Midnight in the Garden of Nurses and Murses

February 2007 -- Five recent episodes of "ER" that chronicle the short ED stint of nurse Ben Parker illustrate the NBC show's sometimes impressive--but still mostly inadequate--portrayal of nursing. "ER" is the only drama now on television to make any real effort to show that nurses are skilled, intelligent, and important to patient care. These episodes, broadcast over the last four months, highlight a strong, competent man in nursing. They also include examples of ED nurses' life-saving skill, patient advocacy and education, especially by tough, expert major nurse character Sam Taggart. But the show's physician-centric structure--after nearly 13 seasons, there is still just one major nurse character--and assumptions mean that each scene with such commendable features will be outweighed by many others suggesting that physicians provide all important care, including key things nurses really do. Notable examples in these episodes include the countless nurse-free patient handoffs from paramedics. Sometimes one scene sends all these messages at once. Showrunner David Zabel and Lisa Zwerling, MD, wrote, together or individually, three of these episodes; Karen Maser and R. Scott Gemmill are each responsible for one of the others. The episodes each drew roughly 11-13 million U.S. viewers.

"Tell Me No Secrets" (November 30, 2006)

"City of Mercy" (December 7, 2006)

"A House Divided" (January 11, 2007)

"Murmurs of the Heart" (February 1, 2007)

"Crisis of Conscience" (February 15, 2007)

"Tell Me No Secrets" (November 30, 2006)

Ben Parker

In Maser's "Tell Me No Secrets," Taggart introduces the other ED staffers to traveling nurse Parker, who hails from Savannah, GA. The veterans think he looks too soft for the rough public ED, placing bets on how long he'll last. There is a dismissive comparison to Georgia peaches. Taggart urges them not to scare Parker off, as she needs him to come back. Later, we see her continuing Parker's tour: "You have to be certified as an MICN in order to take the radio calls. But in the meantime you can use it to do status check. ... There's a new course starting next month, I'll get you the details." This indicates that nurses get professional certifications. (See clip 1 in broadband or dialup.)

These interactions, and other elements of the Parker episodes, suggest that nurses are responsible to other nurses (rather than physicians, as the show has often told viewers). The scenes arguably even imply that Taggart has some nursing management role, though the show has not made that clear since late 2005, when she supposedly became assistant nurse manager under departed manager Eve Peyton.

Wrestling

At one point, a belligerent patient approaches the nurses' station, loudly accusing intern Hope of stealing his diamond ring. Suddenly, he grabs her hard by the hair. Nearby nurses and physicians seem stunned, but Parker quickly wrestles him away: "You shut your pie hole and you come with me." Hope, recovering with the help of Taggart and nurse Dawn: "Thank goodness for Ben." As physicians Pratt, Morris, and Barnett stand and watch Parker subdue the man by himself, attending Pratt directs the staff: "Come on, come on, let's break it up, get back to work, not a big deal." (See clip 2 in broadband or dialup.)

We found this uproarious--many ED nurses will recognize this division of labor, though it's not clear how many viewers will get it. They will get what happens next, as Pratt notes to resident Barnett: "We just got shown up by a murse." Barnett: "Huh?" Pratt: "A male nurse." Barnett: "That's bad..." But as they continue to watch Parker wrestle the patient, attending Morris notes: "Yeah...he's pretty macho, though, huh?" Like a Georgia bulldog, maybe.

A little parlor trick

Later, this same super-aggressive patient starts spitting at everyone from his gurney in a hallway. Again, everyone seems helpless until Ben comes to the rescue, approaching from behind and wrapping a neck brace around the patient's face, explaining that guys like this can bite through masks. Even Ray is impressed: "Where'd you learn that?" Ben: "Just a little parlor trick I picked up at Savannah General." Morris in particular enjoys this, and he even feels bold enough to approach the patient, who now resembles Hannibal Lecter with his mask, and taunt him: "Can I get you some fava beans and a nice Chianti?" (See clip 3 in broadband or dialup.)

This is an effort to subvert Pratt's "murse" slur, which we last saw in 2003 episodes of NBC's "Scrubs." Parker has been set up as possibly too soft, but he comes roaring back as a "macho" guy who shows up the male physicians in subduing a dangerous patient. It's not clear if these events are teaching Pratt and Barnett that male nurses are just like any other men--maybe they're just thinking they've allowed a wimp to show them up. But we don't expect an explicit public service announcement about what the physicians have learned. In another subplot, the episode stresses Pratt's homophobia, which it clearly finds to be a problem. And Morris's "macho" comment seems to be the take-away message. Of course, some might wish the show could subvert the stereotype without popularizing the term "murse." We did note one apparent discontinuity. Pratt and the other male physicians seem to see the new "murse" as anomalous and presumptively effeminate, yet they have worked for years with minor nurse character Malik McGrath, who does not conform to that stereotype.

The dark side

The episode also touches on the nurse-to-physician transition of resident Abby Lockhart. When Taggart introduces Parker to Lockhart, he says evenly: "Hi...Abby--you're the nurse that became a doctor, right?" Lockhart (a little embarrassed): "Yeah, guilty as charged." Parker (kidding): "Got seduced by the dark side, huh?" Lockhart (smiling): "Well, I use my powers for good, not evil." Taggart: "Abby's an R3 now." (See clip 4 in broadband or dialup.)

The effort not to offend here is obvious and commendable, though on balance the exchange is probably a wash. Note how carefully Parker's "nurse that became a doctor" line is phrased and delivered. He's friendly, and not overly impressed or jealous, just acknowledging the move as something you probably don't see every day. The "dark side" exchange is more complex. Of course, on the surface it's a joking reference to medicine as something negative for nurses to do, something that has the seduction of power, but is perhaps less virtuous in some way. (We're actually not interested in nursing being seen as more virtuous, which could feed the "virtue script" image, under which nurses are noble but unskilled; we just want nursing to be seen as equally important and worthy of real respect.) But Parker doesn't seem to have any specific "dark side" problem in mind, or to be thinking of the serious public health consequences of a skilled nurse quitting, so the line reads as just a friendly poke at someone who left his profession for one that has a sometimes tense relation with it. Lockhart's response suggests that physicians have more "power," and of course, they do have more social, economic, and professional power. But viewers could easily take the statement to mean physicians have more life-saving power.

Near the end of the episode, Taggart and Parker have a brief exchange about his first day. Taggart: "Pretty easy once you get the hang of it, huh?" Taggart is presumably just trying to persuade Parker that it wasn't so bad so he will come back, but we don't love the suggestion that a public hospital ED nurse would ever suggest, without apparent irony, that the work was "easy." It really isn't something that a physician character would say about ED medicine, and of course, the entire series shows that there's nothing easy about work in an underfunded trauma center serving vulnerable urban communities.

Nurse-on-nurse communication

Parker says he appreciates Taggart showing him the ropes, and she hopes he'll consider staying. His response is essentially to ask her out. The scene cuts with the two of them gazing at each other with interest. This doesn't just make the point that he's straight, but it also does something rare even for "ER"--it suggests that not all interesting personal relationships in the hospital involve at least one, and preferably two, physicians. These two characters don't seem to have much of a spark, but that's not the point. (See clip 5 in broadband or dialup.)

An interesting side light is the appropriateness of the relationship if Taggart is a manager. The show periodically touches on the issue of physicians having relationships with physicians above or below them in the heirarchy, as this very episode does with resident Ray and medical student Katy, and others have with ED chief of medicine Luka Kovac and girlfriend Lockhart. Of course, it remains unclear if Taggart is still a manager, but if she is, the implication could be that nursing isn't important enough to raise that issue. Taggart might be a nurse manager, but she's not shown to be a real manager.

Dawn

The episode also includes several scenes with new minor nurse character Dawn. Unfortunately, Dawn seems to spend a lot of her time commenting on the actions of the physicians, and notifying physicians that they are needed by other physicians. (See clip 6 in broadband or dialup.)

Sexual assault "nursing"

A key plotline in the episode emphasizes the show's refusal to admit that skilled sexual assault forensic (SAFE) nurses, not physicians, typically do the sexual assault exams at major trauma centers. This plotline involves Danielle, a school girl who arrives having been the victim of an apparent sexual assault. As is often the case, no nurse is involved in the handoff from the ambulance paramedics. Kovac sees that Danielle appears to have been assaulted. He asks for an evidence bag, and goes to Lockhart to do the rape exam. Now, veteran nurse Haleh Adams does have a role: she sets up the exam materials for Lockhart. Lockhart gently explains to the frightened Danielle everything she's going to do. Perhaps the SAFE nurses who actually do this work would be pleased with that. Meanwhile, Adams stands by silently. Later, Lockhart reports to Kovac and a police officer that the rape exam evidence for Danielle is sealed and waiting for the officer's signature ("just see Haleh"). (See clip 7 in broadband or dialup.) Still later, as Danielle's distraught mother tries to comfort her and elicit some information, Adams is around, but she's not doing much.

When surgical resident Neela Rasgotra comes to check on how deep Danielle's cuts are, the girl sends her mother out to talk to the police. Once again, Adams stands by silently. Then Danielle suggests that she knows the cuts are not too deep, which implies that they are self inflicted. But when Rasgotra asks how she know the cuts are not deep, Adams finally finds her voice, asking gently: "Honey...did you do this to yourself?" It turns out that she did, as an apparent result of witnessing a brutal rape of her mother long ago. (See clip 8 in broadband or dialup.)

The problem is that the clear impression this powerful plotline leaves is that nurses are bit players in the care of sexual assault victims and the investigation of these crimes, when in fact they play a leading role. SAFE nurses are specially trained to provide psychosocial and other care to these victims, and to collect the vital forensic evidence that will be needed for possible criminal prosecution. The depiction of Adams as a largely passive, silent assistant in the care of this patient is a damaging distortion. And nurses do not typically wait meekly for surgical residents to stop by and effortlessly elicit key information.

"City of Mercy" (December 7, 2006)

This Christmas episode was written by David Zabel and Lisa Zwerling, MD. Although an early scene features the common nurse-free patient intake from an ambulance, we were impressed to see Taggart and Parker together wheeling in a homeless patient found on the street, presumably by paramedics. (See clip 9 in broadband or dialup.) Morris soon introduces himself to the patient, Lenore Simpkins. But for the most part the episode presents Taggart and Parker as taking the lead on Lenore, who mostly seems interested in escaping the bitter cold.

Taggart--the observant, holistic nurse--soon notices that Lenore has a hospital wristband, and she asks if Lenore has recently been hospitalized. Lenore says that she was at City of Mercy hospital until the previous night with a "chest cold." Lenore: "Lady at the hospital said the ambulance was gonna take me back." Taggart: "Back home?" Lenore: "Don't got one...I make my own way." Taggart: "Well, then, where'd they drop you off?" Lenore: "They left me in a alley near 18th Street....I haven't slept in that neighborhood in years." (See clip 10 in broadband or dialup.)

Taggart starts calling City of Mercy, but can't seem to get a good explanation. She tells Parker: "Mercy said she walked out on her own as far as they know, some administrator's going to get into it." Parker, looking past Taggart, notes: "Looks like they already have." We see that two ambulance drivers appear to be swiping Lenore. Taggart confronts them: "Hey...where you going? She's not ready for transfer." Ambulance guy: "You the nurse on this one? We're from Mercy, we're gonna take her off your hands...Our supervisor said it was all a misunderstanding." Lenore (distraught): "You takin' me back outside." Taggart: "No, uh-uh...you're not takin' her anywhere until somebody explains what's going on." Ambulance guy: "C'mon, a patient ended up in the wrong place, let's not blow this out of proportion." Parker: "No, you heard the lady: Turn it around." And he does. (See clip 11 in broadband or dialup.)

Later, Lenore asks Taggart if she can stay at the ED. Taggart notes that Lenore's getting better, her oxygen level is improved, and she doesn't really need to be hospitalized any more. Taggart asks if there's somewhere Lenore would like to go. Lenore: "Not the street; not tonight." Taggart: "Got any family?" Lenore: "My parents are in Gary, Indiana, where I grew up. But we haven't talked in a long time. I don't know if they'd even recognize me." Taggart tells Parker: "Poor lady's all alone in the world." Parker: "At least we can clean her up, set her up with a new set of clothes for Christmas. I'll see what I can do." (See clip 12 in broadband or dialup.)

A well-dressed woman named Hillary Lerner arrives from Mercy, looking lost among the rabble of a public ED. Taggart immediately dispenses with the pleasantries: "Is it your policy to dump destitute patients on the street?" Lerner: "Why would we do that?" Sam: "Bad for your neighborhood." Lerner: "There was a mistake with Miss...." Taggart: "Simpkins?" Lerner: "That's why I sent my people--" Taggart: "I'm not going to release her so you can have a second chance to make her disappear down some scummy alley." Lerner: "I'm not sure what she told you but--" Taggart (briskly): "Come with me. As far as I see it, you've behaved very badly, so here's your lump of coal, OK? You have your boys take Miss Simpkins to her parents' place in Gary, Indiana." Lerner: "Gary? That's over an hour away--" Taggart: "You pay for the full round trip service and this will never happen again. Because if I ever get wind of another patient being dumped by your hospital, I will call the cops and the news so fast that I'm not sure if you're gonna get fired or arrested first, you got me lady?" Lerner assents. Taggart pulls back the screen on Lenore's bed and addresses her patient brightly: "Hey, Lenore, this is Hillary. She's gonna make sure you get to see your parents for Christmas." Lenore beams. (See clip 13 in broadband or dialup.)

Near the end of the episode, Taggart and Parker are having a drink at a bar. Parker says he spent a couple years in the military (presumably as a nurse--the percentage of male military nurses is far higher than the number for men in nursing generally). Since then he's been "working as a traveler." Taggart says she traveled too, but got tired of it. She's curious how long he's staying, and he notes that County does have "pretty great people. I mean, like, what we did for that lady today--what you did--that was something." Taggart: "Come on--everyone deserves a little bit of happiness at Christmas time." Parker says he called the "nursing director" and signed on for another month. Taggart is clearly pleased. (See clip 14 in broadband or dialup.)

In one of the last scenes, the City of Mercy ambulance pulls up in front of Lenore's parents' house. On the soundtrack we hear Sarah McLaughlan's cover of "River," Joni Mitchell's song of Christmas and loss. Lenore gets out of the ambulance and approaches her parents, who stand in front of the house. Lenore tearfully embraces each parent. (See clip 15 in broadband or dialup.)

This is a fairly compelling depiction of patient advocacy. It's true that Lenore doesn't seem to have any serious physiological problem, so some viewers might view her case as a "light" one, not requiring what they might see as the advanced skills of a physician. And some might not get that Taggart is not just a nice, strong person, but a skilled nurse doing what nurses are trained to do. But we can't really quarrel with a plotline that shows Taggart to be such a fierce and effective advocate. She looks beneath the patient's immediate "medical" problem for root causes, and takes the initiative to pursue a course that is more creative and forward-looking than just dumping her back on the street (whatever happens to Lenore after that first tearful hug). Of course, it's hokey, and it might have been better to put Lenore in touch with some professionals, like a social worker, who could explore more long term solutions for whatever landed her on the street. But hey--it's coming on Christmas.

And we also appreciate the two-nurse clinical approach. It's rare for Hollywood to depict the reality that nurses work together to provide much if not most of the bedside care that patients get. Normally, we're lucky if a show even has a nurse helping the physician character it pretends would give the nursing care. And, perhaps since it's Christmas, we even get a reference to the "nursing director," rather than a suggestion that Parker has been hired by some physician.

"A House Divided" (January 11, 2007)

This episode, by R. Scott Gemmill, features a series of quick nursing portrayals that range from very good to awful. Sometimes, we see that range in the same scene, or series of related scenes--a depiction divided, you might say.

Taggart, Parker interactions

One plotline involves two boys who've had a bad snowmobile accident. In an early trauma scene showing the care of one boy, we actually see both Taggart and Parker, and they each have lines! Normally, even on "ER," trauma scenes have at most one significant nurse character, who may have a few short lines. We may see one or more wallpaper nurses at the edge of the frame, doing something supportive but never speaking, giving viewers a subtle but persistent sense that nurses are pretty much about busy hands. (Often, these actors are the real nurses who are on set to show the actors playing physicians how to do things.) We applaud "ER" for recognizing, in this scene, that nurses are speaking and thinking members of the trauma team.

In the scene in question, we see Parker announce: "Sat's are drifting into the 70's." Taggart addresses the patient: "C'mon Clarke, stay with us..." As they work, Taggart and Parker are also handling some personal tension between Kovac and Lockhart about the right treatment for a pneumothorax. The nurses try to inject some good cheer. When Parker says he'll call the blood bank, Taggart says this is a good idea. She also says she'll call for a portable chest x-ray. Parker says something only partially audible about "waiting on the sliding lung sound." The reaction of Kovac and Lockhart is ambiguous here. But later, Lockhart reports that there is no lung sliding, and Taggart asks: "What the hell is lung sliding anyway?" Kovac: "Normally there is lung movement [inaudible]--" Parker adds: "If it's not there, the lung must be partially deflated." Taggart responds, with mock chagrin: "Showoff." Later, with Lockhart proved correct, Taggart continues her interpersonal work: "Well, it looks like Abby was right, and Luka confirmed the diagnosis radiographically--good work, team." This sounds ridiculous, but the lines are so self-consciously forced, even ironic, that the real message seems to be, "I know there's tension, and this is my intentionally silly way of pointing out that we all make contributions and need to work together."

Unfortunately, the show undermines the positive force of the above interactions toward the end of the scene. Parker offers to take the patient to CT. Lockhart: "I'll take him...in case he crashes." This clearly suggests that physicians and not nurses are essential when a patient crashes. In fact, nurses are critical, and no patient this unstable should or likely would travel without a nurse. It is unlikely that a third year resident would be deemed essential but a veteran nurse would not. But this line tells viewers that nurses are expendable for such care, and physicians can do everything significant that nurses can do, which is false. Yes, we know Lockhart also happens to be a nurse, but we doubt that many viewers will sit there thinking: "Well, Lockhart isn't suggesting she can handle the patient alone just because she's a physician, it's because she's also a nurse." (See clip 16 in broadband or dialup.)

The episode includes other significant interaction between Taggart and Parker. Much of this concerns Taggart's troubled teenaged son Alex, whose role on the show seems largely confined to pouting. Parker shows some signs of being a father figure, and he tells Taggart that he himself was raised by his mother, that he had lots of behavior problems, but that things worked out all right and he's now close to his mother. Taggart's visiting grandmother Gracie schemes to get Taggart and Parker together, and after she, Gracie, invites Parker over for dessert, the two nurses actually do hook up. Unfortunately, their bliss will be short-lived, as the episode ends with Alex accidentally starting a fire in the living room. The Taggart-Parker interactions are not all that compelling, but they do at least show nurses having extended interactions with each other, a rarity in a Hollywood programming environment that suggests everything revolves around physicians.

Snowmobile plot

The episode's depiction of the care of the other snowmobiling brother, Dennis, includes more of the mixed portrayals, in this case involving veteran nurse character Lily Jarvik and resident Ray Barnett. Accurate, helpful messages about nursing alternate with damaging distortions and expressions of disrespect. Jarvik explains to Dennis about his brother's care, noting that "they put a tube down his throat to help him breathe." However, when Barnett brings in Dennis's step-father, he introduces ED intern "Dr. Gates" and surgical resident "Dr. Rasgotra," but completely ignores Jarvik, who apparently has the same status as the equipment. Yes, we know this could really happen--many nurses have trouble introducing themselves--and maybe we're expecting too much. But the show gives no indication that it sees any problem with a physician introducing other physicians to a father but pretending the nurse working to save his son doesn't even exist. Jarvik does get to show the father where his other son is, but not surprisingly, it's Barnett who provides the psychosocial care to the patient.

Later, when Barnett is outside in the ambulance bay, Jarvik pops out of the ED saying: "Your snowmobile kid's not lookin' too good." OK, but "your snowmobile kid?" Does Jarvik agree that she herself is more a piece of equipment than a member of the team? Jarvik does play a role in this declining patient's care. As the team works, she notes: "Crit's stable, he's not bleeding." Barnett asks for surgery. Jarvik: "I already called them." Barnett gives a series of brusque instructions ("Page Neela, tell her I need her down here now!") because he's upset that the kid is having trouble. When surgeon Rasgotra arrives, Jarvik notes: "Systolic's only 90 after 2 liters." When Barnett asks for the patient's father, Jarvik says she already sent fellow nurse Dawn to find him. It certainly seems like the show has taken to heart something the Center began pointing out long ago, that nurses would already have done many of the things it has physicians commanding them to do.

Yet soon after, Barnett tells this same father that he, Barnett, "sent a nurse" to find him 30 minutes ago. Of course, in isolation this suggests that nurses report to physicians, who must tell them to do basic things. But given what the show just said--that one nurse asked another nurse to get the father--what are we supposed to think? Is this just a small example of discontinuity? Or does a physician, as health care overseer, own all nurse actions, even if they were done with no input from him? And no, the show does not seem to be suggesting that Barnett is wrongly taking credit for Jarvik's actions; it's seems a lot more like it's just giving him credit for Jarvik's actions. (See clip 17 in broadband or dialup.)

Baby-sitting

Other scenes illustrate how the show tends to have physicians assigning nurses to what amounts to child care. At one point, Lockhart receives an injured hockey player from the paramedics. Predictably, no nurse is part of this important handoff. But Lockhart does assign nurse Margo to watch the patient's son, who Lockhart suggests can play X-Box. Later, Gates sends Taggart off to watch his young friend (and possible daughter) in the break room. Sure, nurses provide psychosocial care to families, but we rarely if ever actually see them do that on "ER." Instead, such scenes suggest that the physicians are needed for critical care, and nurses are available for child care, even for the children of physicians, since the nurses don't have any comparably important patient care duties. (See clip 18 in broadband or dialup.)

Professional development

One final scene deserves mention. Near the end, Lockhart is saying an emotional goodbye to attending Kerry Weaver, who's going to Miami to be a television health reporter / personality. Lockhart:

I just wanted to say that I think you've probably seen me at my best, and at my worst. And even though we didn't always see eye to eye, you helped me go from a nurse...to a med student...to a doctor ...to a mom.

Maybe the inclusion of "mom" is supposed to blunt the idea that Lockhart is describing an upward progression. After all, nothing could really outrank "doctor," so maybe Lockhart's just describing a series of new experiences, in chronological order. But it's not enough, given the intensely self-satisfied way actress Maura Tierney says the word "doctor." It really seems that Lockhart has become something exalted from such humble nurse beginnings, and so the statement reinforces anti-nurse biases in a powerful way. Weaver's response is more neutral: "You were always there, as a nurse and a doctor and...most importantly, you've always been here as my friend." But the damage is done. (See clip 19 in broadband or dialup.)

"Murmurs of the Heart" (February 1, 2007)

This episode, by David Zabel, has a very good example of Taggart's technical skill. It starts with Taggart and Parker in bed at her apartment, sensing the fire Alex has set. Chaos ensues and firefighters arrive as the building becomes engulfed. The episode seems to suggest that Parker and Gracie get out, but that they've lost track of Taggart and Alex, raising the question of why the macho Parker would leave his love interest and her son to perish in the fire. But maybe it's so Taggart can be that much more of an action hero: soon we see her smash out a high window and call to the firefighters, through her coughing: "I got a little boy and a man with extensive burns."

The show cuts to Taggart and Barnett wheeling Alex into the County ED. Taggart: "He's got smoke inhalation, no thermal burns, sat 94%." When Taggart notes that Parker was also involved, Barnett asks if she means Ben, "the murse?" Taggart ignores the term.

Taggart defers her own treatment, and joins Morris, who is receiving her elderly neighbor Mr. Owens, the burned man she helped get out of the building. The paramedics are reporting burns to his face, chest and arms. Morris barks out various orders, though as is often the case in hospital shows, it's not clear who is going to carry them out (it's enough that physicians appear commanding). Later, Morris, Barnett, Dawn and Taggart are working on Mr. Owens. The physicians are having trouble with the central line. Meanwhile Taggart talks to the patient, explaining that she's not sure how the fire started. Taggart advocates for pain medication, and Morris prescribes morphine.

The physicians are having trouble intubating the patient, whose nasal hair is singed. Morris rejects the fibreoptic option, as there's not enough time. He notes that the airway is already swollen, and they have to get in before it closes. Barnett tries repeatedly to insert a breathing tube, but he can't see the cords, as there is too much edema. Morris: "Help me out, Ray, we don't want to crich this guy." Barnett can't get it. But Taggart intervenes, telling them to hold on, getting a stool and standing over the patient. She starts pushing the sides of the chest, telling Barnett: "Watch carefully, OK? Look for bubbles. This will force the air back up through the trachea. The bubbles will show you where to place the tube." Morris: "That works?" Taggart: "Once in a while." Barnett: "Woah...that's really good, I can see it." He's in, and all is apparently well. Morris is thrilled: "Sam is the man." (So--does that make her a murse? Barnett does not say.) (See clip 20 in broadband or dialup.)

Clearly, this is a great example of an experienced nurse teaching a resident--and an attending-- about a clinical technique that appears to be critical to the patient's immediate stability. Tagg\art thinks quickly and acts effectively. Perhaps some viewers will figure she just knows this because she's been around longer, but in fairness, the show often has senior physicians doing impressive things that seem to be mainly a result of their having worked for a longer time and seen more. Of course, the reason Taggart had to do all this was her troubled son, who has always been associated with poor decisions Taggart made earlier in life. Still, in the clinical setting, Sam does seem to be the man.

"Crisis of Conscience," (February 15, 2007)

Physician disruptive behavior

This episode by Lisa Zwerling, MD, features a couple short scenes with significance for nursing. In one early scene, surgical chief resident Dusty Crenshaw is with his girlfriend, ED resident Jane, in the call room. We see Crenshaw on the phone, saying:

Since it is plainly ludicrous to page a surgeon at 6:15 in the morning for something as silly as Tylenol, the only conceivable explanation I have for your call is that you have crush on me. I'm flattered. Thank you, goodbye.

Crenshaw explains to Jane: "New ICU nurse, she's useless. Someone needs to show her the ropes." And the mention of "ropes" leads back to the couple's S&M activities. (See clip 21 in broadband or dialup.)

This kind of thing could be all right. Some nurses are inexperienced or subject to poor judgment calls, just like the members of any other profession. And the show carefully limits the scope of Crenshaw's words: this nurse is "new," "someone" needs to show her "the ropes," and so clearly not all ICU nurses are "useless." The show even resists suggesting that that someone is a surgeon--otherwise, Crenshaw might have said that he himself would do it--which allows for the possibility that it would be a senior nurse.

Unfortunately, this glib scene, by itself, sends a damaging message about what is actually a critical situation. It's not just that it seems unlikely that even the most "useless" ICU nurse would feel the need to wake a surgeon for Tylenol, and that some viewers might conclude that any idiot can become a nurse, despite the positive examples of nurses like Taggart and Parker.

But more fundamentally, in real life it is more likely that a nurse would be calling a physician about something important and have difficulty getting the physician to take the problem seriously, especially if the physician was away from the hospital premises. Even worse, many nurses have encountered the kind of abuse Crenshaw dishes out when bringing potentially life-threatening care issues to the attention of physicians. Not surprisingly, this contributes to nursing burnout. And it threatens patients: the immediate one who may not get the care she needs, and future ones, because the abused nurse will be less likely to call in the future. In sum, it might have been fine for the show to include this kind of interaction if it did anything to illustrate the larger context. But we can't recall seeing that, certainly not in this episode, and the result is to trivialize a serious issue.

The nursing shortage

The other significant scene occurs when Taggart and intern Gates are going out to the ambulance bay to receive a critical patient. Maybe we should be glad that Taggart is even present, and that she speaks to the patient, reassuring her, as other scenes in the episode feature physicians receiving critical patients with no nurses at all. On the other hand, even in this scene, the paramedic pointedly gives her report only to Gates, ignoring Taggart.

Anyway, on the way out Taggart tells Gates that the nurses are short-staffed: "Lily's sick, Marquez is out on vacation, and the rest of us are doin' doubles tryin' to cover all their shifts. This is why nurses quit: burnout." Gates (sympathizing): "The shortage just keeps getting' worse. What about your boy Ben?" Sam: "Uh, he was lured to a hospital in Minneapolis. New cars for nurses willing to stay six months." Gates: "You cool with that?" Sam (smiling): "What--like I got left for a Camry? Nah, it's a good gig. I can't blame him." (See clip 22 in broadband or dialup.)

We appreciate the show's effort, even in passing, to tell its viewers that there is a nursing shortage, and even that it relates to clinical conditions like excessive overtime, rather than some temporary glitch in training new nurses. No other Hollywood show really does this, and ER does only very rarely.

Unfortunately, viewers may get a distorted impression of the shortage from what we see here. Excessive overtime is a factor in nursing burnout, and in the nursing shortage. But nurses burn out when no one is sick or on vacation. Many are regularly short-staffed, and pressured to work excessive overtime, because of a failure to allocate sufficient resources to staff them adequately on an ongoing basis. This has resulted in many fleeing the bedside. And the same undervaluation of nursing that has driven short-staffing has led to underfunding of nursing education, limiting the number of new nurses who can be trained, even as the Baby Boomers start to retire. In addition, the lines in this scene are a bit of a throwaway, coming right after the show returns from commercial, with the naturalistic bad sound sometimes found on "ER." So many viewers may miss what is going on as they refocus on the show. In this respect, the scene is reminiscent of a 2005 one in which ED nurse manager Eve Peyton announced that the hospital had agreed to minimum nurse staffing ratios.

In any case, the scene clearly marks Parker's exit with a whimper. Perhaps that is not surprising given that the character never really did seem to click on the show.

Liver failure patient

As for Taggart, she goes on to provide more substantial care to the patient she received with Gates. This patient turns out to be a serious gambling addict who is committing suicide by chemicals, in order to help her sons escape the debt she created. At one point, Taggart even defibrillates the patient, which is extremely rare for a nurse to do on "ER," especially when there are physician characters available. After some time, the team determines that the patient has moved beyond hope of recovery (supposedly in part because a long period of CPR has deprived her brain of oxygen, an interesting notion since the whole point of CPR is to keep blood flowing to the brain). Taggart then has exchanges with Gates about whether the patient should continue to get Lidocaine and be treated as a "slow code." These scenes arguably suggest that Gates is the real patient advocate, and Taggart a bit of a rule-bound bureaucrat. But they also suggest that Taggart is probably correct that it's not the health workers' call at that stage whether to withhold aggressive treatment. Chief of ED medicine Kovac later agrees with Taggart. (See clip 23 in broadband or dialup.)

Summary

Of course, in these five "ER" episodes, we're focusing on a relatively small number of plotlines and scenes. With all major characters except one still physicians, there remains little doubt which profession really matters in the show's vision of hospital care. Physicians provide the vast majority of the care the show presents as significant, especially when Taggart is absent, and this includes nursing care. Physicians dominate virtually all care discussions. Nurse characters typically receive direction without comment, though they may inform the physicians of aspects of a patient's condition. Mute uncredited nurses continue to provide the dramatic wallpaper for many trauma scenes. We give the show credit for making many efforts to highlight the nursing role within this structure, and Parker's brief stint is a mostly commendable example. But as long as the show's overall structure and basic approach remains the same, it will continue to send a distorted, physician-centric message about emergency care.

Please send "ER" our instant letter, or one of your own, and let show producers know what you think of their portrayal of nursing. Thank you.

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