6.1 How realistic is "ER"?
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This article is from the ER FAQ, by Rose Cooper cooper@acm.cse.msu.edu with numerous contributions by others.
6.1 How realistic is "ER"?
The question that gets asked the most about ER when it comes to medicine
is, "How realistic is the show compared to real hospitals?" Like most things
in life, you'll get a different answer depending on who you ask -- I'll tell
you it's not that realistic, and other people may disagree with that
assessment. So right off the bat, I'll give a really short answer and say the
show isn't too grounded in reality, and if you don't want to hear why I say
that, you can skip down to the next answer and tune into TLC's excellent
series "Trauma: Life in the ER," which I strongly recommend for anyone who
wants to see what it's really like out there.
But I'll try and say a few (hah) words about it anyway.
The long answer depends on how you want to score them. ER and its
producers get high marks for accurate presentation of diseases and injuries
(although the number of bizarre and fascinating cases tends to be overblown)
and a realistic presentation of patient volume. Most lab values and imaging
studies reveal expected things when they're shown in relation to the
condition for which they were ordered, and treatment options are usually well
done.
Before I get into where they lose marks, a caveat: I'm Canadian, and as
such, some of what I say may not translate well into the American model.
Having said that, however, I have spent some time in American emergency
departments and know their operating patterns pretty well, so I feel fairly
confident and justified in what I'm about to say. Consider this my "gripe
list," or, since it has six broad categories, ER's six deadly sins. Feel free
to disagree with me on these.
[Gripe 1]: Speed. Early on in the fourth season, Elizabeth Corday is in
Trauma One managing a patient with a gunshot wound. Everything is progressing
the way we're used to seeing it, when suddenly, she says, "Why don't we all
just slow down? Things will go a lot smoother." The staffers look at her like
she's nuts, but the people I was watching that with cheered -- loudly. Speed
may have saved Sandra Bullock and Keanu Reeves on that Los Angeles city bus,
but it's not the rule in emergency medicine. Okay, yeah, it gets chaotic at
times and I feel like shouting across the department at somebody, but that
(practically) never happens. I'm frankly amazed that the folks in Cook County
General's ED haven't poked or otherwise caused bodily harm to themselves in
the midst of one of those insane trauma cases they seem to do over and over
and over and over again: going that fast with that much uncoordinated movement
is inviting an accident. Slowing down helps prevent bad things from happening,
both to you as a provider and to the patient. A trauma -- especially a
penetrating trauma -- is a dangerous place to be: there are sharp pointy
things going around the room and there's a lot of blood which is possibly
contaminated.. not a combination that leads to a safe working environment when
mixed with speed.
[Gripe 2]: Get out of my emergency room, damnit! Here's a fun thing to
try: find someone who's critically injured or really sick. Go down to your
local emergency department. Get your accomplis admitted to the department,
then try to follow them back into the patient care area. See how far you get.
The point of this is that the "hysterical screaming friend/relative/
well-wisher" in the trauma bay while the patient is going downhill and
they're cranking the ribs open is really stupid. It makes for great
television, but it just doesn't happen. Patient care areas are by their
very nature restricted (come on, would you want some complete non-medical
stranger to see you in the midst of your misery?); trauma and resuscitation
suites even more so. In real life, Kenny Law would never have been around to
make the (irrational, in my opinion) judgement that his brother was being
mistreated. At most hospitals, if you don't heed a request to leave a
patient care area, you'll either be forcibly removed or arrested, or both.
Access is strictly controlled to only those people who need to be there,
because as I said before, it's a dangerous place and there's no reason
to make it more dangerous by adding someone who might flip out for
whatever reason.
[Gripe 3]: Where is security? [Rose's note: amen, brother!] Touching
again on the stuff I just mentioned, access to the emergency department
itself is strictly controlled, and for good reason. In some places, the ED
is considered to be a refuge from the hostile outside world (inner-city
America, for example), and it's "neutral turf." That won't stop people from
trying to carry wars over into the emergency department, and it happens --
witness what happened in King's County, New York, a few years ago where a man
who felt he had been experimented on at the hospital walked in an ED and shot
(I believe) four doctors. The need for security -- as much to remove
undesirables as to restrain those who require it -- is very real in today's
ED. In every department I've been in, without exception, the first thing you
see when you walk in the door is the triage desk, and right next to it is a
security guard.
[Gripe 4]: Those doors can't take much more pounding. It is the premise
for at least one scene in every episode: there's a siren coming off wail,
followed by a crashing of doors, and a rapid-fire string of words spewing
out of a paramedic's mouth as the patient is whisked down the hall to the
trauma room. While this may happen (in a more sedate form) at some
institutions, it's certainly not the case for all patients, and it never
happens this fast. All patients whether they come in on foot, by ambulance,
or by taxi, are seen and evaluated by the triage officer before being
allowed back to the patient care areas. Medical priority determines who
goes first, and I sometimes wonder who exactly is doing the triage at Cook
County, since more than once a character is heard complaining about the
back-up, but we somehow find time to see the patient with the incredibly
trivial problem that would never have jumped to the front of the line on
a day with a three-hour wait.
[Gripe 5]: Prehospital blunders. While I'm on the subject of patient
arrivals, I could start a whole new section on gripes about their
prehospital care, which, I'm sorry to say (and I did look for a gentle way
to put this), sucks. Big time. Remember the opening moments of "A Bloody
Mess"? Think back -- they had people who had been involved in a motor vehicle
accident, covered in blood, and they don't find out that it's bovine until
they reach the hospital. Uh-huh. First thing's first, in the field as in the
hospital, you do a primary survey, which has a section in it where you look
for deadly bleeding. There was enough blood on those patients to make me
think they'd exsanguinated, and that certainly qualifies as life-
threatening. But did the paramedics find that? Hell no. So what'd they do,
just throw them in the ambulance like they did thirty years ago? Give me a
break. They're trained well enough to start IV lines and intubate in the
field, but they're apparently too dumb to do a proper primary survey.
There are also some problems I have with their standards of care --
trauma patients, particularly penetrating trauma patients -- require as part
of basic trauma life support guidelines spinal immobilization, and I can
remember more than one instance of a patient coming in not only not back
boarded, but not wearing a cervical collar either. Something like 12% of
all trauma patients regardless of mechanism of injury suffer some form of
spinal injury, and roughly 30% of those patients have some long-term
deficits. Given the highly litigeous climate of the United States, I have
a really hard time swallowing that one. (But this is a mostly technical
argument and open to a lot of debate.)
And don't even get me started on Elizabeth and the building back in
"Exodus"..
[Gripe 6]: This place makes me sick. County's infection control practices
stink. There's no way around it. Nobody I know would even think of performing
a spinal tap without a mask, gown and gloves, never mind something as dramatic
as a thoracotomy wearing only those thin yellow gauzy things and a pair of
gloves you yanked out of a box on the shelf. Look, I know why they do it
this way, but that doesn't mean I have to like it. (For what it's worth,
there are places out there that also have pretty lax infection control
procedures, but they're generally few and far between.) This isn't just for
the protection of the doctors and nurses out there, but also for the
protection of the patient.
General complaints: Nobody is ever seen reading journals or going to
lectures, so I'm guessing this teaching hospital isn't very big on academics.
Although, to their credit, we have seen morbidity and mortality rounds. Twice
over four years. It's nice to know they care about the teaching process.
Since when is the trauma team comprised almost exclusively of emergency
physicians? Heck, I've worked traumas where the team showed up, and I didn't
know any of the surgeons on it.
Since when does a chief resident have that much time to see patients? We
laughed and pointed at Kerry when she insisted they spend more time on
administration, but that's how it works. The chief resident has to chip in
with the administrative work, which leaves {him|her} with relatively little
time to treat patients.
We had an interesting time this past season when we tried to figure out
how Morganstern could be head of surgery and emergency medicine -- well,
because of how emergency medicine came into being (it's a fascinating story;
read the relevant sections out of the 1997 "Annals of Emergency Medicine"
[yes, that's every issue; don't worry, they're short articles] for more
information and some frank observations), people seem to think we belong to
surgery. We don't, and while I understand the logic behind putting it in
there (so there's no "Department of Emergency Medicine" but rather a
"Division" or a "Section"; a lot of it has to do with budgets and
administration overhead), it doesn't make me like it more.
The labs and radiology department are really fast. Wish I could get them
to move here.
"ER" staffers fail their CPR recertifications. Their compression rates
are way too slow, and their technique sucks.
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