Notes From a School Nurse

From asthma to AIDS, her role has undergone a revolution

Markeia Johnson, usually quiet and reserved, breaks into the broadest, brightest smile--so big it's visible from the top rows at the back of Roy Wilkins Auditorium. It's graduation night for the seniors of St. Paul's Central High School. As Johnson's name is called, she walks across the stage, her stride slightly lopsided. Before descending the stairs, she flips the tassel from one side of her mortarboard to the other. The 19-year-old has been practicing that for days.

High up in the audience, Johnson's family jumps up, shouting, applauding, and whistling as Johnson smiles so far below.

In another corner of the auditorium, someone else watches just as excitedly--a person who has become as much a part of Johnson's family as the group high up in the stands: Sue Will, licensed school nurse. Will has been a constant presence in Johnson's life since last fall, when Johnson suffered a massive stroke. Doctors did not believe the senior would survive, let alone graduate, so it's something of a miracle that she's with her classmates today.

"Oh my gosh," Will says later. "There are things in life that move you substantially. Being able to see her walk across that stage, and that big smile. It gives me chills.

"You just don't think about these things with kids," she says. "Kids are supposed to go to school and graduate and all these things. But some kids have a harder struggle with it than others."

 

Sue Will is one of those instantly likable people, with an easy laugh and an inquisitive nature that makes you feel like whatever you're telling her is extremely interesting. Her mind seems capable of following a dozen scattered threads of information at any given time, dropping one thought for another, then another, then refocusing on the first. ("I'm so used to distraction," she jokes. "If I have a full thought it scares me.") Her figure, at once matronly and compact, is nimble as she chases through Central's hallways (at her side is her "squawkie," a walkie-talkie that alerts her to any crises in the building), fetching kids who have medical needs.

At first it may seem that Will's job is simply handing out Band-Aids and taking care of tummy aches--like a lunch lady with a first-aid kit. But it soon becomes apparent that her real, often unrecognized mission, is to protect the public health. These days, she and her school-nurse colleagues train a watchful eye on as many kids as they can, all the while adapting to the intensifying dangers to students' health, from poverty to unstable family life to serious disease.

Will offers a history lesson to emphasize the point. This year marks the 100th anniversary of the hiring of the first public-school nurse in New York City, she explains. Back then the major concern of school nurses was containing and preventing contagious diseases. Today the main goal is to curtail threats to the public health while helping students stay in school.

"This job has changed, the issues have changed," Will muses. "But kids are kids, and families are families. Our role continues to be to try to reduce the health barriers to kids' success."

But the challenges are far broader, from immunizations to ADD and chronic fatigue syndrome to broken legs to depression and suicide to tobacco to pregnancy and AIDS. And the trickiest part of the job is that the nurses have no idea which of the problems might arise on any given school day.

It's a warm May morning, a little after 7:00 a.m., and Will has only just opened her office door when the kids start pouring in. One girl needs a note to get out of gym class (they have swimming today, and she had her period). One boy shows Will his jammed finger and asks her to wrap it up ("It's called a buddy tape," Will edifies as she tapes the swollen finger to its neighbor for support). Another girl wonders why her arms are so sore (repetitive stress from the girl's assembly-line job, the nurse hypothesizes as she hands her an ice pack).

All the while a seemingly endless parade of teenagers seek their daily medications: anti-depressants, asthma and allergy pills, drugs to counteract Attention Deficit Disorder. They come in even as Will is talking with other students, taking temperatures, assessing symptoms. The nurse goes to the cabinet where she stores the prescriptions, then doles out the correct dosages. The interactions are routine and brief, and Will sends the students along to class with a standard phrase: "Make it a good day!"

Though the time she spends with each student is minimal, it's clear that Will has gotten to know the kids over months, even years. This morning one student comes in, eager to share pictures from the school's recent prom. The girl hands the nurse one photo to keep--a snapshot of Will sitting with Markeia Johnson. Will tacks it up on the wall next to her desk. When Johnson comes in later, Will shows her the photo, beaming, even as she checks to see how the student is feeling today.

With some of the students who march through the nurse's office, Will might have to do a little detective work, try to figure out whether they are physically ill, or depressed, or both, or neither. Often enough the ailments are simple viruses, and Will instructs the kids to drink lots of liquids and get lots of rest, sometimes directing them to one of the two cot rooms (one for girls, one for boys) to sleep for an hour. Her tone is at times skeptical, especially if it seems that a student might be pulling a fast one. But it just as quickly melts into a gentle compassion when she's talking to a student with a genuine problem.

 

During this past academic year, St. Paul public schools employed nearly 50 full-time nurses; about 16 of them split their weeks between more than one school, explains Ann Hoxie, interim administrator of student wellness for the district. Assignments are based on the number of kids in a school and their needs; schools can also decide to spend part of their budget to have a full-time nurse on site. Of course, Hoxie and the School Nurse Organization of Minnesota wish that St. Paul, and the state as a whole, had more school nurses, but funding is difficult to come by, as budgets tighten and everyone is expected to do more with less.

To be licensed in Minnesota, school nurses must be registered nurses with a four-year degree, and they must have a certification in public health. It's essential, Hoxie says, that school nurses have adequate healthcare skills, but they also need to understand health in the context of school and learning. "We're a big part of the safety net," she explains. "We're the only person in the school with a health footing, but we also look at things differently than our healthcare colleagues."

Will, 54, knows firsthand about the importance--and the evolution--of the institution. She first became a school nurse in 1969, and went on to hold a variety of positions in Minneapolis, Stillwater, and St. Paul schools. In those early days, the issues Will addressed were more along the lines of teaching four-year-olds not to pick their noses than of creating daycare centers for children of adolescent mothers (a task she took on later in her career). In 1993 Will accepted an administrative job working on environmental-health issues with the St. Paul school district. In 1999 she returned to the schools as Central's nurse.

"There was more of everything when I came back," she says, chuckling. As the only nurse for Central's 2,300 students (a ratio three times as high as that recommended by the National Association of School Nurses), Will finds herself busy all day, playing a number of roles. She's often the first to diagnose a student's illness. Or the person who ends up plugging a hole for families with no health insurance, recommending ways for them to get coverage or find low-cost clinics. Or her work is preventive, from tracking immunizations
to promoting healthy behavior. Or she is helping to manage chronic health problems.

In recent years, Will has noticed an increase in mental-health concerns (she sees numerous teens who are depressed, sometimes even suicidal). And she has also marveled at the rise of individualized planning to accommodate kids with special needs, including those with permanent medical conditions. During the span of Will's career, the law has changed to require schools to provide accommodations for kids with disabilities and health conditions. Plus, advances in medicine and technology make it possible for kids who once would have been homebound to go to school.

"Kids live when they wouldn't have before," Will says, matter-of-factly. "And the healthcare industry, they don't keep sick people anymore. These kids are right back in the community in a day or two. Kids are back to school much sooner. We need to be aware of what a child needs to manage himself medically at school--and be safe at school."

 

Markeia Johnson pulls out two photo albums. The first is filled with her senior pictures. In them, her long black hair frames her broad forehead and grand, toothy smile. Johnson looks at the photos and laments that after they were taken, she lost her hair; it has only just started growing back. The second album is filled with snapshots from last fall, when she lay in an intensive-care unit, comatose, connected to too many tubes to count.

Johnson was never sick until her junior year. She had had no contact with the school nurse, recalls her mother, Shellene Johnson. But then, in 2000, Markeia was diagnosed with a severe form of lupus, a disease that can cause pain, fatigue, sometimes death. The diagnosis brought the family in contact with Sue Will. Shellene Johnson was impressed by how the school nurse tracked her daughter's medication, organized a special education plan for her classes, and arranged transportation from the front door of her Lauderdale home to the high school.

One morning last October, Johnson went to wake her daughter. Markeia's eyes were dilated, her speech slurred. Shellene Johnson recognized the signs of a stroke. Paramedics took the girl to Regions Hospital, where Markeia lay in a coma for seven weeks. "They said she was brain dead," Shellene Johnson remembers. "She was paralyzed. She wasn't going to make it.

"I called the school right away," she continues. "Sue came that very same day."

Each year several of Will's students have catastrophic, crippling emergencies, from serious car accidents to emergency surgeries. But if you ask her about the worst health crisis she's faced in her career, the answer comes quickly: Markeia Johnson. "The physicians," she confides, "didn't expect her to survive."

Will visited Johnson three times a week while she was in the hospital. "The connection with the school needs to be maintained during the acute phase of the illness," she explains. "It helps me to know what's going on and what we need to do to take care of her."

Will arranged to have someone read to Johnson each day, to make sure she had some auditory stimulus, even in the coma. And she planned ahead in case Johnson did get better and did come back to home and school. "You really act like a crystal, or a prism," Will says, describing her role. "There are so many things flying out there, and you pull them in and then fan them out in an organized way."

When Johnson returned to school a few weeks after she awoke from the coma, Will arranged for her to come back only half-days at first. She also worked out Johnson's classes to make sure she'd have the credits to graduate, but with a manageable schedule, and courses that took into consideration the reduction in her cognitive skills caused by the stroke.

The effort was nothing short of heroic, in Shellene Johnson's eyes. "We wouldn't have made it without the nurse," she says. "Sue was like Johnny-on-the-spot. She was a liaison between me and everyone there. I didn't have to worry about calling any teachers. She took the strain off of me.

"Had I not met her, I would have had a panic attack," Johnson continues. "But she did so much. She's got back-to-back kids. She's routing them all. Right away she knows what everyone is coming in for, because she knows her kids."

As much as she helped Markeia Johnson get back into the swing of school, Will also helped Shellene Johnson adjust. "She helped me to feel comfortable," Johnson says. "I thought [Markeia] wasn't quite the same, but other people would say, 'No, she's fine.' Sue said she saw the same thing. She's not the same as before the stroke."

 

It's the morning of graduation, and Markeia Johnson is a little antsy about getting to rehearsal on time. But she lights up when you ask if she's eager to graduate. "Yeah," Johnson starts to say, a grin opening up across her face.

She's excited about her summer plans: Thanks to Will, Johnson is enrolled in a program offering vocational training for students with special needs. Johnson will be taking cosmetology classes to see if that's a career she might do well in.

Across town in her office at Central, Will is winding down as the school year comes to a close. In these waning days the seniors are already out of class, so the stream of needy students has slowed to a trickle. She plans to work at the graduation ceremony tonight, to make sure there aren't any last-minute problems for the students with health conditions.

And, on a personal note, she can't wait to see Johnson graduate. "Watching her graduate is just going to have me in tears," she predicts.

With the number and variety of issues and the isolation of the practice, being a school nurse is a hard job. But Will will be back next fall. "It just feels right. It works," she says. "I impact people's health where they live their lives. Nurses in hospitals, they get a couple days with the person. Shoot--I get four years."

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