Letting the Exiles Bleed on Main Street

April 2010 -- The April 2 series premiere of the CBS drama Miami Medical portrays a senior nurse mainly as a skilled and authoritative administrator who helps the brilliant physicians who provide all important care at a level one trauma center. Nurse Tuck Brody is one of the show's five major characters, albeit the least important. He displays some clinical knowledge, sometimes speaks to patients, seems to be part of the show's "Alpha Team" of trauma surgeons, and has some authority over other nurses, perhaps as "charge nurse," as he is once called here, or "head nurse," as the CBS website says. Brody is closer to the evolved handmaiden portrayal of nursing often seen on NBC's ER than the more extreme passive servant depiction that continues to dominate today's most popular network shows, notably Fox's House and ABC's Grey's Anatomy, though it seems unlikely that Brody will ever make the difference in patient outcomes that ER's nurse Sam Taggart sometimes did in that show's final years. In accord with Miami Medical's overall portrayal of hotshot trauma clinicians, Brody may do more swaggering than any television nurse we've seen. But it seems to be largely vicarious, because Brody is also an eager cheerleader for the show's physician glorification. Brody repeatedly presents his trauma surgeon colleagues as intergalactic gods. Think we're exaggerating? Brody calls them "the best and the brightest," "the envy of the known universe," and not just the "rock stars," but the "Rolling Stones" of medicine. CBS promotion has embraced the rock star angle, and by the second episode, the show's main title theme was the Stones' "19th Nervous Breakdown." But oddly, the show seems to have no comment on the skills of the nurses. The minor nurse characters get a few lines (again as on ER), but since Brody is the show's Designated Nurse, it appears that other nurses will rarely play any significant role in patient care, and that in the clinical scenes, only the physicians will really matter. The pilot was written by executive producer and show creator Jeffrey Lieber.

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The Envy of the Known Universe

The Cheerio

The Envy of the Known Universe

The episode begins with a smiling young couple named Mark and Anna, driving down a sunny Miami street, on vacation. Anna is pregnant and craves ice cream. They stop for some, but unfortunately the ice cream shop blows up, an apparent gas leak. There are many casualties. Mark is ambulatory, but Anna has been thrown from the vehicle and is clearly in bad shape. After pulling something out of his neck, Mark hoarsely calls for "a doctor," as if they were likely to appear among the first responders on the scene.

Next, at a hospital, we see nurse Tuck Brody leading a group of new physicians and giving them (and us) an extensive introduction to life in the Ego Zone:

Miami Trauma 1 is a joint you don't want to end up in, because being here means that you're staring at your last hour on this big blue marble. What we don't do--bloody noses or puking teenagers or strained fingers or any of that "sit here and wait till we got time to look at you" junk. We'll leave that to the good folk in the ER. What we do:  golden hour. Last sixty minutes for doctors to save a soul. If you're dying, well then, being here is better than being anywhere else in the world. Because our one and only purpose is to get you stable and to save your damn life. [To someone off screen]. Not your break yet, Andrea. [Resuming.] We got five trauma suites, two helipads, and 15 trauma surgeons who are the envy of the known universe. [Handing a chart to another nurse.] Nurse Carol will now take you upstairs, 'cause we've got incoming.

All the show's characters talk this way. In this long advertisement, Brody has not only said that the surgeons are the "envy of the known universe" and that it is the "doctors" who save souls, but said nothing about his own profession, even in the list of trauma unit features. The helipads make the list, but the nurses do not.

A few moments later, Brody is again orienting physicians, but this time apparently briefing the team of veteran trauma surgeons who will be dealing with the ice cream shop casualties.

We got at least four incoming. First one, auto vs. pedestrian, about six minutes out. We also got a third-trimester pregnancy with multiple lacerations. EMTs trying to stabilize her on the scene before they put her on the bird.

Chief trauma surgeon William Rainer shows up, and speaks briefly to the assembled team, which includes most of the other major characters:  trauma fellow Eva Zambrano, senior resident Chris DeLeo, and new resident Serena Warren.

One critical patient arrives and we see the handoffs from the first responders. Only physicians are involved in that. In a trauma room, physicians surround the patient, and Rainer runs the code. At one point, Brody enters the room to tell the team they have six more incoming. Rainer asks about the pregnant woman (Anna). Brody says she's "on the next bird, four minutes." Rainer wants physicians Chris and Eva on it. Eva asks Tuck to "make sure we type and cross for four units." Tuck says, "got it."

Rainer:  You assign your nurses, Tuck?

Brody:  Yup. OB's been notified, and the BOA cart is standing by in case we're birthing some babies.

Their patient starts crashing, and Brody moves forward, noting that the "pressure's dropping, 50 systolic." The physicians, who were starting to move on to another patient, reconverge and discuss. Brody reports, "PEA, no pulse." The physicians do CPR. Rainer calmly approaches with a needle and inserts it into the patient's chest. Rainer says there was too much fluid around the heart for it to beat; apparently he drained it. The patient improves immediately, and the resident Chris gushes, "You saved him." But then we see Rainer accidentally drop a drop of blood on his shoe, which seems to precipitate a slow freak-out for him. Silently, he looks at the blood all over everything, and takes off his gloves, impervious to the others--including Brody's gentle, "Everything all right, Dr. Rainer?" Rainer slowly exits the trauma room and begins disrobing. The last we see of him, as he exits the area, he has virtually no clothes on. The team is stunned.

The pregnant Anna arrives at the helipad. Two surgeons, Eva and Serena, go to meet her. They discuss Rainer's breakdown, with Serena mentioning that 60% of "trauma doctors wash out" in the first 5 years, which reminds us again how super-macho the physicians are. A man in scrubs is already there at the helipad with a gurney. Presumably he is a nurse, but he never speaks and the surgeons don't speak to him. Paramedics hand Anna off to the surgeons. Eva introduces herself and Serena to the first responders as "Dr. Zambrano" and "Dr. Warren." Whoever the man in scrubs is, he gets no introduction. The two physicians discuss the patient's condition and treatment; the apparent nurse wheels the gurney.

Inside, Tuck greets the group with Anna by reporting that "Trauma Two is prepped and ready." Zambrano tells the patient that "this is our charge nurse, Tuck Brody, who's going to take you the rest of the way." So Tuck gets a name and an introduction because he's special; the other nurses, not so much.

A few moments later in the trauma room, as the team of physicians prepares for Anna, Tuck's job seems to be helping one surgeon get his gown on. Tuck also reports that he called Rainer's cell phone and got voicemail. The surgeons issue commands, and some apparent forearm nurses hand the surgeons things in response. But the team seems a little hesitant.

Tuck:  Rainer's not walking through that door. That was a trauma meltdown. He's not coming back.

The team wakes up. Zambrano runs the code, directing Tuck to "call CT for a head-neck-chest-abdo-pelvis, we're going to shield this baby."

Meanwhile, the patient's husband Mark arrives in a common area to look for her. A woman who seems to be a nurse asks how she can help Mark, and asks if his neck has been looked at; she can see there is a wound there, and she takes his pulse as she speaks to him. Mark starts to explain that he was at the ER in the other building.

Apparent nurse (not letting him finish):  --and they discharged you. I'll take a look for her, why don't you come sit down right over here.

The apparent nurse does not pursue Mark's neck issue. Meanwhile, Tuck and the physicians on what Chris calls the "Alpha Team" continue to treat Mark's wife Anna in the trauma room.

Zambrano:  Tuck, what do we need?

Brody:  Three units, O-neg.

Is she teaching him? Or asking him? Mark approaches and sees Anna from beyond the trauma room's window. He calls to her. In response, she becomes agitated and unstable. The physicians order "somebody" to get ahold of Mark, and Tuck goes outside to wrestle him away from the window. This is more of Hollywood's seemingly endless negative messaging about family presence during critical procedures, which can in fact be helpful to patients and families, as nurses and chaplains have shown. Zambrano finally calms the panicking Anna by letting her listen to her baby's heartbeat, which is actually a great nursing intervention.

A bit later, in some common area away from the trauma room, we see Tuck bring the husband Mark a drink. Mark says he's sorry for the disruption. Tuck says, "No blood, no foul." Mark wonders where Tuck learned to do "takedowns" like that. Tuck says he grew up in Wyoming and spent most of his high school weekends at the rodeo. Mark asks again about Anna, and this is Tuck's cue to reload the trauma surgeon mythology.

We got to her early. Look, I'm partial, but trauma docs? The best and the brightest. The rock stars of medicine. The ones here at Miami Trauma One? The Rolling Stones.

So what does this make Tuck--the tour manager? The guitar tech?

Elsewhere, an unfamiliar senior physician brings another of the victims into a trauma room. This physician will turn out to be Matthew Proctor. Zambrano finds Proctor sewing a patient's hand, bantering with the likely nurse who first greeted Mark. The patient with the injured hand apparently saved a little girl from serious injury at the ice cream shop scene, pushing her out of the way of disaster. Zambrano wonders who Proctor is. He tells her, and explains that his experience includes two tours in the first Gulf war and three years at Landstuhl (the U.S. military's health care facility in Germany). Proctor says he was supposed to start with the hospital's "Charlie Team" the following week but heard that Zambrano's team needed help.

Later, Tuck enters the trauma room to find physician residents Chris and Serena with a patient who has third degree burns over 80% of his body. Chris says they have to find the patient's next of kin; he is dying. Chris asks Serena to get more morphine. Of course, in reality only nurses even have access to drugs like morphine. Serena notes that the patient was repeating a certain foreign phrase they don't understand when he came in. Tuck says he'll find a translator. But Chris takes the lead in finding the man who brought this patient in and convincing him to help. That is the patient's brother, who says the patient has a fiancée. Chris persuades the brother to get in touch with her so they can say goodbye.

Chris joins Eva and Serena in the elevator to ask why the new physician Proctor would be there. A gossipy apparent nurse suddenly confides that she has a friend in Human Resources, and it sounds like marital issues! The physicians absorb this, but don't interact with the nurse. The elevator doors open and Tuck is there, asking who approved "the new guy moving the hand reimplant to an OR." Chris leaves, apparently to chastise Proctor, but he ends up impressed with Proctor's work in severing the hand for later reattachment and managing the patient's outlook.

At one point, the pregnant Anna crashes again. A background nurse calls out that the baby's "heart rate is crashing!" But the physicians do the real thinking and acting, with technical dialogue, in a scene reminiscent of ER. They have to do a C-section to save Anna's baby, and Proctor joins them. Meanwhile, Tuck goes to see Mark, the husband, and tells him his wife is in surgery and "we're doing everything." Mark is pretty broken up. We see the trauma team extracting the baby, who initially is not breathing, but quickly starts to after they do CPR.

Back in the room with the burn patient, Chris enters and asks for "steriles." Some nurse hands him gloves. Tuck is standing by the patient and Chris asks about the kidneys. Tuck says, "shut down." Chris asks about the patient's fiancée, and Tuck says she's driving down from Orlando. Chris says she's not going to make it in time. He decides to do an escharotomy, cutting the burn scars, to give the patient more time. Tuck says that will only give him another half hour, not enough for her to make the drive. (They're discussing all this right in front of the conscious patient.) Chris says that the fiancée can make it to Mercy (hospital) in Orlando. Tuck figures out that Chris wants to do a video hookup, and it appears that Tuck will arrange that. One of the ""rock stars" has come up with another great nursing intervention! And they do manage to get the hookup so the patient can speak with his fiancée briefly just before he dies.

Later, Tuck Brody goes looking for Mark, the husband and father of the new baby boy. The nurse who originally greeted Mark directs Tuck to the men's bathroom. Tuck finds Mark in a bloody pool on the floor. Tuck pulls a nearby alarm and calls a "Code Blue." The scene cuts.

The next scene finds Mark in a trauma room. Chris arrives and Tuck shows him the puncture wound in Mark's neck, saying Mark "must have injured his carotid during the car crash." Another nurse is present, though she does not speak. Chris surmises that Mark clotted off the injury, then later dislodged it. Chris takes over, encourages the patient to hang in there, asks for drugs, and works to intubate. Tuck reports that the oxygen saturation levels are dropping. Serena is there, and Eva and Proctor arrive. Tuck reports that the sats are coming up, but the pressure's only at 70. The surgeons debate care options. Tuck reports that Mark is tachy up to 150, and a moment later, that the pressure is down to 40. Chris's plan to tamponade the bleeding with a balloon doesn't work, so Eva takes over to cut and stop the bleeding, with Proctor guiding. Tuck reports, twice, that the patient is still bleeding. But they succeed in stopping it. Tuck reports that the patient's pressure is up to 75, and that the field looks dry; the bleeding has stopped.

Later, Eva and Serena provide Mark with some psychosocial care, telling him what happened, and showing him his wife, who reports that she and the baby are fine.

Finally, the trauma team unwinds at some bar. Tuck joins them like an actual team member, and he even offers to buy a round. With the others gone to arrange more drinks, Eva tells Chris that Proctor is getting Rainer's job. When the group is back together, toasts are made, and Tuck, worshipful to the end, proposes that they drink "to the best damn surgeons in South Beach." But at the gracious Proctor's behest, they drink instead to the unfortunate Rainer.

The Cheerio

Miami Medical's depiction of nursing could be a lot worse. Unlike House and Grey's, the show does not tell viewers that nurses are irrelevant to serious care. Tuck Brody is one of the show's five major characters, though he is the least prominent. This puts him somewhat ahead of ABC's Private Practice's Dell Parker, who is the least of eight. Tuck is also assertive, and he projects more authority than Dell does, seeming to arrange for nurse staffing and play some management role, managing not only the nurses' breaks but also staffing in response to critical incoming patients. Tuck is more like the lone major nurse characters on ER, both in terms of his experience and his relation to the physicians and patients. He has health care knowledge and skill, and he plays a substantive role in clinical care. Tuck gives the physicians reports about patient conditions, but at times he also displays initiative in a more long-term context. For instance, he arranges for certain care procedures and systems, as when he planned in advance for the possible birth of Anna's baby. Tuck seems to have some triage role. And he even talks to patients and families, though not about very technical subjects, and not when there are physicians around. Maybe Tuck keeps family members posted while the physicians save lives. But at least he can talk.

Then there are the "man in nursing" issues. Here the show seems to mostly ignore them, which is not the worst thing it could do. Neither Tuck nor the other characters have so far made any issue of his gender or sexual orientation, unless you count the fact that the husky nurse was able to do that timely "takedown" of Mark, drawing on his rodeo experience. That may have been an effort to show that Tuck is "manly" in a traditional way. Tuck's manner is not one that viewers are likely to associate with being gay. Unlike certain straight male nurse characters on television--Private Practice's Dell and TNT's Hawthorne's Ray Stein spring to mind--Tuck is not weak or callow.

The depiction of the minor nurse characters is probably somewhere between the one seen on ER and those of the other major hospital shows. The Miami Medical nurses do actually get lines here and there, calling out vitals and even interacting a bit with patients. They are not always just mute ciphers who absorb commands from the brilliant physicians. On the other hand, it's not clear if the show's minor nurse characters will become as recognizable as ER characters like Haleh Adams or Chunie Marquez, who managed to emerge from the background from time to time and actually register as caregivers with some expertise who might even suggest or initiate care. In many scenes, the minor nurse characters here really are mute ciphers, handing the physicians gloves and wheeling gurneys, with the physicians not even acknowledging their existence (and the show making no comment on that, suggesting that's how it should work).

Overall, the depiction of nursing on the show leaves a lot to be desired. It's mostly Tuck, and he is essentially a skilled assistant to the physician heroes. Viewers get little sense that Tuck or the others are autonomous professionals with their own scope of practice. For the most part, Tuck seems to be there to arrange for the care the physicians provide. He even helps them on with their surgical gowns! Tuck has authority over the nurses, but he also seems to report to Rainer about them, suggesting that the physicians just chose one senior nurse as a more convenient liaison, but ultimately the physicians still manage the nurses. Tuck also seemed to have some administrative role in connection with that group of new physicians, but there's no suggestion that he will be doing more than orienting them to the general clinical environment. He doesn't do any real teaching, and there is some sense that he's like a drill sergeant with new officer recruits. Once the new physicians gain some experience and seniority, it seems clear that Tuck will report to them.

Miami Medical has physician nursing. Tuck does some things, but the physicians give drugs, get handoffs of critical patients by themselves, and conduct virtually all patient relations. In reality, highly skilled trauma nurses take the lead or play major roles in much of the care we see the physician characters do here. There is roughly a 1:1 nurse:physician ratio at real level one trauma centers. So if you're going to have four major physician characters and just one semi-major nurse character, you're almost certain to have the physician characters doing nursing.

And there is the surgeon glorification. It's reminiscent of Grey's, but the new show is very explicit about it, rather than simply implying it very strongly, as Grey's does through plotting and melodramatic voiceovers ("Surgeons are often asked to save lives for 48 hours straight while simultaneously having great sex, discussing Sartre, and playing the piano like Franz Liszt. A few of them can't!"). Both shows suggest that surgery is the answer to virtually all serious health problems, and that other health endeavors are inferior (and so presumably less deserving of limited resources).

But maybe Miami Trauma seems worse on the "surgeons are gods" front because here a nurse seems to be the head cheerleader. Tuck Brody makes sure that we know that it is "doctors" who save souls, that trauma surgeons in general are the "best and the brightest" and the "rock stars" of medicine, but that the ones he works with are the "Rolling Stones" and the "envy of the known universe." Maybe you think this is so over-the-top that viewers will just laugh; don't count on it. We've long noted irrational reverence for surgeons even among sophisticated media consumers and creators. It might be different (though still troubling) if Tuck included the trauma nurses in his encomiums. But it does not seem to cross his mind that he and his nurse colleagues might play a key role in making this trauma center so Alpha.

Miami Medical certainly could be worse for nursing, but on the whole, it strongly reinforces the damaging idea that brilliant physicians provide all the health care that matters.

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Miami Medical contact information:

Executive Producers:
Jerry Bruckheimer, Jeffrey Lieber, Jonathan Littman and Steven Maeda

Brett Gold, Publicist
(212) 975-7931
brett.gold@cbs.com

Andrea Ballas, Director, Publicity
818-655-1581
andrea.ballas@cbs.com

Amy Miller, Director, Publicity
(212) 975-4757
Amy.Miller@cbs.com