The extubating babysitter
March 29, 2009 -- This Thursday, April 2, NBC's "ER" will broadcast its series finale, after 15 years of the popular, intense prime time drama about a busy public ED in Chicago. The show has always been physician-centric, with only one major nurse character to balance its 8-10 lead physicians. It has persistently suggested that ED nurses report to physicians, rather than nurse managers. And it has featured a great deal of physician nursing, in which the physician characters provide care that nurses really do, from defibrillation to triage to psychosocial care of patients and families. The show's relative realism and overall dramatic quality has only made these flawed depictions more persuasive to millions of viewers around the world. However, particularly in the last few years, the show has also included some of the best depictions of nursing ever seen on prime time television. Its major nurse character has at times operated with startling clinical skill, and even minor nurse characters have played roles in care that are clearly more important and realistic than those seen on any other recent network show. Episodes broadcast over the last few months illustrate all of these features. So on the occasion of the show's farewell, we discuss several of these plotlines as a tribute to what may well have been--for all its flaws--the best major U.S. network show ever for nursing.
Several recent "ER" episodes have pointedly shown just how skilled and central to patient care nurses are. On December 4, 2008, the show aired "Let It Snow," by Joe Sachs, MD, one of several physicians who have been key writers on the show. An early scene in the episode reminds viewers that Sam Taggart, the show's major nurse character since 2003, is highly skilled and someone who is always thinking about better ways to help patients. As played by the versatile actress Linda Cardellini, Taggart is without question a tough but sensitive patient advocate. Taggart has also recently started a nurse anesthetist program, and although the show has offered few helpful specifics about what that entails (e.g., a graduate degree), it has repeatedly shown Taggart using her new knowledge to help patients.
Here, Taggart and attending physician Simon Brenner are treating a 6-year-old girl with a fever. Taggart reports the girl's vital signs, and Brenner says she will need a catheterized urine sample. Taggart notes that that might be a bit traumatic, and suggests conscious sedation. Brenner says that might be too risky. Taggart is about to pursue it when they are interrupted. Later, we see them with the patient again. Taggart says she has managed, apparently on her own initiative, to get "a nitrous set-up for anesthesia" from the OR. The patient's mother asks if that is safe, and Taggart assures her it is. Brenner quietly asks if they are authorized to use that.
Taggart: Oh come on, dental assistants use this stuff like water, and they don't have our monitoring capabilities.
The procedure goes very smoothly, and the mother reports with wonder that the child did not even flinch. Chase, an observing medical student, pronounces the process "very cool," and wonders why the ED staff does not use it all the time. Brenner says that is a good question, and tells Taggart, "nice work."
One of the major plotlines in this episode is about Taggart's teenage son Alex, who is badly injured in a car accident after her boyfriend, resident Tony Gates, allows him and Gates's daughter to attend a party without Taggart's permission. Alex was driving an inebriated friend home from the party, and another driver caused a fatal crash. Taggart insists on caring for her son--insists on taking the lead, really--and she spends much of the episode riding the line between high-level care and fierce patient advocacy, on the one hand, and emotional breakdown and impaired judgment on the other.
When Taggart first joins the team working on Alex, we see her asking for O-negative blood and a ventilator. She asks Brenner if he is ready to do "the reduction" to repair Alex's badly dislocated shoulder, which they should do "before the paralytics wear off." Taggart also assures surgeon Neela Rasgotra that they don't need to check Alex's blood alcohol level since he does not drink. Rasgotra's look tells viewers that this is a reason Taggart should not be on the case (it turns out Alex's alcohol level is in fact zero, and a police officer later reports that Alex's maneuver in evading the driver who caused the crash actually prevented it from being far worse). We see Taggart on the trauma room phone, starting to flip out because the blood bank is out of O-negative and the Red Cross cannot deliver because of the snow storm underway. Brenner and Rasgotra wonder if they should have a different nurse. Taggart calms down and asks for O-positive, which she says will work until they "get the cross-match." After they manage to fix Alex's shoulder, it's time to take him for a CT scan, and Taggart is moving quickly, exuding competence: "I got the life pack, the O-2 tank is full, the chest tube is on water seal..."
After the CT, Alex is stable but still unconscious. Taggart's boyfriend Gates arrives and joins the team, but when Taggart learns that he let the teens attend the party, she is furious. She resists his care plans, and one reason is personal animosity. When Taggart reports that Alex's heart rate is up to 120, Gates wants to run in another liter of saline. Taggart asks why. Gates says in case they're behind on fluids. Taggart asks what if Alex is bleeding in the belly. Gates says the CT was negative. Taggart says things change, and she wants to get the surgeon Rasgotra to weigh in. Gates suggests that they run another hematocrit and do a fast exam, since that's what Rasgotra would do. Taggart says maybe one of the interns can break out and re-assess him. Gates says that blood loss is unlikely, that he thinks it must be hypoxia, dehydration, and/or pain.
Taggart: What do you know? I want a surgeon in here.
Taggart remains concerned (if not obsessed) about internal bleeding, though no one else is, and the show pretty clearly suggests that she may have lost perspective. After Alex appears to be in sinus tach and his hematocrit drops, Taggart restates her concern about bleeding and fights with Gates, Brenner, and Rasgotra for a repeat CT scan. They won't go for it. She snaps that her kid deserves a surgical attending, asking for physicians Dubenko or Crenshaw. The surgeon Rasgotra (a senior resident) says, fairly mildly, that they are not available. Taggart leaves the trauma room, very distraught.
Later, Alex seems to be doing better, but suddenly his heart rate goes up to 160 and his pressure drops to 80 systolic. Taggart demands Rasgotra, and insists on a transfusion for Alex, though she can't tell Gates where Alex might be bleeding. Rasgotra and Brenner arrive, and there is a flurry of activity as they pursue different possible causes for Alex's condition. Finally, Gates runs the EKG at twice the normal speed to spread out the complexes. He determines that that the problem is SVT (an abnormal type of fast heart rate)--it is not internal bleeding, he says, but an arrhythmia from a bruised heart. Gates defibrillates Alex, and he quickly improves. Taggart manages to quietly thank Gates.
At the end of the episode, Alex seems stable and even starts to open his eyes, but once again he suffers as sudden reversal, as two liters of his blood flood into the chest tube collection device. Gates reports that his pressure is down, they've lost the pulse, and they'll have to open Alex's chest. Taggart, barely able to keep from crying, calls "PEA arrest" and starts chest compressions, as nurse Dawn starts bagging, and Brenner cuts into his chest. The episode ends with Taggart crying.
The December 11 episode, Shannon Goss's "The High Holiday," wraps up the Alex plotline on a more hopeful note. Alex has survived, though for much of the episode he remains on the ventilator, and Taggart frets that he may not get off. In an early scene, she, Gates, and the chief of surgery Dubenko try to extubate Alex, but the physicians think he is too agitated, and Dubenko says they have to wait till the next morning to try again. Later, Taggart tries to persuade a reluctant Dubenko to try again sooner:
Taggart: I've been studying to become a nurse anesthetist, and I think there are some tricks that we can use. We give an anxiolytic before shutting off the propofol, right? That may cut the agitation we see during emergence. Two (mg.) of Versed will be calming and not too sedating. Then we sit him up, and we give him something familiar to focus on... (she shows him a video) the Blackhawks game from last night.
Dubenko: What if it doesn't work?
Taggart: It'll work. I will talk him through it, I will stay there all night, I will make sure he uses the incentive spirometer. Whatever it takes.
Later, we see Dubenko and Taggart try to extubate Alex. Taggart prepares Alex with some clichés about the importance of trying. Dubenko lets Taggart do the actual extubation. And it's a big success. Alex's first words: "Did I miss Christmas?"
Overall, this plotline is a very good example of the show's recent efforts to highlight Taggart's advanced skills and her fierce (if sometimes misguided) patient advocacy. Unlike the nurses on every other network drama, she displays technical mastery and critical thinking. She does not hesitate to challenge physician care plans when she thinks that is required. And although this plotline does suggest that her judgment has been impaired by her relation to Alex, the plotline also includes the extubation, in which she essentially wins over the chief of surgery with her innovative and effective care plan. We're not holding our breath for this kind of thing on "House" or "Grey's Anatomy."
Of course, although the show has at times offered such plotlines, its overall structure and approach still guarantee that viewers will receive an unduly physician-centric vision of hospital care. Physicians continue to provide most of the bedside care patients receive, including most psychosocial care of patients and families, as well as doing exciting, important procedures that nurses would really do. Even in the December 4 episode, it was Gates who defibrillated Alex, though in real life a nurse would likely have done it.
The December 11 episode also included elements that underline the show's continuing failure to provide a fair overall picture of nursing. Consider these perennial favorites. The episode included a nurse-free patient handoff from an ambulance, with only Brenner, Rasgotra, and an ED intern receiving a critical patient. This common "ER" practice is virtually inevitable given the show's major character ratio and its frequent depictions of ED staff greeting ambulances in the ambulance bay, though real physicians rarely if ever do that. The nurse-free handoffs suggest that nurses are not really essential in caring for such ill patients when they reach the hospital, and that nurses need not get the report from the paramedics directly, as if physicians are in charge of all care and will tell nurses whatever they need to know later.
The show also continues to suggest that hospital nurses report to physicians. Early in the December 11 episode, chief of emergency medicine Banfield greets Taggart upon Taggart's return to work, and kindly asks how it is going with Alex. Taggart explains her concerns about Alex not getting off the vent, or having brain damage.
Banfield (gently): Sam...if you need to take a little more time...
Sam declines, noting that she needs to keep busy and can't just keep staring at Alex's monitors, but she says: "Thank you...for the offer." Obviously, this means Taggart reports to Banfield, even though real ED nurses report to nurse managers--whom the show has mentioned only rarely in its long history, for instance in the standout Eve Peyton episodes from 2005. Instead, the show has suggested countless times that the ED nurses report to the chief of emergency medicine, as if nursing were merely a lesser subset of medicine, rather than a distinct science and an autonomous profession.
And not even "ER" is above denigrating nursing as a profession, though it is far more subtle than "House" or "Grey's." In the December 11 episode, there is another ambulance handoff in which Taggart does take part. Paramedics and an ED team wheel back a woman who has collapsed at the mall while waiting with her daughter to see Santa Claus. Taggart carries the 6-month-old child. At one point, Banfield speaks to Taggart:
Banfield: Have social services watch the baby until we can get a family member here.
Sam: Oh, that's OK, I'll look after her.
And Taggart spends time cuddling the infant in the break room, showing her the various ornaments on the staff Christmas tree. Taggart is a little reluctant to surrender the baby when someone finally arrives to take him. In case we miss the point, when the sick mother's partner arrives and inquires after her daughter, Gates responds this way:
Gates: One of our nurses is babysitting, I'll go get her.
Awesome. Although past episodes have shown that Gates sometimes forgets to respect nurses, the show does nothing to suggest that this statement is an inaccurate or offensive description of what Taggart is doing. The infant was in her mother's arms when the mother fell, but Taggart does not assess or treat the infant. Nor is Taggart on a break. She has basically been babysitting as part of her job. Of course we know she is doing it at least in part because of her son's situation, but this still suggests that a nurse at a busy level one trauma center would have time to do this, even that it is part of her job to do it (so much for that bachelor of science degree). It also suggests that Taggart would need Banfield to tell her what to do with the infant, an example of the show's periodic tendency to have physicians command nurses to do things that the nurses don't need physicians to tell them. Indeed, in some such cases, real nurses would know better than the physicians what needs to be done and how to do it.
The episode that aired March 12, 2009, "Old Times," includes two related transplant plotlines that provide vivid final illustrations of how "ER" has fallen short in presenting nurses, and yet how superior its portrayal often is to that of any other network show. Fittingly, this episode was written by executive producer John Wells, who has been the driving force of the show, and it features guest appearances by several characters who were among the most important in the show's early and middle years.
In this episode, Rasgotra and Taggart are dispatched from County General to Seattle to transport a heart back for a mother at County who needs a transplant. While in Seattle, they are also asked to transport a kidney back to Chicago for a patient at Northwestern, who, unbeknownst to them, is the ED physician and former "ER" mainstay John Carter.
In Seattle, the plotline centers on efforts to persuade the grandmother of the potential donor, a teenage accident victim, not to renege on her earlier promise to release his organs--she wants to wait for the boy's mother, who can't be found. It turns out that the transplant coordinator is none other than Carol Hathaway, the show's major nurse character from 1994 to 2000, looking very professional in business attire. Here Hathaway is working closely with her husband, pediatric ED attending Doug Ross, also formerly of County General. The show deserves a lot of credit for acknowledging that transplant coordinators are generally nurses ("Grey's" has featured many transplant plotlines, and nurses have never played any significant role). Hathaway also conveys her usual seriousness, updating a roomful of transport teams from around the nation on the status of the potential donation, and after the grandmother finally agrees, explaining to her which organs they need. On the other hand, it is Ross who takes the lead in providing psychosocial care to the grandmother, and Ross who ultimately persuades her to release the organs, by drawing her out about the boy's good qualities, and asking, at the right time, whether the teen is also "generous." In addition, for most of the plotline, Hathaway could be a lot more supportive of the grandmother. She comes off more as a competent administrator than a full-fledged health professional.
Meanwhile, back in Chicago, as Carter lies in the hospital waiting for his kidney, he receives a visit from his old friend Peter Benton, another former County physician, now a general surgeon at Northwestern. This hospital is presented as a very impersonal, even hostile environment, and the plotline serves as an unusual television critique of how the surgical process can really work (hint: it's all about waiting, and no one holds Carter's hand or explains very clearly what is going on). One surgeon arrives and talks over Carter for his entire brief visit. The hotshot surgeon Kurtag who will do the operation breezes in and out with a posse of junior physicians, while the one nurse who briefly appears can't seem to respond to Carter at all. In this setting, Benton promises to stick around and "make sure Kurtag gets all the sponges out." Of course every hospital patient can use a friend to advocate for him in this era of endemic short staffing. But Benton's half-joking promise to do the key scrub nurse task of ensuring nothing is unintentionally left in the patient is a preview of what Benton will be doing a lot of in the plotline: nursing.
Lying in the OR, Carter says he is hungry, thirsty, tired, and cold, as he and the assembled surgical team wait for the almighty Kurtag to arrive. Benton affectionately tells Carter to stop being a baby. When Kurtag finally does arrive, he is not pleased to see Benton, and he impatiently commands the anesthesiologist to put Carter under.
Benton: Woah, woah, woah, what about the checklist? State surgery checklist?
Kurtag: I've had 10 cases today, doctor.
Benton: All the more reason to take the necessary precautions. It'll only take a minute. John Carter, here for a right cadaveric renal allograft. Does the patient have a known allergy?
Benton: Does anesthesia anticipate a difficult airway?
Anesthesia Professional: No.
Benton: Is the risk of bleeding greater than 500 cc's?
Kurtag: I sure as hell hope not, let's go, put him under.
Benton: Woah, woah, woah, everybody slow down. Now, let's just take our time and introduce the room.
Kurtag: What's next? We all hold hands and sing Kumbaya?
Scrub Nurse: Sheila Lane, scrub nurse.
Circulating Nurse: Paula Cheney, circulating nurse.
Anesthesia Professional: Kay Schumaker, anesthesiologist.
Senior Resident: Randall Ocherman, chief surgical resident.
Junior Resident: Ethan Dean, surgical intern.
Benton: Peter Benton, observing general surgeon. Any concerns from the surgical team?
Kurtag: Only that you're wasting my time.
Benton: Any nursing concerns?
Lane (the scrub nurse): We don't have any reperfusion solution.
Kurtag: We won't be needing it.
Cheney (the circulating nurse): I'll have some sent up.
Benton: Were any antibiotics given in the last 60 minutes?
Schumaker: Just starting them now.
Kurtag: 10 blade.
Benton: Hold on, hold on. If you run the antibiotics prior to incision, you cut the risk of infection by half.
Kurtag: Dr. Benton, you're a guest here, and I don't like guests. As a friend of the patient, you're welcome to sit, observe, and shut up.
Benton finally relents. But later, he stands up and peers at the now-transplanted organ, then asks if it should not be pinking up by now. Kurtag at first resists, but it quickly becomes clear that there is a blood clot in the artery of the kidney, which is obstructing the blood flow, and they'll have to start over.
Kurtag (very annoyed, squeezing the blood clot out of the kidney): Problem solved. Flush with heparin, saline and reperfusion solution.
Benton (with mock surprise): Reperfusion solution?
Benton proceeds to teach the residents (and embarrass Kurtag) by explaining that if they had not gotten the reperfusion solution from the pharmacy ahead of time, in the 15 minutes it would have taken to get it after the blood clot was discovered, they could very well have ended up with a non-functioning kidney. One of the residents asks Benton where he can get a copy of that checklist.
This is a great showcase for the surgical checklist, which has steadily gained adherents as a way to reduce deadly errors and improve OR teamwork (checklist, article 1, article 2). And very alert viewers will note that it was in fact the scrub nurse Lane who raised the critical issue of the reperfusion solution, after the surgeon Benton admirably sought nursing input. Unfortunately, the nursing element will likely slide past most viewers, because the overwhelming theme of the scene is that Benton is saving Carter by repeatedly insisting that the arrogant Kurtag actually follow key safety procedures. Apparently Lane would not have noticed, or would not have had the temerity to say, that they needed the solution if Benton had not asked about nursing concerns. By the end of the scene, the reperfusion solution really seems like Benton's idea. Benton is the one who sees that the organ is not pinking up and actually says so. Benton is the patient advocate.
In addition, the show presents the OR checklist as something a surgeon like Benton is most likely to raise and carry out. But it is nurses who are most likely to play that role, and nurses have been instrumental in increasing the use of such checklists. Of course, a major obstacle has been just the attitudes that Kurtag displays, and you could read the plotline as a suggestion that it might take someone with Benton's stature--a fellow attending surgeon--to get someone like Kurtag to follow the checklist, that few nurses would be able to do so. That's not a farfetched scenario, but we would rather have seen the nurses get credit as the likely initiators of the checklist process, and the professionals who actually carry it out, even if a receptive surgeon is also crucial to its success.
After the operation, Carter awakens to find Benton waiting at his bedside. It is Benton who shows Carter the urine collection bag to prove that the new kidney is working well, and Benton who hands him the cell phone to call his wife in Paris.
During Carter's stay at this hospital, no nurse speaks to him.
We thank the creators of "ER" for all the portrayals of nursing skill and advocacy the show has offered over the years, depictions that go far beyond what any other major Hollywood show has done. But the roles of Benton and Ross in these transplant plotlines do point to the bottom line. In the end, what the NBC drama has given the world in its 330 episodes is a vast, compelling vision of emergency care as primarily the work of commanding physicians.