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Masters and commanders: physicians sail the roiling ED

January 8, 2004 -- "Hollywood has no obligation to be accurate whatsoever." That was the reported reaction of "ER" medical advisor Mark Morocco to the 2002 Kaiser Family Foundation study showing how seriously viewers take the show's depiction of health care. This attitude also seems to be reflected in the show's refusal even to respond to the many nurses who have written recently to object to its damaging misportrayal of nursing.

But Dr. Morocco has now had a chance to show that "ER" does care about accuracy and about nurses, as he is credited with having written tonight's episode "Touch and Go." And in fact, the episode includes a few small efforts to express support for nurses, for which Dr. Morocco deserves credit. Sadly, these efforts are undermined by the show's ignorance of the nursing profession, and its apparent need to display commanding physicians who provide virtually all meaningful health care, regardless of actual practice. The result is another influential, dangerously persuasive vision of nurses as peripheral subordinates.

Consider the episode's efforts on nurses' behalf. One subplot involves the ED nurses, led by nurse/medical student Abby Lockhart working a nursing shift, on a search for some missing Valium that must be resolved before they can go home. It ultimately turns out that it was ED physician Kerry Weaver who evidently misplaced the Valium--the same Dr. Weaver who had snapped that the nurses who seemed to have misplaced it should "learn to count," and that whoever misplaced it was an "idiot." So it might seem like the episode was striking a blow for nurses, albeit a fairly petty one.

The problem is that the whole basis for Weaver's involvement is that the nurses are reporting to her on the issue, that she must "sign off" on their count. This is a complete inaccuracy. In fact, nurses do track the medications they give, and they take this responsibility very seriously. But physicians are not involved and have no authority here. Once again, the show wrongly shows nurses reporting to physicians, and suggests that nurses lack autonomy. And as usual, Lockhart lacks the juice to confront Weaver over her anti-nurse statements or her own apparent responsibility for the problem--typical of the little nurses who can only smile privately at the foibles of the godlike physicians. Actually, because physicians are so removed from the delivery of controlled substances, possession of Valium by a physician would be considered suspect in many circumstances.

At another point in the episode, nurse Lockhart is actually shown, briefly, giving report to fellow nurse character Sam Taggart. "ER" has almost never shown the substantive nurse-nurse interaction that is a key part of care in real ED's. All credit goes to Dr. Morocco for trying to do so here.

However, Lockhart's report is really more of a physician's report--medical tests and treatments--which would be inadequate for a nurse. It lacks key psychosocial data, such as relevant information about the patients' overall physical and mental conditions, family status, and living arrangements. Of course, only nurses would notice this, and given the show's past practice, most viewers will likely be surprised and impressed that nurses even have any substantive knowledge to exchange without physicians around to direct them.

Taggart also gets report--all by herself!--from paramedics delivering a patient from a nursing home. The show has almost never shown nurses playing any significant role in receiving report on emergent incoming patients, and this does suggest some nursing autonomy. We salute Dr. Morocco for this tiny advance. Unfortunately, the show reverts to form for interactions with the paramedics delivering all the other, more emergent patients who arrive during the episode, showing physicians as the only significant players, with nurses either absent or taking direction from the physicians.

After a problem with Taggart's son has once again caused her to depart the ED abruptly, the clerk Frank relays a message to her from the "nursing director" that she is "one emergency break away from probation." We are always pleased on those rare occasions when "ER" admits that nursing managers actually exist. But it's hard to get too excited when they are never shown, when the show far more often shows physicians usurping their roles, and when their only role seems to be to discipline errant nurses.

An important function of this episode appears to be to show physicians as the be-all and end-all of health care. On "ER", the physicians are the tragic heroes around whom all else revolves. This extends even to names. Contrary to practice at real level one trauma centers, "ER" nurses tend to exalt physicians by calling them "Dr. ____," rather than by their given names.

In this episode, a family appears with homemade cookies and worshipful faces for physician Luka Kovac, apparently to thank him for recommending chelation therapy for their children. It's hard to see why this short interlude occurs at all--it creates no drama and teaches us nothing about the children's condition--except as a crude vehicle to glorify the physician. Likewise, when physician John Carter returns from the Congo with new flame Kem, he is mobbed at triage by nurses Chuny, Haleh and Malik, who hail him as a benevolent conquering hero. By contrast, the other physicians merely seem pleased, in a dignified way. And when resident Greg Pratt requests something of the Filipina nurse Severa, who has appeared occasionally this season, she replies with her usual obsequious "Yes Doctor!"--an echo of the "Yes Massuh" of a bygone era.

Of course, to be credible, heroes must also have tragic flaws. Thus, Pratt's eagerness to perform difficult procedures results in his breaking a patient's neck during intubation, causing the patient to become a quadriplegic. But this is the mistake of a real player, someone who holds lives in his hands. At another point in the episode, Pratt's heroism supposedly saves a life, lest we miss the point about the dramatic up and down life of a physician. But "ER" has rarely if ever suggested that nurses have that kind of power. Of course, they do, as research about the effects of nurse short-staffing shows.

Often, the heroism of "ER" physicians takes the form of actions that nurses do in real life. The defibrillation example is painfully obvious, and this episode did not shy away from it just because the Center has placed it in news articles worldwide--one scene had intern Michael Gallant performing a defibrillation. And Gallant also helpfully performed other nursing tasks, such as calling out how much blood had been infused in a coding patient, and how much time had elapsed since the last injection of epinephrine. Of course, since Lockhart was in medical student mode in that scene, there were no nurses present at all.

Perhaps the most striking example of physician usurpation of the nursing role was Pratt's triumphant visit to computerized tomography scan (CT) with a critical car crash victim, a medical student--and no nurses. At CT, as the medical student asks questions revealing Pratt's expertise, the resident insists on exposing himself to radiation so that he can hand-squeeze blood in to maintain the patient's blood pressure during the 20-second scan. He thus gets the information about the patient's aneurysm needed for successful surgery, as the surgeon Corday stops by to confirm.

This is nothing short of absurd. While physicians do at times accompany nurses on such CT missions, they are primarily the nurses' responsibility, and to send such a critical patient without a nurse would be dangerous. Here, it also resulted in a physician taking over the nursing duties of transfusion and IV infusion, and a CT tech performing the nursing task of monitoring the blood pressure. And squeezing in blood by hand would have had virtually no effect in the short time a scan takes, making the whole premise of Pratt's supposed heroism ludicrous. In addition, CT contrast would never be given through the port on blood transfusion tubing, a maneuver that would actually be dangerous. A nurse advisor could have told the show all this. Clearly, "ER"'s failure to consult nurses not only hurts nursing, but also leads to wild inaccuracies that detract from its overall credibility.

As usual, the "ER" physicians also demonstrate their "master and commander" status by telling nurses to do things that real nurses would know at least as well as the physicians and/or already be doing. For instance, at one point Kovac tells Taggart to prime the rapid infuser for a patient losing a lot of blood--as if an ED nurse wouldn't know that. When Taggart is leaving to deal with her son, Pratt tells her she has to find another nurse to replace her--as if she wouldn't know that, and as if physicians have any responsibility for those arrangements anyway.

"Touch and Go" is another apparent attempt to show that "ER" does value nurses, which we obviously encourage. Unfortunately, it amounts to little more than a pat on the head beset by physician-centric inaccuracies and, ultimately, disrespect.


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