With a sore throat and a rising fever, the boy comes to the grade school sick room just as classes begin. The parents hope the school nurse will look at him, provide some comfort, decide whether he should see a doctor. Why wasn't the child kept at home, the nurse wonders, and will there be anyone there if he is sent home?
"Parents are sending sick kids to school, leaving them for the nurse. It's the kind of problem you wouldn't have seen 10 years ago, and it's becoming more common," says Dr. John Krager, Baltimore County's deputy health officer.
"The need for school nursing services has increased three times, maybe even 10 times, in recent years."
The job is more than bandaging playground cuts and taking temperatures: The school nurse today is seeing sicker children and more of them, with a greater range of health problems.
The nurse's office increasingly has become a sort of front-line emergency room or triage station. The impact is especially felt in Baltimore County, the only Maryland county with a full-time registered nurse in each school.
"If anything happens at home, some parents will just send the child to the school nurse to have a look at it, to see if they really need a doctor," says Shirley Steel, president of the National Association of School Nurses and the coordinator of Baltimore County secondary school nurses. It could be a contagious disease or a twisted ankle from after-school play, but it didn't just happen at school, she said.
"Times are different. Parents in the past might take a child straight to the doctor, but that's $50 or $60, and more people just don't have that today," Ms. Steel said.
Lack of health insurance or bare-bones policies are major reasons for the increased traffic in the school nurse's office.
"We see a lot of people in the gray area, without health insurance or Medical Assistance, and the children come to us," said Lorraine Cooney, the nurse at Logan Elementary School in Dundalk for 14 years.
"But we're limited. We can't give a diagnosis, we can't prescribe medicine, we can't take throat cultures.
"We can assess their [children's] condition and say 'please take them to a doctor immediately,' but even then they may not have the money to do it."
With sicker kids coming through the nurse's office these days, Mrs. Cooney says she makes more follow-up calls to parents to see if the children are getting proper treatment.
More and more, school nurses have to be skilled at finding medical help for desperate parents: county health department clinics, the county teachers' Kids Care fund, service organizations such as the Lions Club, or doctors and dentists willing to donate services.
"It's not that they don't want to spend the money for medical treatment but that they want to make sure it's absolutely needed, because there are other basic family needs, like food and shelter," says Robert Mehl, the nurse at Stemmers Run Middle School in Essex.
"There's more personal pressure on me not to over-refer [to physicians] in these cases; you have to be conscious of family resources."
Unfortunately, in some cases they may wait until the problem becomes serious enough to warrant treatment in a hospital emergency room, "where people know they won't be refused care," he added.
About one-third of the children at his school did not list a primary doctor on their records, an indication that many have not recently seen a physician, says Mr. Mehl, who sees about 60 children in an average school day.
School nurses also find themselves checking on healing wounds of pupils and changing dressings if needed. "Parents don't seem to have the money for bandages," Ms. Steel said.
With an estimated 570,000 Marylanders doing without health insurance, that may not be surprising. But affordability of medical care is only one reason for heavier workloads on school nurses.
Growing numbers of latchkey kids, without a parent at home to care for them, and the increasing pressures to place disabled children in mainstream schools have also expanded the need for their services.
"You have more families with two parents working, or single-parent families, and they send the child to the nurse because there's no one home to keep them in bed," said John M. Mead, director of pupil services for Harford County, which has a nurse in nearly all schools.
Nurses not only have to determine if a pupil is too sick to remain at school, but then they must spend time tracking down parents at work and arranging for the child to be sent home, he noted.
With more handicapped and medically fragile children in the public schools, nurses may find themselves cleaning catheters, helping with feeding tubes, administering prescription medicine or assisting a child in a wheelchair in the restroom.
"Schools are seeing more kids with complex problems, who 10 years ago would never have left the hospital because of their conditions," said Dr. John Santelli, Baltimore City's school health director.