If there's one thing Jamie Thim knows for sure, it's that in her profession, a typical day is never typical.

Thim is a certified school nurse in the Bensalem School District. She serves as both the nurse at Cecilia Snyder Middle School and district nursing coordinator.

She could begin her 45-minute commute from her home near Doylestown, thinking of all the health screenings she wants to do.  But often within a few minutes of arriving at work, her day "takes a turn," she said.

A child may get hurt in gym or she may get called to a classroom where a student is having a seizure.

"Health screenings shut down," she said. "There could be two emergencies at one time."

With the cost of medical insurance skyrocketing, district officials have noticed that more parents now are using school nurses as gatekeepers for their children's health care.

The Bensalem School District has more than 6,300 students. Nurses in the district handled almost 68,000 student visits to the health offices during the 2016-17 school year, treating about 40 to 60 children a day at each school. In the 2015-16 school year, there were 66,000 visits and 63,000 in 2014-15.

The school district, which borders Northeast Philadelphia along the Delaware River, is home to a wide variety of students, including children whose families have lived in Bucks County for generations, as well as newcomers from the city and immigrants from other countries. With 55 percent of the children in the district receiving school-lunch subsidies, the economic status of its families varies widely, as well.

In the nurses' offices, Monday mornings are especially busy — sometimes with injuries or illnesses that happened over the weekend.

"Families can't afford to go to the doctor all the time with copays. … They tell their kids to go see the school nurse," said Tammy Wood-Moghal, Bensalem school district's director of pupil services.

Pennsylvania law requires each school district to have one certified school nurse for 1,500 students, but individual schools can use other registered or licensed practical nurses, as well, called staff nurses. Certified nurses, who have taken courses on school nursing, are on the same pay scale as teachers, said Valerie Wendell-Wesolowich, president of the Certified School Nurses of Bucks County association.  Salaries for staff nurses may be less.

At most of the schools in Bensalem, there is only one nurse on site. It's a lot of responsibility, especially when a medical emergency arises. It can be a lonely role, Thim admits.

More ‘medically fragile’ students

Since 1975, when the federal government enacted the Education for All Handicapped Children Act – renamed the Individuals with Disabilities Education Act in 1990 — youngsters with serious health problems have been mainstreamed into public schools.

So, nurses such as Thim care for children who may have cancer, diabetes, epilepsy or another serious, chronic health problem, as well as those with autism, hyperactivity and psychological disorders.

"People don't realize the volume of services nurses provide," Wood-Moghal said. "Because of the least restrictive environment regulations, we have more and more medically fragile children in our public schools."

Thim and the district's other nurses might have to adjust a child's feeding tube or catheter, check sugar levels for a child with diabetes, administer prescription medications, or evaluate an injury.

And they still have routine duties: caring for a child with a stomach ache or putting a Band-Aid on a scratch.

While severe allergies and toileting problems are big concerns with younger students, nurses at high schools face a host of adolescent issues. They have cared for pregnant students and those who have used illicit drugs.  The certified school nurses also give talks to students about puberty and AIDS awareness, with parental permission.

"Mental health is a huge item right now, too," Thim said. If a child or teen keeps coming to the nurse complaining of headaches or stomach pains, "there could be underlying issues they're upset about. We work closely with the counselors and social workers," she said.

Sometimes after examining a child, the school nurse must advise a parent or guardian to seek a doctor's care, especially if the child has been running a fever or is in pain. If the parents have a problem getting the sick child to a doctor's office, the school nurse will try to help by, for instance, referring the child to county health clinics, Thim said.

For state-required physicals, Bensalem schools bring in nurse-practitioners to examine any child who doesn't get screened by a family doctor. Pennsylvania requires children to have physical assessments in kindergarten, first, sixth and 11th grades and dental screenings in kindergarten, first, third and seventh grades.

Thim said many children are evaluated for individualized education programs (IEPs). If there is a medical component involved, the school nurse joins a team composed of the school psychologist, teachers, counselors and parents to develop the plan. These written plans are mandated by federal law for children with health impairments or such conditions as autism, hyperactivity or other educational or emotional challenges that require special education services. Other children with health issues, who do not need special education services, also must be evaluated for a federally mandated plan. These could include children who have special dietary needs because of a condition such as diabetes, or a child with post-concussion symptoms that last more than a few weeks. Both types of plans offer strategies to help a child overcome specific learning or physical challenges.

When immigrant children and parents don't speak English well, the nurse must recruit a language specialist, Thim said.

And before the school year even starts, the school health office makes sure that children have all the needed immunizations.

‘As if they were my own’

The Bensalem district — which has nine schools — employs six certified school nurses, seven other registered nurses or licensed practical nurses, and two nurses who accompany students who are so medically fragile that they need their own nurse, Wood-Moghal said.  Other students have nursing assistants provided through their private medical insurance.

When a school nurse is absent, a nurse from another school may have to juggle the two sites if a substitute cannot be assigned — and districts need more substitutes, Wood-Moghal said. In Bensalem, Thim will fill in at different schools as part of her coordination duties.

She said a key trait a good school nurse needs is confidence – in her knowledge and her ability to make medical decisions. And the school principal must have confidence in the nurse, as well.

Thim graduated from the Bucks County Community College nursing program and earned her bachelor of science in nursing and master's degree as well as her certification in school nursing from LaSalle University.

Despite the pressure, lots of paperwork and long hours that don't end when the school bell rings, Thim loves her job — helping children and their families. And being an educator.

"I do — very much so," she said recently, while visiting Bensalem High School's newly renovated health suite.

And she relishes not having to work nights and weekends in a hospital. She has more time at home with her husband and three young children.

"I always wanted to work with kids," she said. "I treat these students as if they were my own."