I am an MSIV doing my first EM rotation...so I'm no expert...but one of the biggest differences between "ER" and our Emergency Department is the speed of processing. On TV, patients might have to wait for hours before they are seen but once they are, medical miracles happen at an extraordinary pace. In our ED, except for trauma "stats" or bonafide medical emergencies, things proceed at a more sedate but deliberate pace.
Also, real patients are not as glamourous or quaint as TV patients. Sure they attempt to portray the seamy underbelly of society on ER but somehow the TV patients always manage to have either charm, a compelling story, or some obvious redeeming quaity. Even the villains have their charms and are interesting to watch. The reality is that it is hard to get ratings by showing obese, unwashed, non-compliant, alcoholic patients urinating on themselves and sporting nasty, disgusting, fungus-encrusted talon-like toenails.
Sorry. I hate nasty feet.