Putting ideas in her head
November 18, 2009 -- Tonight's episode of NBC's Mercy featured nurse characters acting with considerable expertise and some autonomy to improve patients' outcomes in two very different cases. In one plotline, lead character Veronica Callahan provides critical physiological care to a gunshot victim who appears certain to die, working as more or less a partner with the physicians and at a couple points coming up with good treatment ideas to help save the patient's life. In the other plotline, nurse Sonia Jimenez advocates forcefully for a 15-year-old with a "rare excessive autosomal condition" who, though she has lived her life as a female, turns out to be genetically male. Sonia tries to protect this teenager from her parents, who pressure her to have surgery to eliminate her emerging male features, and from some physicians who seem to see her as no more than a fascinating case study, with no regard for the huge impact the diagnosis is having on her. There are a few questionable elements in these plotlines. The interventionist approach that Veronica and one physician take in the gunshot case could be interpreted as an argument for heroic measures for every patient. Of course, real nurses often see terminal patients face unnecessary suffering and work hard to encourage decision-makers to consider allowing a natural death in that situation. Nevertheless, the episode presents a prime time vision of nurses as strong, skilled health professionals, and we thank those responsible. The episode, "I'm Not That Kind Of Girl," was written by Veronica Becker and Sarah Kucserka.
Keep Mercy on the air! If you value the generally helpful depictions of nursing skill and autonomy that Mercy provides to more than 6 million viewers every week--the kind of depictions that no other regular season show offers--then please watch the show, urge your friends to watch it, and tell NBC to renew it for a second season. Mercy's ratings in the critical viewing demographic are not high, and renewal is questionable at best. If Mercy goes away, regular season television programming for nursing will be very, very bleak (think House, Grey's Anatomy, and Private Practice). Also, Mercy is actually a pretty good show, with some fine writing and acting. Thanks.
Early in the episode, we see physician Chris Sands telling a teenaged patient named Ashley that she has a kidney infection, so Sonia (right) will insert a catheter, and it should be better soon. Sonia asks Ashley's boyfriend to leave for privacy, and tells Ashley to relax, noting that she'll feel a little pressure but Sonia will be quick. Then Sonia calmly asks Sands to "check my work, please." Sands seems surprised, but he looks, then tells Sonia that it looks good. But obviously they have both seen something unusual. Outside, Sonia says, "So that was a penis, right?" Chris agrees.
"Check my work"? Of course, we understand Sonia's request was just a ploy to permit Chris to assess the patient. And the show did have him register surprise--so alert viewers should get that she doesn't need a physician to check her placement of a catheter. And maybe Sonia was simply taking advantage of the teen's likely belief that nurses are just handmaidens. But the comment may still reinforce the sense among many viewers that physicians manage nurses' work. Sonia might have used another excuse. For instance, she might have asked Chris if he thought some imaginary modification to the catheter placement was required, and he probably would have had the presence of mind to respectfully opine that it seemed unnecessary. That would have made them appear more like colleagues, and her less like someone who needed her work checked.
Later, we see Chris arrive and introduce Ashley and her impatient parents to one Dr. Hofstader, an endocrinologist who says that while there is nothing medically wrong with Ashley, they have found something unusual--an ultrasound revealed a pair of internal testes, apparently because Ashley has a "rare recessive autosomal condition." Her external sex organs seemed female at birth, but Ashley is and always has been "genetically a male." This is obviously too much for the parents. Her mother says that's impossible, because Ashley is a gorgeous cheerleader, and her father wants to know how to "fix" it. Hofstader says if Ashley chooses to keep living as a female, they can surgically remove the male organs. "Or we can let nature takes its course, the testes will eventually descend, and the testosterone will simply turn her body into a man's. Thoughts?" Ashley at first says that her "Junior Snow Queen" pageant is this weekend, so just "cut 'em off and let's get out of here."
The physician Hofstader, while not really mean or rude, is clear thrilled and fascinated about this rare case, and not really thinking about how shocking it must be to the family. But Sonia, the nurse, is. Later, when Sonia remarks to fellow nurse Angel that Ashley's condition is "freaky," Angel says that it hurts to get the kind of a look from a parent that Ashley is getting, comparing it to the look his mother gave him when she caught him wearing a dress.
Next we see Hofstader showing off Ashley's genitals to a group of physicians, seemingly gleeful that this fascinating case has appeared in Jersey City. Sonia bluntly ejects them from the room.
Sonia: OK, party's over. I've gotta get some urine cultures.
Hofstader: Actually, we were hoping to interview the patient--
Sonia: Some other time.
And they actually leave. (Keep in mind that none of the show's major physician characters would treat the patient so insensitively.) Ashley seems surprised that anyone would advocate for her, rather than just gawk at her as if she was a bizarre object in a museum.
Ashley: So, do you need me to pee in a cup for you?
Sonia: I don't need any cultures, I just thought you might be sick of those guys.
Sonia notices Ashley's snow pageant dress, and they bond about that briefly.
Sonia: You know, if you need someone to talk to, I'm here.
Ashley: I don't need to talk to some stranger. I have real friends, OK?
But we never see any of those friends, and later, Sonia passes Ashley's boyfriend talking on a cell phone, telling a friend that "now we know why she would never give it up." Sonia tells him that no cell phones are allowed there. The boyfriend ignores her and tells his friend that "even the doctors are grossed out, she's a total freak." Sonia takes his phone.
Sonia: That is a person in there. Try and have some respect.
Boyfriend: Back off, lady--you don't even know what she is.
Later, Sonia returns to the room and finds Ashley in her snow queen outfit. Sonia says she looks beautiful, but Ashley notes that "they're not going to let a girl with a penis win Junior Snow Queen." Sonia again tries to get her to talk about it.
Ashley: You really think a pep talk is gonna fix this? Give it up, nurse lady. My boyfriend's disgusted by me, my parents won't even look at me, I'm a freak and all the makeup in the world isn't going to fix that. Don't pretend like you have the answers. You don't.
Sonia: Well, you're right. I got nothin'.
Ashley: I always knew, OK? There was something wrong with me. All this girly stuff I'm supposed to like...it just always felt fake.
Sonia: Well, maybe what we learned explains why it's been so hard.
Ashley: I'm not this girl...am I?
Sonia: Maybe not. But it's up to you.
Ashley: Good. ... Because I hate it! I hate everything, the whole thing, I hate this dress...
Sonia: It is butt-ugly.
Ashley: I hate these beads...I hate this flower!
Sonia: So screw the dress.
Ashley: Yeah...yeah, screw this dress!
And Ashley actually starts to rip the dress, to Sonia's amusement. But then Ashley's parents arrive and wonder what is going on. It's clear they will not be so accepting of the wrong choice from their daughter. And her father clearly blames Sonia for Ashley's behavior. Next we see the parents in an office, with apparent nurse manager Helen Klowden seated at a desk, and Sonia standing beside her. Nurse managers exist--and have offices!
Dad: We leave her alone for a few hours and now she's not sure if she wants the surgery.
Mom: This is our daughter. You had no right to put ideas in her head.
Dad: Is it some kind of agenda, is that it?
Sonia: No. Ashley's confused. And frankly, I don't blame her.
Klowden: All right, listen up. First of all, I'm sure Nurse Jimenez did not instigate the incident. And secondly, this is a hospital, not day care. The only person responsible for the patient's behavior is the patient. I'm sorry, Mr. and Ms. Jeffries, but this problem is between you and your daughter.
Dad (as they rise to leave): I'm gonna call the nursing board. This is not over.
Sonia: Don't you get it? This isn't about you and me. It's about Ashley. Her whole life just changed. And this surgery is permanent. She's 15! She's gonna have to live with this decision for the rest of her life. Shouldn't you give her a chance to think about it?
The parents have no response to this, and later we see them leave the hospital with Ashley, who presumably has not had the surgery. Ashley glances back at Sonia, and there is a hint of a smile.
This plotline is very helpful. Sonia, though initially somewhat freaked out by Ashley's condition, eventually realizes that the teen needs and deserves her help. Sonia works through Ashley's resistance to give her some of the psychosocial care she's not getting from her parents, and advocates strongly for the teen with some physicians, the parents, and the boyfriend--in short, with everyone who seems to see her more as a freak than a person in crisis. This kind of advocacy is at the heart of what good nurses do. But would a real nurse be this aggressive with powerful physicians and a patient's family? We hope so. The scene with Klowden (right) isn't bad either. Although this nurse manager can be harsh, she tries to support her nurses and act in patients' best interests, and she supports Sonia here, rather than acting like a fearful bureaucrat, countering a common stereotype of nurses with authority as rule-bound battleaxes. In fact, the simple suggestions that nurses have managers and licensing boards tell viewers that nursing is a real and distinct profession. To the show's credit, it does not suggest (at least in this case) that Sonia reports to physicians or that physicians would be involved in handling this complaint.
In another plotline, apparent nurse manager Klowden and Chris Sands ask Veronica about Dan Harris, a physician who seems to have gone off the deep end in declaring a "war on death," refusing to let patients die, following his own wife's death. (Chris and Veronica, incidentally, fell in love while serving together in the Iraq war.) Although the troubled Veronica has previously suggested to Dan that she would join him in his "war," she tells Klowden and Chris that Harris really is a mess and should take time off. Veronica says Chris should talk to him. Chris says he has tried, but Harris is technically his boss and he can't do anything.
Klowden (to Veronica): I'm putting you with [Dan Harris]. You're the only one who's not afraid of him.
This shows that nurse managers control nurse staffing, and suggests that at least some nurses are strong enough not to be "scared" of a powerful physician. On the other hand, it also suggests that the vast majority of nurses would be scared. In any case, Klowden assigns Veronica to a young man named Ben Shin who has been shot in a gas station robbery and is unlikely to survive. Veronica approaches Dan, who watches this patient from the doorway of his room.
Dan: Antibiotics haven't touched his fever. He's becoming progressively tachycardic and hypertensive.
Veronica: Sounds like a set-up for sepsis or an embolism.
Dan: Not on my watch.
Veronica: Dan...don't go nutty on me. There's ten different ways this kid could die. His family's already requested a DNR.
But Dan gives a short speech about physician Virginia Apgar, who spearheaded important care innovations to help babies once thought unsaveable, and says that he wants to try to save the apparently unsaveable Ben Shin. Veronica agrees! They enter the patient's room and meet his wife Julie, part of a large Korean-American family also present. Veronica takes the lead.
Veronica: Hi, I'm Veronica, and this is Dr. Harris.
That naming disparity is unfortunate, though sadly it's not unrealistic. Do any professionals except nurses introduce themselves as "Veronica"? Nurses can be friendly and supportive without suggesting they're just unskilled helpers, while physicians merit honorifics. At least Veronica addressed Harris as "Dan" when they spoke privately, as real nurses generally do.
Julie says she doesn't want to lose her husband. Dan runs down what they were able to repair in the six hours of surgery he's had so far, admitting that a bullet punctured the lung and Ben's "cardiac condition is deteriorating rapidly, but we will get him out of here alive, OK?" Julie says other physicians said Ben would not make it.
Veronica: We'll save him. I promise.
Eeek. Chris later suggests that Dan has "turned" Veronica, and tells her that Dan is picking a fight he can't win. When Veronica and Dan return to see the patient, Julie tells Veronica that her husband is not getting better. Veronica tells her that he is young and strong. Outside the room, Veronica speaks with Dan and Chris about the patient.
Veronica: Maintaining his blood pressure's a problem.
Dan: We're just going to have to be more aggressive. Let's put in femoral A- line to get a more accurate arterial pressure reading.
Veronica: He's on sub-cu heparin. How about pneumatic compression boots, stave off a DVT?
Dan: That would work, good one.
Chris: You could put him in Trendelenburg.
Veronica: Good...that's good.
Chris: Yeah...I'm a sucker for a lost cause.
Later, the three reconvene and examine the patient's chart. Veronica notes that the blood pressure is up. Harris says not enough for him. Chris notes that he's maxed out on dopamine, but they could add some Levophed. Veronica says they'd have to start a central line. Dan says to do it. But when Veronica enters the room and tells the patient's agitated wife Julie that they need to start a central line so they can start another drug, Julie asks what the point is.
Veronica: I know it looks severe, but we really want to try every option.
Julie: Is this helping him, or is it putting him through more pain?
Later, Klowden herself questions what Veronica and Dan are doing.
Klowden: I should have known better than to send Nurse Crazy after Doctor Mean.
Veronica: We're just trying everything.
Klowden: You're flogging the patient. Despite all your Hail Marys, this boy's gonna die, and he should be able to do it with dignity.
Soon, it looks like Klowden is right. Ben crashes, and Veronica, Dan, Chris, and nurse Angel converge to start CPR. Julie, clear upset, says the family is prepared for Ben to go. Dan says it's not over. He asks Veronica to make sure that the fluids are wide open. He notes that the patient is in V-fib, and asks for defibrillator paddles. But Veronica applies them! Even though physicians are present! Meanwhile, the family is chanting to help Ben's soul on its journey. The patient goes into V-tach. Harris wants epinephrine, then vasopressin, then atropine, and Veronica gives each in turn. But the patient is asystole. Veronica and Angel exchange looks.
Harris: Ideas, anybody?
Veronica reminds Chris of a time in Iraq when they used an internal pacemaker wire to jump start his heart. Dan loves this, and Angel yells for a pacemaker. Dan threads it in, and Veronica turns it on. After Veronica readjusts some of the settings, it works. Chris and Veronica both tell Dan good work, but this is to help him; they are not really suggesting Dan alone did it. Later, Dan catches up to Veronica in the hallway, thrilled to be able to tell her that Shin is stable and they should be able to wean him off the ventilator in a few days. He notes that "there's much to be hopeful about."
And there's much to be hopeful about in this plotline. Veronica is pretty much a full partner of the physicians here, and she repeatedly displays real expertise, on two occasions coming up with care ideas that may well have saved the patient's life. And the physicians actually listen to her ideas, as good physicians do in real life. How many other shows have had a senior physician ask for ideas from nurses when a code doesn't seem to be working? In that code scene, there are two nurses and two physicians--closer to real life than other shows, in contrast to the likely scenario on any popular prime time show, where it would probably be 3-5 physicians doing everything that mattered and maybe an insignificant background blur or two that might be a nurse. And Veronica does the defibrillation here. The scenes with Klowden again show that nurses report to nurse managers, not to physicians, as other hospital shows (and at times even this one) have suggested.
The theme about how far Veronica and the others should go in trying to save Ben Shin is a little more troubling. Of course it makes sense for these specific characters, the troubled Veronica and Dan, who seem desperate for something to believe in. Chris also suggests at one point that the Shin case may be causing Veronica to have PTSD reactions because he's a lot like the wounded soldiers they treated in Iraq. Veronica does resist the heroic measures at first. And some patients are miraculously saved, as the young and strong Ben Shin is here. We're just a little concerned that the plotline may mislead viewers about the role nurses usually play in important end-of-life care. Great strides have been made in some care settings to allow patients to (as Klowden puts it here) "die...with dignity." But in many cases, it is physicians and some family members who may fall into what Klowden calls the "flogging" of terminal patients, and nurses who advocate to let the patient go for the sake of all concerned. Of course, Klowden does that here, but she is proved wrong, and maybe viewers will figure that good nurses and physicians do everything possible to keep patients alive in every case--a prescription for a lot of needless suffering.
In any case, despite a few troubling or less-than-credible elements, both of the episode's main plotlines portray nurses as expert patient advocates and life savers, which is not something the show's millions of viewers can really get too much of. We thank those responsible.
See Mercy Wednesdays at 8pm/7c on NBC or watch episodes online at nbc.com/mercy.
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