The end of ER: This time it's terminal

After 15 years, and 332 episodes, ER comes to an end on British TV next week. Tim Walker takes the pulse of a drama that had heart, soul - and plenty of guts

It's the night of Monday, 19 September, 1994. Dr Mark Greene is lying on the bed in a darkened hospital room in his green medical scrubs, catching 40 winks before his shift begins. A nurse knocks at the door, then pops her head into the room. There's a drunken patient at reception for him, she says; and no, the intern can't take care of it. Why? Because the patient is one of his colleagues.

The opening moments of ER's pilot episode were uncharacteristically sedate. Greene, played by Anthony Edwards - best known before then as Goose from Top Gun - found a bed for the inebriated Dr Doug Ross, played by the still-unknown George Clooney, to sleep off the booze. He even had time to set up an aspirin drip to help ease his friend's hangover. But by the end of the show's fourth minute, a building had collapsed in a nearby district, and the emergency room was steeling itself for a flood of victims.

By the time we reached minute 10, a sick old lady had vomited blood over Dr Ross; a stony-faced superior had chided cocky young surgeon Dr Benton (Eriq La Salle); a patient had hit unsuccessfully on the beautiful Dr Lewis (Sherry Stringfield); and Greene had been manhandled by a dead patient's son after bringing him the bad news. As the last of the rush receded, Doctors Greene and Ross shared a moment together in a quiet corridor. "So," said Greene, "That's it." But that wasn't it.

***

It's been a long life and, for the most part, a happy one. But a week today, the last life-support machine will finally be switched off in the emergency room (or "ER") of Chicago's County General Hospital, home to the longest-running primetime medical drama in US television history. You may not have seen a whole episode of ER since the Nineties, but if you've been watching any television in the meantime, then you've felt its influence.

With its hyper-realistic hospital setting, its hyper-complex narrative and especially its hyper-kinetic aesthetic, ER was the first show of its kind. But it also leaves the airwaves - after a 15-year, 332-episode run - as the last US drama consistently able to attract such a substantial viewership. In its mid-Nineties heyday, ER boasted weekly US audiences of 30 million. It was the world's most watched TV drama for 10 years. When the final season signed off in the States last month, it drew the largest audience for a drama since The X-Files finale in 2002; today, however, even the most popular network shows struggle to reach 20 million.

The last decade has been a golden age for US TV drama, with critically-acclaimed cable shows such as The Sopranos, Mad Men and The Wire complementing quality network fare like The West Wing, 24 and Lost. But in its lifetime ER has also been party to a steep decline in the networks' commercial and cultural power. Since its 1994 debut, ER has won 22 Emmy Awards and been nominated for 122: more than any other TV show, ever. Since that first season, however, audiences have fragmented thanks to cable, the internet and the DVD boxset. And the pay-to-view cable channel HBO has stolen not only some of the networks' audience share, but some of their reputation for top-quality drama, too.

ER's fate was tied to that of other scheduled shows in a way we might not understand in the UK. The show premiered three days before Friends, another huge NBC success; and reached its audience peak - a whopping 47.8 million - when an episode aired straight after the finale of Seinfeld in May 1998. It earned itself a permanent place in the schedule: 10pm Thursday, the same sanctified slot formerly reserved for NBC's landmark shows LA Law and Hill Street Blues.

ER did for the medical drama in the Nineties what Hill Street Blues had done for cop shows in the Eighties. The doctors and nurses of County General replaced the superhuman ciphers of Doctor Kildare and Marcus Welby, MD. In the halls of ER's inner-city hospital, its viewers saw an everyday heroism that was absent from the more rarefied environs of the Bartlett White House, or Jack Bauer's counter-terrorism unit. With its characters striving to save lives in an underfunded, under-resourced system, it anticipated The Wire. And with its workplace details and specialist jargon it paved the way for The West Wing. It shared all of that show's idealism, but little of its optimism.

"It was one of the first shows that made doctors fallible," says Stuart Levine, assistant managing editor at Variety magazine. "Before then, doctors on television were godlike, they did everything right, and every week they'd see a patient and fix them. Here you had doctors who made mistakes. They were doing 17-hour shifts and their home lives were a mess. No one had seen that before."

***

By the end of the pilot episode, viewers had also met John Carter (Noah Wyle), the hapless young doctor who would become ER's most enduring character. Carter was the son of privilege who found that he was less skilled at surgery than at interacting with patients - until he was stabbed by one in season six, leaving him physically and psychologically scarred.

As Carter helped to deliver a baby in episode one, nearby, head nurse Carol Hathaway lay close to death after a suicide attempt. Hathaway, played by Julianna Margulies, was originally slated to shuffle off in that pilot episode. Audiences warmed to her so much, however, that she was allowed to live, and immediately added to the permanent cast. Her relationship with (Dr) Ross became a televisual romance to rival Ross (Geller) and Rachel - and one of the joys of the final series has been learning that the pair stayed together since leaving Chicago nine years ago.

Ross was ER's loveable rogue, a philandering drunk redeemed by his magnificent bedside manner and skill as a paediatrician. In season two's "Hell and High Water" episode, he saved a young boy from a storm drain in dramatic scenes designed to tug open the tear ducts of anxious viewers everywhere. Greene, meanwhile, was the gentle everyman whose first marriage was failing, and who later learned to love again in the arms of Dr Elizabeth Corday (Alex Kingston).

Ross left County General for Seattle after five seasons, Greene died from a brain tumour after eight. Carter, who had entered the emergency room a clumsy medical student, finally left it as an experienced senior doctor after 11 years. Each of their departures seemed to mark a gradual diminution of the show's quality. For many, the low point came in Episode 209, when the eminently dislikeable Dr Robert Romano - whose arm had already been shorn off in one helicopter accident - was killed by a second chopper falling on his head.

The televisual term for this sort of thing is "Jumping the Shark" - named after the notorious episode of Happy Days in which Fonzie jumped over a shark while waterskiing. It means the moment when a show goes beyond its own carefully-built bounds of plausibility: when Monica and Chandler hooked up in Vegas, for example, or when Pam Ewing woke to find Bobby in the shower, and realised that the whole thing had been a dream.

ER slowly but surely edged closer to soap opera as the seasons progressed, with shoot-outs and a tank assault among the other less plausible plotlines. Yet it still proved itself vital: by putting Parminder Nagra, a British Asian, in the female lead; or by having doctors Carter, Kovac and Pratt travel to Congo and Darfur with Medecins Sans Frontières, even as the rest of the US media ignored the conflicts in Africa.

"I was very proud of what we did with the John Carter character in his first trips to Africa," ER's producer John Wells recently told a US interviewer. "They were not particularly well received by the audience. A lot of people didn't watch them or tuned them out because the subject matter is very difficult. But I felt it was very important ... to be able to dramatise some of the things that were happening in the Congo and the Sudan, on a broad-based network entertainment show - I was proud of and remain very proud of [that]."

"If it did raise consciousness of those issues then that's to be admired," says Jed Mercurio, a former doctor and creator of the British medical dramas Cardiac Arrest and Bodies. "But I think ER is at its strongest when it's narratively inventive within its own setting, like the episode done in real-time with Ray Liotta as a dying man ["Time of Death", from 2004]. That, as a piece of mould-breaking episodic television, was more successful than transplanting some of the characters to a different setting."

ER's final episodes, which feature Carter's return to County General, have long been in the minds of the creatives involved. Indeed, Wells says he discussed the plot of the finale with Noah Wyle as long ago as season eight, following Greene's death. But a new cadre of characters - in particular the pairing of Maura Tierney and Goran Visnjic as troubled lovers Nurse Abby Lockhart and Dr Luka Kovac - rejuvenated the show and gave it life after Carter.

***

ER has its origins in the experiences of the late author Michael Crichton, himself a former doctor in a Boston hospital, who wrote a screenplay on the subject in 1974. But it was only 20 years later, after working with Steven Spielberg on the film adaptation of his novel Jurassic Park, that the idea finally made it into production as a two-hour TV pilot with Wells, of Spielberg's Amblin Entertainment, in the producer's chair. Crichton's 1974 script remained remarkably unchanged, despite the time-lag, though Dr Lewis became a woman, and Dr Benton an Afro-American.

The pilot had been passed over numerous times before Warner Bros finally managed to secure a commission from NBC to make it; the show's creators remember a glut of behind-the-scenes disagreements before it first aired. NBC were worried by ER's grit. For the first time, people would die regularly in a TV hospital. Blood was everywhere (the production team claim to have used 180 gallons of fake blood since 1994). But the critics loved it, and so did the public. Soon, the network did, too.

ER used its prominent position to deal with ethical issues, from drug abuse to teenage pregnancy, and to show its vast audience the troubles afflicting the US healthcare system. County General was an urban hospital, and the social problems of the inner city frequently spilled through its doors, be they gang members with "GSWs" (gunshot wounds) or blue-collar workers injured on unsafe construction sites. In a bit of good - or bad - timing, the first season began just as Hillary Clinton's sweeping healthcare reforms were crushed in the US Senate. As the power of private health insurance companies increased, hospital emergency rooms like that at County General became the frontline of medical treatment for the masses.

Applications to teaching hospitals' emergency residency programmes shot up in parallel with the show's popularity. A rotating trio of real doctors was attached to the writing staff to maintain the show's engagement with real-life healthcare issues throughout its 15-year run, and to ensure that the fictional doctors and nurses were consistently using up-to-date techniques. In 1995, two of those medical consultants, Neal Baer and Lance Gentile, won a writing Emmy for their episode "Love's Labor Lost", in which Greene misdiagnosed a pregnant woman.

"You don't often see one of your heroes make a dreadful mistake in a medical drama," says Mercurio, "nor do you see it dealt with in such an authentic way. It was very subtle and understated. However, ER did become controversial in the US because nurses thought it was a doctor's show. It didn't really represent the nurse's contribution to medical practice. [Abby Lockhart] was a nurse who, in order to become more part of the action, qualified as a doctor. There was a feeling that you weren't an important carrier of the storyline unless you were a doctor."

In its first season, ER had direct competition from Chicago Hope, another new medical drama from CBS, also set in a Chicago hospital. "Chicago Hope was a David E Kelley show," Levine explains, "and Kelley had a lot more gravitas than the ER creators at that point, because he had made LA Law. The cast of ER was totally unknown, too; whereas Chicago Hope had Alan Arkin and Mandy Patinkin. When ER started, it was a real longshot. But then the pilot blew people away."

The two programmes went head-to-head in a Thursday primetime ratings war. ER won (despite critical acclaim for both shows); Chicago Hope was switched to Monday evening, and finally cancelled in 2000. Since 1994 Wells has become one of the most influential producers in television, with The West Wing and Third Watch also to his credit. As ER's longstanding on-set chief, or "showrunner", he wrote many episodes (including the finale), and directed many more.

Like many hugely successful ensemble shows, ER has launched few big Hollywood careers. Clooney, its one bona fide superstar, was also the first actor to be cast in the show, demanding the ensemble role of Dr Ross over a lead he'd been offered, in a pilot for a long-forgotten legal drama. He returned to ER for one of the final episodes with little fanfare: Warner Brothers kept his involvement secret from NBC until the last possible moment, preventing the network from using his appearance to bump up its ad sales.

"Clooney and John Wells always a very friendly relationship," says Levine. "Clooney stayed on ER for at least five years. In this day and age, if you make it big on television, you try to renew your contract and get a lot of money out of it. Clooney never did that; he honoured the contract, even though he became a huge star after the first season. His return was kept under wraps because of an agreement between Wells and Clooney. Clooney said he'd do it, but he didn't want huge publicity to take away from the other elements of the show."

***

In his book about the positive effects of popular culture, Everything Bad is Good for You, Steven Johnson cites ER as one of the shows that made multi-threaded narrative acceptable to television audiences. Unlike the popular television dramas of the 1970s, which followed a single plot strand in each self-contained episode, ER - along with the likes of Thirtysomething, Twin Peaks, NYPD Blue and LA Law - followed up to 10 threads per episode, many of which remained unresolved for entire seasons. As such, it prepared the ground for later acclaimed dramas like The West Wing, The Sopranos, The Wire and Mad Men.

The social networks in ER are considerably more complex than in Dr Kildare or Starsky and Hutch, whose titles alone betray the narrow focus of their character development, and the ease with which one can dip into a single episode and quickly grasp the plot. Without knowledge of the social links between characters in ER, many of the narrative subtleties would be lost altogether.

"But what really made ER unique was the steadicam," says Levine. "They would do long takes, or 'oners' without any editing, which moved all the way through the hospital." These long shots allowed the scripts' multiple narratives to overlap physically, their plot-paths crossing one another at speed in the hallways of County General.

ER's signature steadicam is now a staple of television drama, heralding the famous, single-take "walk-and-talk" scenes in The West Wing; though in ER's case, it's more like "walk-and-yell-and-perform-open-heart-surgery", a clattering chase through the corridors, doors swinging, gurneys clattering, doctors and nurses yelling clinical acronyms.

The show's innovations attracted some big names behind the camera as well as in front of it. In 1995, at the peak of his fame following Pulp Fiction, Quentin Tarantino directed an episode. In 1997, Thomas Schlamme, later Wells' fellow producer-director on The West Wing, directed a live episode, entitled "Ambush", in which the NBC camera crew was explained away as a documentary crew filming a day at County General. The episode was performed live twice, for audiences on both US coasts.

Johnson also argues that ER set the stage for an increasingly sophisticated dramatic realism in television. Like CSI or The West Wing, its scripts are flooded with the impenetrable jargon of its setting. Watching The West Wing, viewers could be forgiven for wanting an accompanying glossary of American political terms; to understand some of ER's dialogue, you'd need a medical degree. This not only lends plausibility to the plotlines, it also trusts viewers to identify the important narrative markers in an endless stream of information; to separate, as Johnson puts it, "substance" from "texture".

According to Wells, the density and medical content of the dialogue was one reason why many networks originally passed over the pilot script. "[ER] may have more blood and guts than popular TV had a generation ago," writes Johnson, "and some of the sexual content today would have been inappropriate in a movie theatre back then - much less on prime-time TV. But when it comes to storytelling, these shows possess a quality that can only be described as subtlety and discretion."

"Cardiac Arrest was the first British drama to use a lot of medical jargon," explains Mercurio. "ER began the following year and was the first American drama to do that. That created a template, and now medical dramas both here and in the US have far more jargon. ER can be quite graphic, too. It has as wide an appeal as Casualty, yet it doesn't shy away from using prosthetics to be gory when it needs to be. We used ER to back up our argument for Bodies being gory, which was one of the BBC's big concerns about it."

Pessimism is par for the course for viewers of Mad Men or The Wire, but unlike previous television dramas, ER was prepared to end an episode on a resolutely downbeat note, to show its characters defeated and depressed. If a doctor had an awful day at work, he could still arrive home after his shift to find that his wife had left him. These, it seemed to say, are the realities. Sometimes, life is painful.

However, Mercurio goes on, there is at least one way in which ER is less authentic than it could be. "There is still a great sense of idealism running through ER, which is never challenged; nobody ever says, 'This job is sometimes so difficult that it's hard to do it in a caring way.' It has a great deal of procedural accuracy, but you don't have doctors disrespecting patients in American medical drama; you don't have the moral cynicism that you find in the real world in our public services. With Cardiac Arrest, I wanted to show that there were times when doctors really didn't care.

"If you look at American medical fiction written by doctors, like The House of God by Samuel Shem, and The Blood of Strangers by Frank Huyler, both have themes of cynicism and dysfunction running through them that you won't find in ER. You find it in Scrubs, but because that's a comedy, it gets away with it."

***

US television's surviving medical dramas are Grey's Anatomy and House, neither of them especially innovative nor, indeed, remotely plausible. In fact, many American doctors say the most realistic televisual depiction of hospital life since ER is Scrubs, the sitcom that just completed its eighth season on ABC. In the UK, where TV dramas are often compared unfavourably to their American cousins, Casualty and its offshoots survive, but Bodies, The BBC's best hospital drama of recent years, lasted just two series.

"British drama can compete with America creatively," Mercurio insists. "But the two systems are very different. In the US you get 22 episodes in a year, and they have a staff of writers and cast who, if they're involved in a successful show, get paid more money. That keeps talent within the show. Here, we either have continuing dramas, which are run like soaps, with relatively inexperienced writers and relatively low-paid actors; or we have something that's trying to make more impact but only gets six or 10 episodes. Because of the way our system is structured, often quality and quantity compete against each other."

The sort of appointment-to-view shows that made NBC's 10pm Thursday slot impregnable for the last 28 years (since Hill Street Blues' premiere in 1981) now have their viewership splintered by DVD, download and Sky+. Without those big audience numbers, such dramas simply can't pay their way.

As a result, cheaper and more popular reality programming like American Idol - which can still attract a bi-weekly audience of 26 million - are expected to take the place of many quality network dramas. In that Thursday primetime slot on NBC now is not a new drama, but a talk show, The Tonight Show With Jay Leno.

"Here in the States, 10pm Thursday was hallowed ground," says Levine. "So now that NBC is replacing its 10pm dramas with a comedy chatshow, it really is the end of an era. Fifteen years ago, networks were willing to give expensive dramas time to breath and gain an audience. But the leash is very short now; if you don't come out of the blocks well, your chances of survival are slim."

ER may have become too expensive for NBC to maintain, but it has, at least, been able to choose the manner of its passing. Not many shows have that privilege, especially in the US, where they can be cancelled mid-season if the ratings slip. Schlamme's last series, Studio 60 on the Sunset Strip, a big-budget NBC drama written by West Wing creator Aaron Sorkin, was cut short after a single season. Deadwood, the HBO anti-western which earned rave reviews from critics and its few viewers, was not afforded the luxury of tying up its loose ends after the end of its third.

So, how much do you want to know about the end of ER? Wells has written the screenplay for the feature-length finale, which he describes as a "homage" to the show's very first episode. Rod Holcomb, who directed that original pilot, has taken the helm one last time. And I can tell you that County General breathes its last accompanied by some good memories and a few familiar faces. It's had a good run, but sadly there's no saving it; this time, it's terminal. Time of death: 10.45pm, 28 May, 2009.

Treading the wards: ER’s special guest stars

Ray Liotta: Charlie Metcalf, "Time of Death", 2004

Liotta won an Emmy for his portrayal of a dying man in this episode, which was shot in real time, depicting not only the details of his treatment, but his memories of a wasted life.

Bradley Whitford: Sean O'Brien, "Love's Labor Lost", 1995

Whitford would later become known as Josh Lyman in The West Wing, but here he played a young father whose wife died in childbirth after Dr Greene made a terrible mistake.

Forest Whitaker:Curtis Ames, six episodes, 2006-7

Ames blamed Dr Kovac for his debilitating stroke. First he tried to sue for malpractice, then resorted to threats, intimidation and kidnap, finally killing himself in front of Dr Kovac.

Rosemary Clooney: Madame X, "Going Home", 2004

George Clooney's aunt, a notable actress and singer during the 1950s, played an Alzheimer's patient who believed it was 1948, and tried to convince Dr Carter to appreciate the music of the day.

James Woods: Dr Nate Lennox, "Body and Soul", 2006

Woods was nominated for an Emmy for his performance as a professor with Lou Gehrig's disease; his lengthy battle with the debilitating neurodegenerative condition was shown through a series of flashbacks.

Alan Alda: Dr Gabriel Lawrence, five episodes, 1999

Lawrence arrived in the ER as a senior doctor, but after a series of mistakes it became clear that he was himself suffering from Alzheimer's. Alda earned an Emmy nomination for his performance.

Ewan McGregor: Duncan Stewart, "The Long Way Around", 1997

Quentin Tarantino directed this episode, in which McGregor played a petty criminal. When he and his partner robbed a convenience store, Nurse Hathway was caught up in the shootout.

Kirsten Dunst: Charlie Chiemingo, six episodes, 1996-1997

Dunst played a drug user and teen prostitute, whom Dr Ross tried to take under his wing after she arrived in the ER following a brutal assault.

James Cromwell: Bishop Stewart, four episodes, 2001

Cromwell played the churchman who, while being treated by Dr Kovac, helped the Croatian doctor come to terms with his faith, following the death of his family in the Yugoslavian conflict.

Susan Sarandon: Nora, "Old Times", 2009

Though viewers were probably more excited by the return of George Clooney, Sarandon gave a moving performance as a grandmother who must decide whether to donate her dead grandson's kidney to Dr Carter.

Zac Efron: Bobby Neville, "Dear Abby", 2003

Before High School Musical made him a household name, Efron played a teen shooting victim who died after Nurse Lockhart's advice to the doctors about his treatment was ignored.

Rebecca De Mornay: Elaine Nichols, five episodes, 1999

De Mornay's character was a cancer survivor; she had a brief, melancholy affair with Dr Carter, who was her ex-husband's cousin.