Endless Challenges: 48 Remarkable Hours with 8 Pittsburgh Doctors
Follow eight physicians over two days as they perform surgeries, consult on end-of-life care, treat accident victims, discuss hospital programs –– and then reset and do it all over again.
PHOTOS BY MARTHA RIAL
Over two days in February, Pittsburgh Magazine embedded a team at four Pittsburgh-area hospitals to observe eight doctors at work. We saw early-morning operations, sat in on heavy afternoon conversations about end-of-life care and heard about late-night accidents. We were humbled that patients so freely opened their rooms and lives to us. They told us about their illnesses and recoveries. They permitted us to watch surgeries; we saw their pulsing brains through open skulls, their lung-cancer operations, their CAT scans.
In the midst of frigid temperatures and snow, the hospitals never stopped moving; one of our visits took place on Ash Wednesday, when nurses with dark, smudged crosses on their foreheads cared for patients who couldn’t breathe from the flu and surgical teams came together to excise lung tumors.
This is our record of 48 hours — and the countless moments of care patients receive by the hour, shift and day — at Allegheny General Hospital, Children’s Hospital of Pittsburgh of UPMC, Ohio Valley Hospital and UPMC Presbyterian.
7:30AM Dr. Robert Kormos, Director of the Artificial Heart Program and Co-Director of the Heart Transplantation Program at UPMC Presbyterian in Oakland, starts his first surgery of the day. One of his patients had a small heart pump implanted about a year ago to help his weakened heart push blood to the rest of his body; now, the line that comes through the skin from the pump and connects to an external battery and controller repeatedly has become infected. Dr. Kormos and a team of plastic surgeons clean out the area and insert drains, staving off the need to change the heart pump itself.
8:13AM Members of the trauma team at Allegheny General Hospital in the North Side gather around an octagonal table in a room outside of the Intensive Care Unit to discuss their patients: new arrivals, who’s getting better, who’s getting worse, who’s leaving that day. Dr. Allan Philp, Trauma Program Medical Director for Allegheny Health Network, sips a bottle of pink Gatorade and leafs through the two-page list of patients. They have a full docket — car-crash victims, elderly patients recovering from falls and a few people who suffered injuries while committing crimes and will face prosecution when they’ve recovered. Considering that the team sees 3,200 trauma cases a year, it always has a full docket. “If we do our jobs well,” Dr. Philp says, “nothing exciting will happen.”
9:10AM On the seventh floor of Children’s Hospital of Pittsburgh of UPMC in Lawrenceville, Dr. Brian Feingold, the Medical Director of the Heart Failure and Transplant Program, is doing rounds with his residents; they visit the room of a child who, after two months in the hospital following a heart transplant, finally is starting to feel better. The boy also has regained his mischievousness — he grabs a syringe of water and sprays it onto Dr. Feingold’s shirt and pants.
9:15AM Back at AGH, Dr. Philp is doing rounds, including visiting with an older man who had fallen and a man who broke a few ribs and suffered a concussion while skiing. Dr. Philp’s pager buzzes; another man who took a fall is headed to the hospital via ambulance. As one of only three Level 1 — that is, equipped and prepared for any situation, and able to provide long-term and rehabilitative care after an injury — adult trauma centers in the region (the other two are UPMC Mercy and UPMC Presbyterian), AGH frequently is tapped to treat serious injuries — the results of bad car crashes and falls, shootings or assaults, industrial accidents. Philp has been at AGH since yesterday morning, cycling through patients. “It’s a little bit like NASCAR,” he says. “You spend your day just doing laps.”
9:40AM Dr. Rodney Landreneau, Division Director of General Thoracic Surgery at Allegheny General Hospital and Co-Director of the Esophageal and Lung Institute at Allegheny Health Network, is walking Dr. Mark Crye, his medical resident, through a diaphragmatic hernia surgery; both are in full medical gowns and masks. This procedure aims to treat a serious complication that occurs when the diaphragm pushes its way up into the esophagus, causing respiratory problems, acid reflux and abdominal pain. Using a minimally invasive laparoscopic technique, the pair is able to reach into the patient’s body cavity with tools, roughly the size of kitchen skewers, inserted through small ports. Using video cameras, they repair the hernia.
10:00AM Dr. Jean Tersak has been working since 6:30 a.m. — reviewing files and doing her own pre-rounds with patients — before she begins teaching rounds with her team at Children’s Hospital, where she is the Principal Investigator for the Children’s Oncology Group. Her medical residents recite the facts of a case, and Dr. Tersak gently asks questions, prodding them to make recommendations on treatment. They stop in the room of a preteen girl who has just been diagnosed with acute lymphoblastic leukemia, which will require more than two years of treatment. The girl is concerned about losing her hair and her ability to take part in physical activity during the course of the treatment. They agree to a plan to start chemotherapy later that day.
10:27AM Dr. Gary Sauer, a family doctor who in the past has served as the President of Ohio Valley Hospital’s Medical Staff, walks to the emergency room of the facility in Kennedy Township. A patient he’s known for 25 years has been admitted with gastrointestinal bleeding. The patient also is living with mesothelioma, a rare type of cancer which usually is incurable. In pain, he lies on his side, a thin blanket covering him. Two members of his family wait at the foot of his bed. Dr. Sauer puts his hand gently on the patient’s shoulder. “Hi, it’s Dr. Sauer. How are you doing today?” During a thorough exam, the doctor presses on the patient’s stomach and asks the man to squeeze his hand. He pulls back the blanket to see the patient’s pale, swollen feet. More friends arrive in the room to check on the man, and they are blunt: “What is your prognosis?” “I’m not being sarcastic,” Dr. Sauer replies gently. “But my crystal ball doesn’t work any better than yours.” They ask if they should call a priest; Dr. Sauer says yes. The patient has asked to discontinue additional transfusions, so Dr. Sauer orders only medications that help to make him comfortable. He walks out from the curtained room and behind the center pod of desks to dictate. At the end, he takes a minute to wipe his eyes — a rare occasion on which his calm, unflappable demeanor is shaken. Later, he shares his worry that this would be his patient’s terminal event. A short time later, that would prove to be the case.
10:30AM Dr. Robert Friedlander, Head of Neurological Surgery at UPMC and the University of Pittsburgh, meets with a middle-aged patient for a preoperative evaluation. She is scheduled to undergo surgery to treat an aneurysm tomorrow; the aneurysm was discovered after she came to the hospital complaining of a headache, which turned out to be unrelated. One of her brain’s blood vessels has a swollen bulge — akin to a bike tire with a spot that has thinned and swells out with air. Her aneurysm has developed in a very unusual place, nestled between the hemispheres of the brain. There is only a 1 to 3 percent chance of it rupturing in a given year, her doctors assess — but if it does, she has a 50 percent chance of dying. Dr. Friedlander plans to find the aneurysm in her brain and clip it with a tiny metal pincher, essentially making the blood vessel back into the stronger bike tire that it once was. The patient looks at the clips in his hands, and she asks if she can opt for the purple clips. He tells her yes.
10:30AM Hernia fixed, Dr. Landreneau ducks out of the operating room at AGH, grabs his white labcoat and a Styrofoam cup of coffee and sneaks in some quick rounds. Dr. Landreneau spent two decades as a thoracic surgeon at UPMC Presbyterian before doing a two-year stint at the Ochsner Health System Cancer Institute in his hometown of New Orleans. Last year, AHN convinced him to return to Pittsburgh. He checks in on a patient with a torn esophagus; the patient has recovered and is going home tomorrow.
11:04AM Around a dozen medical staff have converged in AGH’s Shock Trauma unit for the arrival of the elderly man who was injured in a fall. The roster includes two emergency-medicine physicians and a resident, a surgery resident, a pharmacist, a handful of technicians, a respiratory therapist and Dr. Philp, the trauma surgeon. It’s a huge chunk of staff, but the response ensures they can deal with almost any injury. Paramedics wheel in the man, who is moved over to the exam table. He is conscious, talkative and complaining of neck pain; after a nurse takes his vital signs and the team determines that he’s stable (X-rays show that he’s broken a bone in his neck), most of the team members are released to head back to their respective departments. “I’d rather be over-triaged,” Philp says. “It’s the whole point of having a trauma system.”
11:15AM At Children’s, Dr. Feingold speaks with a patient’s mother about a conundrum — her son’s medications are controlling his dangerous heart rhythms, but one of the medicines likely is causing him to throw up after eating. They need to find a balance that will ensure he will gain weight but also will prevent further injury to his heart.
11:48AM Dr. Sauer is excited to see his next patient — he has seen this woman walking up and down the halls at Ohio Valley, and he’s thrilled that her leg strength is returning. She checked in with Guillain-Barre, a disorder that resulted in progressive weakness and numbness in her body. Now she can feel her thighs more, her feet no longer are tingling and she feels her fingernails when pressed against her shin. She is delighted when he tells her she’s strong enough to take a shower.
12:00PM Patients who receive cancer treatment at Children’s are encouraged to return annually for a check-in, ongoing education and bloodwork at the hospital’s Survivorship Clinic because a third of childhood cancer patients will have a serious health effect months or years after completing treatment. Today, Dr. Tersak, who founded the clinic, notifies a mother that recent tests on her teen son — who underwent a bone-marrow transplant as an infant — show abnormalities of the liver. He could have a second cancer or a benign lesion, so he will have to return for more tests and, in all likelihood, a biopsy.
1:00PM Dr. Kormos is meeting with Dr. Richard L. Simmons, chairman emeritus of surgery and the former chair of surgery for UPMC. The two are trying to develop a way to better predict the optimal time in the course of illness for a patient to receive a heart pump. They think that inflammatory signals in the blood might be excellent signposts as to when a patient needs the surgery. “Even though a patient might feel good and not want a heart pump operation, it may be that his body and his blood work could tell us that he’s headed into a zone where there could be a lot of problems,” Dr. Kormos says.
1:15PM Dr. Friedlander follows up with a patient at UPMC who suffered strokes due to severe bilateral carotid artery disease, a narrowing of the arteries in the neck that supply blood to the brain, which places the patient at risk of having a stroke. Dr. Friedlander had performed a carotid endarterectomy, removing the inner lining of the arteries to reduce that risk. He is pleased; the patient is doing even better than he expected.
1:50PM Dr. Kelly Zbanic, a general surgeon at Ohio Valley Hospital and a former military surgeon, consults with an elderly patient and the woman’s worried daughter. The patient, a cancer survivor, was nauseated and vomiting when she checked in. Dr. Zbanic is sympathetic; she’s a warm, effusive doctor who can’t help but treat patients like her own family. She often sees the same patients through the years, and she knows this patient and the patient’s daughter. She talks through her plan carefully with them; she intends to insert a nasogastric tube, which will help with the patient’s small bowel obstruction and help to ease the nausea.
2:25PM While waiting on his last surgery to be prepped, Dr. Landreneau steps into a meeting with hospital executives to discuss the creation of a lung transplant program at AGH. Due to the ongoing, years-long battle between UPMC and Highmark, the parent company of AGH and the rest of the Allegheny Health Network, AGH is ramping up its facilities in an effort to ensure its offerings are as strong as those of its competitors. A short time later, down in the operating room, Dr. Landreneau “scrubs in” for surgery on a patient with lung cancer. Dr. Crye has installed metal ports between the patient’s ribs, so the doctors don’t need to cut open the patient’s chest — instead, they extend cameras and long metal forceps directly into the cavity and operate via TV monitors, as is customary for most invasive surgeries. Dr. Landreneau locates the cancerous nodule and removes a small piece of lung, using a tool that cuts and then staples the wound closed. He puts it on the table and cuts it open; the tumor resembles a hunk of white fat in the middle of a steak. He cuts out biopsies to send to the lab for testing, and, letting Dr. Crye finish up the stitches, goes out to give a report to the patient’s family: “He did great!”
4:00PM Dr. Feingold spends a half-hour on the phone. It’s a conference call with fellow investigators working on a national Pediatric Heart Transplant Study project on late post-transplant lymphoproliferative disease, one of the most common side effects that can occur in transplant patients — and one that can result in lymphoma, a blood-cell cancer. In addition to their work treating patients, many of Children’s physicians work on research projects to further understanding of medical treatments.
4:30PM Dr. Kormos and his wife work in time to do their taxes. “Sometimes you put your real life down on the bottom of the list,” he says.
8:00PM At home, Dr. Tersak begins prepping for Thursday afternoon’s Survivorship Clinic at Children’s. To be ready for meetings with patients, she carefully reviews their files to understand their illnesses and medical histories.
4:30AM Up early for most (but not for him), Dr. Landreneau squeezes in work on a manuscript on lung-cancer therapy treatment for the Medical Cancer Journal.
5:30AM Having been awakened three times throughout the night by phone calls regarding admissions at Ohio Valley, Dr. Sauer is tired. One call was for a woman who had pneumonia and fell, breaking her humerus bone in her upper arm. Another involved a patient with diabetes who exhibited symptoms suggesting a stroke. This is something that keeps him up at night — patients, he says, seem sicker and sicker these days. He says he’s frequently trying to balance multiple ailments and treatments.
6:45AM Elsewhere at Ohio Valley, Dr. Zbanic meets with a patient who needs an umbilical hernia repair. His caregivers make sure to identify the patient two ways — typically checking the patient’s birthdate and Social Security number — as well as having the patient state what procedure is being done. The word “Yes” is written on the side of the patient’s body where surgery is planned. Forty-five minutes later, Dr. Zbanic starts the surgery. She makes an incision under the patient’s belly button and dissects around to the fascia, the layer of tissue that holds everything in the abdomen. She dissects down to the defect in the fascia and uses a prosthetic mesh to close it up. The procedure takes around a half-hour, and the patient will be able to go home later that day.
8:15AM On the fourth floor of Children’s Hospital, Dr. Feingold is doing early-morning rounds in the Cardiac Intensive Care Unit, a small, 12-bed unit that houses children in serious cardiac distress — both those in desperate need of a transplant as well as patients who are recovering from cardiac surgery. In the corner room overlooking the Allegheny River, an infant is propped up in a Baby Bjorn bouncer, fussing. Born with a congenital heart defect, he’s already had multiple heart surgeries in his short life and now is awaiting a transplant. Dr. Feingold and his medical fellow, Dr. Meghan Doherty, move around the boy’s bed, waving toys at him as they listen to his heart. Dr. Doherty asks the nurse if the boy always is so fussy. “I was here on Saturday, and I feel like he cried all day,” the nurse replies. “But once his grandmas get here, they hold him all day, and he’s much better.” There’s not much they can do to make the boy less irritable — he needs constant infusions of intravenous medications to keep his heart pumping and liquid nutrition to keep him growing.
8:20AM After working a 36-hour shift from Tuesday morning through 6 p.m. Wednesday, Dr. Philp already is back in the Trauma Center at AGH, ready to pull another 36-hour shift. He continues his NASCAR laps, rounding through new patients and old.
8:35AM Dr. Friedlander begins his surgery on the middle-aged patient with the aneurysm. An incision is made, and the patient’s scalp is pulled back. He uses a drill to take out two parts of her skull in a circle, resembling a yin-yang symbol, to avoid a vein. A plastic bag hangs underneath the patient’s head to catch blood. The brain is strangely beautiful, like a group of shrimp captured in a prenatal sac and breathing as one. “Every time I see it, my heart beats fast,” Dr. Friedlander says.
8:45AM A few patients later, Dr. Feingold meets up with a big group of rounding cardiology doctors and residents outside of the room of a particularly difficult case. An infant girl underwent a heart transplant at Christmastime, but the transplant failed; the heart had to be removed. Now awaiting another heart, she’s being kept alive by twin ventricular assist devices — external pumps that function as the left and right sides of her heart. Even successful heart transplants generally last only around 15 years, doctors note. “Transplant is a good therapy, not a great one,” Dr. Feingold says. “But when you’re in this state, it’s a very easy decision.”
9:15AM After doing post-operative check-ins on his patients from Wednesday, Dr. Landreneau is back in an operating room at AGH, conducting another surgery on a patient with lung cancer, followed by a diagnostic procedure on a patient with esophageal cancer.
9:38AM “Aneurisma è morto,” sings Dr. Friedlander — Italian for “aneurysm is dead.” It took two of the delicate, 2-mm purple clips to cease the blood flow to the aneurysm. To be sure it was indeed dead, he poked a hole in it with a needle to make sure no blood leaks out. Aneurisma è morto.
9:40AM Up on the ninth floor of Children’s, Dr. Tersak is conducting her teaching rounds, accompanied by two interns and one senior resident. She stops in to check on a boy tucked under a Pittsburgh Steelers blanket. With only two days of chemotherapy left, he clearly is over his hospital stint, complaining good-naturedly to Dr. Tersak about being woken up during early-morning rounds. “He’s really an amazing kid,” she says after the encounter. “They are all really amazing.” Fifteen minutes later, she drops in on the pre-teen who started chemo yesterday; balloons fill the corner of the girl’s room, and she’s nearly crowded out of the bed by stuffed animals. Her concern about losing her hair has been replaced with an attitude of resiliency, and she is cheered by the thought of getting wigs made with her own hair. “I’m going to get a bob [haircut],” she tells Dr. Tersak shyly.
10:00AM In a break from rounds at AGH, Dr. Philp, the trauma surgeon, starts a marathon session of meetings — more than four hours in a row. All these talks would be focused on ways to improve patient care at the hospital.
10:40AM A happy hiccup: During rounds, one of Dr. Tersak’s patients is not in the room but instead is down the hall in the playroom, so the doctor will have to return later. “You never pull a child from the playroom,” she says.
11:15AM On the seventh floor, Dr. Feingold checks in on his mischievous child — who, in the past 24 hours, has had his hair shaved into a Mohawk strip. The boy points to Dr. Feingold’s head, and he plays along: “I should get a Mohawk?” The boy nods and his father laughs, “You want me to do it?” The boy pulls out a stethoscope from the doctor’s white coat and places it on his heart and then on his forehead. Turning to the parents, Dr. Feingold delivers the long-awaited news: “You should be able to go home next week.”
11:55AM Dr. Friedlander visits the aneurysm patient, who already is awake. He tells her that she didn’t just get her purple clip — she got two purple clips. She laughs. “And I got you done in time for lunch,” she jokes.
1:15PM At Children’s Survivorship Clinic, Dr. Tersak sees a string of patients in their annual checkups and is happy to inform them that the department’s annual celebration at Kennywood Amusement Park will be back again this year. At one point, Dr. Michael Wollman stops by to see a former patient, a gangly teen who overcame a pelvic sarcoma. Dr. Wollman is the dean of the oncology department — he served his residency at Children’s back in 1970 — and he has seen a revolution in treatment during his career. When he started in medicine, he says, the cure rate for childhood cancers was around 20 percent; today, it’s up to 80 percent.
1:30PM Dr. Kormos meets with a patient in early middle age who is considering a heart pump at UPMC. The patient has a damaged heart and kidneys, as well as a painful hematoma in his abdomen after a car accident. He uses a wheelchair and takes steroids to treat arthritis. Heart pumps can be used to assist three types of people: those waiting for a transplant, those who have a temporary condition from which they need to recover before a transplant can be performed and those who need a transplant but don’t qualify for one because of pre-existing conditions that could be reversible over time. This patient falls in the third category. The heart pump could help him to live more than five years, if the surgery doesn’t hurt his kidneys, trigger a stroke or induce other complications that are possible with any open heart surgery. The patient asks if there are ways the hospital can make him comfortable when he dies. He says he’s seen someone die, gasping for air, and he says he doesn’t want to go that way. Dr. Kormos assures him that there are palliative care experts to make him feel as relaxed and comfortable as they can. “The question is: Do you want to continue to live? Do you want to go through the procedure, knowing that we’re changing the engine of the car but the shocks and the fenders are what they are?” Dr. Kormos asks. The patient considers the option. He’s worried about his kidneys failing. He’s worried about being a burden to his family. And he’s worried about suffering more after living such a painful life. Walking out of the appointment, Dr. Kormos reflects on the blunt and wrenching conversation. It’s not the first time that he has addressed the questions of patients and families as they’ve wrestled with terrible decisions amidst tears. “I want them to understand the reality. Some doctors — their approach is telling people they can fix it and make it better. The worst thing you can do is promise a patient something that then doesn’t deliver.”
2:05PM Dr. Landreneau spends a busy afternoon in the outpatient clinic of AGH’s Allegheny Cancer Center, treating a dozen patients with a variety of conditions, including lung cancer and gastroesophageal reflux.
2:20PM Dr. Tersak takes a quick break from the Children’s Survivorship Clinic and heads over to speak with the family of a boy who has been diagnosed with leukemia; she’s informing them about an opportunity to participate in a clinical research study. She assuages the family’s concerns — they won’t be doing any experimental treatments. Rather, the study will involve taking a small extra sample of his bone marrow to send to a national bank, where scientists and doctors can analyze it. Dr. Tersak tells the boy’s mother: “It really is the way we were able to improve the treatment of leukemia.” The mother agrees; the boy’s treatment will start that evening.
4:00PM Dr. Zbanic consults in The Wound Care Center at Ohio Valley. Many of her patients have complications from diabetes, resulting in damaged nerves that don’t send the appropriate pain signals and lead to injuries. Ohio Valley is known for its Wound Care Center; it has treated thousands of wounds on site. The center also has adopted the use of hyperbaric oxygen therapy — patients sit in a chamber filled with oxygen, which accelerates the healing process.
4:30PM At Children’s multidisciplinary tumor board — a medical team that discusses treatment for patients — Dr. Tersak presents her plan for a very young child with a high-risk neuroblastoma, a type of cancer that affects nerve cells. Dr. Tersak advises an intensive year-long therapy including five courses of multi-agent chemotherapy induction; a surgery to remove the primary tumor in the abdomen; a bone-marrow transplant; radiation therapy; and five courses of a special antibody against the tumor to try to eliminate any remaining disease. The board gives its approval to move forward with the complex regimen throughout the spring.
7:30PM Dr. Sauer makes rounds for two-and-one-half hours at the Residence at Willow Lane, an assisted-living facility that is affiliated with and located across the street from Ohio Valley Hospital. After more rounds at the hospital, office hours and yet more rounds, he finally heads home for the night.
9:30PM After having dinner with his family and putting his kids to bed, Dr. Landreneau returns to his lung-cancer manuscript.
10:00PM Dr. Philp has two general surgery cases land in the AGH trauma center this evening, including a recent heart transplant patient who needs surgery to repair a bowel obstruction and a patient with cardiac disease who needs to have a section of dead colon removed. He will work until 6 p.m. the next evening, handling a car-crash death, as well as admissions for brain injuries, spine fractures and multiple gunshot wounds. For doctors at a hospital such as Allegheny General — or UPMC Presbyterian, or Children’s Hospital of Pittsburgh of UPMC, or Ohio Valley Hospital, or other facilities throughout western Pennsylvania — the laps never end.
Jennie Dorris, a columnist for Pittsburgh Magazine, also has written for Real Simple, Entrepreneur and Boston Magazine. Patrick Doyle is a contributing writer for Pittsburgh Magazine, and his work has been published by Outside, MIT Technology Review and Monocle.