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House, R.N.

December 19, 2006 -- Today The New York Times ran "Is There a Barber in the House?", a "Cases" item by Larry Zaroff, M.D., and Jonathan Zaroff, M.D. The piece tells how an "experienced nurse" with "good sense and a good sense of smell" had "come to the rescue" by making the "correct diagnosis" of a life-threatening illness." The nurse had noted that the patient had a strange odor, coming mainly from her hair." The odor turned out to be poisoning from organophosphate insecticide, stemming from a friend's washing of the patient's hair with a bottle she thought was shampoo. The patient recovered after her head was shaved. The piece is a laudable example of physicians recognizing the key role nurses can play in diagnosis. Of course, the nurse's work was not just the result of "experience," "sense," and a "sensitive nose," but of nursing education, skill and the profession's holistic focus.

The piece begins with a short disquisition on modern society's relationship with hair. Then it describes the patient's arrival at a university hospital with sudden, severe weakness and difficulty breathing. The piece notes that the physicians at the hospital were trained to use their "brains" and some of their senses to diagnose, but unlike in past centuries, not so much their noses. Although "the diagnosis remained obscure for the next hour as [the patient's] breathing got more labored and she became comatose," an "experienced nurse, with good sense and a good sense of smell, came to the rescue. The nurse noted that the patient had a peculiar odor, resembling garlic, most prominently from her hair." Various treatments for organophosphate poisoning followed, including medications and washing, but the woman got better for good only after all her hair was cut off. The piece does not say whose idea that was.

Of course, the patient's "doctors wondered" how the insecticide had brought her to the "brink of death." It turned out that a friend had mistaken a bottle of the insecticide for a similar one containing shampoo. Organophosphates are highly toxic, and can even be adapted to make biological weapons, such as sarin. But "[i]n this case, the patient recovered well, after the correct diagnosis by a nurse with a sensitive nose, proper treatment with drugs and the elimination of the insecticide by balding."

This is an admirable recognition by two physicians of the critical role a nurse played in the diagnosis of a condition that seemed to be about to kill a patient. Too often, physicians alone receive credit for diagnosis and treatment, not only in the media (e.g. Fox's "House"), but in clinical settings, where life-saving nursing judgments and actions are often presented to patients and families as solely the idea of physicians. We commend Drs. Zaroff and Zaroff for countering this practice. We do note their focus on the nurse's "sense" and "sensitive nose," rather than the nurse's education and skill, and the holistic approach of nursing. Nurses are trained to use all means at their disposal to assess patients and their environments, in order to make clinical judgments about their care. This odd smell is just the kind of thing a nurse is trained to notice and consider--with the nurse's "brains."

We thank the New York Times for this generally helpful piece.

You can see the article "CASES; Is There a Barber in the House?" from the December 19, 2006 edition of the New York Times.

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