pop culture

An ER Nurse’s Thoughts While Watching NBC’s ER

Growing up, one of the TV shows I was not allowed to watch was ER. My parents deemed it “too scary” for me. I was furious when my older sister was eventually allowed to watch. The irony, of course, is that now I am ER nurse…without ever having been influenced by the show directly.

Most of my job my parents understand from the context of the show. In fact, most of the public understands health care from the context of medical TV shows. I think this is good in the fact that the public can build empathy for providers. However, this is not great when cardiopulmonary resuscitation (CPR) rates in TV shows are much more successful and can influence people’s understanding of how CPR works. Worst of all in my book, the roles of various health care providers are almost always skewed. Physicians are shown doing the work of nurses, certified medical assistants, physical therapists, respiratory therapists, almost everyone. This is not to say that doctors are not important. It’s only to say that patients can have a skewed perspective that their doctor needs to tell them everything when truly another person on the medical team can do so.

In general, I’m not a fan of medical dramas. I’m especially not a fan of the cynical The Resident on Fox and burst out loud laughing when I saw the name and the trailer. Residents running the show? Hilarious. Find me in July and ask me how many times I’ve directed the plan of care and convinced the resident they can give more than 650mg of tylenol. Scrubs is about the only medical anything I’ll watch, and I’m too scared to re-watch it since becoming a nurse and tainting my rosy memory of the series that I watched in entirety my first semester of college.

So why would an ER nurse who has sworn off every medical drama from Grey’s Anatomy to The Good Doctor attempt to watch ER? Well, mostly to prove a point. At home, I would go over patients I have seen, and my dad asks me if we did a CBC and Chem Scan. Then I would proceed to argue no one calls a basic chemistry panel a chem scan. When ER went on Hulu a couple months ago, I decided to give it a watch to see what they actually call Chem Scans (Hint: it’s a Chem 7). Too, a patient once called me Nurse Hathaway, and I wanted to figure out if that was a compliment or insult.

Surprisingly, there’s a good chunk of literature surrounding TV shows. Did you know a negative portrayal of nurses in medical show affects recruitment? Weaver et al. (2013) found an association. Did you know E.R. created platform to discuss modern health care delivery? Lepofsky and colleagues (2006) thought so. But does E.R. also play into people’s fantasies for better health care? Nielsen and Baerheim (2005) thought so. E.R. was also thought to fight nurse stereotypes according to Rice (1996) and could help with health literacy according to Primrack et al. (2010). (Really? With those defibrillation paddles and all? Shocking people when it’s not indicated by ACLS? Really?!)

Despite obvious flaws and unclear side effects on my profession, I’m hooked. Unfortunately, I’ve been watching it alone and have not had the chance to rant about how inaccurate it can be. So, here’s a handful of thoughts I’ve had while watching Season 1 that I’ve been keeping to myself. 🙂

How are people sleeping on the job? How many episodes have a resident like Mark Greene or Susan Lewis sleeping on one of the rooms? I don’t get it. Working nights in the ER when I first started, no one slept on the job. Yes, medicine and surgical residents or ER residents on an off-rotation will have on call hours where they sleep in on-call rooms, but I have never heard of an ER doctor doing this. Also, sometimes they show them having 24 hours shifts. Does not exist in the ER. That would be horribly unsafe because ER doctors are awake and seeing patients their entire shift.

Why is Mark Greene doing a crash C-section in the ED?  Much of season one episode nineteen (Love’s Labor Lost) focuses on the drama of Dr. Mark Greene taking care of a mother in labor as the case gets worse and worse. But this is not the only episode where all kind of surgery is happening in the ER. Why are they doing an “emergency” re-vascularization surgery in the ED? Hellllllooooooo! There’s an operating room for a REASON. We do not do surgery in the E.D. Ever. Yes, thoracotomies happen. Intubations happen. Cutting does happen. But why they are doing complex surgeries on a regular basis in the ER is completely unrealistic. ER attendings are not taught how to do those! Oh, and the episode where the ER VOLUNTEER STARTS DOING SURGERY!? Lost it to laughing.

WHO THE H*LL ALLOWED A MEDICAL STUDENT TO PUT IN A CENTRAL LINE ALONE?!?! Why are Mark Green and Susan Lewis never checking in with anyone? Where is the attending? Resident physicians must be supervised. Medical students must be supervised, especially in a procedure they have never done before. Invasive ones like central lines require supervision. It’s realistic that eventually medical student John Carter would be left alone to do sutures, but no attending ever would risk their license and give these medical students and residents the freedom that they have on the show. On that note…

Why are people calling John Carter “Dr. Carter” in front of patients when he is a medical student? And why is he calling himself a doctor when he’s a medical student? I get calling people “doctor” to make them think harder. I’ve had attendings call me that when asking me a diagnostic question since they know I’m in nurse practitioner school. It adds a new level of responsibility and thinking. I get it. But no one calls medical students “doctor” in front of patients. It is misleading and frankly dishonest. Medical students are getting their doctorate, yes, but at that point, they are still in school and not a doctor. Residents have graduated and are doctors. So, why is everyone routinely calling John Carter “Dr. Carter?” Makes no sense.

Why does John Carter never leave the ER? Medical students rotate through different specialities each month during their 3rd and 4th years of medical school. So, why does John Carter who did a dermatology rotation never seem to leave his surgical one? He’s there for months on end! Even general surgery residents would switch rotations within general surgery from trauma to acute care surgery to minimally invasive surgery, etc., especially if they are an intern or in their first year of residency. Why John Carter and Dr. Peter Benton are constantly in the ER and even seeing ER patients is bizarre and completely inaccurate. Also inaccurate is Carter getting a whole summer off. And in season two,  Carter has a sub-internship (or Sub-I) with Benton where he acts as if he were an intern or first-year doctor. These exist and are helpful for 4th year medical students, but again, he never leaves the rotation. Constantly being with Benton and constantly being in the ER is inaccurate.

And speaking of John Carter, who is going to have a discussion with him about his choices with females? Sleeping with a patient?! Who surprised you in your car after work!? Attempting to sleep with your supervising resident!? Doing sensitive exams as a medical student on women without a chaperone!? Will this guy even make it through medical school to become a doctor!? Seriously, I do not know a single a man in medicine who would dare touch a female patient between the legs without someone else to witness that he was not violating her. I’ve been called in to chaperone breast exams, even for female providers. Maybe patients did not sue as much in those days and maybe Dr. Larry Nassar was still viewed as a reputable physician at the time, but holy moley, someone needs to talk to Carter.

However, aspects of the inter-professional romantic relationships are realistic. Allegedly, one of the residents I used to work with had to have a “talking to” for getting “too friendly” with the nurses (and ended up married to a fellow resident). Most of season one centers around the relationship of nurse Carol Hathaway and pediatric emergency resident Doug Ross. During season one, despite mutual feelings for one another, Carol dates and becomes engaged to orthopedic surgeon John “Tag” Taglieri. I just started season two, and a paramedic is already dating with this well-loved ED nurse. I could start listing the number of residents, doctors, paramedics, EMTs, ER technicians, nurses, etc. I know who are married or dating one another, but it’d be a lot to list. Anytime there’s a workplace, there’s going to be workplace romance. Sometimes they’re illicit like Benton and married woman and physician’s assistant student Jeanie Boulet. In real life, most people are smart enough where it doesn’t happen at work because if it happens at work, people are going to talk to you about it and your job might even be at risk because it’s unprofessional.

What physical therapist (PT) would go back to school and become a physician’s assistant (PA)? I do not understand a lot of the life choices of Jeanie Boulet, this being one of them. Both schoolings are at least 2-3 years. Sure, according to a quick Google search, PAs make a little more than PTs, but it seems like a lot of school for a small pay increase. Too, I don’t like how it is implied Boulet and her husband don’t have that much money. PTs make good money.

Why would any resident in their right mind, even Doug Ross, show up in their own ER drunk and be allowed to work the next day? This would not happen, merely because the resident would be kicked out or severely punished. Yes, I worked with a resident who I once overheard talk about how he had a girl over who used his iPad to snort cocaine, but even he was smart enough not to show up drunk to his own ER. And then, and then, Carter and Lewis are drinking alcohol on the hospital’s campus. WHAT!? Seriously, would not happen. It does happen when doctors, nurses, and other health care members are addicted to drugs and alcohol, but on a typical day for a typical hospital worker it does not.

Can we please talk about this insane commute Dr. Mark Greene has from Milwaukee to Chicago? Some of the drama of season one center around Dr. Mark Greene and his wife who graduates law school and takes a job in Milwaukee. Greene takes this commute of about two hours regularly. Insane. Just insane. With 12-hour shifts and then a commute like that!? Insane.

Really!? A mass casualty being called more than once in a season? I work at a trauma center and have for over 3 years. We have yet to have one mass casualty, though we do run annual drills. Yes, we’ll have crazy nights and days, but mass casualties with SALT triage are rare for a reason. On that note, why are they doing CPR during a mass casualty? In real life, this would not happen. The patient who be marked expected as in expected to die. In true mass casualty scenarios, a hospital does not have the usual resources it has to spare staff to do CPR. On that note…

What is with these chest compressions? Did they even take a CPR classSeriously, the number of chicken-wing compressions going on in this show is abysmal. I have been told and I tell others, “If you’re not breaking ribs, you’re not doing it right.” And this is so true because you need enough force to pump the heart. This video is more like it:

On that note, WHO THE H*LL IS RUNNING THESE TRAUMAS LIKE THIS!? Watching a trauma resuscitation on E.R. gives me heart palpitations. They’re calling out labs and testing as the patient hits the cart. WHAT ARE YOU DOING!? YOU DON’T EVEN KNOW WHAT’S WRONG WITH THEM YET!! Do they even have a pulse!? Are they breathing!? ARE THEY EVEN ALIVE!? If not, none of those tests matter.

Basically, if a trauma ever ran like this in my ER, I would have a strongly-worded meeting with my managers and whoever I was training. Why? Because beginning in the 1978, a course called Advanced Trauma Life Support (ATLS) was taught so traumas would be run in a systematic fashion. The course was created by an orthopedic surgeon named Jim Styner after a tragic accident claimed the life of his family and his children were injured. He saw the care they received was chaotic and inadequate, so he created ATLS. I audited an ATLS class at my first nursing job, learning how to intubate and place chest tubes with first year residents, though my license does not go that far. As an ER nurse, I can take ATLS or Trauma Nurse Core Course (TNCC). Both classes teach a systematic A (Airway), B (Breathing), C (Circulation), D (Disability), E (Exposure) pattern to traumas.

This is why ER’s traumas given me palpitations. They are not systematic and extremely chaotic. To an outsider, our traumas may look chaotic as well, but everyone at that bedside knows ATLS or TNCC, making it a lot more organized than it appears on the surface. Here’s a decent video on how they should run:

I really dislike this drug rep lady. Who’s letting her walk around like she owns the place!? For a good chunk of season one, Dr. Doug Ross is paired with a flirty drug rep Karen Hines. I think it’s more of a cultural thing now, but drug reps are really not allowed to talk to staff like they used to. We have a couple who come around (as well as reps from nursing homes and hospices) come by and try to drop off literature or say they’ve been talking to someone, but really, unless the higher ups want a rep there, reps cannot routinely talk to staff.

Who is assigning these rooms!? In one episode in season one, a perfectly healthy man with some obsession with color was being seen in a trauma bay while a patient near death was in a room with curtains with other people. Why are they seeing a walking and talking person with shortness of breath who is speaking in full sentences in a trauma room while not one but two codes happened in a shared room in the same episode? WHO IS ASSIGNING THESE ROOMS? In my ER, it’s typically the triage nurses or charge nurse. Rooms are in order of severity, not by color preference. I cannot imagine a real-life Nurse Hathaway being so careless about room assignments. Too, not all ERs have curtains dividing patient care areas. Aside from what I call the “fishbowl,” a supervised internal waiting room for stable patients awaiting a test result, all our rooms aside from the trauma bays are private. Our trauma bays are divided by curtains. I am very thankful for real rooms. Sometimes the lack of them in the trauma room can lead to some…ahem, interesting…situations.

Who is touching their face and hair after just touching bloody and urine-filled patientsSo, true story, infectious disease once told us in a staff meeting that they had seen someone have poop on their hands while leaving a room, and our staff lost it. No one does that. We are very aware of blood, poop, urine, and whatever else on us. Maybe it was the 90s and they knew less about blood-borne pathogens then, but gross!

Now don’t even get me started on the organ donation process on this show. Organ donation is a beautiful thing, but the way it is shown on the show is beyond wrong. No one from the primary team – ER staff, surgeon, nurse, anyone – can talk to the patient or family about organ donation. It’s a violation of trust. Who is going to trust you to make a decision for that patient if you’re wanting his or her organs? In real life, we call a organ donation line if the person just died or if an alive person meets certain criteria like a decreased mental status or long-term ventilation. The organ donation team reviews the chart, and only if the patient meets a lot of criteria, someone from the team will come and approach the family. Now, we may all think organ donation, but none of us actively ask.

Question. How is Carol Hathaway a nurse manager and so involved in patient care while also floating all around the hospital? I adore my managers. They have my back, are dedicated to patient well being, and are very approachable. However, they are rarely in the thick of things, and even so, they are the most involved managers I’ve ever worked with. Having Carol be a “nurse manager” and still work as a nurse is unrealistic. Nurse managers have meetings, evaluations, hiring, budgeting, and variety of other responsibilities. Not that they don’t help out because they do, but having Carol run around like a staff nurse or even a charge nurse while calling her a nurse manager is just unrealistic. Too, I have seen her come up in different units too, continuing to care for patients there. Again, not realistic. ER nurses stay in the ER.

And if she’s a nurse manager, why would Carol Hathaway ever allow that awful peach color to be the nurse scrub color? For real, that peach color is horrible. I have worked at facilities that require all one color, but it’s been a nice royal blue or dark gray. Something that light is going to get blood or at least pen stains on it. At least season two they address it and change to a nice dark cranberry though some of that ugly peach is still lingering around.   

Essentially, I watch ER as I do Friends. Thankfully, someone else thought of this and created a cute little video like it:

Overall, I like the show enough to continue to watch season two. John Carter is probably my least favorite character who seems to be chronically unprepared and complimented on his appearance much too often. And if I have learned one thing (aside from that it’s chem 7, not chem scan), it’s that yes, the comparison to Carol Hathaway is a compliment. 🙂

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