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It’s strange calling this a season finale, because it’s only been an 8-episode summer run, and nearly every episode has had the kind of stunts associated with finales. 

It’s also strange calling it the conclusion of a two-parter, because most of the plots from part 1 (the stripper, the fork-swallower) are wrapped up and not mentioned again. The main thread running through part 2 was whether Topher would survive his GSW, and he was shot in the closing seconds of part 1.

But there was something even stranger about tonight’s episode. Before we get to that, however, let’s cover the medicine - which was all-too typically bad:

  • Topher had been shot in the abdomen by the fake DEA agent, in the CT scanner room. As this episode begins, he gets wheeled to the OR and operated on, by a surgeon - which is pretty remarkable for this show. The source of bleeding is identified, repaired, and the patient lives (in fact, he’s unconscious for less than two hours) and then there’s a humorous subplot where the intern tries to place a foley on his attending (but seriously- why didn’t they place this, when he was under the knife?) Finally, Topher agrees to pee in a jug, only he has frank hematuria and then his pressure bottoms out, as it’s revealed a bullet fragment has led to an epidural hematoma. That gets managed in the OR, as well, and by the end of the episode, the patient is sitting up and talking after his second major surgery in six hours.
  • In the melee with the SWAT team, the shooter got stabbed in Zone II, and needs a CT of the neck. The nightshift administrator needs to remind Jordan, Chief of the Night Shift, that the shooter is a patient too, though she decides to withhold pain meds and tend to his needs half-assedly. When the CT shows carotid involvement, she repairs it herself, in the ED (the ORs, she reasons, were overwhelmed by Topher and the survivors from a chemical plant explosion). Her carotid repair comes undone and the patient dies. The detective who was hoping for his suspect to survive and testify begins to build a case for criminal negligence.

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  • One of the survivors of the chemical plant explosion has trouble ventilating due to extensive burns, and gets an escharotomy in the ED. Her face is all covered up, so it’s hard to identify her, but an ID card is found with her belongings, and a grieving husband is brought to the bedside because it seems she’s moribund. But lo! The nightshift administrator realizes the husband’s wife is a different patient - one who received a cricothyrtomy but seems far less critically ill. The husband is delighted. The doomed escharotomy patient listens to a phone call from a loved one, echoing a far better scene from "ER."

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Beyond Topher’s two near-death experiences, though, other main characters were handed major problems:

  • TC’s Afghanistan flashbacks build to a PTSD psychotic episode in the OR
  • Jordan comes under investigation for criminal negligence.
  • The night shift administrator receives news that he has a tumor behind his eye.

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It’s all heavy stuff, and what’s strange for this show: none of it gets neatly resolved by the end of the episode. In fact, a lot of it is barely processed by the characters during the episode. A competent writing staff may have laid the groundwork for how these difficult challenges will be met by the characters, with their various strengths and flaws, in the coming season. Instead, it just seems like it’ll be one damn thing after another.

The one bit of character-driven action - Jordan consoling TC in the lounge, as they both realize the scope and origin of his PTSD, gets filtered through the lens of a simplistic love triangle, because it turns out the whole time, Scott Wolf from Party of Five was looking on. Whatever this show was trying to say about a character’s motivation, or the resiliency of ED professionals, or the bonds between people, got reduced to the lowest common denominator.

It’s genuinely discouraging to know millions of people are watching this show, and seeing the most outrageous caricatures of emergency care. A bunch of EPs joined me (@nickgenes) in live-tweeting this show (thanks, @MDaware, @thinkstat, @AdamDarnobid, @MKleinMD) and our impressions - mostly eye-rolling, snark and cringing - were in stark contrast to the praise coming in from most tweeters using #TheNightShift hashtag.

We used to fret that patients would develop unrealistic expectations, when in-hospital cardiac arrest survival rate on 90’s TV shows was higher than real life. Now we must contend with the expectation that any EP can perform any surgery in any setting, or the most serious and spectacular injuries are routinely encountered, and usually survivable with minimal complications after a few hours. And I’m still waiting for evidence that the job “Overnight Onsite Administrator” and “Chief of the Night Shift” are jobs that exist, anywhere.

All this medical fiction may be worth it, if was in the service of telling good stories. But all the characters - despite their unbelievable medical abilities - are rarely driving the action. Stuff comes into the ED, and the cast responds. I can only think of one episode where a main character chose a course that was personally difficult, and grew as a result. Instead, the writers usually substitute medical feats for character development - somehow thinking that, if the doctor sweats a bit before performing a miracle, the audience will relate.

So here’s hoping for season 2 to be more grounded in medical reality, which would give some breathing room for the characters to grow and develop - and not just react.

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