The Perfect Storm: Too Few Nurses; Too Many Sick Kids

It’s like the perfect storm waiting to happen.

There’s that creepy thing out there hiding in the shadows called swine flu (H1N1) and way too few school nurses on the front lines to take care of all those kids who are possibly going to contract it. In a perfect world, says the National Association of School Nurses, there would be one nurse for every 225 students in schools that require "daily professional school nursing services." In a school where there are kids with mental, emotional and/or physical disabilities, there should be one nurse for every 125 students.Federal guidelines are more relaxed; they recommended one nurse for every 750 students.

Even at that, most schools don’t even come close to these numbers, according to the association’s 2008 tally. The ratios range from a high of 1–to-275 in Vermont, to 1-to-4,893 in Utah. [Residents in that state have been judged to be among the nation’s healthiest, so maybe they don’t need school nurses.]

Hawaii has no school nurses – and that’s a topic for another discussion.

The global picture is that only about 45 percent of public schools have a full-time nurse, according to the association, and three out of four schools have at least a part-time nurse. That leaves a quarter of all schools with no nurses at all.

Some years ago, I spent a few days with several school nurses so I could write a feature about what it was like for the few who remained after a round of layoffs in one of our local districts. One of the lasting memories of this assignment is the acuity of some of those students – elementary and high school kids who were in wheel chairs, had severe movement and communication disorders, and required regular suctioning, medications and attention for the accidents that seemed to happen with regularity.

I was amazed at how some nurses had to travel from campus to campus, never having time for lunch or a restroom break, and how they remained hours after school to do the paperwork that they weren’t allowed to carry home.

If anything, there are more of these students now than there have been in past decades, and the number of employed school nurses seems to be dwindling. In my area of San Diego County, school nurses apparently are considered dispensable or non-essential because they are laid off regularly. That gives rise – not surprisingly – to battles about what duties non-medical staff can assume in the absence of nurses.

For instance, one school idistrict in the Los Angeles area declared it permissible for an office aide to determine whether diabetic kids are experiencing dangerously high or low blood sugars, then administer or withhold insulin. The dispute went to court and the nurses proved the folly of this.

So back to the present and future, which could prove just how valuable our school nurses are.

If the swine flu rears its ugly head, nurses’ offices will be crowded. But before that happens, nurses should be busy, in between all their other duties, talking about washing hands, using tissues, wiping down desks and using all that Purell hand sanitizer that teachers have requested along with this year’s classroom supplies.

Sick Celebs and the Web Site That Loves Them

I flew home from the Midwest earlier this week and on the first leg of the trip, an announcement came over the intercom. Was there a doctor or a nurse in the house – uh, plane?

The woman next to me hopped out of her seat, as did three others, so I didn’t bother joining the crowd at the rear of the plane. I peaked back a couple of times and it didn’t appear that there was anything urgent happening. When my seatmate returned, I had to ask about the sick passenger. I admit it; I was very curious, so I asked diplomatically. She answered diplomatically, which means she didn’t tell me a whole lot.

“We asked her (the sick passenger) what medications she was on and she told us,” revealed my seat mate, who later told me she was a post-op open-heart nurse, “and then she told us that she hadn’t taken her medications this morning. No reason; just didn’t take them.”

Not very exciting, but still, the nurse didn’t give me the details I wanted.

Well, bravo for her.

She was protecting the privacy of the patient, which is exactly what she should have done. But you can’t blame another nurse for wanting to know, can you? Maybe I should blame part of my curiosity on the reporter/journalist in me, and given my first profession, it’s difficult not to be interested.

I think even those not in the medical professions are curious when it comes to others’ health or lack thereof – although sometimes people tell us more than we want to know! In any case, two Boston physicians (husband and wife) apparently have capitalized on the voyeur in each of us and have created a Web site called CelebrityDiagnosis.com. They use the news, they say, to create teachable moments.

After reading about the site in a magazine, I went straight there and was initially disappointed. The home page is a colorless presentation with a quiz about the ailments and dispositions of well-knowns – from the Farrahs to the physicists to the football players.

The other element of the site is the blog.

It’s more interesting, with photos of celebs, their illnesses and circumstances, and an explanation of the maladies. I didn’t know that singer Natalie Cole had a kidney transplant, that teen singing sensation Nick Jonas was a type 1 diabetic, or that Rachel Ray had to keep her mouth shut after undergoing an excision of a benign nodule from her vocal cords.

For all those medical headlines you missed, there’s an extensive index on the right side of the blog where you can find all the past blogs about sick stars. It is categorized according to illness.

It’s news to me that Dom DeLuise died in May of complications of obesity and that cartoonist Scott Adams (Dilbert) suffers from the rare communication disorder spasmodic dysphonia. And I was saddened to learn that Jerri Nielsen Fitzgerald, MD, lost her fight against breast cancer. She was the amazing woman who diagnosed and treated her own breast cancer while serving at the Amundsen-Scott South Station in Antarctica in 1999. Severe weather conditions made it impossible for her to evacuate for eight months, so she had to perform a biopsy on herself. with the assistance of the station's welder. (Fitzgerald wrote about her experiences in “Ice Bound: A Doctor's Incredible Battle for Survival at the South Pole.”).

What you’ll also find on the blog pages are quite a few ads – many from amazon.com hawking movies in which the celebs appeared, books by and about them, and links to all sorts of other sites and videos that come with more advertising. I don’t knock them for it; someone has to support the site and we can choose to ignore the advertising – although I admit that I sat through a commercial to see the 1984 video of Michael Jackson’s hair on fire.

The Debate On Health Care: Let's Start With Some Basic Questions

Things are getting ugly out there.

The debate on health care and health insurance is spawning some really nasty behavior by those opposed to changes in the status quo, according to news reports that are coming fast and furiously via newspaper, television, the Internet and email. The congressional recess is providing time for legislators to return to their home districts and hold town hall meetings on the topic, but some gatherings are turning into vicious attacks on congresspersons who want to make changes.

My head is spinning with all the debate.

Just today, my local newspaper devoted about two-thirds of its editorial section to opinion pieces on the health care debate and rightly so. It’s a hugely important issue and you won’t find too many people who are not passionate about it – especially nurses. Those in the trenches must deal daily with the heartbreak and frustration that comes with making care decisions based on patients’ health care coverage or lack thereof.

I spoke recently to a woman who was halfway through her chemotherapy when her insurance company pulled her coverage. The company claims she knew she had breast cancer when she enrolled – despite physicians’ letters stating otherwise. But the insurance company is wealthier and more powerful, so too bad for her.

The House and Senate will be back in session soon to further haggle over the 1,000-plus page document that contains all the minutiae of the proposed health care bill, but our representatives are failing to grapple with some important basic (and scary) questions that should be answered first:

• Is medical care a right or a privilege? - If the United States doesn’t have universal health care, does this mean that some people deserve health care and others don’t? Do you deserve health care more than your neighbor? Do your neighbor’s kids deserve health care more than yours?

• Do I deserve better health care than you? - Different plans abound. President Obama and members of Congress, we’re told, have a so-called Cadillac plan; so do high-salaried corporation CEOs. A few other lucky people also have comprehensive insurance coverage that offers low deductibles, low or no co-pays, and coverage for everything from office visits to expensive chemotherapy and heart transplants. The rest of the insured must settle for the Smart Car plan.

• Should health care be contingent on employment? - Oh sure, you can buy insurance on your own (or not), but it’s very difficult and expensive. The idea of employers offering health care insurance evolved after World War II when companies were competing for workers. Offering a perk like health insurance was one way to attract potential employees. Until after the war, health care was mostly a pay-as-you-go system, but there wasn’t that much to pay for. There were no expensive drugs, bypass surgeries, MRIs or months-long chemotherapy. Children who were born with severe handicaps died, and there wasn’t much chronic disease because life expectancy was only about 60 years.

• Should anyone be getting rich from denying health care? - Insurance industry CEOs are making millions [and shareholders earning dividends] because companies are cherry-picking subscribers, fabricating stories about pre-existing conditions or dumping patients because of serious illnesses. There is no mystery about this; company representatives have testified before Congress about rescission practices and feel it is their right to act as they please because their goal is to make money, not see that subscribers get the care they need.

• Shouldn’t we be held accountable for staying as healthy as possible? – There are health problems we can’t control – genetic diseases, some cancers, accidents – but we can control lifestyle. How we eat and move, whether we get immunizations and wear seatbelts, and whether we smoke or abuse drugs and alcohol dictate the state of our health. These lifestyle practices also determine how much we must spend on treating illnesses. Just consider: In 2000, Californians spent $7.7 billion annually to fix health problems caused by its obese residents, according to the Centers for Disease Control and Prevention. Overweight Medicare recipients in New York cost the system $3.5 billion. In 2004, smoking-related illnesses cost the nation $97 billion.

• Should everyone get everything? – Do we spend unlimited resources on every person and if not, how do we decide who gets what? This may be the most difficult question of all, and American expectations and attitudes about the use of technology and other resources and death may have to change.

We had two European exchange students visit my home this past week. The young woman from Germany thought it both amusing and puzzling that health care in this country is a political issue. In Germany, there are public and private options and people pay premiums according to their income. If unemployed, premiums are paid for by federal and local government and by local assistance offices. Premiums never change because of health status and no one loses their coverage because they get sick. It may not be a perfect system, but there must be some lessons for us in there somewhere.

Medically Speaking, the Good Ol' Days Were Not Always So Good

I just finished watching a three-disk, seven-episode series on the life of John Adams, originally aired by HBO in 2008.

It’s a marvelous series and deserved the several awards it received.

“John Adams” chronicles the life of our first vice president and second president from prior to the signing of the Declaration of Independence in 1776 to Adams’ death on July 4, 1826 – fittingly the 50th anniversary of that document. (His political rival, Thomas Jefferson, died the same day.)

The production, starring Paul Giamatti and Laura Linney (as Abigail Adams), not only was a wonderful portrayal of Adams’ life and career, but an amazing depiction of the customs and mores of the day. In this present world of instant communication and gratification, it’s hard to imagine that it took days and weeks to travel from one city to another; months to get a letter from Europe; days and maybe weeks to make basic needs like clothing and soap; and months to grow, process and store basic food staples.

The miniseries also reminded me that in the late 1700s and early 1800s, the practice of medicine was just a notch above primitive. I admit to being simultaneously fascinated and horrified watching various scenes throughout the series that depicted common medical beliefs and practices of the time.

For instance, in one segment, John Adams is in Amsterdam, hoping to raise money to support our War of Independence. He contracts something that looks like a really bad case of the flu, suffering chills, cough, fever and maybe some body aches. Treatment of choice: blood-letting.

A Dutch physician makes a horizontal slice in Adams’ upper arm, places a copper bowl under the incision and compresses the skin around the wound. There are a couple of hold-your-breath moments as the doctor nearly spills the bowl of blood while chasing an agitated Adams around the room.

In another episode, Adams is away from his farm outside Boston attending the First Continental Congress in Philadelphia, leaving Abigail and four children to run the farm. A smallpox epidemic is spreading and Abigail makes the decision to have a local doctor vaccinate her and the children – a new and highly risky treatment at the time.

There were no syringes or sterilization in the 1770s, so to make the vaccine, the doctor brings what looks like a dying person with festering smallpox (kudos to the makeup artists) on the back of a wagon to the Adams’ front door. With a small knife, he digs around in one of the weeping sores, then crudely mixes the tissue that he obtains on a plate. He slices the arms of Abigail and the children, then places this infected bloody tissue inside the incision.

It was pretty horrifying and I could hardly watch – but I was riveted – and then I realized how lucky we are today.

Abigail and her three sons come down with a mild case of smallpox, while her only daughter, Nabby, suffers a full-blown case. She does pull through, though.

Perhaps the most difficult scene to endure, though, occurs after Nabby, then 42, is diagnosed with breast cancer, a dreaded disease even in the early 1800s. A physician and two assistants perform a mastectomy in an upstairs bedroom at the Adams farm with – I’m not making this up – a scythe. The drama did not show the actual mastectomy, but it didn’t take much imagination to figure out how the scene unfolded.

According to an account that you can read at http://www.shsu.edu/~pin_www/T@S/2002/NabbyAdamsEssay.html, this is not quite how it happened; it was actually worse. (Warning: The detailed description on this site is not for the squeamish.)

There was no knowledge of bacteria, no sterile procedure, no pain medication and no anesthesia, so the only help Nabby received was a drink of strong liquor and a padded stick to place between her teeth.

I’m working at erasing the memory of this scene and being thankful for the art and science of modern medicine.