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November 2, 2006 -- Recent plotlines of NBC's "ER" have tried to illustrate some of the importance of ED nursing care, and one even included a minor suggestion of the potential effects of short-staffing. The October 19 episode, Joe Sachs, MD's "Ames v. Kovac" (13.5 million U.S. viewers), focuses on a malpractice suit brought against attending Luka Kovac by a patient who suffered left side paralysis after a stroke in the ED. The show makes some effort to show the important role that the care of Chunie Marquez (right) and other nurses played in the patient's experience. However, it gives the impression that Kovac was ultimately responsible, legally and ethically, for all aspects of the patient's care, good or bad. Tonight, in Janine Sherman Barrois's "Heart of the Matter" (13.8 million viewers), a trial jury finds for Kovac . But again, all the focus is on him, and there's no real indication of nursing responsibility. This episode also suggests that nurse Sam Taggart (below) would be qualified to appear on the local TV news on the ED's behalf, but that she would casually pass up a chance to do so because "nobody wants to hear from a nurse."

The October 19 episode shows the ED stay that led to the malpractice suit by using flashbacks from the trial. It alternates questioning from the lawyers with scenes illustrating the differing accounts of Kovac and the plaintiff, Curtis Ames. Ames stresses that he came into the ED with pneumonia, and left paralyzed. Ames actually spent three days in the ED, a result of Kovac's unwillingness to send him home. Kovac did not trust Ames--a very reluctant patient who denied he was seriously ill --to get the self-care he needed at home, and there was a lack of beds elsewhere in the crowded public hospital .

Although the show seems to share Ames's view that his ED contacts with Kovac were the ones that really mattered, it also includes some indication of the role of the nursing staff. We see lone major nurse character Sam Taggart report, in passing, that she has testified at the trial about hospital procedures. We hear no more about this, and it's not clear if this was because of her role as an ED nurse manager. She was made assistant nurse manager early last season, but there has been no real mention of it since. Later scenes would suggest that Taggart was probably asked about nurse staffing.

We also see flashbacks of scenes where Ames has contacts with nurse Chunie Marquez. Many of these alternate between Ames's recollection of Marquez's insensitivity and Kovac's account of her steady, if somewhat frazzled, competence. Ames's account has Marquez at triage upsetting Ames by telling him, impatiently, that he may have to wait 12 hours because of all the other patients. In Kovac's version, she is far more sensitive. At another point, Ames says that Kovac left him with a nurse who couldn't start an IV--obviously a suggestion that Marquez was both incompetent and a Kovac subordinate. Kovac's account suggests that no one could have started the IV, and it appears that no physician even tried. In fact, this is why they started a central line, as we see Kovac calmly explain to the agitated, reluctant patient. Kovac's account does not address the implication that Marquez reports to him. Other scenes show Ames, with increasing desperation, asking Marquez to get him attention from the physicians. She generally makes an effort to explain what she can do and why. Ames clearly regards Marquez as an indifferent, less than competent physician subordinate. Kovac's version of events counters this vision to some extent, though it could have done so with more force.

The scenes immediately preceding Ames' stroke are more troubling. After a long time lying in his cramped ED bed, the distressed patient complains of about 10 minutes of numbness. Kovac examines him briefly, but sees no signs of a significant problem.

After some time passes, we see Ames (by his own account) telling Marquez that he just had about a half hour of numbness. Marquez refuses to get Kovac. Instead, she tells Ames that Kovac recently checked him out, so he must be OK. She does not ask for details about the numbness, and she does not assess or investigate. Ames becomes agitated, and gets out of bed. Marquez and ED clerk Frank try to calm him. Ames starts yelling about getting his doctor to do what he should--and collapses. This is the stroke, which Marquez at least recognizes at this point, and she and Kovac respond. Kovac never counters Ames' account of this in the court scenes, and of course, we never hear from Marquez.

Instead, we see Ames's attorney press Kovac about whether it was the nurses who were watching the patient more closely over the course of his three-day stay, as physicians went on and off duty--as if that was somehow remarkable, or a sign of bad care, rather than the way it always works, except on television. Physicians aren't trained to monitor patients 24/7 in the way nurses are in any case. But all right--if the nurses were the ones watching, and that's somehow a problem, why aren't they in court? Why don't they seem to be tormented about what happened, as Kovac does? Were any named as defendants ?

Maybe we're supposed to get that Marquez should have examined Ames after his second numbness. But it seems unlikely that many viewers will see it that way. The better interpretation is that Marquez probably should have simply gotten Kovac, as she has no ability to assess his neurological status herself. In fact, nurses do have that ability.

Ames's attorney also suggests, and viewers are pretty clearly meant to suspect, that the central line caused the stroke. Of course, it's also possible that his three-day stay on a cramped gurney with no apparent movement was at least a contributing factor. But maybe that's something a nurse would be more likely to notice .

On the other hand, in one remarkable courtroom exchange, we do see Ames's attorney ask Kovac why he did nothing about the 1-to-8 nurse staffing ratio at the time Ames was in the ED. The attorney notes that "the state" recommends a 1-to-4 ratio. Kovac observes that it's not really within his purview. The attorney presses--why didn't he go to a hospital administrator, the director of nursing, the nurse manager? (They exist? Awesome!) Kovac responds that the hospital can't predict how many patients will come into ED.

Of course, that's true as far as it goes, but the larger issue of short-staffing in many places is a failure to deploy adequate resources, to hire enough nurses to meet the expected patient load. To suggest that the problem, even in an ED, is simply a natural result of patient unpredictability is a dangerous distortion. Of course, the attorney has suggested the staffing should have been better under state guidelines, but the point is not pursued, and Kovac has far more credibility.

Moreover, the idea seems to be that even things that might be beyond Kovac's direct control, like nurse staffing, are ultimately his responsibility. The show has presented Kovac as the "chief" of the ED, and it has previously suggested that he's responsible for nurse staffing. And there's been no indication that the ED even has a nurse manager in almost a year. So it's not clear which nurse Kovac would have been contacting anyway. We do think physicians should help nurses push for better staffing, as Philadelphia Daily News columnist Ronnie Polaneczky recently urged. However, that's not because physicians are ultimately responsible for nurses' work, but because both professions should work to end dangerous health care practices in order to protect their patients.

Whatever its flaws, though, the exchange does at least suggest that nurse short-staffing is dangerous. In fact, recent research found that doubling a post-operative nurse's patient load from four to eight patients--exactly as in this episode--increased mortality by 31%.

In tonight's episode, Kovac's fears are laid to rest, as there is a verdict in his favor. It does seem that Ames will be reappearing periodically to haunt Kovac, but no one else who cared for him. We still hear nothing about how Marquez or any other nurse who cared for Ames feels about this.

A remarkable unrelated scene in tonight's episode suggests both that nurses are genuine health experts, and that the public's ignorance of that fact is no big deal. In a minor plotline, new attending Archie Morris tells ED staffers that a local television affiliate wants a "photogenic, well-spoken ER professional" to do a health piece. Morris asks several physicians, from attending to senior residents. They turn him down. Morris rejects the offer of an intern (he's too new), then, continuing among the group, turns to Taggart: "What about you?" Taggart responds: "Nobody wants to hear from a nurse." Frank notes that it looks like it will fall to Morris, who, of course, wanted to do it all along.

The show obviously deserves a lot of credit for having Morris suggest, nonchalantly, that Sam could do the health piece, even though a new physician would not be qualified. It also gets points for the deliberate reference to the TV station wanting an "ER professional," rather than simply a "doctor." We realize that many stations would have simply asked for a physician, but not all, and we appreciate the nod.

Unfortunately, Taggart's reaction is a problem. Sure, the plot calls for Morris to do the health piece. (It mocks him for his vanity in getting ready, and then attending Kerry Weaver ends up upstaging him.) And it's possible Taggart was just looking for a credible excuse to get out of doing it. But that is not made clear, and Morris has already accepted excuses as weak as "bad hair day," so it's not like Taggart had to resort to this. She delivers the "no one wants to hear from a nurse" line as if she herself doesn't really care. The show could have had her give some other excuse, such as that she's short-staffed, which would tie in with the earlier episode discussed above. But her actual comment suggests that she's basically fine with the idea that physicians are seen as the only ED experts.

And that's what seems to unite these plotlines: the notion that nurses may be skilled and important in patient care, but at the end of the day, physicians get the credit or the blame, and that's basically fine with "ER." But if we're going to resolve the nursing crisis, the importance of nursing in patient outcomes--good and bad--must be understood.

Please send "ER" our instant letter, or one of your own, and let show producers know what you think of their portrayal of nursing. Thank you.