One doctor has an emotional confrontation with a troubled high school student over his potential "kill list." Another struggles to come down from the adrenaline rush of near-endless triage. And a third bookends his day where it started: teetering on the very roof ledge where, early that morning, he convinced a colleague to step away and not take his own life. 

Those are just a few of the dramatic scenes in hour 15 of the riveting Max drama The Pitt, all of which are executed with you-are-there realism and verisimilitude by John Wells, who directed the episode. (Wells, along with his fellow veterans of the groundbreaking NBC medical drama ER, Noah Wyle and showrunner R. Scott Gemmill, created the series. All three serve as executive producers).

Written by Gemmill, "9:00 P.M.," the final episode of the show’s acclaimed first season, concludes an extra stressful shift in a fictional Pittsburgh emergency room, where Wyle’s Michael Robinavitch — known to all as Dr. Robbie — has either treated or overseen the treatment of a steady procession of patients before running point (and running ragged) to prep the hospital for an influx of victims injured in a mass shooting at a local music festival. Along the way, the E.R.'s dedicated charge nurse, Dana (Katherine LaNassa), is assaulted in the ambulance bay by a disgruntled, racist patient and Dr. Robbie struggles with crippling PTSD that resurfaces when, despite exhausting all treatment options, he is unable to save his former stepson’s girlfriend. 

When Dr. Robbie and his staff aren't struggling to treat a young boy with measles against the objections of his anti-vaxxer mother or slipping on blood-slicked floors, they’re battling incessant obstacles created by the hospital administration's red tape and staffing shortages.

The frenetic finale concludes with a much-earned moment of decompression amongst the core medical staff, including doctors and nurses. Below, Wells takes the Television Academy through some of his creative and visual choices, the unfortunate timeliness of the measles storyline and why the episode’s last scene on location in Pittsburgh was shot before the rest of the script was written. Note: Spoilers ahead.

Watch: The Foundation's full interview with John Wells about ER and his Extensive Career

Television Academy: I have to start by saying that my mother-in-law is a nurse in her hospital’s neuro ward, and she was an ICU nurse –

John Wells: Oh, wow. 

She and her colleagues — the doctors, too — they watch the show and can’t find a false note. It’s a very realistic depiction of their day-to-day. 

I’ll let Dr. Joe Sachs [an M.D. who served as a writer and producer on ER and The Pitt] know. They work really hard on it. There are a lot of people down there making sure that we get as close as we can.

One of the finale’s most emotional scenes is the last conversation between Dr. McKay (Fiona Dourif) and David (Jackson Kelly), the troubled teen with the kill list, who she thought was the shooter. There’s that cut to a close-up of David, shedding a single tear, that is just a gut punch of visual storytelling. Can you talk about how you shot the scene and shaped it in post?

Jackson [Kelly] is a fantastic young actor. And, a lot of times, when you're directing — part of the job is to get out of the way. In that scene, when we came in to start to rehearse it, we didn't rehearse it much, because I saw that Jackson was already there; he was already in the [head] space that the scene needed. So I just said to Fiona, who plays McKay, "I'm going to start on Jackson, because I think he's there, and then I'll come around on you." Usually, you’d start with her character, since she has almost all of the dialogue. And, for that reason, we only did a couple of takes.

When you come into a scene like that, a big emotional scene, and the actor is already there and ready to go, you’ve got to take advantage of it. They may not be able to stay in that space for an hour and a half or two hours while you shoot the scene.

Wells (right) on set with Gemmill (left)

When you say that Jackson was already in that head space for the character, I assume that is because he — like the majority of other patients on the show, whether they are series regulars or background actors — have been on set for most of the shoot.  

Right. One of the things to know about the show is — the background actors are often on set for months. So that's actually been a really powerful thing for us. The actors start to become their role within the set […] because they were there for a long time. That's been a really powerful thing for us, because oftentimes, when they're bringing actors who aren't your regulars onto the set, they just come in, and they have to do their scene, and they are just introduced to their scene partner on the day and what the relationship or dynamic is. In our case, they spent months together. So what happens is, the actors start to become their role within the set. They actually explore their relationship when you're not even there directing. We found that to be a tremendous asset.

So when Jackson is first put in that isolation room, he is in there for every episode leading to the finale?

Every time that we're anywhere near that, he's in that room. And the actors are there all day long, so we can pull them in when we need them. A lot of times, if the room's comfortable enough, [the background actors] just stay. Because it was the same background the whole time, particularly the [actors] in the beds, they read books. We had one woman [playing] a pregnant patient who was right by the main hub area. In between takes, she would read books, because she couldn't get up. So she would just pull a book out, read, then put it back under the sheet when it was time to film, and then pull the book out and read. We all started to keep track of how much she was reading; she [had read more than 20] the last time I asked her.

Since The Pitt doesn’t put tape on the floor to mark where the actors need to stand, how challenging is it for you as a director to capture the intent of a scene without prescribed blocking every time? 

Part of it's really dependent upon the kind of camera work that you're doing. The West Wing was a classically done show, a lot of lighting. There, you really have to hit your mark because you're on lenses where you're going to be out of focus if you don't. On The Pitt, the cameras are all handheld, or on a rig — but not on a dolly. So the operator is dancing with the actor. The actor is getting to a spot. We have a general idea of where they're going to be. We block it so they know, like, “Oh, I'm going to come to this monitor,” or “I'm coming to this room on this side of the bed.” But it's really up to the camera that's mobile to maintain the shot and the focus, which is very liberating. 

Also, there's an imperfection in it that you see, which lends to an authenticity, I think, just in our visual language as viewers. That imperfection that we associate with reality, either from all the documentary work that we see, or news footage, things like that. So it's exciting. It's great for the younger actors, because I didn't want them moving around, looking down to see where their marks were all the time. Most of our actors come from the theater, so they just want to be in the moment, and keep going and not be as worried about the technical aspects.

You can see how that visual approach pays off in a scene like the one where Dr. Robbie takes the father of the measles patient to see the makeshift morgue they’ve set up in pediatrics, in an effort to convince him to let the doctors save his sick son. 

Scott wrote that [scene] into the script. Some of that comes from the doctors, like Dr. Joe, who were involved in the show, saying: "How do you convince someone to do something that's the right thing?" You've got to find some way to show them what is possible, because everybody's on their phone now doing "Dr. Google," as we say on the show, right? So the doctors are always talking about, "Okay, you're dealing with people who have all this information at their fingertips that's not very thorough, and they're telling you what they just read." Oftentimes, it is out of context and — particularly now that A.I.is taking over — there's nothing nuanced about it. They're just looking for the most average answer that doesn't have all the various things. So they were talking about how — if we can have an opportunity to show somebody what the aftermath of something might be — it oftentimes is most effective. So that's where that [scene] came from. The whole "Dr. Google" phenomenon is really a problem in the hospitals.

I assume more of that will be addressed in the second season?

Yeah. Because it's almost every physician, every day, is having to confront it. It’s much more nuanced than that.

Moving back to the finale — there is a graphic procedure and incision performed on a patient who had their pelvis crushed and is bleeding internally. How complicated was the special effects rig used to show that procedure? 

It's a practical rig that we built, so that we could stuff the gauze in there. The only thing in it that is visual effects is — we have to add the skin before it's cut, because the piece is already separated or pre-cut. We can put it together, but you're still going to see where the cut is so that they can keep going. So we take the scalpel — we do this a lot — that scalpel goes in and begins to cut, and then we have to make the skin [using CG]. We have to heal [the pre-cut wound], basically. That's very similar to what happened with the burn victim's arm earlier in the season.

The rest of the time it's almost all practical prosthetics, and they're fantastic. Our medical prosthetics and makeup people are fantastic. In fact, Doctor Joe Sachs — who's our lead physician writer on the show — had a great story. I think it was him, but it may have been a friend of his, who went to a dinner, and there was a surgeon there who [approached him], saying, "How are you using this footage? You're breaking HIPAA everywhere. You are violating these patients’ rights by using this footage. I don't know who gave you that footage."

Wow. They thought it was real patients or cadavers?

Yeah. And [Joe] said, "No, it’s all prosthetics. It’s special effects."

Behind the scenes of The Pitt

Did you or Scott ever consider having Dana’s attacker return before the season ended? Or give her some resolution on that, or was it always intended to be addressed off-screen? [Editor’s note: Dana learns that her attacker, who fled the scene, was eventually arrested]. 

Everything was done with a lot of attention to what would really happen — like, the reality of it. And the reality is that it would take a while for the cops to actually find him, then [Dana] has to file a complaint for him to be charged with assault. And then they actually go and arrest him. So there was no way, just within the timeline we were trying to stay very faithful to, that he would actually come back. And the only way he would come back would be if he got beat up a little bit or something, because they wouldn't bring him back to the hospital for it. So once we knew that David was going to get caught outside [the hospital] and be a little beat up and brought back in by the cops, we were like, "Well, we can't be doing the same thing," so that’s why that story point ends up where it does. 

The episode ends with the medical staff hanging out, having beers in a park. Decompressing after their very long and stressful shift. Was the intention always for the season to end on that note, or did you consider other ideas in the writers’ room?

We shot that in September, but we shot the final episode in February. Because it was one day when we went to Pittsburgh in September, we had to shoot everything there for the entire day, because we couldn't come back when the weather had changed. So Scott wrote the scenes on the roof — both the scene in the first episode on the roof, and the scene in the last episode on the roof. He also wrote the scene in the park and the scene where they cross the street getting to the park. And I shot all of those [scenes] in September with no scripts. The rest of the scripts were not written yet. 

So the actors — and Scott was there — we just talked about what we thought [the ending] was going to be. Then, through the last couple of episodes, Scott and I kept talking about, “Well, we already have that scene. It's shot. It's edited. You’ve got to get everybody in that scene to that place.” But, yeah, the last scene was shot months before. And [Scott] landed it. It was great. He did a fantastic job getting it there. It was very helpful for us to be at the real Allegheny General [Hospital] while we were shooting those.

This interview has been edited for length and clarity. 

The Pitt is now streaming on Max.