Family presence: The Sopranos

Family Presence and Psychosocial Care of the
Comatose ICU Patient
Cont. Nursing Ed. HBO-068
Instructors: Carmela and Meadow Soprano

March 26, 2006 -- Tonight's episode of HBO's "The Sopranos" portrays ICU nurses as nasty, rule-bound physician subordinates who actually impede the psychosocial care of the gravely wounded Tony Soprano and his distraught family. One nurse rudely chastises Tony's wife Carmela (right) for dislodging the comatose Mafia boss's drains by climbing into bed to comfort him. Carmela replies that she has "to think that physical affection counts for something." The nurse reacts with contempt, as if she never heard of such nonsense in her two-week nurse training course. The episode, written by Matthew Weiner, was "Mayham" (No. 68, 8.9 million viewers). As in hospital scenes in "Six Feet Under" last year, the physicians here are no Welbys either. They mostly come across as indifferent intellectuals who don't relish interacting with patients or families. The notable exception is series regular Dr. Jennifer Melfi, Tony's long-time psychiatrist. But unlike the battleaxe nurses, all the physicians are seen as expert lifesavers who direct the important care. No one is likely to suggest that Carmela's daughter Meadow (right), a recent Columbia graduate considering a career in medicine, look at nursing instead.

The episode finds Tony in a coma and on a ventilator, having been shot in the belly by his delusional uncle, Junior. Much of the action takes place at the hospital, as Tony's family and subordinates keep watch, impart comfort, and bicker. Nurses appear from time to time, but Carmela and Meadow (right) are seen to take a far more active role in his care, talking to the unconscious Tony, touching him, and in Meadow's case, even climbing into bed to lie next to him.

Physicians come by from time to time to check on Tony. When they do, Carmela is eager to pursue any sign of progress. At one point, "Dr. Plepler" and a physician Carmela calls the "Indian girl" (later identified as "Dr. Badragia" (phonetic)) stop by on rounds. Carmela asks Plepler if "the nurse" told him that Carmela thought she had seen Tony (right) move his eyebrows. If the nurse did not pass that on, Carmela says, she will be "furious." Plepler sidesteps that issue, urging Carmela neutrally to "recalibrate her expectations," as she can't expect much progress until Tony's fever recedes and his white cell count comes down. But he notes that Tony is fighting. At the end of the episode, after Tony has emerged from the coma, a cheerful, confident neurologist, "Dr. Vahabsideh," appears to give Tony his first "mental acuity test." Away from the hospital, Dr. Melfi has a session with Carmela, offering her usual expert psychological probing into the effects of Tony's condition on the family. In total, four physicians are named in the episode, and though some are nicer than others, each is an authoritative expert at the center of onscreen efforts to address ill health, from the most obviously technical to the more holistic, psychosocial aspects of care. Indeed, at one point Meadow tells Paulie, one of Tony's captains, that "the doctors want positive talk" around the comatose Tony, as "it helps in his recovery." Thus, the episode actually sets the physicians (especially Dr. Melfi (right)) up as the perceptive, holistic ones, even when they are not that supportive or warm.

Despite Meadow's request, positive talk is not really Paulie's thing. He exclaims that Tony looks "terrible," and talks gratingly about his injuries from a recent killing, and various other problems. Tony can apparently sense this, as his monitor starts beeping, and blinks the word "TACHYCARDIA." Meanwhile, in Tony's dream state, where he is trapped at a hotel far from home without his possessions, he struggles to get the occupant of the next room to be quiet.

Finally, the beeping and blinking "TACHYCARDIA" results in the entry of a female Asian nurse. We'll call her Nurse A. In fact, since none of the episode's nurses gets a name, thus underlining their fungibility and marginal relevance to serious care, we'll refer to the ones who actually get lines as Nurse A, Nurse B, and Nurse C. Nurse A feels Tony's neck pulse, then--before doing anything else--goes to a wall intercom and pages "Dr. Badragia, stat to room 3." Only then does Nurse A run out of the room, returning quickly with an African-American nurse, Nurse B, and a crash cart. Nurse B soothes the panicking Paulie (right): "Out of the way, sir." Other Soprano family members rush in, wanting to know what's happening and generally freaking out; naturally, no one tells them anything. Nurse A tells the arriving Badragia: "Mr. Soprano, still v-tach on the monitor, thready pulse." Badragia orders the nurses to "get a [resuscitation] board ready." A nurse says: "80 palp." Badragia: "Let's bag him." A machine blinks: "WEAK PULSE." (Of course, monitors register blood pressures in numbers, not with words like "weak.") Badragia counts "1-2-3," and she and the two nurses get the board under the obese Tony. Nurse B reports: "Still v-tach at 210." Badragia orders: "150 mg of amiodarone." Then Badragia orders a junior resident who has arrived to "grab the paddles" and "clear the room." Nurse B does get to put the jelly on the paddles. Badragia: "Stand back." The resident says "all clear" and gives the shock. There is no response, and they do it again. The physicians order the level of charge, while the nurses comply and stand back.

Meanwhile, in Tony's coma dream, he arrives at a spooky formal gathering and is greeted by his dead cousin, who invites him to go inside. But Tony hears Meadow's voice calling, and he declines to go in. Instead, he wakes up to see Meadow and Carmela above him. Badragia: "All right. Normal sinus rhythm; pulse and pressure?" A nurse: "Good." Badragia commands: "Hang an amiodarone drip, and send off a set of electrolytes--now."

In this code scene, the senior physician calls all the shots. The nurses' priorities are to get that physician, to follow her brusque orders, and to report vital signs to her. They display no real initiative after getting the crash cart. And although we were tired of saying it years ago, the two physician characters do the exciting defibrillation task, when in real life nurses generally do that. A real nurse might also have offered the distraught family at least a brief report (e.g., "we're working to get a better heart rhythm"), but that might have broken the commanding physician narrative. In fact, despite the apparent indifference of the code team to the surrounding family, the scene is a kind of endorsement of family presence in resuscitations, something nurses have long pushed despite physician opposition. The very fact that the family's presence here is now plausible--that Nurse B merely ordered Paulie out of the way, rather than all the way out of the room--is in part a tribute to nurses' efforts in this regard. Of course, no viewer will get any sense of this example of nurses' patient advocacy out of the scene.

On the contrary, aside from the code, the nurses in the episode are bitter hospital bureaucrats whose main task seems to be making sure those pesky kids keep off the grass. At one point Nurse A chastises Silvio (right), Tony's consigliere, as he reads a newspaper at the nurse's station: "Sir, it's family only in the unit." Silvio says he will be out of her hair in minute. Nurse A: "I keep telling you people, I'm gonna have to call the hospital administrator." When Meadow leads Paulie in to see the comatose Tony, we see Nurse A working at the bedside, emptying blood out of a drain. She carries the blood away in a cup, looking bitter and eyeing Meadow and Paulie: "Only one person at a time, please." After she leaves, Meadow confirms: "She's a ball buster."

At another point, Carmela enters the comatose Tony's room as a third nurse, Nurse C, is adjusting his tubes. Nurse C looks at Carmela and snaps: "Don't get in bed with him again, you dislodged his drains." Carmela: "That was my daughter, and I can't help but think that physical affection means something." Nurse C shakes her head and leaves, like Carmela is deranged--the very idea that psychosocial support could matter to a comatose patient or his family! What will these deluded patients think of next? Of course, pulling out drains could result in serious complications for the patient. But nurses should and do help families find ways to provide physical affection without adversely affecting patient health. No doubt some relatives do hold out hope for recoveries that will not occur. (Ironically, this seems to be in part because television shows like this one suggest to the public that coma patients are much more likely to recover fully than they really are.) But this episode takes great pains to suggest that Tony is in fact brought back from the edge of death by just this kind of awareness of his loved ones' presence. In effect, Carmela is right, and Nurse C could learn something about psychosocial care and family presence from her.

There is no context to explain why these nurses are petty battleaxes. We get no indication of short-staffing or other poor workplace conditions, or even that the nurses have some issue with caring for mass murderers. Viewers also get little sense of the role of nursing in Tony's recovery. They are unlikely to see the importance of any of the rules the nurses enforce; no one explains the importance of limiting visitors or keeping the drains intact. Indeed, the episode actually suggests that if Paulie had not sat next to the comatose Tony and railed about his problems, Tony might never have been pushed into V-tach, and the presence of Meadow and Carmela might never have helped bring him out of it for good. (We realize that an episode of v-tach, even with family presence, rarely brings comatose patients out of their comas--we're just working with the plot here.)

There is one tiny bright spot for nursing. At the end of the episode, after Tony has been out of the coma for some time, Carmela enters his room with Nurse B, the least negative of the three nurse characters. Carmela notes that Tony is actually out of bed and sitting in a chair: "You've got him up?" Nurse B: "I know how it looks, but he should be upright as much as possible." Nurse B does not explain how this helps Tony; instead, she just checks something off-camera, and leaves quickly. Then, Carmela gives Tony (who isn't speaking yet) lip care with a Q-tip, saying: "That's got to feel good; the simple things." Indeed. One thing that might seem simple is nurses' critical efforts to help sick patients recover by being more and more active, sitting up, walking and so on--efforts that prevent pneumonia, blood clots, and loss of bone mass and muscle tissue. The show's vague, fleeting reference to this is a small step in the right direction, but unfortunately, it's way too little too late. Even in this scene, viewers will likely remember Carmela's lip care, and the soundtrack, which is the classic "Wizard of Oz" song "Somewhere Over the Rainbow." Hey--maybe that's where we can find a fair depiction of nursing in a TV drama.

Somewhere over the rainbow
Skies are blue
And the dreams that you dare to dream
Really do come true

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