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My Crazy Nurse Memory

March 21, 2006 -- Tonight's episode of NBC's "Scrubs" included one of the better plotlines for nursing that the show has run. Mark Stegemann's "My Extra Mile" followed nurse character Carla Espinosa's search for a missing VIP patient. The minor plotline did not reflect much sense of how nurses work or of nursing autonomy. But it did feature an aggressive defense of nurses' technical expertise, as Carla repeatedly demonstrated her encyclopedic knowledge of the conditions and care plans of specific patients. The show set that in contrast to the physicians, who it suggested depend heavily on charting. The episode even suggested that Carla had some independent problem-solving ability. Of course, the episode on the whole reflected the physician-centric approach the show has taken since the beginning. But as "Scrubs" nears the possible end of its run in mid-May, we thank Mr. Stegemann and the other producers for this effort to highlight nursing expertise.

The plotline begins with Carla approaching ultra-crusty chief of medicine Bob Kelso. She asks why she "was told to drop everything" and look after a new patient. The show loses points for having her address Kelso, a physician she has worked with for many years, as "sir," and for suggesting that nurse staffing is determined by physician whims. Kelso explains that the patient, Mr. Summer, is a cousin of one of the hospital trustees: "Not important enough to warrant any face time with me, but connected enough that if one of these dingdongs kills him, it'll be my ass." Here the show earns back some points by suggesting that one role of experienced nurses is to protect patients from inexperienced physicians (of course a nurse could kill the patient too, but for better or worse, it's pretty unlikely many viewers will take the comment that way).

At this point, main character J.D. (now a new attending) approaches and asks Carla if she can "cover my patients." We can't pretend to know exactly what that means--can she unilaterally decide to abandon the patients for whom she is currently responsible to provide nursing care to J.D.'s? Can she "cover" them as a physician? Anyway, Kelso notes that Carla is already "watching someone" for him, and J.D. says he'll find someone else. Carla is offended: "Why? Because I'm just a nurse, I can't look after everybody?" Kelso: "Precisely." Carla turns to J.D. and asks him to tell her what's wrong with a particular patient without looking at the chart. In voiceover, J.D. tells us: "Carla knew that without charts, doctors didn't know much about their patients." In an interlude, we see J.D. looking for a chart to learn what's wrong with a patient who has a kitten stuck in his mouth. Back in the current scene, J.D. manages: "It's not like nurses know everything." J.D. sees that Carla is "gearing up to explode," so he shuffles sideways till he's aligned with her, and snaps at Kelso: "Bob, how dare you?" Carla addresses Kelso:

Exactly. You're worried about what I can handle? Vascular surgery wants an update every two hours on bed one, I'm weaning Mrs. Jones's dopamine from 10 mics to 5, Mrs. Myers' abdominal wound is dehiscing, and Mr. Wilder's about to be turfed to psych because he thinks he's Flo from "Alice."

Mr. Wilder chimes in: "Kiss my grits!" Carla says, "Exactly, Flo, exactly," and stalks off. J.D. tells Kelso he hopes he "learned something today." This scene, strong on the surface, is weakened somewhat by the underlying idea that nursing practice consists of being pulled here and there by physicians.

Later, Carla appears to be taking a history from Mr. Summer. She tells him: "The chief of medicine said to pay special attention to you, and I like to take a couple of seconds to get to know my patients, so first question: Are you allergic to any--" At this point the Janitor hisses for her attention. She stops and approaches the Janitor. Upon learning that he just needs advice on which of Kelso's neckties to "clean up gunk" with, she turns back to Mr. Summer, but he has disappeared. We obviously can't fault the show for suggesting that nurses must sometimes turn their backs on patients for 15 seconds, though again, the suggestion that the chief of medicine controls Carla's practice is not helpful.

Most of the rest of the plotline follows the efforts of Carla and the Janitor to locate Mr. Summer. Carla seems particularly concerned about what Kelso will do if he finds out. This depiction of how a nurse might spend her time is not great, especially the suggestion that Carla's main obligation is to Kelso rather than the patient. But it is the kind of thing the show might have had any of its physician characters do. After they search a while, physician Elliott approaches and tells Carla that "the orderly lost my chart for Mr. Tyler in 406," and asks if "we have his dosages in here somewhere." Without consulting anything, Carla responds: "You were going to put him on penicillin but he was allergic, so you put him on a gram of vancomycin." After Elliot thanks her and leaves, the Janitor tells Carla she should "put some of that crazy nurse memory to use on our missing dude." So she does: "Well, he was an older guy, and he was on an IV so he couldn't have gotten very far. He was jittery, and he had this weird circle tan line on his was the nicotine patch! He was trying to quit smoking!" They check the hospital roof, and there he is.

It's true that Carla never provides any particular clinical care to Mr. Summer--we find out from Kelso at the end of the episode that he has a "spot on his lungs"--but several elements underline her expertise and thinking skills. She doesn't just have a "crazy nurse memory," though that is presented as a good in and of itself. She also understands patients' underlying conditions, the effects of allergies, how to wean someone off dopamine, and how to care for a dehiscing wound. She is a (generally) good multi-tasker, and she displays critical thinking skills in figuring out why her patient is missing (yes, it's ridiculous, but this is "Scrubs"). Despite the various problems, the episode effectively blends a message about nursing skill and advocacy into the plotline.

Elsewhere in the episode, the several major physician characters are shown as essentially providing all care to patients, as usual. In particular, they spend significant time here on psycho-social support. J.D., for instance, goes so far as to shave his head in sympathy with a patient undergoing chemotherapy (his "extra mile"), while his mentor, the nasty Dr. Cox, actually consents to help a patient learn his part in a play. On the other hand, Carla's husband, surgeon Turk, is shown in a cutthroat competition for limited surgical attending slots. But the overall effect is still that the work of physicians is the dominant force in the episode.

Even so, we commend the show for making some effort to recognize nurses' substantive expertise and the valuable contributions they make to patient care

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