ER: Boon for emergency medicine?

Actors and medical advisers strive to make this TV ED true-to-life

Regardless of what you think of NBC’s hit TV show ER, there’s no denying its role in the nation’s current fascination with emergency medicine — even President Clinton tunes in regularly.

"I think it’s been incredibly helpful to the profession, raised awareness in the public, and even in the profession itself, so I think the effect has been 99% positive," says Harlan Gibbs, MD, an emergency physician at Glendale Adventist Hospital in Los Angeles and author of The Medicine of ER.

"The public is getting a good inside view of what emergency medicine and emergency nursing is all about, which has benefitted us beyond words," says Marilyn Rice, RN, a former president of the Emergency Nurses Association who has served as an informal consultant since the show’s inception.

Four emergency physicians work on the show, including two writers and two technical advisors. "A lot of the medical information comes from them, but scenarios and anecdotes are found almost exclusively through contact with emergency nurses and doctors in the field," says Linda Gase, researcher for ER. (See related story, p. 16).

The arrangement provides the show with a high degree of accuracy. "We hope it’s a two-way street. We’re presenting the emergency medicine community in the most realistic way possible, and people in the field seem to feel good about sharing stories with us," says Gase. "None of us kid ourselves here, we know we’re just doing a TV show, and the real heroes are the ones we’re depicting."

Patient education

Some emergency nurses and physicians say their patients who watch ER are more informed. "Patients know more about what to expect if they go into an ED," says Rice. "The show has also taught people a great deal about organ donation and different disease processes, which has helped the profession."

Patients are given an inside look at ethical issues in the ED. "I frequently hear comments from the public about Rubin, who has HIV," says Rice. "I’ll ask people if they’d have a problem with her taking care of them, and generally the answer is no. They’re only concerned because they know the character will probably die at some point, and they feel emotionally touched."

ER also has given a boost to the image of emergency medicine itself. "The show has made people aware that this is a real specialty," says Gibbs. "My father in his 80s still had a tendency to say to me, When are you going into practice for yourself?’ He finally realizes now this is a real profession."

Even political issues have been brought to center stage. "Certainly there are legislators looking at this show, and they know what emergency nurses are because of the show," says Rice. "Maybe they’ve heard something from their constituents on a grassroots level, but when they see it on TV, it’s like, Bingo! This is what people are trying to tell me.’"

The show has brought attention to emergency medicine issues, such as the Patient Safety Act. "On ER, the nurse manager is perceived as not being able to get nurses out of floating, which shows that it’s not fair to nurses or patients to be put in that position, and she’s on a redesign team with monthly meetings, which shows that you need people from the trenches to get involved."

Patients, after learning about these issues from the show, also are empowered to take action. "Right now you can go into a hospital without knowing if you’re being taken care of by a nurse or somebody else, which has been dealt with on the show," says Rice. "Patients need to know they can ask if the individual is an RN or a multiskilled person."

Show fosters understanding

Fans of ER tend to have more empathy for the emergency physician. "Patients will say to me, I know how busy you are; I watch the show.’ I like that it’s portrayed that we’ll see anybody that comes in and will treat everybody but also shows how helpless we feel sometimes," says Kathleen Clem, MD, FACEP, an emergency physician at Loma Linda (CA) University Medical Center, who has reviewed scripts informally for the show’s producers. "We have a big impact on people’s lives, some of whom live on the shady side of society, and your heart goes out to them."

Stories from the trenches

Viewers who work in EDs can have an impact on the show’s story lines. The show’s first season got off to a bad start with emergency nurses after a story line aired about a nurse who overdosed. At that point, the Emergency Nurses Association (ENA) appealed to producers to depict nurses in a more realistic light. "They were already in production and there was nothing anyone could do about it, the story line was written before anyone in nursing got involved," says Rice. "People don’t realize the timing of production, so we had to explain it to them and then make a pitch for turning things around."

A grassroots campaign was started to change the show’s attitude toward nurses. "I told people if they didn’t like the way nurses were depicted, get on the telephone and change it. Two thousand of my closest friends gave ideas to the writers," says Rice, who put the writers in touch with paramedics, emergency nurses, emergency physician attorneys, nurse attorneys, and social workers. The effort resulted in story lines that depicted nursing in a more realistic, favorable light.

Above all, the show depicts the ED’s unique slice-of-life moments. "It shows clearly that people who work in EDs are only human. We have hearts of gold, but we make mistakes too," says Rice. "It depicts very clearly that people in the ED have a very special bond and collegiality and shows that it’s that spirit which makes a difference in the care the public receives."

Past episodes have educated the public about staff roles in the ED, triage, drug-seeking patients, the impact of managed care, and even the types of errors a nurse would make in a busy ED. Many practitioners of emergency medicine identify with their counterparts on the show, holding their breath for a certain outcome in a story line. For example, when nurse manager Carol Hathaway took a physics class, many emergency nurses began hoping she’d go on to medical school, while others are rooting for her to become a nurse practitioner.

The show’s poignant topics often mirror intense moments in the ED. "When a cast member screwed up and sent a woman to a nursing home, and she came back dead, a light bulb went off that he had really treated this man and his wife badly," says Rice. "It shows us how we deal with people and how they perceive us, and also ethical issues, such as when is somebody dead? A few weeks ago, they stopped a code, and Benton came down and started it again, even though the kid was dead."

Many experts suggest that nitpicking about the technical aspects of the show that are not precisely accurate is missing the big picture. "They’re showing people moments in time of a full day in the ED, and the show’s creators have to use creative license," Rice notes. "Sometimes people in the profession are very critical of that, but wouldn’t you rather have this program teach these things?"

Rise in prospective ED residents

Apparently, ER has inspired many future practitioners of emergency medicine. ED chairmen have noticed a sharp rise in applications for prospective interns since ER took off, and ENA’s 1995 president, Susan Sheedy, credited the show’s popularity with the massive interest in emergency nursing at last year’s national student nursing association meeting.

"The show has had a definite positive effect," says Gail Anderson, MD, chair of the department of emergency medicine at the University of Southern California School of Medicine in Los Angeles. "The number and caliber of senior medical students applying for our 18 resident positions significantly increased during the past two years."

There is little doubt that the show’s popularity had a lot to do with that. "I have discussed the impact of the show in terms of motivation to choose emergency medicine with applicants, and they uniformly have expressed the thought that emergency medicine has definitely been enhanced by the show," says Anderson.

"If you take a look at the statistics, emergency medicine is now one of the most popular specialties to go into," says Gibbs. "They have about 700 applicants for seven or eight positions at places like UCLA and Hopkins. It’s astronomical. ER has dramatically raised the awareness of medical students, so the show has had an effect on the profession itself."

Should show be renamed ED?

Since the show’s inception, hundreds of practitioners of emergency medicine have written to complain about the use of the obsolete term ER. Individuals differ as to their degree of sensitivity about the show’s title.

"There was a period in my life when, if somebody referred to the ED as an ER, I’d get defensive and go into how the architectural plans of emergency care areas have changed over the years," says Rice. "Now I really don’t care what they call it; it’s really making a big deal about nothing. We all affectionately call it the ER anyway. Health care is changing so dramatically, we can’t get hung up on titles."

Many ED workers were afraid the show’s story lines would be as inaccurate as its name. "At first, emergency physicians and professionals weren’t too excited about the show," says Clem. "I’ve noticed that the focus of the show has become much more technically correct. They’re beginning to understand it’s a speciality, and the technical aspects of the show are more accurate, with correct dosages. It’s still Hollywood, but it has to be or people wouldn’t watch it. Unfortunately, we don’t have all the kissing in the closet."

When Clem visited the set of ER, she was struck by its realism. "It looked just like where I work. It was a mind trip to see how real they could make it," she recalls. "I could have run a code, but it was all fake. The elevator going upstairs is just a box, but it looks so real. Anthony Edwards talked to me at great length — All the actors are very interested in learning from us," she adds. Other ED physicians suggest the show is almost too real for comfort. "The medicine is really right on. It’s realistic enough that if you work a shift and then go home at night, the last thing you want to do is relive the experience," says Gibbs.