On the eve of its second season finale, “The Pitt” has firmly established itself as one of the most acclaimed and widely watched series on television. What began as a grounded, real-time look inside a Pittsburgh emergency department has evolved into a cultural touchpoint, praised not only for its relentless pacing and emotional weight, but for its unwavering commitment to authenticity. Week after week, the series has drawn audiences into the controlled chaos of frontline medicine, earning admiration from critics and the medical community alike.
Created by R. Scott Gemmill alongside executive producer and star Noah Wyle, and produced under the guiding influence of John Wells, “The Pitt” boasts an ensemble cast that thrives within its tightly constructed, high-pressure environment. The series has distinguished itself through a deliberate avoidance of melodrama, instead leaning into procedural realism and the human cost of healthcare. That approach has allowed it to tackle urgent, contemporary issues with nuance this season, including storylines centered on immigration enforcement and the ever-mounting financial burden of hospital care.
Yet for all of its narrative ambition, one of the show’s most defining achievements is something audiences may not consciously register at all: its physical world. The emergency department at the center of “The Pitt” does not feel like a set. It feels lived in, overstretched, and constantly in motion. That sense of immersion is by design, and it begins with production designer Nina Ruscio, whose work quietly underpins every frame of the series.
Having visited the set firsthand, it is striking how complete the illusion is. It would take a detailed inspection to realize you are not standing inside a functioning hospital. Every corridor connects. Every station is populated with purpose. The scale alone, stretching across more than 20,000 square feet, allows the camera to move uninterrupted through space, mirroring the urgency of the characters who inhabit it. As Ruscio explains, “We wanted the design to be invisible… to ensure the background didn’t distract you from the belief that you are in a real space.”
That philosophy extends to every detail, from the blanched color palette to the embedded lighting systems that eliminate the need for traditional film equipment. “The driver for me was making the space continuous to support the idea of the constant movement and energy of an emergency department,” Ruscio says. The result is a set that allows for complete freedom of movement, where handheld cameras can follow characters from one end of the hospital to the other without interruption, reinforcing the show’s real-time storytelling.
The authenticity does not stop at architecture. Outfitting the hospital required sourcing real medical equipment at scale, often from vendors outside the film industry. “To outfit an emergency department that can accommodate 52 beds or gurneys… we had to work with traditional vendors in the medical world rather than the film world,” Ruscio notes, describing the process as a “Herculean accomplishment” completed in under ten weeks. That dedication has not gone unnoticed, particularly by healthcare professionals who have responded to the show’s accuracy with rare enthusiasm.
For Ruscio, the impact of that response has been one of the most meaningful aspects of the experience. “I get letters from people in the medical community who say the show is so visceral and realistic that their spouses can finally understand what they’ve been doing for 30 years,” she shares. In that sense, “The Pitt” functions as more than just a drama. It becomes a translation of lived experience, a bridge between those inside the system and those observing from the outside.
Nina Ruscio spoke with Awards Focus about building the world of “The Pitt,” from designing a fully functional emergency department before a single script was written to the subtle choices that make the set feel endless, immersive, and undeniably real.
Awards Focus: “The Pitt” has really taken viewers by storm, and it’s wonderful to see a series return for a second season so quickly in the current TV landscape. Regarding the transition between seasons, were there any significant changes to the main production or the set design for season two, given that so much of the show is contained within the hospital and the E.D.?
Nina Ruscio: The physical space was deeply established in season one, but we did some extensions in season two that we hope the audience doesn’t even notice. It should feel as if it’s the exact same space. We extended the triage area because we were trying to hoard available space for support. As season two unfolded, we were able to extend that triage set in a way that felt so natural that I’m hoping nobody noticed it wasn’t there before.
AF: When you watch the show, it looks like a functioning hospital. As a production designer, is it actually more challenging to create a space that people are so familiar with in real life, especially when you have to account for the technical needs of cameras and crew?
Ruscio: You are right in that, in an imaginative world or a completely fictitious space, no one can be a critic because no one has physically experienced it. That level of unimpeachable reality was a critical driving force for us from the very beginning. To a certain degree, we wanted the design to be invisible; we wanted the physical space to be so natural that no one would think twice about it. We wanted to ensure the background didn’t distract you from the belief that you are in a real space.
That is why the blanched palette is so specific. It’s much more common to be in an “under-art-directed” space in reality, whereas medical dramas on television often have perfect lighting with complementary blues and hues. I very bravely chose a blanched palette dominated by whites, natural wood tones, yellows, and blacks. The yellow and black are subtle nods to Pittsburgh, as those colors are everywhere there. We also added historical architectural aspects to give the set a sense of place, like the columns that make you feel like you’re in a basement.
Regarding the space for the camera, that was not the primary driver because we knew we would be shooting handheld. The driver for me was making the space continuous to support the idea of the constant movement and energy of an emergency department, and accomplishing that on just a couple of stages. The lighting is embedded inside the design. We don’t have “wild walls” or grip equipment coming up from the floor. You can shoot from one part of the set—all 23,000 square feet of it—and continuously go to the opposite end and back. The freedom of movement and the curves that make the set feel endless were very important to me from the start.
AF: It’s an incredible achievement. We tend to assume that the medical equipment and supplies we see on screen are medical grade. Was that equipment difficult to acquire, or did you have to get creative to source items that typical Hollywood prop houses might not have access to?
Ruscio: For a hospital of this scale, there was no way we could support it with just what existed in prop houses. Mat Callahan, an amazing set decorator I’ve worked with on many projects, and RIck Ladomade, the prop master, are phenomenal. I call them the rock stars because the whole physical space is populated with accurate objects, right down to the p-touch labeled carts with specific, accurate items inside the drawers. It is all real equipment.
Getting it at scale was a task burdened by our timeframe. At that point, we were not yet a well-known show; we were working in our own little incubator. To outfit an emergency department that can accommodate 52 beds or gurneys, along with trauma booms and monitors, we had to work with traditional vendors in the medical world rather than the film world. We had liaisons from three high-end medical companies that Mat Callahan built relationships with. We also sourced from auctions and hospitals that were closing. Resourcing all of that and building the set in less than ten weeks was a Herculean accomplishment. We were driven by the goal of making sure no one would question whether they were in a real space.
AF: Building that in ten weeks is amazing; it reminds me of the effort to stand up hospitals during the pandemic. Regarding your own research, where did you go to find the models and inspiration to build the world of “The Pitt”?
Ruscio: When John Wells, Scott Gemmill, Noah Wyle, and Michael Hissrich called me for the project, they wanted the design before they wrote a word. They didn’t want to reverse-engineer the geography based on multiple writers’ perspectives of what the space should be. It was very prescient of them. I felt a great responsibility to make it functionally and globally realistic.
I visited as many hospitals as they would let me in. I actually had an infected bee sting at the time, which I used as a way to physically get into spaces. I used it as a calling card so I could go through the actual systems of triage, reception, and admission to see it firsthand. No one really takes pictures of these spaces because they are often traumatic experiences, so the documentation is slim unless a hospital is brand new. We have a great relationship with Providence, and I visited any hospital in the Los Angeles area that I could. I also buried myself in research from HOK Healthcare Systems, which is an architectural consortium responsible for many respected designs. I wanted to understand the norms so I could know how to twist them for our purposes.
AF: That is fascinating. When you were navigating those hospitals as a “patient,” were you relying purely on mental notes, or were you finding ways to sneak a few photos?
Ruscio: I was memorizing as much as I could, and occasionally I would pretend I was working on my phone while I was actually taking pictures.
AF: I don’t think anyone will have a complaint about that now, provided no HIPAA violations took place! Looking back, what was the most challenging part of the set to actually put together?
Ruscio: I might inverse that and say what I feel most satisfied with. One is the depth; no matter where you are, you can see from one end to the other. Because we weren’t going to use traditional lighting equipment like bounce boards, I designed “bounce” into every counter and floor material. The horizontal surfaces serve a secondary purpose of supporting the lighting, which allowed us to be brave with top-lighting.
I’m also proud of how we kept the eye active. There are subtle tricks—the lighting grid isn’t laid out in a rigid pattern; it’s intentional to keep the eye dynamic. The curves in the floor make the set feel endless. I was initially only designing for 15 episodes, but the design has sustained visual interest without people getting the “doldrums.” The architectural elements, like the columns and the marble, prove the hospital is 100 years old. Giving the show a sense of place in what is essentially a claustrophobic world was a challenge I set for myself, and I’m proud those goals were successfully met.
AF: It’s interesting that the writers wanted to see the ground plan before they started writing. How did your design—the curvature and the geography—influence what they were able to do with the scripts?
Ruscio: When I gave them that ground plan, I fully expected they would go into writing mode and then I would have to reinvent everything. But when Scott Gemmill gave the ground plan back to me in April, he hadn’t made notes about what didn’t work. Instead, he gave it back with post-it notes containing the names of patients in each physical room for three different episodes.
He had already used the geometry of the space to clarify the stories in his mind. It gave them the confidence to write a show with deep continuity. If you’re writing a show where time is calibrated hour by hour, you have foreground stories, middle-ground stories, and background stories. All those characters and patients have a life story and a path of travel for their day. The design supported that layer of storytelling.
AF: You mentioned the Pittsburgh influence earlier; how did you ensure the design felt authentic to locals?
Ruscio: During the design phase, we didn’t have a relationship with Allegheny General yet, but they eventually welcomed us with open arms for the exterior shots. Pittsburgh has architectural elements that feel a bit more European compared to New York or Chicago. I wanted to incorporate the marble, brickwork, and stonework to reflect that.
As for the color, you cannot go to Pittsburgh without seeing yellow and black—the bridges, the sports teams, everything. Those are the colorways for the Pittsburgh Trauma Medical Center in the show. There are also subtle “Easter eggs” in the set decoration. For the exterior ambulance bay, which we shoot in Los Angeles, I frosted the space with bricks and elements to relate to our set, but we use a blue screen view of Pittsburgh in the background. Even the “employee entrance” we use has a ramp going down, which plays into the double entendre of “The Pitt” being an underground foundation.
AF: Ultimately, the show is a beautiful tribute to frontline workers. Everyone I’ve spoken to says the cast and crew feel like a family. Given your extensive career, where does this project rank for you, and what has been your reaction to the positive reception?
Ruscio: I love every job I do, but this particular job has an extra layer of emotional and social impact. On a day-to-day level, this is an incredibly well-run organization. Everyone is so happy to be part of the community of “The Pitt.”
The biggest thing, however, is the feedback from the medical world. I get letters from people in the medical community who say the show is so visceral and realistic that their spouses can finally understand what they’ve been doing for 30 years. It validates and recognizes real people doing meaningful things. Knowing that this is a love letter to them gives us all great pride.
AF: I really appreciate you taking the time to talk. Good luck with the rest of the season and the upcoming awards season.
Ruscio: Thank you so much, Ben.