One Hundred Hidden Dangers

— 'I didn't seek to be a school nurse. I was new to the city and I thought, 'I'll give this a try.' " Since giving it a try, Sandy Wright has been working with San Diego City Schools as a project nurse for 23 years. Wright is currently assigned to Benchley-Weinberger Elementary School in San Carlos. "I've worked with medically fragile children, special-ed children, hyperactive children, chronically ill children, and children with all kinds of developmental issues.

"I love it. Every day's a challenge. I have to be a generalist and know a lot of things. This is the hardest thing I have ever done. That's because you work independently, autonomously, you need to think on your feet, and you don't have a hospital backup behind you. We don't have a lot of resources, and most nurses aren't at schools every day, so you have to be well organized, and I like that. I really like seeing my interventions help children and their families. It's very rewarding." Originally from Pennsylvania, Wright worked as an intensive-care nurse for 18 years. "When I came out here, I went into public health, and they recruited me for the schools. Now I work two and a half days in the nursing office as a project nurse and two and a half days at my school."

Of all the health problems Wright and other school nurses face each day, none is as pervasive as asthma -- the most common manifestation of allergies. Because of her experience as a nurse and as volunteer at yearly asthma camps, Wright was approached by the San Diego Unified School District to develop an asthma intervention program. "People know that I am very passionate about asthma and kids miss time from school because of allergies and asthma. It's the chronic illness that causes school absenteeism, and those statistics reach all across the United States."

Wright's program, now three years old, has been adopted by the elementary, middle, and high schools in San Diego Unified. Its first step is identifying the number of chronic asthma students with frequent absenteeism and finding ways to keep them in school. "It started out as a survey, just finding out how many kids had asthma at each school. With that, there are usually food allergies, eczema, and other forms of allergies. We match it with the number of absences of each student. We then take the kids who really miss a lot of school and help the nurse to focus and intervene with those kids. These are kids who are missing [as much as 50] days. We've begun what we call 'asthma focus groups.' They're not mandatory, but they're for schools with high numbers of asthmatics or nurses who really want to learn from each other how we might approach the problem. They've been given information from me, equipment, and ways to approach it. We hope that when we measure it next year, these kids' absentee rates will be coming down. Part of this is making sure they have their medicine at school, they're taking peak-flow readings [a breathing test], talking to parents, the family doctors, structuring their environment and educating everybody, including the teacher."

There is a profile for asthma and where it is most likely to strike. "In San Diego and across the United States, asthma is most common in crowded urban areas. Ethnically, it's highest among the African-American children in urban areas, and that's usually because their environment includes things that trigger asthma, especially irritants. There also may be a prenatal connection."

Parents of children with allergies are often the key factor in reducing absences and making sure everyone knows what to do. "Some of them are protective. They feel like, 'I can't send my child to school because nobody will understand. My child is shy, he doesn't say anything, there's not a nurse there every day, the office staff won't know what to do.' On the other hand, there are parents who don't treat the asthma preventatively, but they understand it is very, very dangerous. Their kids will miss school because they're very sick and they haven't done the treatments that the doctors have prescribed. They're too sick to come to school, so they don't. We're kind of a liaison between all that. We make sure that we have all the information, and then we make up a care plan for that student."

Asthma tends to be predominant in younger children, but it doesn't go away with age. "You never outgrow asthma. Asthma changes in a lot of people as they approach adolescence, then reemerges in young adulthood, usually in the 20s. If kids have gotten really good care and if there's not a lot of lung damage, they will do better as adolescents and young adults and won't have intensive episodes."

Next to asthma, the biggest allergic problem in schools is food allergies. "More and more children are experiencing them. I don't mean intolerance or lactose intolerance or adverse reactions -- that's not the same as a food allergy. What we worry about is the child who ingests food that can go into anaphylactic shock. Dairy products, peanuts, tree nuts -- those are high allergens. The most common are wheat, corn, dairy, and nuts."

Parents, particularly parents who have witnessed anaphylactic shock, are not shy about letting the school know their child's food allergies. "Those parents are very concerned and let us know about it. Their [child's] diet is altered. Sometimes we have emergency medication at the school. Every child that has a severe anaphylactic reaction has an Epi-pen kit. The nurse requests it, and it is kept at school. Not only does the nurse know how to use it, but someone else at the school -- sometimes two people -- know how to administer it. That's within our policy and law. It goes on field trips. When kids get to be about 15 or 16, the child is taught how to do it.

"Sometimes our nurses diagnose allergies. It could be from infants who had feeding problems, a child who got hives or developed asthma -- the nurse will recommend that they see an allergist, which is my bias and what I recommend for care and follow-up. I'm sure all school nurses have experienced this. Sometimes parents don't know why the child is having hives or eczema or whatever, because you can eat things or take medicine for a number of days and not really have a bad reaction. Then the body gets its level, and it goes over the line. Treatment and management has gotten better over the last ten years; specifically, the last five. If parents access that and are compliant, I think they will get very good care for their children's allergies."

The seriousness of food allergies is often not understood until someone has witnessed the adverse effects. "One year, at asthma camp, there was one little boy who was allergic to dairy. I'm talking very allergic. We had to monitor his diet, read all the labels. That's very important, because you often don't think of casein and things that are milk proteins as milk or dairy. He knew and we knew. What he did was, there were corn peels -- you know those orange things with a lot of powder on them, it's a snack food -- Chee-tos or Doritos? We always called them corn curls. He didn't eat any. He just touched one and went into anaphylactic shock. We were in the San Bernardino mountains, and we had to get him down the hill to a hospital. He was very close to being 'trached' [getting a tracheotomy -- a breathing tube inserted externally into the throat] right there at asthma camp. The camp is staffed by nurses and doctors and respiratory techs, and a doctor drove him down. We had him intubated and were 'bagging' [assisting respiration] him all the way down. I've never forgotten that.

"The parents of kids who have these severe food allergies know that their kids can die. They may become overprotective or compulsive. It is very appropriate that they take the measures that they do. It's very appropriate that the whole school know -- the teachers, the bus drivers, all the people. They've had to rush their kids to the hospital because a mistake has been made, and they know their children can die. Other people, those who don't understand this, need education. Take M&M's. Some kids are allergic to nuts but not to chocolate. But in M&M's, the chocolate has ground nuts in it to make it thicker. Parents have to be careful. A child in my school a few years ago was allergic to fish. One day he thought he was eating chicken nuggets in the cafeteria when, in fact, he was eating fish. I don't know why he thought it was chicken, but he came to my office and his tongue was two inches thick and his lips were closed. It was a 911 call that ended up at Balboa Hospital -- the whole deal. I've had kids at asthma camp, where if there was food cooked in peanut oil, they couldn't be anywhere near it or they would go into anaphylactic shock. I take parents very seriously. They may seem to overcompensate, but they don't want to lose their child."

When the allergies are severe or unique enough, relations with other children can be a problem. "We had a child, several years ago, with a skin allergy. He had asthma and was on nine medications. His eczema and atopic dermatitis was so severe that he looked like a lizard. I would go into the classroom every year and talk to the class. Let's say his name was Ben. I would say, 'You can't get anything from Ben.' I would touch him and say, 'Ben's my friend. He has a skin problem, but he's just like you and me.' Sometimes his mom would come in with me. She tried to keep him in long sleeves. After things were explained, he got along fine with the other kids. But when you first see a person like this, it's really frightening, especially to young kids. Older kids can understand this. We protected him from the sun and made sure he took his medication and used his skin cream, but we had to explain it to the kids. As a result, 'Ben' was shy and needed help to break into the group, because he knew he was different. It's horrible. He grew up to be a fine young man, and now he's been diagnosed with Crohn's disease. I am very sorry that he's continuing to have medical problems."

Allergies are not always easily identified and often require detective work. Wright recalls one student who was missing a lot of school with no apparent explanation. "He had asthma. His mother was a nurse, very competent. He got good medical care and was on the right medication, but he would come to school and start wheezing. It was so severe that I'd send him home and to the doctor. Two days later, he'd come back, and it would happen all over again. Now, they had rats and guinea pigs in the classroom, and although he was not allergic to those animals, I thought the protein in the urine or the dander or whatever was probably causing this. I couldn't get the teacher to remove those animals, because the child didn't test allergic to those animals, but after five weeks, I knew there had to be a connection. I started to read and even wondered if the kid was allergic to the print on the page -- I'd had a kid some years earlier who was and had to wear a mask when reading. When everything's in place and the child doesn't get better, we've got to become detectives and figure it out. Finally, I found out that the feed of guinea pigs and rats had peanut shells, and, therefore, the oil and skin of peanuts. This young man was anaphylactically allergic to the feed. He had come in with hives several times. After I figured that out, they were immediately removed. He was much better after that. For a kid who's never had a guinea pig or dogs or cats, the parents may not even know."

Wright believes informing the schools is the strongest tool in fighting allergies. "It's an important problem. Schools can manage if they know. We need to know the children who do have allergies. We need to know how they react. What kind of allergy is it? Do they get hives or do they stop breathing? We need to know all that information. Don't tell us your child has an allergy when they get an upset stomach from milk. Tell us what we're dealing with. We want allergic kids to have Epi-pens. We're capable of giving them and training others to do so. We'd like them to have everything written down and ready for the teacher, so we can teach room mothers and other people what we're doing."

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