Build Your Clipboards - The Pitt s02e08

The Pitt is competency porn. It's no secret that watching really smart, really talented, really capable doctors execute their job exceedingly well is something we Pitt lovers love. Think of all the time they spit out medical gobbledegook and how often its extremely technical yet accurate details capture the spirit of what's happening. It seeps into the brain and knowing absolutely nothing about medicine does not in anyway harsh the show's engaging quality.

So when the first sequence of this episode is Robby, Abbot, and Dr. Al conducting a crash course in all of the changes to procedures and updating how charting, orders, and directives will continue for the foreseeable future. It was like black tar heroin right into my veins. It could have lasted the entire hour for all I cared. And it's basically all exposition and never feels like it.

Even with this small detour, though, the situation in the PTMC is starting to intensify. Every new case adds stressors to an already buckling system, and the final shot conveys that this barely handled chaos is not far from slipping through their fingers. There is a point at which everything will completely crash down. At this point, Robby and his staff are just trying to stay ahead of what they're hoping is not inevitable.

By the end of the episode, there's no end in sight, and the sun hasn't even set yet.

A moment for the Luddites to shine

The chaos of the Pittfest shooting came from external forces: the mass casualty event brought in an endless tide of patients. There was blood everywhere, every bed full, patients packed to the gills, doctors on top of each other. With the network shutdown, though, the problem is internal. The collapse of technology means everyone has to immediately learn an antiquated way of doing things. Already routine requests like prescriptions, lab work, and CT scans are slipping through the cracks. Stickers are missing. People are using felt pens on carbon copies.

Yes, what the doctors have to do is complicated, but their job hasn't changed all that much. Computer programs could easily facilitate the busywork of filing, sorting, and data compiling. The network is an invisible complex of wires and cables connecting the entire hospital's infrastructure, all from the aesthetically pleasing safety of plastic hardware casings and LED monitors. In this new analog world, all of those wires and cables take the form of manila folders, wire baskets in which to file them, worksheets that need circling/crossing out, stickers that connect patients to paperwork, and pads of paper that can make carbon copies off the indentation of a pen's single stroke.

This is all still technology, but it's interesting to look at someone like Robby or Abbot and consider how far the world has come since they were interns/residents. Noah Wyle and Shawn Hatosy are both in their 50s. Assuming Robby's trajectory is not so different from John Carter's career in ER, it's amazing to go back and watch that show and recognize that this "analog system" is not so different from what they were doing there. Robby & Abbot have a muscle memory for this contingency, and they probably evolved with the medical community itself in the transition to digital systems.

It's weird to think about, but the advent of easily re-printable charts complete with drawings and graphic design are still a relatively new invention. Modern medicine itself has really exploded within the last century and a half, with a focus on nursing and treating via vaccination and sterilization rather than poultices and prayers. Even the first carbon copies as we think of them are barely more than a century old. Now they're already almost completely obsolete.

Today that technology seems revolutionarily retro. As though the indentation of ball point pens leaving an inky shadow is somehow an impossible creation.

But this is a problem. If the takeaway of this episode is that technology can't stop quality medicinal practices, user error means mistakes within that technology have the potential to be worse than they seem in the moment. Santos not proofing her AI-assisted charting is exactly the same as using the felt pens. As these small mistakes start to pile up they create small chinks in an already buckling system. These imperfections add to the aforementioned stressors. They will miss key orders, the labs won't get done, necessary CTs won't happen in a timely manner. How long before all of this descends into cataclysm?

No technology can replace empathy

If there is a saving grace within the PTMC, it's that Robby has built his department to be personable. The doctors matter, not the technology they use. They handle cases with an eye towards effectiveness, where efficiency is a quality among many rather than the ultimate end goal.

At its unexpected best, the right person in the right place at the right time is Joy's photographic memory.

It's funny. Looking at the character, that quality is the primary one production used to describe her in the pre-season press. And... thank god she has it. Whitaker's picture of the board is blurry and entirely unusable, but Joy's memory is good enough that they can more or less recreate the entire board in a matter of minutes. It's not a quality that they can infinitely reproduce, but that sort of personal computing power is invaluable in a world where the artificial option is unavailable.

When good care is working normally, it's Dana doing her job and staying in the exam room for half the episode to finish her examination of Ilana. It's good she returns, if for no other reason than because Dana really does need to get back out to the floor to handle the slow motion crisis of the department reverting to the Stone Age. And Dana would not leave her sacred duty as a SANE if it meant helping someone in as much distress as Ilana.

But even that has its limits. The rape kit the police never picked up is impossibly upsetting. After all of her work following protocol, all the emotional taxation, the police never even bothered to pick up the last one? She's done her job. Is it too much to do theirs? She has every right to be absolutely furious at the situation. And in an episode that demonstrates the value of tactile, analog processes, the very real situation of law enforcement minimizing the importance of treating sexual assault cases seriously shows what happens when an institution's focus is in the wrong place.

So Dana calls the cops and reams them out. Hell yeah, Dana. Fuck the police.

Showing a little personal touch

But that personal touch manifests most with the team's delicacy in treating Howard Knox.

Howard Knox is obese, and Ogilvie's raging assholery means he makes seriously insensitive comments about Knox's weight during their diagnosis and examination. It's so bad that when Ogilvie has a legitimately good idea (using the zoo's CT machine to scan him because the hospital's scanners can't take weight above Knox's suspected weight), it comes off as him being a complete and total schmuck. Knox, however, is nothing if not gracious and positive, trying to make the best of a series of bad events that brought him to this point. And the final moments with him, as they wheel him out to wherever he's going next are truly heartwrenching and beautiful. The gratitude and care he has is real and wonderful.

A lot of this bedside manner comes from years of experience, but it also comes from not treating everything like it's a competition. This week's official The Pitt podcast talks about Ogilvie's status as a "gunner", a medical trainee whose ambition knows no bounds; he will show off and do anything to make himself look better, including throwing others under the bus. It explains a lot about what the show is trying to do with his character and why every other character in the show is always looking at him askance when he spouts off the first (if correct) answer to any given situation. Ogilvie is insufferable, and it can be hard to relate his particular arc. That's doubly hard when a show like this has spent a full season creating an ensemble full of literally no bad characters. But Ogilvie, Joy, and Dr. Al all serve as interlopers who feel imperfect when compared to the incredible complexity of literally anyone else in the department.

And yet, knowing that the show is doing all of this, it means that there is a plan. Ogilvie's first shift has been a roller coaster of moderate highs to humiliating lows. For all his gunner-ness the show has taken pains to judge him and slap him around when necessary. Whatever is coming for him, the show has made it clear that it's undeniably there.

But if there's a standout in the empathy this episode, it's Cassie. She's the only one to tell Ogilvie that he needs to cut the denigrating talk, especially in front of the patients. It's about time someone checks him on that, but man how over the line of decorum does he have to be for someone to step out and rein him back in? Even if she's being as gracious and nice as she can when she slaps him down.

As far as a warm moment, the scene with Langdon is gorgeous. Langdon's reception back in the unit has been... patchy to say the least. Whitaker leapt in to stop him from writing a prescription. Robby has avoided him and when he didn't he hazed him in front of staff... Langdon has a good relationship with Mel and Donnie and Dana, but there's not been a ton of interaction with Cassie. Her bonding about being in rehab and getting sober is quietly tremendous and it takes Langdon aback at the simple kindness at her understanding.

The real test, though, is Roxie.

Yes, Roxie is still here. This situation has had flashing red lights for hours, and every episode I've had more and more questions about what exactly is happening and if it's more than my partner's suspicion that she's going for a medically-assisted overdose. First she asks for lots of intense meds like morphine. Then opts to stay once her husband is gone. Then he returns and brings their kids. And now her parents are here. It's made me wonder if there's something underhanded happening here, and if Paul's bottomless well of care and concern was covering up something untoward.

No. Robby confirms it. Cassie is worried about the level of pain meds, but Robby informs her that in a palliative care situation like Roxie's, they treat her pain at the risk (and acceptance) of possible negative side effects. Even if the side effects are death.

There's no way Paul doesn't know this or at the very least suspect it. Why else is he doing everything he can to show Roxie what she'd be leaving behind in her death? Her children? Her parents?

This story isn't over, but it is a new test for Cassie, who has to balance her Hippocratic Oath with the idea that enabling Roxie's death is really something her patient actually wants. Til now it was unspoken, but she has to face with the very real idea that she's about to allow a patient to die on her watch. We've only been living with her for a few hours, but Roxie's story dates back years and... she has a right to dignity. And in this case, her dignity comes with doctors like Cassie giving her their time.

Just like Knox. Just like Louie. Just like Ilana.

But all of these are luxuries. Santos barely finds it in her to afford Harlow any more of her attention than absolutely necessary. Meanwhile, Roxie's taking up precious trauma room space is soaking up time and resources that might better go elsewhere if Roxie would just be honest about what's really going on with her.

As the episode ends and Dana & Robby survey the full scope of the state of their department, there is a sense that things are handled, but only just. It's barely-controlled chaos. Computers sped up processes and bought doctors more time. Without them, the resource becomes even more valuable. Eventually, it will run dry. I just shudder to think about how bad it's going to be when it does.

Meanwhile, around the Trauma Center...

• So many of my notes about the opening scene and the explaining of the procedure is akin to "this is crazy this is crazy this is crazy" (actual note). It shouldn't really seem that. The center clearly has a plan for this contingency, there was life before computers, and all the charts have details that make it easy to use quick marks to summarize a case. It's only crazy because everything else to this point was "easy".
• It might seem frivolous that Whitaker's picture of the board ends up being blurry, but the best thing about that is is that it re-centers audience expectation for where pain points are. Making it the closing seconds of last episode assuages audience fears that the PTMC will have to start over from scratch. The show has another solution, but over the last week I've not worried at all about the board's survival because the show never intended for that to be an issue. Were Joy not present and the show interested in that as a source of drama, Whitaker would have "just missed" grabbing the picture before the monitors went dead. Instead, it feeds into themes that technology is only as useful as its
• Shoutout to Larry and Antoine as the desk attendants handling the flow of paperwork processing. They're immediately great and when they turn out to be messing up (felt pens!) it only makes me love them more.
• They literally bring in a fax machine lol.
• All the details that went into painting the picture of Henry Knox's condition are fantastic. The leg scars in particular start to tell his story before he even has a chance. His body is like a walking forensics case that tell the tragic story of 20 years of medical misfortune.
• The case of sudden blindness is quite scary, but the relationship between Brooke & Wendy is lovely. Again, the show makes it so easy to paint rough pictures of who these characters are so that we can care about them quickly. It helps that they're in vulnerable states, but the economy of that character work remains remarkable.
• Poor Princess trying to hold the department together while Dana remains with the Ilana case. She does a decent job, but all of the new procedures amidst a job she's barely managing means things threaten to fall apart. It sucks when someone tells her she has to run the slips to the lab.
• It's not up above, but is this is the first time this season that Langdon and Santos have interacted? He is sure to give her kind words and they work together on the extremely graphic tongue case... but that apology is still forthcoming. Can't imagine how that's going to go. Can't wait to see how it does.
• Giving Knox the iPad as a communication tool is fabulous.
• Ilana calling Emma a good nurse and then saying to Dana "I'm glad you were here today." Ugh.
• Yoooooooooooo. The revelation that Mel's deposition is because of the spinal tap she performed on the measles kid last season. Yo, I was already like fuck that family but seriously fuck that family. No wonder Mel's been freaking out about it all day. It's so much more precarious than I feared.
• The show calls out that Robbie's friend Duke never showed up today. I remember this from a few hours ago and Robby was looking forward to it. The lack of him feels... insanely not good.
• Javadi and Ogilvie claiming the same patient and then trying to one-up each other... Again, this is a long time coming, but it's nice to see the two of them being great doctors despite the professional animosity. Nothing is better than Joy immediately diagnosing their patient after all of their theoretical work felt like them running in circles.
• Also... that's a scary thing about margaritas. They should warn people. those leg boils are nasty.
• It was during this that my margarita-loving partner said "this is a nightmare I didn't know I had."
• Abbot offering to escort Knox to his next location is nice. And I'm glad he's going to get a nap before the night shift. But god dammit just give me more Abbot on my screen. He's such a fabulous character to watch and in a show full of badasses, he's probably the best one. More more more. Can't believe we're already losing him.
• Baby Jane Doe having rhinovirus is a super interesting complication in that it means she can't go to the nursery or get an entire room to herself. Logistics problems. Always compelling.
• Sweet moment between Mohan and Dr. Al., where the latter encourages the former to look into geriatric medicine. It's not super sexy, but fits with Mohan's care for her older patients. Also, everyone wants to do sports medicine. Go figure.
• Digby emerging from Louie's room is sad enough, but him saying "He was my friend. I had a lot to say... Louie got his wings." Twist the knife more.
• The last shot is something only this show could do. Everyone on their marks, acting perfectly. The behind the scenes tag at the end of the episode talks about the complicated choreography it takes to pull off the show and its insane depth of field. Incredible to see it all come together like that.
• Future Watch:
  • Looks like Mel's deposition is imminent, though Dr. Al's attempts to keep her isolated and in a place where she can collect herself looks like it's going to get a lot of road bumps. But... hey, Dr. Al being encouraging. So different from that first hour.
  • And then... Abbot will probably show up again. Maybe around episode 12. Ugh. Too far away.
• Gross-out Moment of the Week: The lime allergy boils were gnarly, but it's gotta be Jackie's horrific tongue laceration. Blood everywhere, the actual sewing the cut closed... But nothing was worse than watching the hook literally go through the end of the tongue so they could pull it all the way out. Incredible prop work. And also.... doctors can pull tongues out like that? Shiver town.

Next Time...

Looks like we're getting close to Mel's deposition. I don't remember the exact time frame, but it looks like back in episode four the deposition was "five hours away". So... that tracks. When it started it seemed like we were so far away and now...?

Also it looks like a 12-year-old comes in with a firecracker accident and his hand is all bandaged? Jesus that's going to be awful.