J7Accid Emerg Med 1996;13:299-301 299 J Accid Emerg Med: first published as 10.1136/emj.13.4.299 on 1 July 1996. Downloaded from A&E ON TV

Casualty: the BBC series - the role of the medical adviser

Geoff Hughes

The BBC Casualty programme, based at Holby is sought from a nursing and ambulance General Hospital in the fictional city of Holby, adviser, and others specialists as appropriate has been popular for several years, averaging (for example, the police, fire service, and 14-15 million viewers per episode. At the time special interest groups.) of writing this article (December 1995), series Obviously each episode is different. Stories 11 (for screening in the winter of 1996-97) is may include a big stunt (for example, the train in the early stages of production. I have been crash at the start of series 8 or arson at the end a medical adviser to the series since 1991. In of series 7), a specific "hot" topic (that is, this article I will describe how the programme incest, rape or male rape, TB in the homeless, is made and my contribution to it. Jehovah's witnesses, etc), or personal and emotional problems in a variety of domestic General background settings. Political topics related to NHS Holby DGH is an average sized hospital reforms are included from time to time (for serving a metropolitan area of 500 000. It has example, trusts, budgets, contracts, closure of few regional specialties. The A&E department services, the development of triage, nurse sees 40 000 patients per annum. For dramatic practitioning, etc). Intertwined with the big reasons the only medical staffwith dialogue are stories are one or more smaller - and often one consultant, a senior registrar, and one amusing - topics (for example, a tramp with SHO. smelly feet or an "elf" from a store's "Santa's Recent series have consisted of 24 fifty Christmas Grotto" who was unable to get minute episodes which are transmitted through his plastic ears off). Each incident which the autumn and winter. Planning and writing appears in the final script is based on a real http://emj.bmj.com/ of the series starts nine to ten months before event. transmission. Filming of each episode is Many medics ask me "why is there only ever completed several weeks in advance and takes one SHO?" This is a deliberate decision. I'm 10-12 days per episode. told it helps the writers and script editors keep Production ofthe series is a complex but well a tight control of each theme of the story and organised affair with units based in London causes less technical difficulties for a weekly and Bristol. The two sites have separate but programme. It is also a deliberate decision not overlapping roles. The former is the office base to include too much black humour or the on September 26, 2021 by guest. Protected copyright. and is home to the producer, script editors, typical conversations of the staff rest room and researchers, and the production teams re- doctor's mess. It has to be remembered that sponsible for each episode. Bristol is the base the programme is an entertainment and not a for filming, technical support, special effects, documentary. props, and editing, as well as the office for routine administration. Some personnel live in Making an episode or around Bristol but many commute between Once the script is completed the final the two sites. production phase begins. A team led by the director (the person who plans camera and The storyline actor positions and decides what you will see Planning the storyline begins months ahead of on the screen) and including various assistants, filming. The script editors, producer, the make-up, and special effects experts meets with nursing adviser, and myself meet regularly to the advisers and goes through the script in develop ideas which are increasingly fine detail. The director makes decisions about tuned. There are several stories running camera positions at this stage. Special effects, Department of through each series, which are sketched in at stunts, and make-up options are also planned. Accident and this early stage. They include political issues, It is during these discussions that any Emergency Medicine, individual character stories (the soap element), limitations arising for medical and technical Bristol Royal Infirmary, and specific medical topics. Once general reasons are defined (for example, is it possible Bristol BS2 8HW, themes are agreed individual writers are then to make a model to simulate an emergency United Kingdom commissioned for different episodes. Each thoracotomy or escharotomy?) If the story is G Hughes episode matures with several written drafts. too "gory" to be screened, the special effects Correspondence to: Dr Geoff Hughes. Frequent evening telephone calls and brain will be toned down (the philosophy for this to from Accepted for publication storming conversations help produce the final does vary from director director and 19 February 1996 rehearsal script. In addition to myself, advice special effect to special effect). 300 Hughes

After this meeting final plans regarding We received many letters from psychiatrists J Accid Emerg Med: first published as 10.1136/emj.13.4.299 on 1 July 1996. Downloaded from locations, casting of specific characters, and and psychiatric nurses about an episode which scheduling of filming are completed. The portrayed a psychotic patient killing someone. special effects team are given photographs Their concern was that the episode portrayed of real injuries to help them plan make-up mental patients in an adverse light and would and construct their prostheses (which can take have given the public the impression that all days or weeks to make). Before filming, the mental patients are violent. Although this latter actors meet the director for a read-through, point is undoubtedly a true concern, the where ideas and themes are openly dis- programme does not always aim to be cussed. politically correct. There later followed the well Filming of an episode takes 10-12 days. The publicised true case of a schizophrenic killing medical scenes are completed over a weekend a young married man. (rehearsals on Saturday, filming on Sunday). Probably the commonest comment received Occasionally visits to location shoots are is about the quality of cardiac arrest manage- required (for example, the Forest of Dean for ment and failure to follow standard protocols. a mining accident or the Brecon Beacons for The response to this is that cardiac massage is an anaphylactic bee sting). performed on live actors and thus has to be The "Casualty department" itself is located modified to prevent injury to them; also the in a warehouse on a trading estate near Temple editing of scenes means that only snippets of Meads railway station in central Bristol. The an arrest sequence are shown and they can thus outside (or ambulance entrance) of the appear to be out of context. Another point is department is located at a local polytechnic (or that not all true cardiac arrests are textbook in university as it is now called) next door to application at all times. There will always be a Gloucester County Cricket ground. Most conflict between showing a medical scene in a outside scenes are filmed in and around strictly perfect manner (and thus providing Bristol, while the Bristol Royal Infirmary is some medical education) and showing used (at weekends) for theatre and ITU treatment in the incorrect and sometimes interiors. At rehearsal, advice is given to the sloppy ways we have all witnessed (which actors on methods of patient examination, would also be an accurate portrayal of life in practical procedures, pronunciation of medical an A&E department). A viewer from South terms, and use of props (stethoscope, Wales who criticised the performance of a ophthalmoscope, etc). Each scene or incident "peritoneal thump" in a cardiac arrest scene is filmed from different angles and the same did throw me, however! angle often reshot several times. A 10 hour day A consultant anaesthetist once accused me of recording results in only a few minutes of of negligence in an episode about carbon usable film. Although the advisers are present monoxide poisoning. The story showed the at these times, we do not contribute to the final patient receiving 100% oxygen with a editing process which determines what will or Mapleson circuit (one which could be used as http://emj.bmj.com/ will not be transmitted. a high flow or low flow system). He assumed New actors and members of the production that it was the low flow system in use and thus team visit the A&E department at the Bristol I was negligent. When I contacted him to Royal Infirmary to familiarise themselves with discuss it he admitted that it was an the "real world" and speak to members of staff assumption and nothing else. He did (although some writers and actors also visit eventually retract his written comment of their own local departments). Apart from this, negligence. on September 26, 2021 by guest. Protected copyright. virtually all of the advice is given "out of The vast majority of letters, however, are hours", occupying an average of 7-10 hours a positive and complimentary of the way in week, mainly in alternate weekend slots and which sensitive issues are portrayed. Viewers evening phone calls. comment that the stories mirror crises in their own lives and have found them helpful and More background to the series supportive. Some state that they have been Involvement with the series has been a given insight into their own problems and fascinating and privileged experience, exposing others that it has stopped them feeling isolated me to the world of television programme as they realise they are not the only ones to making. Inevitably a variety of humorous and have experienced the problem. interesting incidents occurs, some ofwhich will The programme is an important medium for not translate well onto the page. medical education for both the general and the Letters of complaint from both medical and medical audience; the public pick up many first non-medical viewers have to be dealt with. aid and basic medical facts with surprising ease Many viewers wrongly interpret a story or do and will write in to relate an incident in which not listen to the dialogue. For example, a they provided treatment to somebody based on director of a regional social services de- something seen in an episode. partment became extremely hot under the I try to persuade the writers to include some collar regarding a story of father-daughter specific lines for the medical audience (for ex- incest and the way in which social services were ample, the use of methylprednisolone in spinal involved. Careful review of the transmitted cord injury, the investigation of a widened dialogue and videotape showed that he had mediastinum in blunt chest trauma, the use of misheard the sequence of events. He was told thrombolysis in acute infarction). The writers this but he did not accept our reply and can also be persuaded to include lines about the continued to complain. correct or incorrect use of the A&E department Casualty: the BBC series/Letters to the Editor 301

and the general practitioner (I'm sure that many is popular for many reasons. It is part soap J Accid Emerg Med: first published as 10.1136/emj.13.4.299 on 1 July 1996. Downloaded from readers will believe this is the most important opera, part education, and it appeals to the message of all to portray). In each episode there public fascination with all things medical. It may actually be several messages, each targeting portrays life in an "average" A&E depart- a different type ofviewer. ment, warts and all. I have been fortunate to be involved with it and in Clive Mantle Conclusion (who plays the consultant Mike Barret) I The programme is not perfect as there are have found one of the few people I can beat limitations which define how it is made. It at golf.

LETTERS TO THE EDITOR

Fluid resuscitation in traumatic that directly compared ATLS with some 1 Greaves I, Goodacre S. Grout P. Management of drug overdose in accident and emergency haemorrhage other control. It is for this reason that I departments in the United Kingdom. J Accid suggested in the article, that components of EmergMed 1996;13:46-8. EDITOR,-The article "Fluid resuscitation in ATLS, for example the fluid resuscitation 2 Roy B, Crawford R. Pitfalls in diagnosis and traumatic haemorrhage" by R Cutress' con- regime, be individually taken and put to test. management of carbon monoxide poisoning. JAccid Emerg Med 1996;13:62-3. tains a significant error (or perhaps a mis- 3 Smith JS, Brandon S. Morbidity from acute print). The author states "...ATLS as a RAMSEY CUTRESS carbon monoxide poisoning at 3 year follow package has been shown to be more effective 1 Mill Close, Hemingford Grey, up. BMJ 1973;i:318-21. Cambnidgeshire 4 Tibbles PM, Perrotta PL. Treatment of carbon in prehospital treatment than Basic Life monoxide poisoning: a critical review of Support", citing references 22 and 23. 1 Ali J, Adam R, Butler AK, Chang H, Howard outcome studies comparing normo- M, Gonsalves D, et al. Trauma outcome human Neither of the articles referenced looked at improves following the Advanced Trauma baric oxygen with hyperbaric oxygen. Ann ATLS. They compared ALS (Advanced Life Life Support program in a developing Emerg Med 1994;24:269-76. Support) for ambulancemen (the equivalent country. J Trauma 1993;34:890-8. of extended training) to basic ambulance 2 Vestrup JA, Stormorken A, Wood V. Impact of Advanced Trauma Life Support training on training and found it produced better results. early trauma management. Am Jf Surg However, this conclusion must be regarded 1 988;155:704-7. with caution as the methodology in both studies was weak. The author states that "ATLS has been shown to make a substantial contribution to the management of trauma". As an ATLS Paracetamol overdose enthusiast I agree with the spirit of this state- ment. However, I am unaware of any trial Management ofpoisoning EDITOR,-The treatment of paracetamol showing that ATLS has a significant impact overdose has been and remains a contentious http://emj.bmj.com/ on morbidity or mortality. Perhaps it is not ED1ToR,-The recent paper from Greaves issue among both toxicologists and A&E necessary to prove that it does. But then, as et al' suggests the management of poisoning doctors. The opinions expressed in the recent the author has demonstrated, when you is likely to be variable and that the existing review of the management of drug overdoses examine the conventional wisdom, as he does literature is interpreted in different ways by in A&E departments in the United with intravenous fluid, the results can be different people. The staff in Glasgow Kingdom,' however, were misleading and surprising. deserve credit for diagnosing acute carbon failed to indicate the currently accepted monoxide poisoning and for the satisfactory guidelines for the management of acute para- BRIAN MCNICHOLL cetamol overdosage.2 In both scenario 1 and A&E Department, Royal Victonia Hospital outcome of the patients they report.2 Despite on September 26, 2021 by guest. Protected copyright. Grosvenor Road, Belfast the certainty with which they recommend 2 it was implied that gastric lavage was an hyperbaric oxygen (HBO) for acute carbon inappropriate measure, but from the history 1 Cutress R. Fluid resuscitation in traumatic monoxide poisoning, the data they cite are in both cases gastric lavage with charcoal was haemorrhage. J Accid Emerg Med 1995; the treatment of choice. I find the assertion 12:165. limited.3 Some clinicians hold a contrary view. Authors of a review of controlled trials regarding the patient in scenario 1 comparing normobaric and hyperbaric particularly alarming as the only early diag- concluded that further trials were nostic aid in cases of paracetamol overdose is oxygen the history taken from the patient. It should The author replies needed to establish the role of HBO.4 Until these have been carried out, the risks of be of little relevance how frequently the transferring critically ill patients must be patient attends or how many previous over- I would like to thank Brian McNicholl for doses the patient has taken; patients should pointing out an error in my article "Fluid balanced against possible benefits of HBO. Further studies are needed in other areas of be treated according to accepted guidelines resuscitation in traumatic haemorrhage". As until proof exists that the history is he correctly states the sentence should read poisoning but, to avoid unnecessary dupli- inaccurate. Gastric lavage is rapidly losing "There has been no evidence to date cation of previous work, systematic review of evidence is needed. A is favour in the treatment of paracetamol over- suggesting that prehospital administration of current group dose but gastric lavage alone has been shown intravenous fluids is of benefit to trauma currently trying to establish (with the support and Australasian to lower plasma paracetamol levels by up to patients (reference 21), although ALS of the UK Cochrane 39-3%3 and in combination with charcoal is (Advanced Life Support ) as a package has Centres) a Cochrane Collaborative Review on and envenomation. still regarded as the optimum treatment of been shown to be more effective in pre- Group poisoning paracetamol overdose within two hours of hospital treatment than Basic Life Support Anyone wishing to contribute to this can ingestion. (references 22, 23 )." contact the following: R D Hardem, Accident The effect of ATLS has been studied by and Emergency, St James's University Hospi- J WHI-IrAKER comparing patient outcome before and after tal, Beckett Street, Leeds LS9 7TF, United Accident and Emergency Department, the introduction ofATLS. In this way ATLS Kingdom, or Dr N Buckley, Discipline of Royal Preston Hospital, Preston has been shown to improve patient outcome.' Clinical Pharmacology, Mater Misercordiae 1 Greaves I, Goodacre S, Grout P. Management Such studies however, do not always show Hospital, Watarah, NSW 2298, Australia. of drug overdoses in accident and emergency significant improvement.2 I am sure that departmnents in the United Kingdom. J Accid RICHARD HARDERN EmergMed 1996;13:46-8. there would be inherent difficulties in the Accident and Emergency, 2 Management of acute paracetamol overdosage. design and methodology of an "ideal" trial St James's University Hospital, Leeds Guidelines from the Paracetamol Information