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Hungry Ghosts

Medical Investigation logo December 3, 2004 -- Tonight's episode of NBC's "Medical Investigation," Mark Dodson's "The Unclean," finally puts a small focus on nurses--as serial-killing angels of death! Break out the champagne! Though the episode does indicate that not all nurses are Charles Cullens, its vision of nursing is largely of the "yes doctor" handmaiden school, as the nurse characters seem mainly concerned with fetching physicians or things for physicians. On balance, the episode is yet another regressive blow to the nursing profession from Hollywood.

"The Unclean" centers on a Baltimore hospital with an outbreak of necrotizing fasciitis in post-operative orthopedic patients. An anonymous whistleblower calls in the show's regular cast of National Institute of Health hotshots, led by physician Stephen Connor. Connor's team includes two other physicians, an epidemiologist, and a public relations person. Of course, they are not welcomed by the hospital's administrator, a hostile representative of managed care, nor by the nasty orthopedic surgeon who seems to have operated on all the infected patients. The team gets a better reception from the two main nurse characters, the submissive Molly Kimbrell and Tim Miller--they care about the patients!

The NIH investigators spend most of the show scouring the facility and its personnel for infection control problems--though with an unintentionally comic failure to observe basic infection control procedures themselves, a failure that is often evident both on this show and Fox's "House," which also frequently focuses on tracking deady infections. The team finally realizes that some human--an "angel of death"--has been intentionally infecting patients with a bloody sheet. Initially suspicious of nurse Miller--who turns out to have been the whistleblower, which the NIH team interprets as a potential attention-getting device typical of serial killers--the team ultimately learns that the "angel of death" is in fact meek, helpful nurse Kimbrell. She has gained access to experimental bacteria and, like real-life killer Charles Cullen, has left a trail of suspicious patient deaths at her many prior hospital jobs. The nursing policy implications of this plot seem to have been lost somewhere--Kimbrell gets no lines after she is caught that might suggest why she did it, and no one really remarks on the monitoring and reporting failures that presumably played a role in the string of deaths. (By contrast, significant time is given to reporting and monitoring issues related to the surgeon, whose prior substance abuse is an early red herring.)

The most obvious objection to this episode is the portrayal of a nurse as serial killer. We don't see an inherent problem with Hollywood building a show around a nurse serial killer--there are a handful of Cullens out there, just as there would be in any profession of millions of people who hold lives in their hands. We do have a problem with a show that pretends week after week that those millions of nurses don't exist, or at most are faceless servants instead of life-saving professionals, suddenly deciding that the tiny handful of dangerous criminals among them are the only ones worthy of attention. We have a problem with the term "angel of death," which reinforces stereotypes of nurses as unskilled spiritual beings (whether good or bad), rather than serious scientific professionals. (The show tries to slide out of this by having Connor describe "angels of death" as nurses or physicians, and it's true that the term is sometimes applied to physicians. But physicians don't have a history of being held back by condescending "angel" stereotyping.)

We have an even bigger problem with the handmaiden portrayal of nursing on offer in this episode. Let's start with the killing itself. Note the contrast between the mechanism of death associated with the different professionals here. The surgeon is suspected of having killed the patients because of professional negligence. But the nurse is dangerous mainly because she has gained access to a weapon and used it on defenseless patients. Of course, early on there is a vague implication that any of the staff might have contributed to the spread of infection through poor infection control in a particular physical location. The orthopedic wing and OR are closely examined. But this is not strongly associated with any particular person. The main impressions are that physicians have very technical, responsible jobs, and nurses are helpers with access to patients. There is no direct implication that the nurses might have caused the problem through professional negligence in their infection control or wound care, even though they have far more contact with patients. This is consistent with the show's blasé attitude toward infection control by its characters, but the effect is to reinforce the impression made by other aspects of the show that nurses are not doing anything particularly responsible with the patients. They are just people who speak kindly to the patients--one bitter patient complains about the surgeon, saying only the nurses "care" about the patients--but who fetch a physician when anything serious happens.

For instance, when a post-op patient asks nurse Miller if he can do anything more about her pain, does he say "sure, I'll increase the dosage of your medication," or "you're getting the max now, but let me discuss other options with the physician and get right back with you"? No. He says, "I'll ask the doctor," implying he has no discretion or input on pain management, even though nurses are expert in just that. When Miller then discovers that this same patient has a serious infection in her leg, does he take initial steps to control the infection, discuss the problem with her and her mother, and make a plan to deal with it, which would no doubt include discussing the problem with the physician? No. He looks panicked, says "Let me get someone in here who can help," flees the room, and tells Kimbrell to get the physician right away. The obvious message to millions of viewers is that nurses can't do anything significant with wound care, even though it's something in which they are the experts. Only physicians "can help." Of course, necrotizing fasciitis is a challenge for the whole health care team, but here, nurses are shown to be only bit players on that team.

What about the bright spots? Miller is at least a male. He spots the infection, but it's so obvious that even the average viewer could probably do that. At another point, he is about to inject a patient with Valium before Connor intervenes to question him as a suspect in the deaths. That does at least suggest that nurses have the very responsible job of administering medications; there is a clear implication that the needle might be dangerous, though presumably because of criminal intent, not because the nurse may have erred in his important professional responsibilities. Later, the show says that the pharmacist drew up the medication, which is a fallacy. Either controlled substances come in pre-filled syringes from the pharmaceutical company, or the nurse draws it up. Viewers may simply conclude that nurses inject medications ordered and drawn up by others, without any real input, discretion or technical role.

weasel photoMiller is also the whistleblower, which is a key patient advocacy role and one we might have been glad to thank the show for portraying. But the episode manages to depict Miller as a kind of weasel. He is seen as trying to strike back at the hospital's new corporate culture and physicians like the surgeon who mistreat the staff, rather than as a hero who has saved lives by reporting the crisis even though the hospital failed to do so. Indeed, it's astonishing how little credit the show gives the character for acting to protect patients. Even though Miller is cleared of wrongdoing, he is never really rehabilitated after his interrogation by Connor. In this session Miller at least does not break down, but he is treated like dirt and ends up sputtering about how he will say no more without a lawyer (always the mark of a weasel on cop shows, which "Medical Investigation" essentially is). The NIH team casually discloses his whistleblower status to the hospital administrator, as if risking a nursing career was no big deal. And Miller is given no opportunity to bond with the patients whose lives he has helped to save; those common nursing roles are of course assumed solely by the heroic Connor and his team, who smile benevolently and sit with the main patient and receive full credit and express interest in attending her soccer games.

On the whole, Miller and Kimbrell are essentially humble clerks. They get things for physicians. They do things for physicians. They make and answer phone calls for physicians. They get physicians for other physicians. They change sheets. Connor immediately calls them by their given names, though he remains "Dr. Connor." Shows like "Medical Investigation" and "House," for all the obvious effort they put into their physician characters' discussions of conditions and treatments, appear to spend virtually no effort checking whether their understanding of modern nursing bears any resemblance to reality. They presumably have a vague understanding--perhaps influenced by a history of viewing media products just like the ones they're creating--that nurses are little people who help physicians. No need to check that out, it's common knowledge. These shows have physician script advisors, but that does not seem to have made the slightest positive difference.

Massive Attack photoLet us leave you with a small example of what these shows can bring to bear on what would appear to be the smallest aspects of their production, but rarely to the portrayal of nursing. During a critical scene in this episode, in which one of the NIH team observes the creepy surgeon for signs that he is causing the deaths, a 2003 song by British trip-hop pioneers Massive Attack slips onto the soundtrack. The song is called "Future Proof" (get it?), and the bit we hear features Robert Del Naja whisper-singing about "hungry ghosts" over the band's usual hypnotically ominous electronic music. Massive Attack is not exactly the most original choice, as its cinema-friendly work has been used on other shows, including "House," whose theme song is the band's 1998 track "Teardrop." But neither is the group a household name. And everything about the spooky "Future Proof," even the band's name, evokes the sense that the NIH team is looking for a way to stop someone or something that has infected and killed and must be stopped; the song's non-linear lyrics include "borderline case," "absent friends," "separate the leper" and "we can be numb.". If the makers of the show were to devote anything like the expertise and effort that went into the selection and placement of this music to their portrayal of nursing, we would be having a different discussion.

In Hollywood portrayals, it's the nurses who are the hungry ghosts--blank spirits lurking in the background as physicians save lives, but perhaps hungry to be shown as the full-blooded professionals they really are. As our friend Dr. Phil might say, it's time for them to get real.

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