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- [00:00]
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- [00:32]
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- [00:50]
Sean Hadassey
So if you've been living in the
- [00:51]
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- [01:05]
Dr. Robbie
Monica's a retired clerk. Best of the best. She was kind enough to come in on a holiday and help get us back into shape. Laid off by the digital revolution, not retired. And how's all this digital working out for you now? It's okay.
- [01:17]
Hunter Harris
Exactly.
- [01:18]
Dr. Robbie
All right, then. Who's handling the charts and the orders?
- [01:21]
Medical Assistants
That's us right here.
- [01:23]
Dr. Robbie
How long have you been clerks?
- [01:24]
Medical Assistants
Just today. We're medical assistants.
- [01:27]
Dr. Robbie
Then get out of my space and go do something you know how to do. And no personal calls. Red phones are for emergencies only. This is a hospital, for God's sake. Call you back.
- [01:43]
Dr. Alok Patel
Welcome to the Pit Podcast, the official companion to The Pit on HBO. Max. I'm Dr. Alok Patel and I am stoked to get into this episode.
- [01:50]
Hunter Harris
And I'm Hunter Harris. It's three o' clock in the Pit this week. It's episode nine. And we get to hear from Sean hadassey, who plays Dr. Abbott, who also directed this episode, and hear from Cynthia Adarqua, who wrote on this episode.
- [02:02]
Sean Hadassey
Like the big part of directing this show, there's so many components, but the main one is the mapping of it. Understanding where each scene is and how we can kind of flow it to the next in the most sort of grounded way that makes the most sense.
- [02:17]
Dr. Alok Patel
Today's shift starts now.
- [02:22]
Hunter Harris
I lit one and it went off fast.
- [02:25]
Dr. Robbie
I dropped it. But we're gonna take your bandage off now, okay? I don't wanna see. You don't have to. Just look at me. Okay.
- [02:33]
Hunter Harris
Cutting. Sorry. You're doing great.
- [02:43]
Dr. Robbie
That looks like a lot more than a firecracker.
- [02:46]
Medical Assistants
More like an amini. Or a cherry bomb.
- [02:49]
Dr. Alok Patel
Andre, I think I, out of fear, made a Reference to these types of injuries in one of our first episodes.
- [02:56]
Hunter Harris
Yeah, I mean, that was really, really sad and really disturbing. But I want to say I love how Dr. Santos immediately, like, becomes so understanding. She says, you don't have to see it. It's really good that you dropped it. You say the rest of your hand. I thought that moment was. Was like, a very good character moment for Dr. Santos.
- [03:15]
Dr. Alok Patel
Dang. Even though this is just a show, I feel for this kid because I've seen this exact scenario.
- [03:21]
Hunter Harris
Yes. This is. I don't mess with fireworks like that.
- [03:23]
Volvo Sponsor
I'm.
- [03:24]
Hunter Harris
No. But I do want to say that the Jude storyline gets into his sister, who is his primary caretaker because their parents have been deported to Haiti. And I could not feel more for the sister, who seems like she's truly a difficult position. They have to eventually call in, like, family and child services to do an assessment, maybe because Jude did have alcohol on his breath. But this is, like, a young sister who's trying her best, who's trying to take care of her brother. And I just really feel for the whole situation. It was very sad.
- [03:54]
Dr. Alok Patel
Parents aren't there. Like, they're doing everything they can. So then all of a sudden, you get empathy for this kid who. I don't know the scenario in which he was holding or potentially throwing or lighting a firework, but he's just doing whatever he can to kind of fit in with the group of people while she's struggling. The entire thing sucks and is happening all over America right now.
- [04:12]
Hunter Harris
And I. I just like the immediate emotion in his voice. Like, I don't want to look at my hand. I don't want to see it. It's like, wow, he's so young, and, like, this mistake, like, total accident has, like, you know, changed his life forever.
- [04:26]
Dr. Robbie
Do you still need a rain check for watching fireworks tonight? Thought you were coming over. I made other plans. Okay, cool. I'll try hitting you up tomorrow. We're just keeping it casual, right?
- [04:39]
Hunter Harris
For sure. Alok, there's some big news in the pit. We have confirmation that there's a little love connection between Garcia and Santos. I mean, we kind of. They kind of teased it earlier in the season because how else would Whitaker know, like, that he accidentally used Garcia's toothbrush? Like, how would she know how loud she is? But I was like, I'm kind of into their, like, connection. Does that make sense? I don't know. How do you feel?
- [05:11]
Dr. Alok Patel
I think the connection is awesome, and it's human, and they do such a good job of like teasing out that there's an imbalance maybe, and how invested Santos is versus Garcia. It's also kind of forbidden. But I just want to say I made a joke to you, Hunter, about Whitaker and Santos hooking up. I wasn't being serious. And Reddit wasn't having it at all. Reddit was like, does school watch the pit? Santos and Garcia are clearly having an affair. What show is this guy watching? I was just joking, people. I think we. I think we suspected that these two were having a moment. And you know that elevator scene, I was like, oh, my gosh. We've gone into like the drama of a romantic comedy right now.
- [05:51]
Hunter Harris
I'm like, oh, my gosh, Santos girl, you were being left on red verbally. That was hard to watch. I kind of like, though that, like, they're both kind of tough nuts to crack and they together have this like, funny, funny connection. I think it's good.
- [06:06]
Dr. Alok Patel
Look, I'm just going to say, like, you know, Santos, resident in the er, Garcia, surgery fellow, also wild schedules, but they're still human. They're still trying to like, find a connection. And I may or may not be saying this from experience, but sometimes the inter hospital romance, it's like forbidden, but it's fun, but you don't know what to do with it. But it's like, when does casual fun cross into something more? And like, then your colleagues find out and like, you know, I'm just gonna stop there.
- [06:34]
Hunter Harris
Okay. I. Yep, we're on. We're under a friend da so don't worry. But I do think that there is something that I like about how Sandos and Garc are like, casually together, but they don't work directly together on every single case and every single hour of the day, which I think probably makes for a little bit of distance that can let this work.
- [06:53]
Dr. Alok Patel
Did you feel for Santos a little bit When Garcia was like, I made plans. Of course we're keeping it casual, right?
- [06:58]
Hunter Harris
Of course, of course. And it's nice to see Santos, who's usually so confident and, you know, very cocksure, finally be a little bit, like, vulnerable, a little bit afraid of how she's feeling and wanting connection and like being rejected a little bit bit in that moment.
- [07:15]
Dr. Robbie
Come sweet sweetheart. Is it always like this? Yeah, pretty much.
- [07:22]
Hunter Harris
Wow, there are a lot of smelly people.
- [07:26]
Dr. Robbie
You going to help them all?
- [07:28]
Dr. Alok Patel
Yeah.
- [07:28]
Dr. Robbie
But let's start with you first.
- [07:30]
Hunter Harris
Okay. So Mel's sister comes into the ed and Mel brings her back immediately. She's about to care for her and Robbie stops her and says, okay, you're having a rough day with the deposition, and it's probably not the best idea for you to care for your own sister. It's going to be hard for you to be objective. And who walks in. Beautiful scene choreography there. But Dr. Langdon, who is Mel's favorite resident, and she volunteers him to take over. And Langdon immediately is so sweet and gentle and caring with Mel's sister. Literally, as Mel is leaving the room, he says, would you mind turning off the light? Because that's. They had the interaction last season where, like, a patient will respond maybe a little bit better in a. In a lower light room. As someone who hates overhead lights, I love that moment.
- [08:13]
Dr. Alok Patel
Yeah, I think it showed, like, some emotional growth on Langdon's part. Maybe there was a little bit of preferential treatment because he's got a special relationship with. With Mel. But also Mel's sister, like, wonderful acting job. Like, that is Mel King's younger sister. They just nailed that part.
- [08:29]
Hunter Harris
I really liked watching how patient Dr. Langdon was with Becca, and it really goes back to, like, how close he and Mel are. I think, like, really two peas in a pod. I love their friendship, and seeing him work with Becca was very sweet. And also how Mel was so uncertain on this day and so distracted, but, like, was immediately put at ease knowing that her sister was going to be helped by her favorite person in the ed.
- [08:54]
Dr. Alok Patel
Yeah, she was put at ease. And also, she kind of forgot about all of her stress, and it turned into almost panic when she heard that Becca was in the yard and she sprinted. You know, like, every hour for everyone in this ER is just a beating. But, yeah, Mel, Mel's definitely. There's a lot of things coming at her from every direction.
- [09:12]
Medical Assistants
What about her friends and family? Yeah, they're around supporting her. Yeah, I think they try to, but mostly she's just leaning on me. I'm sure she's really grateful for everything that you do, but it's important to have boundaries. Yeah. Hey, you want to do me a favor?
- [09:41]
Sean Hadassey
Yeah.
- [09:42]
Medical Assistants
You want to house it for me while I'm gone?
- [09:45]
Dr. Alok Patel
I like this moment where Dr. Robbie kind of, like, looks forward, pauses, like, gives him that look, like, bro, are you hitting that? Like, what's happening?
- [09:52]
Hunter Harris
And Whitaker is, like, too sweet and innocent. He's like, well, she has no one else to help her. And I grew up on a farm, and, you know, I feel very close to, like, the situation because I was overseeing her husband's care. And while I empathize, it seems like a bad situation to get involved In. But what do you think of Dr. Robbie offering Whitaker a spot like a bachelor pad? I love that he says, no smoking, no parties, and it's like you ride your motorcycle without a helmet on.
- [10:24]
Dr. Alok Patel
I can't tell what percentage is him truly looking after Whitaker and being like, hey, I know you were struggling with money. Like, here is a way to help you out and take care of the situation, but also, like, trying to reign in whatever he thinks might be happening. I don't actually know, but obviously, like, Amy is coming to Dodger Robbie's house. I'm just gonna tell everyone that now, like, Amy 100% is crashing at that house, like, she's bringing the goats. I don't know what's happening, but a party will be thrown.
- [10:55]
Hunter Harris
No, I. Yeah, I think that's very astute. I'm. I think it's very, like, almost paternal of Robbie to be worrying about Whitaker getting, like, too involved. But I almost wonder if it's coming from a place of experience, because Robbie definitely has the lines blurred in his professional, personal life and also, like, within with his patients, with even his co workers. So I'm. I think it's sweet, but I'm also a little bit skeptical. It definitely makes me concerned. And then right after that, we have, like, Dr. Alhashmi coming in, like, making a joke, and I'm like, totally. Like, this is exactly what we need to kind of, like, deflate the moment just a little bit, because it does get pretty, like, emotionally, I think, intense.
- [11:32]
Dr. Alok Patel
This is when Dr. Al Hashmi comes in and makes that comment about the CPR mannequin and being like, who dressed him up? We have done that so many times in medical school, in residency, in the hospital, dressed at mannequins, having all kinds of shenanigans. Mannequins, shenanigans. rhymed.
- [11:49]
Dr. Robbie
An hour ago, I could have fixed this in 60 seconds with a rectal tube. Now she needs major surgery. I'm sorry. Not good enough. Nepo, baby, you fucked up. Don't trust anything or anybody else when the system's down.
- [12:03]
Dr. Alok Patel
I have so much to say here. So just the quick background, based on what Dr. Robbie saw on the X ray, it seems like this woman had a volvula. So the intestine essentially turned on itself. That causes an obstruction. And, you know, if it happens on and off for a long period of time, people can have abdominal pain, vomiting. If it's an acute, like, you can actually have a surgical emergency, people can die. As it. As is hinted here, and it was missed, you know, The. There's a. The code black and the systems are down and you're just backlogging everything. And this X ray wasn't read on time, et cetera. I really feel for Javati. Yeah. Every single healthcare professional I know of can think of at least one situation where something was missed. And maybe it wasn't a human error, but for whatever reason, something was delayed, something didn't come through, whatever it may be. And you will always remember that case. And what's crazy is the one that I thought of was a volvulous case that I was involved with when I was a resident and the child almost died. It was a delayed presentation. Came to the emergency department really late. It's a long story, but, like, I could feel for Javati, but the one thing that I gotta call out is she's still a medical student, so this is actually not on her. Like, she's taken ownership for it and, like, you know, Garcia is treating her like an equal in this situation, but this is on Whitaker and ultimately in attending. This is not Javadi by herself. Who should be taking blame for this.
- [13:29]
Hunter Harris
So when they were trying to resuscitate her and fix her heart rhythm, watching Javati's face like Shabana, that was like, truly, I think some of the best acting I've seen in the show. Like, she just seemed in such a state of despair and, like, froze. And Robbie's like, okay, like, you need to, like, we need to, like, get this moving. And also, like, Giovanni Whitaker and Robbie, like, running around the ED trying to, like, get this scan, that X ray. It's just like, one of those things that I really empathize on a day like this, when you don't even know, like, if you're supposed to put your own patients on the board where the forms are, where the clipboard is, I was like, geez, everything. It's a real, like, humbling moment for Javati, who has really been like, you know, kind of it girl. Like, really, like, the baby genius of the ED who's, like, has made this big mistake.
- [14:17]
Dr. Alok Patel
Look, the reality is that you can be the baby genius and know everything in a textbook, but sometimes these tricky clinical scenarios happen or the technical support goes down, and all of a sudden you have to rely on experience and instinct. And as you mentioned, her visual acting, I got hit with a visceral sledgehammer. I know exactly what it's like when you're worried about a patient because you're like, oh, my gosh, did we do this right? Did we miss something? And when you find out the patient's okay, where you find out that things are going to be cool. You're like, oh, my gosh, like weight has been lifted. But then, but sometimes it doesn't go that way. That's. That is the harsh reality. And, you know, Garcia is now explaining to her like, this is a big deal. Like, they could have initially used a little tube, goes up the rectum, straighten out the intestine. Now they potentially have to do major surgery, take out part of the intestine. Big deal, big learning moment. Yeah. Young devotee that she will never forget.
- [15:09]
Hunter Harris
I don't like that Garcia said, called her Nepo baby, because we know that she's smart, we know that she's really good at what she does, but she is just like young Hunter.
- [15:18]
Dr. Alok Patel
Of all the scenarios we've talked through in previous episodes, one that I am curious to hear about real world experiences and just to listen to people is the situation with Amaya, this woman who's got this history of pcos, polycystic ovarian syndrome, who winds up having ovarian torsion. So one of her ovaries has turned, threatening the blood supply. She's in a lot of pain. But the fact that McKay used her experience in her instinct to keep her there and say, like, let's just, let's just keep her a little bit longer and also hear her out. But also it touches into, you know, some patients who have either been gaslit, their symptoms haven't been taken seriously, they haven't gotten the care they needed, they've had to advocate for themselves. And if you look at the statistics, there's estimates that around 70% of women with PCOS go undiagnosed. And a higher percentage of those are black women who are not listened to, these diagnoses are completely missed.
- [16:14]
Hunter Harris
I mean, as a black woman, that story really hit home for me. And you know, Amaya has that line where she says, like, like, I would call it lazy doctoring, that, like, I went undiagnosed for so long and it, you can see it kind of like Bump McKay, who is not a lazy doctor who really does try her best, but it's like that's Amaya's experience. And I mean, who are we to tell her otherwise? Like, she has been suffering for so long. And I'm so happy that Whitaker got to see this lesson in like, well, what do you think all of her other doctors have done and what can do differently for someone who obviously has had, who has, like, you know, suffered from medical racism.
- [16:50]
Dr. Alok Patel
Damn. Hunter Harris. Culture critic. Well said. I got nothing to add, but it's such an important lesson for anyone watching, not only on the patient side and, you know, knowing to advocate for yourself, but also for society, for physicians, for everyone to say, like, sometimes what you're seeing, there's more that meets the eye, and we. We have to listen. You know, PCOS presents the hormonal imbalance. People have irregular menstruation. They have changes in their body hair, they have acne, they have emotional changes. Like these could be a larger part of an underlying issue. And I just want to add that, you know, in this country right now, with systemic racism, but also so many pockets of the country where there isn't access to primary care, there's no women's health, and these hospitals are shutting down. Like, I look at Amaya, and I just wonder, and I worry, and I stay up at night thinking about how many more women are being left ignored and untreated. Hunter, I want to get a beer with Dr. Abbott. I feel like there's stories. I feel like there's a vibe. I feel like there might be some, like, trauma male bonding that can happen. I don't know.
- [17:57]
Hunter Harris
Totally.
- [17:59]
Dr. Alok Patel
I feel like there's. Aside from male bonding, there's. There's like, an interesting duality between badass SWAT medic and then someone who might be holding back something. I don't know. I don't know. But you. You also are a fan of Sean Had. We all are.
- [18:12]
Hunter Harris
I am. I think. I think Dr. Abbott is so funny and so, like, very, very quippy, very pithy. I'm into it.
- [18:20]
Dr. Alok Patel
So it's only fitting that we talk to Sean, who directed this episode, and Cynthia Adarqua, a writer who worked closely with him. Let's get into it. Cynthia. Sean, thanks so much for being here. Hunter and I could talk about this show and all the emotional complexity with the cool medical jargon and terminology all day long. So this is going to be exciting. We learn that Dr. Abbott is kind of badass. We learn that he's a SWAT medic and a bullet grazed him while he was saving his colleague's life. I mean, like, all star moment.
- [18:52]
Sean Hadassey
Yeah.
- [18:53]
Dr. Alok Patel
So Dr. Abbott, he's kind of an adrenaline junkie. He's got this bravado, but then that's balanced with his sincere compassion. I just wanted to ask you, what is. What's really driving Dr. Abbott? What's his motivation?
- [19:04]
Sean Hadassey
Well, I don't think he sleeps very well. I think he. He hates to be alone. Part of it is that coming off of last Season, we see them up on the roof together. And I think Abbott's idea of what his purpose is crystallizes in that moment. We're the bees that protect the hive. He finds comfort through the mass casualty event. Cause he knows his purpose. And as we go into the end of the finale, he sort of presents this idea to Robbie that, you know, this stuff has a heavy toll on us, and I've been working on myself, and maybe you should, too. So as we go into and we meet Abbott as a SWAT medic, you know, he kind of says, my therapist says I need a hobby and I suck at golf. So I think he's, in his mind, he's working on himself, but in reality, he's chasing the same kind of dangerous path that Robbie is. Like, he thinks he's doing this great work for himself, but in the end, he's still dodging bullets. I mean, it's. How different is that from Robbie going off on a motorcycle without a helmet?
- [20:10]
Hunter Harris
Cynthia, I want to know about the writing for this episode, and can you talk to me particularly about Jude and his older sister and sort of telling their story?
- [20:18]
Cynthia Adarqua
Absolutely. Yeah. That story is so important, I think, you know, there's a lot happening in America right now, and we just wanted to kind of reflect that in this episode. All walks of life come into the ER so obviously it's July 4th, we have this firework accident, but we wanted to add, like, a little twist to the story with his backstory with his sister, with these immigration issues happening. You know, it really touches close to home for me because I'm a child of immigrants. So telling this story, I felt was super important.
- [20:57]
Dr. Alok Patel
Hey, children of immigrants, rise up. I'm one as well. Cynthia, I read an interview last year with you and Valerie Chu, kind of about the process of adding depth to these characters while also working with the actors. In that interview, you referenced Noah. I just have to ask you, what was it like working with Shawn in writing this episode and creating that character?
- [21:18]
Cynthia Adarqua
I mean, working with Shawn is amazing. You know, like, I brought the words, and he brought kind of the emotion. And obviously he was directing the episode, working with the actors. And it's just. It's so exciting to see words come to life. Like, there's. We can't do it without the actors, you know, So, I mean, particularly with Jude, like, he's a young actor, and Sean was amazing working with him.
- [21:48]
Sean Hadassey
In my experience, there's usually not a writer on set, so this show is very different. You're. We worked together from the beginning. You were there with me when we were doing all of our prep, when we were doing our walkthrough. So it's such a collaborative process as we're sort of like the big part of directing this show. There's so many components, but the main one is the mapping of it. Understanding where each scene is and how we can kind of flow it to the next in the most sort of grounded way that makes the most sense. And we would go through, do the walkthroughs and, you know, I might say, hey, look, we're in north over here. Like, let's throw it to centrals just so we can connect this piece and make it, you know, a continuous take. And just having the writer and being able to collaborate in a way like that was just. It was awesome. And I hope I get to do it again.
- [22:45]
Cynthia Adarqua
I hope so too. You know, and just to like hop on what Sean said, I feel like prep on this show is so important because we're one big stage, our hospital settings. So, yeah, we would go on these walkthroughs and we have pass offs with our characters. And if it wasn't working, I'd work with Sean and like adjust that in the script. So super collaborative and super hands on.
- [23:13]
Dr. Alok Patel
Shawn, did you know that this role of a SWAT medic existed before taking on this part?
- [23:19]
Sean Hadassey
I had no idea. Did you know?
- [23:21]
Cynthia Adarqua
No, that was all Scott, our showrunner. He brought that to the table. It was super exciting.
- [23:27]
Sean Hadassey
You guys had already been up in the writer's room, and I just, you know, I wasn't sure what was going on with Abbott, and he presented this idea to me and I thought, oh, that sounds exciting. Yeah, I think people are going to take that.
- [23:38]
Dr. Alok Patel
You know, we've heard about these positions before, and to see that come to light actually just raises awareness on more topics. So on that note, I was curious if you both could share something that you learned about the er, the medical world that surprised you. You know, as an actor, director, as a writer, was there something that you were like, oh, my gosh, that's so cool.
- [23:57]
Sean Hadassey
I mean, I'm surprised every day. I really am. I'm always thinking about the healthcare workers and medical professionals when doing this work. I just have so much respect and admiration for what they do and how they have to deal with things minute to minute. The world is so immersive and I, I, you know, it becomes this experience of emotion and pain and watching things happen. And some of these people just have no, they just go through it and I don't know that to me is the most. Like, when I first read the role of Abbott, I thought about this experience where I was at a basketball game and one of the referees fell down, collapsed on the court. And he was going through some kind of cardiac event, and everybody was freaking out. The children were, like, moved away. And, you know, we were calling 911 and somebody was trying to. Nobody knew what to do. And then the. The paramedics came in and it was like they were just calmly walking over and. And they just saved the guy.
- [25:16]
Cynthia Adarqua
Like.
- [25:17]
Sean Hadassey
Like. And it was nothing. And they weren't. I don't know. That surprised me the most that the training just kicks in and it's nothing. And I. That was Abbott. When I think about the work, and I'm always thinking about these guys when I'm doing it.
- [25:33]
Hunter Harris
We talked a little bit about how Abbott and Robbie are like foils of each other. But, Cynthia, can you tell us a little bit more about how you think about these characters as mirrors, as foils, and what they have in common, but what sets them apart?
- [25:45]
Cynthia Adarqua
Yeah, I love the dynamic between Robbie and Abbott. I think what. It's exciting because they're equals, so there's only really one person that can step to Robbie, and it's Abbott. We had a scene in 209 this episode that like, literally gave me chills watching Noah and Sean do, because these are two equals talking to each other about their mental health and, like, Robbie's trip. And Robbie can kind of get away with, you know, joking about it with the other staff, but Abbott sees him.
- [26:27]
Medical Assistants
It's gonna be a lot of time to self reflect. Sure, you can handle that.
- [26:37]
Cynthia Adarqua
Abbott, you know, has experienced what he's experienced as far as these mental health struggles go. So this is kind of the first time that we're like, poking the bear, you know, and it's really kind of the first time that we're seeing that this trip that Robbie's been talking about isn't like the golden rainbows trip that we thought it would be. You know, it may be a little bit more dangerous than we expected. And we get that because of the dynamic between Robbie and Abbott.
- [27:09]
Sean Hadassey
Yeah, it's like his goodbye tour really starts in episode nine, and he's not sure he's gonna see Abbott again. So that's where it kind of like, you sort of see the shift. And then once he gets in there with Whitaker and he says, would you take over my house? And he's like, you know, and if I don't come back, you'll have a swinging Bachelor pad and Whitaker's like. It's the first kind of, like, just hint of it. And I know we played with it a couple of ways on the day. And. Is that, you know, is that a joke? Is that you're. Is that the, you know, your tough exterior wall coming down a little bit or so. And it's the beginning of that sort of story and what we're gonna see from Robbie and his decision to drive off into the sunset.
- [28:01]
Dr. Alok Patel
Cynthia. Sean, I've heard a lot of references to the production of the show and theater and a stage and long takes and kind of the difference between what happens on that show versus another TV show. Can you speak a little bit more to that? I think that's fascinating.
- [28:17]
Sean Hadassey
Well, I've noticed that a lot of the cast has a pretty strong theater background or training, and I think that's by design. I think that was a decision because it is. Even as a director, it is very rare to shoot a television show in order. So that's one thing that's amazing. But, yes, the amount of. Some of the scenes can be five pages, and we. Sometimes we'll put two scenes together. So you could be doing eight pages of work, which is like a play. And our resets are not lighting resets. We reset props. We reset blood, bandages, and things like that. But it moves so fast. It's. It is a lot like a play, and it requires a certain kind of focus and training. For me, as Abbott, like, I find that on other. Other characters, when you're just relying on emotional dialogue or things of that nature, I can kind of know it and then just kind and come in and sort of find it. But with this, you really have to understand exactly what you're saying or at least be able to fake it, like, you know, what you're saying. With theater, you're doing a big rehearsal process. You have all the time to spend to get it right. And we do that on this show.
- [29:40]
Cynthia Adarqua
Yeah, I feel like, obviously, our stage is one set, so I think that speaks to the theater aspect and the fluid motion of the camera, which was designed by our DP, JoJo. She's amazing. Our camera ops are amazing. They're constantly following the action. And, you know, our actors, as far as the theater background goes, they're able to, you know, do these procedures and their lines and show these emotions interacting with each other at the same time. It takes big chops, you know, like, it's not easy work. And I, as a writer, you know, sitting back and watching it, I. I commend all of them. I think our cast is phenomenal, and they really do help bring this hospital to life.
- [30:31]
Sean Hadassey
It's funny because no matter what, no matter how well I think I understand it or know the dialogue, there's always a take. And it might be my close up or whatever, where I will. It's not that I freeze, but you get lost in it, and you know what I mean? And all of a sudden, you're doing a resuscitative hysterotomy, you know what I mean? And, like, all that, that just doesn't come off the tongue, and it's not something. And so you get lost in there, and then all of a sudden, the words aren't right. And, you know, we freeze sometimes, and it's just embarrassing.
- [31:05]
Dr. Alok Patel
Gosh. This gives us, like, even more respect for what you both do and even more reason why this show is incredible, is that theater element and the range that everyone has. But appreciate you both. Thank you for sharing all the insight and pearls of wisdom with us.
- [31:18]
Volvo Sponsor
Thank you.
- [31:19]
Hunter Harris
Yes. Thank you, guys.
- [31:20]
Cynthia Adarqua
Thank you.
- [31:24]
Hunter Harris
So I was really interested in what Sean had to say about that last conversation between Dr. Robbie and Dr. Whitaker about, like, hey, if you want to, like, use my house, like, you can house it for me. If I don't come back, you get, like, a swinging bachelor pad. After talking to Sean about that, I had a total reframe of, like, that conversation as being a lot moodier and almost like, I mean, sad and depressing than I had originally thought. Because in my head, I'm like, okay, Dr. Robbie, he's, like, funny, jokey. But after talking to Sean about that shooting that scene, it felt a lot more like, okay, maybe Dr. Robbie is, like, in a darker place than even we imagined at the beginning of this season.
- [32:04]
Dr. Alok Patel
And I think Dr. Abbott is one person who can just go straight to it and call him out and be like, I'm here. Let's open up about it. Charge nurse Dana kind of does. It sometimes feels like a big sister or caretaker relationship, but Abbott's like, bro, open up. And you have experience in writing tv. It's always fascinating to me to see how and hear how actors work directly with writers and they bring to bring forward a concept, and it lands totally.
- [32:29]
Hunter Harris
I mean, I was very interested to see what Cynthia had to say about writing about Jude and his sister, because their story, to me, was, like, one of the most heartbreaking. Only because you're talking to two people who are very good, who are just totally out of options with their parents being in Haiti. And I just really, what you said about that.
- [32:48]
Dr. Alok Patel
So far, every person we've talked to who has been instrumental in writing or directing or even acting in this show has brought something about their own personal life, their own cultural, social experience to the show. The authenticity off the charts.
- [33:03]
Hunter Harris
Yeah, I agree.
- [33:07]
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- [33:40]
Hunter Harris
there's a whole new way to chai at Starbucks that's made perfect for you. Choose your sweetness, dial it up or keep things light. Add a touch of pistachio, a hint of strawberry or vanilla, or make it a spring classic with lavender. Because this season there's endless ways to chai at Starbucks.
- [33:59]
Dr. Alok Patel
I want to go outside the pit and let's talk about some bioethics, because throughout this show we've seen multiple scenarios in both seasons where there is an ethical choice and there's different people involved in helping kind of the family, the patient, colleagues arrive at a decision. And I want to bring in one of the foremost experts in this area, none other than Dr. Justin Baker, who is a pediatric oncologist as well as a pediatric palliative medicine doctor. So basically the boss when it comes to everything we're talking about regarding bioethics. Justin, I'm also partial because you are at Stanford Children's Health as the head of the pediatric palliative care program and the head of the Quality of Life for All, AKA the Koala program. I'm kind of sad you're not in a koala costume right now, but I thank you so much for joining us all the way from Switzerland.
- [34:49]
Dr. Justin Baker
It is so great to be here. And even though it is very late here in Zurich, no other place I'd rather be right now.
- [34:56]
Hunter Harris
I love that.
- [34:58]
Dr. Alok Patel
Justin, could you kind of give us an overview of what exactly bioethics is when it comes to medicine and how these situations show up for you as a doctor?
- [35:08]
Dr. Justin Baker
Yeah. I think one of the most important things to recognize is that when we're talking about bioethics, we're talking about the actualization, the coming to the bedside and having to make real life decisions with families who are faced with impossible questions, with physicians and clinicians who are faced with things that many of us would never imagine except when they watch the pit. These are things that we face every single day. Questions about life or death, questions about right and wrong, when really there are no rights and there are no wrongs. We're trying to think of what's the most right thing to do, what's the best thing to do in the middle of all bad choices. And so if you can picture this, it's something where you would think as simple as a yes or no answer would do. But that's never the case in medicine. We're always thinking about shades of gray. We're always trying to think about the patient and the family, what are their needs, what are the needs of the healthcare providers, what's the right thing to do from each person's perspective. And what we have to do is we have to bring all of that together to the bedside. And frequently in the middle of some pretty quick decisions. That's what bioethics is. It's making real life decisions for real life patients and families in the middle of very murky and difficult situations.
- [36:32]
Dr. Alok Patel
And I just want to clarify, it's not always just a situation about life or death. There's other. It's not always about terminal illness.
- [36:39]
Dr. Justin Baker
I should say that's exactly right. Bioethics is much broader. It might just be about trying to think about what's the right thing to do in this particular situation. When you're thinking about a particular medicine to give it or to not to think about. How do we involve a child in decision making? It might be in thinking about, oh my goodness, look at this family member is involved and this family member disagrees with the other one. Or it might be in a situation where there are clinicians who disagree. All sorts of situations need bioethics engaged and involved. And we're so thankful there are such high level experts out there to help us. As we're thinking through all of these different decisions and all these different situations,
- [37:18]
Dr. Robbie
I don't even know what hurts more,
- [37:22]
Hunter Harris
the cancer or
- [37:26]
Dr. Robbie
knowing I'm never gonna see my sons grow up.
- [37:32]
Dr. Justin Baker
It feels like a cruel joke.
- [37:36]
Hunter Harris
So on the pit, we see a case of a patient named Roxy, who Dr. Robbie recommends that she gets pain medication, which could help her pain, but also maybe hasten her death because she is in palliative care.
- [37:49]
Medical Assistants
Where are we with the morphine?
- [37:50]
Dr. Robbie
10 milligrams an hour.
- [37:52]
Medical Assistants
Okay. You can bolus another two and go up to 12. I will let Princess know.
- [37:56]
Dr. Robbie
12 an hour is a lot.
- [37:57]
Volvo Sponsor
Yeah.
- [37:58]
Dr. Robbie
On top of the Ms. Cotton, she could stop breathing.
- [38:02]
Medical Assistants
Are you familiar with the doctrine of double effect?
- [38:05]
Dr. Robbie
Not really.
- [38:07]
Medical Assistants
It is an ethical principle. In pelvis, we treat pain, and if in doing so, there's a negative side effect, we accept it.
- [38:14]
Dr. Robbie
Even if the negative side effect is death.
- [38:18]
Medical Assistants
In some cases, that could be the best outcome.
- [38:20]
Hunter Harris
Can you sort of tell us about the doctrine of double effect and how that works?
- [38:25]
Dr. Justin Baker
This actually comes up fairly often. It's a great fear of people that opioids, that morphine or other opioids, such as fentanyl or hydromorphone or methadone, that these medicines might hasten death. What we know is that when these medicines are used appropriately, that's not really what happens. What happens is that patients are able to relax. They actually usually live even longer. But what I will tell you is the principle of double effect. The doctrine of double effect is something that's very important to understand, and that is because intent matters. Every time we think about giving a medicine, we have to be thinking about why are we giving that medicine. In this particular situation with Roxy, we're giving the medicine to address suffering, to address pain, which is a very straightforward reason. If we were to give that medicine and Roxy were to have her breathing slow or she were even to stop breathing and her life were to end early, as long as the intent was to make sure that we were giving that medicine to address suffering, to address pain, it would be appropriate. That's the doctrine of double effect. Intent matters. And the reality is, again, when we use opioids, this is not usually the case. We're not really generally struggling with, if we give the right medicine to treat pain, that somebody might die by it. However, because of opiophobia, the fear of using opioids, we have to talk about the doctrine of double effect all the time, where even if we were to give that medicine, if we gave it for the right reason, but something like dying came about because of it. If we used it for the proper intention, if we used it for pain and symptom management, that would still be appropriate.
- [40:13]
Hunter Harris
Opiophobia. Okay, I learned something new today that's very interesting.
- [40:17]
Dr. Justin Baker
Yes, opiophobia, the fear of opioids. Actually, Hunter, it's fascinating. We here in the United States have driven opiophobia all over the world, and that is because of our huge opioid epidemic, a massive problem caused over the past many decades, which is now causing a fear of opioid use all around the world. So I do a lot of work in Africa, and even in Africa now, because of opiophobia, many patients are unable to get opioids even though they deserve, they should be getting those medicines. It's almost impossible because the system is responding to issues that we have here in the United States.
- [40:57]
Hunter Harris
Oh, wow.
- [40:57]
Dr. Alok Patel
I never thought of that.
- [40:58]
Hunter Harris
That's fascinating. There's another case I want to ask you about, Justin, and it's a young woman who is, who's become her brother's primary caretaker when their parents move back to Haiti. And he is like drinking with friends and a firework explodes in his hand. But how do we think about what's right for that family when, you know, maybe it seems like on paper she shouldn't be his caretaker, even though she is like the closest person in his life.
- [41:23]
Dr. Justin Baker
Hunter, this is why bioethics and these conversations matter so much. It is never so obvious when we think about these situations as to what's the right thing to do. We need to do the very best. We need to engage whichever family member is there. We need to do our very best to get a hold of family members, perhaps in Haiti or otherwise. And this is extremely complicated. We need to be taking into account what do we know about this young man. We need to be thinking about what is the impact on his family. We need to be thinking about all the different aspects. What are the likelihood of his condition improving? What is the likelihood of deterioration? What is the impact on all aspects of his life? When we think about caring for patients from Haiti or as I mentioned earlier, from sub Saharan Africa, it's also common that the decision making locus, meaning the way that we make decisions in the United States, is very autonomy driven, very personal. That is very different than many other cultures around the world. Many other cultures. It's really a communal decision. It's a familial decision. And that is so difficult for us as clinicians. We so frequently take our United States autonomy based mindset and try to apply it to almost every situation. And unfortunately, sometimes that actually causes additional suffering, additional complications for patients and families.
- [42:48]
Dr. Alok Patel
This is so enlightening as we look at kind of the difference in palliative care and medications in an American standard and an American kind of stereotype versus other cultures. I never thought of things in this life before.
- [43:00]
Hunter Harris
How do you include children in the decision making and pediatric palliative care?
- [43:05]
Dr. Justin Baker
Yeah, Hunter, I think this is one of the most complicated questions. How do you involve children? So the answer needs to be that we're always engaging the child. The question is how. And that how is really dependent on each family dynamic. And the reality is usually when we talk to children we're going to bring them into this conversation in the way that works best for them. That might be through play therapy. That might be through the parents having the conversation. It might be through a child life specialist or a psychologist having the conversation. What I do know, and actually here in Europe, when I was doing some of my teaching over these last few days, I was doing this work with Ulrike Kreiksberg. And we know from study that she has done that if families involve their child and let them know that they are actually approaching their end of life, none of the families regret talking to their child about the fact that that is happening. Sometimes if families hide this from their child, they regret it. And that's a super important concept. I try to make many of my decisions out of the context of. Of how will we have the fewest regrets possible. And when I think about this, I think of myself being in the regret prevention business. And one of the best ways to prevent regret is to engage the child, to involve the child in whatever way they want to be involved in the decision making in the entire care plan.
- [44:31]
Dr. Alok Patel
The regret less. What did you call it again? What type of business? The least regret.
- [44:35]
Dr. Justin Baker
We say that, yes, we try to be in the regret prevention business. Or sometimes I call it, I want to be the superhero of regret prevention. And here, being from the Bay Area, sometimes I like to think of myself being in the rock band that is called Regret Prevention. Anything to help us think about preventing regret is what I try to do when I teach.
- [44:58]
Dr. Alok Patel
You know, I think it really speaks to the fact that there is a much more nuanced conversation than just Dr. Ravi saying, hey, hey, doctrine of double effect. Justin, this is why you're the best. This is why everyone needs to go and watch Justin Baker's TED Talk. By the way, in which there is a koala costume involved.
- [45:16]
Dr. Justin Baker
There's a couple koala costumes. That is very true. So the koala comes from Q, O, L, A. And you're like, that doesn't look like koala. Well, it means quality of life for all. And we have a koala as a mascot. And the all in all is. Is all capital letters, A, L, L, all capitals. And it's for everybody. Every patient, every family, every clinician. Because the way that we're able to do this work for a very long time is also by taking care of each other. This is super hard work. I'm so impressed by how the pit really beautifully represents that. I'm sure people watching it are like, how can these people do this for any Period of time. And that's why quality of life for all is also about people like Dr. Robinson. How do we make sure that we can take care of him so that he is able to do this work for much longer? Even after his sabbatical, how can he come back refreshed, revitalized, and ready to really make a difference in everyone's life?
- [46:16]
Dr. Alok Patel
I'm not sure if that's a gloss cause or not with Dr. Ravi, but I'm in for the intention with him. I hope he puts on a helmet also during the sabbatical.
- [46:25]
Dr. Justin Baker
Yeah, he's got to wear a helmet. That is very clear. I'm a pediatrician. You must wear a helmet if you're going to ride a motorcycle.
- [46:33]
Dr. Alok Patel
Even better.
- [46:33]
Dr. Justin Baker
Don't ride one. Sorry, I was about to say the
- [46:36]
Dr. Alok Patel
pediatric motorcycle club, like, please don't exist.
- [46:40]
Dr. Justin Baker
Awesome.
- [46:41]
Hunter Harris
Well, Justin, thank you so much. This was wonderful.
- [46:44]
Dr. Justin Baker
I just want to say thank you so much. I'm so excited. I can't wait to see how things turn out. I'm so happy to help
- [46:51]
Dr. Alok Patel
Hunter. Wow. That is why Justin is Justin, because he just. He speaks with so much expertise and compassion and relatability. You know, from my perspective, I think what a lot of people don't understand about palliative care and bioethics, it's not just about life or death. There's so much more that goes into it in treating the individual in the specific situation. What surprised you or what stuck out for you from this conversation?
- [47:19]
Hunter Harris
Oh, my goodness. I mean, I think the pit season one really changed how I thought about palliative care and end of life questions with two adult children who were dealing with their dad. And Robbie was like, telling them, why would you intubate like a painful tube down this man's throat? And thinking about how to involve everyone in the decision making was like, from Justin was a really big reframe for me.
- [47:45]
Dr. Alok Patel
I'm glad he brought that up because people might see TV shows, the Pit, and think that it's a smaller discussion. But oftentimes, as Justin mentioned, you have spiritual services and you have a nursing team, you have pharmacists, there's nutritionists involved. There's play, there's art therapy. There's so much. There's so much there. Even though I've heard him mention it about a thousand times, I still always get kind of choked up. I take a step back and really get reflective. When he brings up the idea of involving children in the decision and why that's important.
- [48:14]
Hunter Harris
No, I mean, I think the idea of like minimizing regret and involving children in the decision and letting them know what's happening is, I mean, gonna stay with me for a really long time.
- [48:25]
Dr. Alok Patel
Well, right on. Minimizing regret, complex medical decision making, cultural competency wrapped up in one. That was. That was a heavy, powerful, necessary interview.
- [48:37]
Hunter Harris
Alok, I want to play a game, a fantasy game for just a second. Let's say you are dealing with this disaster at a water park. You don't know what is going on exactly. You don't know how people are injured or what the situation is, but you get to make a super team of one attending, one resident, and one med student. Who would you choose?
- [49:01]
Dr. Alok Patel
When you first said, let's play a fantasy game, I was like, hunter, are you talking about anthrocon again?
- [49:05]
Dr. Justin Baker
Okay, this is.
- [49:06]
Dr. Alok Patel
This is more. This is. This is more in line. Okay. Wow, this is tough. Okay. For attending in this type of disaster situation with limited resources. I'm going Dr. Robbie. Going Dr. Robbie.
- [49:19]
Dr. Justin Baker
Okay.
- [49:20]
Dr. Alok Patel
And as far as a resident, I'm thinking. I'm thinking Whitaker. I'm gonna go Whitaker with Dr. Robbie. Because if. If you could remove social scenarios, I would go Langdon, But I don't know yet that Robbie and Langdon are working well together. So I'm going Whitaker. I'm going Dr. Robbie, and for med student, I'm going Joy.
- [49:42]
Hunter Harris
I like. I like the pairing of Robbie and Whitaker. I think they get along really well and have a good working relationship. I think that's smart.
- [49:47]
Dr. Alok Patel
I'm gonna ask you the same question, though. Who's your. Who's your all star trio to handle this?
- [49:51]
Hunter Harris
Yours is a good list. However, it's not the right list, I would say. For resident, Dr. Mohan. For attending, Dr. Abbott and medical student Javati, we're going to queen out together.
- [50:06]
Dr. Alok Patel
So Dr. Abbott is in your list of queens. I like it.
- [50:09]
Hunter Harris
Of course, he's one of the girls. He can. He can kiki with us.
- [50:16]
Dr. Alok Patel
Can I kiki with people?
- [50:18]
Hunter Harris
I think you do every day. That's it for today's episode of the Pitt podcast. We'll be here every Thursday right after a new episode drops, and hopefully we'll see you in the comments with any observations, insights, questions, whatever.
- [50:34]
Dr. Alok Patel
And if you work in an er, not just doctors and nurses, but hey, environmental services, security case managers, social workers by unit clerks. We really want to hear from you. Watch us on HBO Max Max. Or listen wherever you get your podcasts.
- [50:48]
Hunter Harris
The Pit podcast is a production of HBO Max in collaboration with prx. The executive producer of PRX is Jocelyn Gonzalez, our Managing producer is Courtney Florentine. Our editor is Lucy Perkins. Our production managers are Ebon Ochoa and Tony Carlson. Our video producer and editor is Anthony Q. Artis with assistant editor Damon Durrell Hinson. This show is engineered by Tom M.E. bazerian. Special thanks to Joe Carlino.
- [51:13]
Dr. Alok Patel
The executive producer of HBO podcasts is Michael Gluckstadt. The senior producer is Allison Cohen Sirocac and the associate producer is Aaron Kelly. Technical director is Insang Kwong. I'm Alok Patel.
- [51:26]
Hunter Harris
And I'm Hunter Harris. We'll see you next week in the Pit.
- [51:39]
Volvo Sponsor
When life gets unpredictable, preparation matters. In medicine, it's all about staying alert, ready for whatever comes through the door. On the road, it's no different. That's why Volvo designs vehicles to help anticipate risk, reduce harm and protect lives. The Volvo XC90's advanced safety systems inspire confident decisions wherever the road takes you. The Volvo XC90 for life, proud sponsor of the PIT podcast. Learn more@Volvocars.com us.