Dr. Fred to ER, Stat!

As a third-year medical student, I spent many a Friday evening hanging out in the emergency department of the Vancouver General Hospital (of Vancouver Coastal Health). I sewed up drunks, washed out stomachs, started IVs, and practiced intubation on the newly dead. That was back in the days of Marcus Welby, MD; Ben Casey; and M*A*S*H, the movie. CPR hadn't been invented; heart failure was still managed by phlebotomy; and heart attacks were treated with oxygen, morphine, and four weeks of bed rest.

Now – 30 years on, and one night earlier, Thursdays on NBC – the whole world can hang out in television's most famous emergency room. You may not be able to smell the BO and the vomit or feel the sticky blood underfoot, but all the sights and sounds are like it really is. There are differences, of course. The occasional tedium and boredom of regular ER duty is missing. The personal dramas may be more complicated. Perhaps the diseases more exotic. But thanks to Dr. Fred Einesman, an onsite medical advisor for Warner Bros.' critically acclaimed medical drama ER, the medspeak and the medical mannerisms will be true to life. His job is to make sure that the script and the action, from a medical/technical standpoint, is 101% accurate.

Dr. Fred On Paper

On paper, Einesman's (folks call him Dr. Fred because they have difficulty pronouncing his last name) career line looks pretty straight: college in Montréal, Quebec medical school at McGill University, also in Montreal, an emergency medicine residency at the UCLA Medical Center, and attending physician in the ER at Cedars-Sinai Health System, in LA. Somewhere along the line he acquired a Master's degree in film production and ended up working on the set of ER.

However, a conversation over lunch reveals that Einesman's career path has been anything but straight. He started out in an experimental arts program at Montreal's Dawson College, where he was president of the student council and editor of the college paper, and he spent lots of time traveling, missing classes, and getting marginal grades. When he applied for an undergrad position at McGill, he was told that he was "'socially unadaptable,' whatever that means" – apparently on the presumption that, because of his long hair, he was a dope-smoking, hippie freak. He certainly looked the part (but he never inhaled). The dean of his college, who knew him well, called McGill and said, "No, no! This guy can do whatever he sets out to do." Einesman was accepted, but warned that he would be watched. A year later he was called to the dean's office at McGill to explain why he had done so well. He had straight A's. Had he been cheating?

He hadn't been cheating, and he continued at McGill, graduating in 1979, with an MD degree, near the top of his class and with a pack of academic awards. He applied to three emergency medicine residency programs and decided to go to UCLA, where he stayed "because it's warm and there's no snow." But he does miss Montreal bagels, smoked meat, and his mum, and still watches Hockey Night in Canada on satellite TV.

Years later, his girlfriend, knowing his love of film and his artsy background, suggested that he apply to the University of Southern California (USC) film school. There he met Dr. Lance Gentile, who was the first doctor to join the ER staff. After Einesman earned his Master of Fine Arts in film production, Gentile called him to see if he was interested in helping with the overwhelming workload on the set of ER.

And as they say, the rest is history.

Blurring the Lines

Now, there are four physicians involved in the production of ER. They are the reason it is so real. Real doctors have been integrated into every aspect of the production, from the first word in the writing room to the last carefully choreographed toss of a glove into the biohazard bin. There is a doctor behind the scenes for every single minute of filming and a real nurse present in every scene that involves trauma. (A real nurse is also in the OR scenes, where proper handling of instruments, proper gloving, etc. are essential.)

Einesman now has two professions running simultaneously and in parallel: one in emergency medicine and the other in film. Sometimes the line of demarcation becomes a little blurred. He remembers one Christmas Eve at the change of shift when a police officer was brought in pulseless. He had been shot through the chest. Two minutes later he was intubated, had two chest tubes and a central line, and was having his chest cracked. Einesman was running the trauma code. Blood was everywhere. Suddenly, in the middle of the action, he had what he calls "one of those déjàvu ER moments." He was giving the dialogue and performing the actions that he had rehearsed so many times with the actors on the set of ER. Was he on a TV sound stage or in a real trauma room? But: "The great thing about ER, the show, is that in the end nobody really dies. In real ERs bad things happen to nice people, and that can wear a guy down. In real life you don't get another take."

Healthcare Professionals are Watching You!

ER is now in its ninth season. It is no longer just entertainment. It has become education. Einesman says, "You know, the actors think that we're teaching them, but really they're teaching us." His real-life ER residents (at Cedars-Sinai Health System) videotape episodes and ask him to critique the show and look for mistakes. And the ethical issues on ER are so true to life that a McGill University professor wants to integrate some of the episodes into his courses.

ER is a billion dollars' worth of free advertising for the specialty. Before the show, nobody knew what an emergency medicine doctor was; now everybody does. No topic is untouchable: medical, political, social, or ethical. The writers try hard to show all issues: unfunded patients, crowded ERs, overworked staff, political indifference or political interference. Ethical dilemmas are often unresolved.

Einesman says that ER's audience has become unbelievably sophisticated. Of course, many of the viewers are doctors and nurses. In response, the program has also become more sophisticated and now shows things that it would not have shown earlier, such as inserting chest tubes, cracking chests, even the beating heart.

As the audience and the scripts have become increasingly sophisticated, so have the actors. They talk like doctors, move like doctors, are dedicated like doctors, perhaps even think like doctors. No longer do they have to visit local hospitals to get the flavor of medicine and trauma. Now they can get it right there on the set. It's a realization of Osler's concept of a lifetime of continuous learning. Fantasy is mimicking life.

And life is starting to mimic fantasy. In the years that ER has evolved, so has real emergency medicine in LA. Einesman admits that on ER they condense time and that, perhaps, the number of exotic diseases is higher than in real life, but the frenetic pace of the TV program is now replicated in every ER in LA. Busy, crowded, overcrowded, saturated from morning to night with patients who are sicker and sicker. All of whom need to be seen. Einesman says that it's become so bad that medical staff are again talking about burnout. But not Einesman.

What Would Make This Happy Guy Happier?

Einesman is a guy who says, "I'm happy almost all of the time." He clearly loves where he's been, what he's doing, who he works with and the friends and mentors who helped him to get to where he's at. His conversation is liberally sprinkled with words like outstanding, remarkable, astounding, gifted, phenomenal, generous, dedicated, gutsy, and incredible. He freely admits that the key to much of the success in his life is that he went to McGill, a good Canadian university with an international reputation. And he gives high praise to his mentors in both phases of his career.

One of the most delightful things about Einesman is that he retains, if not the hair, at least the enthusiasm and unpretentiousness of his youth. There he sits in faded jeans, baseball cap, and polo shirt with a cell phone that plays the "William Tell Overture," chatting to me and waiting for his four o'clock appointment for a root canal. This is the same guy who was "amazed" when he was accepted to USC film school. The same guy who doubted his acceptance into medical school, even though the professor who wrote him a letter of recommendation was also the chairman of the admissions committee. This is the same guy who, back in the days when good news and bad news came in color-coded envelopes, assumed, without opening it, that the letter in the white envelope from McGill denied him admission to medical school. When he finally opened it, it was a request to come and have his class photo taken. The big brown envelope arrived the next day.

One wonders when a white envelope at the Emmys will contain Fred Einesman's name. Or when a medical school class will give its teaching award to the cast of ER.

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