Episode 14: The Pitt

Let's discuss the most accurate medical drama ever: The Pitt on HBO Max. Spoiler free! The TLDL? Go watch it!

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Transcript

Let’s start with a story.

A long time ago, as a…second year resident, I had a patient with an abscess on their…hmm where was it? I think it was somewhere innocent like their armpit or something, but maybe the trauma of what I’m about to share with you has warped the memory. So perhaps it was on their butt? Anyway, they had an abscess, or a collection of pus underneath the skin just begging to come out.

Sure, you can give these patients antibiotics but to cut is to cure. That pus has gotta be released, and so a common procedure Inside the ER is an I and D, or incision and drainage. Basically, we numb the skin, usually with lidocaine, cut the abscess open with scalpel, and then squeeze the pus out. You often have to dig around in there a little bit with some forceps to make sure you break up any pockets. You then leave the incision open to keep draining and let the wound heal on its own. It might sound a little gruesome, but patients get a tremendous relief afterwards.

For this patient in particular, I set up like usual: cleaned the skin, numbed it, and reached for the scalpel. I, however, had made a huge mistake. I forgot to put on any protective gear. Why would I need that? Because the pus in an abscess can be under immense pressure. So as soon I opened this sucker up, the abscess juice shot out like a geyser and landed…right…in…my…eye. I somehow finished the procedure with this bacterial soup impairing my vision and then sheepishly told my attending.

In addition to the tsk tsk, I had the pleasure of getting my own dose of anesthetic so I could tolerate my eye getting flushed out with a morgan lens. It’s this overgrown contact lens with a tube coming out the back. I had to lay there with this thing digging into my eyeball while an entire liter of fluid pummeled it and spilled out all over me. It was annoying, completely my fault, and I never forgot it.

What lesson did I learn that day? If you’re doing any procedure where liquid is liable to shoot out, wear a damn facemask…with an eyeshield, and hell a gown too! Now whenever I see ER providers in real life, on TV, whatever, not wearing proper protective gear, it drives…me…crazy.

All right, let’s get to the episode proper!

Hello hello, welcome to Inside the ER. My name is Padraic Gerety, I’m an ER doc, and this episode we’re going to talk about the Pitt. No, no, not that underground prison Batman has to escape from in the Dark Knight Rises, we’re talking about the medical drama on HBO Max. Yes…yes, I know it’s just called Max now but, it’s such a stupid name I can’t even bear to say it. Max…JUST MAX? That’s just someone’s name! Why don’t they just call it Larry or Sara?!

Anyway, the Pitt portrays the varied staff of nurses, techs, social workers, attendings, residents, students, you named it, during a busy ER shift at the fictional Pittsburgh Trauma Medical Hospital. In short, it is the most accurate medical drama and watching just one episode will give you a great understanding of the ER, so go watch it! Afterwards write in and tell me whatcha think to insidetheer@gmail.com.

Got it? Ok good, thanks so much and see you next time.

Wait, what? Ok ok. My editor is telling me the episode can’t be like three minutes long so let’s get into it a little more. Now, don’t worry, I’m not going into any significant spoilers here, I want you to experience the drama for yourself. And, full disclosure, I’ve only watched the first five episodes, but I was so excited to share my thoughts that I couldn’t wait any longer to get this episode out. Don’t worry, don’t worry. I’ll prolly do another episode down the line breaking down the full season with spoilers.

Ok, so, the Pitt was created by Scott Gemmill and produced by Noah Wyle, both of whom worked on the hit show “ER." Wyle also stars as Dr. Robby, a grizzled attending who is haunted by his past while trying to lead his team and provide compassionate care. Gemmill and Wyle have set out to create the most accurate medical drama ever, where each episode takes place over a single hour in a shift. Forget dramatic music or illicit affairs, no they’re trying to show the real experiences of practitioners and patients. Everything from the pressure cooker environment of the ER, to the diagnoses, to the treatments, to the procedures, to the gore, to the relationships of staff to each other and to patients, is true to life, and frankly, impressive. Even the different personalities of the staff, ya know there’s the nervous student, the cocky intern, the social awkward resident, it’s all on point. They must have worked very closely with ER providers to get it this right. 

In fact, this show is so realistic that it gives me and my colleagues anxiety just watching. Many ER providers can’t even get through an episode because the drama is just too real and like a PTSD trigger. The constant barrage of sick patients, the overflowing waiting room, the angry and abusive patients/families, and the boarding, the boarding!

That was one of things that struck me early. I never thought a TV show would put a spotlight on the scourge of patient boarding as well as the Pitt does. (Quick aside, if you haven’t, listen to episode 7 of the podcast to learn all about boarding.) In first few minutes of the Pitt, Dr. Robby deftly chastises a hospital administrator for not hiring enough nurses to accommodate the hospital’s needs. Then throughout the show, the dangers are evident: the packed waiting room, the constant shuffling of main bed patients, the piling up of admissions. If only the hospital would spend money on nursing so they could actually use the inpatient beds that are sitting empty upstairs.

And speaking of nurses, this show made me realize I’ve committed a grave sin in not more forcefully espousing the critical nature of nursing Inside the ER. Nurses are the lifeblood of the ER. They are responsible for the vast majority of patient care and should be celebrated and handsomely compensated. And if nurses are the ER’s lifeblood, then the charge nurse is its beating heart. You think a doctor’s in charge Inside the ER? Nuh-uh. The charge nurse is the captain of the ship. They decide where to allocate resources, who is assigned where, which patients get beds, and they launch their doctors like harpoons at critical cases. Thankfully, the Pitt highlights the importance of nurses, and the charge nurse in particular, with Katherine LaNasa doing an excellent job as the kind, but stern when necessary, charge nurse Dana Evans.

It’s time for a break, we’ll be right back after a word from our sponsor.

Today’s sponsor of Inside the ER is…not antagonizing the ER staff. Are you Inside the ER? Are you a patient or a family member, well then I have a piece of advice for you, don’t piss off the people trying to help. Yes, yes, I understand, you may be frustrated, or scared, or you just want to have a little power trip, but do you really think being a jerk is in your best interest here? As in, who do you think gets the better care, the people that reflect our kindness back, or the ones that treat us with contempt. I can’t tell you the number of times my ER has encountered insults, threats, racism, sexual harassment, violence, all of it, all while we just want to take care of patients.

Sure, we’re still gonna do our jobs and we won’t retaliate…but why chance it? So next time you find yourself Inside the ER, remember, don’t slap the hand that’s trying to help you, cause you’re only hurting yourself.

Now, back to the show:

The Pitt also does a great job of illustrating the range of attitudes we encounter. Are most patients and their families appreciative, if not apprehensive? Sure, that’s true, but there are many who are aggressive, manipulative, violent, racist, or just plain rude. Some of it isn’t quite the patient’s fault…like a demented or delirious or intoxicated or psychotic patient may not understand what they’re doing. But a lot of people who behave like asses Inside the ER know exactly what they’re doing. And guess what, if they keep at it, they have worse outcomes, they do poorly in the long term, because taking care of someone actively resisting is very difficult.

I recently took care of a woman near-death due to diabetic coma, diabetic ketoacidosis, pneumonia, kidney failure, you know name it. She was a mess. Myself, the ER staff, the ICU staff, we all worked our butts off to save her life, and we did. She’s doing well now. But in those first hours when her fate was unclear, I called her family to deliver the news and I was met with the most perplexing response. 

Instead of letting me speak, asking questions, expressing concern, the family, presumably with some prior impressions, kept interrupting me to let me know how bad of an ER we were and how bad we were at taking care of patients. When I tried to object, they again interrupted saying that I KNEW it was true. Now, I don’t expect praise or even gratitude frankly during these hard conversations, but I certainly don’t expect to be insulted. I held my tongue the rest of the time but kept thinking, “I am literally saving her life, what are you trying to accomplish by speaking to me like this.” The ICU doc later told me that the family immediately threatened to sue during their first talk. Sue for what? Successfully bringing her back from the dead? These kind of moments abound in the Pitt, and drive home the amount of disrespect we encounter.

 And ya know what, another thing that’ll make sense when you watch: let us pee, let us go to the bathroom! Dr. Robby’s struggle to relieve this basic bodily function is real. We are constantly being interrupted and pulled away, rarely given a moment. I have legit anxiety that if I try to pee, fate forbid poop, that I will miss something critical happening. I’ve lost count the number of times I’ve had a “can’t miss” phone call go off when I’m in the bathroom. Do I answer it and and hope for the best? Yes, yes I do. Anything for patient care.

Now, is the show perfect? No, of course not, but it’s pretty close. What are my gripes? Well they’re minor but first, the show can be TOO technical sometimes. I know, I know, that’s the point right? Sure, but if you get lost in weeds with medical jargon, I think the average person can’t follow and will tune out. Like with the gore, what’s happening on screen is realistic, but might turn some people off. If you stick with it though, it does become more digestible.

Second, the pace and critical nature of the cases they’re getting are a bit unrealistic. It’s just TOO crazy in this ER. If it was really this bad, you’d have an army of students and residents. Everyone would be scrambling to rotate there. There is, of course, some stationary time on a shift. You can’t just see new patients and do complicated procedures all the time, that’s not sustainable. There has to be time set aside to think cases over, write notes, disposition, and to call consults…many, many consults.

That brings me to my third minor gripe, there is very little interaction shown with other services. A large part of an ER provider’s job is coordinating with providers from different specialities. An ER provider can not do it all, we have to see patients, stabilize, admit or discharge, and then move on to the next one. The patient volume is too high to not let the inpatient doctors handle patient care after a certain point. The Pitt portrays a pretty antagonistic relationship between the ER and the other services, but thankfully that’s not true at every hospital. 

And lastly….what was the point of my story up top…face masks people! These docs are often not wearing face masks when they should and it drives me crazy. You’ve gotta watch because there is one character in particular who keeps getting splashed in the face but here they are, the next scene, not wearing a face mask! How many times will it take before they learn their lesson!? But…people do do this in real life, and it drives me nuts. I’ve thrown face masks at my colleagues before…so maybe that’s actually accurate? Anyway, cover up your eyes people! Especially when intubating, you never know a vomit volcano is going to erupt.

While watching the second episode, during the umpteenth scene demonstrating the trauma experienced by both patients and clinicians alike Inside the ER, my wife turned to me and said, “What is the point of this show?” What she meant was, “this makes the ER just seem miserable, what should we getting from this?” And at the time my only response was “that my job sucks?” But now, after listening to interviews with Noah Wyle and thinking about it more, I’ve realized something key. 

At the end of the day, even if you take away all of the realistic medicine, the Pitt excels in one key area, conveying  the vibe of the ER and emergency medicine. The job is impossible, the system has stacked the deck against us, and the trauma providers suffer from, both emotional and physical, is largely overlooked. Any ER provider who tells you they haven’t been scarred by this work is lying, deluded, or never had any empathy in the first place. Seeing suffering and experiencing suffering are the not the same, but both will chip away at you. While it is the responsibility of clinicians to be aware of and manage their own psychological trauma, it would be nice if society acknowledged it and offered a helping hand.  

On that uplifting note, that’s it for today, now go watch the Pitt! Even one episode will teach you a lot, but it’s definitely worth your time to watch it through. And please, please, after you watch, write in at insidetheer@gmail.com with your thoughts and if you have any questions about what you saw. As I said earlier, we’ll have another episode after I’ve finished the series, where I’ll discuss it freely, with spoilers, and respond to any queries.

Thanks to everyone for the support, last month we cracked 2000 downloads and counting! Y’all will be hearing from me in about a month, and in the meantime, please direct anyone you think might like the show to our website insidetheer.buzzsprout.com or our socials: TikTok, youtube, instagram, and bluesky. And if you wanna be really nice, please leave a rating or better yet a review, if you deem us worthy.

Thanks for listening and all the best.