Changing how the world thinks about nursing

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It droppeth as the gentle rain from heaven

Mercy cast 
May 2010 -- The May 12 season finale of NBC's drama Mercy turned out to be the series finale, since the network canceled the show soon afterwards because of its low ratings. That's too bad, because in its 22 episodes, creator Liz Heldens's funny, well-acted show included many fine examples of nursing skill, patient advocacy, life-saving, and even some autonomy. The show's nursing portrayal did have flaws. Its generally constructive, peer-oriented approach to nurse-physician relations was at times undermined by suggestions that nurses report to physicians, and the show occasionally fell prey to other nursing stereotypes. The last two episodes of the series illustrate these mixed features. In the finale, lead character Veronica Flanagan saves the life of a boy trapped in a collapsed building, in part by amputating his arm with guidance she gets by cell phone from physician Chris Sands. In another plotline, nurse Chloe Payne correctly diagnoses a patient with airport malaria, despite resistance from physician Gillian Jelani. Both of those plotlines are showcases for nursing skill and advocacy. But both can also be read to suggest that nurses achieve to the extent they act like physicians; Gillian praises Chloe by noting that she was "thinking like a doctor." And that's nothing compared to one of the last scenes in the finale, which finds Chloe reacting to an apparent romantic rejection from cardiologist Joe Briggs by vowing to become a physician herself. Another plotline that conveys real skill and advocacy by nurses Angel Garcia and Sonia Jimenez in caring for a beating victim also suggests that physician Dan Harris directs nurse staffing. Why didn't enough people watch Mercy? Occasionally the show did feel flat, contrived, or silly, but that's also true of some successful shows. Mercy seemed to suffer from a difficult time slot, and the perception that it was the last in a glut of new shows about nurses (Nurse Jackie, HawthoRNe) and that nurses do not deserve so much attention. However, despite Mercy's flaws, the show's message that nurses play the central role in the skilled care of hospital patients and its strong portrayals of nursing expertise and advocacy place Mercy among the best television shows for nursing in Hollywood history.  See the episodes on NBC.com

Can I stay on the case?

Off the team

Thinking like a doctor

You're going to be my nurse

I'm gonna be a doctor

Move forward, fall back

 

Can I stay on the case?

The May 5 episode, "Too Much Attitude and Not Enough Underwear," was written by Peter Elkoff & Joe Sachs, a physician and former ER producer. One plotline is about the care of Camilla, an old high school friend of Angel's who is now the girlfriend of a local gang leader. We see Camilla get dumped out of a moving car near the hospital after having been badly beaten by thugs from a rival Jersey City gang.

In the ED, Angel and Sonia care for Camilla. Angel talks his old friend through procedures, telling her that the tube they are about to insert will fix her collapsed lung, though she'll feel some pressure. Camilla is in pain, and Angel argues with physician Dan for more morphine. Dan tells Angel to check his emotions. The show seems to be siding with Dan here, but in fact, nurses must often argue with resistant physicians to get their patients adequate pain medication. Sonia reports that Camilla's systolic pressure is down to 80. Angel spots that there is a clot in the chest tubing that is preventing the lung from expanding. Dan tells Angel that he's made a good catch, but that he is "still too close to this."

Angel:  Dan, please. If [nurse manager] Helen floats down another ICU nurse, can I stay on the case?

Dan (assenting, with some hesitation):  Take her to CT, I'll meet you upstairs.

So here the show is acknowledging that Angel has a nurse manager who says which nurses work where, yet supposedly ED physician Dan decides whether Angel stays on a particular patient's case. However, nurse managers make these decisions, and physicians are not (or at least should not be) involved. Of course writer and physician Sachs must know better, but that was also true during all the years he wrote for ER, which at times made similar suggestions. The implication in such scenes is that the physicians are completely in charge of patient care, including even nurse staffing, though there may be some nurse like Helen to whom they delegate administrative tasks. However, Angel does not need Dan's permission to care for Camilla, and suggesting that he does undermines public understanding of nursing autonomy. Angel's advocacy for the pain medication is pretty weak too; he seems to give up immediately. Still, he does provide some psychosocial care and display some skill, particularly in catching the blood clot.

Mercy castIn a later scene, we see Angel and Dan with a conscious Camilla, who has called her children. Sonia comes in and reports information, including Camilla's potassium level and her rising BUN. Sonia says Camilla is in "rhabdo." Dan explains that this is rhabdomyolysis from the muscle damage of the beating, which is hurting her kidneys. Camilla crashes, and Angel defibrillates! On Mercy, nurses and physicians at least seem to take turns doing this, a big improvement over the standard hospital show, in which it is always the physician. On the other hand, it's unlikely that the nurse (here Sonia) would be the one to use technical slang like "rhabdo" with a patient, and that the physician (Dan) would need to explain to the patient what it means. Dan tells another nearby nurse to call the cardiologist Briggs so he can place a Quentin catheter.

Later, we see Briggs and Sonia with Camilla, getting dialysis started. Angel delivers dopamine. Briggs joins Angel, Sonia and Dan in Camilla's room. Sonia tells Briggs she "can't draw back the venous port." Angel reports blood in the urine. Briggs examines Camilla. They see she is bleeding from every needle stick. Dan tells her it's a complication called DIC, which means her blood is not clotting. Dan and Briggs asks for several things to address the problem, including transfusions. Dan tells Angel to call her daughter, who is on her way by bus from out-of-state, and tell her she should be on a plane instead. Soon we see Angel on the phone trying to help this daughter arrange a flight. But the only one is very expensive. Then Dan actually lays down his own credit card so Angel can pay for it. Uh-huh.

Angel with MikailaBefore long Camilla is coding again. Sonia does chest compressions. Angel brings in Camilla's daughter, who has evidently just arrived. Dan begins to explain the basic situation, but the daughter says Angel already explained everything. Briggs stops by. Dan asks for epinephrine, though Angel and Briggs question it, with Briggs noting quietly that no one survives with that course of action. But it's clear that Dan is just trying to bring Camilla back briefly for her daughter. He explains to the daughter that they can't fix her mother, and it's time to say goodbye to her. And Camilla does wake before she dies.

These scenes are reminiscent of some of the best nursing portrayals on Sachs's old show ER. The nurses are knowledgeable and helpful, and they may even play important roles in care, like defibrillating and doing compressions, recognizing important symptoms and conditions like rhabdomyolysis, talking patients through procedures, and explaining what's going on to family members. Only rarely would ER's nurses play roles that substantial. But ultimately there is no question that the physicians are directing care here, issuing prescriptions that really are presented like military "orders." Dan has to tell Angel to get the daughter there, which Angel probably would have done on his own in real life. Nurses have a keen sense of how long terminal patients have, and they tend to be very focused on the overall well-being of those close to a patient, and not just on the procedure right in front of them.
 

Off the team

The May 5 episode also continues a plotline involving Chloe's care for a college football player named Andy, who had a bad concussion and now has a serious brain injury. Andy seems able to function well off the field, but he is at great risk if he continues to play. Chloe, who now has a romantic relation with Andy, urges him to stop playing, but he will not.

So Chloe consults Dan, and she suggests that she send a copy of Andy's test results to his football coach. Dan notes that would violate patient confidentiality and subject Chloe to criminal penalties. He suggests she have a serious talk with Andy. But Chloe says he's difficult and gets angry about stupid things, which Dan notes is also a symptom of a brain injury. Chloe agonizes more over the course of the episode, consulting Veronica and Sonia, and eventually decides she will tell the coach. After she does, Andy comes and confronts her, at the bar owned by Veronica's ex-husband Mike where the hospital workers often go. Andy is angry because the coach removed him from the team. He grabs Chloe, but the nearby Briggs intervenes. Andy falls and hits his head. He's not breathing and they start CPR; he has aggravated the brain injury.

This plotline shows that Chloe is debating how she should advocate for her patient, and she has the courage to break a rule to try to protect him. Of course, she is breaking the rule and subjecting herself to serious legal and ethical consequences (how Nurse Jackie!), which the show does not pursue. But the plotline also implies that Chloe would need Dan to tell her about these consequences, as well as the basic symptoms of a brain injury she has seen before.
 

Thinking like a doctor

On the other hand, another plotline in the May 5 episode suggests that Chloe is in no need of health knowledge from physicians. This one highlights the care she and physician Gillian give to a patient with a mysterious ailment. We first see Gillian introduce Chloe to the patient, which is very unlikely, since in real life nurses hand off patients to each other and do not receive patients from physicians. Anyway, Gillian introduces the patient as Bliss Edelstein, who is just back from Amsterdam with a high fever. Gillian asks about other symptoms, but nothing really emerges, so Gillian asks for tests including a CBC and chest X-ray. But Chloe is too distracted by sending scans to Andy's coach and taking his call on her cell phone to be paying much attention; she doesn't look like much of a nurse here.

Chloe, GillianLater Gillian, with Chloe present, tells Bliss that her tests so far are normal. Gillian asks directly about whether Bliss might have HIV or hepatitis. Bliss denies that, and Gillian departs. Bliss is upset by Gillian's brusqueness. Chloe comforts her, saying they will figure it out. Later, Gillian reports that the HIV and hepatitis results are negative, so she thinks it must be meningitis or encephalitis, and wants ceftriaxone and acyclovir. But Chloe directs her attention to the patient's foot, where there is an insect bite. Chloe suggests that it "could be related to her fever," which is not a bad approximation of some nurses' way of suggesting things to physicians indirectly so as not to threaten their egos. Gillian says if it was MRSA there would be surrounding cellulitis. Chloe says that a mosquito could have caused dengue or malaria. Gillian informs Chloe that those tropical diseases are unheard of in Northern Europe, and again asks for the antibiotics, plus a head CT and a spinal tap set up.

Later, we see Gillian approach Chloe, saying it's time for the spinal tap to isolate the organism. Chloe, seeming to muster her courage, says that may not be necessary, and she hands Gillian a test result showing malaria. Chloe explains that Bliss's flight out of Amsterdam originated in Cameroon, and an infected African mosquito must have come along. Chloe notes that it's called airport malaria. Gillian says there's cerebral involvement, so she'll need quinidine. Chloe already has the drug ready and knows the dosage, and she quietly starts walking away to give it.

Gillian:  Hey...at least one of us was thinking like a doctor. Good work.

No, no, no. The show is clearly trying to show how able Chloe is, and this is a great example of a smart, observant nurse looking carefully at a patient's condition and advocating persistently for a correct resolution of the problem, helping the patient avoid mistreatment. But thinking carefully about diagnosis and advocating for the patient does not mean you're "thinking like" a physician, and by implication not a nurse. Of course, diagnosing mysterious illness is more the province of physicians and advanced practice nurses, but we doubt many viewers will see that distinction. Most will simply think Chloe must have been acting like a physician because she displayed real health care expertise. No doubt the show creators think this is a great compliment for the character, but it actually undermines the plotline's good features to a significant extent. (See our FAQ "You could be a doctor!)  
  

You're going to be my nurse

The May 12 series finale was "That Crazy Bitch Was Right," by show creator Liz Heldens and Colleen McGuinness. The main clinical plotline is about Veronica's efforts to help an injured boy in a collapsing building.

The episode begins with Veronica trying to decide whether to rent an apartment. Outside her therapist's office, she sits on some furniture abandoned on the street and calls to accept the apartment. Immediately after she hangs up, she hears a boy call for help from the abandoned building behind her. This is Jonah. Veronica enters the rickety building. Jonah tells her that he was in the crawl space with his friend, Patrick, when it caved in. Now Patrick's knee is messed up. Veronica examines it and tells Patrick that he broke his kneecap, but she will try to make him a splint to reduce the pain. She sends Jonah to look for something to use for the splint. Then she surmises that the boys come here to smoke and look at dirty magazines, and says she hopes it was worth it, because it will take six weeks for the break to heal. The building makes unstable noises, and Veronica tries to get the boys out, but they all fall through and down a whole floor.

When Veronica regains consciousness, Jonah shows her that Patrick is trapped under a beam with a crush injury to his arm. Veronica wants a cell phone, and they start looking for hers, which is in her purse, but they can't find it. Darkness is falling. Patrick is in pain. Veronica's cell phone rings, they find it, and it's Mike, her ex-husband. She tells him the situation. Soon Veronica gets a call from physician Chris (her ex-lover), who is outside the building with the firefighters who are working to get them out. Chris asks about Patrick's injured arm.

Veronica:  His arm is crushed and pinned at mid-humerous. He's in a lot of pain. There's no distal pulses.

Chris:  If there's no circulation he's going to lose his arm.

Veronica asks Chris what she should do. He says Patrick's arm will be dead by the time they get them out, but if she amputates it now, they can try for replantation, which is the best chance they have. She is of course resistant, saying she doesn't think she can do that. He tells her she can do it, and that they will send down morphine and surgical instruments. Veronica makes her decision, and addresses Patrick.

Luke SkywalerVeronica:  Here's what's going on. The doctors up top are real concerned about your arm. It's so crushed that you're losing circulation. So what we're gonna do is take it off so that we can put it back on.

Naturally the kid freaks out about this. Veronica tries to soothe him, mentioning that Luke Skywalker got a new hand in The Empire Strikes Back. Chris tells her, on the phone, that they just sent down the jiggly saw.

Veronica:  Jonah, you're going to be my nurse.

Jonah:  I don't wanna be the nurse. I wanna be the doctor.

Veronica:  No way. Nurses are way cooler than doctors. Doctors are a-holes, take it from me.

Chris:  I can hear you.

Veronica:  Umh. (To Jonah.)  OK, put your gloves on. Now, Patrick, you're gonna have to be brave, but I know you can do it.

He asks if it will hurt, she says just a little pinch. She gives him the morphine, telling him he'll get sleepy.

Veronica (to Sands):  OK, Ketamine's on board.

Chris:  OK, make a circular incision right down to the bone. Go right next to the IV and keep the stump as long as possible.

Jonah asks Veronica if she's done this before. Chris, on the cell, says she knows this procedure because they did a lot of them in Iraq. This impresses Jonah.

Veronica:  All right, Jonah, there's gonna be a lot of blood, so I'm gonna need you to squeeze around his upper arm as hard as you can.

Chris:  OK, after the incision, there's gonna be three pumpers--radial, ulnar, brachial. You gotta get hemostats on them as fast as you can.

She makes the incision.

Veronica:  OK, through the bone, Chris. Crap! I think we lost a hemostat. It looks like a big pumper. Pulse is weak, he may need fluids. I can't move him like this.

Chris asks if the pumper is medial or lateral, and she says medial. He asks whether it's superficial or deep, and she says superficial. He says it's the superior ulnar collateral artery, and tells Veronica to find the biggest vein, the basilic, to look below that to the ulnar nerve, then go below that and take a "big bite" of the triceps. She says she's got it. She puts Jonah in charge of the arm.

But then they smell smoke; somehow a fire has started nearby. Jonah panics. They look for ways out, but are having trouble breathing. Veronica also starts to freak out, though she remained calm throughout her field surgery. Jonah passes out. Finally, they are rescued.

Later, at the hospital, Veronica is an inpatient but seems to be OK. Chris visits, reporting that Patrick is doing well, and that he should "have return of function after a lot of therapy." She thanks him for talking her through the amputation. He reports that her own wheezing has resolved and her carbon monoxide is back to normal, so she can go home.

Veronica two boys buried houseWith this plotline the show comes full circle with its premiere, in which Veronica also impressed by performing a life-saving procedure usually done by physicians (decompressing a tension pneumothorax from a car crash victim in the field, while a helpless dermatologist watched). Here, as there, it's double-edged. The plotline shows a skilled, courageous nurse who manages to successfully perform a life-saving procedure she has presumably never done before under intense pressure. At the same time, she is providing expert psychosocial care to two boys in very different situations:  Patrick, who is in great pain and whose life is directly threatened, and Jonah, who is scared but also prone to negative remarks that could undermine what Veronica is trying to do, as when he notes that the Star Wars character Luke actually got a mechanical hand, not his own. She is acting as a nurse here, and doing great work in very difficult circumstances (though she may want to consider what kind of omen the collapsing building presents right after she accepts her new apartment).

The plotline's messages about nurse-physician roles are more troubling. Once again Veronica is mainly getting credit because she's doing a procedure usually done by physicians, as if that was the ultimate measure of a nurse. Veronica herself tells Jonah he will be "my nurse," suggesting that she (and the show) has bought into the erroneous idea that surgical nurses belong to surgeons. In fact, any nurse here will be the patient's nurse, not a physician's nurse. And of course, Jonah will not be a "nurse" anyway, since he has no nursing training or skill, but we understand that kids are often assigned professional titles when they help adults as a way of encouragement and forward thinking. Maybe we should be glad that Veronica at least sent the message that nurses play a significant role in surgeries, but she might have just said that Jonah would help her. We wouldn't blame the show for Jonah's very realistic desire to be a physician and not a nurse, and we suppose Veronica's "a-hole" response is OK, though a better answer might have been that nurses are just as cool because they save just as many lives. Veronica also subtly undervalues nursing when she tells Patrick early on that the "doctors up top" are concerned about his arm--isn't she also concerned?--though maybe she's just trying to sell him this terrifying procedure, and she knows he'll accept it more readily if she leads with "doctors." Physician glorification can be an effective treatment tactic! Just so long as we remember that's not the way it should be.  
  

I'm gonna be a doctor

ChloeThe finale also resolves the plotline involving Andy, the college football player with the serious head injury exacerbated by a recent fall in a bar. Andy remains unconscious, with diffuse cerebral edema, and none of the medical therapy is working. We see Briggs and Chloe discussing Andy's treatment with an apparent Mercy brain surgeon, who is less than optimistic about Andy's outlook. Chloe suggests a craniotomy, noting that the Army has been doing them for brain swelling. The surgeon--who knows that Chloe has a relationship with Andy--is reluctant because, as he delicately puts it, Andy's brain is "toast." Briggs argues for the craniotomy, and says that he has a friend at the Robert Wood Johnson hospital who would do it. The surgeon finally agrees. Chloe thanks Briggs.

Then Briggs takes a call from his money manager, who is liquidating his assets to raise $1 million that Briggs needs to pay off a Mob boss who will otherwise get Briggs' medical license revoked, using evidence that he once unintentionally killed a patient while high on cocaine. The Mob family has it in for Briggs because he recently ran up a big gambling debt he had trouble paying, and especially because he recently broke the heart of a female family member named Jules, with whom he had a steamy relationship. Please pay attention, because this all ends up playing a role in Chloe's medical school plans!

Later, Briggs reports to Chloe that the craniotomy went well, and that Andy actually opened his eyes. Briggs says that Andy is not out of the woods, but it looks much better than expected. He tells Chloe "good call" and asks how she's doing. Then he must go outside the hospital to meet a potential buyer for his expensive foreign car. The buyer turns out to be Jules, who reminds him that they "did have some chemistry" and proceeds to seduce him in the car.

But before long, Briggs contacts Chloe with bad news. He tells her Andy has taken a turn for the worse, that there is no electrical activity and no cerebral blood flow. He is brain dead. Chloe, crushed, goes to comfort Andy's parents in the waiting room. They say they have heard all about her and they ask her to be in the OR for his organ donation, which she does.

Veronica and Sonia take Chloe out to Mike's bar. Chloe says she doesn't know if she can be a nurse anymore, presumably because of the emotional strain. Veronica says she made it better today for his parents. Chloe declines Veronica's offer to take her home. Briggs is also there, on the phone with his money manager. Briggs learns that he will not be able to raise the $1 million he needs. He sees Chloe, and tells her she did well today:  she thought clearly, she did not let her emotions get in the way, and she was aggressive with her ideas. She notes it did not work; he reminds her that Hail Marys usually don't, but sometimes they do. She's crying, and says that Andy would have been better off if he had not met her; she also spent half their time together trying to get out of their relationship. Briggs tells Chloe that she's "above" the rest of them, because of the "heart" she has,  and how she cares about people: "I can't imagine anybody being better off not knowing you." He kisses her. She kisses back. And she says she has to go.

Back at the hospital, perhaps the next day, Chloe stops by to see Briggs at his apparent office. But she finds Jules, who explains that she has just become Briggs's fiancée--presumably Briggs figured that without the $1 million, getting engaged was the only way to save himself from the Mob family's wrath. Chloe is surprised and seems upset, though she quickly recovers. Briggs arrives, and he and Chloe look at each other; Jules can see there's something between them. Chloe excuses herself and walks to the elevator, for which Angel is also waiting. He asks her what's wrong.

Chloe:  Screw it. I'm gonna go to medical school. I'm gonna be a doctor.

See the clip in Quicktime at broadband or dialup speed.

Since that's basically the last thing the Chloe character will ever say, we'll never know whether she really went to medical school, or exactly why she might have. Here she sounds more determined than happy, as if she's more dissatisfied with how her life is now than eager to be a physician. And it also doesn't seem directly related to Andy or clinical aspects of nursing, despite her earlier comment about not knowing how much longer she could continue being a nurse. Instead, it seems like Chloe is reacting to Briggs kissing her at the bar, then proposing to Jules. Maybe she thinks that, if she were a physician, she would not be disrespected like that. Or maybe she's tired of being seen as someone who has a big "heart" but who can be easily discarded.

Of course, Chloe has repeatedly displayed advanced technical knowledge, as in the Andy plotline and the earlier one about airport malaria. Briggs himself does not just recognize her heart, but also her ideas and composure. From the beginning, the show has stressed that Chloe is the book smart one, with her masters degree from Penn, though the show never explained that degree or how she was using it. In any case, nurses are perhaps 100 times more likely to pursue graduate education in nursing than in medicine," and the medical school path would seem even less likely for a nurse who already has a masters. Still, it's not hard to imagine the show thinking that Chloe would make a good physician, and maybe even that she's "too smart to be a nurse."

But it's always sad when Hollywood shows us a bright, able nurse, only to later suggest that she really wants to be a physician, undermining much of the good the earlier plotlines did. In fact, this plotline is part of a recent resurgence of wannabe physician plotlines on Hollywood shows, a trend that reinforces the idea that the best nurses aspire to medicine. Of course, that message dovetails with the kind of plotlines discussed earlier in which nurses are praised for doing things that physicians normally do, which likewise implies that medicine is superior.
 

Move forward, fall back

Sonia, Chloe, VeronicaFortunately, most episodes of Mercy did not suggest that medicine was better than nursing. They kept the focus on the three main nurse characters (Veronica, Sonia, and Chloe), and showed some of the skilled nursing that saves and improve patients' lives, correctly placing the nurses at the center of hospital care--a rare and commendable thing in a prime time drama. In fact, most episodes of Mercy were as good if not better than the very best episodes of ER in terms of nursing skill and advocacy. And Mercy generally had its nurse characters work collaboratively with physicians, even if it did have some of ER's tendency to suggest that the nurses reported to the physicians. With Mercy gone, there appears to be no significant nurse character on prime time U.S. broadcast television. Of course, that doesn't mean there will be no nursing on the remaining health care shows--the dozens of physician characters will be doing and getting credit for plenty of nursing. But Mercy was a clear step forward for the broadcast networks, and we'll miss it.

 

See the episodes on NBC.com

 

 

 

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