Wednesday, July 08, 2009

Royal Pains, ep. 4: "TB or not TB" (but definitely PA-C)

It's been a big week in the Febrifuge household. Of several new developments, perhaps the biggest was that the household moved 400-odd miles. So, in terms of my own convenience, USA picked a great week to hold off on airing new episodes of Royal Pains. It took me a while to get to it, but I was rewarded with an overall good episode, featuring several refreshing bursts of Divya being awesome. It actually appears to be an intentional story arc that the PA is established as more than "doctor's little helper." Also, I got a job, and as recently noted, I passed my board exam and earned certification not long before that... so it's a good week to be me.

But enough yappin'. On to the show. As always, I'll try to concentrate on the medical stuff, with what I'm sure will be mixed results. Bullet points are for organization, but + means [yay!] and - means [meh.]

* Is it just because I'm watching on Hulu this week, or is the funky underwater title sequence really gone? That was cool, dang it. Okay, we're in a kitchen, people are busy, this one lady is really intense... oh, I see, somebody here is going to be the patient of the week. The head chef is too obvious, so I bet it's the tall skinny guy.

Oh, wait. This only looks, sounds, and feels like House. My mistake. It's Alison, the restaurant owner, who has weird neuro symptoms. She hallucinates that the high-end Italian food in her restaurant is something that Chef Boyardee made yesterday... or no, that's just what it looked like. Looks like there's a prop master out there whose employers need to pay for a few good restaurant meals. For research, y'know? Honestly, the blurry effect really was low-rent House stylings. Better-done, I would have called it an homage.

Medically, they had her experiencing blurred vision, and using the word "pizza" when she meant to say "pasta," then not realizing she'd done it. Actual word salad tends to be much weirder. My good friend M. Giant has had attacks where the language center of his brain crapped out on him as it's suggested Alison's has here. Since he's a writer, you can check out his description, for a more appropriate level of oddity and fear. In an otherwise healthy, young person, these symptoms are very scary indeed.

Since this isn't actually House, Alison's spell resolves, and rather than the sound of Massive Attack, there's another scene or two. The HankMed crew come in to administer PPDs to the restaurant staff.

+ Here, we have some impressively accurate medical procedure. Hank and Divya are both using the correct, 0.5ml syringes, placing little blebs of the solution right into the skin on the forearm, and telling people what the test is, and how it works.

- This week, the one conveniently overlooked part of the process that would obviate an entire plotline is not asking the patients about previous exposure to TB, previous positive tests, or previous immunizations. Especially given that more than a couple of the people working in this particular restaurant are from the old country, where the BCG vaccine is used, you'd think that would have come up. Huh.

+ Later, Hank is speaking privately to Alison about her freaky symptoms, and does some excellent doctoring in the way he counsels her. Sometimes advocating for the patient's best interests means getting in their face a little. And anyway, Hank's such a nice guy (I am 1/16th culturally empowered to call him what he is, a mensch) that he barely seems to be harping on Alison. Honestly, I'm ready to see the character turn the frustration up a notch, and be a little less perfect.

+ No wait, the title sequence is here after all. The show is just messing around with the best place to put it, and seems to be studiously avoiding the most House-ian possible placement, immediately after the 'tease' in which someone gets ill. (And thanks to the CG guy who was nice enough to post a comment saying he'd created it. Yes indeedy, the use of clozapine, an anti-psychotic, on the label was cute. There is no version that comes with APAP - which is acetaminphen, or Tylenol - but I agree that the guy who added that was on to something. I'm all for creative license.)

+ Just after we're back from commercial, Divya delivers a lecture to Evan that is music to my ears. After Evan makes the fatal mistake of calling her "doctor's little helper," she unloads on him with a combination of the "What is a PA?" text off the AAPA website, and a beguiling mix of excellent diction and attitude. "I am a certified Physician Assistant," she says, much the same way one might say "I am going to stomp your smirky face into chunky salsa." I stop to wonder if because she's in New York, she might not want to say "Registered Physician Assistant," instead of the "certified" that is standard everywhere else in the US, but give up the thought as she rolls on.

"That means I practice medicine. I prescribe medications. I order and interpret tests. I assist in surgery..." And then Hank strolls up, having figured out he can't be there in three days to collect results on all those tests, so asks her to do it solo. He delegates that part of the practice to her, having her do it independently, conferring his legal and clinical authority to her.

+ And I pretty much faint, because that's exactly right. That's what it is, that's how it's done. I've been worrying about how the PA will be portrayed in this show, and whining about the "Screw the Midlevel" moments I saw in the first episode or two, and here the show is saying almost exactly what I would tell them they should. And since this is only episode 4, surely this scene must have been written - and filmed - before the pilot aired. So, nice work, show. I feel much better about this whole Divya the PA thing.

- Later, there's a level of product placement that is impressively tricky: advertising two different car brands at once. I applaud at the TV, sarcastic clap style.

+ Paulo Costanzo continues to walk away with all the Evan/Hank scenes, despite an alarming trend toward overly broad, buffoonish moments. Driving a golf cart across town? Ehhh. Maybe not. But Costanzo's tirade against brunch, and especially his delivery of the phrase "french toast salad," are comedy gold.

+ I was impressed by the way that for once, a TV doctor's blunt declaration "she's had a stroke" made some kind of sense. Given that Hank had spoken to Alison previously, and being a kick-ass doctor, it made sense that he could be so sure in his diagnosis so quickly. This was refreshing.

Hey wow, what a concise and timely explanation of thrombolytic therapy. Dr. Exposition, please report to Act Three. Doctor Exposition, Act Three. And I suppose it's cool to show that Hank doesn't get to go wherever he wants inside the hospital, even if he is dating the administrator.

Someone who works in NY state tell me if the short white coat is really what MDs wear in the hospital. I saw the 40-something guy rocking the short lab coat and thought, "huh. Another non-traditional student." And I still say people look like steakhouse waiters in those damn things.

Um... why does Boris need a tiger shark? Who is Katie, and why does she need to be called right away now that he has one? And holy crap, tonic immobility is a real thing, although no way does it last 20 hours. Looks like I must have missed a couple of Shark Weeks.

(Total and utter tangent: this week I also saw an amusing signature line on one of the medical forums I visit: "Live every week as if it were Shark Week." Inspirational, isn't it?)

Wow, they must be rich in the Hamptons, because Dr. Short-Coat responds to Hank's request "Can you get me some thrombolytics" with "sure." Not with "don't you mean tPA, Dr. Slick?" and not with "you mean the package that has to be back in the fridge in half an hour if it's not used, and costs like three thousand dollars if you so much as peel back the foil?" nor with "you don't have privileges here, and can't walk past the yellow line, and I'm going to hand over super-expensive drugs? You want a fistful of Perocet too, you delusional weirdo?"

But then again, not having the magic meds (which looked amazingly like a 10ml saline flush, and apparently didn't require mixing or prep of any kind) would have robbed us, the viewers, of another MacGuyver medicine moment. The DIY Bair Hugger (which in the medical world is essentially what they made: a blanket made of hollow baffles, through which warmed air is pumped) was pretty cool, I'll grant them that. And presumably Divya established two really fast IV lines, with that pimped out SUV kit of hers.

Speaking of which, Mac-compatible, portable Xray? Damn. Notice too how the readout had Hank's name on it; the PA-MD team very often puts the MDs name on stuff like that. The team's medical decisions are ultimately the MDs responsibilities, but the PA has as much latitude and independence as the MD wants to grant, so presumably the practice agreement says that Hank is totally comfortable with Divya's ability to read a chest x-ray. Maybe she'll ask him to check it out later, as a quality measure, but when she says "it looks good," that's the same as Hank saying it.

The episode winds up with what I take to be a future plot point: who was Jill formerly married to? My money's on Boris, actually. If not him, then a new character, played by Ted McGinley.

Overall, I have become very impressed with some of what's coming out of the writer's room on this show. Not having viewership numbers handy, I can't say for sure but they have done more for the public's understanding of the PA profession than our actual professional association has, in my opinion. If only they would add a layer of quality control to the plotting, and stop letting conflicts arise via series of events that would be rendered moot by the same common sense the characters show except when the plot demands they be dumb. That's the kind of story-craft that makes Three's Company plots work.

A- for the episode as a whole. Some good doctoring from Hank, some silliness over poor Italian translation and a critical question never asked in any language, tempered by Divya-liciousness. The minus is for Divya knowing the BCG produces false-positives, but only knowing it in Act Five.

A+ however for what's going on with Divya's character progression. If I find out the AAPA is connected to the bracingly clear way this show presents what a PA is and does, I'll take back most of the things I've said about them.

No comments: