Fake Throat, Real Body, Lived Experience

While The Pitt has never shied away from prosthetics when it comes to blown-off hands or an extremely vivid vaginal birth, there’s nothing fake about Howard Knox, the 472-pound patient wheeled into the ER in season two, episode eight.

Played with compassion and charm by ER veteran Craig Ricci Shaynak, Howard has walked a long path to his current weight. Based in part on Shaynak’s real life, Howard’s plight involves a car accident, some burns, a few surgeries, and years of general isolation, all of which add up to a complicated and sympathetic story when he arrives at the ER with a fever and abdominal pain.

And yet, to holier-than-thou doctors like young Ogilvie (Lucas Iverson), Howard is a cautionary tale: a glutton who can’t control himself, a rube who hasn’t heard of Ozempic, and a lazy slouch who can’t manage to drag himself to aqua aerobics. While Howard’s case is full of nuance, Ogilvie initially only sees him as an overweight patient who might be better served by the medical facilities at the zoo. 

It’s a breathtakingly callous statement, especially when made within earshot of the patient, yet to many larger-bodied people, it’s a very real concern. (Shaynak himself says he feared he’d have to be weighed at the zoo seven years ago when he went to the hospital, only to be told that some hospital beds now have a built-in scale that can weigh patients up to 1,000 pounds.) In fact, all of what Shaynak’s character faces on The Pitt — from the troubled intubation and crass comments to the startlingly high mortality rate for a necessary procedure — stems from a truth that Shaynak and many viewers of The Pitt know all too well: Despite the fact that nearly 40 percent of Americans qualify as obese, the medical Establishment (and the entire world, really) doesn’t care to accommodate overweight people.

“I wanted to pull at the heartstrings of viewers so they’d understand where someone like Howard came from,” says Dr. Joe Sachs, who wrote episode eight. “I wanted them to have empathy for this individual’s life story.” 

The concept: “A very special need for compassion”

Sachs, a writer and onetime emergency-medicine physician who also, coincidentally, wrote Shaynak’s decades-old episode of ER, says the concept for Howard’s arc came from two places: the desire to show a procedure viewers hadn’t seen on the show — an awake fiber-optic intubation — and an interest in illuminating the plight of larger-bodied patients, something the show only touched on during its first season.

“Howard’s story presents an opportunity to highlight the very special need for compassion and understanding of somebody who has that degree of excess body weight,” says Sachs. “It’s also the perfect dramatic situation for the senior doctors to get to teach the more junior doctors like Ogilvie, who lacks some sensitivity, compassion, and bedside manner. He is more interested in furthering his knowledge and procedural skill than being aware of the special needs of the patient.” 

But it was only worth telling this story if The Pitt could find the right actor. “I wasn’t even going to write the episode unless we had that person,” Sachs says. The show didn’t want to put an actor in prosthetics in order to appear bigger, so Sachs wrote a “dummy scene” that roughed out the general beats of Howard’s story line but under a gender-neutral name. Then, casting put out a call for what Shaynak says was “morbidly obese” actors of all genders. “I wanted to see if there was a person of that weight who could pull off the dramatic needs of the scene,” Sachs says. “Casting worked their magic and we had thousands of submissions. When I saw Craig, I knew we had it.”

Once Shaynak was cast, Sachs called him up to talk story beats. Shaynak says it’s the first time he has ever been consulted on a role. In the 90 minutes the two spoke, Shaynak shared a number of details about his life that actually made it into the show. 

“I only left my house four times in 2025,” he says. “I got really heavy during COVID, because I do a lot of computer work from home. I got so reliant on DoorDash, and I became increasingly sedentary to the point where even going to the mailbox felt like too much. After COVID, I’d stopped auditioning for roles because I told my agent and manager, ‘I don’t know if I could get to set.’ I used to walk like crazy — I went to the Edinburgh Fringe Festival for 15 years in a row and did one-man shows — but after COVID I stopped leaving the house. It got to the point where I even sold my car, which in L.A. feels like the ultimate sign of giving up.” 

Shaynak was impressed with the sensitivity of Sachs’s final script. “I don’t think people who aren’t large understand the perpetual shame when you have to go out and do what other people think are very pedestrian events,” Shaynak says. “Getting a checkup — it’s very different when you’re thinking, Am I going to fit in the bed? Can I get to the office? Where am I going to park? Will I have to walk across the entire hospital?”

On set: “I don’t know if you know this, Noah, but I’m a very big actor.”

Though Shaynak had concerns about his mobility as an actor, the opportunity to be on The Pitt felt like too great a chance to pass up. Still, he says, he worried about accessibility on set. He feared how far he might have to walk across the studio lot once he parked his car and having to get from department to department on the set.

But production went out of its way to accommodate him and cater to his concerns, Shaynak says. It gave him a parking spot right next to the soundstage where he’d be shooting and a de facto chauffeur to drive him the relatively short distance from his dressing room to set. “Even Noah Wyle was like, ‘Hey, how’d you get that parking spot?,’” Shaynak says. “And I joked to him, ‘I don’t know if you know this, Noah, but I’m a very big actor.’”

When Shaynak signed on to the show, he knew he’d be putting himself in a vulnerable position. When Howard is wheeled into the ER in episode eight, that’s Shaynak’s real torso on display. The makeup department added scars to Shaynak’s knees and legs to reflect his character’s backstory, but the compression socks Shaynak wore were his own. And when Howard is being weighed on what’s called a Hoyer Lift, Shaynak’s real-life weight at the time — 472 pounds — is what’s displayed. (He says he was actually closer to 500 pounds when he was cast and shed a little weight in preparation for the show.) 

But even the most game actors aren’t necessarily down to have a tube shoved through their nose while awake. Thus, The Pitt had to figure out how to show its awake fiber-optic intubation without having access to real-life-patient footage, something Sachs says is either too low quality to read on TV or protected by privacy laws.

It was property master Rick Ladomade who figured out how to fake what the scene needed, which was to “visually see the tube going around the back of the tongue, through the vocal cords, past the tracheal rings, and all the way down to the fork in the road where the trachea splits,” says Sachs. Ladomade collaborated with a special-effects company to construct a model of a silicone throat that a camera could be threaded through and created a system that was used not only to show Howard’s procedure but also the retrieval of a piece of broccoli from between a man’s vocal cords earlier in the season. The footage inside the silicone throat was shot weeks prior; when the camera cuts to Howard, production used scopes of different lengths to indicate how far the tube may have gone down his throat. “First, it’s a little longer,” Sachs says, “then we cut to the screen and watch it get into the right position. Then, when you come back, you see Dr. Robby with a very short scope right by Howard’s nose. It’s all done in the editing.” 

The dialogue: “The first time I read the script, I gasped out loud.”

While what’s happening to Howard onscreen is medically dangerous and very scary for the patient, the impact of the emergency is magnified by Ogilvie’s insensitive comments, like an under-his-breath “wonder why” when the EMT says they weren’t able to get an IV in, or when he presses Howard about not taking Wegovy or Ozempic. “A gunner,” as Sachs calls hims, Ogilvie is the kind of doctor who wants to show off their exceptional technical skills in an effort to land the best possible residency — but who might not realize there’s more to being a great doctor than medical knowledge and procedural competency. “He thinks what he’s saying is part of the solution today,” Sachs explains, “but the solution is compassion, empathy, and figuring out what’s wrong so that they can treat the patient.” 

Lucas Iverson, who plays Ogilvie, knew his character was insensitive but felt this moment was a degree too far. “I gasped out loud,” he says, when he first read the script. “Then begins the actor’s work of trying to empathize and understand that attitude and that character. Ogilvie represents this bootstraps mentality, where you’re responsible for the state of your own life. He applies that idea to himself and a lot of patients throughout the day.” 

Shaynak, who calls Iverson “a cuddly Muppet sweetheart in real life,” says that, when the cameras stopped after Ogilvie had delivered an insult, Iverson would apologize profusely. Iverson hopes people watching the show see Ogilvie’s comments as both hurtful and unnecessary and strive for empathy in their own lives as a result. “These little comments we make, even if they’re just in our heads, are lacking generosity and curiosity,” he says. “I think we’d all be better if we were a little more curious and open.” 

Fiona Dourif, who plays Dr. McKay, says she thinks Ogilvie’s words land so harshly in part because of how openly Shaynak plays Howard. “Howard handles the whole situation with such grace and humor, but also vulnerability,” Dourif says. “I remember when we were shooting, the whole thing felt quite moving, like he’d held onto his dignity in a way that I thought was beautiful.” 

When McKay admonishes Ogilvie in the elevator on the way to get the VidaTak, Dourif says it’s indicative of how much her character has grown since she made crass comments about a patient’s weight in season one: “It just felt like a continuation of my learning curve eight months later.”

Recovery: “It actually lit a fire under me”

Though Howard faces a 50-50 chance of surviving the procedure and recovery when he heads to the OR in episode nine, Shaynak says he’s hoping for a rosier future off-screen. The doctors who work behind the scenes on The Pitt gave him “great, useful tips” between takes. He’s starting to see more doctors and leave the house more.

“It actually lit a fire under me,” Shaynak says. “I’d like to be able to do more acting, and I’d like to get back to moving around. Having to get up at five in the morning to get to the set every day for a couple of weeks made me think, You know what? I can make it to the car. I can get out and go do stuff. I just went and got new glasses for the first time in six years. I think this’ll be my year.”