Reel RNs
Nurse extras keep it real on the set of television's 'ER' to ensure authenticity and to help cast and crew give it their best shot

By Bree LeMaire, MS, RN
June 4, 2003

Coming on duty, Antoinette Avignone, MSN, NP, RN, is knee-deep in a double trauma. It's an accident involving a husband and wife brought in by ambulance. The husband is being prepped for OR in Trauma One. His wife has a dropping BP in Trauma Two.

Dr. Carter rotates between the two rooms, working on both patients. Nurse Haleh Adams accompanies him to the husband's bedside. "Type and cross match for 6 units of whole blood, Foley and NG tube stat. Start O2 at 15 liters by non-rebreather mask and hang Ringers at 200cc per hour."

Avignone passes up a unit of O-negative blood, and the medical student does a quick ultrasound and confirms internal bleeding.

Dr. Corday in Trauma Two announces, "She's in V-fib. We've shocked her a couple times, but we keep losing her. Looks like a severe cardiac contusion."

"BP, 86 over 46, pulse ox dropping to 82," nurse Adams announces.

Dr. Pratt looks at the patient. "She's had a threatening arrhythmia, with only brief recovery and no sustainable rhythm."

"Call the OR. This guy needs to go now," says Dr. Carter in Trauma One.

"I want to see my wife before I go into surgery," the husband pleads. He is wheeled on the gurney to Trauma Two, where he reaches for his wife's hand and says, "I love you."

The wife opens her eyes and in a small moment of regained consciousness, looks to her husband and closes her eyes. "Cut, print, reset," shouts the director. "Let's do it now for the overhead camera and make sure that mask is inflated and in place."

Avignone steps back and relaxes. The prop people begin the reset, cameras are repositioned and she unwinds for the next take. The reality returns that this is television. Avignone is not on duty at L.A. County ER, but is working as a technical extra in a TV production.

This fall marks the 10th season for "ER," a dramatic television series that takes place in Chicago via NBC and Warner Bros. Studios in Burbank, Calif. The storylines revolve around drama and authenticity, augmented by the use of registered nurses for the trauma, critical care and operating room scenes.

In most high-drama scenes, the nurse at the head of the bed is not an actor, but a proficient ER nurse, such as Avignone, who transmits competency and capability in this televised artificial setting.

On the set

These "real" nurse roles are played by a small group of talented nurses, who replicate for television the tasks they do every working day. The actors carry the drama of the scene, but in and around them realistic medical procedures are taking place. Two physician medical-technical advisers choreograph a move with every line in a scene. The medicine is the wallpaper to the plot or storyline, according to Joe Sachs, MD, writer/producer of "ER."

This means believable medical action takes place behind the drama, and audience focus has to be with the story rather than background activity.

For example, a scene may begin with a hypoxic woman being rolled in through the ambulance entrance. Dialogue continues as she is rolled through the halls into the trauma room, where she is transferred to a gurney. Then medical props are introduced, such as IVs, monitors, oxygen, etc.

Nothing is random, and each line of dialogue requires a certain action to take place. In the middle of all the action is the real nurse, who is pivotal in maintaining the flow.

It can take a full day to shoot such complex scenes because of their intricacy and because many things can-and do-go wrong. The IV bag being passed might block an actor's dialogue, an unscripted shoe might squeak or the special effects guy hiding under the bed might squirt the fake blood too aggressively and hit actor Noah Wyle in the face instead of the chest (a true story). Or someone might bump into the camera operator as he weaves around the bed. Then the director says, "Reset, back to one," and the lengthy process of starting over begins.

"I have a greater appreciation for the complexity of acting," Melette LeBlanc-Cabot, NP, RN, said.

LeBlanc-Cabot has been part of the "ER" cast since the first season and knows the difficulty of translating usual medical procedures for television.

She had just been accepted to the Stanford University Medical Center primary care associate program when she heard from Lance Gentile, MD, a friend and co-worker. Gentile was starting work with the "ER" creators and was looking for nurses to work as extras.

LeBlanc-Cabot said that for actors, learning words like "tracheobronchoscopy" or "lymphogranulomatosis," and then being able to say them comfortably as part of normal conversation, is tricky.

On top of the vocabulary is new equipment, such as a handheld ultrasound, accompanied by stage directions.

That's why, LeBlanc-Cabot said, tech rehearsals are so important. Things such as teaching the actor to look toward the monitor and not the blood pressure cuff when he says, "pulse ox is dropping," are vital.

For seasoned actors, it's much easier. But an influx of new actors on the set has reminded everyone that medical language and equipment truly are foreign.

Some of the actors have an easier time, LeBlanc-Cabot said: Wyle, who plays Dr. Carter, is not only a gifted and well-trained actor, but his mother is a nurse.

"This is probably the hardest job I have, but I love it," Avignone said.

Quality control

Avignone was working in the L.A. County ER when the TV writers came through to gather stories and background information. Avignone told them she had enough stories to last 10 years. A week later, they called to hear her stories, along with an offer to become an extra on the show.

Avignone said that the first day she was on the set, she expected to be a background extra. She hadn't even told friends about her new acting opportunity. Her first scene involved a full arrest on a 10-year-old child, and she was thrown in with actors George Clooney, Anthony Edwards, Julianna Margulies and Wyle, passing everything from blood-drawing material to syringes and medications on cue and acting along with the principal actors.

Every time they did a scene, they had to break and do it over. Avignone had to replicate that same scene so the views would look exactly the same. She spent 15 hours her first day. Somewhere around the fifth hour, she realized what hard work it was.

Early on, she remembers hearing Clooney asking for "another round of e-p-i." It took a pause to realize he meant "epi," for epinephrine.

Margulies also announced that the "lits were in and the potassium was at 7.2." That was corrected to lytes, or reporting electrolyte results.

Problems still crop up with medicines, as they use generic rather than brand names. Valium becomes diazepam, and Benadryl becomes diphenhydramine hydrochloride, for example.

All the nurses who were there remember the live show they did. Annemarie Jowell, EMT, who is studying for her RN, recalls how actors Edwards and Clooney wanted to do a live show. They rehearsed for seven straight days, with scripts, TV cameras and personal cameras, because everyone wanted to get a picture of the process. They did two live shows, one for the East Coast and a second for the West Coast. It was even shown on the Times Square marquee.

Jowell's job was to have two IV bags ready, but the tubing tangled. Consequently, when she had her part, she was fighting with tubing on IV bags in the background. She said it was too realistic.

Jowell said it was a fluke when she got on the show. Friends were doing background or extra work as people who are placed for background activity to create the busy milieu that adds to the drama and realism of the set. One of the stand-ins asked Jowell a quick question about setting up an IV. The prop people usually handle this with the tech adviser, but Jowell helped out. Technical director Sachs noted her expertise, and she has worked steadily since.

Leslie Shea, RN, came to the show as a transplant nurse when they were doing a story about transplants during the '94-95 season. They told her they needed real nurses to set the stage. It was so much fun that she brought her daughter Jane Andrus, RN, on board. Shea said the best time is when she gets to work with her daughter.

Shea describes working on the set as like being on a different planet. They might set up a scene with a patient in a bed and leads to the monitors, and when they say "cut," everyone stands back as the prop people come in to take off the leads, rearrange the bed and do all the things she usually does in her job. In a film production, everyone has their roles to play, and the prop people step in to re-establish a set, not the nurses. Shea said it's strange when you're used to jumping in and doing what's needed.

Andrus has worked on "ER" for three seasons. She specialized in PICU and now works at the Long Beach Memorial Hospital ER. She said she still gets a thrill out of going onto the set and getting her wardrobe or scrubs.

Once, Andrus went to the commissary with a patient/extra who had a massive head wound. Her luncheon partner had an immense head bandage on, with "blood" running down her face and part of her "skin" falling off. Andrus remembers reminding the extra that her "skin" was falling into her salad.

The commissary, Andrus said, is a conglomeration of all the different shows being filmed. Once, she lunched with the Gilmore Girls, a group of astronauts and "ER" cast members in their scrubs.

Scene change

Patrick Nila, RN, was working as an ER nurse at L.A. County when John Wells, the executive producer, saw him and asked him to come on the show. That was during the 1996 season, and he's been working with the show since. "Feel the camera," were words he heard a lot in the beginning. This means, "watch out for the camera." Today, it is just part of a day's work for Nila.

The difference between this work and his real work is that on "ER" they have the luxury of doing a scene over and over until they get it right. A scene typically starts with getting the script, followed by a short rehearsal with the nurses, then the actors are added to the scene, then the props are added for the next rehearsal. The scene is rehearsed at half time, then it speeds up to real time and repeated until it becomes natural.

One trauma scene may take 10 or 11 hours to shoot. It is done for one camera and then repeated for a ceiling view and/or a wraparound view and/or a close-up. Nila listens for his favorite words, "cut, print, great, moving on, new deal."

Actress Yvette Freeman plays the no-nonsense nurse Adams. She prepared for her role by observing the ER activity at Northridge (Calif.) Hospital Medical Center. She tells of being put into a room with a deceased accident victim as a tolerance test for staying in character. Freeman said she was shocked, but she knew her character had seen everything, so Freeman stayed calm. She jokingly brags about being able to take the fastest blood pressure on record, but, please, don't ask her what the numbers are.

Many of the nurses have gone to work on other shows. Actor and pal Wyle helped LeBlanc-Cabot get started during their first season by referring her for an analgesic commercial as an adviser. This helped pay her Stanford tuition and commuting expenses. She has since worked on dozens of shows such as "NYPD Blue," where she was the nurse with actor Jimmy Smits when his character died, along with "The X-Files" and "Ally McBeal." She now is working on a Jack Nicholson movie.

Jowell talks about the movie "Blood Work" with Clint Eastwood and Angelica Huston as his physician. Jowell was the nurse while Huston did an angio on Eastwood. Jowell also has been in the television show "Diagnosis Murder" and is starting her fourth season as set/production medic on "Strong Medicine."

She talks of being hit in the head with the camera once or twice in the beginning. But the training she received working on "ER" has allowed flexibility, and today she works exclusively on medical scenes. Her assignments are steady, although it took almost four years to receive regular calls.

RNs on the set are categorized as technical extras, so they make more than extras, but less than principal actors. Starting pay for a technical extra is $250 for an eight-hour day, plus time-and-a-half for overtime. Technical advisers make more.

All the nurses talk of how much they love what they do and of the set's family atmosphere. They say it's like coming home when they show up for their one- or two-day stints. Everyone wants to hear what's been happening with the other actors and reconnect with old friends.

There's also the excitement of shoptalk, of Emmys or Oscars. Other benefits are the Christmas party and the wrap party, where "ER" jackets, mugs and gift perks are given as presents. There's also a "nurses night," where nurses from the set and outlying hospitals are invited for an elaborate dinner and requested to talk shop while writers take notes on their conversations.

The technical directors of "ER" have a built-in respect and regard for nurses that underscores the appreciation of all those on the set. Freeman said, "I am honored to play a nurse. I see nurses as the most fabulous people ever and pray that I can do honor to the profession."

It's easy to see why these nurses stay with this job and say it's the best work they've had. However, for LeBlanc-Cabot, there is no comparison between her real and television ER work.

"Both can be fun, stressful and exciting," she said. "But there is nothing more satisfying on a deep level than using my abilities as a nurse to make a difference in a patient's life."

Contact Bree LeMaire at peraltapal@aol.com