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Between the Boob and the Tube

September 28, 2006 -- Tonight's episode of NBC's "ER" marked the return of writer Lisa Zwerling, MD, to the County General NICU. Zwerling's January 2004 episode followed a rough NICU rotation by then-medical student Abby Lockhart. This time, physician Lockhart is the mother of a premature infant in the unit. Like the 2004 episode, this one presents the NICU as a physician-intensive care unit. Smart, caring physician characters do everything that matters, including key psychosocial care that nurses generally do in real life. But Zwerling and co-writer Janine Sherman Barrois have expanded the NICU nurse repertoire here. The main nurse character to emerge in 2004 was a battle-axe who suggested that veteran NICU nurses are petty martinets who terrorize medical students. In the new episode, the two nurses who actually get a few lines are utterly incompetent. One is a lactation consultant whose comments are idiotic and insensitive. The other nurse dismisses the concerns of Lockhart's mother Maggie about a critical heart monitor alarm. Maggie has to virtually yell at her to get the physicians--you know, the real life-savers. Naturally, it is a life-threatening problem, and the infant is rushed to surgery. "ER" has at times shown physician incompetence. But it's rarely if ever this extreme, it's usually the result of inexperience, and there are always plenty of counterexamples to balance it. That's not the case for nursing in this episode, which drew more than 14 million U.S. viewers.

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The episode, "Graduation Day," offers familiar examples of the physician nursing that is almost inevitable given that almost all major "ER" characters are physicians. Lone major nurse character Sam Taggart does almost nothing clinically. Her sole plotline charts the aftermath of her rape by her ex-husband. But we do see two physicians rush outside the hospital to meet an ambulance, which strains credulity, and they do so with no nurse, which is even less likely. We do see new attending Greg Pratt doing the job that a mobile intensive care radio nurse (MICN) would do in real life, discussing fairly standard care with paramedics in the field. And we do see Taggart's rape exam performed by physician Kerry Weaver, with nurse Haleh Adams providing only passive assistance. It is unlikely that a Level One trauma center in Chicago would give this task to a physician, rather than a SAFE nurse who is highly skilled in forensics and the physical and psychosocial care of rape victims.

The principal subplot is the struggle of the baby of Lockhart and attending Luka Kovac to cling to life in the NICU. Writer Zwerling, in real life a UCLA pediatrician, revisits some of the themes and elements of her 2004 episode. The voice of authority and knowledge in this NICU is Dr. Rabb, the same gruff but wise attending who mentored Lockhart in 2004. Dr. Rabb again displays extensive knowledge, and does all the meaningful patient teaching. A resident at her side runs things by her, and generally underscores the fact that she is an important leader. Rabb is the one who makes Kovac remove his ED lab coat to reduce the risk of infection. Though she says nothing about several other obvious infection risks, for most viewers the point is made: physicians are the ones who protect NICU babies from infection.

Rabb also pushes Lockhart and Kovac to participate in a clinical trial that ultimately appears to lead to the baby's scary trip to surgery. But the trial was a reasonable choice for such a sick baby, the baby survives, and the show does not appear to be suggesting that Rabb is reckless. In fact, Kovac pushes the trial more strongly than she does. However, no nurse discusses this or any other care option with Lockhart or Kovac, apart from the lactation consultant. This physician-centrism creates the impression that nurses are marginal players in a setting where they are in fact central.

But nurses do emerge in two important NICU scenes. At one point, Lockhart and her mother Maggie are having a tense discussion. Their relationship is troubled, and it appears that Lockhart at this point does not view Maggie's presence as helpful. Maggie begins by jabbering in an ignorant panic about their care options, which is the last thing Lockhart needs. As this is clearly going on, the lactation consultant (who is most certainly a nurse) appears and brightly informs Lockhart that "we're about to start a lactation seminar in the pump room." Seeing, belatedly, that she has stumbled into something, the consultant suggests that maybe this is a bad time. But Lockhart embraces it as a way to get away from Maggie for a while.

Except it doesn't work that way. We see the lactation consultant, Lockhart, and Maggie all together in an adjoining room. The consultant, in a voice that would be suitable for addressing a sleepy toddler, informs Lockhart that the breast shield and tubing goes "between the boob and the tube!" Lockhart seems at a loss, presumably because she's not comfortable with Maggie there, perhaps to some extent because she thinks the infant will not survive. Or maybe Lockhart just can't believe a sentient being could say something as inane as the consultant just did. In any case, rather than gently inquiring what the problem might be or teaching Lockhart how the pumping works, the consultant proclaims: "Breast is best!" Maggie informs her that Lockhart knows that, since "she's a doctor!" The lactation consultant says she did sense some hesitation on Lockhart's part. Lockhart says that some privacy might help her get started pumping. The lactation consultant stops--and seems to disapprove--but she recovers and promises to get a screen. Maggie does not seem to be leaving, so Lockhart makes clear that she means for her to go too. Maggie argues briefly, then goes.

This is an attack on breastfeeding advocacy and the nursing profession. It suggests that those who promote breastfeeding in a NICU--in most cases nurses--are loopy zealots who lack technical and psychosocial skill. The lactation consultant has no idea what to do with a troubled mother in the NICU, blundering into inappropriate happy talk and platitudes with little regard for what the mother might be going through. In this setting, having this fool blurt "Breast is best!" is a good way to caricature a health decision that could make the difference in whether the infant survives. The consultant seems like someone who was hired for her super-cheerful personality and trained for a week, but not like someone with years of college-level health education and hundreds of hours of relevant experience, which lactation consultants must have. It is almost impossible to imagine that any real lactation consultant would behave this way. And the actress playing the character seems to add more tone-deaf enthusiasm than her lines technically require; for this, some blame must go to episode director Joanna Kerns. The only good thing for nursing is that some viewers may not realize the consultant is probably a nurse.

In the other significant scene, Lockhart and Kovac have left the NICU to get some rest, leaving Maggie as the only family. Their reluctance to do this does stem in part from the knowledge that Maggie will probably drive the nurses crazy--which is an indirect recognition that it's the nurses who are actually in the unit 24/7. Maggie sits in a chair by her grandson's NICU bed. A monitor goes off, and the jumpy Maggie is on one of the nurses immediately to respond. The nurse calmly walks over and shuts off the alarm, politely telling Maggie that it was just "the sat wasn't picking up. It happens all the time." But she doesn't explain what "sat" means (oxygen saturation machine) or why the alarm went off. So she does not quite manage to calm the agitated grandmother.

A few moments later, the sat alarm goes off again, soon followed by an urgent heart monitor alarm (we know that sound). Maggie is a little reluctant to bring these to the nurse's attention, since she has been gently rebuffed, but she does. However, the nurse has now concluded that Maggie is just a silly worrier, so she does nothing to check on the infant, but just assures Maggie that all is well. Of course, no real nurse would ignore that particular heart monitor sound, which indicates an immediate life-threatening problem. Yet this nurse is oblivious. Maggie follows her around the NICU, demanding that she get the head physician, who we assume could actually help the infant. The nurse, placating this nutty grandmom, politely informs Maggie that the physicians are busy in radiology, but that she will get in touch as soon as they are finished. The nurse says: "If you overreact to every little blip and bleep in this place you'll make yourself crazy." Maggie starts to lose it. She finally ends up yelling at the nurse and a clerk together: "Page Dr. Rabb, page Dr. Rabb, page Dr. Rabb!" The clerk says: "I'm not supposed to." Viewers may think this clerk is another nurse, and to them this will suggest that nurses are serfs who are not even allowed to contact the mighty physicians when one of their patients is dying.

The scene cuts, and the next thing we know, Lockhart and Kovac are rushing into the NICU to join intense efforts to stabilize the infant and prepare him for surgery. These efforts, like those of the surgery that follows, suggest that only physicians make meaningful contributions to such emergent care. Meanwhile, Dr. Rabb remarks: "Good thing your mom was watching him like a hawk." Certainly, on those rare occasions when physicians are too busy to monitor NICU patients, it's important to have someone around with the skills and motivation to do so!

This portrayal seems a little more nuanced. It's possible that a NICU nurse would fail to recognize signs warning that an infant was in trouble, particularly in a short-staffed setting. And it's also possible that an annoying family member could actually cause her loved one to get worse care by creating an assumption among busy care providers that she was whining about nothing, in this case the grandma who cried wolf.

But Maggie did not just come up and daftly say she thought maybe the infant looked kinda funny. A key, distinctive monitor was blaring; anyone could tell something was going on. It's a core nursing role to use advanced skills to monitor patients, not just hang around so as to be available to respond to family concerns, or to fetch and help physicians. And there is no suggestion of short-staffing or another crisis here. This nurse should have no more than two patients--and it's possible that Maggie's grandson is her only patient. She moves around the NICU with no other apparent urgent task, but does not bother to check on her patient. And her interactions with Maggie also fall well short of competent. She doesn't explain the initial oxygen saturation machine malfunction to Maggie. Her failure to address Maggie's later concerns (rather than just promising to get the physicians later) is condescending and unprofessional.

Obviously this is all a major problem, but the episode doesn't really suggest that it's a failure to meet the standard of nursing care, especially since we hear nothing about any fallout for the nurse, such as a discussion with the nurse manager (oh, we forgot--they generally don't exist). Instead, the show seems to regard the nursing here as fairly normal, as if the nurse has no independent professional responsibility to the patient or his family. Perhaps we're to understand that you shouldn't leave a critically ill patient alone with a nurse, since it's up to the physicians and the family to tell the nurses what to do. And the nurse makes no comment that might cause viewers to question the disrespect that underlies Maggie's demands for the physicians. Evidently it's true that, for any serious problem, the response of a NICU nurse would simply be to get a physician.

The show has at times shown physician incompetence. However, while some physicians have displayed dangerous ignorance or personality defects, very few are as laughable as the lactation consultant. And "ER" physicians who make mistakes are, almost without exception, impaired by inexperience, time pressure, or some other somewhat understandable problem. There is no suggestion of any of that here. Perhaps most critically, physician problems are always balanced by the overwhelming general regard the show has for physician intellect, skill, and concern for patients, regard that dominates every episode. Here, there is nothing remotely comparable to save these two blisteringly negative nursing portrayals. Sam Taggart and Haleh Adams are far from idiots, but they do nothing of significance in their brief appearances either. The focus of the episode is Lockhart and Kovac's horrific NICU experience, where the physicians are brilliant life-savers, but the nurses are indifferent functionaries or dippy PC ideologues.

All three of those primarily responsible for this episode (the writers and the director) are female. And this "ER" episode, like most, takes great pains to show that women can be commanding, intelligent health experts--if they are physicians, like Dr. Rabb. Last week's season premiere featured chief of medicine Kerry Weaver effortlessly taking command following a shootout in the ED, issuing a flurry of orders to submissive nurses who seemed to have no ideas, and who would apparently have been lost without their physician leader. Likewise, the NICU scenes here treat nursing as a profession of inept helpers. Nursing seems to represent the subordinate, low-skilled work that ambitious women have left behind. That view is based on faulty, paternalistic assumptions you might think those interested in women's rights (or at least female physicians) would reject. But we suppose it's easier to embrace an esteemed, traditionally male profession than it is to re-examine the low status of a traditionally female one.

Of course, it's important to keep things in perspective. "ER" at its worst is still better than the relentless contempt for nursing shown on "House" or "Grey's Anatomy." But it is disappointing that the show seems uninterested, so far this season, in building on the modest advances we saw in last season's portrayal of nursing.

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