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 a 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
04:08the United States and with the number of serious serious infections that can present initially as
04:16fever rash we are we are really sensitive to just listen for that and to look for that for us in
04:24the emergency department the the key to measles is immediate recognition and isolation there there's
04:30very little around that's more contagious than measles so we need to be sure that patients are
04:36immediately placed and in appropriate isolation spaces and we protect protect ourselves and our
04:42team with the correct PPE a spinal tap I've read about kids who've been paralyzed from a spinal tap
04:49there is zero risk of paralysis the fear of paralysis from a lumbar puncture is something we
04:57hear here quite often it is it is a safe procedure we do not put the needle in the spinal cord we are
05:06putting the needle into the spinal column which houses the fluid that we need to sample aim for the
05:13umbilicus oh that's pop that's the supraspinous ligament enter slowly next pop is the ligament of
05:20flavum lumbar puncture is a procedure where a needle is introduced into the the patient's lower spine we put
05:29it in just far enough to reach the spinal canal which is connected to the patient's brain cerebral spinal
05:38fluid lumbar puncture can be utilized to quickly rule in or rule out a number of different infections
05:45that then impact the or affect the brain and spinal cord and can present as fever and or rash and or
05:54alter mental status and that can also include measles however in this case they're also ruling out
06:00meningitis it's gonna take a minute to collect but the fluid looks clear that's good right coming out
06:07all done there's the comment about clear fluid clear fluid is telling us that the cerebral spinal fluid is
06:17without evidence of blood and is without evidence of of white blood cells if it were kind of murky and
06:25cloudy it would tell us that there are a lot of white blood cells in there like you may see in bacterial
06:32meningitis the portrayal of the of the lumbar puncture was accurate it looked to me to be the in the right
06:40space with the right equipment and we saw the the clear cerebral spinal fluid coming out I rate this clip
06:47a six it pains me to say it because I do appreciate how vaccine hesitancy and and emergence of measles in
06:57the United States is addressed here the measles vaccine is is safe and effective and and important
07:04to prevent the the re-emergence of this of this serious disease okay you're gonna feel a little pimp
07:10prick here ah me you put in an aisle huh yeah I O stands for intraosseous which means inside the bone
07:21so we have we have a drill with a very sharp a peg on it where we can actually drill into into a bone
07:31surface I O's are utilized when we are not able to find IV or intravenous lines Dr Robbie said everyone gets
07:39an I O if they are unconscious or unresponsive if the patient is awake and alert it's just a standard IV not an I O
07:47it does surprise me that this fourth year medical student grabbed the I O 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 before you
08:02begin any procedure there are some studies that have have shown that patients that are awake actually can
08:10tolerate it I I think we all just think we wouldn't want that to happen to our own bodies while we're
08:17awake and so we generally reserve them for patients who are are unresponsive or in cardiac arrest in the large
08:26majority of patients that we see we have time to to find an intravenous line and if if we have difficulty
08:35with intravenous line our next step would be to use to use ultrasound before placing an I O in a in a in a
08:42patient next finger molecular little finger will guide the tube the placement of the endotracheal tube where he
08:52was facing the patient and using his fingers and placing it placing it blindly is very uncommon in
08:59the emergency department setting we when we think of controlling patients airways we think of plan A
09:06plan B plan C plan D I think that a blind digital intubation would be would be quite a ways down that
09:14list because it's an MCI they were likely working without standard equipment immediately available but I
09:21would think in an emergency department of this size that there would be some airway equipment that
09:26can be can be tried but if you hit the esophagus he's toast you told us never to pass the tube unless
09:31we see the vocal cords I stay in the midline I should be able to get it past the cords the discussion
09:35around around placing the tube in the esophagus is is important because that's that's really how you
09:42fail at intubation the esophagus leads to the stomach and a tube placed there would not be not be
09:49ventilating the patient an unrecognized esophageal intubation can quickly lead to death which is
09:56what he was referring to I read this clip an eight I take one point off for the IO placement into the
10:02patient who was sitting up awake and talking and I take one point off for the blind digital intubation
10:09on the chest tube fifth intercostal space anterior axillary line perfect the location that was called
10:18out and where the incision was made is a standard location for for chest tube placement axillary
10:23meaning armpit so it's it's you know in on the side of your body in line with the armpit and then the
10:29intercostal spaces refer to the the spots in between the ribs counting from rib one here down the chest
10:36tube needs to be placed between the ribs because we're trying to access the the space outside the
10:43lung just behind the ribs that's a muscular a muscular space where we can where we can penetrate
10:49with our instruments in the tube oh my god are you okay oh that's gonna hurt leave it but I haven't
11:00ever been present for something I'm quite as dramatic as a scalpel going into somebody's foot although it's
11:06certainly within the the realm of possibility in this kind of a high high pressure high speed
11:13environment the scalpel which is very sharp dropped at that height I assume that it could penetrate the
11:19sneaker this is a reason why in in healthcare settings we we wear closed-toed shoes in order to
11:26help protect against against injuries of our feet I draw your blood you already did I mean for the HIV and
11:33hepatitis panels the fact that she continued on with the procedure after the knife cut her foot would
11:39be her decision when a needle stick or or a contaminated cut like this does occur it's really
11:47important that the the wound side is immediately washed and cleansed we generally start post exposure
11:53prophylaxis or pep in order to protect the patient from from HIV can I suture for you no I'll do it
12:01myself you can assist set me up a chucks suture tray beta dine irrigation saline syringe on splash guard
12:09and 50 proline the list of items that she was asking for to to self-suture was incredibly accurate what
12:16is less accurate is the fact that she's planning to do it for herself most people when they are have
12:23an occupational exposure like this would register as a patient a lot of my colleagues do like to to
12:30self-treat in this situation I would encourage her to check in become a patient and be be cared for as such
12:40I would give this an eight I think it the knife into the foot can happen but maybe a touch dramatic
12:46all compressions
12:47a system resume compressions slow slow tempo slow tempo we really don't use hands-on defibrillation
12:58hands-on paddles anymore we now use defib or pacer pads which are our adhesive pads onto the patient's
13:05chest one thing that I really appreciated was the attention to chest compressions the scenario where
13:10Dr. Robby asked him to slow down his chest compressions is very common and it it occurs regardless of the
13:17level of training of who's doing the compressions there's obviously a lot of adrenaline it's a tense
13:22situation and it's hard to know exactly what your rate is unless you're looking at the monitor chest
13:29compressions right around a hundred per minute and provide the optimal fill time for the heart so if
13:36you're going way too fast it limits the fill time and so you're really limiting the your compressions
13:42ability to circulate blood through the body really call this not yet dr. Robby said three rounds of epi
13:49it's time let's push another ramp deciding when to end a resuscitation or terminate a resuscitation
13:56is really multifactorial key decision points are what rhythm the patient is in how long the patient
14:04has been down down meaning without pulse and breathing how long resuscitative efforts have been been
14:11underway what I think I just broke some ribs means you're doing it right it is true that ribs are
14:21commonly broken even during effective appropriate well-performed chest compressions in adults we are
14:28pushing the sternum down about two and a half inches and sometimes the the cartilage that is on either
14:35side of the sternum and connects to the ribs can can dislodge or break and the ribs can crack as well I
14:41would give this a nine I really appreciate the attention to excellent high quality CPR if I'm being
14:48really nitpicky here the reason why I took one point off is because of the the paddles stop the
14:55bleeding near the leg but she's still bleeding internally we need Mal no we need to give a
14:58unit of blood and move her to the red zone let me see if they have space this scene is quite accurate the
15:04patient was triaged to the yellow team which is kind of the mid acuity team red patients require
15:12immediate resuscitation in mass casualty incidents there's a triage process where patients are
15:17given a tag a color based on the acuity of their injuries and their clinical appearance stability
15:27what are you doing prepping for roboa are you crazy did Abbott approve this he said do what you have
15:35to do a resident particularly a junior resident in this situation would continue to resuscitate and
15:43the attending should be immediately involved when there's any large procedures being performed it
15:52is uncommon for a junior resident or a resident to place roboa without the supervision of an attending
16:02physician or surgeon roboa is a is a catheter that can be placed into the groin and goes up into the aorta
16:11and a balloon is blown up um and the the goal is to um to stop bleeding um so it'll it'll cut off
16:20the the blood flow in the area past the balloon that's piece of cake all right guide wiring and
16:28introducer sheets whoa radials much stronger now this scene fairly accurately portrayed roboa placement it is
16:37an excellent life-saving tool um that can be utilized um in the emergency department setting although it's
16:44temporizing which means it's not in any way a permanent solution the problem isn't fixed you're just um you're
16:52just controlling bleeding as they demonstrated i would expect the the roboa balloon to go up blood
16:58continues to be um be delivered through the iv lines and the patient has a has a recovery of their of their
17:05hemodynamics their blood pressure their heart rate okay you never should have done that on your own ever
17:12do you understand that was pretty badass you saved your life good job it probably should happen sitting
17:20down outside of the clinical space i think it was important that he let her know that this was
17:26potentially very unsafe and should not happen um without intending involvement i think particularly
17:33in this mci situation uh it's also great that he acknowledged that uh her actions um say likely
17:41saved this patient's life i give this clip a nine it shows um prompt uh accurate resuscitation for
17:48hemorrhagic shock my flyer hit his left floral shocked him once for v-fib transitions of care are really
18:00important um be from the pre-hospital team to the to the ed team and i really liked um the handoff from
18:07the from the helicopter team uh to the to the ed team it was a accurate um concise report into what
18:16that addressed what was going on with the patient and and what had been done this is the path to avoid
18:21the median nerve and all major vessels they're about to perform a forearm fasciotomy using the the marker
18:29to to identify the uh the incision site is uh is something that happens and is important we think
18:38about the procedure we think about the anatomy how much pressure just about this much
18:44it does make sense that this procedure would happen uh on a patient who's been electrocuted fasciotomies
18:53are needed when a patient has compartment syndrome and when there's injuries to those tissues there can
19:00be significant swelling um inside which can cut off blood flow because of the pressure on the blood vessels
19:07emergent fasciotomy which they're showing in the clip release the pressure and allow the blood to flow
19:12the amount of pressure that's needed on the scalpel will be determined by the location on the body the
19:22the type of injury and the appearance and condition of of the skin and tissues that you're trying to cut
19:28through i'd rate this clip a 10. robbie do we need pen today here dr adamson just went down with a full
19:38sox of 65. in this clip we see robbie having flashbacks from the coven 19 pandemic and his work
19:47in the emergency department taking care of patients who who can't breathe and are dying of covid and him
19:53feeling um overwhelmed by the by the patients that he can't save i think this clip is exceptionally accurate
20:02and represents um a lot of what my teammates and colleagues have gone through in the last five
20:10years we in the emergency department are known for dynamic environments we are known for um resilience
20:17and the the covid pandemic really um tested that in a way that many or most of us haven't experienced
20:27before why couldn't you save her i mean this is what you do the appearance of the emergency department
20:39during his flashbacks to to the covid pandemic um looked quite accurate to me i recall being uh in a
20:48similar um hot sweaty space suit um for for many hours um despite being around many people and having
20:56it be kind of a um a dynamic even chaotic environment i recall also it being very um isolating because
21:06it's hard to hear it's hard for people to hear me you lose um contact and and touch um with your
21:13patients and and with with each other one thing that that clip reminded me of was being with my patients
21:21when they were dying their families weren't allowed in the emergency department and so i would
21:26um hold a phone up to my patient who was dying um so that their family uh outside either in the parking
21:34lot or at home um could be with their family at uh on face time i give this clip a 10. we're not ready
21:41to let go yet i may have to honor his advanced directive no you have to honor our durable power for health
21:48care the patient has a has a dnr or a do not resuscitate order and his daughter is attempting to
21:55override it i do exactly what dr robbie did which is try and guide the family to have them not think
22:02about their own wishes but think about what the dying person wants in that moment i try and really move
22:09away from paperwork and legality and really move into a role of partnership with patients and their families
22:16there are a number of instances where the the patient wishes uh stand um one example is um is organ
22:23donation so if you if you have organ donation on your driver's license um that has that has told
22:30everybody that those are your wishes and and that can happen drops into your tongue
22:34sometimes when you pull the breathing tube out the patient um doesn't begin spontaneous respirations
22:48and will will die immediately many other patients have what we call end of life breathing or or agonal
22:55breathing but it's um often shallow irregular so sometimes very slow maybe there will be a pause maybe
23:01then there'll be a couple shallow fast breaths the drops that he placed under the patient's tongue i
23:07would guess are glycopyrrolate um patients um that are having agonal breathing and are nearing the end of
23:15their life glycopyrrolate can um can dry help dry up some of those secretions and so the the patient is
23:23less likely to be um choking on saliva and having having problems managing their secretions i would rate this
23:29scene a 10. i i think that um it's incredibly accurate drug seeking woman kicked off a city bus for
23:39disrupting and disturbing passengers when this patient first arrived in the emergency department
23:43she was screaming out in pain and there was an initial impression that or initial quick judgment that
23:50this patient um was it was because of substance abuse and not her um serious sickle cell disease i'm
23:58doing a retrospective chart review on our past five years of patients of color we don't treat sickle cell
24:03here as well as they do in other hospitals but i'm hoping to change that sickle cell disease are abnormally
24:10shaped or misshapen red blood cells and they can become stuck or lodged in various parts of your body
24:18so it can cause lack of blood flow patients presenting in sickle cell crisis can have
24:26normal vital signs and the only complaint is severe pain the most important data point is what the
24:33patients are telling us so it really requires us to connect with our patients uh to listen to their
24:40history and to um to address their pain immediately and aggressively much like is demonstrated here sickle cell
24:49disease very predominantly affects african americans disease processes that are specific to to to one
24:58gender or one ethnic or racial group um are really important for us to pay attention to with regard to
25:06our own biases and ensuring that we continue 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 earning trust with your patients can be a little bit different based on the
25:24based on the patient and the situation the fact that this doctor spent so much time with the patient and
25:29her partner um listening to them showing empathy um taking a history and understanding the patient's
25:35disease course um helped the team understand what was going on and and recognize uh the critical illness
25:43that was happening i would give this clip a 10. it it nicely demonstrates the um bias that exists in
25:50health care um it demonstrates the the way sickle cell patients can be can be treated um misdiagnosed or or
26:00symptoms under managed i would give season one of the pit a 10. i love the portrayal of the um
26:09societal issues that are are very real and are happening today i really appreciate the way that
26:15um different roles in the emergency department whether it be uh the charge nurse the medical student
26:21the attending physician i love the way that those um those are accurately portrayed and how everyone
26:28works together as a team and then the the medical speak is spot on my friends and i um talk about this at
26:35work and my um we we are sometimes even surprised that our our non-medical partners and family members are
26:44enjoying the show uh so much because of all of the accurate um descriptions and language that's used i have
26:51two favorite scenes from the pit uh the first is the uh sickle cell case i really appreciate that this
27:00show is is calling out um bias and and racism i i really appreciate that the show is showing us all that in
27:11in health care in the in the united states we still have a ways to go the second scene that i appreciate
27:17the most is um dr robbie responding to his flashbacks um from the covid pandemic i think this um this speaks
27:26to reasons for burnout it speaks to um difficulties with resilience and it and it's a charge uh for people
27:34like me to keep working on the the wellness of my team