An R and an N
October 21, 2009 -- Two recent episodes of NBC's Mercy illustrate both the show's flawed portrayal of nursing autonomy and its far more helpful vision of nursing skill and advocacy. The Jersey City drama does at least suggest that there is some nursing management structure. And it captures some of the difficulties that flow from the unequal power between nurses and physicians. But at other times the show suggests that nurses report to physicians, even if there is a nominal nurse manager who presumably handles day-to-day administrative issues. At the same time, the episodes aired tonight and a week ago include very helpful portrayals of skill and patient advocacy by all three major nurse characters, most notably Veronica Callahan's relentless efforts to get a homeless man with hepatitis C into a clinical trial. These plotlines are not flawless. Veronica's advocacy for the homeless man includes simulating symptoms to keep him in the hospital, going behind chief ED physician Dan Harris's back to get an "order" from a less senior physician to get the man into the trial, and throwing a cinder block through Harris's car windshield when he continues to insist that she cut the man loose. Another plotline actually has a hint of the naughty nurse, as nurse Chloe Payne uses a kiss (albeit a fairly chaste one) to help persuade a badly burned high schooler that his social life is not over and he should continue pursuing skin grafts. Still, the show offers millions of viewers dramatic examples of how tough, innovative nurses improve patient outcomes. In one plotline, nurse Sonia Jimenez controls a somnambulist's deadly and apparently untreatable problem by persuading Sonia's boyfriend to give the patient his bark-intensive dog as an "alarm clock." No other regular season show does this kind of thing at all. The October 14 episode was Peter Elkoff's "Pulling the Goalie," and tonight's was "You Lost Me with the Cinder Block" by Dan Dworkin & Jay Beattie.
At the start of the October 14 "Pulling the Goalie" episode, chief ED physician Harris arrives at the hospital in his sports car, as the major nurse characters look on from a nearby food cart. Harris places a burrito on the hood of his car so he can answer a cell phone call, and a homeless man named Gerald Pettit steals the burrito. Harris and Veronica actually pursue Gerald, but before they can catch him, a bicyclist accidentally runs him over.
Gerald ends up in the ED, calling Veronica "Nurse Ratched"--they have a history that includes Gerald urinating on her car. Despite his abuse, she tries to help him, telling him he's dehydrated and needs the fluids in the IV he's trying to pull out. She examines his feet, and advises him that he'll lose a foot if he does not let someone drain the abscesses there. As Harris examines Gerald's chest, Veronica sees that he has a Marines tattoo. That seems to motivate her to help Gerald more, presumably because of her experience as a nurse in Iraq, and maybe because it generally suggests that he wasn't always useless. Harris does not share her enthusiasm. Harris tells Veronica that once Gerald is hydrated and his feet are cleaned up, "banana bag him then cut him loose." Veronica asks Harris if they can keep him overnight.
Harris: We have grandmothers and taxpayers that need beds in this hospital because of the heat. Discharge the burrito bandit.
Veronica remains concerned about Gerald, telling him if he gets shaky or starts seeing things (as a result of alcohol withdrawal) to tell her, and "we'll get you on some benzos." Then she gives him an IV bag of dextrose in water, saying she's trying to keep him ahead of the heat. There is a brief power blackout and Gerald seems to panic from PTSD. Veronica comforts him, clearly bonding about the war experience. Later, she explains to Sonia and Chloe that the IV was actually designed to subvert Harris's plan to discharge Gerald.
Veronica: I hung a glucose bag after I dumped 3 amps of D50 into it. Earned him a room.
Later, Veronica confesses to her husband Mike that she "kind of bent the rules" for Gerald. Mike admires that she puts herself on the line for others. Harris confronts Veronica the next day.
Harris: Why wasn't Gerald Pettit discharged yesterday, and who ordered a blood panel for him?
Veronica (brightly): You did. ... OK, I did. But you would've.
Harris (right) disagrees, and is upset Gerald is now in a room. He wants Gerald discharged. Veronica claims that Gerald was presenting with diabetic symptoms, but Harris implies that he knows she manipulated Gerald's symptoms, and he says Gerald is not diabetic. (The IV Veronica gave Gerald created temporary diabetic symptoms.) But, Harris says, Gerald does have hepatitis C, which he presumably learned from the blood tests Veronica got. Veronica asks Harris if Gerald can get into a free interferon program the hospital has.
Harris: He's a non-compliant, homeless, chronic alcoholic. Treatment would be a waste of time.
Veronica: Come on, you don't know that.
Harris: He's not going to stop drinking. He won't show up for the injections. He can't recover on the street.
Veronica: What if I can find him a bed? I know that this guy has been a real a-hole. But underneath he's all right. I think we can bring him back if we do him a solid.
Harris: Some people think that they can do whatever they want, and that the world will keep doing them solids. They're wrong. Discharge him now.
Obviously both of them are also talking about Veronica here.
Gerald is upset, and suggests the hospital gave him the hepatitis. Veronica dismisses this, and says it's transmitted through the blood, noting that he lives on the street and falls down a lot, and probably slams a little dope, self-medicating his PTSD since the first Gulf War. They discuss what sets off their PTSD. She suggests the interferon program.
Veronica: It's a strong antiviral drug that can put the hepatitis C into remission, but you need to stop drinking, and you need to come off the street. I have a connection at a VA halfway house. Bed. Meetings around the clock. Meals.
Gerald: I don't...I can't.
Veronica: The next stop on this train is the last one, Gerald. Birds nesting in your hair, ranting like a madman on a throne of garbage in a hospital parking lot. Come on...as a favor to me. I need something to work out. Give it a try, OK?
Gerald agrees. But later, Harris sees that Gerald is still not gone. So Harris goes to confront physician Chris Sands, asking why Chris gave Veronica a "verbal order" to get Gerald into the interferon program, since Harris had "ordered" him discharged. (Chris had an affair with Veronica in Iraq, when she was estranged from her husband, to whom she has recently returned.) Harris lectures Chris:
It's not up to you to contradict my orders. ... OK, I see what's happened here. Veronica has put you up to this. A word of advice: Keep your guard up when around her. I mean, technically she's a good nurse, but this fanatical belief that rules don't exist for anybody with bad habits or bad luck borders on mental illness. ... I mean, you don't want to have to explain to anybody that she's convinced you to order a mammogram for a drag queen, I think you know what I'm saying.
Meanwhile, Veronica is vouching for Gerald with her friend at the half way house. She succeeds in getting him in. Later, Chris Sands confronts Veronica.
Chris: Next time I contradict another doctor's orders on your behalf, would you mind having the consideration to let me know?
She notes that she used to "forge" his signature all the time in Iraq, but he says she can't take those "liberties" anymore. She says Gerald is a veteran who deserves more than Harris is willing to give, so it's actually about a patient's needs, not hers.
Later, Veronica tells Gerald that she is disappointed with his urine output color. She explains that his liver scans show some scarring, early cirrhosis from the alcohol, so it's key that he follow the program, so the interferon can work. Harris comes in and says he's removed Gerald from the interferon program, and demands that he be discharged immediately. Veronica says Gerald wants to do the program, and she got him a bed at the VA house.
Harris: Discharge him.
Harris: Nurse Callahan, join me outside.
They go outside.
Harris: Discharge Mr. Pettit.
Veronica: Tell him he's not worth our free medicine.
Harris: Can you read the letters on my badge? Mine has an "M" and a "D," yours has an "R" and an "N." I tell you what to do. Discharge Mr. Pettit.
Harris: You are using this hospital and its patients to fend off your own demons. The only reason that you care about saving Mr. Pettit is because you somehow think it will prove that the world will do the same for you when you finally unravel. And trust me, you will. You're a liability. I may not be able to prevent you from co-opting Dr. Sands, but I will find someone with the clarity to introduce you to the consequences of your actions.
Veronica: Tell Mr. Pettit he's not worth our free medicine.
Harris goes to Gerald's room to do that, and Veronica follows. But Gerald is already gone.
Veronica: You had better hope that I find him.
She rushes outside, and can't find Gerald, but does spot Harris's sports car. She sees some construction materials nearby, picks up a cinder block and hurls it into the windshield. Gerald appears behind her, surveying the smashed windshield.
Gerald: What do you say we hit a meeting at that half-way house?
We see her helping take his cart of possessions into the shelter, and they sit together silently at a meeting there.
This plotline does show a tough, expert nurse advocating fiercely for her patient, whether she is doing so to exercise her personal demons or not. There are unlikely elements (like what happened to the rest of her shift), but what will stay with many viewers is that Veronica never stops thinking about how to help her patients, and that she uses all physical and interpersonal tools at her disposal, including some that others might regard as beyond appropriate boundaries. But in this respect, she hardly differs from heroic physician mavericks like House.
The real problem is the messages the plotline sends about nursing autonomy. Veronica subverts and even directly refuses to bow to Harris's apparent authority over the patient. But the show does not question that he has that authority, with his careful explanation of what the letters on their ID badges mean, and the frequent references to "orders." In fact, physicians like Harris do not "tell nurses what to do." They make care plans, including discharge plans, and the nurses carry them out (in addition to their independent nursing duties) if the care plans are consistent with good care. If not, nurses can and ethically must question the plans, if necessary going to the physicians' superiors or to the appropriate ethical and administrative authorities at the hospital. That is what Veronica should have done, rather than just saying "no" or throwing cinder blocks, a notably unimpressive (and of course illegal) way for an adult to resolve problems.
The Gerald plotline continues in tonight's "You Lost Me with the Cinder Block" episode. As Veronica and her husband Mike are having a housewarming party at the house Mike is building for them, the police show up, wanting to ask Veronica about the cinder block. The next day, Veronica confronts Harris about this. He says she put a cinder block through his windshield. She says it could have been anyone.
Meanwhile, a husband and pregnant wife arrive at the hospital, victims of a car accident. The husband is a lawyer who won't let Chris Sands operate on his leg unless they track down his pregnant wife, Kerry Whitlow, who came in a different ambulance. Veronica, who seems to be the go-to person for difficult patients, says they would have "turfed" her to OB, and she promises to track Kerry down. On the OB ward, Veronica consults with physician Gillian Talbot about Kerry. Gillian says Kerry has a lacerated liver, and they want to confirm there is no internal bleeding. Veronica deploys her expert interpersonal skills, and calms the panicky Kerry, assuring her that the pre-term surgery anesthesia will not harm the baby. Gillian clearly admires Veronica's skills. In fact, Veronica makes such a connection that the patient demands Veronica stay with her. But Veronica is released long enough to reassure Kerry's husband, who then agrees to the surgery.
But apparent nurse manager Helen Klowden is waiting for Veronica outside the OR. Klowden says she has to talk to Veronica about the Harris problem. Veronica denies knowing anything. Klowden tells Veronica not to insult her, and she will not insult Veronica. Klowden says she herself has wanted to throw a brick through Harris's windshield, but has suppressed the urge.
Klowden: It's called impulse control. It's what separates us from the animals. You're a skilled nurse, Veronica, but you are a dumb animal.
Veronica: OK, what happened to the not insulting me part?
Klowden: Harris filed a complaint with Risk Oversight.
Veronica: About his car?
Klowden: About how you went behind his back to get Gerald Pettit in the interferon program. They're bringing in...Hameker.
Veronica: The Dark Helmet? I thought he was a myth.
Klowden: We'll find out tonight. Your disciplinary hearing is at 6:00. He'll be there. You will too if you like your job.
Sonia and nurse Angel Lopez poke fun at Veronica about getting in trouble with the legendary risk manager Hameker. Sonia does tell Veronica she will back her about standing up to Harris for a patient, but "you lost me with the cinder block."
Later, Veronica wheels Kerry's post-op husband in to see her. Kerry admits to a little pain, but downplays it. Veronica presses, asking how bad it is on a scale of 1-10. Kerry: "Oh, I don't know, maybe...11." Veronica investigates where the pain is, and determines that Kerry's water broke. The couple are distressed, noting that the baby is only at 31 weeks.
Veronica: It's okay, this happens sometimes. I'm going to page your OB.
Gillian urges Veronica to keep checking on Kerry, but Veronica says she can't, since Kerry is not her patient, and she has a disciplinary hearing coming up. Gillian insists, noting that patient won't take a sedative, "so that leaves you." Gillian notes that the patient trusts her. Later, Gillian will ask Harris to go easy on Veronica. He basically says it's none of Gillian's business.
Later, Gillian actually sends for Veronica to help with and consult about Kerry, whose baby is in distress--a nice reversal of the usual fungible nurse character paging the uniquely valuable physician. Gillian decides they'll have to do a C-section. Veronica again deploys the psychosocial skills to persuade the very reluctant Kerry that this makes sense. In the OR the team whisks the baby off without even showing him to the mother, but Veronica immediately explains to Kerry that he's going to the NICU, and he's breathing, which is the main concern. The physicians struggle to contain bleeding from the placenta, which was damaged in the accident.
Later, Gillian tells Veronica they can't stop the bleeding and that the senior OB plans a hysterectomy to save Kerry's life. (As she does here, Veronica often calls physicians like Gillian by their given names as if they were peers, which is common in real life, but not with most nurse characters on hospital shows--even this one.)
Veronica opposes the hysterectomy, since Kerry's baby still may not make it. Gillian agrees, but says the senior OB is "old school, this is what he does." Veronica proposes an arterial embolization, as they often did in Iraq for hemorrhaging. Gillian admits that could work, but the senior OB has probably never done one. Veronica suggests that Chris Sands could. Gillian says she'll try to persuade the senior OB, and asks Veronica to get Sands, which she does. Klowden appears to remind Veronica that the disciplinary hearing is in five minutes. Veronica, who doesn't want to go to the hearing anyway, says she has to help Kerry. At the disciplinary hearing, Harris asks Hameker to note that Veronica is late. Later, we see Veronica telling the post-operative Kerry that they did not need to do the hysterectomy, and carrying the relatively healthy baby from dad to mom. Gillian says Veronica did nice work. Veronica responds, "back atcha."
Even with the Kerry situation under control, Veronica is going to blow off the hearing. But Chris persuades her not to. So she goes. Along with Hameker, there are two other men in suits who say nothing, as well as Harris and Klowden. Veronica seems annoyed, but not intimidated.
Harris: Ignoring my orders, she put an alcoholic homeless man into a Phase III clinical trial--
Veronica: His name is Gerald Pettit, and he is not homeless, he has a bed in a VA--
Harris: You're obfuscating. (To Hameker.) She's obfuscating.
Veronica: He deserves to be in that trial.
Hameker: Ms. Callahan, the worthiness of Gerald Pettit is not at issue here.
Veronica: I know that. This isn't about that at all. (To Harris.) I will admit I was angry. OK? Dan, I was mad, and I put a cinder block through your windshield, and it was wrong.
Hameker: You put a cinder block through his windshield?
Harris: This is not about my car.
Veronica: Of course it is.
Harris: I want you off my floor. (To Hameker.) I want her off my floor, she's a danger to this hospital.
Veronica: And you're a soulless dick.
Klowden: OK! It's...been a long day. Can I suggest maybe continuing this tomorrow?
Harris (standing up): No! We are not putting this off. She's a menace, she does whatever she wants, she operates under her own set of rules, and someday she's going to get someone killed.
Veronica (softly, but loud enough to be heard): You don't even know what my job is. (Standing up.) I'm going home. You can let me know what you decide.
Meanwhile, Chloe is on a fire department ride-along. The crew responds to a call that a woman has been critically injured in a home break-in. She has suffered severe blunt head trauma, and has a weak pulse. Chloe realizes from photos in the house that the injured woman is Harris's wife. Chloe at first seems shocked, but in the ambulance she takes charge, redirecting the driver to Mercy (which is the "same distance"). Chloe notes that Harris's wife is going into V-fib.
Angel breaks into the disciplinary hearing Veronica has just left to tell Harris about his wife. Veronica, on her way out of the hospital, sees Chloe and the paramedics bringing Harris's wife into the ED. A somewhat agitated Chloe gives a report to Chris. Harris arrives, looking shocked. Veronica notes that his wife has just gone into V-fib. She grabs the paddles and gives them to Harris. He seems to wake up, and shocks his wife several times, to no avail. Sonia and Angel are also working on her, as they alternate CPR and defibrillation. Harris asks how long she's been down. Chloe says 12 minutes. He looks dazed. Veronica does the next defibrillation. They continue CPR. But Harris tells them to stop, and calls time of death.
Later, in a sort of garden outside the hospital, we see Veronica sit down next to Harris. He says the police have a lead, then asks where his wife is. Veronica says Chris "certified" her, but she'll have to stay for an autopsy. Harris is not sure what to do.
Veronica (gently): Did you ever talk about what she would want?
Harris: No, we never....I think she would...want me to take her home to her family.
Veronica: OK...then we should talk to the Russian consulate about travel. (She starts to rise.) I can call them now if you--
Harris (gently putting his hand on her shoulder): Not yet, not yet...not yet.
Veronica looks shocked at this tenderness. She takes Harris's hand.
There are many good elements in these scenes. Obviously the show is focused on demonstrating Veronica's psychosocial prowess, from her calming of the pregnant wife and her husband to her light touch with the grieving physician she has just called a "soulless dick." But she can also expertly assess the pregnant woman and propose an arterial embolization to save the patient from undergoing a hysterectomy. Veronica does a defibrillation, even with physicians present, which is common in real life but a rarity in Hollywood. Her final comment at the disciplinary hearing--"You don't even know what my job is"--would seem to be a reference to her duty to advocate for patients, not do whatever Harris says, though we're not sure how many viewers will get that. Even the portrayal of nurse manager Klowden isn't too bad--she seems tough but basically supportive of the "skilled nurse" who seems to have some control issues. Klowden could have been a battle axe, but unlike Nurse Jackie, the show resists. Of course, Klowden could also have projected more genuine authority, particularly in the face of some of the things that Harris says.
And those things are the main problem. It's clear that Harris sees his care plans as "orders" that Veronica must follow, and no one really challenges that idea. Harris regards their workplace as "his floor," and no one challenges that. Hameker tells Veronica that Pettit's worthiness is not the issue, and while that is true to some extent--how she resolved the dispute with Harris is the issue--that exchange may not convey to viewers that Veronica should have found a more constructive way to challenge Harris. Instead, it will likely convey to most that the issue is whether she followed physician orders. That is, Veronica had to bend to Harris's will because physicians do tell nurses what to do, even if the nurses might get some latitude. But that's wrong. Veronica's somewhat cryptic comment about what her job is gets at the reality, which is that it is actually her job to challenge Harris if she feels she must, and if necessary to go around and above him (with notice to him, of course) for a higher authority to resolve their disagreement. But the show has to make this much, much clearer to avoid reinforcing the misimpression that most viewers have formed over the course of their lives: that nurses report to physicians.
In one plotline in last week's "Pulling the Goalie" episode, Chloe cares for Jason, an apparent high schooler who has been badly burned in a propane tank explosion. His skin grafts are infected, and he is very angry, rejecting all of Chloe's efforts to encourage him and bond with him (they are not that far apart in age). Chloe tells physician Chris Sands that Jason doesn't like her, which is squirm-inducing--it's not her job to make Jason like her, and to have her reporting this to a physician as if he oversees Chloe is unfortunate. Chris assures her that if anyone can "put a smile on his face" it's her, which sounds nice, but makes nurses' role in counseling patients seem trivial.
Later, Chris tells Jason that they'll have to get the infection cleaned, and then they can try a new graft. But Jason says he's done with the fake hope, since he'll be a freak no matter what. Chloe tries to sell him on the new graft, with no success. Later, Angel tells her that Klowden has made Angel Jason's nurse, at the patient's request. Chloe confronts Jason. He's very mean, and cruelly tells her that she's wasting her time mooning over Chris (which is correct). Chloe grits her teeth and tells Jason about another option to save the dying graft, the hyperbaric oxygen chamber.
In the evening, Chloe goes out with Chris on a sort of date, but learns he's still in love with Veronica. Chloe returns to the hospital and tries again to console Jason, leading him to the hospital roof. He's more respectful, explaining that he's despondent partly because he'll never have a chance with someone as beautiful as Chloe is. She kisses him. He asks if they taught her that in nursing school. She says yes, "in the class on how to get fired." He says he won't tell if she won't.
Obviously this is problematic. Even the hint of this kind of sexual healing--and it couldn't be much more benign and chaste than it is here--still recalls the naughty nurse image that has plagued nursing for decades. The show senses this, making clear that even what Chloe has done is technically improper. And no one could mistake the sincere, graduate-prepared Chloe for a brainless bimbo, as she fights for patients and regularly displays significant expertise. She is not offering herself to Jason, but simply trying to show him that women will not find him ugly, so he will not give up. But the show should still avoid this kind of thing, which is unrealistic, unnecessary, and reinforces (even if vaguely) a pernicious stereotype.
Another plotline in tonight's "You Lost Me with the Cinder Block" episode finds Sonia in bed with Nick, her police officer boyfriend. Sonia doesn't want to get up and go to work. Nick suggests she not go.
Sonia: But if I don't go to work, people die. So I have to go, right?
Right. Maybe that makes up for the naughty overtones in the Chloe plotline. But before Sonia does go to work, she has a negative interaction with Nick's small dog, who barks every time she moves. Nick explains that he rescued the dog from a methamphetamine dealer; it's named Crystal. She suggests that the dog will have to go.
On the way to work, Sonia spots a naked man walking the street. She watches as he climbs a fire escape, then jumps off. Sonia runs to help. The man, Trevor Wallensky, ends up at Mercy with broken ribs and a concussion. Naturally, Sonia is his nurse. It turns out that he is a somnambulist who says he can't sleep with any clothes because it's "constricting." Sonia aptly terms this a "perfect storm." Trevor says his life is a disaster--he's an astronomer, but says he could not go to "sleep-away college," so instead of working at NASA, he is a docent at the planetarium. We see Trevor doing some of his naked sleepwalking in the hospital hallway. Sonia and Angel try to wake him, but can't seem to. Suddenly there is a banging of metal bedpans from down the hallway. It's Trevor's mother, who obviously knows how to wake him safely.
Later, Trevor's mother says that, given what has happened, her son's living on his own was an experiment that failed. Trevor notes that he's 28 and has been on his own for less than 90 days, and now his mother wants him to come back home. Sonia says this cries out for pajamas, and she is visibly disapproving upon learning that at home, his mother locks him in a windowless room every night. Trevor's mother explains that when Trevor was 12, he sleepwalked into a neighboring house and got shot, so "don't talk to me about so-called solutions."
Sonia consults Harris about this. Sonia calls him "Dr. Harris," while he calls her "Sonia." Harris asks Trevor about various treatments, but Trevor has already tried them all, to no avail. Sonia again suggests pajamas. Ultimately, Harris wants to try again with one of the drugs that have not worked before; he tells Sonia that otherwise his "hands are tied." This gives her the idea to actually restrain Trevor in his hospital bed with a sleeping bag and bungee cords. But that doesn't work either (which may be just as well, since this is no long term solution). However, Trevor doesn't just escape the restraints. He ends up almost climbing off a high balcony inconveniently located just beyond a set of glass doors down the hallway from his room. Angel and Sonia manage stop him at the last second, with Angel's contribution being a piercing scream that wakes Trevor as he gets close to the edge, after which Sonia pulls him back.
Trevor is about to leave the hospital to go home with his mother. He thanks Sonia for trying. Angel jokes to Sonia privately that maybe she should have let him jump. She says maybe she should have sent Angel with him to scream every time he starts to sleepwalk--a comment that gives the resourceful Sonia another idea. She actually gets her boyfriend to bring his loud dog Crystal to the hospital. Outside, she takes the dog to Trevor and his mother, who surprisingly is willing to try Sonia's idea: that Crystal will be Trevor's "alarm clock." The dog shows that he can do the job by barking shrilly as soon as Trevor reaches out to pet him.
However plausible this resolution may be, the show is once again demonstrating the practical ingenuity of the nurse characters in solving patients' problems. Sonia and the others often come up with innovative solutions to problems with no evident solution, or no solution that the physicians can offer. The nurses are alert to small things that can make a big difference. Sonia in particular, while perhaps less likely than Veronica or Chloe to propose a cutting-edge medical procedure, is adept at identifying underlying issues and proposing novel, holistic solutions.
On the whole, the show's commendable presentation of the nurses' skills and patient advocacy to such a large television audience clearly outweighs its sometimes inaccurate or unhelpful portrayals of nursing autonomy. We could do without elements like the physician "orders" and the less obvious implications of physician superiority inherent in more subtle features like the disparity in how characters are addressed. But the show is definitely worth our free medicine.
See Mercy Wednesdays at 8pm/7c on NBC or watch episodes online at nbc.com/mercy.
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