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Kill Bill, Vol. N

February 12, 2004 -- Tonight's episode of NBC's "ER," written by Yahlin Chang, focuses on major nurse character Sam Taggart's professional and personal life. It features some of the show's increasingly common efforts to be sensitive to nurses' concerns, including a pretty good portrayal of Taggart's autonomous care for a sexual abuse victim. Sadly, most of these efforts are undermined by the show's physician-centric structure and approach. Notably, the episode touches on some important issues relating to violence against nurses and the potential for nurses with dangerous problems to evade detection, but in such a way that few viewers are likely to realize it.

The episode's title, "Impulse Control," refers to Taggart's struggle with her tendency to respond aggressively, even violently, when threatened. Here, Taggart confronts the fiancé of a minor female patient, who professes to have nothing but love for him. In fact, the fiancé and his friends have impregnated the patient in a highly abusive encounter that seems a lot like gang rape. Taggart angrily tells this man that he and his friend must leave the area where the patient is, and accuses him of assaulting the patient. The fiancé grabs Taggart's arm. Taggart asks him to let go, and when he refuses, she decks him with serious martial arts skills. The man does not appear to have any serious injuries, but the show regards it as excessive force, and later interim ED chief of medicine Kerry Weaver tells Taggart that a visiting human resources consultant has recommended that she be fired. Though Weaver is no fan of this consultant, she is clearly displeased. She notes that the hospital will likely be sued, and informs Taggart that the "director of nursing" will speak with her the next morning. Taggart mounts only a token defense of her actions, mentioning what the fiancé did to the patient, but also notes that if she gets fired, she'll get another job that is just as good. Weaver responds that she's checked and Taggart reportedly had similar problems at her last three jobs. Taggart notes that she did not get fired from any of those, and Weaver suggests that was only because she quit first.

Violence and other abuse against nurses is a serious problem, especially in the ED. It is exacerbated by the critical nursing shortage that "ER" has long ignored, as patients, families and even fellow caregivers vent their frustrations at too few nurses trying to care for too many patients. Security is often inadequate. Nurses bear the brunt of the abuse because they (not physicians, as "ER" viewers might suppose) are the ones who spend the most time with patients and their families. What is the proper response for a nurse in Taggart's position is a complex issue. Ideally, she would have been freed instantly, by herself or security, with no more force than absolutely necessary. But this is often impractical, and what force is necessary may be unclear. Nurses do have the right to defend themselves.

At the same time, it is quite possible that nurses with serious problems could move from job to job without detection, because short staffing creates high turnover, the shortage puts a high premium on experienced nurses, and monitoring systems are imperfect. This may have been what happened with Charles Cullen, the Pennsylvania nurse who according to press reports recently stated that he had used medication to end patients' lives at many different facilities in order to relieve their suffering. The regulation of nurses is a very serious issue because, unbeknownst to much of the public, nurses have so much responsibility in caring for patients.

Unfortunately, "ER" viewers are unlikely to get much of this, and will likely conclude that Taggart is a dangerous person who overreacts. But the real problem here is the abuse of nurses by patients and others, not the relatively few nurses who may overreact. Perhaps even more damaging to nursing, the show once again suggests that the ED medical chief supervises the nurses, though with more subtlety than at times in the past. Weaver says that the director of nursing will speak with Taggart, but the rest of the scene--with Weaver in the role of the boss coming down on her subordinate, considering her dismissal, checking her records--sends the message that Weaver is in charge. The throwaway reference to the director of nursing makes her sound like a human resources person who works for Weaver. As usual, there is no actual appearance by the director of nursing , the nurse manager, or the charge nurse, all of whom would have been the ones to handle this situation in real life. Of course, on "ER," there's no real need for nurse managers, since the physicians play that role.

On the brighter side, the plotline involving this confused minor is in some ways a very positive depiction of nursing, especially for "ER." Over the course of the episode, Taggart slowly gains the patient's trust, elicits what really happened to her, shows her support and lets her know she has options. And though the patient eventually leaves with the abusive fiancé, near the end of the episode the patient returns alone, seeking Taggart's help. This is a generally good picture of nursing autonomy and care, and to the show's credit, there is no real suggestion that the patient belongs to attending physician Luka Kovac, who essentially steps back and lets Taggart handle it. Unfortunately, this surprisingly good plotline is undermined somewhat by medical student Abby Lockhart's ordering of Taggart to leave the patient at a critical moment to do something else, and at a deeper level by the clear implication that Taggart's actions are driven not by professional expertise so much as her own personal experience with unwanted teen pregnancy. Still, in some ways, this is progress.

Another plotline shows Taggart's distress at caring for a dying car crash victim who reminds her of her own son, with whom she has struggled. Taggart is shown to be a sensitive person despite her combativeness, and she also provides some key information and support to the highly distraught mother, explaining the purpose of the cervical tongs which are attached to the child's head. Unfortunately, the physicians still do most of the patient and family support, and the unnerved Taggart also tries to trade the patient to another nurse, which the show is unlikely to have shown an experienced physician doing. In general, here and elsewhere, "ER" typically has the physicians doing the education and counseling that Taggart and the other nurses would do in real life. Of course, the most direct reason is that the show wants to feature its major characters, and they are almost all physicians. So the effect is that the physician characters must do a lot of nursing. If the show stuck to what physicians really do, it would not be nearly as engaging.

At other points, the show could easily let the nurse characters do their own nursing, but still refuses. For instance, when the driver whose heart condition caused the crash collapses to the floor, Taggart calls for Kovac's help. Then she stands by as Kovac defibrillates the patient, which of course she herself would have done in real life.

At another point, resident Archie Morris insists on eating French Fries at the triage desk where Taggart is working, spilling ketchup on some papers, then choking. Annoyed, Taggart gets up and whacks him extremely hard on the back with her doubled fists, then dislodges the food with the Heimlich maneuver. Here the show does have a nurse autonomously saving a life, and we would not question Taggart's disgust with the endlessly tiresome Morris. Still, though it's unclear how many viewers would notice or care, Taggart's action was needlessly brutal: the forceful whack could have lodged the food deeper in his respiratory tract and is not generally done while the patient is still conscious.

We are ambivalent about the show's apparent desire to paint Taggart as a tough swashbuckler who may or may not be in control. We wanted a stronger major nurse character than the meek Lockhart, a character who would stand up for herself. Now we've got her.

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