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A Tale of Two ED's

November 18, 2004 -- It was the best of times, it was the worst of times. Tonight's episode of NBC's "ER," Lydia Woodward's "White Guy, Dark Hair," was in some ways a surprisingly good showcase for the show's sole major nurse character Sam Taggart. The Taggart character actually provided autonomous nursing care, teaching and advocacy to a critically injured rape victim. Sadly, these unusually positive elements were undermined by significant physician-centric elements that the show just can't seem to get past--almost as if the episode featured two different ED's. It would not have taken much revision to fix most of the problems here, but as usual, it probably would have taken meaningful nursing advice on the script.

It was the spring of hope. We were almost giddy to see the show at several points portray Taggart acting with a high level of autonomy in caring for the rape victim, whose head and neck swelling prevented her from speaking clearly. For much of the episode, Taggart was something like a full partner with her physician boyfriend Luka Kovac in caring for this patient. She discussed the case with Kovac, and had several solo interactions with the patient and with the police investigating her case. The show slowed down its usual hectic pace, and Taggart was able to comfort the patient and explain aspects of her condition, as well as what the ED staff was doing to help her. Taggart also displayed initiative and expertise in pursuing an option whereby the patient could communicate well enough to give a police detective a description of her attacker, a brutal rapist who had killed another victim and severely wounded others. This procedure, which Taggart performed by herself, involved taking the patient off the ventilator for short periods and deflating the tracheostomy balloon. This, of course, was also an example of patient advocacy, since Taggart was fighting for her patient's interest in pursuing the rapist, as well as society's interest in preventing the rapist from striking again. On a few occasions, nurses in the episode actually suggested a course of action to the physicians rather than simply waiting for direction, or even reported that they had already done things the physicians requested, constant features of real ED care that "ER" has not often shown.

But perhaps the most striking example of the episode's unusual effort to portray nursing with some depth and realism was that it actually showed Taggart defibrillating the patient, even though a very competent physician (Kovac) was available to do it. We can think of only two prior instances where "ER" had a nurse performing this exciting everyday nursing task. On one occasion, LVN Malik McGrath did briefly defibrillate a patient, but the scene was so focused on the physicians who were working on the patient that McGrath's action barely registered. The other was when an exasperated nurse Abby Lockhart (soon to return to medical school) did it when there was no physician available. Lydia Woodward, the show's other producers and its technical advisors deserve credit for this one small milestone, which the Center has been advocating since 2001.

It was also the winter of despair. No matter how an "ER" episode may try to portray nursing accurately or sympathetically--and it is not completely unprecedented for the show to make such an effort--the physician-centrism that seems embedded in its DNA seems to undermine it. And we were genuinely sad to find that this episode was no exception. The episode featured the usual sprinkling of themes and comments suggesting that physicians control or direct all important ED care. The scenes about new chief of ED medicine Susan Lewis, and the fallout from her initial performance review by chief of medicine Kerry Weaver, clearly suggested that Lewis ran the whole ED, including nursing. Of course, "ER" has never established any nursing equivalents to these physician managers. Viewers would naturally conclude that the physicians run the whole ED, especially since the show also tends to suggest that nurses report to the physicians in the care of specific patients.

Moreover, in this episode, physicians John Carter and Lockhart--along with a social worker, to the show's credit--provided all significant care to a new teenage mother who was denying that she had even been pregnant. In real life, it is likely that this patient's nurse would have had a central role in dealing with her emotional and physical wellbeing, her child, and her relations with her troubled family, rather than leaving it all to an attending and a new intern. But here, nurse character Haleh Adams' involvement in the patient's care was limited. It seemed to center on ferrying messages between the two physicians about trying to get through to the new mother, rather than trying to do so herself, as a real nurse would.

But the most disappointing messages were some of the underlying themes of the rape victim plotline itself. First, though Taggart got the patient's consent for the procedure to enable her to speak with the detective, she stated that she also needed Kovac's approval, which is unlikely to have been the case in real life. Kovac expressed reservations early on about the safety of the procedure that suggested he would not have given that approval. He also pointedly cut Taggart off when she was trying to explain the patient's condition to the detective, ostensibly on privacy grounds, as if the detective was not going to learn the extent of her injuries anyway. Taggart reprimanded Kovac later in private for this, but at the time she remained silent. In addition, though the episode indicated that Taggart had at least assisted with the patient's rape exam, at a real level one trauma center a certified Forensic Nurse Examiner (which Taggart is not) would have performed the exam. "ER" consistently ignores the contributions of such Advanced Practice Nurses.

Taggart went forward with the procedure to allow the patient to speak anyway when she learned that the detective was about to leave, and Kovac was not available to discuss a final decision. The episode made sure that we noticed circumstances that by chance delayed Kovac's learning about what Taggart was doing, giving the impression that had any of these gone the other way, the outcome would have been different. And the outcome was bad: while the patient struggled valiantly to tell the detective what she knew, all she was really able to remember was that the assailant was a white guy with dark hair. Oh, and then there's the fact that the patient vomited and aspirated the vomit into her lungs because the tracheostomy balloon was down, crashed and died, despite the best efforts of Taggart, Kovac, nurse Chunie Marquez and others. The episode clearly indicated that Taggart's well-intentioned recklessness was the direct cause of the patient's death.

As it happens, though few viewers are likely to notice, Taggart could have performed this procedure far more safely by ventilating the patient in between questions, or at least not occluding her airway for an unrealistic 2-3 minutes. Had she done so, the patient may not have been stressed to the point where she vomited. It is possible the show realizes all this and just felt this would be an effective vehicle to heighten drama. But it also seems possible that the show is not aware of it, because while "ER" is very focused on technical accuracy, this was a purely nursing procedure--manipulating and guarding the airway to facilitate emotional support--not a physician procedure. Since "ER" appears to receive meaningful technical advice only from physicians, it would not be surprising if they simply got it wrong. They could have had even a safer procedure go wrong without suggesting that Taggart was reckless and in over her head; like any professional who makes the wrong call with tragic results, she still would have been devastated.

The distraught Taggart was saved from grave professional consequences only by Kovac's cover story that the tracheostomy balloon must have ruptured, a story he supposedly made coroner-proof by bursting the balloon himself after the patient was already dead. The implication was that Taggart was out of her depth in making this kind of life or death decision and in doing the procedure on her own, and possibly that her judgment was distorted by her own past experience with an abusive man. At the end, of course, she had to be rescued by her forgiving physician boyfriend. The episode ended with a tearful Taggart resting her head on his manly chest.

This conclusion was eerily similar to last month's final broadcast episode of CBS' "Dr. Vegas," which focused on a nurse practitioner's inability to handle her own unrequited love for a physician colleague, which resulted in the unauthorized distribution of dangerous drugs. This NP had to be rescued by this same physician love interest, who covered for her even at the risk of his liberty and license.

This is a disturbing trend. Just like physician characters, nurse characters don't always have to succeed in saving patients, and it's fine to show them making mistakes, especially when the gravity of the mistake makes clear how responsible nursing is. But episodes like these suggest that nurses can't handle serious tasks and decisions--and possibly that their competence can easily be undermined by a troubling personal relationship. They have to be rescued by their physician boyfriends. It might be different if shows like "ER" regularly showed the more common occurrence of nurses making heroic efforts to save lives and succeeding, or at least not failing because of their professional errors. But it is rare for a popular prime time drama to present a nurse character with the level of autonomy and attention Taggart received here. To see it subverted by such regressive themes was truly disappointing.

In addition, some viewers may conclude that determined patient advocacy by nurses is a dangerous aberration, because Taggart's advocacy--which the show rarely depicts--resulted in such a disaster, and because it may have been driven by her personal demons. In fact, all nurses have a professional responsibility to advocate for patients who (like this one) cannot do so for themselves, and nurses frequently do just that. As a result, nurses and physicians often disagree about how to provide patients with care that is respectful of their physical, psychological and social needs. We wonder how soon the show will have a nurse's vigorous patient advocacy result in the saving of a patient's life, as often happens in the real world.

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