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The Pitt is a popular award-winning medical television program, highlighted by suspenseful emergency room drama and excellent character development. Numerous colleagues of mine enjoy the show. In Episode 12 of Season 1, The Pitt’s writers do a major disservice to the anesthesia profession when they depict their star physician, Dr. Michael “Robby” Robinavitch, played by Noah Wyle, rescuing a failing anesthesiologist who is unable to place an endotracheal tube into an unconscious patient. Dr. Robinavitch inserts the breathing tube successfully and takes the opportunity to teach the anesthesiologist how he did it.
This scene would never happen as portrayed.
Anesthesiologists are the airway experts in every hospital. We place hundreds of endotracheal tubes in every type of patient for every type of surgery each year, without the assistance of an emergency room actor or the actor’s screenplay writers.
Episode 12 of Season 1 of The Pitt involves mass casualties arriving simultaneously at the emergency room after a shooter opened fire at an outdoor concert. The show does a fine job of portraying the preparation for multiple trauma patients arriving at once. Dr. Robinavitch is the leader in the triage and care of the critically ill patients, and is also involved in teaching physicians and medical student trainees as they cope with the challenging situation.
At the 28-minute mark of Episode 12, an anesthesiologist wearing an orange vest with bold capital letters reading “PRIMARY ANESTHESIA MD” is shown inserting a direct laryngoscope into an unconscious patient’s mouth as he is attempting to place an endotracheal breathing tube.
The dialogue proceeds as follows:
Anesthesiologist: “I need suction.”
Nurse: “We don’t have any.”
Anesthesiologist: “Too many secretions. I can’t see shit.”
Dr. Robinavitch arrives on scene. Dr. Robinavitch says: “Wipe it out with 4 X 4s.”
Anesthesiologist: “Are you kidding me? Do you guys have a fiberoptic laryngoscope?”
Dr. Robinavitch: “No, just a rigid GlideScope, except we don’t have any room for it, so just pull out and we’ll bag for a minute.” They successfully bag/mask ventilate the patient.
Anesthesiologist: “When did this guy last eat?”
Dr. Robinavitch: “We never know down here. Let me get in there.”
Anesthesiologist: “I’ll keep some cricoid pressure. If he vomits, we’re fucked.”
Dr. Robinavitch: “Hold on, hold on, hold on, hold on. Oh yeah, this one looks tough.”
Anesthesiologist: “No shit. Prep the neck?”
Dr. Robinavitch: “Hold on. McKay, come over here. Just give me a chest compression.”
McKay: “CPR? Did we lose the pulse?”
Dr. Robinavitch: “No. Just give me one good push. O.K. Two. And do it again.” Dr. Robinavitch advances the endotracheal tube into the mouth. “O.K. I think I am in. Bag him. Check the end tidal.”
McKay attaches an Ambu bag to the endotracheal tube and successfully ventilates the lungs. The end tidal CO2 indicator on the airway turns yellow, indicating that the tube is indeed in the trachea. McKay says: “Yellow. We’re good. How did you do that?”
Dr. Robinavitch: “Bubble intubation. You gave him the compression; I followed the air bubbles. More than one way to tube a cat.”
Anesthesiologist: “Imagine that.”
Entertaining? Perhaps. Realistic? Not at all. The fiberoptic laryngoscope the anesthesiologist asked for is not a useful instrument in this situation. And the anesthesiologist would never ask, “When did this guy last eat?” because in the emergency room setting, no one knows when any patient last ate, and every physician assumes the patient has a full stomach. The anesthesiologist’s suggestion that they “prep the neck” (for a front of neck emergency airway such as a cricothyrotomy) is wrong, since the staff already demonstrated they were able to successfully bag/mask ventilate the patient. A patient who can be ventilated with an Ambu bag and a mask would never need a surgical airway cut into the front of their neck.
The standard emergency room approach to place an endotracheal tube in a patient like this was to use a GlideScope, an outstanding tool that is one of the major advances in anesthesiology and emergency room airway management.
GLIDESCOPE
The GlideScope is the same size as the direct laryngoscope used by Robinavitch in Episode 12, except the GlideScope has a video camera on the tip of the scope. That video camera is advanced into the patient’s throat, enabling the physician to see the inside of the airway on a video screen located near the patient’s head. Is the GlideScope too big, so that there “is no room for it?” No, the Glidescope is not too big, it’s the same size as the tool Dr. Robinavitch uses. Would the ER have a GlideScope available? Absolutely, it’s standard equipment in the 21st Century. What if the airway was truly obstructed by blood and secretions, and the anesthesiologist cannot see the vocal cords even with the GlideScope? The correct step is to use a suction cannula to suction out the throat so you can clearly see the vocal cords. But the nurse in Episode 12 said there is no suction. This is absurd. There are suction cannisters and tubing at every patient station in every emergency room.
Anesthesiologists are routinely called stat to emergency rooms to manage complex airways and assist emergency room doctors with these airways. An excellent ER doctor can handle most urgent airway emergencies, but there are always difficult airways in which an airway expert—a board-certified anesthesiologist—will come to their rescue. Portraying the “PRIMARY ANESTHESIA MD” as an incompetent airway specialist who needs to be displaced by a TV actor/emergency room doctor is simply false. I’m all for entertainment, but this scene is so blatantly inaccurate that any medical professional would groan and change the channel. I understand the appeal of making Dr. Robinavitch into a physician-hero—a multitalented wizard who is the medical equivalent of a Marvel superhero—but not at the expense of my profession.
One of the screenwriters must have heard of the technique in which the physician could follow the trail of air bubbles coming out of the windpipe, and thought that concept would make an exciting scene. Writing a scene with a conclusion in mind sounds like a good idea, but the path to that conclusion must be credible. Following the trail of bubbles in a spontaneously breathing patient to successfully perform a difficult endotracheal intubation in an adult has been reported in the medical literature in Anesthesia & Analgesia. Following the trail of bubbles in a patient who is not breathing by pressing on the patient’s chest has been described in neonatal and pediatric airway management, because the patient and their chest are smaller in size. Pressing on an adult’s chest to generate bubbles to guide endotracheal intubation in an adult patient has never been reported.
An additional prominent inaccuracy of the episode is that almost none of the mass casualty patients, who are lying center stage on multiple gurneys throughout the emergency room, are connected to any vital signs monitors whatsoever. Routine vital signs monitors include the cables to a pulse oximeter, an electrocardiogram, and a blood pressure cuff, and are an absolute standard of care in an emergency room. In the television episode, none of the doctors or nurses could have any idea which patient has a low blood pressure, a low oxygen saturation, low blood pressure or a high blood pressure. The vital signs monitors in Episode 12 seem to be in the same place as the suction cannulas—that is, inexplicably absent.
VITAL SIGNS MONITOR
Prior to my anesthesia residency at Stanford, I was a full time internal medicine faculty member in the Stanford Emergency Room. The Stanford ER serves as a Level One Trauma Center, equipped with helicopter transport for trauma patients. The number of times I witnessed an anesthesiologist saying “imagine that” after an ER doctor showed them how to place an endotracheal tube was zero.
It’s medical lore that each ER doctor is by necessity a “jack of all trades,” because of the variety of patient problems which can arrive at any hour. The full description of this moniker is a “jack of all trades, but a master of none.” Emergency room doctors must have the skills of an anesthesiologist, a surgeon, a cardiologist, a pulmonary specialist, a pediatrician, an obstetrician-gynecologist, and a psychiatrist. Is the ER doctor as experienced and skilled as an anesthesiologist, a surgeon, a cardiologist, a pulmonary specialist, a pediatrician, an obstetrician-gynecologist, or a psychiatrist? No. Not in real life, and not in The Pitt.
Many MDs are reluctant to watch medical dramas like The Pitt. After a full day of taking care of patients in a real-world hospital or operating room, watching a Hollywood depiction of what drama writers think that might look like is not appealing.
In contrast, watching a medical comedy like Scrubs, or reading an outstanding medical satire like The House of God can bring a smile to a physician’s face.
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Yeah this scene is awkward and unrealistic. Its sequence of events seemed to be written to make the ER doctor the hero but they picked the wrong speciality to be the brunt of ridicule.
JC,
I agree!
Rick
As a dual trained EM & Anesthesiologist, I must play devil’s advocate, Obviously, the Pitt being a television show, will dramatize any clinical scenario it demonstrates to maximize impact. That being said, your response is typical of an anesthesiologist and short sighted. You have clearly never dealt with a mass casualty event nor worked in a lower-resource hospital in critical status. You work at Stanford, one of the most well-supported and well-supplied hospital systems with a low ratio of full trauma activations involving penetrating trauma.
You describe inaccuracies such as patients not being attached to continuous monitors. I hate to break it to you, but there are patients in EDs across the nation that are having multiple active symptoms (chest pain in patient with CAD, asthma exacerbations sitting in the waiting room) that have q2 hr vital AT BEST. And that is in a typical day with dozens of boarding patients and overwhelmed EDs, not even discussing an MCI. I am sorry you have not been exposed to such care at your privileged site at Stanford, nor have you had the experience of working in a conventional ED, but the Pitt depicts a scenario that is much more reality than you know to exist.
Your incredibility towards the idea of an EM physician teaching an anesthesiologist a new trick in a setting they are not accustomed to, shows your incredibility and isolation within your field. You should seriously consider exposing yourself to other hospital systems and EDs across the nation before commenting as if you have any expertise in this field.
David,
Thank you for your comments.
Rick
A Hospital where I worked was opening a new pediatric urgent care facility in the new building of the hospital complex. As part of the opening process there was a “mock pediatric code blue”. I responded to this as I was the only fellowship-trained pediatric anesthesiologist on staff.
When I arrived, the ER resident was in position to intubate the “patient” (a dummy). He was handed a traditional direct laryngoscope (I forget if it was a MacIntosh or a Miller blade–getting old is fun, isn’t it). The resident looks at the blade, says: “the light on this thing is too weak, do we have a CMac (competitor to the GlideScope)?” He obviously did not know how to use the tool and was covering his ignorance by blaming “the light”. This is caused by the fact that the never use direct laryngoscopy anymore in the ED. Though using video laryngoscopy first is probably a good idea clinically, not knowing how to use a direct laryngoscope is a deficiency that will come back to haunt the practitioner in situations like the one described… Especially if there is bleeding in the airway. The camera lens becomes dirty and obscured, you’re SOL because you only have an indirect “view” of what is going on… Game over (ofr the patient).
Rob,
Great story! Thank you for your comments!
Rick
Only people who rescue physician anesthesiologist are crnas. Haha. Thr public has no idea.
It’s sad that the public obtains 99.9% of their medical awareness from a TV show. I experienced that when Wyle was on E.R. and I was starting my private practice in anesthesiology. I had to remind patients that they weren’t paying me to “go to sleep”; they were paying me to “wake them up” fully intact with the mental capacity God gave them — going to ‘sleep’ was “on-the-house” — as they were induced with “Stairway to Heaven” playing in the background.
Agree!
Rick
Talk to the anesthesiologists in Vegas who went through this scenario for real. I never heard one story from them about any ED docs rescuing an airway. I moved there the following spring, the stories were still fresh. In my 20+ years of practice in anesthesia I’ve been called plenty of times to rescue airways for the ED, not the other way around. Not to take anything away from the ED docs, but airways are what we deal with day in and day out. Plan B, C, D, and E roll off our tongues like reciting the alphabet. That’s not to say we might not need an extra pair of hands. We are all a team after all. I do, however, hate defending my skills against a poorly written television show to patients who believe everything they see on TV….along with having to explain that my fentanyl didn’t come from the street!
I agree, Dr. Katcher!
Rick Novak