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"She's the nurse, maybe she doesn't know"

ER logoFebruary 17, 2005 -- Tonight's episode of NBC's "ER," written by Dee Johnson, associates nursing with embarrassingly invasive or unpleasant procedures whose value viewers are unlikely to see. Meanwhile physicians direct the obviously key treatment, demonstrate the important knowledge, conduct the dramatic patient relations, and get all credit for patient outcomes. In the episode, "Alone in a Crowd," a stroke patient discounts nurse character Sam Taggart's reassuring smile because "she's the nurse, maybe she doesn't know" how bad the patient's condition is. We see little in the show to contradict this view. Later, Taggart acknowledges to the stroke patient that another patient's incontinence brief is "pretty stinky," and cheerfully says "welcome to my world" as she goes to change it. The episode is a stroke edutainment vehicle, and it features a virtual ad for the Merci blood clot retrieval system, but the message it sends millions of viewers about nurses is far less glowing. In fact, it's pretty stinky. Welcome to our world.

The main plotline follows busy mother of three Ellie Shore (guest star Cynthia Nixon), who keels over with what turns out to be an embolic stroke. At County General, Shore struggles to understand her condition and cope with her inability to speak or move her right side. Taggart, attending physician Luka Kovac, and intern Abby Lockhart care for her. As Taggart makes Shore more comfortable, Shore says in voiceover: "She's smiling. Maybe that means it's not so bad. But she's the nurse, maybe she doesn't know." Shore looks at Lockhart: "She's the doctor, she's not smiling as much. Maybe she's just more serious." Later, during Taggart's "welcome to my world" scene, the camera lingers on her beginning to change the brief. Shore watches, wide-eyed. After Shore's children arrive with a neighbor, ER logoShore starts coughing, and Taggart asks the neighbor to take the kids outside. The neighbor says: "Come on, kids. Let the doctors take care of your mom." At another point, physician Lockhart gives the panicking Shore the narcotic fentanyl.

Shore later undergoes the cutting edge but risky Merci concentric retrieval procedure, in which the clot in her brain is removed with a catheter threaded up through the femoral artery. At radiology, the reassuring physician "Dr. Medford" explains that they will begin cleaning Shore's leg for insertion of the catheter, while nurse "Martha" says she is about to shave part of Shore's pubic hair. This elicits a sarcastic "fantastic" from Shore. Kovac conducts all significant interactions with Shore's family. He shows up in radiology to stand by her during the Merci, in which he is not involved. Shore returns to the ED and, after extubation, is able to speak. Her first words? A heartfelt "thank you" directed solely at Kovac, though Taggart is standing right there.

In the most significant other patient-centered plotline, intern Neela Rasgotra provides every single bit of care to a slightly injured child with two young siblings and a seemingly disassociated, mildly intoxicated father. Rasgotra gets this family from the waiting room, provides all care including getting the patient a meal and discharging him, and even follows up by visiting the kids at their home with fellow intern Ray Barnett, after she discovers that the "father" had simply been hired to pose as one by the oldest sibling. It turns out that the children's mother has been dead in the next room for some days, but the kids were trying to hide it because they feared being split up. Not a single nurse appears in this plotline.

Of course, "ER" episodes tend to throw nursing a few bones; if they didn't, they would be far less persuasive in drilling the show's vision of nursing's peripheral subordination into the global mind. Here, Taggart is the one to notice that Shore (who can't speak) wants to write a message, though rather than simply getting pen and paper as a real nurse would, Taggart waits for Kovac to tell her to. Taggart does give Shore the powerful heart medication Adenosine. Taggart discusses the patient's condition with Kovac, a few times ER logoshowing some general awareness of stroke care. And she also explains a couple relatively simple things to Shore, and provides needed comfort to her on several occasions. That's all fine.

Now let's look at the other side of the scale. Giving the show the benefit of the doubt as to the incontinence brief and pubic hair shaving scenes, we'll assume the idea was to show how hard it is to be a nurse (and a patient), and perhaps that nurses like Taggart are underappreciated. But when the show does nothing to show why these procedures are actually critical to patient outcomes, and little to illustrate the full range of other critical nursing practice, the impression is that we should honor nurses because they're menial workers willing to do things that would disgust most of us, and not for their life-saving skills. The camera lingers on Taggart changing the brief, and Shore stares. We'll remember: maybe simple, unpleasant tasks pretty much are the nurses' world. Likewise, the reassuring radiologist "Dr. Medford" and the pubic hair-shaving nurse "Martha" together form a predictable vision of esteemed physician and menial, familiar nurse.

Shore's "she doesn't know" comment is in the classic "ER" tradition of "just trying to help" damage to the nursing image. Perhaps the idea is to show that Shore has stereotypes about Taggart's knowledge. But when there is no real rebuttal in this scene or elsewhere, viewers are likely to conclude that Shore's unvarnished thought is harsh--not something you'd say out loud--but essentially correct. This reminds us of the brutal anti-nurse comments the show likes to give to prickly attending characters, but never really rebut, leaving us to think the senior physicians are nasty, but right. Even conceding that Shore's comment was in the context of diagnosis, how likely are most viewers, with little understanding of nursing, to think: "well, that's diagnosis, nurses have a world of other vital knowledge physicians don't"? And in fact, an experienced ED nurse like Taggart would be well aware of the condition and prognosis of a major stroke victim like this based on her nursing assessment. Nor does it seem to have occurred to the apparently intelligent Shore that Taggart might ER logobe smiling simply to provide her comfort regardless of her condition; maybe she thinks nurses are too simple for such a calculated maneuver.

Elsewhere, as usual, the episode presents numerous elements to suggest that physicians direct or perform all significant care, subtly confirming the unrebutted stereotypes above. Kovac conducts all meaningful interactions with Shore's distressed family, while Taggart merely stands by and observes, like an assistant. In real life, nurses are at least as likely to provide such emotional support. Likewise, it is the attending Kovac who stands by in radiology during the Merci procedure; Taggart is absent. In real life, neither one of them would be there. Lockhart's giving Shore fentanyl is classic physician nursing; in real life, nurses give medications, especially narcotics like fentanyl--physicians do not even have access to them. The neighbor's comment about letting the "doctors" care for Shore--which passes unremarked even though it was a nurse who just spoke to the neighbor--would be astonishing in a rational universe. But we live here, and we've seen this kind of thing many times from "ER," as patients and caregivers persistently act as if only physicians are providing care. The same goes for Shore's final "thank you," directed only at Kovac. Rasgotra's scenes are perhaps the most obvious physician nursing. In fact, physicians do not triage patients in the ED waiting room, escort them back, handle every aspect of their physiological, psycho-social and family care, and discharge them by themselves. Nurses triage patients, are deeply involved in their care and discharge, and would be more likely to pick up on the family issues presented here. Of course, since "ER" has never had more than one major nurse character, it's probably inevitable that there will be constant physician nursing.

On the whole, this episode is yet another portrait of nurses as skilled, compassionate physician helpers. That Taggart is presented so positively, and is so deeply involved in the care of the stroke patient, merely adds to the subtle power of the show's vision, showing once again why "ER" is the world's foremost purveyor of the handmaiden image of nursing.

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