This article contains spoilers for Episodes 12 and 13 of The Pitt.
This week, on Episode 13 of Max’s hospital drama The Pitt, Dr. Robby (Noah Wyle) and the rest of the emergency room’s staff were in their second hour of treating the victims of a mass shooting at a music festival. In the eye-opening Episode 12, we saw the emergency department enter “code triage,” preparing for the massive influx of gunshot wounds by moving every other patient to other parts of the hospital and using color-coded slap bracelets (yes, just like the ones from the ’90s) to mark whether patients were at risk of death within five minutes, or merely at risk of death within an hour. In Episode 13, which unfolds between 7 p.m. and 8 p.m., the staff tends to multiple critical patients at once, and Dr. Robby tries—and fails—to save Leah, the girlfriend of Jake, the boy who’s been a son to him, from her gunshot wounds.
Dr. Christopher Colwell is a physician with 30 years’ experience in urban Level 1 trauma centers. He was called to the scene after the shootings at Columbine High School in 1999, was in the emergency department during the response to the Aurora, Colorado, movie theater shootings in 2012, and again during the response to the UPS shootings in San Francisco in 2017. He is now the chief of emergency medicine at Zuckerberg San Francisco General Hospital and Trauma Center and an endowed professor and vice chair in the Department of Emergency Medicine at UCSF School of Medicine. We asked Dr. Colwell whether the show did a good job reflecting the reality of these horrific situations. Our conversation has been edited and condensed for clarity.
Slate: What, overall, did you think of the accuracy of these episodes?
Dr. Christopher Colwell: I think they did a remarkable job. I was very impressed with the way they were able to capture a number of very real things, not just the obvious structural operational issues but even some of the emotional issues. And I’ve got to say in some cases, it was a little hard to watch for that reason.
The dilemma that you face when it becomes at all personal is extremely real. I’ve had the opportunity to serve on panels and talk to a lot of people who’ve been involved in mass shootings in addition to myself, and some are in communities where they know a number of the victims, and there’s no way to have that not impact you. I didn’t know any of the Columbine or Aurora victims personally, but certainly Aurora brought up thoughts of Columbine and other shootings.
I remember even just—walking through the high school at Columbine and seeing a version of the high school math textbook I had used, out on the table in the library, on the table under which there were three dead students. I have such a vivid memory of that.
Wow. What do you think about how Dr. Robby handled the situation with Leah, Jake’s girlfriend?
The only way you can truly know that you’re giving the best care is being able to take yourself out of it personally. We talk about the idea of “VIP care,” which is when there are people coming in that are high-profile people and we give them “special care”—but sometimes we risk actually giving them inferior care because we deviate from what we do every day.
With Leah, Dr. Robby deviated from what even he had articulated earlier were their plans. Everybody was recognizing that he was doing something that was different than he would’ve done had he not had a connection to the victim. Your primary driver in situations like this has to be the greatest good for the greater number. And that’s a whole different discussion on how you define that, because that may not necessarily be “lives saved.”
And in these episodes of The Pitt, there was a very limited number of attending physicians despite a very high number of very high acuity patients. I will say, they went away a little bit from reality there. You typically are only going to see about 10 percent of patients in a mass shooting situation that really need the OR that quickly. I get it, that’s part of the dramatic effect. But regardless, in this situation, there was a very clear limited number of attendings that were very much needed, and Dr. Robby spent that very focused attention on one patient when he was needed elsewhere, and what cost was that? Who lost their lives because of that when you’re focusing your resources on somebody who is very, very unlikely to gain any benefit from it?
About that “greatest good for the greatest number” idea: I’m assuming that’s something you guys talk about specifically, when preparing for this kind of event? Or is that more of a general principle?
Both. But we do talk very specifically about it in relationship to this kind of event. And the reason is because, we have to assume until proven otherwise that our resources are going to be overwhelmed. If you walk into my normal shift—like the shift I had yesterday—if somebody had collapsed in the emergency department or in the waiting room or come in with a gunshot wound to the chest and did not have a pulse, everybody would’ve dropped everything and focused every resource we have on that patient until we had done everything we could for that patient. Whereas if you’ve got multiple victims, some of which might be somebody that we could save, and here we have somebody who is extremely unlikely, even if we give them everything, to be saved, you have to start thinking in terms of Where am I most likely to do good?
In this kind of situation, we have to be very honest: Older patients are going to be much more fragile, and it’s going to be much more difficult for them to survive some of the same injuries that a young patient might be able to survive and go on to have 40 or 50 years of functional living after that. That’s the kind of factor that goes into your decision-making. What do I apply to this patient in front of me and what do I have to keep, to apply to the others that are coming in?
One interesting aspect of these two episodes is that it seems like people in this ER are pretty well prepared.
Oh, more so than in actuality. First of all, opening up 25 ORs? I don’t know any place that can do that. And I’ve worked in some of the busiest trauma centers. The Pitt opened up 25 ORs, and I said right away, “There’s just no way.” We could bring in every resource that we have in a matter of an hour, which is not practical to do, and we still couldn’t open up 25 ORs. And having those beautiful MCI [mass casualty incident] kits that they brought in? We struggle with just keeping nonexpired equipment for those types of situations, because you just don’t use them very often.
Here’s another thing I remember feeling a little bit uncomfortable with. They intubated a lot of patients, and that’s one of the areas you have to really think about, in reality. If your resources are overwhelmed, you’re not going to have the ability to intubate and ventilate multiple patients. You’re going to run out of equipment, and you’re going to run out of personnel. And every time you intubate and ventilate somebody, you are taking up at least one person and often many people in order to manage that person. And in a true MCI, until you have defined the limits of that MCI, you have to assume that a patient that is not able to breathe on their own is not a salvageable patient. If patients are able to breathe on their own, then those might fall into what they were defining as the red category—the highest priority. And if they’re not breathing on their own, then they would fall more into the expectant category—meaning either dead, or expected to die. We wouldn’t intubate them, and they intubated a number of those patients.
So, in some ways it sounds like the show has an optimistic view of how many people would’ve been able to get that kind of attention.
Yeah. And that’s the drama of it. I mean, it’s not that much fun if you bring in 100 victims and only five get the intense treatment.
One of the things that they did well is showing them setting up doctors to receive incoming patients in front. They assign someone who just started as an attending three months ago. But in reality, you would put your most experienced people up there, because they’re the ones that can make the quickest decisions as to who needs the OR, who needs the red zone, who needs the other zones. You would take your most experienced emergency physician and your most experienced surgeon and put them up front and have them do the triage.
That’s hard to do because—having been in that situation, I know, you want to lay hands on patients, and yet many times that’s the last thing you should be doing. There are more people that can lay hands on patients and fewer people that can actually make the most important decisions as to who’s most likely to benefit from what care.
I get that they wanted the drama of Dr. Robby being a badass. But when you have a situation like this where you have an unknown number of victims, you might hear, “Active shooting going on, multiple victims, expect hundreds.” That was the exact message we got during Columbine and the pretty similar message that we got during Aurora. And when you hear that, then yes, you would want to really strongly consider taking your most experienced people, putting them up front to make those decisions.
I really was impressed with the way they depicted the hospital administrator. This hospital administrator did exactly what you want an incident commander to do, which is to basically say, I’m at your service. Let me know what you need. I’m going to stay out of here—because you don’t want the incident commander in the middle of the muck. You want them to be somebody you call saying, I need X, get me X, and they then go about getting X, and they’re not involved in patient care. The first early renditions of these incident command systems, people thought, Well, you’d have your head surgeon or your head emergency physician be the incident commander. That’s the last thing you want. You want an incident commander that is not laying hands on patients in any way, shape, or form and is just concentrating on getting resources available that are needed.
Speaking of equipment, there are a number of off-book treatments that they do, creative uses of equipment. How realistic is that?
I love the idea, but in point of fact, something that you only do once in a blue moon, you don’t do in a setting like this. We do well what we do often, and you need to revert to what you do often.
They put a Foley catheter in the neck to stop bleeding? I haven’t seen that done in 30 years. You can put a Foley catheter in the heart if you have a wound in the heart. This has been done a couple of times. Not very common. But I’ve never seen that done in the neck. There were a couple of the ways that they got neck intubations that were new and novel ways to do that. This is not the time you would revert to something that you haven’t done in 25 years.
When Dr. Santos put a REBOA in … it was very dramatic. The concept is a wonderful one, and it’s one that I personally really like. Somebody with a retroperitoneal fracture that’s bleeding out that you can’t compress—you don’t have other good means of doing it, and can’t go to the OR immediately. Putting a balloon in and inflating it under the renal vessels, which is what they were talking about, that is a great idea. But it isn’t established yet as a clear standard, and it would never be done by an intern.
In these two episodes, there are some people, like Santos, who seem to take on more responsibility than they would in a normal day. Is that realistic? I couldn’t believe that they weren’t more worried about malpractice suits.
There are a couple of answers to that, because you do need to think differently in an event like this. We are assuming until proven otherwise that we are not going to have the resources to address the situation. That’s a disaster, right? It’s when the situation overwhelms the resources, you have to address that. You do have to put people in different roles.
But you don’t have people doing procedures that they don’t do, because that’s not going to benefit anybody. I don’t do craniotomies. A neurosurgeon does that. To have me do a craniotomy in this situation—well, desperate times call for desperate measures. And I would say that when you’re in a situation like this, there’s not a contraindication to doing something if the only other option is death, and you know you have the resources to do it. … But mostly what that entails in reality is assigning people responsibilities they wouldn’t normally have but are within their scope. So for example, I might be able to take you, I don’t know what your medical background is, but let’s just say it’s none?
Oh yeah. None.
I may be able to say to you, “OK, I’ve intubated the patient, all I need for you to do is to squeeze this bag once every 10 seconds for the next 10 or 15 minutes until I can get back to this patient.” I could do something like that, where I would never do that under normal circumstances. It’s something that I could reasonably have you do or a medical student do or something like that. I would potentially put a third- or fourth-year resident in charge of a yellow or green zone where the primary responsibilities are to recognize if somebody’s getting sicker and move them up. They can do that. It would be more than what they would do under normal circumstances, but still within their skill set.
What about malpractice suits, in this kind of situation? Are people preparing for this kind of incident thinking about legal matters?
The way we need to be thinking about this is what are we held to for a malpractice situation? And I’m going into the legal part of this, because I do some work in this area. We are held to a standard of care, and a standard of care is defined as what a reasonable person would do under the same or similar circumstances. And so, we are now in a disaster, right? So it’s different than under normal circumstances. And so the question isn’t what would be the standard of care for this person under normal circumstances; it’s what is the standard of care under the same or similar circumstances? We have to think about that in terms of we can’t go rogue. You can’t do things that are unreasonable. But it’s back to that question of what would a reasonable person do under the same or similar circumstances? That’s the question you have to ask. And that’s the standard to which we are held.
OK, I have to ask you about this IO drill thing, where they just drill right in the bone marrow. I’m not the only one obsessed with it now. Is this real?
Yes, it absolutely is real. It allows us to give medications and, in some cases, fluid and even blood, when we can’t get intravascular access for any variety of reasons. We do use this on critical patients fairly often—I would say, maybe not daily, but certainly every week we have patients that have IO lines in. But none of them are awake and talking and stable, like the patient Whitaker drilled, because then we wouldn’t need to put in an IO. I can definitely say that!
So we can relax about that. These doctors and nurses are working like crazy, even though this situation happens near the end of their regular shift. I wonder if you could say anything more about the energy that comes into the situation when you are facing something like this.
One of the most impressive parts of these episodes in my mind was the way they captured the emotional effect and toll of these things. You absolutely feel the adrenaline. When I was called to Columbine, I arrived there in the afternoon. I didn’t leave there until 8 that night. It wasn’t until 10:30 at night that I realized because I’d been up since 7 that morning, how exhausted I was.
In Episode 12, Dr. Robby said, “We need to call some people to tell them to go home and get to bed because they’ll need to relieve us.” That was brilliant, that’s exactly what you need to do at the beginning of this kind of response. We saw this at Columbine. We saw it in Aurora. We saw it in the UPS shootings. And you see it in events like this. Everybody shows up and everybody comes to the emergency department. In fact, sometimes you have too many people. And one of the things you can forget about is that, in an event that’s going to go on for a period of time, we have to send people home, to go to bed so they can come relieve us.
That’s a critical resource, because this is exactly what’s going to happen. You’re going to have adrenaline and you’re going to be able to go full tilt for a lot longer than you thought, and then you’re going to collapse and you’re going to be no good to anybody. And you have to be able to have some people who can recognize that and say, first of all, “OK, tap out. You’re gone. You must leave.” And No. 2, they’ve got to have somebody to replace you. I loved that they incorporated that in the show.
Well, thank you so much for talking to us about this.
These episodes were tough to watch, because they did capture some of the real emotions that come up in events like this. But I will say, my son is a Pitt viewer. And we talked about these episodes, and it allowed us to talk about my experiences in a way we never had. It was still a year before he was born, when Columbine happened. So he obviously knows a lot about it, but had some more specific questions, after watching this, that I was glad to be able to answer. Some discussion that was not easy but was really important to have.
