September 2011 -- ABC's summer drama Combat Hospital is a Canadian show about an international team of military health workers caring for the wounded near the front lines of the Afghan conflict in 2006. The first two episodes, airing in late June, indicate that Combat Hospital has some positive features for nursing. Nurse manager Will Royal holds the military rank of commander, and at times he displays authority and clinical skill. And the show seems almost obsessed with tweaking physician entitlement by making physician characters mop floors! But the show on the whole still perpetuates the same damaging myth that the more realistic Hollywood hospital shows like NBC's ER have: that physicians are the smart masters of health care and the only health workers worthy of any sustained interest, while nurses may have some skills but are there to assist. The show's five major characters are physicians. Royal is the only significant nurse character, and he is by far the least important among the health professionals. Royal functions as an unusually assertive aide-de-camp. He actually harasses one surgeon for his arrogant, caddish ways. But Royal's own lines also suggest that physicians are automatically in charge of care, no matter how inexperienced they are; he introduces one brand-new trauma physician to "your nurse." Royal's role is not unlike that of Tuck Brody in CBS's Miami Medical (2010). Brody was also a competent, aggressive black male nurse manager who could display real authority, but who was essentially a logistics manager for the trauma physician stars. Here, as there, nurses rarely play a notable role in direct care except to call out vital signs and carry out physician commands. Combat Hospital could be far worse for nursing. But it's unlikely to disrupt the popular narrative that brilliant physicians rule and pragmatic nurses serve. The show was created by Jinder Oujla-Chalmers, Douglas Steinberg, and Daniel Petrie Jr.
Mopping the floor
The June 21 premiere ("Welcome to Kandahar") was written by Jinder Oujla-Chalmers, Douglas Steinberg, and Daniel Petrie Jr. The show's central character, Rebecca Gordon, a Canadian major and trauma surgeon, arrives at Kandahar Airfield, where the "combat hospital" on which the show focuses is located. Gordon meets Bobby Trang, a U.S. captain and new physician, who is also looking for the hospital. At the hospital, we see Colonel Xavier Marks, a wise, authoritative figure who seems to be in charge. Hotshot neurosurgeon and civilian Simon Hill asks Marks where the "fresh meat" is (he means Gordon and Trang).
As they enter the hospital and look around, the fresh meat seems a bit taken aback at the rudimentary facilities. Commander Will Royal spots the nonplussed pair, mistakes them for patients, and tells them that the outpatient clinic is closed, but they'll be seen as soon as possible. Gordon says they're not sick, but reporting for duty. Royal apologizes, but quickly recovers, noting that they can use help, because they just had a rush and are about to have another. He hands the two physicians mops (!) and asks them to clean the blood off the floor so that no one slips. The physicians are taken aback. Meanwhile, another woman in scrubs, apparently a medical technician ("medtech" on the show) has appeared at Royal's side.
Gordon: You don't understand. We're doctors.
Medtech: What, does that mean you don't know how to mop a floor?
Gordon assures them she knows how, and she seems to be starting to say that mopping floors does not seem to be a great use of their time, but Royal simply says that's great. He and the medtech turn and leave before the physicians can say more. The physicians start mopping. We understand that this could really happen in a military hospital, when nurses have many things to do and physicians have down time. And clearly viewers are meant to enjoy the sight of nurses and medtechs asking high and mighty physicians to do something they regard as menial.
Col. Marks leads the two new physicians on a little tour of the facility. When they meet Hill, he asks Gordon if they tried to hand her a mop; she says they succeeded. Hill: "They tried that with me, they didn't get very far, let me tell you." Meanwhile, Marks makes Trang a "trauma team leader" in one of the trauma bays, even though the very new Trang says he has only the standard three months of training in that area. Marks assures Trang that he'll be fine. Gordon says she has "TTL" experience, but Marks wants her free for surgery. As the wounded start to arrive, Royal guides Trang to the trauma bay. Three people in scrubs are already there.
Royal: All right, everyone, I'd like you to meet Dr. Bobbie Trang. This is Captain Pam Everwood, your nurse. These are your medtechs, Larry Alexander and Christie Nazareth. OK? (Trang looks worried.) Don't worry about it, they got your back. (Royal hands him a pair of gloves.) You're gonna need this. (Moving on.) OK, everyone, let's go!
Their first patient has been wounded by an IED blast.
Trang: GCS 9, should we tube him?
Nurse Everwood: Your call, doctor.
A medtech reports shallow breathing and falling blood pressure. Trang is uncertain. Everwood looks expectantly at Trang. He decides to intubate the patient and tries to do so, but has difficulty. Someone, apparently Everwood, says "20 of etomidate." A medtech continues to stress to Trang how fast the BP is falling. Trang is still having trouble. The nearby Col. Marks asks if Trang needs help with the airway. Trang says yes. Marks does it easily. But the patient's lung function remains shallow. The surgeon Gordon approaches and cuts the patient open, asking for a chest tube. The medtech reports better breath sounds, and someone reports that the patient's O2 level is improving. Gordon asks Marks if the patient should go to the OR. Marks asks Trang. Trang is distressed about functioning poorly; he says they should do whatever Marks says.
These scenes capture the show's nursing portrayal pretty well. Commander Royal is fairly commanding, though the show never makes his authority quite clear. He appears to have authority over the nurses, and perhaps over the medtechs also. But Royal also seems to function as one of Col. Marks' right hand persons, a kind of general aide-de-camp with responsibility in a variety of areas, particularly in mobilizing the hospital staff for tasks and enforcing rules. What he does not seem to have, and clearly no other nurse has, is much genuine autonomy in patient care. Royal himself introduces Everwood to Trang as "your nurse" even though she seems to have the same military rank as Trang. And Everwood presents herself as an assistant; she does not greet Trang as a peer. Apparently everyone here is automatically an assistant to Trang, no matter how junior and clueless he may be. And note how everyone is introduced by military rank except Trang; does "Dr." outweigh any military rank? The clinical elements of the scene are very much in the ER / Miami Medical tradition.
The nurse and medtechs are involved, they note vital signs, and they have some skill; they are not just mute order-taking ciphers. Everwood did seem to ask for etomidate on her own and the medtechs gave it without physician involvement. But she and the others look to the physician for direction on anything important. Thus, the timid Everwood clings to the notion that the intubation decision is "your call" and she either can't or won't offer anything more to the flailing Trang. We hope an experienced trauma nurse would suggest tubing the patient and inserting a chest tube in this situation. But there is no evidence of nursing autonomy or advanced skills here.
Royal: No, don't get up just yet, son. I'm Commander Royal, your nurse. Everything's going to be fine. (Seeing the patient look down.) Yeah, you've got your arms and your legs, everything that you had yesterday, including some ugly-looking plastic tubes that you have sticking out of your chest. So, we gotta keep you in for a few more days. Yeah, your ribs are gonna be sore for a bit; you in any pain at all?
Soldier: No, sir, not really.
Royal: Well, you speak up if there's anything that you need. Anything at all.
Marks arrives and tells the soldier that he's getting a Purple Heart and that they have arranged for him to call home, while his buddies are in the waiting room. The soldier thanks "both of you" (Marks and Royal). Marks says he doesn't have to thank them, they're just the ones who got to give him the good news.
This scene is actually not a bad presentation of a nurse's psychosocial skills. Royal orients and comforts the patient, giving him information he needs in a sensitive way, and checking for pain. And far from mocking Royal for being a male nurse, the patient thanks him along with Marks. And the soldier also calls him "sir" because Royal is an officer who outranks him. Media depictions of military nurses do have the positive feature of presenting nurses as officers, which doesn't mean the nurse characters are better humans, but may subvert public perceptions that they are assistants in every context.
Meanwhile, Marks is trying to build Trang's confidence as a trauma team leader, and he faults Gordon for undermining it. Then he adds, to Gordon and Trang:
Marks: That thing about the mop. Don't believe Simon, it's not some fraternity hazing ritual. Blood is slippery, we don't want anybody falling. Now nurses and the medtechs, they know where everything is, what needs to be re-stocked. Doctors don't. So, doctors mop the floors.
Again, this is probably a small effort to puncture physicians' sense of entitlement, but let's not get too excited that physicians may have to do a seemingly menial task in this extreme setting because nurses know where supplies are. It's a slight challenge to what most people see as a rational health care hierarchy, and maybe it's a little revenge fantasy, but you could also see it as a humorous reinforcement of the hierarchy as a general rule, because the plot doesn't necessarily question the idea that physicians are generally too important for care tasks that seem basic. This is a war zone and things are different. Also, knowing where supplies are probably is not going to blow many viewers away compared to the physician skills the show glorifies as life-saving. The show also suggests that when lives are directly on the line, nurses assist physicians.
Later, we see some of this patient's buddies talking to the hospital's Afghan translator. Royal is nearby. As one soldier scratches his side, his shirt moves up, and Royal notices a big red bruise on the soldier's side. Royal asks about it. The soldier says it's nothing, explaining that it's from the same blast that felled his friend, but that his frag vest absorbed the impact, so it didn't even break the skin. Royal tells him he should still get it looked at. The soldier says, "Sure, sir, but really it's nothing." Royal looks doubtful. The soldier's look suggests that maybe he will get it checked, even though he doesn't think it's necessary.
A later scene appears to show us rounds--which seem to include nurses! Marks is the leader here, but at one point he turns it over to Commander Royal, who addresses group.
Royal: All right, I'd like everyone to take a look at this [gesturing to wall], this is a fresh shrapnel hole. We've seen these around the building before, in spite of the fact that we are surrounded by glass, walls and containers. In case you haven't noticed, we are in a plywood and canvas building.
Marks: Yet there are still people who are slow getting into their helmets and flak jackets. Unacceptable. Now, I don't wanna single anyone out, but Simon, what are you waiting for, an engraved invitation?
Here again, Royal seems articulate and to have some authority, but it's not necessarily authority or expertise in patient care. Indeed, soon we get a more direct statement of who really does the life-saving at the combat hospital. We see Trang introduce Gordon to the episode's first patient as the "one who saved your life." Gordon graciously says she "just assisted," meaning Trang saved his life. And they go on, each telling the patient he should thank the other one, as if the only question was which of the two physicians was solely responsible for saving the man's life.
Nearby, the soldier's friend with the bruise collapses and starts shaking. Trang gives drug orders, and Everwood and a medtech rush to comply. Trang questions the first patient about the explosion that caused the injuries. Gordon uses ultrasound to determine that there is blood in the collapsed soldier's belly, apparently a splenic rupture. Trang says they need the neurosurgeon Hill, and a medtech fetches him. Gordon and Hill operate. Everwood reports cardiac arrest and starts CPR, but the patient's oxygen level is falling, and the physicians don't think much can be done. Hill asks if anyone thinks there's anything else they can do. No one does. Hill commands Everwood to "stop CPR." Gordon, Trang and Royal tell the first patient and his buddies, who can't believe their friend is dead. Maybe if we had gotten to him sooner, says Gordon.
There are a few good elements here, notably Hill's question about whether anyone on the team--presumably including nurses and medtechs--has any other ideas to revive the patient. That's a realistic touch that has rarely appeared on Hollywood shows, which remain intent on telling viewers that only physicians could have such ideas. Everwood also plays an active role in the team's efforts, showing some skill. But it remains clear that she is an able assistant to the physicians who are calling the shots, for instance by telling her to stop CPR. No nurse weighs in with any independent thoughts during the code. As for Royal, he had the right instinct that the bruise should be examined, but he did not follow through. Some might see that as a failure of advocacy that cost this patient his life, as Gordon's final statement implies, though the show probably did not mean for us to fault Royal--it's the physicians who are deemed ultimately responsible.
Leave my nurses alone!
The June 28 episode ("Enemy Within"), written by Gub Neal, provides further insights into the show's generally positive but flawed vision of nursing. A major plotline is about an Afghan Army fighter with a mysterious infection. This soldier is brought to the hospital by a U.S. special operations trainer, who flirts with Gordon throughout the episode. Trang, again the trauma team leader, says the patient is burning up, so "get me vitals." Nurse Everwood is part of the team pulling off the patient's clothes. She also calls vitals and complies with an ibuprofen request from Trang. They find what looks like a big hole surrounded by swelling and red spots on the patient's chest. Trang, now a confident leader, wants ice and IV Ringers wide open.
Meanwhile, a minor plotline in the episode concerns a young female nurse named Beverly who is hooking up with neurosurgeon Simon Hill. Beverly seems to be in love with Simon; he seems to be having a good time, and nothing more.
On what appear to be rounds, Trang presents the case of the Afghan soldier with the mysterious infection. As this serious case is being discussed, Beverly passes a note for Hill through a frowning Gordon. When Hill passes a note back, Marks sees it and chastises Gordon for what is, after all, a fairly juvenile activity. Marks wants the surgeons to study new fasciotomy procedures in preparation for an upcoming conference call with the "head of U.S. trauma," who Marks says can display "wrath" even at Dr. Hill. Hill says he will do his homework. Royal snipes: "That'd be a first." Outside, Gordon sees Hill and Beverly at a picnic table, and thanks them for making her look like an idiot on rounds. Beverly is eager for the attractive Gordon to leave; she can tell that Simon is intrigued by Gordon, and Beverly confesses to Simon that she is jealous. Any sensible nurse would be when a physician like Gordon competes for surgical affections!
We see Trang and Gordon answer a 911 page. They discover the Afghan patient and Royal, who says: "Fever spiked at 104 degrees and rising, [a medtech is] running back to Dfac [the dining facility] to get more ice." Trang wants more ibuprofen and the lab report. The physicians, including Col. Marks, debate the diagnosis and treatment of the mystery infection. Trang suggests advanced cephalosporins; Marks agrees they can try those. Marks also asks his aide Graham to get a local physician expert named Tarzey to consult on the patient.
Later, we see Simon Hill and Beverly sleeping together. He doesn't want her to miss her flight out; she says they have another night together. Simon says he will be on call; he is making excuses. There doesn't seem to be much going on in Beverly's head except romance with Simon.
In the hospital, we see Royal examining a leg that seems to be infected. He calls: "Get Captain Trang and Colonel Marks! The infection has spread to another patient." At least Royal can see what has happened, but his immediate reaction to get the physicians, without any further actions, will probably reinforce the sense that nurses basically assist physicians. Later, Royal does at least give a simple report to the physicians, noting that the patient came in for an open compound fracture to the tib-fib, with no signs of infection. Trang asks if the patient was in the ICU near the Afghan patient. Royal says no, explaining the patient's moves through the hospital. Marks concludes that they have a highly contagious, antibiotic-resistant infection, so they must isolate the two patients and decontaminate where they've been. Royal says that could be half the hospital. Marks asks him to "be aggressive with whatever antibiotics we've got," which probably overstates the discretion that a physician would provide or that a nurse would accept here.
Later, we see Marks visit the second infected patient. Nurse Everwood reports the patient's vitals, and it seems like nurse Beverly is also there caring for the patient, but she makes no impression. Marks wants more ice and a specific antibiotic. Everwood: "Yes, Colonel." Still later, Royal appears, saying the drug is not working, and they're down to one option. Trang gets that Royal means double amputation, but Trang says the patient is too unstable. Royal says the patient will die if they don't operate now. But it is too late. When Marks arrives, Trang is doing CPR. Trang also seeks ideas, apparently of Royal! But Royal has none, nor does Marks. Trang doesn't want to stop CPR, and Marks has to push him, calling off the resuscitation.
In these scenes, Royal and Everwood at least play some role in patient care, especially in reporting vital signs. Everwood is deferential enough to qualify as a standard Hollywood "yes, doctor!" nurse, but Royal gives some account of the patient's movements through the hospital and even advocates for a care option, though his amputation idea does not seem viable. And again a physician, this time Trang, seeks ideas from the team, including nurses. Royal also discusses with Marks how to respond to the spread of infection, though we wish Royal came off as more of a leader in that response, rather than just an order-taker and status updater. Nurses are at least as focused on the care environment and its threats to patients as physicians are.
Later, at a staff meeting, Marks outlines the infection situation. He says Landstuhl (the major U.S. military health facility in Germany) is still working on a solution for them. So all they can do is clean everything. Royal says they've been doing that, using 10% bleach. Marks says they'll have to do it again, and he'd like everyone to volunteer for two shifts. Hill, annoyed at the "mop thing again," simply leaves, and nurse Beverly follows. She shows no more professional commitment than Hill does. In a quiet corner of the hospital, Hill spurns Beverly's advances. He says they had fun, but she'll soon be leaving and so she should "grow up." Beverly suspects this attitude has something to do with "that new doctor" (meaning Gordon), though Hill denies that.
The Afghan soldier with the mystery infection is dying, but the local expert physician Tarzey arrives, and after examining the patient, he immediately determines that the infection is a toxic strain of pseudomonas and the solution is not fancy new antibiotics, but some old-fashioned polymixin antibiotics, which Marks asks Graham to find. Tarzey also says they may have to bleach-clean over and over again to really be rid of the infection.
So the scrubbing and mopping, including by Gordon and Trang, continues. Some casualties arrive, but they have to be seen outside the hospital because of the contamination inside. Royal asks Marks what to do, which is not a great display of initiative. Marks wants to see what injuries the new patients actually have, which seems like something Royal might have come up with himself. Marks ultimately orders that the patients be sent to other parts of the facility like the DFac. While we mostly see physicians triaging these patients, Royal seems to get to do that also, perhaps because he is so senior. Royal tells Marks, correctly, that his patient is dead.
Later, while moving patients, Royal has this to say to Simon Hill.
Royal: One of my nurses was just crying right now; she wouldn't tell me why.
Hill: Oh, I'm sorry about that.
Royal: You know, you can screw the doctors, and they can screw you too for all I care, but you leave my nurses alone.
Hill explains that Beverly was scheduled to go home, and she must've known their thing would not lead anywhere. Royal disagrees. Hill asks if Royal would believe him if he were to promise not to "sleep around again." Royal says no, shakes his head and walks away.
Royal is advocating for his nurse, and the show does not suggest that a senior nurse would be wrong to do so. But this is not really a patient care issue, or even a work issue. Beverly is an adult, and although Hill is a jerk, he has not used his power as a physician to do anything to her that she did not want. The plotline is sadly reminiscent of the May 2008 Grey's Anatomy plotline in which nurses actually boycotted the surgeries of plastic surgeon Mark Sloane because of his caddish ways with them. That plotline was truly ludicrous, and Grey's had no positive nurse counterexample (Combat Hospital at least has Royal). But the Combat plotline still sets the nurse up as a lowly victim of the godly physician, who should show her more mercy. And Beverly's pursuit of Hill is pathetic enough to recall the nurse-as-physician-gold-digger stereotype. We never do see her play any significant clinical role.
Later, Royal sees Hill doing a lackadaisical job mopping, and he can't resist another shot: "Are you kidding me? Put some spirit into your swing, Simon."
We give the show credit for presenting Royal as a consistent pain in the arrogant neurosurgeon's side, taking every opportunity to mock his bad study habits, his poor work effort, and of course, his nasty personal traits. We wish Royal's advocacy were a bit closer to displaying technical health knowledge, but still, he's not weak, and that's something. And maybe he has some effect on Hill, because later, the surgeon actually apologizes to Beverly, though he manages to turn even the apology into an ego trip. Hill tells her that he's a neurosurgeon, and "we don't do ordinary," which also explains his aversion to the mop. So "romance," while "great for other people," is "not me." Hill says Beverly should go home and find someone who's right for her.
So Royal is an intriguing character, a strong and able nurse who seems to play a significant role in the care environment at the hospital. He even occasionally displays some health care expertise. But his screen time is limited and he never really gets three dimensions. Meanwhile, the other nurses seem to be mainly order-takers and vital-sign reporters, and it is the brilliant physicians who dominate the care environment and the dramatic environment. We are never invited inside any nurse's psyche or decision-making the way we are with Gordon, Trang, or Hill. In the end, the nurses on Combat Hospital seem to be competent health workers with some skills but without any great clinical authority or professional care model, other than helping physicians.
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