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Physician-Intensive Care Unit

January 15, 2004 -- Tonight's episode of NBC's "ER," credited to story editor and physician Lisa Zwerling, follows medical students Abby Lockhart and Neela Rasgotra on a harrowing rotation in a Neonatal Intensive Care Unit (NICU) that seems to be staffed mainly by physicians and medical students, rather than the highly skilled nurses who do it in real life. In this physician-intensive care unit, one of the two nurse characters is a battle-axe who leaves the impression that veteran NICU nurses are petty martinets obsessed with rules and terrorizing medical students, whereas the noble medical staff provides not only most of the bedside care, but virtually all the emotional support to the agitated parents.

See clip 1 and clip 2 in Quicktime at broadband speed.

In the episode, "NICU," Lockhart and Rasgotra enter what one resident calls the "box," where critically ill newborns cling to life, and the families and health workers endure great stress. The unit is presented as so terrifying that when ED resident Greg Pratt and nurse Sam Taggart help deliver a patient from the ED, they retreat back into the elevator with a shudder. The patient is left with the NICU resident who accompanied them from the ED. No nurse takes the patient, and Taggart gives no nursing report.

In this NICU, it appears to be the physicians and medical students who provide most of the care. It is not so much that the episode has them at every bedside all the time--there are large groups only on morning rounds--as it is that there never seem to be more than 2-3 nurses for the entire many-bed unit. In real life, the nurse to patient ratio in an ICU is (or should be) 1:1 or 1:2, which for a 20-bed unit would mean the bare minimum of 10 staff nurses. In this episode it is also the medical staff who provide nearly all of the education and emotional support to the babies' family members. In real life nurses assume primary responsibility for these key tasks. A medical student also hunts down missing family members, giving credit to medicine for the work that social workers do. Once again, this inaccurate physician-centric focus gives viewers the impression that nurses and other health care workers are marginal players in an environment where they are in fact central.

Two NICU nurse characters emerge briefly from the "ER" wallpaper. The main one, Virgie (no last name), is introduced by the NICU attending as a 20-year veteran whose mission is to protect the babies from medical students. That's fine as far as it goes, and a rare instance in which "ER" does get at one of nursing's core functions. Of course, it's only one part of the nurses' patient advocacy role, which also includes protecting patients from harm from residents and even the attendings, which the show has rarely if ever acknowledged. And nurses do far more than that in caring for patients and teaching them to return to health.

Unlike some nurses on "ER," Virgie is not weak or eager to defer to the physicians. But she is a true battle-axe: hostile, rule-bound and--contrary to the attending's introduction-- unconcerned with the well-being of the patients. She refuses Lockhart's request that she give a deteriorating patient medication to stop his seizures without advance physician authorization, and when Lockhart does it herself, Virgie whines that she will report Lockhart to the attending. Virgie makes no effort to find a way to help the patient. The impression is that she cares only for rules, whereas medical student Lockhart has courage and is the true patient advocate. Virgie also confronts Lockhart for having changed a diaper without weighing it, ruining her count of "ins and outs." Lockhart apologizes but notes that the diaper is now in the trash. Virgie snaps "not good enough!" and insists that Lockhart dig it out and weigh it. With no explanation that ins and outs are critical measures of a newborn's health, helping nurses to save lives by signaling problems like dehydration, viewers will probably see Virgie as nothing more than a petty witch. At another point, Virgie carps that Rasgotra has not yet completed a patient's discharge summary. There is no discussion of why discharge planning is crucial to patient outcomes, or that nurses, not physicians, take the lead in it. Virgie is a cheap knockoff of the early Margaret Houlihan from "M*A*S*H," a senior but pathetic control freak--though Houlihan at least displayed real skills and authority, which Virgie has no chance to do.

A defender of the show might note that the NICU attending is also gruff and apparently hostile to the students, but her manner is shown to be her way of toughening and guiding them, as she dispenses wisdom and ultimately warms to Lockhart. By contrast, Virgie never steps beyond her one, deeply unpleasant dimension. Perhaps aware of just how far off the deep end the Virgie character is, the episode also includes a few appearances from Tom (no last name), a kind, cooperative nurse who treats the students with respect and defers to them. The show doubtless thinks this portrayal balances Virgie, but as Virgie herself might say, "not good enough!" Respect is critical in any workplace, but deferring to physicians is not always consistent with good nursing practice, which requires nurses to assess all care plans and advocate for better ones when needed. And Virgie dominates the episode's vision of nursing, and is a key part of its theme that the NICU is a stressful, scary place.

On a couple of occasions, the episode comments on nursing directly. In one scene, ED physician John Carter says that Lockhart must be doing well in the NICU rotation or else the nurses would not give her "the time of day." This is praise for former nurse Lockhart, and the episode as a whole shows her thriving while Rasgotra struggles, an interesting reversal of past episodes. But the implication is that NICU nurses tend to be like Virgie, hostile and unwilling to help, when in fact they spend a lot of time teaching medical students and residents. In this episode, the medical students learn nothing useful from the nurses.

Lockhart's own remark that nurses learn in nursing school to be "territorial" is not especially impressive. Of course, nurses are only human, and the profession does have internal issues to resolve in this time of crisis. Oppression is not usually ennobling. But a responsible treatment of those issues seems beyond "ER"'s ability or interest, and Lockhart's flip comment is likely to be viewed as a wise put-down of a limited profession she has gladly left behind for the richer world of medicine.

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The writer of "ER"'s "NICU" episode may be contacted directly:

Lisa Zwerling, MD
Story Editor
4000 Warner Blvd
Building 103, Room 102
Burbank, CA 91522


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