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"ER" and the patient advocate

February 26, 2004 -- Tonight's episode of NBC's "ER," written by Bruce Miller, was one of the show's better recent episodes for nursing, as major character Sam Taggart advocated for patients in several situations, displaying substantive knowledge and a concern for patients' overall wellbeing that is one of the hallmarks of nursing. Unfortunately, the presentation of Taggart's advocacy was problematic, and other aspects of the episode continued to promote the idea that nurses are skilled assistants to physicians.

In one plotline of the episode, "Forgive and Forget," a brain-damaged man is brought in with sepsis. He is accompanied by his young adult daughter, who has been caring for him (inadequately) since moving him out of a nursing home. Taggart forcefully questions whether heroic measures should be taken to keep the patient alive, as these would appear likely to prolong his suffering without offering much chance of improvement. Taggart is opposed in this by the agitated daughter and by senior resident Jing-Mei Chen, whose reaction may be influenced by her own current struggle to care for her declining father. Evidently there are no advance directives. Persisting, Taggart apparently receives authorization from the patient to avoid heroic measures after asking him to blink his eyes twice, but the show does not show us the patient's face, leading us to wonder whether Taggart has fabricated the signal, in what would be an understandable but unethical maneuver. In any event, Taggart eventually submits to Chen's greater power and, as Chen commands, participates in successful resuscitation when the patient crashes. This seems to follow a recent trend on the show--have a nurse argue with a physician about care, displaying some knowledge, but have her ultimately submit to the physician's superior knowledge or power--with a curious twist. In the last scene of the plotline, which commendably shows Taggart comforting the man's daughter at his bedside, the daughter reveals that he had sexually abused her for many years, leading us to wonder whether Taggart's advocacy might have failed to protect the patient not merely from an irrational care system, but from an abused child having her revenge.

On another occasion, Taggart advocates for a 13-year-old boy with groin pain, arguing with physician (and new boyfriend) Luka Kovac that testicular torsion should be considered. Taggart prevails in the sense that Kovac agrees to test for this, though only after Taggart--who has previously told Kovac she wants to keep their relationship casual, to his chagrin--indicates that she would consider a more serious relationship with him if it was that or nothing. Taggart does not say this in order to get her way with the patient, and it's certainly believable that Kovac would be better disposed toward her views if he felt more positively about their relationship, but the subtle link between personal romantic concession and professional result still made us uneasy. In the event, Taggart's suspicion proved, as on prior occasions, to be incorrect; the boy had chlamydia.

In another scene, Taggart and others treat a young boy from a serious car crash in one trauma room while the boy's father is treated in the adjoining trauma room. The boy screams and flails, as Taggart stands below his midsection trying to restrain him. Ultimately Taggart finds a simple but highly effective solution: she opens the door between the two trauma rooms so the boy can interact with his father. He immediately quiets, and the team is able to help him. This is an excellent example of a nursing intervention that a nurse would be far more likely than anyone else to think of, and all credit to Mr. Miller and anyone else involved.

Unfortunately, the scene had some flaws. Part of the problem in this and most other "ER" trauma scenes is that the nurses are far too passive and uninvolved with patients, who interact mainly with the physicians. In real life, a nurse like Taggart would likely have been at the patient's head, talking him through the procedures and providing crucial emotional support while she monitored his status. Of course, it's difficult for "ER" to show this because it would inevitably mean a far more prominent, compelling role for the nurse characters and the reverse for the numerous physicians who currently dominate the show. It may also be that Linda Cardellini, the actress who plays Taggart, could benefit from additional advice from real nurses. Cardellini is a good actress, and she has no trouble conveying assertiveness with physicians or patients--to say the least--but she sometimes seems a little lost in scenes like this, unable to assume the authoritative, central role that a real nurse would in interacting with the patient and managing his overall wellbeing in a crisis.

Of course, there's a limit to what Cardellini or any actress can do on a show bent on having the nurses serve the physicians, while the physician characters do the nurses' jobs. Examples of such physician nursing in this episode include Chen's defibrillation of the sepsis patient while Taggart stands by, and medical student Neela Rasgotra's triaging of a patient with facial trauma, and providing significant emotional support to the wife of ED clerk Frank, who has suffered a heart attack.

But the episode is actually more remarkable for showing physicians commanding nurses to do seemingly simple tasks that physicians often do in real life. Chen orders nurse character Chuny to draw up lidocaine for a suture repair, a task that physicians can generally manage on their own. Surgeon Elizabeth Corday orders Taggart to dress a wound site after putting in a central line, and although nurses are generally more skilled at doing such dressings, a surgeon can do this herself and probably should, rather than asking a nurse who is not standing there with sterile gloves and may be busy with something else. Such scenes tell viewers that nurses report to physicians, and that nurses exist to do simple tasks that physicians are too important to do.

Elsewhere, as usual, a host of small things reinforce the handmaiden message. Nurses answer phones for physicians, as if that was part of their job. Contrary to practice at real Level One trauma centers, nurses call physicians "Dr. _____," while nurses are called by their given names. Nurses tell patients that a given physician is "the best," though we are still waiting to hear a physician tell a patient that a particular nurse is "the best."

This episode gives the "this physician is the best" warhorse a special kick by having Taggart say it about Kovac to the sexually active teenage male patient, then leave, immediately after which the teen tells Kovac that Taggart is "hot." Rather than bore the boy with a defense of his nursing colleague's professional expertise, Kovac says nothing. Could this scene really happen? Does it serve the episode's dramatic ends? Of course, of course. And does it reinforce ugly stereotypes about physicians and nurses? Of course.

If anyone needs us, we'll just be over here forgiving, but not forgetting.

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