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Ithaca-area man’s life-saving care hinged on ED coordination, postponing vacation and cancelling a connecting flight

When Carl Gehres’ referral first crossed Oleg Shapiro’s desk on a recent February morning, he figured he would set him up with an appointment with his office in a week or two.

Gehres has kidney cancer and was referred to Shapiro, MD, director of clinical operations in the Urology at Upstate Medical University.

But when the nurses called Gehres to see how he was doing and to set up the appointment, Gehres reported that he could not urinate, but that he was passing a lot of blood.

When Shapiro heard this, he told Gehres to come to Upstate immediately.

“It sounded pretty ominous,” Shapiro said.

From there, a chain of events that unfolded in less than 12 hours and involved precise coordination between doctors, departments, and hospital locations—including two doctors rearranging their travel schedules—was set into motion to save Gehres’ life.

Gehres, 71, lives outside of Ithaca. About a week earlier, he noticed blood in his urine in the middle of the night, so he went to the nearby emergency room. He was diagnosed with kidney cancer and referred to Upstate.

He started having trouble urinating and some pain, and when he reported this to Shapiro’s office that day, Shapiro told him to get to the emergency department at Upstate Community Hospital immediately. Shapiro was supposed to leave for vacation that night with his family, but he pushed back his departure so that he could coordinate Gehres’ care and then do the surgery.

Gehres said he arrived at the Community Emergency Department around noon. His CAT scan was given priority and read quickly and that’s when Shapiro saw something else that made the situation even more dire and complicated.

In addition to the large tumor in his kidney, the scan revealed Gehres had a Level 3 IVC thrombus.

IVC stands for inferior vena cava, the largest vein in the body that carries blood to the heart. A thrombus develops when cancer cells grow inside the veins and Level 3 refers to the location of the thrombus. This one was pretty close to Gehres’ heart. Any delay and the thrombus could have reached his heart, requiring much more complicated surgery.

Shapiro would need to order an MRI for Gehres to see how far up toward the heart the thrombus went, but immediately called Urology Chair Gennady Bratslavsky, a urologic oncology specialist who he said is the only doctor skilled enough to deal with the thrombus.

Between Gehres’ bleeding and the thrombus, surgery could not wait.

“He could have died,” Shapiro said. “He was bleeding out significantly.”

Bratslavky, MD, the Phillip Capozzi M.D. Endowed Professor of Urology, was at John F. Kennedy International Airport in New York, on a layover on his way to San Francisco for a medical conference when Shapiro called around 6 p.m. Bratslavsky immediately booked himself on the last flight to Syracuse that night. He did not hesitate.

“A decision that was made quite easily and it is something I teach my residents,” he said. “It is answering a simple question. ‘What would I do if this was my family member.’ Despite all the inconvenience and delay in travel plans and missing a very important meeting thinking about it that way makes things quite clear and simple.”

In the meantime, Shapiro had Gehres transferred to the downtown campus for an MRI and to prepare for surgery in the morning.

From start to finish, everyone had to mobilize quickly.

Shapiro said credit goes to Community’s ED staff to get Gehres in quickly, get blood and scan him. At the downtown campus, Refky Nicola, associate professor of radiology, was arranging for a STAT MRI to see how high up the thrombus went toward the heart, Jennifer Lee from the urology department was arranging for surgery and cardiac clearance to be completed and Xiuli Zhang, MD, chair of anesthesiology, was arranging for cardiac anesthesia coverage on short notice.

Bratslavsky got back to Syracuse around midnight and at 7:30 a.m. the next morning was prepping for surgery. In the four and a half hour surgery, Bratslavsky removed the cancerous kidney as well as the IVC thrombus, resected and reconstructed the vena cava. He credited Thomas Vandermeer, MD, with assisting on the surgery. Vandermeer is Division Chief of Surgery and Interim Director of Upstate Cancer Center.

“Because of timely recognition, ambulance transfer, strong radiology performance, superb anesthesia, great administrative support, residents, many teams working together, this patient is alive,” Bratslavsky said. “A true example of a strong care at Upstate. He is walking and drinking today because of such responsiveness, willingness to help and accommodations.  He is alive because of this teamwork. This case highlights how tight the Upstate family is.”

Gehres, a retired carpenter and contractor, was up and walking the night of his surgery and after recovering for several days was discharged and is doing “fantastic,” according to Bratslavsky.

He will continue to come to Upstate for cancer treatments.

“I was impressed with how smoothy everything went,” Gehres said. “They really knew what they were doing. The nurses and everybody up there at Upstate were extremely qualified and they took very good care of me. I have to give credit to everyone in the ICU, my nurses, everyone. Even down to the guy cleaning the floor. In my world, in the construction world we always say you can judge a man by the way he sweeps the floor. I was impressed by everybody there.”

Urology residents Matthew Beamer, MD, Alexandr Pinkhasov, MD, and Michael Basin, MD, were also critical in Gehres’ care.

Caption: Carl Gehres, on a recent visit to the Upstate Cancer Center.