School nurses in more demand for mental health issues

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WINTHROP — On a recent morning, Rachel Miville was focusing on the health needs of at least eight children.

At one point, Miville received a visit from two JV basketball players at Winthrop High School, a boy with a swollen ankle and a girl with an inflamed toe, who both worried they’d miss their games against Lisbon High School the next day.

While dealing with the basketball players, Miville also assisted two other high-schoolers. One declined to be observed by a reporter. The other, a junior, hit her head recently, and Miville gave her a short neurological assessment, asking how she was sleeping, how her balance was, and other questions.

Then Miville, who has worked as a school nurse for 10 years, grabbed a walkie-talkie, threw on her coat, left the building and made the short drive to Winthrop Middle School. One student complained of swollen lymph nodes, another had an ear ache, and a third asked to see her later in the morning. In between talking with students, Miville was communicating with other staff members of the Winthrop School District via text message.

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It seemed like a busy morning, but it was a typical one for Miville, the only nurse in a school district of about 900 students. Besides going between the middle and high schools, which are next to each other, “Nurse Rachel” also makes trips to Winthrop Grade School, more than a mile away, and to students’ homes.

“No matter what (school) building I walk in, it’s consistent like that,” she said. “School nurses have this reputation of giving out Tums and putting Band-Aids on, but it’s not like that. I make home visits. I’m often the first in line to catch things. … Do they have adequate food, water, access to heat?”

Given the growing number of health and social problems facing Maine children, Miville and other Winthrop school officials say the district’s nursing services could use even more support in the future to ensure students are healthy and ready to study.

The problems include a rise in children being diagnosed with complicated, chronic conditions such as diabetes and asthma, as well as mental illnesses such as anxiety.

In the Winthrop School District, Miville is overseeing 122 students with asthma, 51 with anxiety or depression, 36 with life-threatening allergies, seven with seizure disorders, and six with diabetes, she wrote in an email. She was not immediately able to provide multiple years of data, because the numbers were not saved in one place or in an easily comparable format.

At the same time, the number of low-income Maine children enrolled in federally subsidized health care programs has been dropping, leaving many school nurses on the front line in recognizing health problems. And with the nation’s ongoing opioid epidemic, the rise in substance abuse among adults has also harmed children in various ways.

“The health problems of students are certainly more dramatic than they were 17 years ago when I started this job,” said Ann Bouchard, of Waterville High School, who was recently named school nurse of the year by the Maine Association of School Nurses. “We have kids with chronic health conditions that are physical, but we also have a large number of kids with serious mental health issues, including skyrocketing levels of anxiety.”

Deborah Hagler, a Brunswick pediatrician who serves as vice president of the Maine chapter of the American Academy of Pediatrics, agreed that mental health and behavioral health problems are growing among children, and said that those ailments can manifest in physical symptoms.

“The data supports that,” she said. “I’m sure the school nurses see that in the form of belly aches, headaches, students who are tired. We see that more and more.”

Told how many students Miville is responsible for in the Winthrop schools, Hagler added, “It would depend on how many children have complicated medical needs, but I would assume that’s not optimal. That’s a lot of little people for one person to potentially administer and keep track of medications. … You don’t know if a child is using an inhaler the right way, or has the correct insulin dose.”

No recent information was available about the average staffing levels of nurses in Maine school districts. In 2008, the National Association of School Nurses found that the average school nurse in Maine oversaw 602 students, the ninth lowest rate in the country.

In 2016, the American Academy of Pediatrics recommended that there be one full-time, registered nurse in every school building — a threshold that school districts like Winthrop don’t meet.

While school counselors, health aids and other staff can play an important role in the care of children, it’s best to have a registered nurse who can perform physical health assessments, according to Ilmi Carter, a school nurse in Rockland and president of the Maine Association of School Nurses.

Not only can nurses free up time for teachers or administrators who may have to attend to students, they can also pinpoint what’s causing a complaint and prevent the student from having to leave school for the day, Carter said.

They can also catch more serious problems, particularly among students whose guardians can’t provide them with steady health care, said Janis Hogan, a school nurse in the Camden area who is Maine director for the National Association of School Nurses.

On one Monday morning, Hogan said, a boy came into her office on the instruction of his mother and asked her to look at a circular rash.

Hogan suspected Lyme disease and instructed the parents to bring the child to a doctor, who put the boy on antibiotics, Hogan recalled. But that night, the boy was taken to the hospital with a high fever and diagnosed with Lyme carditis, in which bacteria was attacking his heart.

Lyme carditis “can be fatal,” Hogan said. “He was sent to Barbara Bush Children’s Hospital and was in the ICU for close to a week, so I wonder what would have happened if he hadn’t come here.”

On the recent morning in Winthrop, Miville also called several parents and asked them to bring their kids to the doctor. She gave the basketball players ibuprofen and other remedies, but offered no assurances about their games the next day.

“I’m really wanting to play tomorrow,” said Noah Dunn, a freshman, who was icing his wrapped-up ankle in Miville’s office and intermittently scrolling through his phone. “I hope I can.”

“If anything, you need to go home, so you can be off that foot,” Miville told him.

In fact, Miville’s workload this year has been be slightly lighter than it was one year ago.

Until this year, the Winthrop School District has employed a full-time health worker to assist her in the grade school. But this year, it was able to pay a second health worker to assist her in the middle school, after receiving extra funding when it took a student from Fayette, according to Superintendent Gary Rosenthal.

The extra set of hands has helped, Miville said, because “I would have had to run up here at least three more times if she wasn’t here.”

Still, both Rosenthal and Miville say the district could use even more nursing support. While Miville recognizes the budgetary constraints facing the town, she thinks the town should hire a second full-time nurse.

This past summer, town councilors suggested they might be willing to raise funds for another health worker position, but that funding was dropped from the final budget.

“These are family issues and home issues and social issues that we have no control over but that we have to deal with every day,” Rosenthal said. “The nurse is the best liaison who deals with this stuff every day.”

Winthrop school nurse Rachel Miville, left, calls the parents of Noah Dunn, right, to come and pick him up after she wrapped up his ankle in her office Thursday at the high school in Winthrop. (Joe Phelan/Kennebec Journal)

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