Dr. Reed Caldwell rates scenes from the HBO Max medical drama "The Pitt," starring Noah Wyle.
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00:00oh my god are you okay oh that's gonna hurt leave it but I haven't ever been
00:09present for something I'm quite as dramatic as a scalpel going into
00:13somebody's foot although it's certainly within the realm of possibility my name
00:18is dr. Reed Caldwell I'm the chief of the emergency department at NYU Langone's
00:22Hospital in Manhattan the Pearlman Center for emergency services I've been
00:26working in EMS or emergency medicine since 1999 today we're going to look at
00:31scenes from the pit and judge how real they are you got yourself a fight bite
00:39well I am sure you are in the clear for rabies and HIV human mouths are filthy a
00:45fight bite is the wound that occurs when one individual punches another and it's
00:50it strikes their teeth and their their mouth we make sure that the skin is
00:55intact and there's there's no wound and also because different from some other
01:01you know regular lacerations like if you cut your if you cut your hand with a
01:06knife making dinner that's a very different bacterial environment than if
01:12you cut your cut your hand hitting somebody's mouth the bacteria in in
01:18mouths humans cats dogs is packed full of of bacteria that can cause rapid bad
01:27infection we need to determine if the bite extended into the joint space if it
01:31did you're gonna need IV antibiotics on a trip to the OR to see a hand surgeon as
01:35was demonstrated here the other part of a fight bite is that you can actually
01:38push that bacteria into the joint so not only do you have a skin infection but you
01:44can also have a joint infection it's dangerous and a big problem if the
01:48infection is in the joint it can quickly spread and become become much worse I am
01:54going to inject some sterile saline into your knuckle joint they become spraying
01:58back out of the bite wound we'll know ready there she blows the steps in this
02:03scene are are accurate I think in most emergency departments a hand surgeon or
02:10orthopedic surgeon would be would be pretty quickly involved as a consultant
02:16promise you'll be seen as soon as a provider is available but how can they
02:19become available if new people keep cutting the line I'll take my chances the
02:27violence in healthcare and violence in the emergency departments is sharply on the
02:32rise I find this clip incredibly accurate both just in kind of the general
02:38volatility after the patient punched the nurse in a horrifying way he dropped the
02:44AMA form on the ground AMA form AMA means against medical advice most
02:50patients want to understand what's happening with them because patients are
02:54frustrated or because other other factors in their life are occurring some
02:58elect to leave against medical advice I give this clip a nine what about the rash
03:03but it's more prominent on the lower body not much on the face do you know what
03:08this is nope resuscitate first diagnosed later the thing that immediately jumps out
03:14to me is that they're the patient presents with ultra mental status fever and rash and
03:19that the none of the staff are in appropriate PPE I would expect them to be have N95s on I
03:28would expect them to be in an isolation room I would I would expect there to be to limit the
03:33amount of of staff to only essential essential team members at the bedside so to me that that
03:40that's a little inaccurate you ever seen anything like this before nope well that just goes to show
03:50you how old I am this looks like measles I don't know exactly how old dr. Robbie is but I would guess
03:56that he actually isn't old enough to have seen a lot of measles either personally or professionally
04:02so I found that I found that comment interesting also with measles unfortunately on the rise in the
04:08United States and with the number of serious serious infections that can present initially as fever rash
04:17we are we are really sensitive to just listen for that and to look for that for us in the emergency
04:24department that the the key to measles is immediate recognition and isolation there there's very
04:30little around that's more contagious than measles so we need to be sure that patients are immediately
04:36placed and in appropriate isolation spaces and we protect protect ourselves and our team with the
04:44correct PPE a spinal tap I've read about kids who've been paralyzed from a spinal tap there is zero risk of
04:51paralysis the fear of paralysis from a lumbar puncture is something we hear here quite often it is it is a
05:01safe procedure we do not put the needle in the spinal cord we are putting the needle into the spinal column
05:09which houses the fluid that we need to sample aim for the umbilicus oh that's pop that's the supraspinous
05:17ligament enter slowly next pop is the ligament of flavum lumbar puncture is a procedure where a needle is
05:25introduced into the the patient's lower spine we put it in just far enough to reach the spinal canal
05:32which is connected to the patient's brain cerebral spinal fluid lumbar puncture can be utilized to
05:40quickly rule in or rule out a number of different infections that then impact the or affect the brain
05:48and spinal cord and can present as fever and or rash and or alter mental status and that can also include
05:56measles however in this case they're also ruling out meningitis it's gonna take a minute to collect but the
06:04fluid looks clear that's good right coming out all done there's the comment about clear fluid clear
06:13fluid is telling us that the cerebral spinal fluid is without evidence of blood and is without evidence
06:21of of white blood cells if it were kind of murky and cloudy it would tell us that there are a lot of
06:28white blood cells in there like you may see in bacterial meningitis the portrayal of the of the
06:35lumbar puncture was accurate it looked to me to be the in the right space with the right equipment
06:41and we saw the the clear cerebral spinal fluid coming out I rate this clip a six it pains me to say it
06:49because I do appreciate how vaccine hesitancy and and emergence of measles in the United States is
06:58addressed here the measles vaccine is is safe and effective and and important to prevent the the
07:05re-emergence of this of this serious disease okay you're gonna feel a little pimp prick here ah meat you put
07:14in an aisle huh yeah IO stands for intraosseous which means inside the bone so we have we have a drill
07:24with a very sharp peg on it where we can actually drill into into a bone surface IOs are utilized when
07:33we are not able to find IV or intravenous lines Dr Robbie said everyone gets an IO if they are
07:40unconscious or unresponsive if the patient is awake and alert it's just a standard IV not an IO it does
07:48surprise me that this fourth year medical student grabbed the IO and and placed it in this patient
07:53alone I think it this is the reason why I tell our our med students and residents please let me know
08:01before you begin any procedure there are some studies that have have shown that patients that are awake
08:09actually can tolerate it I I think we all just think we wouldn't want that to happen to our own bodies
08:16while we're awake and so we generally reserve them for patients who are are unresponsive or in cardiac
08:24arrest in the large majority of patients that we see we have time to to find an intravenous line if if
08:34if we have difficulty with intravenous line our next step would be to use to use ultrasound before
08:39placing an IO in a in a in a patient next finger molecular little finger will guide the tube the
08:49placement of the endotracheal tube where he was facing the patient and using his fingers and placing
08:54it placing it blindly is very uncommon in the emergency department setting we when we think of controlling
09:04patients airways we think of plan a plan B plan C plan D I think that a blind digital intubation would be would
09:12be quite a ways down that list because it's an MCI they were likely working without standard equipment
09:20immediately available but I would think in an emergency department of this size that there would be some airway
09:26equipment that can be can be tried if you hit the esophagus he's toast you told us never to pass the tube unless we see the
09:31vocal cords I stay in the midline I should be able to get it past the cords the discussion around around
09:37placing the tube in the esophagus is is important because that's that's really how you fail at
09:43intubation the esophagus leads to the stomach and a tube placed there would not be not be ventilating the
09:50patient an unrecognized esophageal intubation can quickly lead to death which is what he was referring
09:56to I read this clip an eight I take one point off for the IO placement into the patient who was sitting up awake and
10:05talking and I take one point off for the blind digital intubation on the chest tube
10:11fifth intercostal space anterior axillary line perfect the location that was called out and where the incision was made is a
10:19standard location for for chest to placement axillary meaning armpit so it's it's you know in on the side
10:27of your body in line with the armpit and then the intercostal spaces refer to the the spots in between
10:32the ribs counting from rib one here down the chest tube needs to be placed between the ribs because we're
10:40trying to access the the space outside the lung just behind the ribs that's a muscular a muscular space
10:47where we can where we can penetrate with our our instruments in the tube
10:51oh my god are you okay oh that's gotta hurt leave it but I haven't ever been present for something I'm quite as
11:02dramatic as a scalpel going into somebody's foot although it's certainly within the realm of possibility in this kind of a high
11:10high high pressure high speed environment the scalpel which is very sharp dropped at that height I I assume
11:18that it could penetrate this sneaker this is a reason why in in healthcare settings we we wear
11:23closed-toed shoes in order to help protect against against injuries of our feet I draw your blood you
11:31already did I mean for the HIV and hepatitis panels the fact that she continued on with the procedure after the
11:37knife cut her foot would be her decision when a needle stick or or a contaminated cut like this
11:45does occur it's really important that the the wound side is immediately washed and cleansed we generally
11:51start post exposure prophylaxis or pep in order to protect the patient from from HIV can I suture for
12:00you no I'll do it myself you can assist set me up a chucks suture tray beta dine irrigation saline
12:07syringe on splash guard and 5-0 proline the list of items that she was asking for to to self suture
12:14was incredibly accurate what is less accurate is the fact that she's planning to do it for herself most
12:21people when they are have an occupational exposure like this would register as a patient a lot of my
12:27colleagues do like to to self-treat in this situation I would encourage her to check in become
12:38a patient and be be cared for as such I would give this an eight I think it the knife into the foot can
12:44happen but maybe a touch dramatic all compressions
12:49we really don't use hands-on defibrillation hands-on paddles anymore we now use defib or pacer pads which
13:02are our adhesive pads on to the patient's chest one thing that I really appreciated was the attention to
13:08chest compressions the scenario where dr. Robbie asked him to slow down his chest compressions is
13:13very common and it it occurs regardless of the level of training of who's doing the compressions
13:19there's obviously a lot of adrenaline it's a tense situation and it's hard to know exactly what your rate
13:27is unless you're looking at the monitor chest compressions right around a hundred per minute
13:32provide the optimal fill time for the heart so if you're going way too fast it limits the fill time and
13:39so you're really limiting the your compressions ability to circulate blood through the body really
13:46call this not yet dr. Robbie said three rounds of epi it's time let's push another ramp deciding when
13:52to end a resuscitation or terminate a resuscitation is really multifactorial key decision points are what
14:01rhythm the patient is in how long the patient has been down down meaning without pulse and breathing how
14:08long resuscitative efforts have been been underway what I think I just broke some ribs means you're doing it right it is
14:20true that ribs are commonly broken even during effective appropriate well-performed chest compressions in
14:27adults we are pushing the sternum down about two and a half inches and sometimes the cartilage that is on either side of the
14:35sternum and connects to the ribs can can dislodge a break and the ribs can crack as well I would give
14:42this a nine I really appreciate the attention to excellent high quality CPR if I'm being really nitpicky
14:48here the reason why I took one point off is because of the the paddles we stopped the bleeding near
14:55the leg but she's still bleeding internally we need Mal no we need to give a unit of blood and move her to
15:00the red zone let me see if they have space this scene is quite accurate the patient was triaged to
15:06the yellow team which is kind of the mid acuity team red patients require immediate resuscitation in mass
15:14casualty incidents there's a triage process where patients are given a tag a color based
15:21on the acuity of their injuries and their clinical appearance stability what are you doing prepping for
15:31roboa are you crazy did Abbott approve this he said do what you have to do a resident particularly a junior
15:38resident in this situation would continue to resuscitate and the attending should be immediately
15:46involved when there's any large procedures being performed it is uncommon for a junior resident or a
15:56resident to place roboa without the supervision of an attending physician or surgeon roboa is a is a
16:05catheter that can be placed into the groin and goes up into the aorta and a balloon is blown up and the
16:15the goal is to to stop bleeding so it'll it'll cut off the the blood flow in the area past the balloon
16:24piece of cake all right guide wiring introducer sheets whoa radials much stronger now this scene fairly
16:35accurately portrayed roboa placement it is a excellent life-saving tool that can be utilized in the
16:42emergency department setting although it's temporizing which means it's not in any way a
16:47permanent solution the problem isn't fixed you're just you're just controlling bleeding as they demonstrated
16:54I would expect the the roboa balloon to go up blood continues to be be delivered through the IV lines and the
17:01patient has a has a recovery of their of their hemodynamics their blood pressure their heart
17:08rate okay you never should have done that on your own ever do you understand that's pretty bad as you
17:16saved your life it probably should happen sitting down outside of the clinical space I think it was
17:23important that he let her know that this was potentially very unsafe and should not happen
17:29without intending involvement I think particularly in this MCI situation it's also great that he
17:37acknowledged that her actions say likely saved this patient's life I give this clip a nine it shows
17:44prompt accurate resuscitation for hemorrhagic shock my flyer hit his left floral shot two months for v-fib
17:57transitions of care are really important be from the pre-hospital team to the to the ED team and I really
18:05liked the handoff from the from the helicopter team to the to the ED team it was a accurate concise report in
18:14to what that addressed what was going on with the patient and and what had been done this is the
18:20path to avoid the median nerve and all major vessels they're about to perform a forearm fasciotomy using the
18:28the marker to to identify the the incision site is is something that happens and is important we think about the
18:38procedure we think about the anatomy how much pressure just about this much it does make sense that this
18:48procedure would happen on a patient who's been electrocuted fasciotomies are needed when a patient
18:56has compartment syndrome and when there's injuries to those tissues there can be significant swelling
19:02inside which can cut off blood flow because of the pressure on the blood vessels emergent fasciotomy which
19:08they're showing in the clip release the pressure and allow the blood to flow the amount of pressure
19:14that's needed on the scalpel will be determined by a location on the body the the type of injury and the
19:24appearance and condition of the skin and tissues that you're trying to cut through I'd rate this clip a 10
19:30in this clip we see Robbie having flashbacks from the coven 19 pandemic and his work in the emergency
19:48department taking care of patients who who can't breathe and are dying of covid and him feeling
19:54overwhelmed by the by the patients that he can't save I think this clip is exceptionally accurate and
20:03represents a lot of what my teammates and colleagues have gone through in the last five years we in the
20:11emergency department are known for dynamic environments we are known for resilience and the the coven
20:20pandemic really tested that in a way that many or most of us haven't experienced before why couldn't you
20:29save her I mean this is what you do the appearance of the emergency department during his flashbacks to to
20:42the coven pandemic looked quite accurate to me I recall being in a similar hot sweaty space suit for for many hours
20:54despite being around many people and having it be kind of a dynamic even chaotic environment I recall also it being very
21:04isolating because it's hard to hear it's hard for people to hear me you lose contact and and touch with your patients and and with with each other one thing that that clip reminded me of was
21:19being with my patients when they were dying their families weren't allowed in the emergency department and so I would hold a phone up to my patient who was dying
21:31so that their family outside either in the parking lot or at home could be with their family at on FaceTime I give this clip a 10 we're not ready to let go yet I may have to honor his
21:45advance directive no you have to honor our durable power for health care the patient has a has a DNR or a do not resuscitate order and his daughter is attempting to override it I do exactly what
21:58Dr. Robby did which is try and guide the family to have them not think about their own wishes but think about what the dying person wants in that moment I try and really move away from
22:10paperwork and legality and really move into a role of partnership with patients and their families there are a number of instances where the patient wishes stand one example is is organ donation
22:24so if you if you have organ donation on your driver's license that has that has told everybody that those are your wishes and and that can happen
22:33drops in your tongue
22:43sometimes when you pull the breathing tube out the patient doesn't begin spontaneous respirations and will will die immediately
22:50many other patients have what we call end of life breathing or or agonal breathing but it's often shallow irregular so sometimes very slow
23:00maybe there will be a pause maybe then there will be a couple shallow fast breaths the drops that he placed under the patient's tongue
23:07I would guess are glycopyrrolate patients that are having agonal breathing and are nearing the end of their life glycopyrrolate can can dry
23:19help dry up some of those secretions and so the patient is less likely to be choking on saliva and having having problems managing their secretions
23:29I would rate this scene a 10. I think that it's incredibly accurate
23:37Drug seeking woman kicked off a city bus for disrupting and disturbing passengers
23:41When this patient first arrived in the emergency department she was screaming out in pain and there was an initial impression that
23:48or our initial quick judgment that this patient was it was because of substance abuse and not her serious sickle cell disease
23:58I'm doing a retrospective chart review on our past five years of patients of color
24:01We don't treat sickle cell here as well as they do in other hospitals but I'm hoping to change that
24:07Sickle cell disease are abnormally shaped or misshapen red blood cells and they can become stuck or lodged in various parts of your body
24:17So it can cause lack of blood flow patients presenting in sickle cell crisis can have normal vital signs and the only complaint is severe pain
24:31The most important data point is what the patients are telling us
24:34So it really requires us to connect with our patients to listen to their history and to address their pain immediately and aggressively
24:46Much like is demonstrated here sickle cell disease
24:50Very predominantly affects African Americans disease processes that are specific to
24:57To to one gender or one ethnic or racial group
25:01Are really important for us to pay attention to with regard to our own biases and ensuring that we
25:08Continue to treat all patients like they're our own family members
25:12What you did in there building a relationship with your patients earning their trust
25:17It's what this is all about
25:19Earning trust with your patients can be a little bit different based on the based on the patient and the situation
25:26The fact that this doctor spent so much time with the patient and her partner listening to them showing empathy
25:32Taking a history and understanding the patient's disease course helped the team understand what was going on and and recognize the critical illness that was happening
25:44I would give this clip a 10
25:46It it nicely demonstrates the bias that exists in healthcare
25:51It demonstrates the the way sickle cell patients can be can be treated misdiagnosed or or symptoms under managed
26:02I would give season one of the pit a 10
26:05I love the portrayal of the societal issues that are very real and are happening today
26:13I really appreciate the way that different roles in the emergency department
26:18Whether it be the charge nurse the medical student the attending physician
26:23I love the way that those those are accurately portrayed and how everyone works together as a team
26:29And then the the medical speak is spot-on my friends and I talk about this at work and my
26:36We we we are sometimes even surprised that our our non-medical partners and family members are enjoying the show
26:45So much because of all of the accurate descriptions and language that's used
26:51I have two favorite scenes from the pit
26:53The first is the sickle cell case
26:57I really appreciate that this show is is calling out bias and and racism
27:06I I really appreciate that the show is showing us all that in in healthcare in the in the United States
27:14We still have a ways to go the second scene that I appreciate the most is Dr. Robby responding to his flashbacks
27:22from the COVID pandemic I think this this speaks to reasons for burnout
27:28It speaks to difficulties with resilience and it and it's a charge for people like me to keep working on the the wellness of my team
27:52And in the future
27:55Enjoy the rest of the early on
27:58T dare to understand our focus
28:01The last word about the need of opportunity
28:04Find your knowledge
28:07To do knowledge
28:09Find your knowledge
28:11Find your knowledge
28:13Find your knowledge
28:15Find your knowledge
28:17Find your knowledge