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Nothing more than a persistent illusion

September 13, 2007 -- The "ER" episode rebroadcast tonight was yet another in the show's long tradition of suggesting (at times) that nurses are skilled and important to patient care, yet also suggesting (at times) that nurses merely assist the physicians who have the real expertise and responsibility. Don't get us wrong: we'd miss a prime time world in which this NBC show did not regularly present us with the challenge of parsing the diverse and sometimes subtle messages it sends. These range from some good care and advocacy from sole major nurse character Sam Taggart, to the little bits of skill displayed by the minor nurse characters, to the regular physician nursing and nurse-free care scenes, to the implication that the show's countless wallpaper nurses are there to push gurneys, have physicians sign forms, and hold objects during codes. If this is "ER"'s last season, we face being left mostly with a stunningly regressive prime time landscape of mute handmaidens (or more precisely, with glimpses of their forearms and backs), with the occasional "naughty nurse" thrown in. Still, parts of this episode, notably the relentless physician nursing we see in the care of a physicist with septic shock and the growing role of new ED medical chief Kevin Moretti, show how short even "ER" falls of a good overall portrayal of nursing. The episode, "Sea Change", was written by Lisa Zwerling, MD, and drew 9 million U.S. viewers when it originally aired on May 10.

The physicist plotline illustrates the range of the "ER" nursing universe. Taggart generally comes off as a skilled, tough patient advocate, from the time she calls the patient to the attention of attending physician Greg Pratt in the ED waiting room. Taggart not only shows some nursing expertise and works steadily to focus the overwhelmed Pratt on the case, she also basically diagnoses the woman's underlying problem correctly when Pratt fails to do so. She seems to order tests, she pesters Pratt for an antibiotics prescription, and when she learns that the patient has "gram positive cocci," she clearly suggests to Pratt that the patient is septic. Taggart is a bit too blank when the patient explains that she studies quantum processing, and that she has shown the theory that an atom can exist in two places at once can "work in a larger matrix." Taggart: "I have no idea what you just said." No idea at all? We assume Taggart knows what an atom is, and most nurses do take physics.

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But Taggart does seem to know health care. She argues to Pratt that the patient is still febrile and tachy, and pointedly asks how he would know she doesn't have sepsis, when he has not even looked at her. Ultimately, Taggart calls the "rapid response team," which the show presents as a bold but necessary move--going around the physician--to save the patient. It is a rare depiction of nurses' unsung efforts to get patients the care they need when physicians are unable or unwilling to help. These efforts call for significant interpersonal skill, and they can carry professional risk, in view of physicians' generally greater institutional power.

The rapid response team is led by the hospital's current ICU "clinical director" Moretti. Moretti is the show's new Mr. Contempt-For-The-Less-Brilliant, a more thoughtful but less amusing version of the late surgeon Robert Romano. At one point, Moretti sees Pratt on the phone struggling to get a medication order filled. Moretti tells his team of one medical student acolytes that "learned helplessness is pervasive in the ER; we can't have a home-schooled pharmacy tech wagging the dog." Score: Moretti 1; ED staff, pharmacy staff, and home schoolers 0. Naturally, as on "House," no character seems able to scrub the veneer of faux intellectual prowess off this glorified playground bully. Instead, we are invited to take vicarious pleasure in his half-informed arrogance. It's true that Pratt suffers most directly in this episode, but (as on "House") it's only a matter of time for the nurses, who tend to be less able to defend themselves on these dramas.

Moretti orders Taggart to tell him the deal with the physicist. She reports the patient's basic condition, and Moretti takes over, issuing orders, his manner dripping with smug contempt at Pratt's having "dropped the ball" on the patient whose sepsis is "obvious." Pratt says he can manage his patients, but Moretti says if that's so, "why did one of your nurses activate my team?"

Moretti pompously explains to the patient's distraught husband that they need "goal-directed resuscitation for septic shock." Pratt objects that this will require ICU-level monitoring that the ED does not have time for and can't do. Moretti: "You can and you will. Watch." Meanwhile, he inserts the CVP line, as if that's all there is to it. Taggart notes calmly that they lack the "nursing capacity." Moretti just gives an amused smirk--these silly little people, whining about short-staffing! Of course, it may not be clear to most viewers that the fluid resuscitation and close hemodynamic and cardiovascular monitoring is nursing work, since Moretti speaks almost exclusively to Pratt, as if Pratt was involved or in charge of it. The physicians are thus shown to be doing and/or directing nursing work.

Honorary chief of nursing Moretti then proceeds to banter with the physicist--his only intellectual equal in the scene--about Einstein and Hawking. Pratt admits that the ED does not get to patients quickly enough, but says that's just the "reality" of the situation. Moretti intones: "Reality is nothing more than a persistent illusion." The physicist notes with pleasure that this is a quote from her hero Einstein. Moretti follows up with an attempted quote from Hawking that the physicist laughingly chides him for mangling, but the point is clear--Moretti and the physicist are working in a larger matrix.

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But back in "reality," rapid response teams generally consist mainly of nurses and few contain any physicians or med students at all. And they exist not primarily to fill gaps in physician care, as this plotline suggests, but to help nurses who think a patient has become unstable short of a code. They mostly provide additional nursing care. By telling viewers that rapid response teams are all about physicians and diagnostics, the show again suggests that physicians are dominant in a key area in which nurses actually are, giving the sense that physicians have primary responsibility for hospital care and nurses are pretty much there to help them.

Still other elements of the episode reinforce this impression. When the physicist is being moved from the surgical ward to the ICU, the show has a wallpaper nurse help OR resident Neela Rasgotra push the gurney. But it's obvious that's all the nurse is doing. She does not seem to be managing the second-to-second care of oxygenation, IV drips and cardiovascular stability. In "reality," nurses manage the patient's health during these trips, and physicians go along mostly to help push the gurney and continue their diagnostics on the patient upon arrival at the new unit. When Rasgotra and this nurse reach the ICU hallway and Moretti approaches the patient, the nurse simply departs without a word. She does not conduct the usual 15-minute verbal and physical handoff to the ICU nurse.

The patient then goes into v-tach, and Moretti, Rasgotra, and a med student pretty much do everything, including defibrillation. Very careful viewers will notice a bit of a nurse at the edge of the frame a couple of times, doing something or other. But almost no viewer will doubt that physicians are the ones who accompany unstable patients on unit transfers, and they are the ones who resuscitate them when needed. Indeed, perhaps to underline the irrelevance of nursing in critical situations, in the middle of this code a nurse actually appears to insist that the med student take a phone call from someone who says it's an "emergency." Why would a nurse be answering a phone in the middle of a code, instead of resuscitating the patient? A nurse only finally appears at the code to take over bagging for the much in-demand med student.

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Incidentally, the show also indicates that this patient move really happened so that if the patient died, it would not show up in an audit the chief surgical physician ordered because of some apparent problems in care. Earlier, when the OR chief told his chief resident about his plans for this audit, the resident suggested that the nurses would "hate" the OR chief for it. The OR chief responded that they would actually hate the resident, since he, the resident, would be in charge of the audit. No busy person relishes getting more work to do, but the shared assumption here is that the post anesthesia and OR nurses would not understand that such an audit might be necessary to resolve problems and improve care. The implication is that nurses are not educated science professionals focused on the big picture, or on evidence-based practice. They're just flunkies looking to get through the shift.

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Other plotlines include the usual physician nursing and nurse-free care, almost inevitable functions of the show's lopsided major character ratio. Late in the episode, Moretti confronts Pratt about the history of delay in the ED, particularly an old case in which a woman had a heart attack in the ED waiting room after waiting seven hours to be triaged. This is probably based on a real case, but Moretti's raising it only with Pratt suggests that physicians are in charge of triage and patient flow through the ED. They are not. Triage is primarily a nursing responsibility, and if Moretti wants to complain, he should be talking to the ED head nurse, except, of course, there is none. And the speed at which patients move through the ED has at least as much to do with nursing as it does with medicine.

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In fact, no patient would wait seven hours to get triaged, except in a disaster. Nurses normally triage patients in the first half-hour, and then patients wait for further care, which unfortunately can take hours. The triage nurse is also supposed to be monitoring triaged patients for signs of decompensation while they are in the waiting area. Of course, nurses can err in this monitoring and in the triage itself, especially when they are short-staffed, or when they lack the proper equipment, training, experience and facilities. But this level of nuance is obviously lost on the show, which seems determined to have two physicians battle about a nursing function the physicians would in reality have virtually nothing to do with.

There are plenty of other examples of physician nursing--physician defibrillation, an intern taking a patient to CT scan alone, a serious ambulance admit with no nurse involvement, a physician handing over a piggyback full of dilantin for infusion (which if given properly would have been pushed over 20 minutes anyway). In the absence of Taggart or one of the minor nurse characters, nurses in the various trauma scenes don't talk at all--to each other, to the physicians, to the patients or the families. Of course, these nurses do busy themselves. They hand physicians clipboards to sign, they hold things steady during codes, and they move briskly out of the way when physicians approach a patient to conduct their important work.

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For the zillionth time, the show has a distraught family member start to fall apart in a trauma room and present a distraction, only to have a physician character command that she stay out of the way. Sometimes the physicians will order nurses to keep a family member away, as if the person was a wild hyena, rather than a human who also needs care from the health team. We have never seen a nurse on this or any other show mention modern thinking on family presence, or note that research shows it actually improves care, or advocate for the family member to stay. Of course, the trend toward family presence has been driven mainly by chaplains and nurses, and resisted by many physicians, so it may not represent something that has made it onto every radar screen. But if we're going to have a persistent illusion, we'd at least like the 2007 version.

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Like past episodes, this one also uses word choice to subtly convey physician ownership of patients and nurses. One typical "ER" scenario is to have nurses alert physicians to a problem. At one point here, minor nurse character Chuny Marquez calls to a resident: "Abby, your head injury in trauma 2 lost her pulse!" At another point, a nurse opens the door to a trauma room and calls: "Dr. Morris, your TPA patient is seizing." "Your?" Lines like these suggest that the patients actually belong to the physicians, that only the physicians are ultimately responsible for them. But aren't nurses assigned a finite number of cases, just like physicians, leading to some patients being "theirs" and some not? So why aren't they "our" patients or "the" patients? And as noted above, Moretti asks Pratt why one of "your" nurses activated "my" rapid response team. We've noted that the team would be unlikely to belong to an ICU physician, but the statement also suggests that Taggart belongs to Pratt. And no, the statement was not about her belonging to the ED generally; Pratt said he could handle his cases. On the bright side, at least Marquez called her old friend and fellow nurse "Abby" and not "Dr. Lockhart."

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At the end of the episode, Moretti tells a hospital physician executive that he will accept the now-vacant ED chief of medicine position, at least temporarily. We just hope Moretti can help his nurses unlearn their helplessness, so that his patients can get better care.

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.