HE SUN HAS BEEN UP for about 15 minutes when Dr. Pyongsoo Yoon maneuvers his silver Toyota Sequoia into the parking lot at Forum Health Trumbull Memorial Hospital in Warren.
The drive from his home in Poland has been smooth; the previous night's rest was not. When he arrived home from the hospital around 8:30 p.m. the night before, he ate a quick dinner with his wife and 22-month-old son.
Exhausted from performing two surgeries, he sank down on the couch to watch a DVD of "The Incredibles." The 44-year-old surgeon loves movies, and he enjoyed this one, especially because it gave him extra time with his son and it did what he wanted it to do: It relaxed him and helped sleep to come easily.
That sleep, however, didn't last long. The phone rang at 1:30 a.m., again at 3:30 a.m., and for a third time at 4:30 a.m. He didn't really try to go back to sleep the last time.
"This is the worst part of the job," Dr. Yoon says. "It's part of our life, but it's hard. You learn to sleep when you can." His wife handed him a grab-and-go breakfast sandwich, and he headed for Warren before 6 a.m. On his schedule: patient rounds, two coronary bypass surgeries at Trumbull, quick visits with the families of his surgical patients, a trip to Northside Medical Center in Youngstown for his third surgery of the day, more visits with patients and anxious family members.
And if he's lucky, dinner -- probably a very late dinner -- with the family. Dr. Yoon is chairman of the cardiovascular medicine department at Forum Health.
Chance of a lifetime
In many ways, it's his dream job. He joined the staff at Forum in August 1997, coming to the area after five years in Pittsburgh.
Three years ago, Forum asked him to create a heart surgery program at Trumbull. He took on the task with a surgeon's confidant bravado -- he wanted the best of everything, and in large measure, he got it.
His primary operating room at Trumbull is a large, gleaming room with the latest in high-tech equipment. A camera situated directly over the patient beams the surgeon's every move to a monitor six feet across the room.
Another machine, a transesophageal echocardiogram, allows the surgeon and anesthesiologist to keep an eye on complications that might arise during surgery. Yoon is especially pleased with the epiaortic ultrasound, which measures the degree of calcification in the aorta.
Without the machine, a surgeon palpitates the ascending aorta for signs of atherosclerosis. Palpitation is inexact, and without ultrasound's precise measurement, patients run a much higher risk of a stroke, which Dr. Yoon says is the "most devastating" complication of bypass surgery.
Perhaps his favorite high-tech introduction is endoscopic vein harvesting. Using this method lessens one of the most painful parts of bypass surgery, Yoon says. To perform bypass surgery, a vein from the patient's leg, called a saphenous vein, is removed and grafted into the heart, replacing blocked arteries.
Getting to that vein is usually done by making a single incision from the patient's groin to the ankle. The pain from that incision is much greater than pain in the chest after surgery, Dr. Yoon says.
"Most people are going to complain about pain in the legs," Dr. Yoon says. "They don't talk about their chest. It's the leg. It takes a long time to heal. And there's a long, ugly scar."
Endoscopic vein harvesting changes all that. The technique uses a long, thin instrument with a tiny camera attached to create a tunnel in the leg down the length of the saphenous vein.
Carbon dioxide gas is used to inflate the tunnel as branches leading to the vein are sealed. The vein is removed through the tiny incision.
The cut to the leg is about one centimeter, and patients have minimal pain after surgery.
"Less wound complications," Dr. Yoon says. "Better for the patient. Especially easier for the ladies with the big fat legs. So much less pain after surgery."
The endoscopic technique is not used at every hospital, Dr. Yoon says, but he believes it should be.
"This is our standard of care," he says. Yoon explained how the machines work like an 8-year-old demonstrating his Xbox on Christmas morning. He likes what technology can do but it's not because he's dazzled by the wizardry of it all, he says. For Dr. Yoon, it comes back to what it does for the patient.
"We try these things because we are dedicated to the patient 100 percent," Dr. Yoon says. "We can't hold back. We can't say, 'Oh that's new, that's too complicated, we can't try that, we might get sued.' To me, that should not be an issue. You're the only hope that patient has. I think there is a way to minimize risk, to give this patient an improved chance at life."
On this midweek morning, it's a few minutes before 7, and Dr. Yoon is heading for the coronary intensive care unit to check on a patient whose bypass he completed 14 hours earlier.
She's in her 70s, he explains, a very sick woman who came through the surgery with no complications. He expects her to be doing well this morning. It's a brisk walk through a maze of corridors. Dr. Yoon has about 15 minutes before he's due in the operating room; his team is already there, prepping the patient for surgery.
He arrives at the nurse's station on the floor, slowing down but not quite stopping as he calls out to a nurse: "How's she doing this morning?" He doesn't wait for an answer. He walks to the patient's bedside. "How you doing today? You doing good?"
He quickly checks a chart, chats for a few seconds with the patient, who is still groggy but responsive. He gives a brief instruction to a nurse, then keeps moving, perpetual motion in royal blue scrubs.
In the next five minutes, he answers two beeper calls, consults with another doctor and heads to his office to show a visitor the computer pictures of blockage in the arteries of the patient who is waiting for him in the operating room.
At 7:22 a.m., he joins his team in surgery. He trades his glasses for some high-tech specs. They're black, horn-rimmed, custom-made glasses with tiny microscopes built in. They're kept in a wooden box with an engraved nameplate on it.
"These are thousand dollar glasses," he says, laughing. "You would think they'd look better for a thousand dollars."
"Hey, you can get them for $300 on eBay," a staff member cracks.
"As nice as these?," Dr. Yoon fires back, with a laugh. "Next time, I'll go to eBay."
Dr. Yoon picked and trained his team at Trumbull when he set up the program. After 1,000 surgeries together, they work as if choreographed. There's not a lot of technical chatter; everyone has a job and they do it without instruction.
The surgery begins at 7:28 a.m., with physician's assistant Anna Gursky making the leg incision to start the vein harvesting. At her side is another physician's assistant, Erica DiFrangia.
The two work together on the patient's right side; a monitor showing the endoscope's progress in the leg is two feet away, to the left of the patient.
At the patient's head is Royce VanDervort, a certified registered nurse anesthetist. He administers the mix of drugs that keeps the patient sedated during surgery and he watches vital signs along the way. He works with anesthesiologist Dr. Mike McMannis as the surgery progresses; one or both of them are in the room at all times.
Dr. Yoon is stationed at the patient's chest, ready to make the incision. But first, he deals with a housekeeping issue: music. "Turn the music up," Dr. Yoon says. "I can't hear it."
Now he can hear it, and he's not happy.
"What the hell is that?," Yoon asks as George Michael sang "Careless Whisper." "Let's have some music from the '70s," he says. His team alternately groans and snickers.
"Come on ... let's have some old people music." Fleetwood Mac is on now, and the doctor is happy. A nurse laughs about his taste in music, which she says is either classic country (Hank Williams, Conway Twitty) or Christmas tunes.
"It doesn't matter what time of year it is," she says. "He loves Christmas music."
The surgery is moving along. Dr. Yoon makes an incision in the middle of the chest and separates the breastbone by using a small saw. There's a slight burning smell as he uses a cautering pen to stop bleeding. At 7:40 a.m., he asks for a stool. At this point in the operation, he has a better view if he's seated.
Once he's made the first cut, he instructs a nurse to call the family to let them know what's going on. Meanwhile, the vein harvesting is going slowly. Women, the doctor explains, have smaller legs and smaller veins, and the process can take longer.
"I need three pieces," he instructs Gursky. "I'll give you about 10 minutes ... 1001, 1002, 1003 ... " Dr. Yoon is always in a hurry, and his team kids him about it. He's impatient, frequently clapping his hands together, saying, "Chop-chop." As he waits for the vein he needs, someone asks," Are you this impatient at home?" Yoon laughs, telling them that his son is picking up his habits.
"His first words were 'Mommy,' 'Daddy,' and then 'chop-chop.'"
"I believe it," someone answers. Dr. Yoon's beeper sounds; a nurse answers it and relays a message to the surgeon. He tells her to return the call. He's often interrupted during surgery, he says. "It's just part of what we do."
The veins are now ready for attachment, and the patient is ready for the heart-lung machine. The patient's heart is stopped, and this machine, which does the work both of the heart (pumping blood) and the lungs (oxygenating the blood) is put to work, operated by a trained technician called a perfusionist. On the Trumbull team, two perfusionists are working: Pete Glatz and Paul Thomas.
At this point, the tone changes in the operating room. Music is turned down; chatter stops. The doctor is all business.
"Our goal is to spend as little time as possible on the machine," he explains. Careful note is made of exactly when the machine starts working and when it stops. Every second counts.
"I have the whip in my hands," he says. Dr. Yoon and Gursky work on either side of the patient's chest, putting plump new veins in to replace the thin old ones.
In just a little over an hour, the patient is off the machine and breathing on her own.
He's now ready to reattach the breastbone with surgical steel wires. As soon as she's stitched up, he flies out of the room, on his way to a room where family members are anxiously waiting for news.
"She's good," he tells the four family members who join him in a tiny room. In all, four arteries were replaced; one was completely blocked, one had about 80 percent blockage and two had 90 percent blockage.
"The heart muscle looks good," he tells them, drawing the new arteries on a diagram of a heart. "Everything looks really good. We're kind of mimicking what God gave her here."
From there, he's on his way to the doctor's lounge where a treat awaits. It's Doctor's Day at Forum Health and two massage therapists are standing by to give back and neck rubs to the physicians. Yoon bypasses coffee for a turn in the chair.
For 10 minutes, he is quiet as doctors around him watch CNN, drink coffee and grab pastries.
Glatz is relaxing between operations, too. A former skater and landscaper, he said he loves his job as a perfusionist because it's "extreme" -- stressful, difficult, demanding and rewarding.
Doing hearts, he says, is the best job in the hospital, and Yoon has been a great teacher. "He's the kind of guy you'd take a bullet for," Glatz says. "He's in this for all the right reasons, and what I mean by that is that the patient's best possible care is his motivation. His work ethic is indescribable."
Thomas agrees. "He's got that ability to think and act in a crisis. He demands perfection ... and he should, because we're dealing with people's lives."
His team members say he's quick to take them to task, and he can be harsh. But that never leaves the operating room. Yoon doesn't hold grudges, they say, and that isn't always the case in a hospital.
"He respects you, personally and professionally," Thomas says. "He will chew you out in a minute if you make a mistake, but then it's over. And he doesn't hold it up to you later."
Over lunch in the hospital cafeteria, talk turns to the heart -- but not surgery. Yoon is telling the story of how he courted his wife, Sina. He got married in his native Korea in April 2002; he left the country with his parents in 1973, but he goes back nearly every year to teach and perform surgery. A first-time dad at 42, he delights in fatherhood.
"My son is a Xerox of me," he says.
After an orange soda and grilled chicken salad, he dashes off to his second bypass of the day. The patient is in his 40s, young by heart surgery standards. Yoon looks at the lungs, noting the black splatters that signal a smoker.
"I think he says he was going to quit," he says. "He should quit. Look at the lungs." The surgery is a quick one, even though five arteries were attached. Because he was a young man, his veins were thicker and easier to work with. Less than an hour on the heart-lung machine and the patient is stitched up.
While his team wraps up, Yoon peels off his gloves and dashes down to the waiting room to give the anxious family the good news.
With no time to spare, he's on his way to Northside, where an 84-year-old patient is being prepped for the doctor's third bypass of the day. Yoon was a track star in high school. He says the stamina he developed as a cross-country runner helps him now, even with the 25 pounds he's put on since getting married.
He was a multi-tasker even then: he went to school, was a state champion runner and worked the night shift in his father's doughnut shop.
"As a runner, you are competing against yourself, and that's what I do now," Dr. Yoon says. "I am pushing all the time to be better. I learned self-discipline and endurance ... and I hate doughnuts."
At Northside, he's stopped three times on the way to the operating room; when he arrives, the surgery is without complication. As he does after every surgery, he congratulates his team.
"I couldn't do it without these guys," he says. "I'd like to think I can, but I can't."
For the third time in seven hours, he heads to a waiting room to give good news to a family. This time, the patient's son jumps up and pumps the doctor's hand.
"Doc, do you remember me?," he says. "You did my heart, three years ago."
"Sure, I remember," Dr. Yoon says. "Let me see your scar." After a quick check on patients, Yoon sits down for another treat. In honor of Doctor's Day, unit clerk Maryanne Lloyd has something special waiting for him -- his favorite, pineapple sherbet from Handel's.
It's after 6 p.m. -- dinnertime in most households -- but he's still got patients to see. His wife calls and they chat briefly in Korean. He'll be home, he says, in about an hour.
Being married to a heart surgeon is difficult, he admits. When he comes home, he collapses, plays with the baby and falls asleep. He loves to watch movies -- "Gone With The Wind" and "The Sound of Music" are his favorites -- but his work doesn't leave much leisure time.
He plans to keep operating for 11 years, but don't look for him on the golf course at 55.
After he hangs up his scrubs, he wants to teach, preferably in underdeveloped countries where medical education is needed. Before then, he says, his goal is modest: He wants to build a program that lives long after he's gone.
"I want to leave a legacy," he says. "I want to build a stable, perpetual program with good people and a good system. And I want another baby."