is likely to be that some care, such as administering medications, would be taken over by school staff trained by a nurse instead of a medical professional, he said.
That makes Takirah's mom, Tasleem El-Amin, a little nervous. She was diabetic as a child also, and she knows what it's like to not have support in school.
Tasleem El-Amin said it gives her comfort to know that if her daughter passes out, which has happened at school, chances are now that a medical professional "will be there to help her."