Leaning on a refrigerator in the nurse’s office, Breanna Skelly sticks a needle in her right arm, using her left thumb to inject insulin.

Behind Skelly on the counter is a calculator she used to figure her carbohydrate intake at lunch to help determine her insulin dosage. Pat Christie, a school nurse at Snider High School, looks on from her office chair on the other side of the room.

Self-sufficient in managing her diabetes, Skelly, who has red wavy hair and energy to burn, says shots are just something she’s gotten used to, though she’s looking forward to the day she’ll use an insulin pump instead. The 14-year-old seems unfazed by the needle in her arm, smiling at a reporter and photographer observing her after-lunch routine. In a matter of seconds, she’s off to class.

Though Skelly needs little help, other students – especially younger ones – require a hand from nurses or volunteers to manage their diabetes. With a few exceptions, area parents and students who shared their experiences for this story said schools do well to accommodate the needs of students with diabetes.

Still, lapses in care in the state and around the country and a push from the American Diabetes Association prompted Indiana to pass the Diabetes School Care Act this spring.

The law essentially establishes that individualized diabetes management and treatment plans be created and implemented for every student with the disease – and the school’s responsibilities clearly stated; that schools should be open to blood sugar monitoring, letting students prick themselves to check their blood sugar in class if need be. It also calls on nurses to keep up with the latest technology and treatment and allows them to teach volunteers working at schools to help students, even administering insulin for them, when nurses or the students themselves can’t.

Many of the provisions have long been in place at area schools, including care management plans. But others, such as allowing students to check blood sugar in class and allowing volunteers to administer insulin, aren’t as common or vary by district. Nurse-to-student ratios also vary greatly, leaving those nurses with the most students in their care strained to treat chronic conditions, such as diabetes.

Like Skelly, Whitney Robbins, a 13-year-old now attending DeKalb Middle School, doesn’t need much help managing her diabetes. She goes to the nurse’s office daily before lunch to check her blood sugar levels and uses a pump to give her body the insulin it needs.

Occasionally she has to leave class to check her blood sugar as well, though her blood glucose levels are usually where they need to be. The spontaneous trips to the office – perhaps two or three weekly on top of lunchtime visits – generally take about 20 to 25 minutes out of class each time.

“I feel like I miss class, but like, my teachers, they always make sure I know what’s going on,” Robbins said.

Maximizing class time while properly monitoring diabetes are central tenants in the Diabetes School Care Act. But those ideals heed pragmatic realities when applied to individual students and classrooms.

Robbins, for one, says she’s never advocated for in-class testing because she prefers the privacy of pin-pricking away from peers, in the nurse’s office. Others like to be able to test in class so they don’t miss anything.

Before the school year started, Kathryn Jenkins, 12, was looking forward to being able to do just that for the first time. The seventh-grader at St. Charles Borromeo Catholic School in Fort Wayne has two homeroom lockers: one for her books and another for diabetes supplies.

Like many other students with diabetes, Kathryn takes seriously the associated risks and responsibilities and is proactive in managing the disease. But the less time it takes out of her day, the better. In previous years, she’s had to walk to the nurse’s office to test her blood sugar, but this year she’s maximizing time in the classroom by testing in class, something she prefers.

According to the American Diabetes Association, 20.8 million children and adults in the U.S. – or 7 percent of the population – have diabetes. If not properly controlled, it can lead to kidney failure, blindness, amputation among other complications, and even death.

Still, after getting over the initial shock of diagnosis, most people settle into a routine that allows them to go on with their lives. Students with diabetes and their parents say a strong support structure is important, and that extends to schools.

“I felt like we were very lucky as far as the school’s concerned; … they were familiar with what (students with diabetes) needed,” said Shelli Jenkins, Kathryn’s mother, who is a registered nurse.

Parochial and private schools aren’t covered by the Diabetes School Care Act. But like public schools, St. Charles Borromeo has long had provisions in place regarding diabetes care. That includes individual care management plans with collaboration between school officials, parents and medical professionals.

Similarly, parents of students with diabetes at Fort Wayne Community Schools generally gave the district high marks. Still, some wondered whether care could be improved by increasing the nursing ranks.

Mary Hess, a health services specialist for Fort Wayne Community Schools, doesn’t dispute the need for more school nurses. Many schools in the district share nurses including Shambaugh Elementary, a school Whitney Robbins attended after she was first diagnosed with diabetes at age 6.

At the time, Robbins’ mother or a relative would come to school several times a week to administer her insulin shots when the nurse couldn’t be there. That was more than six years ago. Today, nurses still split time among many schools in the district, especially smaller ones, making care for young student patients even more of a juggling act.

For 9-year-old Jack Collins, a third-grader at Irwin Elementary, lunch comes with a note from his mom detailing the contents’ carbohydrate count. He enters the information into an insulin pump, which sends the proper amount into the young diabetic’s body.

On Monday through Thursday, a nurse is present to monitor his daily routine. On Friday, no nurse is on-site during his lunch period, and instead he talks to the regular nurse by phone. Though he’s nonchalant about the arrangement, he says that “it helps a lot when she’s at school.”

His mom, Connie Chapman, says the arrangement has worked out all right. During the reporting of this story, Hess double-checked with Chapman to make sure the care plan for Jack was OK. Chapman told The Journal Gazette that she feels comfortable with the plan. Still, she too wishes there was a nurse for every school. “They just really need more nurses.”

Hess says school officials work closely with parents, diabetes specialists and doctors to develop a care management plan that all are comfortable with for each student. That plan must receive approval from all involved before it’s put in motion. But she understands parents’ frustrations with the lack of nurses.

Ideally, Hess says there would be a nurse at every school. But the reality is that many split time among several schools, with only one nurse to every 1,330 students. That’s well below the minimum nurse-to student ratio – one nurse to every 750 students – recommended by the National Association of School Nurses.

“It’s definitely a strain,” Hess said.

And it’s hardly an issue exclusive to Fort Wayne, though other Allen County school districts meet the minimum nurse recommendation for a general student population.

Because of limited school nurses, the Diabetes School Care Act calls for volunteers to help students manage the disease. It even recommends training volunteers to give shots as deemed appropriate.

Fort Wayne Community Schools has long employed the services of trained volunteers, generally office staffers, sometimes teachers and other school personnel, in diabetes care. The district works to keep up on the latest technology in care and gets free help from certified diabetes educator Nancy Yoder – a nurse with Parkview Hospital – and other nurses employed by the hospital.

But there are limits on what volunteers are asked to do. For now, Hess said, there isn’t a need for non-medical volunteers to administer shots. She’s hesitant to go down that path because of the risks related to giving the wrong dosage of insulin. If a person’s blood sugar levels inadvertently go too high, she said, it can lead to confusion, loss of consciousness or – in a worst-case-scenario – seizure or even death.

“I think the big fear with this, … (is that) if they do make an error the consequences could be extremely serious.”

mschroeder@jg.net