The Pitt was compelling TV.

As an emergency nurse educator for a Stanford campus in Northern California, there is one thing that is required viewing for my new graduate nurses: The Pitt.

The ambitious series did an admirable job portraying the complex world of the emergency department. The procedures were clinically accurate. The spectrum of patients and social issues was nuanced and believable. They even showcased the incidence of post-COVID PTSD, an insidious force among health care workers that we have yet to speak about openly.

I have one complaint though—it didn’t go far enough.

I have spent almost two decades in the emergency department. The Pitt felt authentic, but the action was dialed back, restrained for dramatic effect. In real life, it is exponentially more chaotic. It portrayed the essence of American emergency care, but at one-tenth speed.

The most realistic part: Dana, the charge nurse, masterfully portrayed by Katherine LaNasa. She felt like the most fully realized character. I spent many years in her shoes, leading a talented team of professionals who together perform miracles.

The role of the charge nurse can be difficult to define. It was my job to anticipate what resources were needed, which patients were sickest, what disaster was on the way. You are the consummate advocate for everyone in the department. You do whatever it takes to make sure everyone has what they need.

They got the most important part right—the epidemic of workplace violence in the emergency department.

She was punched in the face and still had to work.

She had a skull fracture, a more serious issue than most patients in the waiting room. And she worked overtime through a mass casualty event. She didn’t have a choice; there was no one else.

I have been there—violently assaulted by patients twice my size. Having to push that pain aside because there was work to do.

During the finale, she pauses for a significant moment. She looks around her unit. There is subtle wistfulness. She spends more time with this team than with her family, trauma bonded after so many life and death dramas.

Yet without saying a word, we know what else is behind those eyes. She is wondering if she has the strength to return. Does she have anything left to give to a career that has done nothing but take?

What it is really like in the ER

As an ER nurse, I have found myself in the middle of the worst day of a patient’s life. Multiple times a shift. Emotions run high and we guide people through crisis with empathy, skill, and stubbornness. The human connection is what keeps me there.

Unexpected illness brings out not the worst in people, but who they are. Many patients have poor coping mechanisms and become belligerent because they are scared. It is extraordinarily challenging to manage these behaviors while continuing to monitor patients and decide who gets the next room.

That waiting room is the worst place to be. People die there, routinely and with increasing frequency.

For almost two decades, I have watched emergency departments become steadily busier. We open every nook and cranny to squeeze in a bed or chair to see another patient. We order labs and imaging while they wait, trying to find the very sick needle in an ever-expanding haystack.

Patients sometimes become violent. I have been physically assaulted four times while performing patient care—punched, scratched, and verbally abused almost daily. When I was assaulted, I wasn’t allowed to clock out. The police refused to take reports, telling me assault was part of the job.

No one in nursing school told me violence was part of the job.

The hidden economic impact of Medicaid cuts

Tiny critical access facilities are kept afloat solely by Medicare and Medicaid—often 60 percent or greater of their revenue. Emergency Medicaid is especially vital for uninsured patients. An ER visit can cost thousands of dollars and medical bankruptcy is increasingly common.

Rural hospitals stay open not because it’s profitable—they don’t even cover expenses. But if they close, communities rely on volunteer EMTs to drive hours to the next facility. The nursing homes are wretched. This is where the ‘expendable’ COVID deaths happened. Entire nursing homes of forgotten elders died alone.

Communities struggle to staff these facilities—40 bedbound patients for one caregiver. When a community hospital closes, people lose access to dialysis, labor and delivery, emergency services, and preventative care. They become health care deserts.

Then came COVID. Everything broken by the pandemic was going to break eventually. It revealed the fragility of our health care delivery. Nurses close to retirement left. Decades of nursing wisdom were lost forever. Prior to the pandemic, hospitals faced 100 percent turnover every three years due to poor retention.

There has never been a nursing shortage—there is a shortage of people willing to tolerate the working conditions.

During the pandemic, hospitals closed to students. They lost access to hands-on training that takes hundreds of hours to learn. Their instructors did their best, but it’s impossible to learn these skills over Zoom. The soft skills—how to speak to patients, alert physicians, or recognize deterioration—cannot be simulated.

New nurses and physicians are now exponentially less prepared. They’re learning from nurses with only three to four years of experience, versus the 30 to 40 years of their predecessors.

The ER waiting room—the last safety net

The health care environment now is unspeakably dangerous.

The ER was always America’s safety net. EMTALA requires emergency departments to assess and stabilize everyone, regardless of ability to pay. Patients are sicker than ever. Lack of primary care means chronic illnesses develop more advanced complications.

Hospital space is diminishing rapidly. U.S. hospitals operate at 85 percent capacity, leaving no room for surges. We’ve been in disaster mode since 2020. Patients stay longer because there’s nowhere to discharge them to. Nursing facility closures mean some stay for weeks. Social workers expend monumental energy looking for rehabilitation space which will become more scarce.

The longer patients stay, complications skyrocket—pneumonia, bedsores, falls, sepsis. As facilities close, patients languish longer, creating an everlasting backlog.

Labor and delivery departments aren’t profitable. The care is expensive, and Medicaid reimbursement will disappear. Obstetrics is no longer attractive to physicians due to high liability. We’ll see more hospitals shuttering these departments. In a society increasingly pronatalist—where will these children be born? U.S. maternal and infant mortality is already highest in the developed world.

Back to the emergency department. People are sicker. Their mental health is worse. They’re more irritable. They wait hours—five hours is average for most urban emergency departments. The wait is longer because admitted patients wait in ER beds for hospital beds to become available. Sometimes for days. When dying patients arrive, they take resources that are spread thin.

Patients experiencing mental health crises now come to the ER and wait days in a high-stress environment. Even children, exposed to violent adults. They wait hours to speak to a psychologist through a screen. They are sedated and restrained because we have no other way to keep them safe.

Meanwhile, ambulances stack up. When there’s no room at the inn, patients stay on ambulance stretchers, holding EMTs hostage. This means longer response times when you call 911 for help.

The profit in human misery

Private equity ownership of health care facilities is rising. MBAs in leadership are beholden to generate profit, not just stay afloat. Decisions are based on shareholders, not patients. Hospitals already operate on shoestring budgets, giving nurses five or more critically ill patients. They’ve eliminated nursing aides who focused on patient comfort. They’ve eliminated nurse educators like me, who help bridge the education gap. They’ve eliminated education reimbursement, meaning nurses pay out-of-pocket to learn new skills.

The health care system delivers care 15 years behind current science as a result.

We have a serious physician shortage. Doctors no longer choose emergency medicine and hundreds of empty residency spots went unfilled this year. Most medical students rely on loans, then work 70 to 80 hours weekly to pay them off. Now the cutoff for graduate education loans is $150,000. Not even close to covering the cost of med school.

Hospitals rely on H1B visas to bring physicians to these remote communities. Foreign-born physicians have kept these hospitals open. But the current hostility toward immigrants means not even guaranteed visas will attract foreign talent to these health care deserts.

Exhausted humans make more mistakes. Emergency services workers have twice the divorce rate, elevated stress-related illnesses, and suicide rates four times the national average. Their life expectancy is five years shorter.

Bedside nurses and physicians have paid heavily to keep a foundering system from imploding.

Will the charge nurses keep coming back?

Critical access facilities have begun closing, anticipating catastrophic Medicare revenue loss. Nursing homes will close. The “sandwich generation,” already stretched, caring for children and aging parents, relied on Medicaid for respite care.

Profit-driven MBAs will eliminate “unnecessary” services once Medicaid reimbursement disappears. Nursing personnel, the largest budget item, faces the most cuts. Fewer nurses mean lower quality care, more preventable complications. More death.

Medical errors already kill 250,000 Americans yearly. Expect that number to skyrocket.

When hospitals close and people have nowhere to go and no way to pay, they’ll come to the emergency department as they always have. The safety net for American health care. The last man standing.

That net is fragile, already stretched beyond capacity. People are dying in waiting rooms nationwide.

It is immoral to profit from the lives and health of American citizens. Insurance companies, pharmaceutical companies, and hospital associations have lobbied against us in secret for decades. Nursing and physician organizations fight for workplace violence protections while the hospital lobby complains about the expense.

Hospitals have relied too long on the empathetic nature of health care professionals. We close gaps created by fiscal mismanagement. They assume we’ll stay, counting on our loyalty while collecting six- and seven-figure bonuses based on money saved, not patient safety or employee retention.

Only the best academic medical centers with private donor endowments will continue putting patients first. Few Americans have access to that care; fewer will afford it without Medicaid.

Those of us in “the pit” will do our best. Emergency nurses are resilient; we’ll work with whatever we have. We’ll find a way.

But we’re losing hope. We never expected the system to save us. We’ve been saving each other.

Health care in America has been held together by nurses, physicians, and others in the caring sciences. By our compassion and sacrifice. We give our lives to a system that treats us as expendable.

Is Dana going to come back? It’s a question every ER nurse asks. Is it worth it? Does anyone care?

We must pray she comes back for season two. That they all come back.

We can only hold things together for so long.

Kristen Cline is a professional development practitioner for the Emergency Service Line at Stanford Tri-Valley Medical Center and holds an academic affiliation with Stanford University.

With over 15 years of experience in emergency departments, intensive care units, and critical care transport, she brings clinical depth and a commitment to education and advocacy.

Kristen is board-certified in multiple specialties and speaks nationally for organizations such as Paragon Education and Solheim Enterprises, focusing on certification review and emergency nursing practice.

She has authored and co-authored several publications and textbooks, including contributions to the Emergency Nursing Scope and Standards of Practice, 3rd edition.

Her peer-reviewed work includes articles in Annals of Emergency Medicine, on “Optimizing Pediatric Patient Safety in the Emergency Care Setting,” and in Pediatrics, on “Access to Optimal Emergency Care for Children.”

Recognized among ENA Connection’s “20 under 40,” she advocates for nurse wellness and trauma-informed care through speaking engagements, her Medium blog, and social media platforms like Instagram and Facebook.