Like many of life’s opportunities it all started by accident. I was having a corridor conversation with a past CEM President, John Heyworth, who was relating his previous day’s activities – “I had a meeting with the Academy of Royal Colleges, caught a bit of the Lords’ Test and then met a researcher from Casualty”. We chatted a bit about the medical politics and England’s batting order and as we finished up to head to the shopfloor, I tried to subtly ask about the BBC meeting (JH is one of the coolest people I’ve met and I didn’t really want to seem too starstruck – after all it’s telly. And I really love telly). He gave me the email address of one of their researchers and there began my relationship with Saturday evening medical drama.
Casualty is the longest running emergency medical drama on television and is broadcast every Saturday night in the UK with only the occasional break for special events and a summer break. It regularly has over five million viewers, or put another way is watched by 1 in 10 people in the UK. (Those of you who haven’t seen the show can watch a highlights reel from the most recent series here)
My role on the show is as a “Medical Advisor”. This isn’t, as it turns out, in anyway glamorous and only rarely involves trips to the studio in Cardiff, but is a mainly telephone and email based job. I work with the writer to try to help them add medical stories into their story arcs. The show works to a strict, tried and tested, formula, usually two “guest” storyline with some ongoing background serial for the regular characters. Stunts are a major feature and so major trauma represents a disproportionate number of cases (it’s hard to make ankle sprains dramatic, although we have tried). The process begins with “commissioning”, where a writer presents their ideas and is engaged to work on a particular episode. My involvement usually begins after this, with a series of telephone calls and emails trying to sort out the medicine for each character. Many of the writers will have ideas about this, but occasionally there is a need to try to “retrofit” a suitable diagnosis into the drama and may involve trying to find suitable responses to an, entirely genuine, email like this one.
“What I’m looking for dramatically is something like this:
His vital signs have crashed. There is massive internal trauma from the car crash. What do they do to try to save him?
They try one thing. It doesn’t work.
They try something else. It doesn’t work.
They try something else. It appears to work – and then it doesn’t.
They try shocking him. It doesn’t work.
They try chest decompressions. They don’t work.
The team is Zoe, Sam, Tess, Fletch, Linda, Charlie. What do they each do and say during this resus attempt?
I just want it to be exciting and dramatic with the patient dying in the end.“
The early days
Each episode has five “Acts” with one of the key features being the “Act 4 Crisis”. This is probably the most tricky part – trying to find something medically that can happen about half way through an episode that puts the patient in danger, makes the team look heroic, yet often requiring the character to not only survive, but to have their moment of redemption before the credits role. There is a constant battle to find scenarios where the patient is not intubated, as this lessens even the best actor’s ability to communicate, and those with severe injuries cannot rush off to theatre as all the action needs to happen in the ED.
Each script goes through five drafts before a “Shooting Script” can be issued. Medical Advisors read all but one of these and we make notes trying to keep the medicine on the right track, occasionally suggesting medical dialogue. All of this is done in close collaboration with Pete Salt – the show’s long term nursing advisor who has been involved since the very beginning and was the original inspiration for the iconic character that is Charlie and has experienced every twist and turn that the process can throw up. The whole writing process takes approximately three months and there is then often a long gap before broadcast, so discussions about Christmas storylines often start in the heat of summer.
Once the final script has been issued that is usually the end of my involvement in any particular episode and it is the then in the hands of the director, editor and actors. Despite the script being polished and checked what you see on the telly can sometimes, frustratingly, be different to the written word. There are advisors on set, often ED nurses who live locally, who try to ensure medical accuracy, but, with so many episodes to make, in the rush to get it shot, mistakes do slip through, although many of these would not be spotted by the “lay” viewer.
I enjoy my work with the show greatly. It has allowed me to glimpse into the strange and mysterious world of television, and provides a balance to the sometimes unrelenting real life pressure of the ED. I know that many of my colleagues, both in the ED and outside, scoff at the programme (often not having seen it for years), but I take my involvement incredibly seriously. I am a vocal advocate for Emergency Medicine and everything it has to offer both as a career and a service to our patients. I still struggle to fathom the numbers who watch and do believe that if we get it right, it can have important messages about the specialty and what it is that we do. One of my proudest recent achievements is the team winning a “Mind in Media” award for an episode that discussed anorexia and the complicated issue of capacity and consent in mental illness. Yes, in the real world there are fewer thoracotomies, cars hanging off bridges, explosions and hostage situations, but I hope that in amongst the drama (and after all at its heart that is what the programme is all about) it gives a honest portrayal of what it is we all do.
Consultant in Emergency Medicine
Associate Social Media editor EMJ