School nurses on front line of health care as district seeks cuts

Michelle Theriault Boots
Denise Brakora talks about her roll as school nurse at Begich Middle School on Tuesday, December 10, 2013 in her office.
Bob Hallinen
UAA nursing student intern Miriam Kipngeno checks the ankle of Alena Russell who twisted it during recess. Kipngeno is interning with Sand Lake Elementary School nurse Jordis Clark on Tuesday, December 10, 2013.
Bob Hallinen
UAA nursing student intern Miriam Kipngeno listens to Sand Lake Elementary School nurse Jordis Clark as she explains what she is seeing in the ears of student Bella Cardenas who reported sick on Tuesday, December 10, 2013.
Bob Hallinen

You can learn a lot about a school by spending a few hours in the nurse's office.

At Sand Lake Elementary, there are bellyaches, playground falls and diabetic kids counting the carbohydrates in their lunches. At Begich Middle School in Muldoon, nurse Denise Brakora functions like a primary care provider, monitoring a parade of untreated ear infections.

At Service High School, to a girl "asking for a friend," nurse Panna Jarussi tells a cautionary tale about the hazards of a strain of synthetic marijuana showing up at parties. (Psychosis and death are among them.)

The nurse's offices at three schools in three corners of Anchorage have something in common: They are never, ever empty.

But as busy as they are, nurses aren't immune from budget cuts at a time when the Anchorage School District must slash $49 million over the next two years.

The school district employs 112 nurses: 94 school nurses and 18 health treatment nurses who rove from school to school helping the most medically fragile students, some of whom rely on ventilators to breathe and feeding tubes to eat.

On an average day, the nurses see 2,700 children for illness, injury or medication, making the district one of the largest providers of pediatric health care in the city.

By comparison, the Anchorage Neighborhood Health Center sees 1,000 children a year, said executive director Kimberly Cohen.

The numbers can be staggering. At Sand Lake Elementary, the district's largest, Jordis Clark saw an average of 43 children a day in November, according to her records.

At big high schools, where the population tops 2,000 -- roughly the size of the town of Cordova -- nurses might see 80 kids in a day, according to Nancy Edtl, the district's head of health care.

In recent years, the Anchorage School District has expanded its staff of school nurses to keep up with the growing medical needs of 48,000 students.

Middle and high schools have long employed a full-time nurse. But elementary schools used to have part-timers or circuit-riding nurses who traveled from school to school during the day.

The breaking point came in 2006, Edtl said.

At the time, a group of elementary principals, spooked by the increasing numbers of students coming to school with complex and potentially life-threatening chronic conditions such as severe asthma and diabetes, warned district officials that not having a trained nurse all day could be disastrous. Without someone watching closely, a child with poorly controlled diabetes could slip into a coma.

That came close to happening, Edtl said.

"Sometimes we weren't there when the kids crashed."

The district added enough positions to put one full-time registered nurse at every noncharter elementary, middle and high school.

But now, with a budget crisis looming, that arrangement seems fragile.

At the end of last year, 10 nursing assistants working in Anchorage high schools had their positions eliminated as the district shaved about $20 million from its budget.

With millions to cut in each of the next two years, officials have warned that layoffs will likely go deeper into core areas, including classroom teachers.

Yet even as the district is looking for ways to spend less money, the role of nurses has expanded with increases in childhood chronic illnesses and poverty.

In the past decade, the percentage of children who qualify for free and reduced lunches has nearly doubled, rising from 26 percent to 48 percent.

Poverty among students brings a host of physical, mental and emotional issues that wind up in the nurse's office, nurse Brakora said.

People who don't work in schools still imagine the job as dispensing Band-Aids, she said. They don't realize that for an increasing share of district kids, the school nurse may be the only health care provider they ever see.

Nurses say they hope the Affordable Care Act may help cover previously uninsured students. But for now, at Begich Middle School, where more than two-thirds of students come from economically disadvantaged homes, parents send sick children to school so they can see the nurse.

"They truly use us as a primary care provider," Brakora said.

On a recent day, a shaggy-haired boy came in with an ear infection.

Brakora pronounced it worse than before.

The boy left a message for his dad and on his way out mentioned he needed ice for an injury suffered when he "saw a kid getting jumped" in the woods off campus and intervened.

Brakora counseled him against violence, even if for a good cause.

Nurses say they are uniquely situated to know the most intimate details about students' lives.

They hear first about pregnancies and sexually transmitted diseases. They know that students who come in with an afternoon stomachache might, after a few questions, admit they haven't had anything to eat since the previous day's lunch.

They try to save students from the humiliations of poverty by dispensing donated snow pants and keeping stashes of applesauce and goldfish crackers on hand for kids whose parents haven't gotten it together to get them on the free-lunch rolls.

They also deal with lice infestations and give flu vaccines -- 17,000 this year. They perform mandatory tuberculosis screenings and sometimes act as stand-in social workers. One time, Service High nurse Jarussi arranged for swim lessons for a boy who lived in a decrepit trailer and had such poor hygiene he was bullied. The swim class was the first thing in the morning, guaranteeing the boy a shower.

Sometimes the nurse's office just offers a quiet bathroom to throw up in.

The nurses themselves tend to be wisecracking women (only four nurses districtwide are men) with highly calibrated nonsense detectors.

"Are you playin' me?" Jarussi often asks.

"Is this an owie or an injury?" is Clark's elementary school version of the same question.

Most have worked in another setting: hospitals, clinics or even jails. Hospital nursing pays more, Edtl said.

But nurses want to work for the school district because it offers autonomy: Usually, the school nurse is the sole health care provider in the building.

For that reason, she won't hire people without at least two years of experience.

"They have to be able to recognize the different between 'my stomach hurts' and 'this kid has E. coli.' "

Jarussi makes those calls daily.

The scariest case Jarussi has seen in recent years was that of a boy who showed up in her office with unevenly dilated pupils, drooling like a baby, in the midst of a psychotic episode and running a temperature of 105 degrees. He had taken spice, a synthetic marijuana.

On a recent morning, mundane ailments make up the parade of visits to her office.

A whisper-quiet boy with a sprained ankle. A boy who lives in the state foster-care group home across the street who wants to lie down for a while.

Before lunch, Jarussi gets a radio call that a girl has lost consciousness outside her classroom.

She sprints down the hallway, dreadlocks bouncing behind her. The diagnosis: A possible seizure. She calls the girl's parents. They want to know if she can still take the bus home.

Reach Michelle Theriault Boots at or 257-4344.