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November 8, 2007 -- The episodes of NBC's "ER" broadcast tonight and a week ago send typically mixed messages about nursing autonomy and expertise. On the one hand, the episodes include some helpful suggestions of nursing skill. These include lone major nurse character Sam Taggart's (right) quick thinking to prevent a combative patient's suicide, and in a pediatric trauma scene, a rare indication that some nurses are more skilled than others. Sadly, other scenes suggest that nurses report to physicians, that physicians manage nurses' work at triage, and that physicians have to persuade nurses to allow a natural death for terminal patients. And there is the usual focus (even by the nurse characters) on physicians' professional hierarchy and advancement, while the nursing analogs are utterly ignored. The November 1 episode was "The Test" by Lisa Zwerling, MD (9.1 million viewers), and tonight's episode was David Zabel's "Blackout" (8.4 million viewers).

Video Clips in Quicktime

Film clip 1 (Nov. 1) at broadband or dialup speed. (triage, Heather)

Film clip 2 (Nov. 1) at broadband or dialup speed. (ethics)

Film clip 3 (Nov. 8) at broadband or dialup speed.

"ER," unlike other TV hospital dramas, often presents nurses as skilled workers who actually interact with physicians and even patients. In these two episodes, as in most, there are small depictions of nurses weighing in with vital signs or confidently accepting technical physician care plans. Of course this amounts to little in the context of nurses' real role in hospital care, but in today's Hollywood environment, it counts as a striking portrayal of nurses as sentient beings whose work matters.

One plotline in the Nov. 1 episode focuses on a troubled teenage patient. Heather's wealthy widower father seems to have abandoned her for a new wife in New York, hiring staff to meet her physical needs. Taggart plays an important role in handling this almost comically obnoxious patient, assessing her headache and trying to contact a family member. Taggart asks how bad Heather's pain is on a 1-10 scale. When Heather calmly says "10," Taggart responds: "Pretty calm for a 10." Taggart also confronts Heather when her supposed parental phone number turns out to be a video rental store.

Heather continues to berate and insult the staff, but she seems to be in no great pain or danger, so none of the staff take her condition very seriously. At one point, Taggart kicks her off a staff computer. At this point, Taggart has just suffered significant abuse from a physician colleague (and the show, as we explain below), but she remains alert enough to spot the instant messaging Heather has been doing, which suggests the girl has just downed some Valium and has plans to jump in front of the El train. Taggart sprints from the ED to the station, and pushes Heather out of the train's path just in time. As the staff treats her Valium overdose and what turns out to be hypoxia, which has caused the combative behavior, attending Skye Wexler credits Taggart with saving Heather. Of course, some viewers may not see Taggart's alertness, quick thinking, and decisive action as indicating health care skill--a lay person might have done it--but it is something.

The plotline concludes with Taggart dabbing sweat away from Heather's skin and speaking tenderly as the patient seems to awaken:

Taggart: "Hey...you're OK. We got rid of all the pills you took. Although we didn't take very good care of you last night.   I'm sorry for that. Your Dad's on a plane. He'll be here in about an hour."

Heather explains what she sees as her father's abandonment, then:

Heather: "Why did you do it? Why did you save me? I wanted to die."

Sam: "Things will get better. I swear."

That's pretty lame, but the show does seem to be suggesting that Taggart is providing important psychosocial care, and that Heather is responding somewhat constructively. Again, it may not strike viewers as reflecting a lot of health care skill, but at least it does show a nurse playing a central role in patient care.

In tonight's episode, one plotline suggests that some nurses are more knowledgeable than others. In one scene, the staff confronts a baby who suddenly suffers heart failure (the infant's underlying condition has eluded all of them except resident Abby Lockhart, who has left the ED). As usual, physician interactions dominate the scene. But at one point, veteran nurse character Haleh Adams (right) helps lead a virtual inquisition into the poor care provided by a terrified new ED staff nurse, whose name turns out to be Tiffany.

Adams:   "What's the SAT?"

Tiffany:   "I don't know."

Adams:     "You don't know?"

Tiffany:   "I'll do one now."  

The physicians discuss what's going on with the parents, then:

Attending Archie Morris:   "How come [the baby] doesn't have an IV?"

Tiffany:   "I was told she was going home."

Adams:   "Get me an IV kit."

Attending Greg Pratt:   "Where's the EKG Abby ordered?"

Tiffany:   "I haven't done it yet."

Pratt:   "Listen, I know you're new and I don't know your name--"

Tiffany:   "It's Tiffany."

Pratt:   "--but that EKG was ordered hours ago."

Tiffany:   "We didn't have neonatal leads down here. I called Central Supply."

Adams:   "Central takes forever, you can't wait for them on a day like this. Run to the NICU, run! Get those leads and get back here!"  

Pratt (softly, to Adams):   "Where'd you find that one?"

Where? The show invites viewers to guess--as it has in the past in similar portrayals of clueless Southeast Asian nurses. No one mentions the increasing role of recently recruited foreign nurses in U.S. care, or why that situation has developed. The plotline provides no additional context about why Tiffany is so clueless. Is it that she's new to County General? Inadequate training? Cross-cultural issues? Are some nurses always going to be better than others? Is short-staffing a factor? Pratt's focus on Tiffany's name is revealing. Her name matters somewhat--unlike those of nurses on "House," for instance--but we never do hear her surname. We don't fault the show for this; this is the way many nurses would introduce themselves. By contrast, imagine a physician introducing herself as "Tiffany."

Leaving all that aside, the plotline is good in that it shows that some nurses are better than others, as Hollywood regularly stresses is true of physicians and other professionals. And the plotline shows what happens when an ED nurse is clueless. The show suggests that Adams would not have made these errors, because she is knowledgeable and takes the initiative. Some of what Adams displays will strike viewers as site-specific practical knowledge--she knows that you can't wait for Central--but she also seems to show an awareness of which patients deserve more attention and how to prioritize key tasks.   

Unfortunately, the modest benefits to nursing from these features are outweighed by several highly damaging suggestions that nurses report to physicians, whose professional status remains of intense interest to all. Both episodes send troubling messages about the role of nurses and physicians at triage. Last week, one small strand of the episode involved how the staff was coping with chief of ED medicine Moretti's new triage policies. At one point, Moretti had this exchange with Taggart:

Moretti:   "Sam, you're supposed to be covering triage right now."

Taggart:   "What?"

Moretti:   "Yeah, nurses rotate every two hours.   You're up."

Taggart complies. This tells viewers, wrongly, that (1) physicians direct nurses, and (2) physicians direct triage, which is in fact a nursing function and one overseen by nurse managers. The show has made similar suggestions many times over the years, and the fact that it continues to do so is unfortunate, to say the least.

The episode also shows resident Tony Gates bristling under chief of ED medicine Moretti's new policy of placing residents in the waiting room "doing triage." This appears to involve Gates walking around assessing patients, and responding to pleas that their conditions merit quicker attention. This is in fact how Heather is seen more quickly. At one point, Gates begs Moretti to come back and clear beds. Moretti responds: "Last month a woman arrested in an ER waiting room because nobody was paying attention."

In fact, there was such a real case in Illinois where the death was ruled homicide. However, it seems to us that the overall solution to such problems is more likely to be better nurse staffing at triage and the entire ED. Viewers will not get from the Gates triage plotline that it's already the nurse's job to be "paying attention" to the waiting room and using advanced skills to assess and prioritize patients--not just sitting at a desk filling out forms and absorbing patient abuse, which is generally what "ER" viewers see, on the rare occasions when they see the triage desk.

Tonight's episode briefly revisits the physician triage issue. Near the start, we see Gates and Taggart leading a group of nurses, including nurse characters Chunie Marquez and Dawn Archer, through the ED:

Gates:   "What we're talking about here is pain. Proactively treating it right here in triage with you guys, all right?"

Taggart: "Most of you know how to use the Wong-Baker scale."

Gates:   "Any kid coming in we assess the pain from 0 to 10. Any score above 0 we give 'em analgesia at the desk.   Put it in your charts, the docs will be checking."

Marquez whispers to Archer: "He's been Moretticized."

Archer:   "Umh-hmm, Gates drank the Kool-Aid."

We appreciate Taggart's role as one of the apparent leaders here, and the kind of standard medication plans depicted can be helpful. But there's a lot wrong with this. It suggests, again, that physicians manage nurses, and that physicians direct triage. It suggests that at least some ED nurses are unfamiliar with the importance of pain and how to assess it, which is absurd, since nurses generally have more expertise in that area than physicians do. It suggests that nurses have to be told to record medications in charts, and that physicians will be "checking," as if nurses were school kids who might forget to do their homework. Similarly, at one point in last week's episode, Taggart informs attending Wexler of a Moretti protocol under which Taggart does not need doctor's "orders" to give asthmatics Solu-Medrol if a patient meets certain criteria. Again, this is a good idea and showing it highlights nurses' abilities to some extent, but the implication that nurses report to physicians--underlined by the misnomer "orders"--is unmistakable. It would be more accurate to use the term "prescription," which indicates no more than the legal authority to request that medications be given. Of course physicians have a lot of practical power, but nurses are still ethically required to advocate, when necessary, for medications that may be more appropriate for a patient, or to decline to administer those prescribed.

One of the plotlines in last week's episode is about a precocious 13-year-old named Josh, long a patient and friend of Gates. Josh is dying of an incurable neurological disorder. The plotline shows Taggart as a spirited patient advocate and educator. But it also presents her as a somewhat myopic subordinate player who can be excluded from key care discussions, and who must ultimately give way to the holistic, end-of-life wisdom of the physicians.

The plotline does show Taggart as a patient educator. We see her explain to Josh why they've put a heart line in ("so we can check your blood gases without needles"). Later, she asks him: "So, you understand everything the doctors are saying?"

The main problem is how the plotline treats Josh's request to Gates that he be allowed to die, without going on a ventilator. The boy, who is gifted in both intellect and wisdom, tells Gates he doesn't want the vent but that they should not tell his mother the idea was Josh's, because she will never agree. Instead, Josh suggests, his mother will waste the next year and all her resources trying to keep him alive. Gates consults attending Wexler, who approves but tells him to run it past ethics. No one even tells Taggart this is going on, much less asks for her opinion or her help.

Gates then presents the new plan in the ED room with the patient, his mother, Wexler and Taggart present. The mother seems stunned. Taggart cannot believe that this decision has been made for or by a 13-year-old boy--she has a son roughly the same age--with no consultation of his mother. Wexler assures Taggart that "Dr. Gates and I have discussed the options at length"--meaning, don't worry your little nursey head about this. Taggart, firing back, wonders if this is such a good idea on Wexler's first night as an attending in this ED. Wexler: "I've been attending for 10 years." Taggart relents when Josh himself clearly endorses Gates' plan, at which point his mother also seems to acquiesce.

However, Taggart is not satisfied, and she has it out with Gates in the hallway outside. He finally informs of her of what the boy has requested. Taggart notes that 13-year-olds often make bad decisions. Gates stresses that his obligation is to his patient. Taggart suggests that doesn't mean his mother has no rights. Gates explains to Taggart how awful vents are--presumably because as a second year resident, he understands that far better than someone who's been a nurse for a decade.

Gates:   "He doesn't want to lay around in bed, hooked up to a bunch of machines, waiting for a miracle. What part of that do you not understand? We're not intubating, Sam. ...

Taggart starts to calls the hospital's ethics person--we admit no other show would have a nurse even think of going that far--but Gates says he's already discussed it with ethics, then actually grabs the phone from Taggart's hands and slams it back on the receiver, yelling:

Gates: "Stop! I'm the doctor. This is my call. Now you can either mix this morphine drip or you can take yourself off this case, because we're done here."

Taggart stalks off. As is almost always the case when "ER" physicians tell nurses off with this level of heat, Taggart has no answer, leaving the impression that maybe Gates was a bit harsh, but what he says is correct--major care decisions are "his call," and he has the right to declare when discussion has ended, because at the end of the day, he is in charge.

While the plotline presents Taggart as a fairly forceful patient advocate, it also suggests that she is an uninformed, superficial one. Moreover, by effectively endorsing the exclude-Taggart-from-serious-discussions approach, it suggests nurses need not be included in such decision-making. At a minimum, Taggart should have been informed of the patient's request in advance. Ideally, nurses should play key roles in such discussions, since they tend to be sensitive to patient needs and relevant family dynamics.

In addition, the plotline presents Taggart as advocating for a high-tech, life-preserving intervention over quality of life concerns raised by the physicians, when the reality is far more likely to be the reverse. Nurses are the experts in these types of interventions, since they tend to manage them. They are also far more likely to advise against needless interventions that prolong life beyond any hope that a meaningful quality of life will return. Nurses tend to focus on allowing humane deaths since they are the ones who actually care for patients 24/7 and constantly see what patients endure. But this plotline presents the physicians as the holistic, big picture advocates who guard against overtreatment and are really close to the patients, saving them from the inflexible rules of the inflexible nurses.

Finally, the plotline effectively affirms that at the end of the day, physicians are in charge of patient care and of nurses. Maybe yelling and grabbing the phone was a bit much, but no viewer will see Gates as having done an improper end run around Taggart, or wrongly excluded her from these discussions. On the contrary, the plotline functions as a turning point in Gates' professional development. Uppity nurse Sam thinks she can tell Gates what to do because he's just a resident, but our lil' resident is growing by leaps and bounds. A real second year doesn't have to listen to nurses any more because now he knows more. Being a real physician means being able to take down the nurses, and sometimes that means ordering them around, and reminding them that you're the boss.

The November 8 episode also includes a helpful reminder of this supposed hierarchy. One major plotline concerns whether attendings Pratt and Morris have passed their exams to be board-certified in ED medicine. The whole staff has a party at a local bar to celebrate the physicians' exalted new status, and the nurses enthusiastically join in. Taggart, Marquez, and Archer sit at a table. Marquez says it is weird to think of Pratt and Morris as the "top of the heap." She remembers when (physicians) Mark Greene and Doug Ross were "running the place." Obviously these statements assume that the nurses are physician subordinates. And of course, no one wonders why it is that everyone in the ED celebrates the physicians' professional milestones, but no one celebrates those of the nurses. Do they have exams and certifications? Whatever.

On the whole, these two episodes are vintage "ER." They include tantalizing suggestions that nurses are not just the clerks that other Hollywood shows portray. But these suggestions are undermined by firm assurances that it is and should be a physician-shaped health care world.

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