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\n To tell the story of Howard, a 472-pound patient facing a dire procedure, The Pitt followed actor Craig Ricci Shaynak\u2019s lead.
\n Photo: Warrick Page\/HBO Max\n <\/p>\n
While The Pitt has never shied away from prosthetics when it comes to blown-off hands or an extremely vivid vaginal birth<\/a>, there\u2019s nothing fake about Howard Knox, the 472-pound patient wheeled into the ER in season two, episode eight<\/a>.<\/p>\n 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\u2019s real life, Howard\u2019s 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.<\/p>\n And yet, to holier-than-thou doctors like young Ogilvie (Lucas Iverson), Howard is a cautionary tale: a glutton who can\u2019t control himself, a rube who hasn\u2019t heard of Ozempic, and a lazy slouch who can\u2019t manage to drag himself to aqua aerobics. While Howard\u2019s 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.<\/p>\n It\u2019s a breathtakingly callous statement, especially when made within earshot of the patient, yet to many larger-bodied people, it\u2019s a very real concern. (Shaynak himself says he feared he\u2019d 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\u2019s character faces on The Pitt \u2014 from the troubled intubation and crass comments to the startlingly high mortality rate for a necessary procedure \u2014 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\u2019t care to accommodate overweight people.<\/p>\n \u201cI wanted to pull at the heartstrings of viewers so they\u2019d understand where someone like Howard came from,\u201d says Dr. Joe Sachs, who wrote episode eight. \u201cI wanted them to have empathy for this individual\u2019s life story.\u201d<\/p>\n Sachs, a writer and onetime emergency-medicine physician who also, coincidentally, wrote Shaynak\u2019s decades-old episode of ER, says the concept for Howard\u2019s arc came from two places: the desire to show a procedure viewers hadn\u2019t seen on the show \u2014 an awake fiber-optic intubation \u2014 and an interest in illuminating the plight of larger-bodied patients, something the show only touched on during its first season.<\/p>\n \u201cHoward\u2019s story presents an opportunity to highlight the very special need for compassion and understanding of somebody who has that degree of excess body weight,\u201d says Sachs. \u201cIt\u2019s 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.\u201d<\/p>\n But it was only worth telling this story if The Pitt could find the right actor. \u201cI wasn\u2019t even going to write the episode unless we had that person,\u201d Sachs says. The show didn\u2019t want to put an actor in prosthetics in order to appear bigger, so Sachs wrote a \u201cdummy scene\u201d that roughed out the general beats of Howard\u2019s story line but under a gender-neutral name. Then, casting put out a call for what Shaynak says was \u201cmorbidly obese\u201d actors of all genders. \u201cI wanted to see if there was a person of that weight who could pull off the dramatic needs of the scene,\u201d Sachs says. \u201cCasting worked their magic and we had thousands of submissions. When I saw Craig, I knew we had it.\u201d<\/p>\n Once Shaynak was cast, Sachs called him up to talk story beats. Shaynak says it\u2019s 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.<\/p>\n \u201cI only left my house four times in 2025,\u201d he says. \u201cI 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\u2019d stopped auditioning for roles because I told my agent and manager, \u2018I don\u2019t know if I could get to set.\u2019 I used to walk like crazy\u00a0\u2014\u00a0I went to the Edinburgh Fringe Festival for 15 years in a row and did one-man shows \u2014 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.\u201d<\/p>\n Shaynak was impressed with the sensitivity of Sachs\u2019s final script. \u201cI don\u2019t think people who aren\u2019t large understand the perpetual shame when you have to go out and do what other people think are very pedestrian events,\u201d Shaynak says. \u201cGetting a checkup\u00a0\u2014\u00a0it\u2019s very different when you\u2019re 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?\u201d<\/p>\n 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.<\/p>\n 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\u2019d be shooting and a de facto chauffeur to drive him the relatively short distance from his dressing room to set. \u201cEven Noah Wyle<\/a> was like, \u2018Hey, how\u2019d you get that parking spot?,\u2019\u201d Shaynak says. \u201cAnd I joked to him, \u2018I don\u2019t know if you know this, Noah, but I\u2019m a very big actor.\u2019\u201d<\/p>\n When Shaynak signed on to the show, he knew he\u2019d be putting himself in a vulnerable position. When Howard is wheeled into the ER in episode eight, that\u2019s Shaynak\u2019s real torso on display. The makeup department added scars to Shaynak\u2019s knees and legs to reflect his character\u2019s backstory, but the compression socks Shaynak wore were his own. And when Howard is being weighed on what\u2019s called a Hoyer Lift, Shaynak\u2019s real-life weight at the time \u2014 472 pounds \u2014 is what\u2019s displayed. (He says he was actually closer to 500 pounds when he was cast and shed a little weight in preparation for the show.)<\/p>\n But even the most game actors aren\u2019t 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.<\/p>\n It was property master Rick Ladomade who figured out how to fake what the scene needed, which was to \u201cvisually 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,\u201d 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\u2019s procedure but also the retrieval of a piece of broccoli from between a man\u2019s 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. \u201cFirst, it\u2019s a little longer,\u201d Sachs says, \u201cthen 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\u2019s nose. It\u2019s all done in the editing.\u201d<\/p>\n While what\u2019s happening to Howard onscreen is medically dangerous and very scary for the patient, the impact of the emergency is magnified by Ogilvie\u2019s insensitive comments, like an under-his-breath \u201cwonder why\u201d when the EMT says they weren\u2019t able to get an IV in, or when he presses Howard about not taking Wegovy or Ozempic. \u201cA gunner,\u201d 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 \u2014\u00a0but who might not realize there\u2019s more to being a great doctor than medical knowledge and procedural competency. \u201cHe thinks what he\u2019s saying is part of the solution today,\u201d Sachs explains, \u201cbut the solution is compassion, empathy, and figuring out what\u2019s wrong so that they can treat the patient.\u201d<\/p>\n Lucas Iverson, who plays Ogilvie, knew his character was insensitive but felt this moment was a degree too far. \u201cI gasped out loud,\u201d he says, when he first read the script. \u201cThen begins the actor\u2019s work of trying to empathize and understand that attitude and that character. Ogilvie represents this bootstraps mentality, where you\u2019re responsible for the state of your own life. He applies that idea to himself and a lot of patients throughout the day.\u201d<\/p>\n Shaynak, who calls Iverson \u201ca cuddly Muppet sweetheart in real life,\u201d says that, when the cameras stopped after Ogilvie had delivered an insult, Iverson would apologize profusely. Iverson hopes people watching the show see Ogilvie\u2019s comments as both hurtful and unnecessary and strive for empathy in their own lives as a result. \u201cThese little comments we make, even if they\u2019re just in our heads, are lacking generosity and curiosity,\u201d he says. \u201cI think we\u2019d all be better if we were a little more curious and open.\u201d<\/p>\n Fiona Dourif, who plays Dr. McKay, says she thinks Ogilvie\u2019s words land so harshly in part because of how openly Shaynak plays Howard. \u201cHoward handles the whole situation with such grace and humor, but also vulnerability,\u201d Dourif says. \u201cI remember when we were shooting, the whole thing felt quite moving, like he\u2019d held onto his dignity in a way that I thought was beautiful.\u201d<\/p>\n