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We expect you to know what's going on around you

September 14, 2006 -- The May 2006 season finale of NBC's "ER," rebroadcast tonight, is a good example of last season's better episodes for nursing. It includes a commendable number of small portrayals of ED nursing skill. Yet these are offset by suggestions that physicians are ultimately in charge of the clinical setting, as well as by some physician nursing, particularly with regard to triage. After all these years, the ensemble drama's most glaring problem remains that it has one, and only one, major nurse character. The episode, "21 Guns," was written by show runner David Zabel.

In contrast to the nurse characters in other current hospital dramas, "ER" nurses actually appear on a regular basis, and they get to say more than "yes, doctor." This episode has a number of scenes in which nurse characters Sam Taggart (above), Haleh Adams (right), and Chunie Marquez (below) briefly discuss care with physicians, and occasionally, even with each other.

Near the beginning, Adams bring an EMT trainee, Mary, to see Taggart. Mary needs a nurse to shadow, but neither Haleh nor Sam really wants to do it. Haleh explains that she has to "irrigate a full-body road rash." Sam notes that she is dealing with "the mother of all meth-mouths." Sam grudgingly agrees to mentor Mary, and then explains to her how methamphetamine has eaten away her patient's teeth.

Throughout the episode, Taggart's efforts to train the clueless Mary allow her to display some technical knowledge. This is a faint echo of the intense physician training that has been the show's major focus for 12 seasons. Of course, educating someone with virtually no knowledge or skill in basic aspects of care isn't quite the same as guiding a bright resident through highly technical procedures. Later, after Mary tells Sam she has gotten the vitals on the "medium timer," Sam informs her that she means the mediastinal mass. Similarly, Sam informs Mary that the blood pressure Mary recorded on a non-critical patient--28/17--would indicate that the patient was "practically dead." Sam urges Mary to ask if she isn't sure what she's doing. Still later, the show seems to make a point of having Sam explain to two separate patients technical aspects of her wound care.

At another point, Taggart leads Mary into a trauma room, where Taggart effortlessly absorbs a blur of medication and testing requests from physician Abby Lockhart. At the same time Taggart is starting on these, she is asking the patient's friends what happened, and whether the patient is currently taking any medications. This is a pretty good display of technical expertise and multi-tasking. After Abby intubates the patient, Sam notes that his heart rate is down to 38, that his IV has blown, and that they've lost the pulse. Abby asks them to start compressions, and Sam gives the CPR to the hesitant Mary.

Perhaps the most striking example of Sam's skill is that, near the end of the episode, she actually intubates a patient under the most difficult possible conditions. This occurs after Sam's ex-husband Steve, now a prison inmate, has been brought into the ED along with a fellow inmate, with whom he was fighting. But that was just a ploy to escape, and the two inmates--conveniently placed in adjoining trauma rooms--manage to overpower the correctional officers guarding them. They do so with the assistance of someone on the inside: Mary, who turns out to be not so much an EMT trainee as she is the other inmate's girlfriend. The now-heavily armed inmates plan to force Taggart to walk them out of the hospital. But chief of ED medicine Luka Kovac walks into the trauma room and resists. Mary stabs Kovac with a syringe containing vecuronium bromide, and he soon collapses.

Taggart tells the inmates that the "vec" will paralyze Kovac and he will asphyxiate. She asks Mary for the "ambu mask" and works frantically to intubate Kovac, a difficult procedure the show normally gives to physicians. Though real paramedics and nurses do sometimes perform the procedure, Taggart has obviously had limited practice. Her ex-husband Steve wants to give her a chance to save Kovac. But his inmate friend is constantly yelling that they have to leave, and threatening Sam with a gun. Sam, deeply frustrated that she cannot see to get the tube in, has Steve push on Kovac's neck to reveal the placement of the vocal chords. She ultimately succeeds just as the inmates have lost all patience. As they drag Sam from the room it appears that Luka will survive (never mind that simply intubating him will make no difference without a person or machine to force air through the tube into his lungs, since he will remain paralyzed for some time). This is another example of the show suggesting that nurses achieve by mastering physician activity, and we always have to wonder if scenes like this mean Taggart is ready to abandon nursing for medical school, as Lockhart did. But it's a pretty good example of a skilled nurse stepping up in a crisis.

The three make their way out of the ED, Sam pushing Steve in a wheelchair and the other inmate dressed in one of the guards' uniforms. Sam subtly signals to the staff they meet that something is amiss. Although chief resident Archie Morris is too dense to get it, Sam scores when she cleverly addresses Abby Lockhart as "Abigail." Unfortunately, after two police challenge the inmates, a bloody gun battle ensues, and ED staff and a police officer are wounded. Sam herself is forced to climb into the getaway van with the inmates after she sees that her ex-husband has abducted their son. Still, in these scenes Sam is a skilled, bright, and courageous actor trying to protect her patients and friends.

Of course, no one could miss that the episode revolves around physician care, and there is some physician nursing. For instance, chief resident Morris does a lot of nurse-free triage, assigning arriving patients to specific physicians with no nurse involvement and no mention of nursing care.

The episode also suggests more directly that physicians are in charge of the clinical environment. Before Haleh introduces the fake EMT trainee Mary to Sam, she introduces her to chief of medicine Kerry Weaver. Kerry appears to be in the ED for this shift to replace fired attending Victor Clemente. Haleh asks Kerry what she would like to do with Mary. Kerry says Haleh should have Mary shadow the nurses and see how they do "the primary." This suggests that Kerry is in charge of how the nursing staff manages trainees, though there is little doubt that this would actually fall within the authority of a nurse manager. Of course, since the Eve Peyton character was fired earlier in the season, the show has had no nurse manager. The show has made no mention of Sam Taggart's promotion to assistant nurse manager since Peyton's departure, suggesting that that promotion (like then-nurse Abby Lockhart's forced promotion to nurse manager years ago) was just a fleeting plot device. Indeed, the show has gone for long periods with no suggestion that the nurses even have a manager. Evidently, the physicians generally handle that.

Several scenes with chief of ED medicine Kovac reinforce the idea that physicians direct the nurses' clinical activities. One plot strand involves Kovac's handling of the troubled Clemente, which Weaver lets Kovac know has put him in a tenuous position with those higher up. This questioning of Luka's management ability sets the stage for his later impatience with Mary's stumbling efforts to do CPR. Luka snaps that Mary "can't profuse the brain that way," and that Taggart should be "showing [Mary] the right way to do things." Later, Taggart takes Kovac aside and apologizes for the poor job Mary was doing. That's fine, since Mary clearly was acting under Taggart's authority.

The problem is that Kovac approaches the situation as if Taggart reports to him even with regard to her nursing functions. Perhaps Kovac is supposed to be the administrative director of the ED in addition to chief of ED medicine. But the show has never made that distinction. Indeed, apart from some suggestions during the Eve Peyton episodes that the ED medical chief may not have authority over the ED nursing director, the show has constantly invited viewers to believe that the chief of ED medicine is automatically in charge of the whole department.

Here, Kovac chastises Taggart in terms that clearly suggest that Taggart reports directly to him: "You're a senior nurse, I expect you to know what's going on around you." (Saying Sam is "senior" does at least suggest that nurses are not identical widgets, that it takes time to learn how to be a good one.) Later, Mary suggests to Taggart that Kovac needs to lighten up, but Taggart responds: "It's his department." In fact, many EDs are managed by nurses. But we're not holding our breath for the episode in which a physician responds to a medical student's complaint about a nurse manager by saying: "It's her department." In any case, in general, a nurse manager is in charge of nursing, and physicians are in charge of physicians.

Many "ER" episodes, like this one, portray nursing in a way that is significantly better than any other drama we see on television. But they still fall well short of adequate in conveying the importance and autonomy ED nurses would really have in the dramatic clinical situations they depict. As always, much of this comes back to the current structure of the Hollywood shows. There's only so much you can do to give a real sense of hospital care and drama when virtually every major character must be a physician.

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