April 21, 2025 • 53 mins
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.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Support for the Nocturnist comes from the
California Medical Association.
At the Nocturnist we arecareful to ensure that all
stories comply with healthcareprivacy laws.
Details may have been changedto ensure patient
confidentiality.
All views expressed are thoseof the person speaking and not
their employer.
This is the NocturnistConversations.
(00:25):
I'm Emily Silverman.
As you may know, we recentlylaunched our Uncertainty series
here at the Nocturnist and thoseepisodes will continue to drop
on Thursdays as planned.
But today, tuesday, we'rebringing you a special bonus
episode because thisconversation was just too fun to
postpone.
(00:46):
Today I sit down with thecreative minds behind the HBO
Max television show, the Pit, anew medical drama that has
captivated so many of us in thehealthcare world.
At the time of this interview,the first 11 episodes of the Pit
had aired and since then thestakes have only grown higher.
The characters on the Pit feelso incredibly real my personal
(01:09):
favorite is Dana, the chargenurse and the medical cases on
the show also hit close to home,which just goes to show how
much the writing teamunderstands what it's really
like to work in an emergencydepartment, and part of why they
nail the authenticity of theshow is that they have a lot of
doctors involved in the creativeprocess, which brings me to
today's three extraordinaryguests R Scott Gemmel, longtime
(01:33):
television writer and producerknown for his work on ER NCIS
Los Angeles, and now the creatorand showrunner of the Pit.
Joe Sachs, an emergencyphysician and TV writer who
worked on ER for years and nowbrings his clinical expertise to
the Pit.
And Mel Herbert, a belovededucator in emergency medicine,
the founder of the MRAP podcastand consultant on season one of
(01:56):
the Pit.
As someone who works at theintersection of medicine and
storytelling, I have to say Iwas a little starstruck to be in
conversation with these legends.
We talked about everything fromhow they set out to make a
medical show unlike anythingwe've seen before.
How they write to the moment,bringing in real world crises
from healthcare like burnoutboarding, even press Ganey
(02:19):
scores.
Why they chose to tell thestory in real time, with each
episode covering one hour of theshift.
How they nailed the realism ofthe show from a hand-designed
airway that they built and canintubate to a fake toilet on set
that may have been a little tooconvincing.
And what they hope the Pit willmean to clinicians and the
(02:40):
culture at large.
I hope you enjoy thisconversation as much as I did.
But before we dive in, take alisten to the trailer for the
Pit, streaming now on HBO Max.
Speaker 2 (02:58):
Morning Jack, what are you doing here Working?
Speaker 3 (03:10):
And if you jump?
Speaker 2 (03:11):
on my shift.
That's just rude man.
I hope I'm never one of yourpatients.
Makes two of us my friend.
Hey D, what's a good word.
Speaker 4 (03:18):
We're f***ed.
52 in the waiting room and it'snot even 7.
Robbie's working the shift.
Speaker 2 (03:23):
by the way, Got him a little slack today.
Speaker 4 (03:28):
It's the anniversary of Dr Adamson's death.
Who left this mess?
Nothing like a little challengeevery now and then.
We've got some new faces withus today.
Hi, come on over, I'm so happyto be here.
Talk to me at the end of theday, clear Forceps.
Speaker 3 (03:42):
Suction Med student down.
Welcome to the pit.
Let's go save some lives.
Speaker 2 (03:48):
The systolic is only 80, 14 days.
Speaker 3 (03:50):
Alex, you've lost a lot of blood.
You need to go to surgery rightaway.
Am I gonna die?
Not now that I'm here, easypeasy.
I'm in Good, well done.
That was awesome, isn't italways this busy?
Speaker 4 (03:59):
No, always this busy.
No, it gets a lot busier.
Speaker 1 (04:03):
There's a nursing shortage across the country.
Speaker 2 (04:05):
That is bullshit.
If you paid them a living wage,they'd line up to work here.
Speaker 1 (04:08):
Other hospitals are managing this crisis either step
up or step aside.
Speaker 3 (04:12):
Are you okay.
Why wouldn't?
Speaker 1 (04:14):
I be.
It's five years ago today.
You can't block your feelingsforever.
Speaker 4 (04:22):
Oh, you'd be surprised.
Speaker 3 (04:24):
Crash guard, let's go no pulse.
Speaker 1 (04:26):
Clear Hold compressions.
Are we ready to call this?
Speaker 4 (04:40):
150,000 people die every day in the world.
Today, you got one of them, andwe're gonna get more of them
before the shift is over.
Speaker 3 (04:48):
Tier 1 trauma now Four of morphine.
I'm gonna stop the bleeding.
Speaker 4 (04:52):
You learn to accept it.
Find balance, you found balance.
Speaker 2 (05:04):
No, not even close.
Speaker 1 (05:11):
I have the pleasure of sitting here with Scott
Gemmel, joe Sachs and MelHerbert.
Thank you so much for beinghere today.
Speaker 3 (05:18):
Thank you for having us Our pleasure.
You're welcome.
Speaker 1 (05:21):
So I've watched all 11 episodes of the Pit that are
out thus far.
I think we have a few more andI 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
(05:41):
like.
That's exactly the words that Iwould say if I were in that
situation.
Everyone is talking about theauthenticity of this show.
I think for me and my doctorfriends and the physician
community, something that we'refeeling a lot with this show is
just feeling really seen in away that maybe we haven't with
other medical shows in the past.
(06:02):
There's just something in thewater at the show that just
feels like it really representsour experience.
So, to begin, I just wanted toask if that was a conscious goal
from the start, as you broughtthe show into existence.
Speaker 3 (06:16):
Joe.
Well, I'm going to let Scotttalk because he has the created
by credit.
Speaker 2 (06:21):
Yeah, absolutely.
If we're going to do something,we want to do it well and we
want to do it respectfully tothe community and physicians and
nurses and everyone else that'sinvolved in health care.
And, trust me, it's not alwayseasy, as Joe and I went through
this morning as we were tryingto agree on how to tell a story
about a sim lab and what wasreal and what wasn't.
So, yes, we do strive to be asauthentic and honest as possible
(06:44):
.
Speaker 3 (06:45):
I think it came from Scott.
It came from John Wells, andwhen I was brought into the
project I just wanted it to beas real and authentic as
possible.
And John I remember in theearly moments of this show's
conception, said I want amedical show the way no one has
(07:05):
seen a medical show before.
So I knew what had to be done.
Speaker 1 (07:10):
And just to be clear, we have some physicians in the
room, we have some writers inthe room who have written
medical drama but aren'tphysicians, and then we have
some who are both.
So maybe can you just walk methrough who here has the
physician hat, who here has thewriter hat and who here has both
.
Speaker 2 (07:27):
Well, I'm a shaman and a writer.
No, I'm just a writer.
I've written a bunch of medicalshows, but I'm just a writer.
I'm a one trick pony.
These other guys have multipleskill sets.
Speaker 3 (07:38):
I'm a writer and an emergency physician with 33
years in the pit, as they say.
The short answer to how I camedown this path is while I was in
medical school, I also went tofilm school because I had an
interest in public healtheducation and as I was learning
how to evaluate and plan publichealth campaigns, I became more
(08:02):
interested in the creative sideof 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 firstseason they were in need of
some help and they reached outto me.
Speaker 1 (08:20):
Do you still practice , joe?
Speaker 3 (08:21):
or are you full time?
I do, I do.
I've worked in a Los AngelesCounty trauma center for 33
years, including at the peak ofthe COVID epidemic, including
intubating the sickest patientsin full.
Ppe began to have itsconception.
(08:42):
I made a decision to cut backto urgent care just because the
amount of time that I need tospend with every aspect of the
show is monumental and I justcouldn't afford the time
constraints of working anovernight or working till three
in the morning, because I reallyam working seven days a week on
the show when we're inproduction.
Speaker 1 (09:04):
And Mel, how did you get involved with this?
Speaker 4 (09:07):
So I'm an ER doc and I retired from clinical work
actually to run my educationcompany full time because it had
gotten too big and busy.
I still work clinically inother countries but I don't
really practice in the USanymore.
But I got involved back in theday.
Joe was my attending when Ifirst got off the boat from
(09:27):
Australia in 1991.
Speaker 3 (09:29):
Wow, I like to say.
I taught Mel everything heknows.
Speaker 4 (09:33):
And I don't know anything, so I don't know what
that means.
So Joe got me involved in ERyears ago, basically as a
medical consultant, so he'd runcases by me.
And what do you think aboutthis?
What do you think about that?
And our education program isall about emergency medicine and
so a lot of the cases wouldcome 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 likethat sounds like a fun game,
(09:54):
let's do that again.
Speaker 3 (09:56):
I think one of the things at the beginning of
season one I wanted to bringScott and Noah Noah Wiley, who's
both an actor and a writer, andsome of the other writers to
meet all of the key physiciansat MRAP.
So we would attend the liveGrand Rounds session just
because I wanted to giveeveryone a sense of the
(10:17):
complexity of academic emergencymedicine, of the teaching, and
to meet giants in the field likeMel Stuart Swadron, sean Nort,
and we would watch and listen toGrand Rounds and then have
dinner and those were veryenlightening and successful for
some of the other writers to geta sense.
(10:37):
And then Mel's relationship tothe creation of stories would be
very informal, like once ortwice a week I'd be driving home
from Warner Brothers and Iwould say, hey, mel, I'm
thinking about doing this storyand it's gonna be a
seven-year-old drowning victimand I need it to go on for this
(10:57):
and this and this, and I knowshe's gonna be hypothermic and I
know we're gonna warm her andthis or that, but I need a
really good way to finish it.
And Mel goes make her potassium12, because nobody ever comes
back with potassium 12.
So Mel was kind of the spiceand seasoning that would often
put the finishing touches on thecases that we were creating.
Speaker 4 (11:20):
Isn't there a spice girl called Mel?
Is that me?
Speaker 1 (11:21):
There is a spice girl .
Yes, I think that's SportySpice.
Speaker 4 (11:26):
Just so your listeners know, I run a program
called MRAP, which is a very bigeducation program within
emergency medicine.
It's got 65,000 users acrossthe world so it's hard to find
an ER doctor that doesn't useMRAP.
We're a 25-year overnightsuccess.
One of our most religiouslisteners is Joe Sex, and so I
think a lot of the cases anddiscussions come from Joe's
(11:46):
intimate knowledge of thatprogram, which comes out every
week.
Speaker 1 (11:50):
So I had the pleasure of sitting in on a teaching
session with one of your writersa friend of mine, max teaches
screenwriting and had her in asa guest, so I got to sit and
listen to her talk about the pitand your creative process, and
she was talking about how a lotof TV shows will start with the
characters or start with theplot, but that in procedurals
(12:10):
like medical TV shows, thatoften you start with the medical
cases.
So I was wondering if you couldbring us into that process.
Do you just start with awhiteboard and you have the
cases and you shuffle themaround, or what does that look
like?
Speaker 3 (12:24):
Well, I'm going to contradict her which is to say
that we start with the drama.
We start with the dramatic needsof the character.
What is their arc during a15-hour shift?
What is going to be revealedabout them?
And then the medical casesaugment that in a subtle way
(12:44):
that get us to learn more aboutthe characters and their
relationships with each other,with the attendings.
So the medical cases aren'tjust randomly chosen and then
try to put a square peg into around hole.
And something as simple as acase in the episode that Valerie
wrote was an ankle sprain.
(13:05):
I didn't start with the ideathat, oh, we need to do a story
about an ankle sprain becausethe world needs to know about
ankle sprains.
But something as simple as anankle sprain was a chance for
Mel to show her incredibleskills at patient care and
compassion and understandingwith somebody with autism
spectrum disorder, as opposed toLangdon who had no patients, no
(13:30):
time and was doing everythingwrong.
So that was a cool case and allof the medicine was right in
terms of her differentialdiagnosis and thinking about a
dancer's fracture and a Jonesfracture.
And, of course, the patient hadGoogled everything infinitely
and was asking an infinitenumber of annoying questions.
(13:50):
But she had the patience andshe got through to the patient
in a way that Langdon nevercould.
So that's just an example of avery simple case that speaks to
the needs of the character.
But I'll let Scott commentabout that too.
Speaker 2 (14:04):
No, I think that's you know.
We start with the characters.
Who are they, where do we wantto take them, what is their
journey, where do they come fromand then where do we want to
end up with them?
This show is a little unique inthat it's told in relatively
real time.
In a traditional TV series,whether it's eight episodes or
(14:28):
24 episodes, you're not usuallyhour by hour.
You may be day by day, it couldbe 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 thecharacters where we only have 15
hours.
So it's a very truncatedversion of character development
(14:50):
and exploration.
So we have to be very preciseabout that.
But the constraints also are agreat creative challenge,
because then you have to workwithin a certain size box, work
within a certain size box.
So that's where we start, andthen it's really about finding
the cases that will bring outthose elements of the story that
(15:11):
we want to tell, whether it'sexposing someone's insecurity or
their overconfidence or any ofthose elements that you saw
throughout some of the episodesyou've watched already.
So it's a little bit of both,but generally we start with the
character, who they are andwhere do we want them to be at
the end of the season.
Speaker 3 (15:30):
Let me give an example of three stories that
came out of the dramatic needsof the Javadi character, the
third-year medical student.
Great character, so thechallenge of the first episode
was hey, joe, what's a case thatwould make a third-year medical
student faint in the traumaroom?
So the degloved, fracture,dislocation of the ankle came
(15:50):
out of that and it was prettyeffective and it was brilliantly
done by our makeup department,which is a whole other sidebar
that we'll get to because theyare geniuses.
A second thing would be howdoes Javadi's mother, who's an
attending physician in surgery,embarrass the hell out of her?
So her mother comes down toexamine a young man with
(16:14):
appendicitis and, in thepresence of another medical
student and an intern, startsteaching slash pimping.
We know about pimping, yes,about recent studies about
non-operative management ofappendicitis, and the other
medical student is able to quotethe CODA study from the New
England Journal from 2020.
(16:35):
And the mother looks at herdaughter and says honey, you
knew that we talked about thatover dinner.
Speaker 4 (16:40):
And then honey, everyone is like oh my.
Speaker 3 (16:43):
God, that's your mother.
So that was an example of acase that highlighted that, but
was accurate, and mosttelevision writers probably
couldn't cite a New EnglandJournal of Medicine article from
2020.
So that's the kind of thingthat made it so unique and
specific that I think people areresponding to.
And then the last one in alater episode, the question came
(17:07):
how can Javadi show up hermother?
So how can a third year medicalstudent beat her mother to a
diagnosis?
And that was the basis of theBlack Widow spider bite, because
a Black Widow spider bite cancause such intense spasm of the
abdominal musculature that itcan be mistaken as peritonitis,
and people have actually gone tothe operating room when they've
(17:29):
had a black widow spider bite.
So those are examples.
Start with the dramatic needFind a cool case that can speak
to that and make it reallyaccurate, and that's the
marching orders.
Speaker 4 (17:43):
I can give you a little color as to what it looks
like in there, because theseold guys have been doing it so
long that I don't even know howinteresting it is.
So this is my first time thatI've actually been in the
writer's room.
So for season two, I'm now inthe writer's room and so you
have basically just this roomand there's four not one, but
four whiteboards all around theroom, divided up into the 15
(18:04):
episodes, and you've got a groupof people who are super smart,
creatives that are going backand forth with each other.
Well, what about this idea?
No, no, we could do it this way, and we could do it this way.
Two docs, but the rest arewriters going back in this
process, and then they're likeokay, in this hour we'll do this
thing, and then we can see thisarc, and then it'll happen over
here, and then we'll do theprocedures.
(18:24):
We'll do this thing and then wecan see this arc, and then
it'll happen over here, and thenwe'll do the procedures, we'll
do the medicine stuff.
But to watch something beingcreated out of nothing for me is
fascinating.
Just these smart peoplethinking about arc ideas and
then having them fleshed out,agreeing, disagreeing, calling
each other names and having funwith it, then coming out with
what the arc is going to be forthe non-writer in the room is
(18:44):
absolutely fascinating.
Like I said to him, it's almostas if you guys are making this
up as you go along.
Speaker 3 (18:50):
And the dramatic arcs are very subtle because they
happen in the course of a15-hour day and we just have to
learn new things about thecharacter and season two I may
be talking out of school, butseason two is going to start
sometime in the future fromseason one.
(19:10):
So people's status, is itstatuses or stati?
People's status have changedand all those need to be
reflected in the storytelling.
Speaker 2 (19:21):
Season two is 300 years in the future.
Speaker 4 (19:24):
Millennium in the future.
Speaker 1 (19:26):
The AI doctor and the pocket ultrasound.
Speaker 2 (19:29):
AI may actually play a part in it.
Speaker 1 (20:02):
Scott, you mentioned the choice to compress time and
I love the way that each episodeis just one hour.
Episode one, I think it waslike 7am to 8am, and I love it
for so many reasons.
I think one, it just makes itfeel so heightened.
But I think, two, it alsoreally shows how intense it is
to be in the ER and all thethings that happen and the
(20:24):
moment to moment and the waythat it's choreographed and
edited, where people are sort ofpopping in and out of different
rooms and he goes to pee and hecan't even pee.
You know, someone comes in andsays now you got to go in this
room.
So I was wondering if you couldspeak to that choice, because I
don't think I've ever seen amedical show before operate in
that way where they'reallocating a 60 minute episode
(20:48):
to 60 minutes of real time, andthe thought process that went
into making that choice for thenarrative form.
Speaker 2 (20:54):
We've sort of done Joe and I and John and Noah,
sort of done the Mac Daddy ofall medical shows.
So when the opportunity cameabout to revisit doing another
medical show, when theopportunity came about to
revisit doing another medicalshow, one that we wanted to make
completely different, it waslooking at how can we tell these
stories differently than wehave in the past.
And once it became a streamerbecause it was HBO Max who was
(21:27):
asking for it we knew already itwas 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 thatare now six, eight, 10, 12 is
maybe the most and we weren't onstreaming.
I don't know if I would havecome up with that idea, but it
was because it was 12 episodesand the shift is 12 hours it
seemed like a really logical fitand the more we thought about
it, even though it seemed apretty daunting task at first,
(21:51):
the one thing that really, Ithink, differentiates the
emergency department from otherforms of medical practice is the
time element.
People come to the emergencydepartment sometimes through
ambulance service, where time isof the essence, so time just
seemed to become such animportant part of the whole
(22:11):
process.
One of the things with ERphysicians and these guys can
speak to it much better than Ican, but is how often they're
pulled away to another situation, another case, Someone else
needs them that every three tofive minutes they're on
something else.
So that became really important,as we talked earlier about the
authenticity, and so rather thanfollowing a patient through the
(22:34):
course of one episode and theycome in and we fix them up and
by the end they're bettereveryone who's been to the
emergency department knows yourweight alone is going to get you
through four or five episodesand we really wanted to capture
that, and so the time elementbecame a really big part of it
and as challenging as it was andwe weren't sure it was going to
work I think it really elevatesthe show.
(22:56):
It's very hard to capture thatfeeling of the emergency
department because it's so aliveand it's so electric and
there's so much going on and itseemed like if we took the
audience into that environmentand didn't let them out.
We're not going to commercialbreaks, we're not coming back
two hours later.
Speaker 1 (23:16):
Or even into their homes.
We don't go into their privatelives at all.
Speaker 2 (23:19):
No, and so it's kind of like Robbie not being able to
find time to use the restroom.
The audience doesn't get achance to step away.
They're sort of juggling thecases, the same way the doctors
are, and I think that reallyhelps pull you into the
storytelling, because you can'tleave until that hour or that
shift is over.
Speaker 3 (23:39):
The other thing that real-time allows us to do is to
keep the audience guessing whenyou meet a patient, is this
patient going to be one and doneone episode?
Is it going to evolve intosomething that's going to last
for four episodes or eightepisodes or 15 episodes?
It's just the mix of everythinggoing on and having to pay
(24:02):
attention to what's going on.
And the astute viewers mightlook in the waiting room in
episode one or two and seesomebody sitting there who
becomes a major character athour four or five that we would
just actually pay the actors tosit in the waiting room for one
scene and then come back muchlater.
(24:24):
And likewise, when Scott andNoah and John first approached
me about emergency medicine in2024, I said we got to come in
and see a waiting room packed tothe gills.
We have to come in and seeevery inch of wall space filled
with boarding patients who can'tgo upstairs because there's no
room upstairs.
(24:44):
And we did that and theintensity of the volume is real
and I think that's what peopleare responding to.
And the reality of the boardingpatients is fascinating because
one of our background nurses isa former charge nurse at UCLA
(25:04):
Santa Monica Hospital who's nowretired, but his job was to
track all the boarding patientsand to make sure, hour to hour,
their IVs went down by 100 cc's,that meals were brought to them
, that a breathing treatment wascome in, that physical therapy
came and took them.
So everything that's going onhour to hour is real.
(25:25):
And then the background artists, also known as extras.
When they first showed up tosay, oh, I'd like to work on
this show, Well, if you're goingto be a boarded patient, you're
going to be in your gurney forthe next seven months because
we're going to be filming 15episodes and you're going to be
sitting in the gurney the wholetime.
So that's another interestingaspect of production.
Speaker 1 (25:49):
You mentioned, Joe, if we're going to do a show
about the emergency room, thewaiting room has to be packed.
You know it needs to be likethis and like this, and I was
wondering how you see thisseries fitting into this
particular moment.
In healthcare and in the world.
There are themes that arealready weaving in to the cases
and the characters.
For example, we have the ladyfrom corporate who keeps coming
(26:11):
down to hound Robbie aboutpatient satisfaction scores.
We have problems of patientscommitting violence against
healthcare workers, which is atopic that's really important
right now.
We even have the flashbacks tothe COVID pandemic and sensing
the PTSD that the healthcarecommunity still has from that
(26:33):
time.
It was kind of long ago, butalso wasn't that long ago.
So I was wondering how youthought about weaving in some of
those bigger themes into theseries, because it just feels
very topical.
Speaker 3 (26:45):
Well, we wanted the show to be current and accurate,
and if we're current andaccurate, we have to show
waiting room medicine, which ispatients who just stay in their
chairs in the waiting room andget pulled back for labs and
x-rays and then dischargedbecause there's no beds and that
doesn't lend itself to patientsatisfaction.
(27:06):
We had to show the boardingpatients and we had to show the
pressures of a corporate culturethat's looking at Prescani
scores and other metrics thatare important to them.
These are people who arefighting an unwinnable battle
because all the cards arestacked up against them, and to
(27:26):
provide compassionate care andto try to do the best you can do
under these circumstances isreally heroic, and that's what I
think we're showing.
I think in season two we'regoing to try to address some of
the issues that have been raisedwith changes to prevent
violence against health careworkers.
(27:47):
A recent ENA Emergency NurseAssociation survey, 56% of
nurses had a physical assault inthe last month.
What can be done to addressthat in a way that can make the
emergency department and thehospital safer for everyone?
What is the systemic root issueof this boarding crisis?
It's not door to provider time,because we know if you can see
(28:12):
the patient in five minutes witha provider in triage.
That's not going to open upbeds upstairs, but there are
ways of addressing that problemand we've spent a good bit of
time speaking with Peter Vecelio, who is in the emergency
department at Stony BrookHospital, and he has had some
very successful and innovativeapproaches to address this whole
(28:36):
waiting room medicine boardingissue.
That has nothing to do with theemergency department but
everything to do with how theflow of admissions and
discharges and scheduledadmissions works in the hospital
.
So we may see some of that inseason two.
Speaker 4 (28:51):
Another thing that really stunned me was how much
effort is going to make itrealistic not just from an ER
point of view, because Joe cando that he's been an ER doc for
1.8 million years but it's thewriters.
Getting together with Joe andinterviewing real experts like
Peter Bocelli or like somebodywho is an expert in trans youth
or whatever it might be.
(29:12):
Getting these experts in andspending time with them and
finding out all of those nuancesand how to make it accurate is
something that this group hasgone 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 expertscoming into the writer's room
and telling them here's how thiswould really work, and to me
that was fascinating.
(29:32):
It's the best education ever.
I feel like I'm getting thiscollege degree from world
experts just by sitting in thewriter's room.
Speaker 3 (29:38):
We've probably had 12 Zoom expert briefings in the
last two weeks on a variety ofsubjects, including PTSD and
health care workers, addressingthe boarding crisis, trans youth
issues under new executiveorders, medicaid issues what's
going to happen in Pittsburghwhen people lose their Medicaid,
(30:00):
what resources are going to beavailable to them?
And on and on and on.
Speaker 4 (30:05):
And a bunch of things he can't tell you because it
would be a spoiler alert.
Speaker 1 (30:09):
Yeah, I sensed a hesitation there.
I was like don't say it.
Wait, no, say it.
You mentioned Zoom experts inthe writer's room.
You also talked a little bitalready about the writer's room,
how there's four whiteboardsand a bunch of really smart
people sitting around creatingthings.
Bring us a little bit more intothe writer's room.
Like what is a typical day,what is the generation process
(30:29):
like?
What is the revision processlike?
Sounds like, maybe some daysthere's a guest, some days
there's not a guest.
What is that all like?
Speaker 2 (30:38):
It changes throughout the season.
Obviously Right now is in someways the scariest time, but it's
also the most fun time becausewe come with a blank slate maybe
not so much as the beginning ofthe show, where there is no
show.
When we first came back.
We do a little bit of an M&M interms of what worked and what
didn't last year, what we werehappy with, what we weren't, so
(31:00):
that we don't fall back intosome habits that were not
serving us well.
And then we also look at whohas outstanding story elements
to address.
For instance, what might happenwith Langland?
We saw him get booted out atthe end of episode 11.
Is Dana going to quit?
We address that.
(31:20):
Where do we want to take that?
And then it's about, like Isaid earlier, where do we want
these characters to end up atthe end of the season?
What sort of personal storiesare going on with them?
We start to lay that down andthen slowly stories, and then
Mel will show us some reallydisturbing photos of cases he's
done and then we try to figureout how we can incorporate those
.
So it's a little show and tell.
(31:42):
That's sort of the way it works.
There's no hard and fast ruleand every day can be a little
bit different.
It's harder for me to tell youbecause I'm on one side of it.
Joe and Mel actually might havea better perspective on what a
day is like for those guys.
Speaker 3 (31:58):
Yeah, there's never a plan, there's never an agenda.
This is the early days of theseason.
This is the early days of theseason.
It's a process for each episodeof looking at an outline.
A story outline will be a brief, one or two sentences about
each scene and then everybodyreads that and comes in and
weighs in and gives notes andonce the story outline is in
(32:21):
good shape, the writer will gooff to write a first draft and
then the first draft will comeback two weeks later and we'll
sit down and discuss the firstdraft, what's working, what's
not working.
They'll get notes, go back andeventually you know, it'll be
three or four drafts before it'sready to go to production.
I'm going to back up for alittle bit because once the
(32:43):
outline is approved, the writersmost of whom are not doctors,
need to get their medical notes.
They need to learn how to writeall of the technical dialogue
for all the scenes.
So we would divide up themedicine and say why don't you
do the appendix story, ariel,talk about how a surgeon would
(33:07):
do bedside teaching and how shewould quote the CODA article,
and in another episode, greg,give them all the technical
dialogue.
They would need to do aretrograde intubation through
the cricothyroid membrane, and Iwould get their notes and do
the scenes I was going to do andkind of polish them and edit
them.
So the writer gets sometimes a20-page document of all of the
(33:31):
technical knowledge that theyneed to know to write their
technical scenes.
Then, once the episode preps income three new residency
trained board certifiedphysicians in emergency medicine
whose responsibility is on set.
So part of it is prepping everyscene.
What props do we need?
What makeup do we need?
(33:52):
What prosthetics need to bebuilt?
What special effects forsquirting blood need to be done?
What scenes need real nurses inthem to assist with complex
procedures.
And sometimes the heads up oncomplex prosthetics are done
months in advance.
To do a thoracotomy with abeating heart, to do a full-on
(34:16):
vaginal birth, rotating the baby, for shoulder dystocia, those
take a long time to build.
So it's a lot of prep that goesin medically and then each of
those doctors are on set everyminute of production, from call
to wrap, to be sure everythingis looking okay, procedures,
(34:36):
pronunciation of words,instruments are held correctly.
Speaker 1 (34:40):
It's almost like the doctors are choreographers.
How do the actors take to beingcoached in that way?
This is how you say this word,or this is how you thread this
catheter.
Do you find that they're prettyquick on the uptake?
Speaker 3 (34:52):
Yeah, for the most part, and they love it.
They want to be real, they'renot upset and they're not angry
If someone comes in and goes,you know what?
On that last take, there's abetter way to hold the scalpel.
Let's try it again and do itthis way, and then you get it on
take two or on take 10.
I have to give huge shout outto our makeup department, who
(35:13):
builds all the prosthetics, allthe wounds, everything.
To our prop department, and ifthere's a scene that requires
100 props, as soon as thedirector yells cut, four prop
people have to run in, clean andreset everything to its
original position in pristineform, because we're going to do
at least 12 to 20 takes of everycomplicated critical care scene
(35:36):
to get the wide master shot andthen to get everybody's close
ups.
So the props department isessential.
And then the productiondesigner, nina, who designed the
whole set.
Speaker 1 (35:46):
The set is amazing Central.
And then the productiondesigner, Nina, who designed the
whole set.
The set is amazing the nursingstation, the TV screen with the
board.
Speaker 3 (35:52):
Yeah, yeah.
And actually if you come to theset, every Post-it note in the
Central work area, every littleflyer in the break room,
everything is so real.
And there's another departmentcalled set decoration and matt,
who's the head of that, isabsolutely brilliant in
(36:13):
attention to detail.
When you walk in and mel mel,you can talk about your
experience of walking into theset to see what it's like it
feels so real.
Speaker 4 (36:21):
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'slike no, this can't be fake.
It's so real.
The procedures are so real.
I've literally had a number ofdocs say Mel, how do you get
around HIPAA?
When it comes to thoseprocedures that you're showing
on TV, I'm like no, that's theprop department, these geniuses
(36:44):
making up ghosts.
Some of them are so real it'shard to differentiate it from
reality.
It's really stunning.
Speaker 1 (36:51):
Where is the set?
Speaker 2 (36:53):
Warner Brothers.
Speaker 1 (36:54):
So is it in a big.
Speaker 2 (36:56):
Stage.
Yeah, we have two stages.
We're basically wall to wall onour main stage and then we have
another stage that has ourtriage area and the waiting room
and then there's a little piece.
As people come through intotriage you see the wall of
heroes and there's the glassblock wall.
We have that same repeated onthe other set so you can match
(37:17):
to it.
So it seems seamless.
And we also matched ourreception area waiting room.
That matches perfectly toAllegheny General Hospital in
Pittsburgh.
Their entrance to the ER.
Nina and her team are amazing.
Nina studied a lot of ERdesigns.
I can't remember thegrandfather of all of them, who
seems to be a design like 300,but he has a book that Nina used
(37:40):
and we just sat down and Ninacame up with the sweeping
curvature feel and I think thatallows us to really maximize our
space and the whole idea is tomake it very useful for kinetic
movement.
We have two doors to certainrooms.
We have three differentcorridors and Nina did an
amazing job and we had herdesign it before we started
(38:01):
writing so that we could writespecifically to it, Otherwise
you wouldn't know what you'rewriting to.
So that made a huge difference.
On day one the writers go downthere with their scripts
sometimes, and at lunchtime thedirectors are down there
prepping their episodes, walkingthrough, making sure how do we
get from here to here.
We try to make sure that'salready in the script, but
(38:22):
sometimes we want to make somechanges.
So it's very much a process ofgetting your fingers dirty a
little bit and getting downthere and really working the set
.
It's as much a part of our showas anything, and that goes for
not just the set itself but thecolor scheme.
And one of the things that'sunique about our sets are we
have a ceiling, which a lot ofsets don't, and all our lights
(38:43):
are practical.
So I forget how many hundredlights we have, but every single
one of those lights is an LEDlight that can be controlled for
intensity, color temperature etcetera, which is all run by a
giant computerized board, and sowe don't do any lighting setups
like a traditional show would.
So when we come and startshooting, we just hit the ground
(39:04):
running, turn the lights on,and they make some tiny
adjustments here and there, butit allows us to do all that
movement without having to comein and move lights and things
like that.
The other thing that was reallyunique to our show is we shoot
it in continuity Traditionalshows.
If you're going to be in thisroom for four or five scenes
over the course of an episode,you'll shoot them all back to
(39:24):
back.
We don't shoot like that.
Day one is usually page one,scene one, and we work through
that.
It really helps the actorsbecause they don't have to
remember what was I supposed tobe or when was.
Speaker 1 (39:35):
I already punched, or was I not already?
Yeah, it's all in order.
Speaker 2 (39:38):
I think that also adds to the authenticity because
that allows us to do thecontinual movements and the
handoffs and when it works it'sreally kind of special.
Speaker 3 (39:49):
There are two wizards of Oz on the set that if you
were to walk around theperimeter, you would come to the
lighting area, where there'sfour workers with a giant
control board of dimmers for allthe lights everywhere and being
able to create the propereffect and lighting for the
(40:09):
people who are walking whereverscenes are being played, for the
people who are walking whereverscenes are being played.
And the other is the videoplayback team, which is at least
three, because with technology,every cardiac monitor in every
room has to be controlled andsimulated to the heart rate, the
(40:30):
blood pressure, the pulse, ox,and if there's an abnormal
rhythm, if it's atrialfibrillation 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 showingall the patients and their
status.
We have the electronic medicalrecords that we had to invent
(40:52):
and create on our own because wedon't actually have a real
vendor that would put amulti-million dollar system in
place Sponsored by Epic.
Yeah, that didn't happen.
And also ultrasounds and x-raysthat magically appear.
Those have to be created andthose have to be put onto
screens.
(41:12):
And here's a really interestingfact the ultrasound cannot be
performed in real time on a realactor.
Warner Brothers Legal will notallow us to do that, and the
reason being is what if there'ssome slight abnormality that we
didn't notice when we werefilming the segment, and would
(41:33):
Warner Brothers be liable formissing an early neoplasm or
something of that nature?
So nothing that's done withultrasound is actually on the
real patient.
Even a normal study is playbackof existing footage.
Speaker 1 (42:25):
Are there any memorable moments or mishaps or
behind the scene stories thatyou think would be fun to share
with the audience?
Speaker 4 (42:33):
Has anybody pooped in the toilets?
Yes, on set.
Yes, that already happened.
Tell that story.
Speaker 2 (42:40):
Every time.
Yeah, some of the bathrooms yousee when people go in the
bathrooms are actually the realbathrooms outside the writers
and production office.
But we do have a bathroom thatthe young woman locked herself
into who wanted the medicationabortion.
We can run water through thereand we can use the shower, but
it's limited.
(43:00):
Obviously, you have tanks onthe other side of the wall, and
it happened on other shows too.
The toilet is not practical.
Every now and then, someone whois not maybe as accustomed to
working on a television showwill use that toilet, thinking
it works, and then we have a bitof a problem.
Speaker 3 (43:18):
The first clue is there's no water in the commode.
Speaker 2 (43:20):
Yes, there's no place for it to flush anyways, it
would just go.
Speaker 3 (43:25):
I'll tell you one thing that's kind of interesting
.
We have a wonderful, wonderfulultrasound expert, jalen Avila,
who supplies us with all of theultrasounds.
Mel, do you know the name ofJalen's website?
Is it 5-Minute, 5-minute,son-elk?
Those are invaluable.
So the other thing that's newtechnology is video laryngoscopy
(43:49):
for intubations.
So when our doctors areintubating, you'd think there
would be someone who couldsupply us with the footage to
put on the screen.
Well, that's pretty hardbecause, oh, we need one that's
really bloody, where you can'tsee any landmarks even though
you're suctioning.
We need one with a right-sidedmass that's distorting all the
anatomy, which is hard.
(44:11):
So our prop god, rick Latimade,said Joe, let's just build one.
So he had his prop resourcesbuild an entire upper airway and
it took about five tries beforethey got everything right.
He says no, guys, theepiglottis isn't right, and the
retinoid folds?
Let's do this.
So after about five trials wegot it right.
(44:33):
So now I can do the intubationson this little model and we can
throw tons of blood in, or wecan distort the anatomy, or we
can do whatever we want, andthat's what you're gonna see on
the screen rather than realplayback.
It's going to be me using theglide scope and throwing
(44:53):
whatever pathology we need tointo this model.
Speaker 2 (44:57):
And there may have been somebody actually intubated
at one point for getting thefootage, but we don't talk about
that.
Speaker 1 (45:06):
It would be ironic if someone actually had a medical
emergency on set and they werelike in a fake ER.
Speaker 2 (45:13):
Joe's used his medical talents in the past on
fake shows.
Speaker 3 (45:16):
Yeah, without getting specific.
Okay, there are actors who havereceived two liters of normal
saline rather than going homeand calling an insurance day and
ending everything for the 300people who are working, and it
was at their request, not at myrequest.
If we can do this, do you thinkI can get through the next two
(45:36):
hours, if you really want to doit?
Speaker 2 (45:38):
we'll do it, but of course we never do that anymore,
that's never passed.
Speaker 1 (45:44):
Okay, can we do a quick lightning round?
Sure, okay, so we'll go.
Joe Scott Mel for the answers.
Speaker 3 (45:55):
So one word to describe the pit Authentic.
Speaker 4 (45:56):
Hopeful.
Speaker 1 (46:00):
Intense.
Speaker 3 (46:03):
Favorite medical case on the pit Twiddler's syndrome.
Speaker 4 (46:07):
Pass Shoulder dystocia.
Speaker 1 (46:10):
If you could swap roles with anyone on set for a
day, who would it be?
Speaker 3 (46:16):
Craft service.
Those are the people who bringthe snacks.
Speaker 4 (46:20):
Noah, of course I'd say Noah, he's so damn nice and
so handsome.
Speaker 1 (46:24):
If you had to survive a real ER shift as a patient,
which Pitt doctor would you wantto be by your side?
Speaker 4 (46:31):
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 themost amazing ER doc in the
future.
Speaker 3 (46:40):
I love Mel too, or after you see the next two
episodes.
Speaker 1 (46:45):
Dr Abbott, Last lightning round question.
Speaker 2 (46:50):
Dream guest star for the Pit Brad Pitt, james Brown.
Speaker 4 (46:55):
Robert F Kennedy.
Speaker 1 (46:57):
Fabulous.
Well, it has been so, so fun tohear you talk about the show,
the process, the set, everything.
It just sounds like an amazingproject to be working on.
And just speaking on behalf ofthe medical community, I want to
thank you for everything thatyou do to produce and entertain,
but also to bring some of thesereally serious issues into the
(47:17):
public consciousness.
I feel like, as much as thisshow is a joy and fun and
entertainment, it's doing reallyimportant work in the advocacy
realm as well.
So, as we round to a close, isthere anything else you'd like
to share or say to our clinicianaudience?
Speaker 3 (47:33):
I know what Mel wants to say.
Speaker 4 (47:35):
No, what actually?
What I want to say is I want tosay thank you, as well as a
clinician, as an ER doc of 30plus years, joe in particular
has been under-recognized thework he has done for emergency
medicine.
But both of these gentlemen,when I started in residency at
UCLA, er had just started and itmade emergency medicine this
incredibly sexy thing to do.
And now, 30 years later, tohave a show that shows just how
(47:59):
things have not gotten betterand, in fact, have gotten worse
and we're in crisis, is anincredibly important public
health message that everybodyneeds 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, andthey're doing a better job than
I've ever done on all oureducation programs, showing the
world what that looks like.
Speaker 3 (48:21):
I'm going to go back for a minute to Noah's notion of
what he wanted to bring to theshow.
Noah travels all around theworld and wherever he goes
travels all around the world,and wherever he goes, doctors,
nurses, paramedics come up tohim and say thank you so much.
It's because of watching youthat I decided on my career path
(48:42):
, and that was based on a showfrom 1994 to 2009.
And as time went on, especiallypost-COVID, emergency medicine
fell out of favor, so much sothat they had trouble filling
residency spots, residency spots.
I saw that, yeah, residencyspots were not being filled and
(49:02):
NOAA really wanted to inspire anew generation of people to go
into medicine, to accept theresponsibility, to recognize the
challenges but recognize therewards, and that is one of his
guiding principles in what hewants to do and what he wants to
(49:23):
show, both as a writer and anactor.
So my hat is really off to Noahfor having this altruistic goal
to become a role model and aninspiration for a new generation
to enter healthcare.
Speaker 2 (49:38):
I would just add, as someone on the other side of
that even though you know I geta lot of credit for creating the
show it really is just a lovestory to the medical profession.
I mean, when I'm around theseguys and when I'm at MRAP, or
when I'm around we had aresidence night recently or when
I do go to the ER, it's very,very humbling to see real people
(50:01):
really helping people, savinglives, and they never get the
credit they do and we expectthem to be there 24-7 when we
need them most.
And if our show canfictionalize that a little bit
so that people actually payattention as opposed to just
telling the storiesstraightforward in a
(50:21):
journalistic point of view, Ithink we've done our small part
to helping with that situation.
But I mean, these guys arebrilliant and I'm a typing
monkey, but they are the realdeal.
And if we can portray that andwhat they go through day to day
and what they've been throughwith COVID and the things they
are expected to just solve notjust one thing in an hour, not
(50:46):
just two things and then over 12hours and then we like to sue
them because something didn't goexactly the way we want it.
Speaker 1 (50:53):
And not just medical things, things related to
caregiver burnout or, you know,the kids, all that yeah.
Speaker 2 (50:59):
So it really is a love letter to the profession
that I think is sometimes justtaken for granted, like air
traffic controllers or otherpeople who we rely on.
We just assume it's going to bethere when we need it, and
these guys are the best justassume it's going to be there
when we need it, and these guysare the best.
Speaker 3 (51:20):
I've heard some online comments that really
warmed my heart, which is thatreal emergency health care
workers state.
For years, I've tried to tellmy friends, my family, my
significant others what it'slike to work a shift, and I've
never been able to put it intowords before and I never have
been able to give a sense ofwhat it's really like.
And now that the show's on theair, they can watch it and I can
(51:42):
say, yes, that's what I do.
Speaker 1 (51:45):
Yeah, scott, you use the word hopeful or hope, and I
feel that I think, even thoughthe show has a lot of serious
themes and some cases that havesad outcomes, you can feel the
hope and the celebration of thework and of the work ethic and
the commitment of the healthcareworkers, and I think that's
another reason why the show isjust, you know, as authenticity
(52:06):
aside and accuracy aside is justresonating so, so strongly in
our community.
So thank you so much again forall the magic you make and thank
you for coming on theNocturnist podcast to speak with
me.
I'm truly honored.
Speaker 2 (52:20):
Thanks for having us.
It was wonderful.
Speaker 3 (52:23):
Thank you so much, emily.
Thank you Emily.
Speaker 1 (52:29):
This episode of the Nocturnist was produced by me
and John Oliver.
John also edited and mixed.
Our executive producer is AllieBlock, Our head of story
development is Molly RoseWilliams and Ashley Pettit is
our program manager.
Original theme music wascomposed by Yosef Monroe and
additional music comes from BlueDot Sessions.
The Nocturnist is made possibleby the California Medical
(52:52):
Association, a physician-ledorganization that works
tirelessly to make sure that thedoctor-patient relationship
remains at the center ofmedicine.
To learn more about the CMA,visit cmadocsorg.
The Nocturnist is also madepossible by donations from
listeners like you.
Thank you so much forsupporting our work in
storytelling from listeners likeyou.
(53:12):
Thank you so much forsupporting our work in
storytelling.
If you enjoyed this episode,please like, share, subscribe
and help others find us bygiving us a rating and review in
your favorite podcast app Tocontribute your voice to an
upcoming project or to make adonation, visit our website at
thenocturnistsorg.
I'm your host, Emily Silverman.
(53:34):
See you next week.
Support for the Nocturnist comes from the
California Medical Association.
At the Nocturnist we arecareful to ensure that all
stories comply with healthcareprivacy laws.
Details may have been changedto ensure patient
confidentiality.
All views expressed are thoseof the person speaking and not
their employer.
This is the NocturnistConversations.
(00:25):
I'm Emily Silverman.
As you may know, we recentlylaunched our Uncertainty series
here at the Nocturnist and thoseepisodes will continue to drop
on Thursdays as planned.
But today, tuesday, we'rebringing you a special bonus
episode because thisconversation was just too fun to
postpone.
(00:46):
Today I sit down with thecreative minds behind the HBO
Max television show, the Pit, anew medical drama that has
captivated so many of us in thehealthcare world.
At the time of this interview,the first 11 episodes of the Pit
had aired and since then thestakes have only grown higher.
The characters on the Pit feelso incredibly real my personal
(01:09):
favorite is Dana, the chargenurse and the medical cases on
the show also hit close to home,which just goes to show how
much the writing teamunderstands what it's really
like to work in an emergencydepartment, and part of why they
nail the authenticity of theshow is that they have a lot of
doctors involved in the creativeprocess, which brings me to
today's three extraordinaryguests R Scott Gemmel, longtime
(01:33):
television writer and producerknown for his work on ER NCIS
Los Angeles, and now the creatorand showrunner of the Pit.
Joe Sachs, an emergencyphysician and TV writer who
worked on ER for years and nowbrings his clinical expertise to
the Pit.
And Mel Herbert, a belovededucator in emergency medicine,
the founder of the MRAP podcastand consultant on season one of
(01:56):
the Pit.
As someone who works at theintersection of medicine and
storytelling, I have to say Iwas a little starstruck to be in
conversation with these legends.
We talked about everything fromhow they set out to make a
medical show unlike anythingwe've seen before.
How they write to the moment,bringing in real world crises
from healthcare like burnoutboarding, even press Ganey
(02:19):
scores.
Why they chose to tell thestory in real time, with each
episode covering one hour of theshift.
How they nailed the realism ofthe show from a hand-designed
airway that they built and canintubate to a fake toilet on set
that may have been a little tooconvincing.
And what they hope the Pit willmean to clinicians and the
(02:40):
culture at large.
I hope you enjoy thisconversation as much as I did.
But before we dive in, take alisten to the trailer for the
Pit, streaming now on HBO Max.
Speaker 2 (02:58):
Morning Jack, what are you doing here Working?
Speaker 3 (03:10):
And if you jump?
Speaker 2 (03:11):
on my shift.
That's just rude man.
I hope I'm never one of yourpatients.
Makes two of us my friend.
Hey D, what's a good word.
Speaker 4 (03:18):
We're f***ed.
52 in the waiting room and it'snot even 7.
Robbie's working the shift.
Speaker 2 (03:23):
by the way, Got him a little slack today.
Speaker 4 (03:28):
It's the anniversary of Dr Adamson's death.
Who left this mess?
Nothing like a little challengeevery now and then.
We've got some new faces withus today.
Hi, come on over, I'm so happyto be here.
Talk to me at the end of theday, clear Forceps.
Speaker 3 (03:42):
Suction Med student down.
Welcome to the pit.
Let's go save some lives.
Speaker 2 (03:48):
The systolic is only 80, 14 days.
Speaker 3 (03:50):
Alex, you've lost a lot of blood.
You need to go to surgery rightaway.
Am I gonna die?
Not now that I'm here, easypeasy.
I'm in Good, well done.
That was awesome, isn't italways this busy?
Speaker 4 (03:59):
No, always this busy.
No, it gets a lot busier.
Speaker 1 (04:03):
There's a nursing shortage across the country.
Speaker 2 (04:05):
That is bullshit.
If you paid them a living wage,they'd line up to work here.
Speaker 1 (04:08):
Other hospitals are managing this crisis either step
up or step aside.
Speaker 3 (04:12):
Are you okay.
Why wouldn't?
Speaker 1 (04:14):
I be.
It's five years ago today.
You can't block your feelingsforever.
Speaker 4 (04:22):
Oh, you'd be surprised.
Speaker 3 (04:24):
Crash guard, let's go no pulse.
Speaker 1 (04:26):
Clear Hold compressions.
Are we ready to call this?
Speaker 4 (04:40):
150,000 people die every day in the world.
Today, you got one of them, andwe're gonna get more of them
before the shift is over.
Speaker 3 (04:48):
Tier 1 trauma now Four of morphine.
I'm gonna stop the bleeding.
Speaker 4 (04:52):
You learn to accept it.
Find balance, you found balance.
Speaker 2 (05:04):
No, not even close.
Speaker 1 (05:11):
I have the pleasure of sitting here with Scott
Gemmel, joe Sachs and MelHerbert.
Thank you so much for beinghere today.
Speaker 3 (05:18):
Thank you for having us Our pleasure.
You're welcome.
Speaker 1 (05:21):
So I've watched all 11 episodes of the Pit that are
out thus far.
I think we have a few more andI 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
(05:41):
like.
That's exactly the words that Iwould say if I were in that
situation.
Everyone is talking about theauthenticity of this show.
I think for me and my doctorfriends and the physician
community, something that we'refeeling a lot with this show is
just feeling really seen in away that maybe we haven't with
other medical shows in the past.
(06:02):
There's just something in thewater at the show that just
feels like it really representsour experience.
So, to begin, I just wanted toask if that was a conscious goal
from the start, as you broughtthe show into existence.
Speaker 3 (06:16):
Joe.
Well, I'm going to let Scotttalk because he has the created
by credit.
Speaker 2 (06:21):
Yeah, absolutely.
If we're going to do something,we want to do it well and we
want to do it respectfully tothe community and physicians and
nurses and everyone else that'sinvolved in health care.
And, trust me, it's not alwayseasy, as Joe and I went through
this morning as we were tryingto agree on how to tell a story
about a sim lab and what wasreal and what wasn't.
So, yes, we do strive to be asauthentic and honest as possible
(06:44):
.
Speaker 3 (06:45):
I think it came from Scott.
It came from John Wells, andwhen I was brought into the
project I just wanted it to beas real and authentic as
possible.
And John I remember in theearly moments of this show's
conception, said I want amedical show the way no one has
(07:05):
seen a medical show before.
So I knew what had to be done.
Speaker 1 (07:10):
And just to be clear, we have some physicians in the
room, we have some writers inthe room who have written
medical drama but aren'tphysicians, and then we have
some who are both.
So maybe can you just walk methrough who here has the
physician hat, who here has thewriter hat and who here has both
.
Speaker 2 (07:27):
Well, I'm a shaman and a writer.
No, I'm just a writer.
I've written a bunch of medicalshows, but I'm just a writer.
I'm a one trick pony.
These other guys have multipleskill sets.
Speaker 3 (07:38):
I'm a writer and an emergency physician with 33
years in the pit, as they say.
The short answer to how I camedown this path is while I was in
medical school, I also went tofilm school because I had an
interest in public healtheducation and as I was learning
how to evaluate and plan publichealth campaigns, I became more
(08:02):
interested in the creative sideof 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 firstseason they were in need of
some help and they reached outto me.
Speaker 1 (08:20):
Do you still practice , joe?
Speaker 3 (08:21):
or are you full time?
I do, I do.
I've worked in a Los AngelesCounty trauma center for 33
years, including at the peak ofthe COVID epidemic, including
intubating the sickest patientsin full.
Ppe began to have itsconception.
(08:42):
I made a decision to cut backto urgent care just because the
amount of time that I need tospend with every aspect of the
show is monumental and I justcouldn't afford the time
constraints of working anovernight or working till three
in the morning, because I reallyam working seven days a week on
the show when we're inproduction.
Speaker 1 (09:04):
And Mel, how did you get involved with this?
Speaker 4 (09:07):
So I'm an ER doc and I retired from clinical work
actually to run my educationcompany full time because it had
gotten too big and busy.
I still work clinically inother countries but I don't
really practice in the USanymore.
But I got involved back in theday.
Joe was my attending when Ifirst got off the boat from
(09:27):
Australia in 1991.
Speaker 3 (09:29):
Wow, I like to say.
I taught Mel everything heknows.
Speaker 4 (09:33):
And I don't know anything, so I don't know what
that means.
So Joe got me involved in ERyears ago, basically as a
medical consultant, so he'd runcases by me.
And what do you think aboutthis?
What do you think about that?
And our education program isall about emergency medicine and
so a lot of the cases wouldcome 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 likethat sounds like a fun game,
(09:54):
let's do that again.
Speaker 3 (09:56):
I think one of the things at the beginning of
season one I wanted to bringScott and Noah Noah Wiley, who's
both an actor and a writer, andsome of the other writers to
meet all of the key physiciansat MRAP.
So we would attend the liveGrand Rounds session just
because I wanted to giveeveryone a sense of the
(10:17):
complexity of academic emergencymedicine, of the teaching, and
to meet giants in the field likeMel Stuart Swadron, sean Nort,
and we would watch and listen toGrand Rounds and then have
dinner and those were veryenlightening and successful for
some of the other writers to geta sense.
(10:37):
And then Mel's relationship tothe creation of stories would be
very informal, like once ortwice a week I'd be driving home
from Warner Brothers and Iwould say, hey, mel, I'm
thinking about doing this storyand it's gonna be a
seven-year-old drowning victimand I need it to go on for this
(10:57):
and this and this, and I knowshe's gonna be hypothermic and I
know we're gonna warm her andthis or that, but I need a
really good way to finish it.
And Mel goes make her potassium12, because nobody ever comes
back with potassium 12.
So Mel was kind of the spiceand seasoning that would often
put the finishing touches on thecases that we were creating.
Speaker 4 (11:20):
Isn't there a spice girl called Mel?
Is that me?
Speaker 1 (11:21):
There is a spice girl .
Yes, I think that's SportySpice.
Speaker 4 (11:26):
Just so your listeners know, I run a program
called MRAP, which is a very bigeducation program within
emergency medicine.
It's got 65,000 users acrossthe world so it's hard to find
an ER doctor that doesn't useMRAP.
We're a 25-year overnightsuccess.
One of our most religiouslisteners is Joe Sex, and so I
think a lot of the cases anddiscussions come from Joe's
(11:46):
intimate knowledge of thatprogram, which comes out every
week.
Speaker 1 (11:50):
So I had the pleasure of sitting in on a teaching
session with one of your writersa friend of mine, max teaches
screenwriting and had her in asa guest, so I got to sit and
listen to her talk about the pitand your creative process, and
she was talking about how a lotof TV shows will start with the
characters or start with theplot, but that in procedurals
(12:10):
like medical TV shows, thatoften you start with the medical
cases.
So I was wondering if you couldbring us into that process.
Do you just start with awhiteboard and you have the
cases and you shuffle themaround, or what does that look
like?
Speaker 3 (12:24):
Well, I'm going to contradict her which is to say
that we start with the drama.
We start with the dramatic needsof the character.
What is their arc during a15-hour shift?
What is going to be revealedabout them?
And then the medical casesaugment that in a subtle way
(12:44):
that get us to learn more aboutthe characters and their
relationships with each other,with the attendings.
So the medical cases aren'tjust randomly chosen and then
try to put a square peg into around hole.
And something as simple as acase in the episode that Valerie
wrote was an ankle sprain.
(13:05):
I didn't start with the ideathat, oh, we need to do a story
about an ankle sprain becausethe world needs to know about
ankle sprains.
But something as simple as anankle sprain was a chance for
Mel to show her incredibleskills at patient care and
compassion and understandingwith somebody with autism
spectrum disorder, as opposed toLangdon who had no patients, no
(13:30):
time and was doing everythingwrong.
So that was a cool case and allof the medicine was right in
terms of her differentialdiagnosis and thinking about a
dancer's fracture and a Jonesfracture.
And, of course, the patient hadGoogled everything infinitely
and was asking an infinitenumber of annoying questions.
(13:50):
But she had the patience andshe got through to the patient
in a way that Langdon nevercould.
So that's just an example of avery simple case that speaks to
the needs of the character.
But I'll let Scott commentabout that too.
Speaker 2 (14:04):
No, I think that's you know.
We start with the characters.
Who are they, where do we wantto take them, what is their
journey, where do they come fromand then where do we want to
end up with them?
This show is a little unique inthat it's told in relatively
real time.
In a traditional TV series,whether it's eight episodes or
(14:28):
24 episodes, you're not usuallyhour by hour.
You may be day by day, it couldbe 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 thecharacters where we only have 15
hours.
So it's a very truncatedversion of character development
(14:50):
and exploration.
So we have to be very preciseabout that.
But the constraints also are agreat creative challenge,
because then you have to workwithin a certain size box, work
within a certain size box.
So that's where we start, andthen it's really about finding
the cases that will bring outthose elements of the story that
(15:11):
we want to tell, whether it'sexposing someone's insecurity or
their overconfidence or any ofthose elements that you saw
throughout some of the episodesyou've watched already.
So it's a little bit of both,but generally we start with the
character, who they are andwhere do we want them to be at
the end of the season.
Speaker 3 (15:30):
Let me give an example of three stories that
came out of the dramatic needsof the Javadi character, the
third-year medical student.
Great character, so thechallenge of the first episode
was hey, joe, what's a case thatwould make a third-year medical
student faint in the traumaroom?
So the degloved, fracture,dislocation of the ankle came
(15:50):
out of that and it was prettyeffective and it was brilliantly
done by our makeup department,which is a whole other sidebar
that we'll get to because theyare geniuses.
A second thing would be howdoes Javadi's mother, who's an
attending physician in surgery,embarrass the hell out of her?
So her mother comes down toexamine a young man with
(16:14):
appendicitis and, in thepresence of another medical
student and an intern, startsteaching slash pimping.
We know about pimping, yes,about recent studies about
non-operative management ofappendicitis, and the other
medical student is able to quotethe CODA study from the New
England Journal from 2020.
(16:35):
And the mother looks at herdaughter and says honey, you
knew that we talked about thatover dinner.
Speaker 4 (16:40):
And then honey, everyone is like oh my.
Speaker 3 (16:43):
God, that's your mother.
So that was an example of acase that highlighted that, but
was accurate, and mosttelevision writers probably
couldn't cite a New EnglandJournal of Medicine article from
2020.
So that's the kind of thingthat made it so unique and
specific that I think people areresponding to.
And then the last one in alater episode, the question came
(17:07):
how can Javadi show up hermother?
So how can a third year medicalstudent beat her mother to a
diagnosis?
And that was the basis of theBlack Widow spider bite, because
a Black Widow spider bite cancause such intense spasm of the
abdominal musculature that itcan be mistaken as peritonitis,
and people have actually gone tothe operating room when they've
(17:29):
had a black widow spider bite.
So those are examples.
Start with the dramatic needFind a cool case that can speak
to that and make it reallyaccurate, and that's the
marching orders.
Speaker 4 (17:43):
I can give you a little color as to what it looks
like in there, because theseold guys have been doing it so
long that I don't even know howinteresting it is.
So this is my first time thatI've actually been in the
writer's room.
So for season two, I'm now inthe writer's room and so you
have basically just this roomand there's four not one, but
four whiteboards all around theroom, divided up into the 15
(18:04):
episodes, and you've got a groupof people who are super smart,
creatives that are going backand forth with each other.
Well, what about this idea?
No, no, we could do it this way, and we could do it this way.
Two docs, but the rest arewriters going back in this
process, and then they're likeokay, in this hour we'll do this
thing, and then we can see thisarc, and then it'll happen over
here, and then we'll do theprocedures.
(18:24):
We'll do this thing and then wecan see this arc, and then
it'll happen over here, and thenwe'll do the procedures, we'll
do the medicine stuff.
But to watch something beingcreated out of nothing for me is
fascinating.
Just these smart peoplethinking about arc ideas and
then having them fleshed out,agreeing, disagreeing, calling
each other names and having funwith it, then coming out with
what the arc is going to be forthe non-writer in the room is
(18:44):
absolutely fascinating.
Like I said to him, it's almostas if you guys are making this
up as you go along.
Speaker 3 (18:50):
And the dramatic arcs are very subtle because they
happen in the course of a15-hour day and we just have to
learn new things about thecharacter and season two I may
be talking out of school, butseason two is going to start
sometime in the future fromseason one.
(19:10):
So people's status, is itstatuses or stati?
People's status have changedand all those need to be
reflected in the storytelling.
Speaker 2 (19:21):
Season two is 300 years in the future.
Speaker 4 (19:24):
Millennium in the future.
Speaker 1 (19:26):
The AI doctor and the pocket ultrasound.
Speaker 2 (19:29):
AI may actually play a part in it.
Speaker 1 (20:02):
Scott, you mentioned the choice to compress time and
I love the way that each episodeis just one hour.
Episode one, I think it waslike 7am to 8am, and I love it
for so many reasons.
I think one, it just makes itfeel so heightened.
But I think, two, it alsoreally shows how intense it is
to be in the ER and all thethings that happen and the
(20:24):
moment to moment and the waythat it's choreographed and
edited, where people are sort ofpopping in and out of different
rooms and he goes to pee and hecan't even pee.
You know, someone comes in andsays now you got to go in this
room.
So I was wondering if you couldspeak to that choice, because I
don't think I've ever seen amedical show before operate in
that way where they'reallocating a 60 minute episode
(20:48):
to 60 minutes of real time, andthe thought process that went
into making that choice for thenarrative form.
Speaker 2 (20:54):
We've sort of done Joe and I and John and Noah,
sort of done the Mac Daddy ofall medical shows.
So when the opportunity cameabout to revisit doing another
medical show, when theopportunity came about to
revisit doing another medicalshow, one that we wanted to make
completely different, it waslooking at how can we tell these
stories differently than wehave in the past.
And once it became a streamerbecause it was HBO Max who was
(21:27):
asking for it we knew already itwas 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 thatare now six, eight, 10, 12 is
maybe the most and we weren't onstreaming.
I don't know if I would havecome up with that idea, but it
was because it was 12 episodesand the shift is 12 hours it
seemed like a really logical fitand the more we thought about
it, even though it seemed apretty daunting task at first,
(21:51):
the one thing that really, Ithink, differentiates the
emergency department from otherforms of medical practice is the
time element.
People come to the emergencydepartment sometimes through
ambulance service, where time isof the essence, so time just
seemed to become such animportant part of the whole
(22:11):
process.
One of the things with ERphysicians and these guys can
speak to it much better than Ican, but is how often they're
pulled away to another situation, another case, Someone else
needs them that every three tofive minutes they're on
something else.
So that became really important,as we talked earlier about the
authenticity, and so rather thanfollowing a patient through the
(22:34):
course of one episode and theycome in and we fix them up and
by the end they're bettereveryone who's been to the
emergency department knows yourweight alone is going to get you
through four or five episodesand we really wanted to capture
that, and so the time elementbecame a really big part of it
and as challenging as it was andwe weren't sure it was going to
work I think it really elevatesthe show.
(22:56):
It's very hard to capture thatfeeling of the emergency
department because it's so aliveand it's so electric and
there's so much going on and itseemed like if we took the
audience into that environmentand didn't let them out.
We're not going to commercialbreaks, we're not coming back
two hours later.
Speaker 1 (23:16):
Or even into their homes.
We don't go into their privatelives at all.
Speaker 2 (23:19):
No, and so it's kind of like Robbie not being able to
find time to use the restroom.
The audience doesn't get achance to step away.
They're sort of juggling thecases, the same way the doctors
are, and I think that reallyhelps pull you into the
storytelling, because you can'tleave until that hour or that
shift is over.
Speaker 3 (23:39):
The other thing that real-time allows us to do is to
keep the audience guessing whenyou meet a patient, is this
patient going to be one and doneone episode?
Is it going to evolve intosomething that's going to last
for four episodes or eightepisodes or 15 episodes?
It's just the mix of everythinggoing on and having to pay
(24:02):
attention to what's going on.
And the astute viewers mightlook in the waiting room in
episode one or two and seesomebody sitting there who
becomes a major character athour four or five that we would
just actually pay the actors tosit in the waiting room for one
scene and then come back muchlater.
(24:24):
And likewise, when Scott andNoah and John first approached
me about emergency medicine in2024, I said we got to come in
and see a waiting room packed tothe gills.
We have to come in and seeevery inch of wall space filled
with boarding patients who can'tgo upstairs because there's no
room upstairs.
(24:44):
And we did that and theintensity of the volume is real
and I think that's what peopleare responding to.
And the reality of the boardingpatients is fascinating because
one of our background nurses isa former charge nurse at UCLA
(25:04):
Santa Monica Hospital who's nowretired, but his job was to
track all the boarding patientsand to make sure, hour to hour,
their IVs went down by 100 cc's,that meals were brought to them
, that a breathing treatment wascome in, that physical therapy
came and took them.
So everything that's going onhour to hour is real.
(25:25):
And then the background artists, also known as extras.
When they first showed up tosay, oh, I'd like to work on
this show, Well, if you're goingto be a boarded patient, you're
going to be in your gurney forthe next seven months because
we're going to be filming 15episodes and you're going to be
sitting in the gurney the wholetime.
So that's another interestingaspect of production.
Speaker 1 (25:49):
You mentioned, Joe, if we're going to do a show
about the emergency room, thewaiting room has to be packed.
You know it needs to be likethis and like this, and I was
wondering how you see thisseries fitting into this
particular moment.
In healthcare and in the world.
There are themes that arealready weaving in to the cases
and the characters.
For example, we have the ladyfrom corporate who keeps coming
(26:11):
down to hound Robbie aboutpatient satisfaction scores.
We have problems of patientscommitting violence against
healthcare workers, which is atopic that's really important
right now.
We even have the flashbacks tothe COVID pandemic and sensing
the PTSD that the healthcarecommunity still has from that
(26:33):
time.
It was kind of long ago, butalso wasn't that long ago.
So I was wondering how youthought about weaving in some of
those bigger themes into theseries, because it just feels
very topical.
Speaker 3 (26:45):
Well, we wanted the show to be current and accurate,
and if we're current andaccurate, we have to show
waiting room medicine, which ispatients who just stay in their
chairs in the waiting room andget pulled back for labs and
x-rays and then dischargedbecause there's no beds and that
doesn't lend itself to patientsatisfaction.
(27:06):
We had to show the boardingpatients and we had to show the
pressures of a corporate culturethat's looking at Prescani
scores and other metrics thatare important to them.
These are people who arefighting an unwinnable battle
because all the cards arestacked up against them, and to
(27:26):
provide compassionate care andto try to do the best you can do
under these circumstances isreally heroic, and that's what I
think we're showing.
I think in season two we'regoing to try to address some of
the issues that have been raisedwith changes to prevent
violence against health careworkers.
(27:47):
A recent ENA Emergency NurseAssociation survey, 56% of
nurses had a physical assault inthe last month.
What can be done to addressthat in a way that can make the
emergency department and thehospital safer for everyone?
What is the systemic root issueof this boarding crisis?
It's not door to provider time,because we know if you can see
(28:12):
the patient in five minutes witha provider in triage.
That's not going to open upbeds upstairs, but there are
ways of addressing that problemand we've spent a good bit of
time speaking with Peter Vecelio, who is in the emergency
department at Stony BrookHospital, and he has had some
very successful and innovativeapproaches to address this whole
(28:36):
waiting room medicine boardingissue.
That has nothing to do with theemergency department but
everything to do with how theflow of admissions and
discharges and scheduledadmissions works in the hospital
.
So we may see some of that inseason two.
Speaker 4 (28:51):
Another thing that really stunned me was how much
effort is going to make itrealistic not just from an ER
point of view, because Joe cando that he's been an ER doc for
1.8 million years but it's thewriters.
Getting together with Joe andinterviewing real experts like
Peter Bocelli or like somebodywho is an expert in trans youth
or whatever it might be.
(29:12):
Getting these experts in andspending time with them and
finding out all of those nuancesand how to make it accurate is
something that this group hasgone 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 expertscoming into the writer's room
and telling them here's how thiswould really work, and to me
that was fascinating.
(29:32):
It's the best education ever.
I feel like I'm getting thiscollege degree from world
experts just by sitting in thewriter's room.
Speaker 3 (29:38):
We've probably had 12 Zoom expert briefings in the
last two weeks on a variety ofsubjects, including PTSD and
health care workers, addressingthe boarding crisis, trans youth
issues under new executiveorders, medicaid issues what's
going to happen in Pittsburghwhen people lose their Medicaid,
(30:00):
what resources are going to beavailable to them?
And on and on and on.
Speaker 4 (30:05):
And a bunch of things he can't tell you because it
would be a spoiler alert.
Speaker 1 (30:09):
Yeah, I sensed a hesitation there.
I was like don't say it.
Wait, no, say it.
You mentioned Zoom experts inthe writer's room.
You also talked a little bitalready about the writer's room,
how there's four whiteboardsand a bunch of really smart
people sitting around creatingthings.
Bring us a little bit more intothe writer's room.
Like what is a typical day,what is the generation process
(30:29):
like?
What is the revision processlike?
Sounds like, maybe some daysthere's a guest, some days
there's not a guest.
What is that all like?
Speaker 2 (30:38):
It changes throughout the season.
Obviously Right now is in someways the scariest time, but it's
also the most fun time becausewe come with a blank slate maybe
not so much as the beginning ofthe show, where there is no
show.
When we first came back.
We do a little bit of an M&M interms of what worked and what
didn't last year, what we werehappy with, what we weren't, so
(31:00):
that we don't fall back intosome habits that were not
serving us well.
And then we also look at whohas outstanding story elements
to address.
For instance, what might happenwith Langland?
We saw him get booted out atthe end of episode 11.
Is Dana going to quit?
We address that.
(31:20):
Where do we want to take that?
And then it's about, like Isaid earlier, where do we want
these characters to end up atthe end of the season?
What sort of personal storiesare going on with them?
We start to lay that down andthen slowly stories, and then
Mel will show us some reallydisturbing photos of cases he's
done and then we try to figureout how we can incorporate those
.
So it's a little show and tell.
(31:42):
That's sort of the way it works.
There's no hard and fast ruleand every day can be a little
bit different.
It's harder for me to tell youbecause I'm on one side of it.
Joe and Mel actually might havea better perspective on what a
day is like for those guys.
Speaker 3 (31:58):
Yeah, there's never a plan, there's never an agenda.
This is the early days of theseason.
This is the early days of theseason.
It's a process for each episodeof looking at an outline.
A story outline will be a brief, one or two sentences about
each scene and then everybodyreads that and comes in and
weighs in and gives notes andonce the story outline is in
(32:21):
good shape, the writer will gooff to write a first draft and
then the first draft will comeback two weeks later and we'll
sit down and discuss the firstdraft, what's working, what's
not working.
They'll get notes, go back andeventually you know, it'll be
three or four drafts before it'sready to go to production.
I'm going to back up for alittle bit because once the
(32:43):
outline is approved, the writersmost of whom are not doctors,
need to get their medical notes.
They need to learn how to writeall of the technical dialogue
for all the scenes.
So we would divide up themedicine and say why don't you
do the appendix story, ariel,talk about how a surgeon would
(33:07):
do bedside teaching and how shewould quote the CODA article,
and in another episode, greg,give them all the technical
dialogue.
They would need to do aretrograde intubation through
the cricothyroid membrane, and Iwould get their notes and do
the scenes I was going to do andkind of polish them and edit
them.
So the writer gets sometimes a20-page document of all of the
(33:31):
technical knowledge that theyneed to know to write their
technical scenes.
Then, once the episode preps income three new residency
trained board certifiedphysicians in emergency medicine
whose responsibility is on set.
So part of it is prepping everyscene.
What props do we need?
What makeup do we need?
(33:52):
What prosthetics need to bebuilt?
What special effects forsquirting blood need to be done?
What scenes need real nurses inthem to assist with complex
procedures.
And sometimes the heads up oncomplex prosthetics are done
months in advance.
To do a thoracotomy with abeating heart, to do a full-on
(34:16):
vaginal birth, rotating the baby, for shoulder dystocia, those
take a long time to build.
So it's a lot of prep that goesin medically and then each of
those doctors are on set everyminute of production, from call
to wrap, to be sure everythingis looking okay, procedures,
(34:36):
pronunciation of words,instruments are held correctly.
Speaker 1 (34:40):
It's almost like the doctors are choreographers.
How do the actors take to beingcoached in that way?
This is how you say this word,or this is how you thread this
catheter.
Do you find that they're prettyquick on the uptake?
Speaker 3 (34:52):
Yeah, for the most part, and they love it.
They want to be real, they'renot upset and they're not angry
If someone comes in and goes,you know what?
On that last take, there's abetter way to hold the scalpel.
Let's try it again and do itthis way, and then you get it on
take two or on take 10.
I have to give huge shout outto our makeup department, who
(35:13):
builds all the prosthetics, allthe wounds, everything.
To our prop department, and ifthere's a scene that requires
100 props, as soon as thedirector yells cut, four prop
people have to run in, clean andreset everything to its
original position in pristineform, because we're going to do
at least 12 to 20 takes of everycomplicated critical care scene
(35:36):
to get the wide master shot andthen to get everybody's close
ups.
So the props department isessential.
And then the productiondesigner, nina, who designed the
whole set.
Speaker 1 (35:46):
The set is amazing Central.
And then the productiondesigner, Nina, who designed the
whole set.
The set is amazing the nursingstation, the TV screen with the
board.
Speaker 3 (35:52):
Yeah, yeah.
And actually if you come to theset, every Post-it note in the
Central work area, every littleflyer in the break room,
everything is so real.
And there's another departmentcalled set decoration and matt,
who's the head of that, isabsolutely brilliant in
(36:13):
attention to detail.
When you walk in and mel mel,you can talk about your
experience of walking into theset to see what it's like it
feels so real.
Speaker 4 (36:21):
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'slike no, this can't be fake.
It's so real.
The procedures are so real.
I've literally had a number ofdocs say Mel, how do you get
around HIPAA?
When it comes to thoseprocedures that you're showing
on TV, I'm like no, that's theprop department, these geniuses
(36:44):
making up ghosts.
Some of them are so real it'shard to differentiate it from
reality.
It's really stunning.
Speaker 1 (36:51):
Where is the set?
Speaker 2 (36:53):
Warner Brothers.
Speaker 1 (36:54):
So is it in a big.
Speaker 2 (36:56):
Stage.
Yeah, we have two stages.
We're basically wall to wall onour main stage and then we have
another stage that has ourtriage area and the waiting room
and then there's a little piece.
As people come through intotriage you see the wall of
heroes and there's the glassblock wall.
We have that same repeated onthe other set so you can match
(37:17):
to it.
So it seems seamless.
And we also matched ourreception area waiting room.
That matches perfectly toAllegheny General Hospital in
Pittsburgh.
Their entrance to the ER.
Nina and her team are amazing.
Nina studied a lot of ERdesigns.
I can't remember thegrandfather of all of them, who
seems to be a design like 300,but he has a book that Nina used
(37:40):
and we just sat down and Ninacame up with the sweeping
curvature feel and I think thatallows us to really maximize our
space and the whole idea is tomake it very useful for kinetic
movement.
We have two doors to certainrooms.
We have three differentcorridors and Nina did an
amazing job and we had herdesign it before we started
(38:01):
writing so that we could writespecifically to it, Otherwise
you wouldn't know what you'rewriting to.
So that made a huge difference.
On day one the writers go downthere with their scripts
sometimes, and at lunchtime thedirectors are down there
prepping their episodes, walkingthrough, making sure how do we
get from here to here.
We try to make sure that'salready in the script, but
(38:22):
sometimes we want to make somechanges.
So it's very much a process ofgetting your fingers dirty a
little bit and getting downthere and really working the set
.
It's as much a part of our showas anything, and that goes for
not just the set itself but thecolor scheme.
And one of the things that'sunique about our sets are we
have a ceiling, which a lot ofsets don't, and all our lights
(38:43):
are practical.
So I forget how many hundredlights we have, but every single
one of those lights is an LEDlight that can be controlled for
intensity, color temperature etcetera, which is all run by a
giant computerized board, and sowe don't do any lighting setups
like a traditional show would.
So when we come and startshooting, we just hit the ground
(39:04):
running, turn the lights on,and they make some tiny
adjustments here and there, butit allows us to do all that
movement without having to comein and move lights and things
like that.
The other thing that was reallyunique to our show is we shoot
it in continuity Traditionalshows.
If you're going to be in thisroom for four or five scenes
over the course of an episode,you'll shoot them all back to
(39:24):
back.
We don't shoot like that.
Day one is usually page one,scene one, and we work through
that.
It really helps the actorsbecause they don't have to
remember what was I supposed tobe or when was.
Speaker 1 (39:35):
I already punched, or was I not already?
Yeah, it's all in order.
Speaker 2 (39:38):
I think that also adds to the authenticity because
that allows us to do thecontinual movements and the
handoffs and when it works it'sreally kind of special.
Speaker 3 (39:49):
There are two wizards of Oz on the set that if you
were to walk around theperimeter, you would come to the
lighting area, where there'sfour workers with a giant
control board of dimmers for allthe lights everywhere and being
able to create the propereffect and lighting for the
(40:09):
people who are walking whereverscenes are being played, for the
people who are walking whereverscenes are being played.
And the other is the videoplayback team, which is at least
three, because with technology,every cardiac monitor in every
room has to be controlled andsimulated to the heart rate, the
(40:30):
blood pressure, the pulse, ox,and if there's an abnormal
rhythm, if it's atrialfibrillation 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 showingall the patients and their
status.
We have the electronic medicalrecords that we had to invent
(40:52):
and create on our own because wedon't actually have a real
vendor that would put amulti-million dollar system in
place Sponsored by Epic.
Yeah, that didn't happen.
And also ultrasounds and x-raysthat magically appear.
Those have to be created andthose have to be put onto
screens.
(41:12):
And here's a really interestingfact the ultrasound cannot be
performed in real time on a realactor.
Warner Brothers Legal will notallow us to do that, and the
reason being is what if there'ssome slight abnormality that we
didn't notice when we werefilming the segment, and would
(41:33):
Warner Brothers be liable formissing an early neoplasm or
something of that nature?
So nothing that's done withultrasound is actually on the
real patient.
Even a normal study is playbackof existing footage.
Speaker 1 (42:25):
Are there any memorable moments or mishaps or
behind the scene stories thatyou think would be fun to share
with the audience?
Speaker 4 (42:33):
Has anybody pooped in the toilets?
Yes, on set.
Yes, that already happened.
Tell that story.
Speaker 2 (42:40):
Every time.
Yeah, some of the bathrooms yousee when people go in the
bathrooms are actually the realbathrooms outside the writers
and production office.
But we do have a bathroom thatthe young woman locked herself
into who wanted the medicationabortion.
We can run water through thereand we can use the shower, but
it's limited.
(43:00):
Obviously, you have tanks onthe other side of the wall, and
it happened on other shows too.
The toilet is not practical.
Every now and then, someone whois not maybe as accustomed to
working on a television showwill use that toilet, thinking
it works, and then we have a bitof a problem.
Speaker 3 (43:18):
The first clue is there's no water in the commode.
Speaker 2 (43:20):
Yes, there's no place for it to flush anyways, it
would just go.
Speaker 3 (43:25):
I'll tell you one thing that's kind of interesting
.
We have a wonderful, wonderfulultrasound expert, jalen Avila,
who supplies us with all of theultrasounds.
Mel, do you know the name ofJalen's website?
Is it 5-Minute, 5-minute,son-elk?
Those are invaluable.
So the other thing that's newtechnology is video laryngoscopy
(43:49):
for intubations.
So when our doctors areintubating, you'd think there
would be someone who couldsupply us with the footage to
put on the screen.
Well, that's pretty hardbecause, oh, we need one that's
really bloody, where you can'tsee any landmarks even though
you're suctioning.
We need one with a right-sidedmass that's distorting all the
anatomy, which is hard.
(44:11):
So our prop god, rick Latimade,said Joe, let's just build one.
So he had his prop resourcesbuild an entire upper airway and
it took about five tries beforethey got everything right.
He says no, guys, theepiglottis isn't right, and the
retinoid folds?
Let's do this.
So after about five trials wegot it right.
(44:33):
So now I can do the intubationson this little model and we can
throw tons of blood in, or wecan distort the anatomy, or we
can do whatever we want, andthat's what you're gonna see on
the screen rather than realplayback.
It's going to be me using theglide scope and throwing
(44:53):
whatever pathology we need tointo this model.
Speaker 2 (44:57):
And there may have been somebody actually intubated
at one point for getting thefootage, but we don't talk about
that.
Speaker 1 (45:06):
It would be ironic if someone actually had a medical
emergency on set and they werelike in a fake ER.
Speaker 2 (45:13):
Joe's used his medical talents in the past on
fake shows.
Speaker 3 (45:16):
Yeah, without getting specific.
Okay, there are actors who havereceived two liters of normal
saline rather than going homeand calling an insurance day and
ending everything for the 300people who are working, and it
was at their request, not at myrequest.
If we can do this, do you thinkI can get through the next two
(45:36):
hours, if you really want to doit?
Speaker 2 (45:38):
we'll do it, but of course we never do that anymore,
that's never passed.
Speaker 1 (45:44):
Okay, can we do a quick lightning round?
Sure, okay, so we'll go.
Joe Scott Mel for the answers.
Speaker 3 (45:55):
So one word to describe the pit Authentic.
Speaker 4 (45:56):
Hopeful.
Speaker 1 (46:00):
Intense.
Speaker 3 (46:03):
Favorite medical case on the pit Twiddler's syndrome.
Speaker 4 (46:07):
Pass Shoulder dystocia.
Speaker 1 (46:10):
If you could swap roles with anyone on set for a
day, who would it be?
Speaker 3 (46:16):
Craft service.
Those are the people who bringthe snacks.
Speaker 4 (46:20):
Noah, of course I'd say Noah, he's so damn nice and
so handsome.
Speaker 1 (46:24):
If you had to survive a real ER shift as a patient,
which Pitt doctor would you wantto be by your side?
Speaker 4 (46:31):
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 themost amazing ER doc in the
future.
Speaker 3 (46:40):
I love Mel too, or after you see the next two
episodes.
Speaker 1 (46:45):
Dr Abbott, Last lightning round question.
Speaker 2 (46:50):
Dream guest star for the Pit Brad Pitt, james Brown.
Speaker 4 (46:55):
Robert F Kennedy.
Speaker 1 (46:57):
Fabulous.
Well, it has been so, so fun tohear you talk about the show,
the process, the set, everything.
It just sounds like an amazingproject to be working on.
And just speaking on behalf ofthe medical community, I want to
thank you for everything thatyou do to produce and entertain,
but also to bring some of thesereally serious issues into the
(47:17):
public consciousness.
I feel like, as much as thisshow is a joy and fun and
entertainment, it's doing reallyimportant work in the advocacy
realm as well.
So, as we round to a close, isthere anything else you'd like
to share or say to our clinicianaudience?
Speaker 3 (47:33):
I know what Mel wants to say.
Speaker 4 (47:35):
No, what actually?
What I want to say is I want tosay thank you, as well as a
clinician, as an ER doc of 30plus years, joe in particular
has been under-recognized thework he has done for emergency
medicine.
But both of these gentlemen,when I started in residency at
UCLA, er had just started and itmade emergency medicine this
incredibly sexy thing to do.
And now, 30 years later, tohave a show that shows just how
(47:59):
things have not gotten betterand, in fact, have gotten worse
and we're in crisis, is anincredibly important public
health message that everybodyneeds 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, andthey're doing a better job than
I've ever done on all oureducation programs, showing the
world what that looks like.
Speaker 3 (48:21):
I'm going to go back for a minute to Noah's notion of
what he wanted to bring to theshow.
Noah travels all around theworld and wherever he goes
travels all around the world,and wherever he goes, doctors,
nurses, paramedics come up tohim and say thank you so much.
It's because of watching youthat I decided on my career path
(48:42):
, and that was based on a showfrom 1994 to 2009.
And as time went on, especiallypost-COVID, emergency medicine
fell out of favor, so much sothat they had trouble filling
residency spots, residency spots.
I saw that, yeah, residencyspots were not being filled and
(49:02):
NOAA really wanted to inspire anew generation of people to go
into medicine, to accept theresponsibility, to recognize the
challenges but recognize therewards, and that is one of his
guiding principles in what hewants to do and what he wants to
(49:23):
show, both as a writer and anactor.
So my hat is really off to Noahfor having this altruistic goal
to become a role model and aninspiration for a new generation
to enter healthcare.
Speaker 2 (49:38):
I would just add, as someone on the other side of
that even though you know I geta lot of credit for creating the
show it really is just a lovestory to the medical profession.
I mean, when I'm around theseguys and when I'm at MRAP, or
when I'm around we had aresidence night recently or when
I do go to the ER, it's very,very humbling to see real people
(50:01):
really helping people, savinglives, and they never get the
credit they do and we expectthem to be there 24-7 when we
need them most.
And if our show canfictionalize that a little bit
so that people actually payattention as opposed to just
telling the storiesstraightforward in a
(50:21):
journalistic point of view, Ithink we've done our small part
to helping with that situation.
But I mean, these guys arebrilliant and I'm a typing
monkey, but they are the realdeal.
And if we can portray that andwhat they go through day to day
and what they've been throughwith COVID and the things they
are expected to just solve notjust one thing in an hour, not
(50:46):
just two things and then over 12hours and then we like to sue
them because something didn't goexactly the way we want it.
Speaker 1 (50:53):
And not just medical things, things related to
caregiver burnout or, you know,the kids, all that yeah.
Speaker 2 (50:59):
So it really is a love letter to the profession
that I think is sometimes justtaken for granted, like air
traffic controllers or otherpeople who we rely on.
We just assume it's going to bethere when we need it, and
these guys are the best justassume it's going to be there
when we need it, and these guysare the best.
Speaker 3 (51:20):
I've heard some online comments that really
warmed my heart, which is thatreal emergency health care
workers state.
For years, I've tried to tellmy friends, my family, my
significant others what it'slike to work a shift, and I've
never been able to put it intowords before and I never have
been able to give a sense ofwhat it's really like.
And now that the show's on theair, they can watch it and I can
(51:42):
say, yes, that's what I do.
Speaker 1 (51:45):
Yeah, scott, you use the word hopeful or hope, and I
feel that I think, even thoughthe show has a lot of serious
themes and some cases that havesad outcomes, you can feel the
hope and the celebration of thework and of the work ethic and
the commitment of the healthcareworkers, and I think that's
another reason why the show isjust, you know, as authenticity
(52:06):
aside and accuracy aside is justresonating so, so strongly in
our community.
So thank you so much again forall the magic you make and thank
you for coming on theNocturnist podcast to speak with
me.
I'm truly honored.
Speaker 2 (52:20):
Thanks for having us.
It was wonderful.
Speaker 3 (52:23):
Thank you so much, emily.
Thank you Emily.
Speaker 1 (52:29):
This episode of the Nocturnist was produced by me
and John Oliver.
John also edited and mixed.
Our executive producer is AllieBlock, Our head of story
development is Molly RoseWilliams and Ashley Pettit is
our program manager.
Original theme music wascomposed by Yosef Monroe and
additional music comes from BlueDot Sessions.
The Nocturnist is made possibleby the California Medical
(52:52):
Association, a physician-ledorganization that works
tirelessly to make sure that thedoctor-patient relationship
remains at the center ofmedicine.
To learn more about the CMA,visit cmadocsorg.
The Nocturnist is also madepossible by donations from
listeners like you.
Thank you so much forsupporting our work in
storytelling from listeners likeyou.
(53:12):
Thank you so much forsupporting our work in
storytelling.
If you enjoyed this episode,please like, share, subscribe
and help others find us bygiving us a rating and review in
your favorite podcast app Tocontribute your voice to an
upcoming project or to make adonation, visit our website at
thenocturnistsorg.
I'm your host, Emily Silverman.
(53:34):
See you next week.
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