November 9, 2006 -- Tonight NBC's "ER" included two plotlines in which nurse Sam Taggart came off as a tough, adaptive critical thinker who was well-qualified to handle difficult patients, interns, and attendings. The episode is marred by significant missteps, which tend to reinforce the idea that nurses are physician subordinates who take their "orders." But in one of the episode's major plotlines, Taggart masterfully manages two personalities of a patient with dissociative identity disorder. She finally persuades the patient's extremely hostile, resistant persona that he should allow a pericardiocentesis, effectively saving the patient's life. The scene in which Taggart does this, however realistic it may be, is one of the best depictions of a nurse's expert psychosocial care that we have ever seen on U.S. network television. The episode, Virgil Williams's "Jigsaw," drew 14.5 million U.S. viewers and it will be seen by millions more around the world.
The more minor plotline features the idealistic, somewhat naïve ED intern Hope. Hope is troubled because attending Kerry Weaver has declined to provide a hard-working but poor high-cholesterol patient the drugs he needs to get him to his next clinic appointment. Hope privately asks asks Taggart, the show's lone major nurse character, to get some samples of Levistatin from the "medicine cabinet" (kudos to the show for at least acknowledging that nurses control medication administration, which it often fails to do). Taggart notes that samples are limited, and suggests that Hope get an attending to write a prescription. Hope: "Dr. Weaver asked me to get it for one of her patients." Taggart gets her the samples, and Hope gives them to the patient. But Hope later feels guilty for having gone behind Weaver's back. So she tells Weaver what she did. Weaver interrupts Hope's verbose apology to tell her, "you did a good thing." But Taggart, who overhears, has a different message for Hope:
Taggart: You told me those drug samples were for Dr. Weaver's patient.
Hope: Well, they were...technically.
Taggart: Well, technically, you lied to me. There are rules for breaking the rules, rookie, and rule number one is that you never ever lie to the nurses, you got me?
Hope (genuinely distraught): I'm so sorry.
Later, we see Hope, still upset, consult attending Archie Morris. He admits that Hope's actions were a "bad move," and observes: "Piss one nurse off, piss 'em all of, like the Mafia." Morris, who at times seems interested in a relationship with the devout Christian intern, suggests that Hope consider what Jesus would do. Hope spells this out somewhat amusingly--what would Jesus do if all the nurses hated him? (This is a question we wish more media creators would ask themselves.) In any case, Hope concludes that she was doing the right thing, but she did it the wrong way, presumably meaning she should have raised the issue with Taggart directly, rather than lying to her.
On the whole, this isn't too bad. Taggart is introducing Hope to the rules of the ED game--training her--and forcefully advocating for the interests of ED nurses generally. Taggart is cast to some extent in opposition to Hope's efforts to do the "right thing," but she isn't really against giving the patient the samples, as her comment about "rules for breaking the rules" shows. She simply means that Hope should have confided in her. And Taggart's larger point about not lying to the nurses is a critical one. Lives might well hang in the balance if nurses are not given accurate information (contrary to the irresponsible advice given to Good Housekeeping readers in November 2005 by one anonymous "Doctor X," who told ED patients to lie to the triage nurse to be seen faster).
The plotline might have had Taggart briefly explain to Hope why telling her the truth is so important. Taggart would have far more experience with this kind of patient than an intern, and she might have known something that would change the course of action. She can't fulfill her own professional duties if she does not have accurate information.
Morris's comment is also less than ideal. We're not too bothered by the Mafia reference, but it may suggest that nurses are united more by some toxic class-based bond than by a concern that physicians practice in a way that allows nurses to practice.
In the major plotline, a somewhat confused, feverish-looking young man appears in the ED waiting room. He briefly joins a young boy in Hot Wheels play. But the boy's mother abruptly pulls the boy back, seemingly uneasy that a strange man is playing with her son this way. Also abruptly, the young man seems to become another person, approaching the triage desk and starting to yell at the nurse behind the reinforced glass about having to wait so long when all he has is the flu. He calls her a "bitch," which viewers will learn is his favorite word. The nurse seems unsure what to do, but the streetwise Taggart appears and diffuses the situation, noting that there are a number of other patients, and telling the man: "Sit down and shut up, I'll bring you back here in a few minutes." We give "ER" credit for showing nurses doing triage--something no other Hollywood show does--though this scene does not present triage as the critical, skilled work it really is.
Later, we see the patient, Clyde, in the back with Taggart. Taking his temperature, she asks how long he's been congested. The patient snaps: "Does it matter?" Taggart: "No, I'm just making conversation." Morris approaches, and Taggart says, "temp's 99, URI symptoms." The patient rudely translates this as "the flu." Morris approaches the patient with a stethoscope, and the patient reacts violently to the cold instrument. Morris is taken aback. Taggart again intervenes: "Listen, Prince Charming, the quicker we check you out, the quicker you can go."
Still later, we see Taggart ask the patient why he hasn't yet put on the hospital gown as she asked. He resists, but ultimately rips off his shirt and throws it at her, sneering that she "could at least buy me dinner first." Meanwhile, Morris is on the diagnosis trail, noting that tests have revealed an unusually large heart and signs of many prior fights. As Taggart puts EKG wires on the patient's chest, Morris examines him, and reports that he has a pericardial effusion. Sam explains that this means "fluid around your heart," which is a good small example of patient education. Morris says he wants to do a pericardiocentesis. But the patient adamantly refuses when he learns that this will entail a needle going into his heart, again becoming abusive--did Morris get his "doctor degree through the mail?!" The patient storms out of the ED screaming about Kevorkian.
A little later, Morris is discussing the case with resident Ray Barnett. Morris is convinced there's a neurological issue, but Ray is skeptical, because Morris's reputation is of an abrasive, marginally competent physician. Ray seems to assume that Morris probably caused the patient's aggression, and that any novel ideas of his are probably wrong.
Later, Morris and Taggart wait outside the building for two ambulances to arrive (yes, it wouldn't be "ER" without physicians outside greeting ambulances, only sometimes with nurses present). Morris tells Taggart he wishes he were still a resident, so that he would not have the weight and frustration of an attending's duties. Taggart: "Morris--can I tell you something, as a friend? Sometimes you are such a little bitch. You make three times as much as I do. And for what? To give orders instead of take them? Boo hoo for you."
The show may think this strikes a blow for nursing, but it actually does more harm than good. We appreciate the thought that the pay differential between experienced nurses and physicians may not accurately reflect the relative difficulty or worth of their work. But the reason Taggart gives for her objection--that Morris merely gives orders rather than takes them--is absurdly simplistic, and it suggests that nurses report to physicians. In general, "giving" orders can be a lot more difficult than "taking" them, if giving the orders involves more thinking, knowledge, and responsibility, as is often the case in many fields. That should not be the only factor in compensation, but it's ridiculous to pretend there's little difference between setting a course of action and carrying it out.
Taggart's "boo hoo" comment also suggests that hospital nurses report to physicians, that they take "orders" from them. Physician care plans are often wrongly referred to as "orders," but nurses are obligated to evaluate those plans and push for better ones if they are not in a patient's best interest, declining to implement the plans if necessary. More generally, the majority of nursing care is done pursuant to the nurse's own autonomous scope of practice, not physician "orders," as Taggart's broad comment implies.
And the show reinforces this distortion of workplace authority when the ambulances arrive. Morris assigns Ray and nurse Malik McGrath to one, and says, "Sam and Hope, you're with me." This obviously suggests that Morris, as an attending, assigns nurses and residents to patients. In fact, charge nurses assign nurses to patients. Of course, we can't recall ever seeing a charge nurse on "ER," and we haven't seen a nurse manager since late 2005.
One of the new patients turns out to be the abusive patient Taggart and Morris saw earlier. Since this patient left the ED, he has been in a bad fight (what a shock), but he now has a different, cooperative adult persona--Willis--and no memory of his prior visit. Willis readily agrees to the pericardiocentesis, and Morris and Taggart, though puzzled, prepare to perform it. But Willis soon becomes agitated by the sight of a young patient yelling in pain in the neighboring ED room--it's the same boy he played Hot Wheels with earlier--and he reverts to the abusive Clyde persona, refusing the procedure.
Morris realizes that the patient has dissociative identity disorder (DID), given his radically different personas and his old abuse injuries. He pages Pysch. for a consult, but when that department fails to respond, he urges both Ray and then attending Greg Pratt to join him in "double doctoring"--proceeding without the patient's consent with the approval of two physicians--since the patient's declining condition could soon kill him. But neither of the other physicians will agree. Ray has little respect for Morris's diagnostic skills, and he remains convinced that the patient is hostile mostly because Morris is kind of a jerk. Pratt advises Morris to treat the patient "conservatively" and wait for Psych.
Taggart seems to believe Morris is correct, though unfortunately she does not weigh in, which suggests that even a nurse who has observed such a patient closely would have no role in diagnostic discussions that would seem to rely heavily on such observations. When Taggart and Morris are alone later, Morris tells her he has found the patient's old ED file, which details some bad abuse injuries. Morris says he knows everyone thinks he's a joke, but he knows he's right in this case; yet all he can do is "watch this guy die." Taggart tells Morris that he did what he could (what about her?), and she adds: "You're not a joke; you're an attending." Really? Would anyone suggest that a nurse was automatically not a joke because she had three years of experience? Leaving that little bit of physician glorification aside, most viewers will probably get that Taggart is providing sensitive support to Morris, that she can handle him different ways in different situations. And he says: "Thank you."
That would seem to be it for the patient, who evidently will now slip toward death in his antisocial Clyde persona. But Taggart enters his room and goes to work.
Taggart: "Heart's gettin' worse, you know."
Clyde: "NO! You need me to spell it?"
Taggart: "You keep refusing treatment, it's gonna go down one of two ways. One, the doctors are gonna come in, tie you down, and do the procedure--"
Clyde: "They can't touch me, I got rights!"
Taggart: "--or two, we get to watch you die."
Clyde: "Fun for you."
Taggart (softening): "There's a third option: you give consent, we fix your heart, and you go home. All we want to do is help."
Clyde: "Yeah, you've been loads of help, so far."
Taggart : "I know you're scared."
Clyde: "No, I ain't scared of nothing!"
Taggart: "I know you've been hurt, a lot. But you are safe here. I know you don't want to trust us. But you can. I promise."
With this emotional balm, the patient changes, and looks very confused. He transforms into Willis, the cooperative, gentle one.
Willis: "Was I sleeping?"
Willis: "I lost time. I lost time again."
Taggart: "Willis? Clyde's been giving us a hard time."
Willis (nodding): "I thought he was gone."
Taggart: "You know about Clyde?"
Willis: "Yeah, my friends told me about him. He's very negative."
Taggart: "Well, Clyde doesn't want us to help you. So all we can do is give you some medicine, but that's not working too well."
Willis: "Well, can you still fix me?"
Taggart (with some force): "Willis, I need Clyde's permission."
Willis (becoming distraught): "I can't make him do anything, I can't."
Taggart: "We can't start and stop again, we're running out of time."
Willis (scared, weakly): "No, no, no, no..."
Taggart (suddenly in his face): "Willis, let me talk to Clyde, right now! Do not make me hurt you! Let me talk to Clyde."
And Clyde is back, leaping forward at Taggart, who jumps back.
Clyde: "How many times I gotta tell you to get off me, bitch, how many times, huh?!"
Taggart (pausing a beat, and now with an even tone): "I saw Willis. He's letting us do the procedure."
Clyde: "He's a pansy."
Taggart (stronger): "Yeah, well, he's brave enough to let us stick a needle in his heart."
Clyde: "Piss. Off. Bitch."
Taggart (dismissively): "Fine. You be a tough guy all the way to your funeral. I'm done."
She walks toward the door, but as she reaches it, Clyde speaks.
Clyde: "Hey! ... You stick my heart, that means I get out of here, right?"
Clyde: "Do it. I told you I ain't scared of nothin'."
Is this credible--that the patient would be won over this quickly? Is this a responsible way for Taggart (not a psych. nurse) to handle a volatile patient in this situation?
Whatever the answers to those questions, the scene as it will be received by most viewers is one of the most impressive depictions of nursing psychosocial care we've ever seen on network TV. The scene isn't too extensive. But in it Taggart, using interpersonal skills and a holistic approach, works her way through the patient's two personalities, probing, soothing, threatening, and dismissing, until she basically saves the patient's life. She has observed the patient carefully. She knows how to push him toward one persona or another. She knows his pressure points, most of which relate to fear, and she uses them. In fact, we were reminded of the masterful police interrogation conducted by the Ed Exley character (Guy Pearce) in the 1997 film "LA Confidential." There, Exley switches back and and forth between two detainees, using information from one on the other, persuading, abusing, and manipulating. Taggart does a version of this, but all with one person.
After the pericardiocentesis, which is not shown, Morris pays a visit to the patient. The patient's vitals are now back to normal, and he is waiting to go up to the floor. He is now in his gentle boy persona--Andre. Andre is a bit scared, but Morris sits and assures him that he's "here all night." Andre tells Morris about the boy in the waiting room, and he and Morris start bonding about Hot Wheels. This scene suggests, as the show often does, that physicians take the lead in providing emotional support. But this and the prior scene together invert the common public perception about nurse/physician duties--here, we see the nurse's actions dramatically change the patient outcome, and the physician provide comfort.
Although the episode has some problems, we thank "ER" for its depiction of a nurse's effective interpersonal skills, and in particular for a rare and powerful look at her life-saving psychosocial care.