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October 30, 2008 -- Tonight's episode of NBC's "ER" features a remarkable minor plotline about physician attitudes toward nursing, particularly the nurse anesthetist program that major nurse character Sam Taggart began in earlier episodes this month. This episode includes scenes in which Taggart's boyfriend, resident Tony Gates, condescends to Taggart both with regard to her current work and her anesthesia program. Gates does so in the context of his clinical teaching of an attractive intern who seems to have a crush on him. Taggart sets them both straight about nursing autonomy and skill, at one point successfully taking over an urgent intubation from the flailing intern. And other physician characters express support for Taggart. We commend writer Karen Maser and the show for the episode, "Haunted," which drew 9.2 million U.S. viewers.

See the relevant film clips in Quicktime broadband speed or dialup speed.

An early scene finds Taggart respectfully explaining to intern Daria that Daria is drawing an arterial blood gas at too steep an angle and will have better results if she holds the needle at 45 degrees. This is a good example of nurses' informal teaching of residents. At another point, Taggart drops some cards she is using to study for a test she must take the next day in the nurse anesthetist program. Daria asks if Taggart will be "learning to push drugs for an anesthesiologist." Taggart responds, pleasantly: "I'll be able to administer them myself." But Daria won't let it go: "Yeah, but a real anesthesiologist will be watching over your shoulder, right?" Taggart:   "Actually -- no." Another intern, Laverne, marvels at how Taggart can go to classes, work full time, and raise her teenage son. Daria wishes Taggart luck on the test; Taggart says she'll need it. Attending Simon Brenner chimes in: "Nonsense. A year from now, Sam will be running her own cases in the OR."

Later, Taggart and Gates have a seemingly mild disagreement about a girl's diagnosis. Taggart suggests that the signs point to strep and the girl needs penicillin. Gates wants a rapid strep test first. Taggart notes that the patient has exudate and lymph adenopathy (swollen lymph glands). Gates says he doesn't want to give unnecessary antibiotics. Taggart rolls her eyes but seems to be letting it go. Gates then asks Taggart to get a positive blood culture from the front desk and take it to medical records, and hunt down a chart. Taggart says she has a trauma case and six other patients, so Gates should send his intern. Gates: "I don't have one today, and there's no point sending a doctor on a no-brainer like that." Taggart responds, "Sure, no problem." But the look on her face and that of fellow nurse Dawn make it very clear that they have not missed the insult.

In a later scene, Taggart, Gates, and Daria are caring for a patient whose wronged wife has put glue in his bowling ball, with the expected result. Gates says this is a good teaching case for Daria, and there is an air of flirting. Taggart suggests to Gates that she give another 4 mg. of morphine.

Gates:   Yeah, morphine fine, amphetamine fat. Morphine overdose gives you fine constricted pupils, amphetamine gives you fat dilated pupils. It's a mnemonic, might help you out with your test.

Daria (explaining to Taggart):   A mnemonic is a saying you use to remember complicated facts.

Taggart:   Yeah, I know what a mnemonic is. And I also know what morphine does without some stupid saying.

We might have wished for a little more from Taggart's response to Daria ("Oh, like mnemonic moronic?"). But at least the show is clearly registering that the physicians' condescension is misplaced.

Soon, we see how misplaced it is. A team including Taggart, Daria, and Brenner is working on a critically injured child with a blood clot in his brain. Taggart notes that the patient is hypoventilating and needs an endo-tracheal tube. Brenner asks Daria to place the tube, and then asks Taggart for certain medications to sedate and paralyze the boy. Taggart tells him she is already pushing them. Daria, struggling, says she cannot see the chords. Taggart offers to help with some suction. A fight breaks out in the adjoining trauma room and Brenner goes to break it up. Daria continues to struggle and grows increasingly desperate, as the patient's condition is deteriorating. Taggart tells Daria to pull the intubation blade up. Daria yells that she is. Taggart tells Daria: "No, you're rocking it back," which won't work. Daria, ignoring Taggart, calls for Brenner, but he is too busy with the fight next door. Taggart demands the tube, and Daria protests, but finally allows her to take over. Taggart intubates the patient with ease, then observes: "You don't need a mnemonic to save someone's airway."

In a scene near the end of the episode, Taggart is leaving work to attend a review class for her test the next day. Gates says he thought she was going to blow that off.

Taggart:   Yeah, well, school isn't just a cutesy little hobby, you know.

Gates:   What're you talking about? You know I support this.

Taggart:   Oh, I know, when it's convenient for you, doesn't interfere with your life. I know you have an outdated, sexist view of what nurses do. We do a helluva lot more than change bedpans.

Gates:   I know that, Sam.

Taggart:   I wish you would respect what I'm trying to do and what I'm trying to learn. Heaven forbid you get an intern to do your scut work. You're trying to show off to Daria by making me look small. You know what? That is never gonna fly.

Gates:   Hey, teaching the interns is part of my job. What do you want me to do?

Taggart:   Nothing. Forget it.

Gates:   You're nervous. Let's go home and I'll help you study.

Taggart:   OK. What's the anesthetic of choice for open heart surgery?

Gates has no answer.

Taggart:   That's what I thought.

She walks away.

On the whole, this plotline is very helpful. Taggart's interactions with both Gates and Daria make clear that Taggart has significant expertise as an RN. And she is not afraid to advocate for patients, even in the face of contempt from the physicians, which remains a significant problem for real nurses. The "outdated, sexist" comment at least hints at the cluster of enduring stereotypes that continue to undermine nursing worldwide. Maser's script and actress Linda Cardellini's portrayal of Taggart manage to present the nurse as someone who is trying to practice collaboratively--she is making suggestions and trying to teach Daria in a non-confrontational way. Possibly some viewers would see Taggart as insecure. But here Taggart does not really react until the physicians' disdain becomes very clear.

The episode also indicates that nurse anesthetists receive rigorous training, and that they operate with autonomy. Attending Brenner expresses confidence in Taggart (even as she doubts herself) and the last scene suggests that Taggart's knowledge of anesthesia has already surpassed Gates'. It would be too much to expect the show to hint that anesthesia work is an especially good fit with nursing because of the premium it places on relentless, skilled patient monitoring, at which nurses excel. We could quibble with some aspects of the show's presentation of the advanced practice nursing program, something no major show seems to be able to get really right. In this and prior episodes, the nurse anesthetist program has been described as more of a course than a rigorous two-year university graduate program, as is generally the case. No one on "ER has ever asked what university Taggart is attending. Still, "ER"'s portrayal is easily the best depiction of advanced practice nursing that we have seen recently on a major Hollywood show.

In what really does appear to be "ER's final season, the show remains physician-centric, but it also continues to offer the only serious depictions of nursing practice issues on a major U.S. television show in prime time. That will be missed.