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The good, the bad, and Zoey's stethoscope

June 22, 2009 -- Tonight's episode of Showtime's Nurse Jackie continues to present Jackie as a clinical leader with a vast skill set, and to show that nursing can be as compelling as medicine--if you actually let nurse characters do the nursing, as no other major show has done on a regular basis. Here, Jackie provides skilled care to a dying heart patient and a young woman who has become addicted to Vicodin. She also joins her best friend, physician Eleanor, in an amusing but deceptively important effort to teach nursing student Zoey not to be intimidated by physicians. One of the most impressive aspects of Nurse Jackie is that it goes out of its way to show not only that Jackie is clinically expert and a strong patient advocate, but also how patients and their families benefit from her advanced psychosocial skills. These are all the more amazing given her somewhat raw approach to colleagues and the addiction to painkillers that seems to haunt her. Small parts of the episode do reflect what may be the show's most significant ongoing problem, its iffy portrayal of nursing autonomy and authority. Jackie's interactions with physician Coop suggest she has little idea about what the hospital's upper management structure is--it seems to consist of the physicians. And the episode's depiction of Jackie's boss Gloria Akalitus tells viewers that nurse managers are not really nurses. On the whole, though, the episode offers another engaging look at what a strong, skilled nurse can do for patients. The episode, "Chicken Soup," was written by Mark Hudis.

Chicken soup for Nurse Jackie's soul

You can't just stop taking opioids like that

We are powerless against the crushing force of the Pixus!

The good, the bad, and Zoey's stethoscope

Please tell us--and the producers of the show--your thoughts on Nurse Jackie!

 
Chicken soup for Nurse Jackie's soul

A major plotline in the episode follows Jackie's care for ED patient Bernard Zimberg, an older man with a long history of congestive heart disease. As Jackie sets up an EKG, the wide-eyed first year nursing student Zoey enters (Zoey often functions more like a first year nurse than a nursing student, but whatever). Zoey proudly introduces Jackie to a new stethoscope that her mother has given her by saying, "Ta-da!"

Jackie:   First, get me those leads. Second, don't ever say 'ta-da' again, OK? The only people who say 'ta-da' are magicians and idiots.

Enter Jackie's best friend, the senior physician and designer clothing maven Eleanor O'Hara. Eleanor immediately takes Zoey's precious stethoscope from around her neck ("May I?") and turns to the patient.

Jackie:   Mr. Bernard Zimberg, fluid in his lungs, shortness of breath.

Eleanor:   So, Mr. Zimberg. How long have you had congestive heart disease?

Bernard:   I had a quintuple bypass...the same year the Rangers won the Stanley Cup.

Eleanor turns to Jackie for a translation.

Jackie (smiling):   That's 1994. I'm still having dreams about Mark Messier.

Bernard:   Canada's finest import since bacon.

Eleanor explains that Bernard's arteries are not cooperating, that they are closing up, restricting the blood flow. Eleanor wants cardiology consults, but she says Bernard is looking at more angioplasty at the least, another bypass at the most. Eleanor then says she wants a word outside with the "nurse," but this turns out to be just a way to set up her daily lunch date with Jackie at an expensive restaurant. Eleanor takes off without giving Zoey's stethoscope back. Zoey can't bring herself to ask for it.

Then Bernard tells Jackie what he really wants:   no cardiologist, no angio, no bypass. His wife arrives, and they tell Jackie that all he needs to get better is in the bag she has brought. Jackie says, kindly: "That must be some bag!" It turns out that the bag contains only chicken soup. The couple banters with Jackie about chicken's soup's mystical and health qualities--it's the "Jewish penicillin!"--and they suggest that it has enabled Bernard to live two years when he was told he had only 6 months. Jackie gently makes sure they understand the medical tests and procedures that are recommended for them. They insist they don't want any of that.

Jackie:   OK, I'm sorry, but I need to be perfectly clear about this. So, you are refusing medical treatment, and you are choosing to eat soup instead?

Bernard says yes. It's obvious that the couple knows what this means. Jackie accepts the decision immediately, and merely asks them to let her know if she can be of any help. As it happens, they do need her help in warding off the "administrator"--which we have assumed means nurse manager--Gloria Akalitus. Akalitus throws back the curtain and abruptly asks who Bernard's "doctor" is. The wife replies that he does not have a doctor; he is eating soup. Jackie arrives and claims they are waiting for test results. Akalitus says they can wait in the waiting room. Jackie takes Akalitus outside.

Jackie:   Gloria, can you be a nurse again for one second? Stick your head in there and tell me what you see.

Akalitus goes, looks for a few moments, and returns.

Akalitus:   He's dying.

Akalitus gives them till the end of Jackie's shift. But Bernard does not need that much time. Before too long, his heart monitor emits a solid tone. Jackie arrives and waves off the code team (incidentally, the team seems to be composed mainly of nurses--yet another little bit of reality that no other Hollywood show would be likely to include).

Jackie (to Bernard's wife):   I'm so sorry. You know, I think the soup really did help ease his suffering.

Bernard's wife smiles and says that's all she wanted; she knew her husband was dying, although he did not want her to.

Akalitus shows up, telling the wife abruptly and insincerely, "I'm sorry for your loss." Akalitus jerks her head at Jackie, meaning to get the dead patient and his wife out. Bernard's wife says something pleasantly in Yiddish to Akalitus. Akalitus thanks her and leaves. When Jackie asks, the wife tells her the phrase means "go sh** in the ocean."

This plotline is a good example of Jackie's expert psychosocial care and patient advocacy. It's obvious that she is the leader in caring for this patient, although she informs Eleanor at lunch of what is going on. She practices her usual deep listening, makes sure that the patient really does not want further treatment, then calmly ensures that he and his wife have the ending they want, resisting Akalitus and the code team in the process. Also on the plus side, Jackie uncovers something in Akalitus that underlines nursing expertise. When she forces Akalitus to assess the patient as a nurse, viewers see how quickly and accurately veteran nurses can gauge patient conditions--a vital nursing skill.

Some elements of the Akalitus interactions are more troubling. The depiction of the nurse manager as barely human will strike some as a bit harsh. But more subtly, when Jackie asks Akalitus to "be a nurse again," she is suggesting that Akalitus is not a nurse now, reinforcing the misconception that nursing is physical work that happens only at the bedside. Would anyone suggest that the physician in charge of ED physicians was no longer a physician? The idea is that Akalitus is now just a paper-pusher, a bean counter. Some nurses may see their managers that way, but if Akalitus is bad for patients, it's not because she is no longer a nurse, it's because she is now a bad nurse. We're also not sure why nurse Akalitus would ask the patient who his "doctor" was; if she wanted a full picture of what was going on, asking for the nurse would make more sense and it would be most likely what a nurse would do.

 
You can't just stop taking opioids like that

Another plotline in the episode focuses on a patient who is about 30 years old and who arrives with her husband. She is cramping, sweaty, panicked. Jackie alone provides the care we see for this patient--something that has virtually never happened on Hollywood shows in recent years. Jackie measures the patient's vitals, which are fine, apart from a high pulse. Jackie orders a pregnancy test, and the couple seems thrilled at that possibility. Jackie also guesses correctly that the couple is from the Midwest. Amazed, they ask how she knows. Jackie:  "Because you're in pain and you're apologizing."

Later, Jackie spots the young husband at the hospital news stand, struggling to find a magazine for his wife to read, which is apparently something he never does. Jackie picks through his possible choices, politely noting that one is for 40-year-olds, one is for teenagers, one is in Spanish. She chooses two others for him. He is impressed, and tells her that what "they" say about New Yorkers is not true. Jackie assures him that it is true.

Eventually, Jackie's close confidant nurse Mo-Mo gives her the lab results, noting that the young woman "ain't preggers." Jackie goes to the patient (whose husband is absent) and tells her she is not pregnant. Wasting no time, Jackie informs the patient that she is instead "withdrawing from opiates. So what were you taking and how much?" The patient is shocked, and denies it. Jackie: "If you bullsh** me, I can't help you." The woman asks how she knows. Jackie: "Cramps, sweating, it's my job to know." The patient says that she got started on Vicodin after having her wisdom teeth out six months earlier; she loved it, and it's so easy to get online! Jackie's face makes clear to us that she understands the attraction very well, but she is all business, asking if the woman ran out of the drug. The woman says she did not think she would need it on her trip to New York.

Jackie: Well, you can't just stop taking opioids like that, you've got to taper down slowly, because you're on a very slippery slope.

Patient: Well, no, I'm OK, it's not like I'm addicted.

Jackie (skeptically):   Um-hmm. By the way, trying to get pregnant while you're taking painkillers recreationally--that's not a great plan.

Patient: Please don't tell him [her husband]. His Dad drinks, this'll kill him.

Jackie (seeming to assent): I'm going to get you a phone number.

Jackie's diagnostic deductions--the wife's illness, the couple's Midwest roots--are not unlike those of Greg House, though without the fancy terminology. She also goes beyond the immediate issue--the addiction--to note that the woman is endangering the pregnancy she and her husband want so much, not a huge leap, perhaps, but still an example of nurses' holistic approach. And of course, Jackie's treatment expertise extends even to reading material. But what may be most striking is that Jackie manages to provide finely tuned psychosocial care, tough love that is not too tough, to a patient whose addiction problem is not so different from Jackie's own. (Jackie's use is perhaps not so recreational, since she really does have continuing back pain.)

 
We are powerless against the crushing force of the Pixus!

At another point, Jackie goes to see the young physician Fitch Cooper in an effort to get him to help her keep pharmacist boyfriend Eddie from being replaced by a robot drug dispenser called the Pixus. Jackie appears to really believe that the machine will be a major impediment to efficient nursing care, forcing nurses to jump through unnecessary logistical and security hoops, though of course we assume that the new system might also limit her personal access to the painkillers Eddie gives her freely.

Approaching Cooper, Jackie calls him by his nickname "Coop," which pleases him greatly, since he has clearly developed great respect for her. Like a kid, he wants to show her a cool X-ray of a messed up hand. She tries to play along, then gets to the point.

Jackie:   Listen, I need you to put in your two cents with the board, or whatever it is, that wants to put a Pixus in the pharmacy--

Coop: Shut up, we're getting a Pixus? Even the name sounds cool, "Pixus," I love that!

Jackie: No, it's not cool, it's the opposite of cool. Vote no, on the Pixus.

Coop (Talking into his stethoscope like it's a Star Trek communicator): Captain, we are powerless against the crushing force of the Pixus. [He makes space explosion noises.] Jackie, we're talking about the seamless integration of man and machine, come on, step into the future--

Jackie: Stop it, please. First of all, that machine is not only an insult to nurses, it's also squeezing Eddie out of a job.

Coop: Woah, woah. You don't want me to put my two cents in, you want me to put your two cents in. So how about, the next time you need a favor, you just ask? (Jackie turns to leave.) Oh, wait, wait, wait. Is this...ah...have a little crush on Eddie?

Jackie: Yeah, that's it Coop, I have a huge crush on Eddie. In fact, we f*** every day at noon. You're a moron.

The scene cuts to Jackie and Eddie having sex in the pharmacy at 12:01 pm. Later, Coop tries to apologize to Jackie while they are seeing a different patient; Jackie ignores this, as if she is really hurt.

OK, but, "the board, or whatever it is?" Jackie, the ultimate savvy veteran who is best friends with Eleanor, really does not know who runs the hospital? And she assumes that a new resident like Coop would have input on what the hospital board does? Does she think all physicians automatically have some special relation with hospital boards, or that they sit on such boards? Maybe this plot element will not make a huge impression on most viewers, but it does have an odd "physicians are the master race" feel to it.

The show also leaves somewhat ambiguous whether Jackie is resisting the Pixus more as an addict who wants her supplier to remain, or as a nurse. If the machine really would burden nurses and lead to worse care, then she is fighting the crushing force of a soulless bureaucracy, like her subversive forebears in CBS's M*A*S*H -- the surgeons, that is, since nurse Margaret Houlihan might have had more kinship in some respects with the harsh bureaucrat Akalitus. (It's also worth noting that the heroic lead renegade in M*A*S*H -- Hawkeye Pierce -- himself had a serious alcohol problem.) But speaking of Akalitus, why isn't Jackie talking to her about the Pixus? She might be hostile, but unlike Coop, she is a manager, and as a nurse, she would have something to do with giving medication.

 
The good, the bad, and Zoey's stethoscope

Running through the episode is a funny but lacerating plotline about the timid, goofy Zoey's quest to recover her stethoscope from the physician Eleanor O'Hara.

At one point, Zoey reports to Jackie that she has put in all the IV's (actually not a task a nursing student is likely to be trusted with). Jackie asks where Zoey's stethoscope is. Zoey reminds her that "Dr. O'Hara" took it. Jackie says she doesn't care, it's "part of your uniform," so she must get it back. But Zoey seems too scared.

Zoey:  Dr. O'Hara is...a doctor.

Jackie:   OK, here's a tip. Doctors take sh**. Sandwiches. Stethoscopes. Credit. It's what they do, they can't help themselves. Figure it out, Zoey.

In later scenes, Jackie continues to push Zoey on this. Zoey continues trying to muster her courage. Finally, Zoey spots Eleanor standing at the nurses station doing paperwork. Zoey begins rehearsing what she will say, then finally starts to approach Eleanor.

Zoey (to herself): I saved 2 lives today. Doctors are just people. Hi, Mrs. O'Hara...Hi, Dr. O'Hara...my stethoscope that you borrowed from me this morning, I...Dr. O'Hara, it's come to my attention that you have my stethoscope.

She says the last line with increasing conviction as she advances on Eleanor, but she reaches the physician just too late for her to actually hear it. Finally, Eleanor turns to look at Zoey.

Eleanor:   Oh, hello Angela.

Zoey:   It's not An--um...thank you!

Zoey does a ridiculous jumping about-face and scurries away empty-handed.

Later, Jackie and Eleanor have what seems to be their daily lunch date in a high end restaurant. It's never clear how Jackie manages to get away for these off-site lunches, given how crushed most nurses are by short-staffing. Perhaps it's not a huge deal given all the positive things the show is doing, but we do wish the show would at some point convey the heavy workload many real Jackies face, which is a factor in, just to take a random example, back injuries. In any case, at one point Jackie casually raises the stethoscope issue with Eleanor.

Jackie:  You know you took my precept's stethoscope this morning, right?

Eleanor:  Oh, I know, I've been having the most marvelous time watching her muster the courage to ask for it back.

They both cackle.

Later, Zoey finally approaches Eleanor, who poses motionless on a bench in a hospital hallway, wearing cool sunglasses. The background music conveys martial suspense.

Zoey:  Hi, it's me...Zo...uh...Angela.   I was wondering if I could get...the stetho...

Eleanor does not move or react in any way and appears to be sleeping upright.   Slowly, slowly, Zoey slips the stethoscope off of the still-motionless Eleanor.   Zoey turns and leaves, giddy.

Eleanor (smiling, to herself):  Well done, Angela.

Of course, this is pathetic, but let's be honest:   Is it farfetched that a nursing student, or maybe even some practicing nurses, might have a little bit of Zoey in them? Zoey with her patterned scrubs, which Jackie and Mo-Mo never wear? The sad reality is that too many nurses--even knowing that they save lives as Zoey says--do fear physicians. And in some cases this is a factor in poor care, as intimidated nurses are less likely to raise key issues with physicians, from potential errors to broader practice issues like, well, the Pixus. Granted, this fear is partly a function of the ongoing power disparity between the professions, as well as disruptive physician conduct, but it can never change without efforts by nurses to assert themselves--efforts like Zoey's in the admittedly absurd training through which Eleanor and Jackie put her here. Today, Zoey's stethoscope. Tomorrow, perhaps, her patient's life.

The stethoscope is patient advocacy--and nursing advocacy.

 
Please tell us--and the producers of the show--your thoughts on Nurse Jackie!

The show's publicists and producers are following comments on our discussion board, so please post your thoughts here. Thank you!

If you would like to send your comments to the show directly please send them to the show's publicist Faye Katz at  Faye Katz email address   and please send us a copy at letters@truthaboutnursing.org. Thank you!

 

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