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Yes, doctor! Right away!

Pam and Andy Three RiversOctober 25, 2009 -- Tonight's episode of CBS's Three Rivers is a good example of the new hospital show's presentation of nurses as physician subordinates who are peripheral to serious care. The show follows the heroic exploits of a team of elite Pittsburgh surgeons, but it virtually ignores the central role skilled nurses play in transplantation, including in procuring organs, transplant surgeries, and the critical recovery period after surgery. Here the physicians conduct all significant treatments and patient interactions. The show's transplant coordinator character is not a nurse. Indeed, though he is well-meaning, he has no health care training, and he makes foolish errors (as in this episode), an ongoing insult to real transplant coordinators, who are usually nurses. There is one minor recurring nurse character, Pam Acosta. In this episode she is shown briefly treating a lightly injured patient, but even that is a rarity, since her role usually involves only occasional light banter with the godlike lead surgeon Andy Yablonski. Although the nursing portrayal in this episode is probably one of the show's best, the other nurse characters remain nameless handmaidens whose dialogue is mostly limited to submissive TV-nurse statements like "Yes, doctor!" and "Right away!" The episode, David Amann's "Code Green," drew 7.9 million U.S. viewers.

See the relevant film clips from the show in Quicktime at broadband or dialup speed.

How did I just walk away?

Calling Dr. Yablonski

The Bachelor of "Yes Doctor" Science

How did I just walk away?

The episode's main plotline is about the aftermath of a deadly crash of a bus carrying a high school football team. When the first of many victims arrive, we see an ED physician doing the triage, though nurses do that in real life. The physicians (mainly the transplant team, it seems) conduct all patient interactions. They ask patients about their conditions, while silent nurses do some physical stuff in the background. No nurse speaks to a patient or to another nurse; they are there to carry out physician commands. Of course, that doesn't mean they have no role at all. Let's take a look at what their role is!

At one point, the star surgeon Andy Yablonski is examining a patient who can't move his toes. Yablonski speaks politely to a nearby nurse.

Yablonski:   Nurse, send him to radiology, get me a CT of his spine, cervical to lumbar, and call neurosurgery, he may have a spinal cord injury.

The nurse nods obediently.

At another point, the physician chief of transplant surgery, Sophia Jordan, takes charge of another arriving patient. She gets a brief report from a paramedic, as an apparent nurse does CPR.

Jordan:   Continue CPR.

Nurse:  Yes, doctor!

Of course, the nurse would never have known to do that without this order!

Jordan, transplant fellow Miranda Foster, and transplant resident David Lee take the lead on the other patients. They examine, monitor, and issue commands for drugs and equipment to the ether, or to nurse figures at the side of the frame or in the background. Nurses hand things to the physicians or take things from them, and watch intently as the physicians work. But the physicians alone discuss what might be wrong with the patients, and what should be done next. Only they have brilliant ideas about how to save the patients.

At one point, Jordan and Foster are working on Blair, the quarterback, who is initially conscious, but begins having seizures. The physicians determine that he has a subdural hematoma. Jordan will do a burr hole, and she asks a nurse for a drill. But she and Foster can't save Blair; he's brain dead.

Meanwhile, Lee continues CPR on the bus driver Rose. After tiring himself, Lee motions for a nearby nurse to take over compressions.

Nurse:   Yes, doctor!

Lee goes to see Jordan, his boss, and suggests that they discontinue efforts to revive Rose. Jordan tells him keep going. So he returns and they continue. After more CPR by Lee, a different nurse speaks.

Nurse (looking at the monitor):   We got something--sinus tach at 20.

That counts as a pretty impressive nursing portrayal for Three Rivers --the nurse could read the monitor! (We'll try to overlook the fact that sinus tach is a heart rate over 100--sinus brady would be less than 60.) Lee asks Rose to squeeze his hand if she can hear him. She does. Lee is exhausted because he's done almost all of the CPR. The physicians don't just do all of the thinking; they do all of the heroic physical work as well.

At one point, Lee is bandaging a patient, and he asks for tape.

Nurse:   Yes, doctor!

And at another point, Lee asks for an ICP monitor for the patient's Foley catheter, checking for abdominal compartment syndrome, which turns out to be the right call.

Nurse:   Right away!

These early clinical scenes do include a short scene involving nurse Pam Acosta that is one of the best the show has done for nursing. The only football team member who comes through practically unscathed is the equipment manager, Bobby. Here Acosta is caring solo for Bobby in the ED (never mind that she, like the physicians, works in the OR). And we even see her applying a stethoscope to his chest!

Acosta:   Take a deep breath.

Bobby:   Blair said some messed-up stuff on the way here--he thought he was in France.

Acosta:   He probably got a concussion, try not to worry, Bobby, he's in good hands. (Moving a penlight in front of his eyes.) You wanna follow this for me? Your parents know you're here?

Bobby:   It's just my mom. She's in San Francisco on business.

Acosta:   You should probably call her so she doesn't hear about this on the news. About how many people were on that bus?

Bobby:   Forty-two.

Acosta:   You sound pretty sure.

Bobby:   It's kind of my thing to keep track. I'm the equipment manager. Forty players, Rose the driver, and me. That's forty-two. How did I just walk away?

Acosta:   Well, you were just amazingly lucky.

Well, look at that. Acosta actually has basic clinical knowledge, she provides a little psychosocial care, and she even asks about others in the crash, as if she has some broader role in the hospital's response to the tragedy. The count of those on the bus will matter, because an ED physician later realizes one passenger is missing, and Jordan will send Foster out in a helicopter to rescue him. However, Acosta does not seem to be involved in that, and it's important to realize that she gets Bobby because there is virtually nothing physically wrong with him. No nurse would play a big role in the care of a seriously injured patient.

Later, we see Bobby in the waiting room as Acosta approaches.

Acosta:   Blair...he didn't make it. I'm sorry, I really am.

That's not bad as a fleeting depiction of psychosocial care. But it is the resident Foster who talks to Blair's parents. Physicians do all significant family interactions.

Calling Dr. Yablonski

Meanwhile, Brandon, a patient of Yablonski's, urgently needs a heart transplant. In one scene, he seems to be struggling. His monitor starts to beep alarmingly and his nearby wife starts freaking. A nurse is there, and she is focused on the IV pump.

Patient's wife:   What's happening? Do something!

What will the nurse do? Will she know what's going on and do something to help? Will she display advanced technical knowledge and initiate life-saving measures? Will she--

Nurse:   Calm down--I'm calling Dr. Yablonski. (She calls, he answers.) Sir, it's Mr. Ayers. His flow alarm is going off, breathing is labored, and his BP's dropping.

Yablonski:   It's because the ECMO is drying him out. Give him a unit of packed cells and call me back in five minutes if he doesn't get better.

Nurse (to the ether):   I need one unit of packed cells, stat.

So the nurse really can't do much of anything on her own. For actual health knowledge and a way forward, she must immediately consult a physician. She can report symptoms that anyone could have seen, symptoms the patient's wife also identified. Plus--"sir"? Is the show kidding? Yablonski is not her boss, and if she doesn't know him and doesn't feel right about "Andy," she might try "Dr. Yablonski."

Meanwhile, the national transplant coordination authority UNOS offers a heart for Brandon. But it's in Lancaster, several hundred miles away, and the surgeons will have to recover it quickly. Ryan Abbott, the eager young transplant coordinator with no health care training, tells Brandon's distraught wife about the heart before Yablonski has had a chance to assess whether they can use it. Yablonski is annoyed, because he might have rejected the heart if there were some reason it would not work for Brandon. And as it happens, it will be difficult to procure the heart in time because all the qualified surgeons are supposedly occupied by the bus crash. Yablonski has to explain this to Brandon's wife. He tells Abbott to find a way to get the heart.  

Later, as Yablonski operates on another patient, time is running out to get the heart in Lancaster. In this scene, Acosta seems to be the circulating nurse.

Acosta:   Maybe it's time to make that call to pass on the heart.

But just then Abbott calls. He has tracked down a friend of Yablonski's, a fellow transplant surgeon god named "Gonzo" Gonzalez from the Cleveland Clinic. Ryan gets Gonzo to call into the OR on video hookup (the show is nothing if not tech-forward). Gonzo and Yablonski banter about who owes who what favor, and about that time in Vegas, and Gonzo agrees to zip off in one of the Clinic's jets and get the heart for Yablonski. (Incidentally, Gonzalez is a real Cleveland Clinic transplant surgeon who plays himself here, in a wonderful promotional opportunity for him and his hospital.) Abbott eventually picks up the heart from the airport, and he is redeemed.

Later, we see Yablonski putting the heart in Brandon.

Yablonski:   OK, new heart is in. Let's start to come off heart-lung, please.

Anonymous Nurse:   Yes, doctor.

Yablonski politely asks Acosta for water. The heart doesn't start right away, and he asks Acosta for the internal paddles, which she hands to him. They get a heartbeat.

The Bachelor of "Yes Doctor" Science

On the whole, despite a few unusually substantive bits of work from the nurse characters--Acosta's brief's interactions with Bobby, a few other fleeting indications that nurses have some technical knowledge--the episode presents trauma and transplant care as directed entirely by physicians. Physicians do all of the important thinking and treatments, and all of the key interactions with patients and family. Nurses are generally mute assistants who exist to carry out physician commands not just without question, but with an embarrassing level of obsequiousness. And they rarely speak to patients.

However, in real life, nurses play a central role in this care, and in the long and tricky recovery process that Three Rivers rarely spends much time on. Nurses spend the most time with patients, nurses explain to them what is going on, and nurses monitor and intervene to save them 24/7. Nurses teach the patients how to live with their conditions. The depiction of the transplant coordinator is indicative. Real transplant coordinators are usually nurses. And they are highly skilled professionals who play the key role in managing the transplant process from start to finish, not wide-eyed neophytes who mostly watch computer screens and blurt things prematurely to family members.

Three Rivers faces a very uncertain future. Nursing would not suffer from its loss.

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