Dirty White Coat
Mel Herbert, MD, and the creators of EM:RAP, UCMAX, CorePendium, and the collaborators on "The Pitt" and many of the most influential medical education series present a new free podcast: “Dirty White Coat.” Join us twice a month as we dive into all things medicine—from AI to venture capital, long COVID to ketamine, RFK Jr. to Ozempic, and so much more. Created by doctors for clinicians of all levels and anyone interested in medicine, this show delivers expert insights, engaging discussions, and the humor we all desperately need more of!
Dirty White Coat
The Nocturnists Present: Inside 'The Pit': Medicine's Most Authentic TV Drama
The Nocturnists Podcast with Emily Silverman, MD
The HBO Max series "The Pit" has struck a chord with healthcare professionals unlike any medical drama before it. What makes this show so different? Why are doctors and nurses messaging each other saying, "You have to watch this—they finally got it right"?
In this special bonus episode, I sit down with the brilliant creative team behind the show that's capturing the true essence of emergency medicine: R. Scott Gemmel (creator and showrunner), Joe Sachs (emergency physician and writer), and Mel Herbert (renowned ER educator and consultant).
Our conversation reveals how "The Pit" breaks new ground through its revolutionary real-time storytelling format—each episode covers just one hour of a 15-hour shift, immersing viewers in the relentless pace experienced by healthcare workers. We explore how the team meticulously crafts authentic medical scenarios, using actual cases as jumping-off points for character development while ensuring perfect technical accuracy.
The show's commitment to authenticity extends beyond medicine to address systemic healthcare challenges—the boarding crisis, corporate pressure over satisfaction scores, staff shortages, and the alarming rise in violence against healthcare workers. As Joe reveals, "56% of nurses reported experiencing physical assault in the last month." By tackling these realities head-on, "The Pit" serves as both entertainment and powerful advocacy.
We also get fascinating behind-the-scenes insights into the production process, from the incredibly detailed set design (complete with sometimes-too-convincing fake toilets) to the custom-built anatomical models created for intubation scenes. The team's dedication to getting every detail right explains why healthcare workers are feeling so seen by this groundbreaking show.
The conversation concludes on a hopeful note as the creators share their ultimate mission—to celebrate the extraordinary dedication of emergency medicine professionals while inspiring a new generation to enter healthcare despite today's challenges. As Scott beautifully puts it, the show is fundamentally "a love letter to a profession that is sometimes just taken for granted."
Listen now to discover how storytelling can bridge the gap between healthcare realities and public understanding in ways that might just change how we all see the emergency department and those who work there.
Support for the Nocturnist comes from the California Medical Association. At the Nocturnist we are careful to ensure that all stories comply with healthcare privacy laws. Details may have been changed to ensure patient confidentiality. All views expressed are those of the person speaking and not their employer. This is the Nocturnist Conversations. I'm Emily Silverman. As you may know, we recently launched our Uncertainty series here at the Nocturnist and those episodes will continue to drop on Thursdays as planned. But today, tuesday, we're bringing you a special bonus episode because this conversation was just too fun to postpone.
Speaker 1:Today I sit down with the creative minds behind the HBO Max television show, the Pit, a new medical drama that has captivated so many of us in the healthcare world. At the time of this interview, the first 11 episodes of the Pit had aired and since then the stakes have only grown higher. The characters on the Pit feel so incredibly real my personal favorite is Dana, the charge nurse and the medical cases on the show also hit close to home, which just goes to show how much the writing team understands what it's really like to work in an emergency department, and part of why they nail the authenticity of the show is that they have a lot of doctors involved in the creative process, which brings me to today's three extraordinary guests R Scott Gemmel, longtime television writer and producer known for his work on ER NCIS Los Angeles, and now the creator and showrunner of the Pit. Joe Sachs, an emergency physician and TV writer who worked on ER for years and now brings his clinical expertise to the Pit. And Mel Herbert, a beloved educator in emergency medicine, the founder of the MRAP podcast and consultant on season one of the Pit.
Speaker 1:As someone who works at the intersection of medicine and storytelling, I have to say I was a little starstruck to be in conversation with these legends. We talked about everything from how they set out to make a medical show unlike anything we've seen before. How they write to the moment, bringing in real world crises from healthcare like burnout boarding, even press Ganey scores. Why they chose to tell the story in real time, with each episode covering one hour of the shift. How they nailed the realism of the show from a hand-designed airway that they built and can intubate to a fake toilet on set that may have been a little too convincing. And what they hope the Pit will mean to clinicians and the culture at large. I hope you enjoy this conversation as much as I did. But before we dive in, take a listen to the trailer for the Pit, streaming now on HBO Max.
Speaker 2:Morning Jack, what are you doing here Working?
Speaker 3:And if you jump?
Speaker 2:on my shift. That's just rude man. I hope I'm never one of your patients. Makes two of us my friend. Hey D, what's a good word.
Speaker 4:We're f***ed. 52 in the waiting room and it's not even 7. Robbie's working the shift.
Speaker 2:by the way, Got him a little slack today.
Speaker 4:It's the anniversary of Dr Adamson's death. Who left this mess? Nothing like a little challenge every now and then. We've got some new faces with us today. Hi, come on over, I'm so happy to be here. Talk to me at the end of the day, clear Forceps.
Speaker 3:Suction Med student down. Welcome to the pit. Let's go save some lives.
Speaker 2:The systolic is only 80, 14 days.
Speaker 3:Alex, you've lost a lot of blood. You need to go to surgery right away. Am I gonna die? Not now that I'm here, easy peasy. I'm in Good, well done. That was awesome, isn't it always this busy?
Speaker 4:No, always this busy. No, it gets a lot busier.
Speaker 1:There's a nursing shortage across the country.
Speaker 2:That is bullshit. If you paid them a living wage, they'd line up to work here.
Speaker 1:Other hospitals are managing this crisis either step up or step aside.
Speaker 3:Are you okay. Why wouldn't?
Speaker 1:I be. It's five years ago today. You can't block your feelings forever.
Speaker 4:Oh, you'd be surprised.
Speaker 3:Crash guard, let's go no pulse.
Speaker 1:Clear Hold compressions. Are we ready to call this?
Speaker 4:150,000 people die every day in the world. Today, you got one of them, and we're gonna get more of them before the shift is over.
Speaker 3:Tier 1 trauma now Four of morphine. I'm gonna stop the bleeding.
Speaker 4:You learn to accept it. Find balance, you found balance.
Speaker 2:No, not even close.
Speaker 1:I have the pleasure of sitting here with Scott Gemmel, joe Sachs and Mel Herbert. Thank you so much for being here today.
Speaker 3:Thank you for having us Our pleasure. You're welcome.
Speaker 1:So I've watched all 11 episodes of the Pit that are out thus far. I think we have a few more and I have to say that never before, when watching a medical show, have I turned so many times to my husband on the couch and said, oh my God, that is so real, that is so realistic. That's exactly what happens, that's exactly what that looks like. That's exactly the words that I would say if I were in that situation. Everyone is talking about the authenticity of this show. I think for me and my doctor friends and the physician community, something that we're feeling a lot with this show is just feeling really seen in a way that maybe we haven't with other medical shows in the past. There's just something in the water at the show that just feels like it really represents our experience. So, to begin, I just wanted to ask if that was a conscious goal from the start, as you brought the show into existence.
Speaker 3:Joe. Well, I'm going to let Scott talk because he has the created by credit.
Speaker 2:Yeah, absolutely. If we're going to do something, we want to do it well and we want to do it respectfully to the community and physicians and nurses and everyone else that's involved in health care. And, trust me, it's not always easy, as Joe and I went through this morning as we were trying to agree on how to tell a story about a sim lab and what was real and what wasn't. So, yes, we do strive to be as authentic and honest as possible.
Speaker 3:I think it came from Scott. It came from John Wells, and when I was brought into the project I just wanted it to be as real and authentic as possible. And John I remember in the early moments of this show's conception, said I want a medical show the way no one has seen a medical show before. So I knew what had to be done.
Speaker 1:And just to be clear, we have some physicians in the room, we have some writers in the room who have written medical drama but aren't physicians, and then we have some who are both. So maybe can you just walk me through who here has the physician hat, who here has the writer hat and who here has both.
Speaker 2:Well, I'm a shaman and a writer. No, I'm just a writer. I've written a bunch of medical shows, but I'm just a writer. I'm a one trick pony. These other guys have multiple skill sets.
Speaker 3:I'm a writer and an emergency physician with 33 years in the pit, as they say. The short answer to how I came down this path is while I was in medical school, I also went to film school because I had an interest in public health education and as I was learning how to evaluate and plan public health campaigns, I became more interested in the creative side of things and made the decision to go to film school. And that served me well, because as I finished my residency in emergency medicine, a show called ER came along and about halfway through the first season they were in need of some help and they reached out to me.
Speaker 1:Do you still practice, joe?
Speaker 3:or are you full time? I do, I do. I've worked in a Los Angeles County trauma center for 33 years, including at the peak of the COVID epidemic, including intubating the sickest patients in full. Ppe began to have its conception. I made a decision to cut back to urgent care just because the amount of time that I need to spend with every aspect of the show is monumental and I just couldn't afford the time constraints of working an overnight or working till three in the morning, because I really am working seven days a week on the show when we're in production.
Speaker 1:And Mel, how did you get involved with this?
Speaker 4:So I'm an ER doc and I retired from clinical work actually to run my education company full time because it had gotten too big and busy. I still work clinically in other countries but I don't really practice in the US anymore. But I got involved back in the day. Joe was my attending when I first got off the boat from Australia in 1991.
Speaker 3:Wow, I like to say. I taught Mel everything he knows.
Speaker 4:And I don't know anything, so I don't know what that means. So Joe got me involved in ER years ago, basically as a medical consultant, so he'd run cases by me. And what do you think about this? What do you think about that? And our education program is all about emergency medicine and so a lot of the cases would come from there. And then, when the pit started, he's like do you want to play that game again? And so for season one, I'm like that sounds like a fun game, let's do that again.
Speaker 3:I think one of the things at the beginning of season one I wanted to bring Scott and Noah Noah Wiley, who's both an actor and a writer, and some of the other writers to meet all of the key physicians at MRAP. So we would attend the live Grand Rounds session just because I wanted to give everyone a sense of the complexity of academic emergency medicine, of the teaching, and to meet giants in the field like Mel Stuart Swadron, sean Nort, and we would watch and listen to Grand Rounds and then have dinner and those were very enlightening and successful for some of the other writers to get a sense. And then Mel's relationship to the creation of stories would be very informal, like once or twice a week I'd be driving home from Warner Brothers and I would say, hey, mel, I'm thinking about doing this story and it's gonna be a seven-year-old drowning victim and I need it to go on for this and this and this, and I know she's gonna be hypothermic and I know we're gonna warm her and this or that, but I need a really good way to finish it. And Mel goes make her potassium 12, because nobody ever comes back with potassium 12. So Mel was kind of the spice and seasoning that would often put the finishing touches on the cases that we were creating.
Speaker 4:Isn't there a spice girl called Mel? Is that me?
Speaker 1:There is a spice girl. Yes, I think that's Sporty Spice.
Speaker 4:Just so your listeners know, I run a program called MRAP, which is a very big education program within emergency medicine. It's got 65,000 users across the world so it's hard to find an ER doctor that doesn't use MRAP. We're a 25-year overnight success. One of our most religious listeners is Joe Sex, and so I think a lot of the cases and discussions come from Joe's intimate knowledge of that program, which comes out every week.
Speaker 1:So I had the pleasure of sitting in on a teaching session with one of your writers a friend of mine, max teaches screenwriting and had her in as a guest, so I got to sit and listen to her talk about the pit and your creative process, and she was talking about how a lot of TV shows will start with the characters or start with the plot, but that in procedurals like medical TV shows, that often you start with the medical cases. So I was wondering if you could bring us into that process. Do you just start with a whiteboard and you have the cases and you shuffle them around, or what does that look like?
Speaker 3:Well, I'm going to contradict her which is to say that we start with the drama.
Speaker 3:We start with the dramatic needs of the character. What is their arc during a 15-hour shift? What is going to be revealed about them? And then the medical cases augment that in a subtle way that get us to learn more about the characters and their relationships with each other, with the attendings. So the medical cases aren't just randomly chosen and then try to put a square peg into a round hole.
Speaker 3:And something as simple as a case in the episode that Valerie wrote was an ankle sprain. I didn't start with the idea that, oh, we need to do a story about an ankle sprain because the world needs to know about ankle sprains. But something as simple as an ankle sprain was a chance for Mel to show her incredible skills at patient care and compassion and understanding with somebody with autism spectrum disorder, as opposed to Langdon who had no patients, no time and was doing everything wrong. So that was a cool case and all of the medicine was right in terms of her differential diagnosis and thinking about a dancer's fracture and a Jones fracture. And, of course, the patient had Googled everything infinitely and was asking an infinite number of annoying questions. But she had the patience and she got through to the patient in a way that Langdon never could. So that's just an example of a very simple case that speaks to the needs of the character. But I'll let Scott comment about that too.
Speaker 2:No, I think that's you know. We start with the characters. Who are they, where do we want to take them, what is their journey, where do they come from and then where do we want to end up with them? This show is a little unique in that it's told in relatively real time.
Speaker 2:In a traditional TV series, whether it's eight episodes or 24 episodes, you're not usually hour by hour. You may be day by day, it could be week by week Depends on the nature of the story. So you have in some cases days, if not months, to tell a story or to reveal things about the characters where we only have 15 hours. So it's a very truncated version of character development and exploration. So we have to be very precise about that. But the constraints also are a great creative challenge, because then you have to work within a certain size box, work within a certain size box. So that's where we start, and then it's really about finding the cases that will bring out those elements of the story that we want to tell, whether it's exposing someone's insecurity or their overconfidence or any of those elements that you saw throughout some of the episodes you've watched already. So it's a little bit of both, but generally we start with the character, who they are and where do we want them to be at the end of the season.
Speaker 3:Let me give an example of three stories that came out of the dramatic needs of the Javadi character, the third-year medical student.
Speaker 3:Great character, so the challenge of the first episode was hey, joe, what's a case that would make a third-year medical student faint in the trauma room? So the degloved, fracture, dislocation of the ankle came out of that and it was pretty effective and it was brilliantly done by our makeup department, which is a whole other sidebar that we'll get to because they are geniuses. A second thing would be how does Javadi's mother, who's an attending physician in surgery, embarrass the hell out of her? So her mother comes down to examine a young man with appendicitis and, in the presence of another medical student and an intern, starts teaching slash pimping.
Speaker 3:We know about pimping, yes, about recent studies about non-operative management of appendicitis, and the other medical student is able to quote the CODA study from the New England Journal from 2020. And the mother looks at her daughter and says honey, you knew that we talked about that over dinner.
Speaker 4:And then honey, everyone is like oh my.
Speaker 3:God, that's your mother. So that was an example of a case that highlighted that, but was accurate, and most television writers probably couldn't cite a New England Journal of Medicine article from 2020. So that's the kind of thing that made it so unique and specific that I think people are responding to. And then the last one in a later episode, the question came how can Javadi show up her mother? So how can a third year medical student beat her mother to a diagnosis? And that was the basis of the Black Widow spider bite, because a Black Widow spider bite can cause such intense spasm of the abdominal musculature that it can be mistaken as peritonitis, and people have actually gone to the operating room when they've had a black widow spider bite. So those are examples. Start with the dramatic need Find a cool case that can speak to that and make it really accurate, and that's the marching orders.
Speaker 4:I can give you a little color as to what it looks like in there, because these old guys have been doing it so long that I don't even know how interesting it is. So this is my first time that I've actually been in the writer's room. So for season two, I'm now in the writer's room and so you have basically just this room and there's four not one, but four whiteboards all around the room, divided up into the 15 episodes, and you've got a group of people who are super smart, creatives that are going back and forth with each other. Well, what about this idea? No, no, we could do it this way, and we could do it this way.
Speaker 4:Two docs, but the rest are writers going back in this process, and then they're like okay, in this hour we'll do this thing, and then we can see this arc, and then it'll happen over here, and then we'll do the procedures. We'll do this thing and then we can see this arc, and then it'll happen over here, and then we'll do the procedures, we'll do the medicine stuff. But to watch something being created out of nothing for me is fascinating. Just these smart people thinking about arc ideas and then having them fleshed out, agreeing, disagreeing, calling each other names and having fun with it, then coming out with what the arc is going to be for the non-writer in the room is absolutely fascinating. Like I said to him, it's almost as if you guys are making this up as you go along.
Speaker 3:And the dramatic arcs are very subtle because they happen in the course of a 15-hour day and we just have to learn new things about the character and season two I may be talking out of school, but season two is going to start sometime in the future from season one. So people's status, is it statuses or stati? People's status have changed and all those need to be reflected in the storytelling.
Speaker 2:Season two is 300 years in the future.
Speaker 4:Millennium in the future.
Speaker 1:The AI doctor and the pocket ultrasound.
Speaker 2:AI may actually play a part in it.
Speaker 1:Scott, you mentioned the choice to compress time and I love the way that each episode is just one hour. Episode one, I think it was like 7am to 8am, and I love it for so many reasons. I think one, it just makes it feel so heightened. But I think, two, it also really shows how intense it is to be in the ER and all the things that happen and the moment to moment and the way that it's choreographed and edited, where people are sort of popping in and out of different rooms and he goes to pee and he can't even pee. You know, someone comes in and says now you got to go in this room. So I was wondering if you could speak to that choice, because I don't think I've ever seen a medical show before operate in that way where they're allocating a 60 minute episode to 60 minutes of real time, and the thought process that went into making that choice for the narrative form.
Speaker 2:We've sort of done Joe and I and John and Noah, sort of done the Mac Daddy of all medical shows. So when the opportunity came about to revisit doing another medical show, when the opportunity came about to revisit doing another medical show, one that we wanted to make completely different, it was looking at how can we tell these stories differently than we have in the past. And once it became a streamer because it was HBO Max who was asking for it we knew already it was going to be different in terms of what you can show, language, but also in terms of how many episodes you do. So we're looking at shows that are now six, eight, 10, 12 is maybe the most and we weren't on streaming. I don't know if I would have come up with that idea, but it was because it was 12 episodes and the shift is 12 hours it seemed like a really logical fit and the more we thought about it, even though it seemed a pretty daunting task at first, the one thing that really, I think, differentiates the emergency department from other forms of medical practice is the time element.
Speaker 2:People come to the emergency department sometimes through ambulance service, where time is of the essence, so time just seemed to become such an important part of the whole process.
Speaker 2:One of the things with ER physicians and these guys can speak to it much better than I can, but is how often they're pulled away to another situation, another case, Someone else needs them that every three to five minutes they're on something else.
Speaker 2:So that became really important, as we talked earlier about the authenticity, and so rather than following a patient through the course of one episode and they come in and we fix them up and by the end they're better everyone who's been to the emergency department knows your weight alone is going to get you through four or five episodes and we really wanted to capture that, and so the time element became a really big part of it and as challenging as it was and we weren't sure it was going to work I think it really elevates the show. It's very hard to capture that feeling of the emergency department because it's so alive and it's so electric and there's so much going on and it seemed like if we took the audience into that environment and didn't let them out. We're not going to commercial breaks, we're not coming back two hours later.
Speaker 1:Or even into their homes. We don't go into their private lives at all.
Speaker 2:No, and so it's kind of like Robbie not being able to find time to use the restroom. The audience doesn't get a chance to step away. They're sort of juggling the cases, the same way the doctors are, and I think that really helps pull you into the storytelling, because you can't leave until that hour or that shift is over.
Speaker 3:The other thing that real-time allows us to do is to keep the audience guessing when you meet a patient, is this patient going to be one and done one episode? Is it going to evolve into something that's going to last for four episodes or eight episodes or 15 episodes? It's just the mix of everything going on and having to pay attention to what's going on. And the astute viewers might look in the waiting room in episode one or two and see somebody sitting there who becomes a major character at hour four or five that we would just actually pay the actors to sit in the waiting room for one scene and then come back much later. And likewise, when Scott and Noah and John first approached me about emergency medicine in 2024, I said we got to come in and see a waiting room packed to the gills. We have to come in and see every inch of wall space filled with boarding patients who can't go upstairs because there's no room upstairs. And we did that and the intensity of the volume is real and I think that's what people are responding to.
Speaker 3:And the reality of the boarding patients is fascinating because one of our background nurses is a former charge nurse at UCLA Santa Monica Hospital who's now retired, but his job was to track all the boarding patients and to make sure, hour to hour, their IVs went down by 100 cc's, that meals were brought to them, that a breathing treatment was come in, that physical therapy came and took them. So everything that's going on hour to hour is real. And then the background artists, also known as extras. When they first showed up to say, oh, I'd like to work on this show, Well, if you're going to be a boarded patient, you're going to be in your gurney for the next seven months because we're going to be filming 15 episodes and you're going to be sitting in the gurney the whole time. So that's another interesting aspect of production.
Speaker 1:You mentioned, Joe, if we're going to do a show about the emergency room, the waiting room has to be packed. You know it needs to be like this and like this, and I was wondering how you see this series fitting into this particular moment. In healthcare and in the world. There are themes that are already weaving in to the cases and the characters. For example, we have the lady from corporate who keeps coming down to hound Robbie about patient satisfaction scores. We have problems of patients committing violence against healthcare workers, which is a topic that's really important right now. We even have the flashbacks to the COVID pandemic and sensing the PTSD that the healthcare community still has from that time. It was kind of long ago, but also wasn't that long ago. So I was wondering how you thought about weaving in some of those bigger themes into the series, because it just feels very topical.
Speaker 3:Well, we wanted the show to be current and accurate, and if we're current and accurate, we have to show waiting room medicine, which is patients who just stay in their chairs in the waiting room and get pulled back for labs and x-rays and then discharged because there's no beds and that doesn't lend itself to patient satisfaction. We had to show the boarding patients and we had to show the pressures of a corporate culture that's looking at Prescani scores and other metrics that are important to them. These are people who are fighting an unwinnable battle because all the cards are stacked up against them, and to provide compassionate care and to try to do the best you can do under these circumstances is really heroic, and that's what I think we're showing. I think in season two we're going to try to address some of the issues that have been raised with changes to prevent violence against health care workers.
Speaker 3:A recent ENA Emergency Nurse Association survey, 56% of nurses had a physical assault in the last month. What can be done to address that in a way that can make the emergency department and the hospital safer for everyone? What is the systemic root issue of this boarding crisis? It's not door to provider time, because we know if you can see the patient in five minutes with a provider in triage. That's not going to open up beds upstairs, but there are ways of addressing that problem and we've spent a good bit of time speaking with Peter Vecelio, who is in the emergency department at Stony Brook Hospital, and he has had some very successful and innovative approaches to address this whole waiting room medicine boarding issue. That has nothing to do with the emergency department but everything to do with how the flow of admissions and discharges and scheduled admissions works in the hospital. So we may see some of that in season two.
Speaker 4:Another thing that really stunned me was how much effort is going to make it realistic not just from an ER point of view, because Joe can do that he's been an ER doc for 1.8 million years but it's the writers. Getting together with Joe and interviewing real experts like Peter Bocelli or like somebody who is an expert in trans youth or whatever it might be. Getting these experts in and spending time with them and finding out all of those nuances and how to make it accurate is something that this group has gone out of their way to do. So it's not just like well, this is one doc's opinion, this is a series of world experts coming into the writer's room and telling them here's how this would really work, and to me that was fascinating. It's the best education ever. I feel like I'm getting this college degree from world experts just by sitting in the writer's room.
Speaker 3:We've probably had 12 Zoom expert briefings in the last two weeks on a variety of subjects, including PTSD and health care workers, addressing the boarding crisis, trans youth issues under new executive orders, medicaid issues what's going to happen in Pittsburgh when people lose their Medicaid, what resources are going to be available to them? And on and on and on.
Speaker 4:And a bunch of things he can't tell you because it would be a spoiler alert.
Speaker 1:Yeah, I sensed a hesitation there. I was like don't say it. Wait, no, say it. You mentioned Zoom experts in the writer's room. You also talked a little bit already about the writer's room, how there's four whiteboards and a bunch of really smart people sitting around creating things. Bring us a little bit more into the writer's room. Like what is a typical day, what is the generation process like? What is the revision process like? Sounds like, maybe some days there's a guest, some days there's not a guest. What is that all like?
Speaker 2:It changes throughout the season. Obviously Right now is in some ways the scariest time, but it's also the most fun time because we come with a blank slate maybe not so much as the beginning of the show, where there is no show. When we first came back. We do a little bit of an M&M in terms of what worked and what didn't last year, what we were happy with, what we weren't, so that we don't fall back into some habits that were not serving us well. And then we also look at who has outstanding story elements to address. For instance, what might happen with Langland? We saw him get booted out at the end of episode 11. Is Dana going to quit?
Speaker 2:We address that. Where do we want to take that? And then it's about, like I said earlier, where do we want these characters to end up at the end of the season? What sort of personal stories are going on with them? We start to lay that down and then slowly stories, and then Mel will show us some really disturbing photos of cases he's done and then we try to figure out how we can incorporate those. So it's a little show and tell. That's sort of the way it works. There's no hard and fast rule and every day can be a little bit different. It's harder for me to tell you because I'm on one side of it. Joe and Mel actually might have a better perspective on what a day is like for those guys.
Speaker 3:Yeah, there's never a plan, there's never an agenda. This is the early days of the season. This is the early days of the season. It's a process for each episode of looking at an outline. A story outline will be a brief, one or two sentences about each scene and then everybody reads that and comes in and weighs in and gives notes and once the story outline is in good shape, the writer will go off to write a first draft and then the first draft will come back two weeks later and we'll sit down and discuss the first draft, what's working, what's not working. They'll get notes, go back and eventually you know, it'll be three or four drafts before it's ready to go to production.
Speaker 3:I'm going to back up for a little bit because once the outline is approved, the writers most of whom are not doctors, need to get their medical notes. They need to learn how to write all of the technical dialogue for all the scenes. So we would divide up the medicine and say why don't you do the appendix story, ariel, talk about how a surgeon would do bedside teaching and how she would quote the CODA article, and in another episode, greg, give them all the technical dialogue. They would need to do a retrograde intubation through the cricothyroid membrane, and I would get their notes and do the scenes I was going to do and kind of polish them and edit them. So the writer gets sometimes a 20-page document of all of the technical knowledge that they need to know to write their technical scenes. Then, once the episode preps in come three new residency trained board certified physicians in emergency medicine whose responsibility is on set.
Speaker 3:So part of it is prepping every scene. What props do we need? What makeup do we need? What prosthetics need to be built? What special effects for squirting blood need to be done? What scenes need real nurses in them to assist with complex procedures. And sometimes the heads up on complex prosthetics are done months in advance. To do a thoracotomy with a beating heart, to do a full-on vaginal birth, rotating the baby, for shoulder dystocia, those take a long time to build. So it's a lot of prep that goes in medically and then each of those doctors are on set every minute of production, from call to wrap, to be sure everything is looking okay, procedures, pronunciation of words, instruments are held correctly.
Speaker 1:It's almost like the doctors are choreographers. How do the actors take to being coached in that way? This is how you say this word, or this is how you thread this catheter. Do you find that they're pretty quick on the uptake?
Speaker 3:Yeah, for the most part, and they love it. They want to be real, they're not upset and they're not angry If someone comes in and goes, you know what? On that last take, there's a better way to hold the scalpel. Let's try it again and do it this way, and then you get it on take two or on take 10. I have to give huge shout out to our makeup department, who builds all the prosthetics, all the wounds, everything. To our prop department, and if there's a scene that requires 100 props, as soon as the director yells cut, four prop people have to run in, clean and reset everything to its original position in pristine form, because we're going to do at least 12 to 20 takes of every complicated critical care scene to get the wide master shot and then to get everybody's close ups. So the props department is essential. And then the production designer, nina, who designed the whole set.
Speaker 1:The set is amazing Central. And then the production designer, Nina, who designed the whole set. The set is amazing the nursing station, the TV screen with the board.
Speaker 3:Yeah, yeah. And actually if you come to the set, every Post-it note in the Central work area, every little flyer in the break room, everything is so real. And there's another department called set decoration and matt, who's the head of that, is absolutely brilliant in attention to detail. When you walk in and mel mel, you can talk about your experience of walking into the set to see what it's like it feels so real.
Speaker 4:It's hard to describe how real it feels until you stand outside it and you're like, oh, this is fake. And then you step back in it's like no, this can't be fake. It's so real. The procedures are so real. I've literally had a number of docs say Mel, how do you get around HIPAA? When it comes to those procedures that you're showing on TV, I'm like no, that's the prop department, these geniuses making up ghosts. Some of them are so real it's hard to differentiate it from reality. It's really stunning.
Speaker 1:Where is the set?
Speaker 2:Warner Brothers.
Speaker 1:So is it in a big.
Speaker 2:Stage. Yeah, we have two stages. We're basically wall to wall on our main stage and then we have another stage that has our triage area and the waiting room and then there's a little piece. As people come through into triage you see the wall of heroes and there's the glass block wall. We have that same repeated on the other set so you can match to it. So it seems seamless. And we also matched our reception area waiting room. That matches perfectly to Allegheny General Hospital in Pittsburgh. Their entrance to the ER.
Speaker 2:Nina and her team are amazing. Nina studied a lot of ER designs. I can't remember the grandfather of all of them, who seems to be a design like 300, but he has a book that Nina used and we just sat down and Nina came up with the sweeping curvature feel and I think that allows us to really maximize our space and the whole idea is to make it very useful for kinetic movement. We have two doors to certain rooms. We have three different corridors and Nina did an amazing job and we had her design it before we started writing so that we could write specifically to it, Otherwise you wouldn't know what you're writing to. So that made a huge difference.
Speaker 2:On day one the writers go down there with their scripts sometimes, and at lunchtime the directors are down there prepping their episodes, walking through, making sure how do we get from here to here. We try to make sure that's already in the script, but sometimes we want to make some changes. So it's very much a process of getting your fingers dirty a little bit and getting down there and really working the set. It's as much a part of our show as anything, and that goes for not just the set itself but the color scheme. And one of the things that's unique about our sets are we have a ceiling, which a lot of sets don't, and all our lights are practical. So I forget how many hundred lights we have, but every single one of those lights is an LED light that can be controlled for intensity, color temperature et cetera, which is all run by a giant computerized board, and so we don't do any lighting setups like a traditional show would.
Speaker 2:So when we come and start shooting, we just hit the ground running, turn the lights on, and they make some tiny adjustments here and there, but it allows us to do all that movement without having to come in and move lights and things like that. The other thing that was really unique to our show is we shoot it in continuity Traditional shows. If you're going to be in this room for four or five scenes over the course of an episode, you'll shoot them all back to back. We don't shoot like that. Day one is usually page one, scene one, and we work through that. It really helps the actors because they don't have to remember what was I supposed to be or when was.
Speaker 1:I already punched, or was I not already? Yeah, it's all in order.
Speaker 2:I think that also adds to the authenticity because that allows us to do the continual movements and the handoffs and when it works it's really kind of special.
Speaker 3:There are two wizards of Oz on the set that if you were to walk around the perimeter, you would come to the lighting area, where there's four workers with a giant control board of dimmers for all the lights everywhere and being able to create the proper effect and lighting for the people who are walking wherever scenes are being played, for the people who are walking wherever scenes are being played. And the other is the video playback team, which is at least three, because with technology, every cardiac monitor in every room has to be controlled and simulated to the heart rate, the blood pressure, the pulse, ox, and if there's an abnormal rhythm, if it's atrial fibrillation at 80 or 140, or if they deteriorate into VTAC, they're going to be simulating all of that on the monitors. We have the big board showing all the patients and their status. We have the electronic medical records that we had to invent and create on our own because we don't actually have a real vendor that would put a multi-million dollar system in place Sponsored by Epic.
Speaker 3:Yeah, that didn't happen. And also ultrasounds and x-rays that magically appear. Those have to be created and those have to be put onto screens. And here's a really interesting fact the ultrasound cannot be performed in real time on a real actor. Warner Brothers Legal will not allow us to do that, and the reason being is what if there's some slight abnormality that we didn't notice when we were filming the segment, and would Warner Brothers be liable for missing an early neoplasm or something of that nature? So nothing that's done with ultrasound is actually on the real patient. Even a normal study is playback of existing footage.
Speaker 1:Are there any memorable moments or mishaps or behind the scene stories that you think would be fun to share with the audience?
Speaker 4:Has anybody pooped in the toilets? Yes, on set. Yes, that already happened. Tell that story.
Speaker 2:Every time. Yeah, some of the bathrooms you see when people go in the bathrooms are actually the real bathrooms outside the writers and production office. But we do have a bathroom that the young woman locked herself into who wanted the medication abortion. We can run water through there and we can use the shower, but it's limited. Obviously, you have tanks on the other side of the wall, and it happened on other shows too. The toilet is not practical. Every now and then, someone who is not maybe as accustomed to working on a television show will use that toilet, thinking it works, and then we have a bit of a problem.
Speaker 3:The first clue is there's no water in the commode.
Speaker 2:Yes, there's no place for it to flush anyways, it would just go.
Speaker 3:I'll tell you one thing that's kind of interesting. We have a wonderful, wonderful ultrasound expert, jalen Avila, who supplies us with all of the ultrasounds. Mel, do you know the name of Jalen's website? Is it 5-Minute, 5-minute, son-elk? Those are invaluable.
Speaker 3:So the other thing that's new technology is video laryngoscopy for intubations. So when our doctors are intubating, you'd think there would be someone who could supply us with the footage to put on the screen. Well, that's pretty hard because, oh, we need one that's really bloody, where you can't see any landmarks even though you're suctioning. We need one with a right-sided mass that's distorting all the anatomy, which is hard. So our prop god, rick Latimade, said Joe, let's just build one. So he had his prop resources build an entire upper airway and it took about five tries before they got everything right. He says no, guys, the epiglottis isn't right, and the retinoid folds? Let's do this. So after about five trials we got it right. So now I can do the intubations on this little model and we can throw tons of blood in, or we can distort the anatomy, or we can do whatever we want, and that's what you're gonna see on the screen rather than real playback. It's going to be me using the glide scope and throwing whatever pathology we need to into this model.
Speaker 2:And there may have been somebody actually intubated at one point for getting the footage, but we don't talk about that.
Speaker 1:It would be ironic if someone actually had a medical emergency on set and they were like in a fake ER.
Speaker 2:Joe's used his medical talents in the past on fake shows.
Speaker 3:Yeah, without getting specific. Okay, there are actors who have received two liters of normal saline rather than going home and calling an insurance day and ending everything for the 300 people who are working, and it was at their request, not at my request. If we can do this, do you think I can get through the next two hours, if you really want to do it?
Speaker 2:we'll do it, but of course we never do that anymore, that's never passed.
Speaker 1:Okay, can we do a quick lightning round? Sure, okay, so we'll go. Joe Scott Mel for the answers.
Speaker 3:So one word to describe the pit Authentic.
Speaker 4:Hopeful.
Speaker 1:Intense.
Speaker 3:Favorite medical case on the pit Twiddler's syndrome.
Speaker 4:Pass Shoulder dystocia.
Speaker 1:If you could swap roles with anyone on set for a day, who would it be?
Speaker 3:Craft service. Those are the people who bring the snacks.
Speaker 4:Noah, of course I'd say Noah, he's so damn nice and so handsome.
Speaker 1:If you had to survive a real ER shift as a patient, which Pitt doctor would you want to be by your side?
Speaker 4:Dr Robbie yeah for sure, yep, dr Robbie. Yeah for sure, yep, dr Robbie. Or Mel I love Mel. I think she's going to be the most amazing ER doc in the future.
Speaker 3:I love Mel too, or after you see the next two episodes.
Speaker 1:Dr Abbott, Last lightning round question.
Speaker 2:Dream guest star for the Pit Brad Pitt, james Brown.
Speaker 4:Robert F Kennedy.
Speaker 1:Fabulous. Well, it has been so, so fun to hear you talk about the show, the process, the set, everything. It just sounds like an amazing project to be working on. And just speaking on behalf of the medical community, I want to thank you for everything that you do to produce and entertain, but also to bring some of these really serious issues into the public consciousness. I feel like, as much as this show is a joy and fun and entertainment, it's doing really important work in the advocacy realm as well. So, as we round to a close, is there anything else you'd like to share or say to our clinician audience?
Speaker 3:I know what Mel wants to say.
Speaker 4:No, what actually? What I want to say is I want to say thank you, as well as a clinician, as an ER doc of 30 plus years, joe in particular has been under-recognized the work he has done for emergency medicine. But both of these gentlemen, when I started in residency at UCLA, er had just started and it made emergency medicine this incredibly sexy thing to do. And now, 30 years later, to have a show that shows just how things have not gotten better and, in fact, have gotten worse and we're in crisis, is an incredibly important public health message that everybody needs to understand. That we are just thanking you, as you said at the beginning, for being seen. It's really a problem right now. It's really a crisis, and they're doing a better job than I've ever done on all our education programs, showing the world what that looks like.
Speaker 3:I'm going to go back for a minute to Noah's notion of what he wanted to bring to the show. Noah travels all around the world and wherever he goes travels all around the world, and wherever he goes, doctors, nurses, paramedics come up to him and say thank you so much. It's because of watching you that I decided on my career path, and that was based on a show from 1994 to 2009. And as time went on, especially post-COVID, emergency medicine fell out of favor, so much so that they had trouble filling residency spots, residency spots.
Speaker 3:I saw that, yeah, residency spots were not being filled and NOAA really wanted to inspire a new generation of people to go into medicine, to accept the responsibility, to recognize the challenges but recognize the rewards, and that is one of his guiding principles in what he wants to do and what he wants to show, both as a writer and an actor. So my hat is really off to Noah for having this altruistic goal to become a role model and an inspiration for a new generation to enter healthcare.
Speaker 2:I would just add, as someone on the other side of that even though you know I get a lot of credit for creating the show it really is just a love story to the medical profession.
Speaker 2:I mean, when I'm around these guys and when I'm at MRAP, or when I'm around we had a residence night recently or when I do go to the ER, it's very, very humbling to see real people really helping people, saving lives, and they never get the credit they do and we expect them to be there 24-7 when we need them most. And if our show can fictionalize that a little bit so that people actually pay attention as opposed to just telling the stories straightforward in a journalistic point of view, I think we've done our small part to helping with that situation. But I mean, these guys are brilliant and I'm a typing monkey, but they are the real deal. And if we can portray that and what they go through day to day and what they've been through with COVID and the things they are expected to just solve not just one thing in an hour, not just two things and then over 12 hours and then we like to sue them because something didn't go exactly the way we want it.
Speaker 1:And not just medical things, things related to caregiver burnout or, you know, the kids, all that yeah.
Speaker 2:So it really is a love letter to the profession that I think is sometimes just taken for granted, like air traffic controllers or other people who we rely on. We just assume it's going to be there when we need it, and these guys are the best just assume it's going to be there when we need it, and these guys are the best.
Speaker 3:I've heard some online comments that really warmed my heart, which is that real emergency health care workers state. For years, I've tried to tell my friends, my family, my significant others what it's like to work a shift, and I've never been able to put it into words before and I never have been able to give a sense of what it's really like. And now that the show's on the air, they can watch it and I can say, yes, that's what I do.
Speaker 1:Yeah, scott, you use the word hopeful or hope, and I feel that I think, even though the show has a lot of serious themes and some cases that have sad outcomes, you can feel the hope and the celebration of the work and of the work ethic and the commitment of the healthcare workers, and I think that's another reason why the show is just, you know, as authenticity aside and accuracy aside is just resonating so, so strongly in our community. So thank you so much again for all the magic you make and thank you for coming on the Nocturnist podcast to speak with me. I'm truly honored.
Speaker 2:Thanks for having us. It was wonderful.
Speaker 3:Thank you so much, emily. Thank you Emily.
Speaker 1:This episode of the Nocturnist was produced by me and John Oliver. John also edited and mixed. Our executive producer is Allie Block, Our head of story development is Molly Rose Williams and Ashley Pettit is our program manager. Original theme music was composed by Yosef Monroe and additional music comes from Blue Dot Sessions. The Nocturnist is made possible by the California Medical Association, a physician-led organization that works tirelessly to make sure that the doctor-patient relationship remains at the center of medicine. To learn more about the CMA, visit cmadocsorg. The Nocturnist is also made possible by donations from listeners like you. Thank you so much for supporting our work in storytelling from listeners like you. Thank you so much for supporting our work in storytelling. If you enjoyed this episode, please like, share, subscribe and help others find us by giving us a rating and review in your favorite podcast app To contribute your voice to an upcoming project or to make a donation, visit our website at thenocturnistsorg. I'm your host, Emily Silverman. See you next week.
