Dr. Justin Goralnik
Middlesex Health physician Justin Goralnik was first introduced to critical care during his medical internship, and was immediately drawn to working with the hospital’s sickest patients.
“To be honest, I found a lot of the other areas of medicine rote and unexciting, but I liked the kind of thinking on your toes and making quick decisions that came with critical care,” recalls the pulmonary critical care specialist, adding that he ultimately selected pulmonary medicine as a co-specialty because the two fields tend to go hand-in-hand. “Many of the people in critical care are on life support (i.e. ventilators),” he explains. “And there’s a lot of hands-on in both fields. I like doing things with my hands.”
Dr. Goralnik pursued his fellowship in critical care and pulmonary medicine at the University of Connecticut School of Medicine, where he gained a particular interest in interventional pulmonology and developed a skill set in that area through the teaching of his mentor, Dr. Omar Ibrahim. He became proficient at bronchoscopy, a diagnostic procedure in which a fiber optic scope is threaded through the nose or mouth and down into the lungs to evaluate the airways.
“I felt that I had a sort of talent for these advanced bronchoscopic procedures, and I wanted to bring my skill to Middlesex, where we are trying to build a program to identify and diagnose patients with lung cancer early on, to get them on the path to treatment as soon as possible.” Dr. Goralnik joined the Middlesex staff in July.
A CONNECTICUT NATIVE
Dr. Goralnik did not initially set his sights on medical school; in fact, he began his career in a lab, where he spent the majority of his time doing animal research. “But I didn’t like what I was doing because it involved mice – and having to kill them.” So he pivoted toward clinical medicine. He completed his pre-med requirements during a post-baccalaureate program at Central Connecticut State University, finishing with a Masters of Science in biomolecular science, and earned his medical degree from St. George’s University School of Medicine in Grenada.
Though he grew up in Florida, Dr. Goralnik was born in Cheshire, and as a teenager, worked during the summers in his native state, making deliveries for his family’s business, Lyon & Billard Lumber. “I drove all over the state of Connecticut growing up, which is how I knew about the different areas and the hospitals in the state,” he says.
After graduating from medical school, Dr. Goralnik knew he wanted to stay in the region, preferably at a small community hospital. So when it came time to look for a job, he contacted Todd Bishop, chief of the hospital’s pulmonary division, who had often given pulmonary grand rounds at UConn. “They just happened to be looking for somebody, which was lucky for me,” says Dr. Goralnik. “Middlesex was a good fit.” Dr. Bishop is now his partner.
A GOOD MIX
Dr. Goralnik, who spends about a third of his time covering the critical care floor, and the rest seeing patients and performing pulmonary procedures, says that one of the things he appreciates about his specialty is that “it’s a good mix of diagnosing and treating.” He might spend one week in the critical care unit, taking care of extremely sick patients, the next at the clinic seeing outpatients or in the hospital doing inpatient consultations, and the next week performing lung biopsies and other diagnostic procedures.
Though working in the intensive care unit is exciting, he says, it is also difficult. “Unfortunately, we have to deal with a lot of death, and tough decisions regarding patient care, like how long to keep a patient on life support,” he explains. These are shared decisions, he says, that physicians make with family members. “But by the same token,” he adds, “it’s very gratifying and rewarding when you are able to take the sickest patients in the hospital and turn them around.”
In his pulmonary clinic, Dr. Goralnik sees a wide array of patients, with diseases ranging from chronic obstructive pulmonary disease (COPD) to asthma. Advances in the treatment of asthma have been a real boost to patients suffering from that disease, he says. “We are now in an era of targeted therapy. We’ve identified certain cells in the body that trigger the asthma, and there are now therapies that target these specific cells to suppress them or turn them off.”
He says COPD, which encompasses conditions like emphysema and chronic bronchitis, is really a smoking-related disease in which years of smoking lead to inflammation and irreversible destruction of the lung tissue.
The mainstay of COPD treatment is oxygen therapy. Although he cannot “cure” these patients, Dr. Gorlanik says, he can extend their survival, and provide symptomatic relief through oxygen therapy and with the use of medications that help open up obstructed airways. Quitting smoking is the most important step for these patients to take, he says, and Middlesex does offer a smoking cessation program and support group.
TARGETING LUNG CANCER
Smoking, of course, is also the most significant risk factor for lung cancer, and Dr. Goralnik’s hope is that he will be spending an increasing proportion of his time identifying – and hopefully saving – these patients.
“We are really trying to jump-start the hospital’s high-risk lung nodule program,” he says.
Pulmonologists follow very strict guidelines when it comes to lung cancer screening, notes Dr. Goralnik. This is because such screening yields a significant number of false positives, which could result in unnecessary follow-up testing and even invasive biopsy procedures. “Candidates for screening include patients aged 55 to 77 with a greater than 30-pack-year smoking history – that is, people who have smoked a pack per day for 30 years,” he says. “If they are former smokers, they have to have smoked in the past 15 years.”
Screening the right patients, however, can save lives, he adds. “We have been able to change the course of patients with lung cancer by finding cancers at an early stage,” he says, “and have been able to cure some of them with surgery.”
Dr. Goralnik, who will be heading up the hospital’s high-risk lung nodule program, will follow high-risk patients with annual low-dose CT scans. Those with nodules will undergo any necessary additional testing – and a biopsy when appropriate – and will be followed by continued monitoring, which might include a repeat CT scan in three to six months. “The goal is to detect lung cancer earlier in high-risk, asymptomatic patients,” he says, “ and we have certainly done that.”
Thanks to advances in bronchoscopy, lung cancer diagnosis and staging are much less invasive than they once were, says Dr. Goralnik. “Bronchoscopy has now become one of the best ways to stage lung cancer. With endobronchial ultrasound, we are able to view nodules and masses that are in the actual lung tissue, beyond the airways.” Guided by ultrasound, the surgeon can also insert a needle through a channel in the bronchoscope and actually biopsy and stage lung masses at the same time, instead of having to do two separate procedures. “It streamlines the process. Any time you can put a patient through less anesthesia and fewer procedures, the better off they will be.”
The bronchoscope allows doctors to find lung cancer at an early enough stage that they are able to perform potentially curative surgeries, like a lobectomy (removal of the affected lobe of the lung) or stereotactic radiosurgery, which attacks small tumors with precisely focused beams of intense radiation.
Dr. Goralnik says early detection is key, which is why he believes the high-risk lung nodule program is so important. Patients whose nodules have been diagnosed incidentally during a CT scan for something else, or through imaging ordered by a primary care or emergency room physician will also be carefully evaluated, he says, and brought into the program if they meet the high-risk criteria.
“We don’t want any patients slipping through the cracks because they aren’t admitted to the hospital or because they don’t have a primary care provider,” says Dr. Goralnik. “And I can’t tell you how many times we see patients who have been having the same symptoms for months or even years and by the time we see them, they have extensive metastatic disease.”
Pulmonary symptoms to look out for, he says, include a lingering cough that doesn’t subside for weeks to months, the presence of blood with a cough, and/or unintentional weight loss. “It always surprises me when I see patients in the office who tell me they’ve been coughing up blood for months,” he says. “That tells me that the patient is either a) very stubborn or stoic, or b) not educated on the symptoms to look out for.” More education, he says, is clearly needed.
Lori Miller Kase is a freelance writer living in Simsbury.
New Haven photographer Tony Bacewicz knows everyone has a unique story. He relishes the opportunity to photograph people and events in their natural environments all over the state.