Code Black

A clerkship turns into a film festival favorite
Spring 2014

Doctors scramble. Dozens shout. Machines beep. A gurney rumbles over tile. A new documentary directed by Ryan McGarry (MD ’09), Code Black, depicts the emergency department as a living system subject to challenges—extreme waiting lines, long physician hours, and the turbulent emotions experienced by patients and their families. “If you’re an outsider, this looks like total chaos,” says McGarry in a voiceover. “But as a doctor, I see unity in that chaos. There’s a team here in all that coming together to save someone’s life.”

As a med student at the University of Pittsburgh, McGarry participated in a clerkship and research rotation at Los Angeles County General, which his documentary describes as “the birthplace of modern emergency medicine.” Rather than staffing an emergency department with doctors of varying specialties, in the late 1970s, LA County General leaders decided that training a group of physicians in all aspects of care was the best way to save lives. (Under Peter Safar and others, early reforms were also under way at Pitt.) When McGarry arrived in September 2008, the LA department operated out of a compact, one-room space and thrived using an all-hands-on-deck approach.

“I had no intentions of coming to LA to make a film,” says McGarry at a coffee shop in Manhattan, where he is now on staff at NewYork–Presbyterian and assistant professor of emergency medicine at Cornell University. “It was accidental, really, which is often how documentary films get started.”

Having studied English as an undergrad and read cinematography journals since childhood, he maintained an impulse toward creative work and recognized early that the hectic environment had real cinematic potential. Just a few weeks into his LA rotation, McGarry began lugging around a 40-pound camera.

“The visual quality of the space—it was literally a 16-by-9 aspect. Most doctors [elsewhere] only take care of one patient at a time in one room. This was like a movie; it had six patients side by side in wide screen,” he says.

Initially McGarry wanted to make an experimental, non-narrated film that immersed viewers in the visceral world of emergency medicine. He served as his own film crew and could anticipate where to go next. “With a [larger] crew there would have been a lag time, where I’d have to be like, ‘Okay, they’re going to cut this guy’s chest open next. Let’s move over to this corner,’” he says. Instead, the new trainee was able to move quickly, absorbing knowledge himself while capturing intimate shots of young doctors peering into devastated body cavities and shaky med students tugging at their bloodied gloves.

When his four-week emergency medicine clerkship was nearing an end, the University of Pittsburgh gave him an extension to continue filming—a move he calls a “game changer” for the project. The school gave him an additional four-week research rotation, after McGarry demonstrated that he would have a product in the end. The feature-length documentary is now sweeping the festival circuit and earning top prizes nationwide, including Best Documentary Feature at both the 2013 Los Angeles Film Festival and the 2013 Hamptons International Film Festival. The project developed its plotline when McGarry returned to LA County for his residency and continued filming.

By 2012, LA County’s emergency department had moved to a new building, a far more modern and sprawling complex that drastically changed how it operated. The team was forced to comply with a slew of administrative and privacy requirements that were simply not an option at the old, relatively antiquated space. (By the way, McGarry was careful to get consent to film anyone appearing in Code Black.)

“The new filming was more loaded,” says McGarry. “At some point in the documentary process you decide what you want to build your story on, and you go for it.”

The focus became a question: How can the unpredictable, team-oriented world of the emergency department function within the rigid terms of modern health care? The new rules forced doctors to spend 8 minutes documenting a 2-minute exam. To maintain patient privacy, there is an endless routine of signing in and out that one physician admitted made him briefly look for the log-in at the bathroom stall.

McGarry narrates the film and serves as its main subject, but the story is completed by the voices of his resident colleagues. Together they represent a new generation of emergency medicine physicians immersed in protocol, policy, forms, and checklists.

In crowded emergency departments, doctors assign a color code to the overall workload, ranking how busy they are from “code blue” to “code black.” At code black, “we are so saturated with waiting room volume, admits, and, of course, incoming ambulance traffic, that it feels like the resulting gridlock is an understatement—somehow we’re piling multiple, towering layers of gridlock onto more gridlock,” says McGarry.

It is entirely possible for a patient at LA County to wait upwards of 14 hours before seeing a doctor. (These are often uninsured patients who rely on the county emergency room for primary care.)

For McGarry, the crowded waiting room is “the most real representation of one of our greatest problems.” As a director, he says, “I wanted you to experience what it’s like to walk through that waiting room and to feel this canyon of eyes on you, going, ‘We’re all here.’”

In this way, Code Black is exhausting, and it’s meant to be. But ultimately, the film has a permeating optimism. The physicians are clearly driven to help their patients. At one point the team rallies to move certain chairs from the waiting room into the treatment area so doctors can visually monitor pending cases (an experiment that doesn’t necessarily translate smoothly to every space).

The film illustrates McGarry’s wish to inject adrenaline and doctor-patient immediacy back into emergency care. He says that Paul Paris, Pitt’s former chair of emergency medicine, with his “get-it-done” style, was an early role model.

Today McGarry continues to balance his work in film and medicine. Serving several long shifts in the emergency department each week frees up some blocks of time; he’s got several writing and TV concepts in the works.

At film festivals, McGarry no longer stays in the theater to watch the documentary in full. “But I stay for the first 15 minutes to make sure that everyone’s okay.”

Code Black is graphic. In Aspen, one audience member fainted. So McGarry stays at least for the dramatic opener, he says. “That’s the physician in me.”