A Review of Showtime’s Nurse Jackie

She Does What we Only Wish We Could Do to Some Patients

I recently watched the pilot episode of Showtime’s new show, “Nurse Jackie”, with the night crew. Jackie, played by Edie Falco, snorts crushed vicodin, steals money to give to the poor, forges an organ donor’s card, has sex on the job with the pharmacist who supplies her with the vicodin and flushes an arrogant jerk’s ear down the toilet after some choice words – and that’s just in the first episode.

In many ways – sex and drama aside – Nurse Jackie is the quintessential “take-no-crap” ER nurse that has served as an experienced den mother of sorts to so many young doctors and nurses still finding their way in the medical field. I still work with , and learn from, nurses like that, who continue to enlighten me with their experience, wisdom and knowledge. And no, I didn’t grab their boob or have sex with them in the supply room.   

On one hand, I fear that people will actually believe that nurses behave this way and treat them with even less respect.  I guess we will just have to leave it to shows like ER and Hawthorne to teach people to respect and admire the amazing efforts that nurses make to brighten, save and enrich so many lives on a daily basis in hospitals and clinics throughout the world. It is a noble profession that is too often the unsung hero. But back to the show …

Although it does present a flawed character portrayal of nurses, it is kinda fun to see someone act out what we all sometimes wish we could do with at least some of our patients. She has a distorted sense of ethics that leads her to do what will in the end be the most benefit to society in her opinion, and other times just gives people what we all know they really deserve. Except maybe her poor husband, but maybe the reasons for that will play out later.

From a doc’s perspective, I thought the whole Heimlich scene was coldly amusing. I get a similar feeling when responding to “Is there a doctor on the plane?”, because you really are never on vacation as a medical professional. It is a blessing, and sometimes it can be a drag, but no doubt it is wonderful to always be able to impact people’s lives – although not always in such dramatic fashion.

The nurses who watched it with me – male and female – enjoyed the show and were looking forward to future episodes. It presents an entertaining contrast to shows like ER and Grey’s where political correctness sets a border around the characters. So many of us in medicine hold back what we really think of some of the pathetic excuses for humanity that we see on such a regular basis from the the drug seekers, the self-righteous and those who feel they have the “right” to put us down, the domestic abusers who beat on their spouses, all the way down to child abusers and those who have children when they have no intention of doing anything remotely resembling parenting or loving, etc. It might just provide an outlet for those of us who bite our tongue and “do the right thing” even when it would feel so good to tell these people what we really think.

What I really want to know though is why the pharmacist has a bedroom in the hospital?

The Radiologist Examined a Patient!

Those of us in the medical field know the radiologists – the doctors who read xrays, CT’s, etc. – usually sit in their dark room all day and read films, often times with CYA statements at the end of their official report that say something like, “_____ cannot be excluded, and so a [another imaging study inserted here] would be recommended …”.  The type of person who typically goes into radiology is a person who doesn’t much like dealing with other people, and so they only “see” patients when, and if, they have to do a procedure, or if they pass them in the hall. It is rare that I even have the chance to discuss my clinical exam with a radiologist since they don’t usually seem to care about our seemingly worthless thoughts.

But in my hospital, I have the great honor (doesn’t always feel that way) of working with some of the smartest doctors in the world when they moonlight here away from their Ivory Tower. Their hospital is internationally recognized as one of the best medical centers in the world. Among this distinguished group are the radiologists that will moonlight here on weekends. I have to say that some of them have their nose so stuck up in the sky that we only look like ants to them, and that is how they speak to us. But something cool about medicine is that experience almost always trumps medical training. There are many nurses I would rather have treat me that some of doctors I have had the horror to meet.

So, last week I came into work and my first patient was a poor old woman who was run over accidentally by her husband with a farm tractor. I called to request a CT of the chest, concerned about flail chest and significant thoracic injury. The Ivory Tower radiologist balked at my request and stated with great annoyance (how dare I interrupt his computer game) that he would read it, but that he thought it was totally unnecessary. He felt a simple x-ray should provide adequate information. I responded by saying innocently that I was unaware that x-rays would show vessel damage since after all there are some big pipes running through the chest (aorta, IVC, subclavians and oh, that darned thing that keeps beating).

He made getting the CT a chore as well (some sort of punishment I suppose) by having the techs refuse to do it until I checked her kidney function. It was a trauma! Why should I wait for kidney function? But they insisted.

He humbly called me back an hour into this poor woman’s ER course to tell me, “Man, this lady’s really messed up!” I asked if that was his medical diagnosis.  The “official” report was that she had broken 10 ribs on one side, had a collapsed right lung, and bilateral lung bruising. Nah, we didn’t need that CT now did we? I resisted the urge to rub it in and focused on taking care of the patient instead.

But every now and again, we do get an exceptional resident from the Ivory Tower. This weekend, I have the true honor to work with one such radiologist. Professional and personable, so much so that I am almost convinced that he is not a radiologist by training. Maybe he’s like that guy from Catch Me If You Can? He doesn’t call us to give us reports, but comes in to see us in person on almost every case in order to discuss the case and provide his report. This not only makes him courteous, but way smarter than the other radiologists because getting the clinical backdrop is a very good way to not miss something important. When you understand in detail why the test was ordered , it helps you zoom in on the area of concern with a different perspective.

But then he did the unthinkable. Our stellar resident actually went and examined the patient! I don’t think that in all my years of medicine I have ever witnessed such an event. I thought radiologists had lost the art of examining patients by the time they finished their internship, but this guy proved us wrong. Kudos to you my friend and maybe you will be an inspiration for the others in your field to come back down to earth.

You Don’t Need to Come to the ER at 3am for “Strep Throat”

Among the more frustrating ER visits that you will never see on your favorite TV medical drama of choice is that of the 3am visit for possible “Strep Throat”. The sad reality though, is that this is something that we as a medical community have contributed to in a potentially large way. Some people are afraid of Strep because of the supposed connection to Rheumatic fever, while others are just uninformed (putting it nicely) and think that getting that holy prescription for Amoxicillin will make their discomfort go away in a space of hours (which it doesn’t). I guess I should be glad that most of them don’t come in trying to get Percocet to kill the pain (which doesn’t work well in this case either).

Regarding the whole strep and rheumatic fever issue though, I came across an article a few months back that addresses this issue. I will reproduce it at the end of the post for whoever would like to read it, but since it is medical speak to a degree, I thought it might be thoughtful to at least summarize it for those who don’t have the time or medical background to read it.

Basically, the article states that our current understanding that untreated Strep results in Rheumatic fever comes from only one large study that appears to be an anomaly. Two more recent and rigorous medical studies show that there is actually a relatively low risk of Rheumatic fever connected to Strep, and that the number of cases of serious side effects from our overly generous use of antibiotics far outweigh the risks of the limited number of cases of Rheumatic fever in this matter. It recommends against use of antibiotics in this case, but I wonder if the damage is already done? Trying to explain this to the average soccer mom would more likely result in a complaint than a “Oh thank you Doctor for looking out for our best interests!”.

In today’s internet society, too many people come to the doctor looking to get an order filled as opposed to getting an evaluation and medical advice. We keep saying that it is Burger King and we are not here to fill your order, but that message seems to have been missed by Hospital Administration and the general public.

For those who may be interested, here is the article:

Antibiotics for Strep Do More Harm Than Good

By David H. Newman, MD

Military and civilian medicine have always been intertwined, but nothing compares to the strange tale of Warren Air Force base in the 1940’s. Perched on the high plains outside of Cheyenne, Wyoming, the combat training center was, mysteriously, a bacterial cauldron. For more than a decade virulent strains of group A streptococcus caused unprecedented rates of pharyngitis among the trainees, and history’s worst epidemic of rheumatic fever.

A small cadré of military researchers at the base seized the moment, executing a provocative series of trials that tested the potential of antibiotics to prevent post-streptococcal rheumatic fever. Roughly 2% of the trainees given placebo in their studies developed rheumatic fever, while under 1% of trainees given antibiotics experienced the disease. For every 50-60 trainees treated with antibiotics, the researchers had successfully prevented one case of rheumatic fever. It was a small, but decisive victory.

Prior to the epidemic at Warren Air Force base there was little interest in ‘strep throat’. During the twenties and thirties in the Unites States, sore throat care focused on diphtheria, “the strangling angel.” The characteristic ‘bull neck’ and the dreaded grey pseudomembrane led to a gruesome, asphyxiating death for thousands of children each year. Comparatively, strep throat was a minor nuisance that often received little more attention than the common cold. But by the 1940s vaccination programs had nearly eradicated diphtheria, and antibiotics were becoming widely available. When the Air Force studies were reported in the early 1950s, they resonated. Rheumatic heart disease was common among adults, making its prevention seem immediate and intuitively important, and antibiotics for a bacterial infection made good sense. Identifying and treating ‘strep throat’ quickly became a staple of medical education, and little has changed.

The problem, of course, is that one can only prevent rheumatic fever where it may plausibly occur. Outside of Warren Air Force base in the 1940s, is rheumatic fever a plausible risk? Apparently not. There have been only two other cases of rheumatic fever ever reported in a pharyngitis study, both in 1961. In fact, despite large, contemporary studies tracking tens of thousands of strep throats in the general community, many of whom received placebos or no treatment, there hasn’t been a case of rheumatic fever reported in a study for nearly fifty years. When the incidence dropped to less than one per million in the general population in 1994, the Centers for Disease Control and Prevention stopped tracking rheumatic fever entirely.

At Warren Air Force base only 50-60 recruits were treated to prevent one case. Today, preventing one case would likely require antibiotic treatment for hundreds of thousands of strep throats, making it a mathematical certainty that antibiotics will do more harm than good. For each case of rheumatic fever prevented in modern practice, a few dozen patients either die or suffer near-fatal anaphylaxis, toxic epidermal necrolysis, colitis, or other antibiotic reactions, and many thousands more suffer diarrhea, rashes, and yeast infections.

Fortunately, rheumatic fever has been declining for a century, starting well before the introduction of antibiotics. While strep throat is no less common today, ‘rheumatogenic’ strains have dwindled, leading epidemiologists to conclude that antibiotics have little or nothing to do with rheumatic fever’s disappearance. Changes in hygiene, nutrition, population crowding, access to care, and changes in the bacterium are all felt to be important factors, which explains why the disease is now typically seen most in third world settings.

There are, arguably, other reasons to consider antibiotics for pharyngitis, but the evidence does not rise to support them. The Cochrane group estimates a 16-hour reduction in symptoms with antibiotics, but ibuprofen, acetaminophen, or a single dose of corticosteroids is as good or better, with fewer side effects. And while peritonsillar abscess may be minimally reduced by antibiotics, abscesses typically present primarily rather than after strep throat, and in most cases are easily treated. No studies have shown that antibiotics reduce the transmission of strep or reduce other complications.

The administration of antibiotics for strep throat, endorsed universally by practice guidelines and professional societies, is based exclusively on data from the world’s most concentrated epidemic of rheumatic fever. Using this to guide modern therapy is like administering antibiotics to prevent bubonic plague.

The essence of evidence is its ability to point us toward truth, and we must first understand what truth we seek. We do not ask whether antibiotics may be useful during a military epidemic of rheumatic fever. We ask a different question. We ask if antibiotics are beneficial for every day strep throat. Those who have written our guidelines and crafted our recommendations have, unfortunately, failed us. The strange tale of Warren Air Force base is a lesson in evidence: The only way to get an answer right is to pay attention to the question.

David H. Newman is the author of
Hippocrates Shadow (Scribner $26)