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"You're the surgeon, hon -- you tell us!"

Nurses still the servants in Grey's Anatomy's 9th season

Grey's Anatomy 
May 16, 2013 -- Tonight's season finale of ABC's Grey's Anatomy capped another season of the all-surgeons-all-the-time drama, which has become of one of the most popular hospital shows in U.S. television history. The show has also been one of the most damaging to nursing, and this ninth season was no exception. As usual, clinical plotlines wrongly told viewers that surgeons do virtually everything that matters in the hospital, including all the skilled monitoring, critical interventions, patient education, and patient advocacy--things that nurses do in real life. A December 2012 episode did briefly feature an apparently knowledgeable nurse cajoling a nervous surgical intern into managing an infant patient in crisis. The scene suggested the nurse was training the surgeon to assume command, like a drill sergeant, but that nurses cannot act without physician direction. In the end, the nurse came off as an anonymous testing device for the surgeon, whose experience dominated the scene. A March 2013 episode included a fleeting suggestion that nurses were actually required for the hospital to do surgeries! But the rest of the season included apparently nurse-free surgeries. And the show otherwise presented nurses as obsequious servants, doing mundane physical tasks and absorbing commands with a standard "yes, doctor!" or without comment. In tonight's season finale, a major storm threatened the hospital, in a plotline seemingly based on what happened at NYU Langone Medical Center during Hurricane Sandy in 2012. In real life, NYU nurses transported critical NICU patients to safety. But here, Grey's surgeons appeared to staff the NICU pretty much by themselves, ventilating the babies and providing emotional support to distressed parents. And late in the episode, the show offered a classic Grey's insult. Attending surgeon Miranda Bailey, too upset by a bad patient outcome to perform surgery, is seen ferrying blood to the OR. Surgeon Richard Webber, not recognizing Bailey at first, says "Thank you, nurse," then, seeing his mistake, apologizes. This underlines just how far Bailey has fallen, that she could be mistaken for a nurse. Soon Bailey is operating again, and the responsibility for carrying objects from point A to point B is back where it belongs.

Upside down

Transplant wasteland

Rescue heroes
 

Upside down

The episode broadcast on December 6, 2012 ("Love Turns You Upside Down," written by Stacy McKee) focuses on the show's pretty new group of surgical interns. Like their predecessors on the show, these new interns are thrilled to already be so awesome, and giddily eager for patients to start dying in the coolest ways, so they can do the coolest surgeries and become even more awesome! Remember, these are actual adults, and the show's heroes.

In one scene, the physician intern Jo Wilson, acting in place of pediatrics attending Alex Karev, is thrown into a situation with a 15-year-old mother whose newborn baby has been diagnosed with CDH (Congenital Diaphragmatic Hernia). That is basically a hole in the diaphragm that allows abdominal organs to move into the chest and restrict lung development. Right away a seemingly experienced, but of course unnamed, nurse character explains to Wilson that the ultrasound showed CDH, tells Wilson what that stands for, and notes that it means the baby may not be able to oxygenate. So far not bad, right? Some real knowledge there. Another apparent nurse seems to be helping the mother. Wilson holds the bloody baby and looks helpless.

Wilson:  What do I do?

Nurse:  You're the surgeon, hon--you tell us!

After a commercial break, the nurse again asks, "Dr. Wilson, what do you want us to do?" Wilson haltingly starts giving commands, including for equipment to help her intubate. The baby's SATs (which measure oxygen saturation) are dropping. The patient's grandmother wants to know the status, but Wilson is too distracted intubating. The nurse seems to be about to urge Wilson to respond to the grandmother, because as we all know nurses are not allowed to speak to patients or families. But the nurse stops, maybe because distracting someone during a difficult procedure is dangerous, or maybe because the nurse's real focus, like the show's, is Wilson. So the nurse assures Wilson that she is doing fine, then prompts: "Now what's next?" The nurse suggests, "How about suction, and maybe you want to put in an umbilical catheter?" Wilson agrees. Later, we see Wilson and Karev wheeling the baby, with background nurses, to receive ECMO (extracorporeal membrane oxygenation). Wilson tells Karev she never intubated before.

In this retelling, it certainly sounds like the nurse was training the intern, and like she was a critical force in saving the patient, doesn't it? And in fact, nurses do play a key role in training new physicians, though this role is not often acknowledged. We give the show credit to the extent viewers realize that is happening.

But it's remarkable how the nurse character can do so much without being likely to receive much notice or credit from the average viewer. All the directorial attention is on Wilson, what she is experiencing, what she is doing, how she is handling being in command. Wilson never thanks the nurse, nor is the character named or identified as a nurse. And when Wilson mentions the intubation to Karev, it sounds like she managed the patient all by herself.

Perhaps the worst part is the nurse's comment about the surgeon telling the nurse what to do. On its face the comment suggests that the surgeon has all the knowledge and authority, and nurses just await orders. But even in the context of the scene, which shows that nurses do have some knowledge, the comment suggests that nurses are not allowed to do anything without a physician order. In real life, even though nurses are not yet permitted to practice to the full scope of their ability, there is plenty they can and will do to save patients, particularly when a physician is flailing. Real nurses would not let a patient die or almost die so a physician could learn to take responsibility. If the show wanted to force Wilson to make a plan and execute it under pressure as a training exercise, couldn't the nurse have said something like, "Come on now--what's the first thing we do with a baby who's having troubled oxygenating? Good--and now?"

This is not new ground for Grey's Anatomy. When the show started in early 2005, there were at least two episodes in which the first crop of interns confronted similar situations, with nurses demanding that new surgeons tell them what to do with crashing patients. In the March 2005 series premiere, the bitter nurse Tyler insisted that Meredith Grey herself tell him and a handful of other nurses what to do. Meredith eventually defibrillated and saved the patient, with no real indication that Tyler knew anything and was just training Meredith. But a scene that was much more similar to Jo Wilson's came in a May 2005 episode. There, as here, the guiding nurse showed knowledge, but she was unlikely to register with viewers as a serious professional worthy of respect. Instead, in both cases the nurse was more like a humanoid simulator installed next to the patient to train the intern. So for most viewers, these scenes likely amount to no more than stress tests for baby interns.

Elsewhere in the December 2012 episode, it's more of the usual physician nursing. There are NICU scenes in which only surgeons seem to be doing anything that matters. Only they talk to the parents who hover over the incubators. And at another point, cardiothoracic surgeon Cristina Yang orders an intern to watch a patient and "do an ABG every two hours and monitor his pH level"--tasks that nurses generally take the lead on.

Transplant wasteland

In the episode that aired on March 14, 2013 ("Transplant Wasteland," written by Zoanne Clack), the struggling Seattle Grace Hospital is in the midst of a change of ownership. The show's attending physician characters, backed by a wealthy foundation, are buying the hospital, which is so great because the one problem the hospital has always had is that the physicians don't have enough power. But it has been a difficult transition, with fears that the hospital might close.

In one scene, chief of surgery Owen Hunt is talking to an OR scheduling nurse. She informs Hunt that they do not have enough nurses to do surgeries because they all quit in the wake of the recent buyout chaos--including the transplant coordinator. The comment is good as far as it goes. It is at least an abstract statement that nurses are needed to do surgeries and that transplant coordinators can be nurses. But it's just a throwaway comment, and in all its years on the air the show has never highlighted the key role transplant coordinators (who are mostly nurses) play. On the contrary, Grey's has at times suggested that the surgeons--even the interns--do all of that themselves. And the rest of this episode is as physician-centric as usual, calling into question whether the hospital really would need nurses to do the surgeries.
 

Rescue heroes

Margot Condon holding the babyIn the May 16 season finale ("Perfect Storm," by Stacy McKee) the hospital is suffering the effects of a massive storm almost certainly based on what Hurricane Sandy did to New York hospitals, particularly NYU Langone Medical Center, in October 2012. In real life, as the news media actually reported and even President Obama noticed, NYU neonatal intensive care nurses transported their fragile patients to safety after power failed at their flooded hospital. Those nurses had to figure out how to keep the fragile infants alive while taking them and their equipment down nine flights of stairs without hospital power or light.

But soon after we arrive at the NICU in this Grey's episode, a surgeon remarks that only two nurses made it into the NICU in the storm. Did the nurses on duty just abandon their tiny patients? Could nurse managers not arrange adequate staffing? Oh, right--there is no such thing as nurse managers. Evidently the NICU will be staffed by what seems like 6-8 surgeons. Pediatric surgeon Arizona Robbins basically takes charge. The power is failing, and when the ventilators shut off, the surgeons could be bagging the babies all night (or they could maybe transport them elsewhere, like we seem to remember happening in some recent situation…never mind). Later, the vents do all fail and surgical bagging begins. One father complains that they don't have enough physicians to ventilate 12 babies. (The two nurses never really appear.) Rescue HeroesNeurosurgeon Derek Shepherd, who happens to be there because his own baby is in the NICU, suggests they just teach the parents to do it! It's pretty easy, the physicians say--one intern notes that they learned this on the first day of med school. Yes, almost anyone can squeeze an ambu bag to inflate the lungs in a crisis. But it takes an educated health professional, preferably a nurse, to ensure that the lungs are being inflated at the right volume and speed to provide adequate oxygenation and cardiovascular stability without overinflating the lungs and causing a pneumothorax (collapsed lung) or a depleted amount of carbon dioxide. In any case, the scene as a whole wrongly suggests--again--that physicians run the NICU and provide all significant NICU care.

Later in the episode, surgeon Richard Webber is operating in one of the ORs. He sees someone in scrubs delivering more blood. Lighting is poor in that area of the room and Webber assumes it must be a nurse, but in fact it is surgeon Miranda Bailey, who has been reluctant to resume surgery after being involved in a small but deadly MRSA outbreak in a prior episode.

Webber:  Thank you, nurse…Oh, uh, sorry Bailey, I thought you…

Bailey says she is just trying to do what she can to help out. But it's very clear that this is a terrible loss of face for her. She has been mistaken for a nurse, someone who does menial messenger tasks like delivering blood, rather than important, life-saving things like surgery. And in fact, other surgeries in the episode do seem to be nurse-free, including the delivery of Meredith Grey's baby by C-section. That procedure turns out to be particularly difficult because Meredith fell earlier, injuring her spleen. Eventually Bailey feels forced to rescue Meredith, and she resumes doing surgery.

In the ninth season of Grey's Anatomy, as in the previous eight, surgeons provided all important care and nurses were insignificant helpers. Who cares, because everyone knows it's just a television drama that could not affect how anyone actually thinks? Grey's AnatomyWell, aside from all the research showing otherwise, consider the show's March 28, 2013 episode, in which Scrubs actress Sarah Chalke played a mother whose son had a mysterious ailment the surgeons finally diagnosed as Kawasaki Disease.The plotline was entertainment education, the result of Chalke herself lobbying Grey's creator Shonda Rhimes to include it after Chalke's own son was belatedly diagnosed with the rare condition. Is it reasonable to think viewers will learn something about Kawasaki Disease from a few scenes in this one episode, but learn nothing about the roles of health professionals from the show's overall plotting, main characters, and directorial choices?

 

 

 

 

 

 

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