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"I don't use nurses"

April 28, 2008 -- Tonight's episode of Fox's "House" seemed designed to placate nurses unhappy that the show has spent the last four seasons pretending nurses play no important role in hospital care. The show's isolated effort to make amends did not focus on what nurses actually do, but instead relied on a strike plotline which supposedly showed how bad things get when nurses are absent--much as "Grey's Anatomy" did in 2006. In this episode, House's team works to determine what is making the husband of one striker too nice. It includes a brief scene in which this nurse saves her husband's life by diagnosing a heart attack and performing CPR. We thank the show for this. Sadly, we never learn why the nurses are striking. And the only scene that seems to show the effects of the strike simply shows an overcrowded ED, and implies that physicians just have to work extra hard to make up for the absence of nurses--as if physicians can do everything nurses can. They can't. The strike makes no real difference in the episode, since, as House glibly says, he does not "use nurses" and does not even know what they do. It doesn't count as irony when what you say is the simple truth for the show. As always, House's smart physician crew provides virtually all bedside care. Except for the heart attack scene, the patient's wife projects the same blankness in the face of technical care that we've come to expect from the few wallpaper nurses who appear on the show to absorb physician commands. And as usual, no one rebuts House's anti-nurse slurs--because, though mean and nasty, they are portrayed as being as ruthlessly correct as his other diagnoses. The episode is "No More Mr. Nice Guy" by David Hoselton and show creator David Shore. It drew 14.5 million U.S. viewers.

See video clips of this episode at this link

The episode focuses on the condition of Jeff, who is married to one of the hospital's striking nurses, Deb. Jeff is walking with Deb on the picket line outside the hospital. When a delivery guy tries to push through the picket line prematurely, even bashing his dolly into Deb's legs, Jeff's reaction shows that he is way nicer than any normal person. After giving the obnoxious delivery guy a hug, Jeff's eyes roll back in his head and he seems about to collapse. In the chaotic ER where Jeff is taken, we see House encounter a very overloaded Cameron, formerly one of House's physician underlings. She welcomes House to a "world without nurses," and hands him some charts, as if he's going to help provide health care. House: "It's not my fault. I don't use nurses." Later, while "dean of medicine" Cuddy is having one of her usual verbal battles with House, she informs him that she is busy because "we have a nurses strike."

In a later scene, House and his team are with Jeff and Deb in Jeff's inpatient room. While Jeff is speaking, he begins to display clear one-side facial paralysis, an obvious sign of possible stroke. But Deb looks baffled, asking "What's the matter?" Fortunately, one of House's clever underlings reports "he's stroking," and the physicians rush to care for Jeff as Deb steps back, clearly out of her element. On the other hand, in a later inpatient scene with just Jeff and Deb, Jeff displays symptoms of a heart attack, and Deb actually diagnoses it, calling out: "My husband's having a heart attack, can somebody help me please?" She begins CPR, and finally is able to attract the attention of one of House's new minion physicians, who just happens to be walking by. In the next white board discussion scene, another House underling reports that "she saved his life." House: "Or she scabbed; depends on your point of view."

The diagnostic puzzle the House team confronts with Jeff involves the possibility that Jeff got neurosyphillis from Deb. Jeff refuses to believe that. The show does suggest that this may indicate Jeff is a bit too nice and trusting, but this diagnosis is later ruled out, and the show at least refrains from doing anything to reinforce the naughty nurse stereotype.

Later, House teases Cuddy by purporting to present her (his boss) with a performance review. She reads part of it: "'Your management of employees is...well, let's face it, they're outside carrying signs.'" Cuddy looks up and says: "The strike ended. The nurses have been back for two shifts already." House: "You would think I'd have noticed. What exactly did they do around here?" Cuddy also picks this time to note that House has breached an agreement in which he and his friend Wilson's girlfriend Amber have to share Wilson's time according to a set of rules. House does not deny his breach, but notes that Amber breached confidentiality. Cuddy, evidently the enforcer of the agreement, indicates that both House and Amber will be punished. This turns out to be by having to change a soiled patient together.

It's not just a coincidence that this episode uses the same strike vehicle as "Grey's" did in its let's-pat-nurses-on-the-head episode. Despite the presence of nurse advisors, neither show has ever displayed much interest in showing nurses doing what they really do in hospitals, partly because the physician characters spend half their time performing nursing. Maybe it would be awkward to work nurse characters into the care scenes--anything approaching reality might create too much cognitive dissonance with the shows' usual approach. So it's easier to use a plotline based on the nurses' absence, and just suggest that this makes things kinda busy, in a frazzled administrative sort of way. This is the sense we get from the ED scene with Cameron. She suggests that House might want to help her, and we see House's newer minions all gathered around one ED patient, all of which implies that physicians would be willing and able to take up the slack in the absence of ED nurses. They wouldn't. Nurses' clinical skills are unique in many respects, and physicians could not begin to do much of what nurses do for patients, including technical tasks.

The one real bright spot in the episode is the brief heart attack scene. Here Deb actually diagnoses Jeff's heart attack by noting his clenched demeanor, observing the monitor, and taking his pulse. The scene cuts after she begins CPR, but in the physicians' next we're-so-smart diagnostic white board encounter, another of House's minions observes that the nurse saved the patient's life. House's sarcastic response about scabbing (the nurses were still on strike) may be the closest the House character will ever come to acknowledging that a nurse has made a positive difference with a patient, or that nursing involves saving lives, so you all enjoy that. But don't get too excited. Many viewers could have probably seen the patient was having a heart attack too, and lots of people can do CPR. The show also botched the technical aspects of the scene--for instance, the nurse started CPR before the patient's heart had actually stopped--though few viewers will get that. Anyway, we do thank the show for this one scene.

One interesting element is whether the heart attack scene is sending any message about what role the strike might have had. Would this patient have died without his wife's presence because of the strike? Or because there just did not happen to be any physicians around? Do nurses only save lives in unusual situations? In any case, this scene does distinguish the episode from the "Grey's" one, which suggested that nurses were basically needed to fetch and carry, and to remember trivial patient quirks.

And that's not the only thing distinguishing the episode from "Grey's." We should note that the "House" episode manages to present a plotline about a nurse who might have syphilis without having one of the beautiful physician heroes refer to her as "skanky syph nurse," something "Grey's" has had trouble with. Very impressive. Though we are starting to wonder what it is about Hollywood, syphilis, and nurses.

Unfortunately, Deb seems baffled when Jeff has a stroke earlier, and she simply steps back to let the physicians handle that--as if nurses have no idea how to deal with strokes, or no right to participate in care when there are physicians around. That would explain why she reacts so differently here from the heart attack scene. Of course, this mute deference is the show's usual approach to nursing, and it is consistent with the idea that if nurses can improve outcomes, it really just happens when physicians can't be there.

Possibly the most interesting parts of the episode are House's comments that he doesn't "use nurses," that he has not noticed the strike has ended, and that he is not sure what the nurses did anyway. House is an ironic guy, and actor Hugh Laurie certainly delivers the lines in that mode. But it really doesn't work unless you give viewers some reason to see that the opposite of what House says is true, or that House knows his views of nurses are flawed. None of that is happening. It would be like House saying ironically that diagnosis equals cure. Well, yeah, that is the message his character and the show send each week--where's the joke? Since 2004 the show has relentlessly told viewers that House's nurse statements are literally true: the show has always presented hospital care as something House's team can pretty much do by itself, as they provide all important procedures, all testing, all patient education and support. This very episode proves it, as there is no difference in the clinical scenes with Jeff from what would normally occur on the show, apart from Deb's brief heart attack scene. So House's nurse comments really can't be considered jokes, unless they are post-modern ones, winking at the show's own absurdity.

Few viewers will see House's comments as anything but more harsh and funny--but deliciously accurate--insults from the show's master wit. House insults everyone, as people never tire of informing us, but he has rarely made a statement viewers are not meant to regard as basically accurate at some level. His harsh analyses of people are almost always proved correct. Don't get us wrong--it's not so much that mean people suck as it is that, in stark contrast to House's supersmart physician foils (e.g., Amber), there is never a nurse deploying her own wit to counter House's slurs. That means the slurs are free to fester in the viewers' minds, and it underlines the sense of nurses as meek, dull servants.

Note also the choice of language. House could have said he doesn't practice with nurses, or (translating into House-speak) that he wouldn't let those morons with Daffy Duck on their clothes anywhere near his patients. Instead, he says he doesn't "use nurses." This suggests (with no contradiction) that nurses are really just physician tools that could be employed or not, depending on personal preference, presumably for basic physical tasks. So nurses are akin to objects, and they report to physicians--they are not autonomous. The show confirms this in the exchange with House and Cuddy about the end of the strike, where both indicate that Cuddy is in charge of the striking nurses. But the "dean of medicine," which presumably means chief of medicine, would not have authority over the nurses--that would be the chief nursing officer's job. And of course, none of House's patients would survive long without nurses, but whatever.

And yet, there is an implication that House knows nurses do one thing in hospitals: the final scene in which he and Amber clean a soiled patient as a punishment for violating the agreement with Wilson. We know House knows this is a nursing task, since in an earlier episode he remarked that cleaning up (in that case getting a fallen patient off the floor) was why God/House "invented nurses." And of course, viewers will know it is a nursing task, and--just as in similar "Grey's" episodes--they will understand that nursing tasks are disgusting drudgery that no intelligent, ambitious person would do, unless they were being punished for wrongdoing. Yet the show refrains from having House or Amber make any nurse-related insult here, e.g., "I admit it--you make a better nurse than I do."

How enlightened.

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