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"Thanks for everything"

March 24, 2005 -- Tonight's episode of NBC's "ER" included something we weren't sure we'd ever see from the show: a patient's mother thanking nurse character Sam Taggart for making a catch that would play a key role in her son's impending surgery, followed by a "ditto that" from the intern who had resisted Taggart. What can we say? Nursing skill, patient advocacy, informal teaching of young physicians, due credit for patient outcomes--it's almost like episode writers David Zabel and Lisa Zwerling, M.D., were actually paying attention to our concerns. Of course, this is just a minor part of one plotline. The episode still has nurses reporting to the chief of ED medicine, and it remains focused on the physicians' work, largely ignoring nursing when it's not showing physicians doing it. But we certainly commend the show for this effort to show the value of nursing.

In this episode, "Back in the World," one plotline is about a likable 12-year-old boy who has accidentally shot himself with a gun he felt forced to carry for self-protection. Shortly before the boy is to be transported to surgery, the show's lone major nurse character, Taggart, does a sensory exam with a Q-tip on his leg below the wound, and discovers some tingling in a spot well below where the bullet rested as shown on the X-ray. She shows intern Ray Barnett the boy's X-ray, which she says shows that the bullet has lost a chip. She surmises that the chip is in the popliteal artery--behind the knee-cap. Barnett is skeptical and in a hurry, telling her the boy is "my patient" and that he doesn't want to pursue it. But Taggart pushes him to consult with attending John Carter, and calls to arrange another X-ray. Later, Taggart spots Barnett and senior resident Pratt taking the boy up for surgery. They tell her the X-ray showed she was right. Pratt tells her it was a good catch. The boy's mother speaks directly to Taggart: "Thanks for everything." Barnett says: "Ditto that." Taggart practically melts.

And so did we, for a moment. In this one interaction, the episode addressed many of the concerns we have with the show. Taggart displayed important health knowledge and critical thinking skills, she pursued her concerns despite resistance from an intern, whom she effectively educated, and she received credit for her work, not only from the patient's mother, but even from the intern and the senior resident. We could quibble with the fact that the expertise Taggart displayed is actually more likely the province of physicians and advanced practice nurses (APRNs). Staff nurses do assess patients for motor and sensory deprivation, but generally don't do such detailed fine point sensory exams with Q-tips or fine point reading of X-rays. Similarly, an ED nurse probably would have gotten concurrence from a physician or APRN before scheduling an X-ray. So this is really a physician's vision of how a nurse might be impressive--by doing things physicians normally do. Because the show does not consult nurses on its scripts, it has little idea about what most nurses really do to improve outcomes. We're aware it may sound like we're complaining about the show giving nurses too much expertise and authority, but our point is that it's still not quite the right expertise and authority. Just as physicians should not be credited for nursing work, nurses should not be credited for physician work. That kind of inaccuracy really serves no one's long term interest (though we can't say we've heard of many physicians complaining about how "ER" and other Hollywood shows persistently depict them doing the work of several other types of professionals). Moreover, true to the show's general practice, Barnett's remark about it being "my patient" is not rebutted, leaving viewers to think he's mean, but not wrong. Still, for "ER," this small plotline is a huge success. Of course, whenever "ER" has a nurse character display initiative, knowledge and skill, we worry that she's outgrowing nursing, and getting ready for medical school.

Elsewhere, the episode is more true to physician-centric form. Not long after this triumph, Taggart encounters chief of ED medicine Susan Lewis. Lewis tells Taggart that she's lost "my MICN nurse" (mobile intensive care nurse) and tries to get Taggart to work overtime until nurse Chuny Marquez can arrive to work the rest of the MICN shift. (MICNs advise paramedics in the field by radio.) This scene tells viewers that nurses report to physicians, which is false and damaging. This kind of staffing issue would typically be resolved by the ED nurse manager, charge nurse or nursing supervisor, and ED physicians would have nothing to do with it. But since the show has virtually never even shown members of nursing management, there is no one available of the show's nine major physician characters. Likewise, intern Neela Rasgotra continues her recent pattern of getting patients directly out of the waiting room, as if nurses who triage and decide when patients can be seen in the treatment area do not exist. On the whole, the episode largely holds to the show's overwhelming focus on its physician characters, who often do work that nurses are more likely to do in real life, such as providing emotional support to patients and families, and coordinating care by other health professionals.

We salute the show's effort, at long last, to give a nurse character explicit credit for improving a patient's outcome and for helping to train young physicians. It's certainly a start. But a journey of a thousand miles also requires the second step. We'll be watching.

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