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"Hey, did I ever thank you for all the help you've given me over the years?"

April 18, 2006 -- Tonight NBC's "Scrubs" showed nurse Carla Espinosa helping interns learn key aspects of clinical practice by catching their errors and teaching them how to avoid them. The subplot also presented Carla as wisely protecting the interns from the undue wrath of their attending physicians. And in one scene, Carla even expertly takes charge of handling a patient's seizure, with an intern following her lead (!). The show does seem to view Carla's acts more as a result of her fine personal qualities than as a professional nursing obligation. And though we ourselves have often said that nurses deserve credit for teaching physicians, given prevailing biases, this may suggest to many that nurses are important to the extent they help the physicians whose care really matters. This episode, like hundreds of other prime time episodes in the last decade, is all about training physicians--only. We have yet to see a media product suggest that physicians are important because they help train new nurses. Even so, the intern errors plotline is a rare and admirable effort by a network show to convey that nurses play an important role in health care and training. The episode, "His Story III," was written by Angela Nissel.

The subplot begins with new attending Elliot Reid scolding her interns for various failures. She says it's time for them to sink or swim: "I got to where I am on my own." The nearby Carla says, neutrally: "Nobody helped you out in the beginning, huh?" Elliot assures her that no one did, because the nasty Perry Cox was her attending.

Later, we see Carla examining charts at a patient's bedside. Lisa, one of Elliot's interns, is present, and Carla addresses her: "Lisa, why did you order 100 units of insulin for Mrs. Best?" Lisa replies: "No, that's only 10 units, I just put a smiley face after the zero." Carla: "Look, Lisa, you have to be crystal clear with your medication orders." Mrs. Best starts seizing. Carla notes that the excess insulin is "causing a bit of a seizure." Carla takes charge, calling to the nearby Janitor [the only name the show has ever given him]: "Hey Janitor, come here. Would you hold her legs down, please." The Janitor is thrilled, thinking: "I'm in the show...Dr. Jan E. Tor!" Carla continues: "We'll give her an amp of D50." Meanwhile, intern Lisa silently holds down Mrs. Best's torso. Soon Mrs. Best stops seizing. The Janitor, who works hard to maintain an unhinged image, says that he didn't see the demon leave her body. Carla: "I'm sure it did. Hey Janitor--good job!" But Lisa is in no mood to celebrate: "Dr. Reid will kill me when she finds out about this." Carla tells her to relax, that she will talk to Elliot and it "won't be a big deal." We cut to a later shot of Elliot: "What?! Oh, I'm gonna make someone burn for this. Who did it, Carla?" Carla is taken aback. Elliot: "Seriously, Carla, I need to know who's responsible for this." Carla: "I don't know. It was just a clerical error. There's no way to trace it."

We have to mention a few issues before going on with the subplot. First, the idea that the error could not be traced is of course laughable, but perhaps most viewers don't know that. More importantly, the implication is clearly that someone just went ahead and gave Mrs. Best an amount of insulin that Carla saw at a glance was way too high. Presumably this was not Carla, but the characterization of it as an "order" will suggest to viewers that it was some nurse. Thus, some viewers may assume that nurses other than the sharp Carla mechanically give medications without regard to whether they make any sense, when in fact nurses are legally and ethically obligated to use their advanced training to prevent just this kind of error. All attention goes to the physician error, as if that was all that mattered, but this would appear to be a major nursing error as well. Of course, this implication of nursing ineptitude may be too subtle for most viewers to get, particularly since prime time shows commonly have physicians themselves giving medications.

What's not so subtle is the Janitor's "Dr. Jan E. Tor" line. Why would he fantasize about being a physician when it's a nurse who has given him his chance to get "in the game" and who is clearly directing this procedure? Just the assumption that men aren't nurses, an assumption the show largely supports (with one limited exception years ago)? Or the assumption, despite what is happening in the scene itself, that only physicians matter? We won't necessarily tag the show itself with the Janitor's views. But we get no suggestion that there is much distance between the two either, as might have been the case if the Janitor had said the line out loud and Carla had given him a withering look.

Later, Elliot gathers her interns and demands to know "who screwed up" with the insulin. Carla tries to discourage her, noting that "interns stick together" and they will not "rat each other out." Elliot vows to get it out of intern Keith, whom she is seeing romantically (never mind; this is "Scrubs"). After Elliot leaves, Carla warns Keith not to tell. Keith: "But Elliot scares me." Carla: "Elliot is a blond 108-lb. ski pole from a cul-de-sac in Connecticut. I am an underpaid, pregnant nurse, from the block, who over the next six months will become fatter and angrier. Now--who are you really afraid of?" Keith: "The fatty?" Carla: "Be careful Keith." We guess we're supposed to like the "underpaid" comment, but without context it's pretty much a throwaway.

Keith does tell Elliot that Lisa made the error, and that Carla told him not to tell. Elliot, furious, charges off to get Carla. But Cox intervenes, telling Elliot that "of course" Carla covered up for the intern because "if interns got hammered by their attending every time they messed up there wouldn't be any interns left. And lucky for everyone in this dump, Carla happens to have been here long enough to identify when someone needs to be protected." Elliot sputters about "these kids" needing to "start standing on their own two feet." Cox facetiously agrees, noting that "you sure got where you are all on your own." Elliot: "Well, you sure didn't give me any help." Cox: "I didn't say I did."

Elliot is momentarily puzzled by this, but she resumes her charge toward Carla. Then, to her surprise, she flashes back to a scene from her own residency in which she and Carla were at the bedside: Intern Elliot: "Dr. Cox is gonna kill me." Carla: "Dr. Cox doesn't have to find out. Just promise me that you're going to practice repositioning swans [swan-ganz catheters]." That memory stops attending Elliot cold. Later, when Elliot does find Carla, her message has changed. As lead character J.D. delivers part of a voiceover about "the support of a friend," Elliot addresses Carla with affection: "Hey, did I ever thank you for all the help you've given me over the years?" Carla responds casually, without looking up: "Don't sweat it." But when Elliot has looked away, Carla does look up, and it's clear that she cares.

On the whole, this subplot is a commendable effort to show a veteran nurse catching dangerous errors, teaching interns, providing autonomous care, and using interpersonal skills to manage relations with interns and attendings. Of course it is not necessarily so simple to say how nurses should handle errors like this. But whatever would or should happen in real life, the show is clearly telling viewers that Carla's way is adroit and effective. And the episode even underlines how some physicians can overlook nurses. Elliot just assumed that only a physician could have made a significant contribution to her clinical education. Finally, the scene in which Carla handles Mrs. Best's seizure, though brief, is a rare example of a prime time show showing a nurse character autonomously and expertly handling an emergency, with an intern following her lead.

On the other hand, the subplot does not convey that educating residents is part of what nurses do, nor that it's a nurse's job to catch such errors. It is not clear if viewers will get that what Carla displays is standard nursing skill, not just the acts of a "good friend" or "good worker." J.D.'s voiceover reference to the "support of a friend" underlines this. So does Cox's comment about Carla's knowledge of which interns need protection. That statement--though in one sense a strong tribute to Carla's contributions--links her judgment to her time at the hospital, rather than her training or skills. "Scrubs" is not alone in slipping into this kind of portrayal even as it tries to pay tribute to nurses. In a recent episode of "ER," an attending noted that nurse Haleh was qualified to assess an intern's performance in a code because she had worked there longer than anyone else.

The episode's handling of the Janitor's plots reflects a similar mix of good intentions and limited understanding. Janitor is over the moon about helping to handle the seizure, until he overhears a physician suggesting that he's going on and on about it because he doesn't really make a difference at the hospital. The show appears to agree, running a "without Janitor" replay of the scene in which nothing has changed. But at the end of the episode, a patient with "blocked-in syndrome" (severe paralysis) does thank Janitor for giving him psychosocial support while he is waiting for his new eyelid-controlled speech computer. As with the nurses, the show is more right than it knows about the contributions of the housekeeping staff. The hygienic conditions for which they are responsible are a critical part of a safe hospital environment. Of course, that kind of thing is far more of a nursing concern, and we would not expect a show without significant nursing input to get it. (It's also true that Janitor doesn't really do much cleaning, as the show often suggests.)

Finally, it seems to us that the message that nurses help train physicians has limited value. Nurses rightly seek credit for it, but viewers may get the sense that nurses are important to the extent they help physicians, rather than for their other work, because it is physician work that most people think really matters. The fact that this and hundreds of other recent prime time episodes have focused heavily on physician training--while very few have shown any nurse training at all--makes this clear. Would anyone suggest that physicians are important because they play a role in training new nurses?

Despite these issues, we thank Angela Nissell and the other "Scrubs" producers for this unusual effort to recognize a nurse character's important role in hospital care.

 

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