If she didn't have six schools to cover, Maureen Shapiro would be at John Muir Middle School every day to make sure the teenage diabetics didn't head to lunch with their friends before checking their blood glucose levels.

Fortunately, Shapiro was there on Wednesday. In a tiny room off the attendance office, a girl who had been skipping her blood sugar checks that week came in at 26 milligrams of glucose per deciliter, a level easily low enough to render someone unconscious.

Minutes later, a boy had hit the other end of the spectrum, registering a 452 on the blood sugar meter. Anything over 250 or under 70 is considered cause for concern.

But both kids told the nurse they felt "fine" — and, Shapiro suspects, they might have gone about their days as usual if she hadn't intervened. With his father's permission, she took the boy to get the insulin he had left at home.

"If I wasn't here today, what might have happened?" she wondered.

Those who assume every school has a nurse who sits in an office and waits to disinfect skinned knees and take temperatures are sorely mistaken. Shapiro is one of just two nurses for the 8,700-student San Leandro School District; Julie Greenfield, a nurse in Hayward, covers seven schools with more than 6,000 children.

The recommended student-to-nurse ratio is 750 to one, but few districts in California, if any, come close.

"Any way you look at it, they're obscene ratios," said Nancy Spradling, executive director of the California School Nurses Association.

Need a Band-Aid?

At San Leandro's Wilson Elementary School last week, tearful childrened trickled into the office with bumps and scrapes. But for the most part, the office staff tend to the playground injuries. Shapiro, who visits the school only about once a week, focused her attention on a young diabetic girl who needed a dose of insulin.

As school districts try to make budget cuts "away from the classroom," nursing staff is often one of the first to go. At the same time, nurses say, they are seeing more acute and chronic illnesses — conditions that require constant monitoring, staff training and coordination between families, doctors, clerical staff and teachers.

Ten of Greenfield's patients have Type 1 diabetes, a disorder that affects the body's natural ability to produce insulin, a hormone that regulates blood sugar levels.

The condition, which requires regular blood sugar tests and insulin injections, is estimated to affect one in 400-500 children. Researchers are still trying to determine the risk factors for the disease.

Greenfield and her colleagues — who also are responsible for conducting thousands of hearing, vision and scoliosis screenings each year — carry cellular phones. Sometimes it takes 20 minutes to get to a child in need, but, so far, they have managed to avoid a major crisis.

School staff are directed to call 9-1-1 in an emergency, even if a nurse is present. Still, Greenfield added, "Some of the emergencies wouldn't be emergencies if we had somebody who knew how to take care of them."

A matter of responsibility

Children's health advocates argue the shortage of licensed professionals on staffs at many school districts make it difficult for medically vulnerable children to thrive, and in extreme cases, could be life threatening.

Some districts, such as Oakland and Los Angeles, have added or plan to add nursing positions. In fact, Oakland is hiring at least one nurse to monitor only diabetes cases, said district spokesman Alex Katz.

But others, such as New Haven Unified, have only one nurse. Some don't even have that.

Meanwhile, a legal debate is brewing about who should be allowed to monitor insulin injections if a parent or a nurse is not on hand and the child isn't old enough to take the drugs without supervision.

A class action lawsuit filed last October by the American Diabetes Association on behalf of four children alleges the California Department of Education as well as the Fremont and San Ramon Valley school districts have failed to provide appropriate diabetes care. 

To comply with federal disabilities laws, the plaintiffs argue, schools must provide trained staff — even if they don't have a medical license — to monitor blood glucose and to help with insulin or other needed treatment.

The California School Nurses Association's position, however, is that only licensed personnel or parents can administer insulin.

Larisa Cummings, a staff attorney for the Disability Rights Education & Defense Fund, said the nurses association has an "unduly restrictive view."

The Berkeley-based advocacy organization is working on the class action case.

"It's the kind of thing that lay people do all the time," Cummings said. Expecting a parent or caretaker to provide that care, she said, creates "unnecessary strain on all those involved."

Cummings said attorneys are in discussions with the California Department of Education about the agency's stance on the issue.

"We strongly support the presence of school nurses, but the numbers are so off right now that it's unrealistic to propose that as the only solution," Cummings said.

Staying close at hand

Brenda Broussard is thankful she's self-employed. She has arranged her day around the lunch schedule of her 9-year-old granddaughter, Najwa Sneed, who doesn't flinch when she pricks her finger for blood tests.

Almost every day since Najwa started kindergarten, Broussard said, she has made sure to stay close to school in case of an emergency.

Sometimes she wonders what would happen if she couldn't make it in time and Greenfield was tied up elsewhere.

"They want me there every single day, and sometimes, that's not possible," she said. "In the event that Julie's not there and I'm not there, what are they going to do?"

But Broussard said she had mixed feelings about the idea of unlicensed staff members helping her granddaughter administer insulin. In a sense, it would be a relief — and it would also allow her to help other diabetic children — but she would also worry someone might give Najwa the wrong dosage by mistake.

"It took me awhile to figure out how to read the sliding scale," Broussard said. "I would feel more comfortable for a trained, professional nurse to monitor her."

Greenfield also was leery of the idea. "If you give the wrong dose, you could put a kid in insulin shock very easily," she said.

Prefilled "insulin pens" — which don't involve syringes and are easier to use — might be a good compromise, she said.

Still, she couldn't help but wonder why the attorneys weren't pushing for more nurses. To her, that's the only real solution.