April May Be Cruel, but November's Pretty Lousy, Too

A favorite story from my housestaff days at Bellevue Hospital is of the man who, dripping with lice, walked into the emergency department and announced, “My head feels funny.” His hemoglobin concentration turned out to be about 3.0 g/dL, but of course we did not find that out until after the nurses had “Kwelled” him. We found no gastrointestinal problems or other cause of the anemia; our diagnosis of exclusion was iron deficiency anemia due to chronic body lice infestation. I spent 4 years at Bellevue talking about lice, laughing about lice, and writing orders about lice, and yet I finished my residency having no idea what a louse looked like.

Fate, particularly the pediculous kind, is inescapable. Fast forward to a new life as a wife, mother, and attending physician. One sunny November day, I was informed that my 6-year-old son Daniel had head lice. And so began another lice saga.

The treatment seemed so simple (why, even a doctor could do it!): Apply the pediculicide and comb out the nits while the sheets and clothes are being laundered. But what if it takes you 3 weeks to be able to distinguish between nits and dandruff? What if the same holds true for the parents of all of the other children in the class? What if your son likes to do headstands on the furniture and wrestle with his little brother? What if his little brother likes to rub big brother's shirts on his head because he knows it drives his parents crazy?

Needless to say, the problem did not go away overnight. Days and evenings were spent doing laundry and vacuuming the floor, the couch, the chairs—everywhere a head had been. Pillows, coats, hats, quilts, soft toys went into quarantine. Gentle reminders to “Get your head off the floor” were delivered in the tone of voice usually reserved for such warnings as “Don't stick that spoon in the socket!”

And then there were the inspections. Every night we spent hours chasing down both boys and bugs. We finally convinced them (the boys, that is) to hold still with the promise that they could examine anything that we dredged up from their scalps under the microscope. We found plenty of buried treasure for them to view. For the adults, the only thing more distressing than the sight of a louse jogging across the comb was one waving to us under high-power magnification. The kids thought it was cool.

Pillow talk, that quiet time in the evening when my husband and I would brood over the day's hassles and victories, gave way to tweezer talk, as we did our best to imitate our primate forebears and turn nit-picking into a social occasion. (It didn't work; the anxiety level was too high.) Comb and hunt, hunt and comb. Every time we found a new louse or nit, it meant more washing, more vacuuming, more gnashing of teeth.

At last, the lice seemed to disappear for a few days. Then we found them again, this time on Daniel and me. These were desperate times, times that called for short hair. … We also consulted a term paper that Chris, the school nurse, had written about lice; it described ideal hatching conditions, natural history, and such. On the basis of those data, we turned the thermostat down (not pleasant with all of the blankets in plastic bags) and allowed the humidity to drop so low that one could read in bed at night by the light of static flashes. After finally stumbling on an effective intervention (a combination of haircuts, endless combing and inspections, an increase in the learning curve in the course of 3 weeks, louse-hostile atmospheric conditions in the apartment, and garlic shampoo), we won. And life has finally gotten back to … well, never mind.

For the health economists among you, I would suggest that an estimate of the direct and indirect costs of a head lice infestation should include the following variables (don't forget to factor in the poor quality of life):

1. Bottle of permethrin shampoo (with or without a bottle of lindane shampoo; experts don't recommend it, but many pediatricians do, and the peer pressure to use it is phenomenal)

2. Bottle of enzymatic louse loosener

3. Approximately 25 to 30 extra loads of laundry

4. Dry cleaning for clothes that can't be quarantined

5. Extra louse combs

6. Extra brushes

7. Time off from work (minimum, one-half day)

8. Unproductive time spent at the office worrying about lice

9. Child's crew cut (minimum, one)

10. Bribe for child's crew cut (minimum, one)

11. Parent's hair cut (minimum, one)

12. Evening hours lost to louse inspection, vacuuming, doing laundry, and talking to the school nurse.

As a physician, I am confronted daily by ailments that are disabling and diseases that are quickly or slowly fatal. How humbling and exasperating it was to be so ill-equipped to handle this minor problem; how embarrassing, in retrospect, that something so harmless seemed so intractable and important at the time. If nothing else, I granted myself a year's worth of CME (continuing mommy education) credits that month. I'll need them; this will not be our only encounter with Pediculus humanus capitis. And should any patient, colleague, or parent come to me with that characteristic look of befrazzlement, I will not assume a detached, professional demeanor or comfortingly agree that lice can be very frustrating. Instead, I will sit that person down and say, “Do I have a story to tell you. …”

• Copyright ©2004 by the American College of Physicians