Take the blue pill
July 6, 2009 -- Tonight's episode of Showtime's Nurse Jackie is yet another powerful showcase for Jackie's clinical virtuosity. The focus in several plotlines is not so much on Jackie's care for ED patients' immediate ailments as it is her holistic focus, how she expertly manages the larger family dynamics that have such a huge impact on health. Here she negotiates hospital rules to help a precocious 10-year-old continue to manage her mother's debilitating lupus. She also finds a creative way to advocate for a stroke victim, demonstrating to his obnoxious family that he's "still in there," even though he can't speak or move much of his body. At the same time, Jackie continues to mentor nursing student Zoey and new physician Coop, teaching the former about triage and the latter how to relate to the 10-year-old girl. The show even includes a quick but telling comment on patterned scrubs and the nursing image. The episode is slightly marred by its depiction of triage--it does involve assessing serious conditions, but it's not a "very simple" task that would ever be assigned to a student. And the portrayal of nurse manager Gloria Akalitus seems to reflect the battleaxe stereotype. Akalitus is a disagreeable killjoy, obsessed with enforcing rules regardless of whether they advance the wellbeing of those around her. The show punishes her constantly, her scenes are often funny, and of course some nurse managers are bureaucratic. But Akalitus is the show's Percocet, a quick way to feel better, but with potentially serious long term costs. This kind of image may suggest that female nurses can't handle authority, and that any strong woman who chooses to be a nurse must be twisted and bitter. Of course, Jackie herself belies that suggestion, and on the whole this episode offers a persuasive depiction of her advanced nursing skills. The episode, "Daffodil," was written by Taii K. Austin.
The episode's portrayal of triage is a mixed one. Of course the very fact that the show gives a remotely realistic view of ED nurses doing triage is an achievement. And some of Jackie's advice to Zoey is witty, persuasive and revealing. First we see Jackie typing at a computer while talking to Zoey.
Jackie: OK, it's very simple. Whatever [patients] tell you, you type in their file. Whatever they don't tell you, but you know to be true, type in their file.
Zoey: Nights are different.
Jackie: Yes. More stab wounds, more drunks. Less nut jobs, less children. OK. You prioritize by severity of their condition. Gunshots, stabbings, cardiac arrest, followed by bleeders and shallow breathers.
Zoey: What about someone who can't breathe at all?
Jackie: They are already dead, they go to the waiting room.
Akalitus (entering): Correction. When a patient arrives unable to breathe, check their belongings for identification. Unconscious patients bypass the --
Jackie: -- formal registration until such time as they are stabilized and can provide the necessary information--
Akalitus: --or until their emergency contact arrives and does it for them.
Jackie: She's a smart girl, she would have figured that out.
Zoey: I am actually pretty smart. But also, very nervous.
Akalitus: Can't relate.
Jackie (to Akalitus): You don't usually work nights. What's up?
Akalitus: You tell me. You make the nurses' schedules, always working with your favorite people. I'm concerned about the level of socializing.
Akalitus stops to yell at a 43-year-old security guard for flirting with a much younger nurse in the waiting room. The two separate and slink away, embarrassed.
Jackie offers some persuasive remarks about triage here, and viewers get a basic sense of what triage is and the range of conditions nurses must handle. But it's not "very simple," and it would never be given to a nursing student. In fact, only experienced nurses should be doing triage, because assessing the relative urgency of different conditions requires advanced diagnostic skills. Patients have died because they were not triaged correctly. And "Gunshots, stabbings, cardiac arrest?" What is Zoey supposed to make of that? Gunshots are always the most severe? And do cardiac problems always announce themselves clearly? Akalitus's comments advance her mission to destroy happiness whenever possible, but they also make clear that nurses like Jackie control their own work environments by making schedules. Presumably Jackie is the charge nurse.
Ten-year-old Stephanie arrives at the ED waiting room with her wheezing mother. Stephanie notes that her mom has lupus. Jackie puts the mother in a wheelchair, and tells her to go to the front of the line (a triage assessment!). But as they head back to the treatment area, Akalitus intercepts them, reminding Jackie of the rule that no one under the age of 15 can be back in the treatment rooms or in the ICU. Jackie claims that's not so, because a 4-year-old is in the ICU. Akalitus notes that that child is on a ventilator. Jackie notes he's still in the ICU, so Akalitus has to be "more specific next time" with her rules. Akalitus isn't buying it. She asks Stephanie who she is with. Stephanie says her grandmom is coming from New Jersey. Akalitus tells Stephanie to come with her. Jackie tells Stephanie that it will be OK, that she'll come get her in a little while. Jackie continues back with mom in the wheelchair, muttering about Akalitus, "Grinchy f---er."
Jackie is quite the lawyer here, trying to find a loophole in Akalitus's rule, though her argument is admittedly absurd. Of course, Akalitus's rule itself is counterproductive, at least as applied to the ED--a patient's mature 10-year-old daughter can't be with her in the treatment room? We might have hoped that a nurse-focused show would have some idea about the trend in recent decades toward allowing family presence when possible in these situations, a movement led by nurses and hospital chaplains that has been shown to offer patients and families real benefits [see links one, two, three]. But at least Jackie is advocating to keep Stephanie as close as possible, immediately seeing that this is in her mother's interest.
Later, in a staff area with Akalitus, Stephanie looks through some flash cards, studying for a spelling test. Jackie arrives. Akalitus tells Jackie that if the grandmother does not show up, Jackie should get social services involved. Jackie sees a folder in Stephanie's backpack marked "Emergency Info." Stephanie has carefully recorded her mother's blood pressure every day on a sheet with little stars on it. Jackie: "What was her blood pressure this morning?" Stephanie: "120/80." Jackie asks if her grandma is really coming. Stephanie's face says no. Jackie takes her to see her mother. There they meet the young physician Fitch Cooper, with whom Jackie has a somewhat tense mentoring relation.
Jackie: This is the daughter, Stephanie. She's 10. Be cool.
Cooper (getting down to Stephanie's level and using a toddler voice): Well, hello there Stephanie, I'm Dr. Cooper. Want a sticker?
Jackie: 10, not 2.
Jackie and Cooper speak privately.
Cooper: She's a kid, Jackie.
Jackie: Do you think I would bring her in here if I didn't think she could handle it?
Cooper: You're not always right, OK? What do you know about kids?
Apparently Jackie is not "out" about her family status to everyone at work, since she actually has two kids. Presumably this helps keep her pharmacist boyfriend Eddie in the dark about the fact that she is actually married. So Jackie cannot respond that one of her own daughters is roughly Stephanie's age.
Jackie: Show her some respect, please.
Cooper: How about you let me do my job?
Jackie: Your job is to provide your patient with the best possible care, which includes informing the caregiver of their condition. She is the caregiver. Get your head out of your ass.
Jackie deflects an attempt by Coop to grab her breast, which the physician supposedly does involuntarily when under stress.
Jackie: Are you kidding me? ... Freak.
Later, Jackie tells Stephanie that her mother is better. Jackie says that continuing to care for her mother will be hard, but she knows Stephanie can handle it. Jackie collects a ton of medication from the pharmacy for Stephanie to use because her insurance is not good. Jackie's boyfriend Eddie watches: "You're a good egg, Jackie Peyton."
Jackie finally escorts Stephanie and her mother out of the ED in a wheelchair, but unlike the menial wheelchair duty of nurse Malcolm in a June episode of Fox's Mental, here Jackie is directing patient care, and always thinking. She speaks to Stephanie.
Jackie: So you have my cell number, day and night. And Dr. Cooper wanted me to tell you what a great job you're doing with your mom, he was very impressed.
Of course it's very unlikely Coop said anything like that, but it will presumably add to the confidence Stephanie will need to make it. Jackie hands over all the drugs.
Stephanie: Thanks...I could have gotten these by myself.
Jackie (smiling) : I know. You've got better things to do, you have a spelling test tomorrow. (Just before Stephanie is out the door.) Daffodil.
Stephanie (turning): D-A-F-F-O-D-I-L.
Jackie smiles. Later, after her shift, Jackie arrives at her home in Queens, clearly exhausted. Sitting at the kitchen table, she gets a cell phone call. It is Stephanie. Jackie asks the girl to take a deep breath and tell her what's up with her mom.
Stephanie: Well, I gave her the Anatran after she ate, like you said, but she just woke up, and her arm...she can't really move it. It hurts too much.
Jackie: All right, sweetie, this is what you're going to do, OK? Find a Percocet. [Jackie searches for her own Percocet, and follows the rest of her own instructions as she is giving them to Stephanie.] That's the blue one. Get a butter knife, and cut the pill in half, OK? Do you have any cranberry juice? OK, take half the pill, give it to your mom with a little bit of juice. All right? She'll be fine.
This plotline demonstrates not only Jackie's commitment to her patient, but her psychosocial skills and her insight into family dynamics. The show does not even bother giving us any details about the mother's lupus. What matters is that Jackie knows how to calm the patient's 10-year-old daughter and explain to her how to give a potentially dangerous drug to her mom, in an effort to keep the family together. Yes, some of what Jackie does for Stephanie may be inconsistent with the rules; who knows how Jackie and Eddie account for all the drugs Jackie took for Stephanie. But Jackie is clearly weighing all that against the real possibility of foster care for Stephanie, which could threaten the wellbeing of the child and her mother. The show is suggesting that Jackie knows when to bend the rules, and when to bend to the rules. Things could go wrong here, but Jackie is at least trying to negotiate a complex, flawed system in an effort to achieve a better long-term result for her patient and her patient's caregiver.
Another plotline is about Alex Dubenko, a patient who has had a stroke. He is surrounded by his obnoxious, profane family, who complain about why it is taking so long, and seem to fight constantly. Alex cannot speak, but he seems stressed by their conflicts.
Jackie: Everybody, get out of here. (They leave, arguing.) Mr. Dubenko, my name is Jackie. Can I talk to you for a minute? (He looks pained, but seems to assent.) We're still waiting for your MRI, but it looks like you had a stroke. I wanted to give you a little test. Is that all right? Three questions, that's it. Can you smile for me? (Apparently not at all.) OK, can you lift both arms for me? (He raises only the right one.) Nice work, good work. Can you say something to me? Can be anything at all. (He tries hard, but can't.) OK. That's OK, I hear ya.
Later, Alex's family is trying impatiently to communicate with him.
Jackie: With stroke patients you have to slow down and give him a chance to process what you are asking. He is still in there.
Patient's wife (sarcastically): I'm sorry, you know my husband better than me. How do I get so lucky to have a nurse who knows my Alex so well? Thank you God!
Jackie: Listen. This man has had a stroke. You are lucky he's alive. So, be patient, or get out. This is a hospital.
Zoey: We're here to save lives!
British physician Eleanor O'Hara, who is Jackie's best friend, throws back the curtain surrounding the treatment area, and says, "Famished!" This means she wants Jackie to join her for dinner, as usual. But Jackie can't, so Zoey volunteers. To Jackie's amusement, Eleanor agrees, telling Jackie: "That's how easily you're replaced." But at the fancy restaurant they visit, Zoey is out of place. Eleanor tells her which fork to use.
Zoey: I'm just excited...to be eating at a place like this. (Adopting a mock-pompous British accent.) And with a doc-tor!
Eleanor: Christ, what have I done?
Another diner walks by and stares at Zoey's patterned scrubs in disbelief.
Eleanor (smiling): Make-A-Wish Foundation.
The diner smiles awkwardly and moves on. The actions of Eleanor and the other diner together make a striking comment on patterned scrubs, suggesting that no self-respecting person would dress that way in public, that Zoey is an adult dressing as a child might. But despite her goofiness and apparent naivete, Zoey's next words illustrate that she is actually not an idiot at all--the scrubs are a cultural issue that could be corrected.
Zoey (smiling disarmingly at Eleanor): I think it's really interesting how you use humor to cover up your real emotions. Somebody in your past must have really hurt you. And I'm sorry for that, because I think you're one of the most generous people I've ever met!
Eleanor (seeming stunned, but too sophisticated to let it show much): Darling, the point of these little feasts is to eat, and never to dip into...whatever the hell that was. So if you think you've got a rat's ass chance in hell of getting a pudding, you better come up to the surface where I can breathe. Next subject.
Zoey: My dad's in prison for manslaughter.
Eleanor: Fabulous, go!
Later, Jackie gets an idea from the spelling test study cards Stephanie has left behind. Jackie writes words on some of them. Next we see Alex, the stroke patient, holding several of the cards Jackie has made.
Alex's wife (with contempt for Jackie): Note cards! You think he can read note cards? He won't even nod his head yes or no!
Jackie is silent as Alex holds the cards with his usable hand, looking at each in turn, letting each fall until he reaches the last two. He gives these two to his wife, suggesting this is what he would like to say. She reads them out loud, in order.
Wife: "Shut the f--- up. Seriously."
The family is speechless. Alex looks pleased. Jackie smiles slightly and leaves.
This is another awesome performance by Jackie. Here she does demonstrate that she knows how to sensitively assess a stroke patient, with her three questions. But the real focus is how she advocates for Alex with his difficult family, repeatedly trying to help them understand what has happened to him and how they can start to adjust to it, undeterred by their general boorishness and Alex's wife in particular. Finally, Jackie uses an item another patient has left not only to show Alex's family that he is still there--that they should not give up on him, but try to help him--but also to give Alex a voice, offering him some words that, under the circumstances, his family will not soon forget. Yes, the words are a little rude, but Jackie has observed how this family relates, and calibrated her MacGyveresque intervention precisely.
One small note: it's not unrealistic that Jackie would introduce herself simply as "Jackie," but we wish more empowered nurses like her would introduce themselves as other professionals do--using their surnames. It would not impede relations with patients--nothing prevents nurses from continuing on a first-name basis--but it would project a better initial image. Things will never be quite right as long as the nurse is "Jackie" and the physician is "Dr. Cooper."
In one scene, Jackie and her friend nurse Mo-Mo share a coffee outside the hospital entrance, discussing Mo-Mo's love life. Mo-Mo is smoking a cigarette. Gloria Akalitus pops out of the hospital entrance and immediately yells at Mo-Mo.
Akalitus: You are a health care professional, stop smoking!
Mo-Mo motions toward a group of physicians on the other side of the hospital entrance, at least one of whom is also smoking.
Mo-Mo: Dr. Zander's head of pulmonary.
Female physician: Keep moving, Gloria.
Nothing is more fun than punishing Akalitus! Here she suffers humiliation for being a shrill, controlling zealot, though she's not crazy to suggest that health professionals might consider setting an example, and not undermining their own work in promoting health. Let's also dismiss her as "Gloria," even though the named physician is "Dr. Zander!"
But that's nothing. Later in the episode, Akalitus finds a Taser in a hospital hallway and starts berating the whole hospital about it, since there is no one else really nearby. Still ranting as she enters an elevator, Akalitus accidentally Tasers herself and lies twitching on the floor of the elevator. In an earlier episode, the smug enforcer drank Jackie's coffee, not realizing it had been enhanced with Jackie's painkillers. Akalitus spent the rest of the episode embarrassing herself with goofy, slurred affection for the colleagues whom she normally terrorizes. So what's next for Akalitus? Will the producers give her lung cancer because she harassed Mo-Mo about smoking?
We laugh at Akalitus too. But consider that the prevailing Hollywood battleaxe image is a bitter veteran nurse who is obsessed with enforcing hospital rules, regardless of whether they serve the interests of patients and colleagues. In many cases, battleaxes actually impede good care. Recent examples have appeared on ABC's Grey's Anatomy, NBC's ER, and even an HBO show called The Sopranos. In a 2006 episode of that show, a mob boss's faithful wife proved to have better nursing instincts than the nasty hospital nurse-bureaucrats who were caring for her badly wounded husband. (We wish that mob boss's wife could meet Jackie!) Unfortunately, such one-dimensional stereotypes often suggest that female nurses can't handle real authority, and that any strong woman who would choose to be a nurse must be twisted and bitter. It appears that these days, any normal woman who is smart and ambitious and wants a health career must become a physician. (See chapter 8 of our book Saving Lives, for a more in-depth look at the battleaxe stereotype.)
Despite these relatively minor issues, the episode on the whole is another great illustration of nursing expertise and dedication, and we thank those responsible.
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