1. Kennedy, Maureen Shawn MA, RN, FAAN


The importance of case finding.


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Earlier this year, the media buzzed with news about the lead-contaminated water supply of Flint, Michigan. City officials had switched the city's water supplier in April 2014 to an unpotable source, and then denied and mismanaged the ensuing problems. Many reports focused on the city's appalling lack of accountability. A mother's refusal to stop asking questions stands at the heart of this story.

Figure. Maureen Shaw... - Click to enlarge in new window Maureen Shawn Kennedy

During the summer of 2014, Flint resident Lee Anne Walters noticed that her young son developed a recurring skin rash after bathing or swimming in the family pool. His health care providers dismissed the rash as scabies or contact dermatitis. But Walters had her doubts, and, after several guests at a pool party also developed rashes, she had her water tested. When the lead level came back seven times higher than the acceptable maximum, she had her son tested. His serum lead level indicated lead poisoning. Yet during that summer and for more than a year afterward, city, state, and federal officials persisted in saying the city's water was safe. Not until the fall of 2015, after independent environmental researchers verified that Flint's water had highly elevated lead levels and a local pediatrician reported data showing a sharp increase in the number of children with elevated blood lead levels, did officials admit there was a problem. I can't help but wonder what those 18 months of lead exposure will ultimately mean for the long-term health of Flint residents, especially those most vulnerable. (See our two-part series "Lead Hazards for Pregnant Women and Children," October and November 2008.)


In the Flint water crisis, it was a mother who recognized a pattern of signs and symptoms, raised questions, refused to be placated by illogical answers, and doggedly pursued an appropriate response. Would her son, and countless others, have escaped lead poisoning if providers had asked about recent environmental changes during their assessments, or had themselves made the connection? Nurses at the point of care are usually the first to take stock of a patient's problems. But how often do we do it by habit, following a checklist without the mindfulness that might lead us to ask other, more important questions? Often, the crucial question is not "What's the problem?" but "What's been happening?" It makes a huge difference when nurses apply critical thinking skills to assessment.


AJN has covered many such stories. I'm thinking of Mary Pappas, the New York City school nurse who first recognized a pattern of symptoms in students that marked the onset of the 2009 H1N1 influenza pandemic in this country (see In the News, June 2009). I'm also thinking of Carole Bower, an occupational health nurse who, in 2006 and 2007, recognized similarities in the complaints of workers at a Minnesota slaughterhouse and reported her findings to the state health department (see AJN Reports, October 2008). Her case finding led to the discovery of a new illness, progressive inflammatory neuropathy, probably caused by an autoimmune reaction to pig brain proteins aerosolized during meat processing. In this issue, we're publishing a report by Sara Barron, a nurse in rural Washington who, in 2012, realized that the birth of three infants with anencephaly within weeks of each other at one hospital was unusual. She contacted colleagues in nearby facilities and, upon learning of other cases, called the state health department. An investigation revealed that the rate of anencephalic births in south central Washington was more than four times the national average, and it has continued to climb. No cause has yet been determined.


Today we have abundant research implicating environmental factors in disease outbreaks and birth defects, although definitive proof is often lacking. For example, in the current mosquito-borne Zika virus outbreak in Brazil, the World Health Organization noted that while a causal link from maternal infection to infants born with microcephaly is probable, it is not yet proven and may take years to do so. It will take painstaking research and analysis of multiple factors to make that determination-very much like what the investigators are doing in Washington.


Case finding isn't only the responsibility of public health investigators; it falls within the purview of all nurses. Nursing assessments must include questions about patients' homes and neighborhoods and jobs and pets and military service. All of us, wherever we work and live, must be alert for patterns of illness and be proactive in bringing them to light.