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November 2010 -- Three episodes of ABC's Grey's Anatomy airing this month include plotlines that illustrate the show's occasionally sympathetic but mostly contemptuous portrayal of nursing. The November 18 episode includes a limited but fairly good portrayal of a nurse--as a patient's mother. This nurse is knowledgeable and a strong advocate for her critically ill son. Surprisingly, the skilled surgical resident Meredith Grey treats the nurse's views with respect. Popular hospital shows seem willing to present nurses as family members who know and do more than the average person, as in a comparable April 2008 episode of Fox's House in which a patient's wife (a nurse) resuscitated him. But perhaps having expert nurses act as clinical colleagues of the physician characters on a regular basis would be a threat to the natural order. The most popular shows, like Grey's, generally limit nurse characters to holding and fetching objects and saying "yes, doctor!" Meanwhile, the dominant physician characters spend a lot of time doing nursing work. In the November 18 Grey's episode, Meredith and fellow resident Alex Karev appear to be the only hospital workers who provide any significant care to the nurse's son--no practicing nurse appears. The episodes airing November 4 and 11 likewise showcase physician nursing, as residents Cristina Yang and Jackson Avery provide skilled monitoring of patients. The obvious effect is that physicians get credit for the work of nurses. And the November 4 episode includes another of the show's occasional naughty nurse insults. In that episode, plastic surgeon Mark Sloane says that orthopedic surgeon Callie Torres deserves better than "off-brand crap" cupcakes for her bon voyage party because it's not just a "baby shower for some nurse who couldn't keep her knees together." Grey's Anatomy's fleeting efforts to present nurses as sentient beings are admirable, but they are overwhelmed by the show's relentless indications that nurses are low-skilled physician helpers.

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Working the system

Aren't you the doctor?

Watching a post-op

Some nurse who couldn't keep her knees together

 

Working the system

Stark, MeredithThe November 18 episode that includes the nurse as a patient's mother is "Slow Night, So Long," written by Zoanne Clack. In one plotline, surgical resident Meredith treats a 9-year-old chest surgery patient named Drew McNeil. The responsible attending physician, Robert Stark, says he's heard Meredith is good, and so she will not need to contact him after he leaves the hospital--meaning he wants to be left alone. The show has previously presented Stark as an incompetent jerk, so there is a sense of foreboding here. Meredith introduces herself to the boy's mother. There is no practicing nurse in evidence. Mother McNeil tells Meredith that her son is in a lot of pain. Meredith says that's not unusual for this type of surgery. But this nurse won't be put off.

See the clip in Quicktime at broadband or dialup speed.

McNeil:  Abdominal pain is not normal after pectus excavatum surgery, and it's been going on for two hours. I'm a nurse at Seattle Pres[byterian]. (The boy groans.) It's OK, Drew honey, Mommy's right here.

Meredith:  His abdomen does seem a little tender.

McNeil:  I'm concerned about his vitals. And I know my son; he's not a complainer. Something is wrong. Can you please call Dr. Stark?

Meredith says she will do that right away. In this scene, McNeil is a strong advocate for her son, and she might be seen as a little pushy, but Meredith's measured, respectful reaction will probably influence most viewers to see her as a reasonable person concerned about her son.

Nurse mom, StarkNext we see Stark, having returned to the hospital in his suit, in the room examining Drew. He nods at the mother but says nothing, then walks over to Meredith. Starks slams her for tearing him away from dinner at a nice restaurant to examine a kid with gas. Meredith says the boy was in a lot of pain and his vitals were borderline, and she explains that they are better now because she gave him a liter bolus of IV fluids. Stark says she should have given him an anti-flatulent, because abdominal pain after chest wall surgery in a patient on narcotic pain killers is gas or constipation until proven otherwise. He hands back the chart and starts to leave. Meredith reminds Stark about the boy's pain; he just says "tiramisu" to remind her that the dessert he was enjoying is more important. This kind of interaction will be familiar to practicing nurses, but all we have here is Meredith, who apparently gives medications as part of her role as the sole bedside care giver.

Later, we see mother/nurse McNeil and Meredith with Drew, who is moaning with pain.

McNeil:  His pain is getting worse, his color looks bad, his vitals haven't stabilized. I've seen gas, Dr. Grey; this isn't gas. 

Meredith:  Well, we have to give the medicine a little time to work.

McNeil:  We gave it time to work, it didn't work, which means this is not gas. I've worked the night shift, I know what goes on. I've lived through horror stories of patients falling through the cracks because residents are running around half asleep and their attendings are nowhere to be found. I will not let that happen to my son.

Meredith:  I won't either, I promise. And I agree that it's not gas. So, let's run some tests and find out what's going on, OK?

McNeill:  Thank you.

Meredith reacts very well to McNeil's insistent advocacy; there is no evident contempt and no defensiveness. We give the show credit for showing how a physician should deal with a nurse's concerns, even if this nurse is also a mother advocating for her son and so presumably worthy of more respect.

Nurse momLater, Meredith complains about Stark to fellow resident Alex Karev, who has experience with Stark. Alex confirms that getting Stark to come back to the hospital is difficult. Meredith notes that "this kid's mother is a nurse at Seattle Pres." Meredith asks Alex, who also has specialized pediatric experience, to help her. Alex suggests additional tests to run, noting that you have to cover all bases with Stark, so that if you do call him, he has no excuse not to come in.

Later, we see Meredith tell Alex that she's waiting on the CT results to call Stark, but there is only one CT tech available. Suddenly, chief of surgery Richard Webber enters. Alex wonders what the chief is doing there at that time of night.

Webber:  Well, when a screaming mother calls me at home to tell me my residents are about to kill their son, time becomes irrelevant, wouldn't you say? Dr. Grey, are you familiar with Mrs. McNeil?

Meredith:  She called you? I did not give her your number--

Webber:  She's a nurse. She worked the system. But what concerns me is not how she got my number, it's why she felt the need to call me in the first place. Now what the hell is going on?

Meredith:  I have a plan in place, I'm just waiting for a CT, and the guy is just very backed up down there.

Webber:  How long have you been waiting?

Meredith:  Two hours.

quoteThe three physicians arrive at CT. Webber demands that the surly CT tech get immediate on-call help from a colleague or they will both be fired. He tells Meredith and Alex that that's how you get things done at night. The CT results show Drew has a perforated ulcer. It's bleeding and must be from the anti-inflammatory drugs the boy has received. Meredith tells Alex that she called Stark, but there was no answer. The residents agree that the boy needs surgery.

Meredith takes Alex to Drew and mother/nurse McNeil. Alex tells McNeil about the ulcer, and McNeil asks if Drew needs surgery. The residents say yes, and say they have called Dr. Stark and he is on his way. Alex says they can start prepping Drew immediately. McNeil is almost tearfully grateful, and thanks both residents. Neither resident displays any resentment that McNeil called their boss Webber, and that may be pushing the bounds of realism just a tad.

Privately, Meredith tells Alex that she can't believe they're really going to call in a whole OR team without an attending. Alex reminds her that the boy could die, and says he can do the surgery that may be needed better than Stark anyway. Next we see them in the OR, with the surgical team assembled, and Alex taking the lead. An apparent nurse is calling Stark every five minutes, and also trying to reach attending Miranda Bailey to see if she can help. Meredith wonders if Alex can really handle the surgery. But he does. Bailey has gotten drunk with many of the other attendings at a local bar, so she is useless. Later, we see an OR nurse with a phone glued to her ear, but there is still no word from Stark. So Alex and Meredith keep going. As usual, the clear message of the OR scenes is that physicians alone play the important care roles; the OR nurse basically acts as a clerk, making calls and fetching physicians for other physicians.

quoteFinally, much later, we see Meredith and Alex in a conference room, waiting for Stark to come in and have a tantrum about what they did. Alex notes that the kid is in good shape, the mother is happy, and they did what they were trained to do. Starks does come in and yell at them, but outside chief Webber is watching and smiling--they can see he is on their side.

The show deserves some credit for presenting a strong, articulate nurse character, at least in the few scenes described above. McNeil is knowledgeable and tough. She does not accept brush-offs or platitudes, and she intervenes forcefully to protect her son, even calling the chief of surgery, which not every real nurse would do even if it was for her son. Yet the episode manages not to present her as obnoxious or overly demanding, in significant part because of the surprisingly measured, respectful reactions of the physicians, a standard that real care givers might struggle to meet. It is true that the ABC Publicity summary of this episode describes McNeil as "very pushy," perhaps a result of a different perception of what is reasonable conduct from a nurse and mother; some may consider any outsider who Alex, Meredithchallenges the show's godlike surgeons to be pushy. In any case, McNeil's concerns about the patient are proved correct. She has caught a critical problem that it's not clear Meredith would have seen without her. McNeil has helped save her son's life, though of course Meredith and Alex get most of the credit.

Unfortunately, there are some downsides to the plotline. Most obviously, there is the irony that one of the very few bright, strong nurses to ever appear on this long-running show is not even a colleague of the roughly 15 major physician characters, but someone who just happens to be there because her son is a patient. Her son's Seattle Grace nurses never appear, and a viewer might well conclude he does not have any. Maybe nurses are optional. In real life, the boy's nurses would have been playing the central role in his care and would surely have been at least involved in helping the mother frame and pursue her concerns. These nurses might even have had concerns of their own, and could have helped the patient's mother "work the system"!

What little we see of practicing nurses in this plotline and the rest of the episode conforms to the Grey's standard--they are anonymous lackeys who fetch and hold things for the physicians. In fact, it's hard to reconcile the McNeil character with the nurses who generally appear on the show. And consider McNeil's account of the "horror stories" she has "lived through" on the night shift. She says she has seen patients go down the tubes because physicians were not adequate, but it's not clear that she or any other nurse did or could take any action to try to prevent that. Maybe all she can do as a nurse is observe these bad events, but as a patient's mother she is empowered to actually say and do something? Should we celebrate that the show is saying nurses may have some sense when physicians are allowing patients to die, even if those nurses lack the power or courage to do anything about it? In fact, nurses have legal and ethical responsibilities to protect patients from this kind of incompetence, and many do at least try.

Of course, part of what's happening here is that Meredith is having trouble getting a senior physician to respond to a deteriorating patient--a problem that is not uncommon for nurses. If the show had any significant nurse character drawn in a remotely realistic way, the problem Meredith has with Stark might be a recurring theme. But since the show has never had such a character, it has to be a junior physician's problem. The show doesn't just have physicians spend much of their time doing nurses' work--the monitoring, the procedures, the advocacy, the psychosocial care. It also shows the physicians experiencing and overcoming problems nurses encounter.  
 

Aren't you the doctor?

Both the November 4 and 11 episodes include depictions of physician nursing, specifically resident characters doing skilled monitoring of critical patients, for which the residents get considerable praise from senior physicians. In the November 4 episode (Austin Guzman's "That's Me Trying"), hotshot resident Cristina Yang spends significant time monitoring a critically-ill lung transplant patient. Cristina is still shaky in clinical settings after being involved in a terrible mass shooting incident. In this episode, Yang's mentor, senior heart surgeon Teddy Altman, asks Yang to "monitor" a lung transplant patient and keep an eye out for the middle-aged man's adult daughter, while Teddy deals with the paperwork and retrieves the new lungs.

See the clip in Quicktime at broadband or dialup speed.

Yang is not exactly a people person, but here she manages to provide the patient with real psychosocial care. That's important, because he has not seen his daughter for 20 years and she is not friendly. Then he crashes. Apparent nurses immediately rush in with a crash cart, but we can barely see them. The jittery Yang freezes, and the daughter blurts, "Aren't you the doctor? Do something!" There's a nice summary of the Grey's approach:  only "the doctor" can really do anything. This scene does show nurses rush in with a cart, but they are faceless and we never see the result. The focus is on Yang. When we come back to this plotline, Yang alone is explaining the man's situation to the daughter. She explains that his heart has sustained severe damage, and that he may need a new one. Then Yang hands a monitor to a faceless apparent nurse, ordering her to "Take over here," and Yang leaves, saying that she will go to get Altman.

But Altman is still retrieving the donor lungs, and a cardiac fellow asks Cristina to insert an intra-aortic balloon pump to keep this patient going till they are ready to transplant his new lungs. Cristina's friend Meredith runs through the list of things like hemolysis that Yang should be watching for. That's key because there seem to be no nurses involved in the procedure or the monitoring, though they would play the leading role in operating the balloon pump in real life. Cristina assigns Meredith to update the patient's daughter. Meredith proceeds to provide psychosocial care to the distraught daughter. Next, the surgeons determine that the patient needs to go on ECMO (extracorporeal membrane oxygenation), and Cristina seems to do everything that matters with that as well. Later, we see Cristina alone monitoring the ECMO machine. An apparent nurse does appear to say that Altman is almost back with his lungs and they need to get the patient to the OR. Once again, nurses do have a role--as errand girls for the physicians.

The surgery goes well, and Altman says they'll "just going to have to wait and see if Dr. Yang's hard work has paid off." Seeing that it has, Altman concludes: "Nice work, Dr. Yang. Well done." Chief Webber later seconds the "well done." Even so, Cristina soon quits, realizing that she has lost the will to be a surgeon. There is no discussion of whether she has also lost the will to be a nurse, a role she was effectively playing in running the intra-aortic balloon pump and the ECMO, and in coordinating all psychosocial care to the patient. 
 

Watching a post-op

In the November 11 episode (William Harper's "Something's Gotta Give"), it is resident Jackson Avery's turn to play nurse. In one plotline of this episode, chief Webber asks attending Bailey to handle Louise Cortez, a post-surgical patient who's been re-admitted for chronic pancreatitis. Apparently, the CT scan showed a pancreatic fistula and the patient is "spiking a fever." Bailey asks Webber if he put in a drain. He says he did, and asks Bailey "just keep a close eye." She in turn asks Avery to help her do that. Cortez does not understand why she's there. Bailey explains that a fistula is a surgical complication, and that they use a drain to take leaking fluid out of her body so it won't go where it's not supposed to and digest her other organs--this explanation, appropriate for a lay person, sounds like something a nurse might say. Outside, Bailey tells Avery he's not scrubbing in on another surgery because she has other plans for him.

See the clip in Quicktime at broadband or dialup speed.

Bailey:  Watch Mrs. Cortez. If the fluid in her drain changes color, you page me. If her fever goes up one digit, you page me.

Avery:  Because the fever could be--

Bailey:  An abscess, early sepsis, pneumonia, a number of nasty things. Remember your first rule of residency, "Eat when you can, sleep when you can---"

Both together:  "--and don't screw with the pancreas."

Later, Avery complains to another resident that although he's on Bailey's service, she has him "watching a post-op for fluid into a bag every two minutes." He believes the attendings have lost confidence in him generally, because of past problems. Another resident tells Avery to "relax" with his "easy day." Later, Avery reports "no change" to Bailey, and wonders if he can scrub in now. She says no, because she needs him to watch Cortez. He is clearly disappointed. But later, Avery arrives at the patient's room and as he enters, for just a fleeting moment, there appears to be a nurse at his elbow. The patient is sweaty and feverish and muttering.

Avery (not really addressing anyone):  She's delirious, pulse is thready, I think she's in shock, give me her vitals. (Seeing the dark color of her fluid.) No, no, no, get me a monitor in here, and call Dr. Bailey now.

Nurse-blur:  Right away, doctor.

The nurse-blur scurries out. Next we see Bailey in surgery, on the phone, ordering Avery to get the patient into surgery and open her up, and Bailey will soon join him. Avery is shocked and thrilled to hear Bailey say "open her up." In surgery, Avery waits for Bailey, but when there is no word, he asks for a 10 blade and begins. When she does arrive, the patient is dead. Bailey is upset and Avery is defensive.

Avery:  This is not my fault. She had a fistula, a delayed hemorrhage, post-op pancreatectomies always get fistulas. I didn't screw this up.

He continues to freak out, while Bailey tries to calm him, and finally orders him to "step out of my OR." She examines the patient, sadly. Later, she shows chief Webber the chart, saying she got there as fast as she could. The chief says it was a grade C fistula with a ruptured splenic artery, and that she and Avery did everything they could. She is thinking about why they see so many fistulas after pancreatic surgeries, maybe 20%, and she wants to figure out how to bring that rate down. Webber says sure, she can look into it. She asks if she can use Avery, because "he actually gave me the idea, he was great today."

The relatively limited plotline's vision of nursing is fascinating. Avery is asked to do a monitoring task that amounts to nursing, which he does not appreciate because it seems less glamorous than cutting people open with knives. Then Avery detects a serious problem, which should show viewers that the monitoring was not a waste of time, but the scene in which that happens includes one of the show's frequent insults to nursing, as the nurse-blur at Avery's side has no role aside from fetching objects and obsequiously responding "Right away, doctor!" Bailey says Avery did "great" and spotted a trend in post-op complications that she finds worth pursuing. So this surgeon is asked to play the role of a nurse, but the actual nurse character is a cipher. No nurse character speaks to this patient. Of course, that fits on a show that regularly endorses the assertions of physicians that they own the care environment, such as Bailey's reference to "my OR." The OR does not belong to physicians, or anyone. The basic result of this plotline may be a slight increase in the public's appreciation for the value of skilled monitoring and observation--and the awarding of all credit for those key nursing tasks to physicians. 
 

Some nurse who couldn't keep her knees together

Nurse, knees apartThe November 4 episode also includes a gratuitous nurses-are-sluts comment, something the show indulges in occasionally, despite the fairly high number of sexual partners some of its surgical heroes have. In one plotline, plastic surgeon Mark Sloane arranges a bon voyage party for his good friend and baby mother Callie Torres and her girlfriend Arizona Robbins in the "doctor's lounge." Callie, an orthopedic surgeon, is planning to leave for Africa with Arizona, a pediatric surgeon. But Sloane is having trouble getting someone to pick up the cupcakes for the party. He asks a series of physicians to do it--it's not entirely clear why he did not simply assign a nurse, since that would be consistent with the show's vision of nursing--and eventually he gets to his own ex-girlfriend Lexie Grey, a resident. Lexie buys some cupcakes, but Sloane is not satisfied that she is taking the project seriously enough, and he asks her to describe them.

See the clip in Quicktime at broadband or dialup speed.

Lexie:  I don't know, they're chocolaty-looking, with sprinkles.

Sloane:  Where'd you get 'em from?

chocolate cupcakes sprinklesLexie:  At that grocery store down the street.

Sloane:  This isn't a baby shower for some nurse who couldn't keep her knees together, Grey. Torres and Robbins deserve better than off-brand crap.

Lexie:  I'm not an errand girl. I'm a doctor, with a patient who's about to make a giant, butt-shaped mistake.

This is a reference to the cosmetic plastic surgery these two physicians will soon be doing to give a young patient larger buttocks.

There is no reason that the show needs to involve nurses in this scene; it's a completely gratuitous, offhand remark designed to make the moment a little naughtier, even nastier. Maybe it bears some relation to Sloane's persona as someone who sleeps with lots of women, including nurses. He should know whether they're sluts, we suppose. And maybe a viewer who really thought about it would note that Sloane could be talking about himself, a person who has spent years having casual sex but failed to make many serious connections. He himself recently learned he had fathered a child decades earlier, clearly with someone who couldn't keep her knees together. And maybe Sloane has some vague sense that his own bon voyage party might merit only off-brand crap. But we suspect that for most viewers, the comment will be just a tasty little insult that helps viewers feel superior and worldly for a moment. But that kind of naughty nurse imagery has real world effects, undermining nurses' claims to the resources and respect they need to save lives, which they manage to do in between casual sex and baby showers.

We urge the show to avoid gratuitous insults that undermine nursing, and to consider having nurse characters do at least some of the skilled nursing its physician characters now do.

 

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