Prologue
“Help me understand,” she said.
My patient was the delightful silver-haired matriarch of a large family. I was seeing her in consultation for a pulmonary nodule in the Vanderbilt-Ingram Cancer Center’s Thoracic Oncology Clinic on a crisp afternoon in the spring of 2010. What she wanted to understand was why she had this spot on her lung, what it could be, and what could be done about it.
As I had done thousands of times before, I launched into my spiel about pulmonary nodules: where they come from, what they could be, and what to do about it. In her case the most appropriate next step was to perform bronchoscopy and obtain a biopsy.
* * *
The word “bronchoscopy” derives from the Greek brongchos (“conduits to the lungs”) and skopos (“to aim or target”). A physician performs a bronchoscopy using a bronchoscope—a long, flexible instrument (about the diameter of a coaxial cable that plugs into the back of your TV) with a light and camera on the end that captures an image and displays it on a video monitor. The current standard of care for sedation is to give medicine in the IV to create a calm and relaxed state and apply topical anesthetic (numbing medicine like at the dentist) to the mouth and nose to abolish both cough and gag reflexes. The bronchoscope is then introduced into either the mouth or the nose, advanced past the voice box and into the bronchial tubes of the lungs, where it can then be advanced into each lobe of lung and to lesions for biopsies.
“Does it hurt?” she asked.
“No, there are no pain fibers in the lung,” I explained. “It is an outpatient procedure and you can go home the same day. It’s a piece of cake,” I added glibly.
Her demeanor changed. “Piece of cake! Have you ever had it done? How dare you say that it is a piece of cake!” she scolded me.
I apologized, scheduled her for the bronchoscopy the next day, and went on to the next patient.
However, that conversation kept coming back and occupying my thoughts. I ruminated about it during my daily commute, at work, and as I lay awake in bed before falling asleep.
I finally figured out the reason it kept coming up: She was right. I had no idea what it was like to have a bronchoscopy. I was a hypocrite.
Even more, I had no idea what it was like to be a patient. Thankfully, I have never been hospitalized, never had surgery or a procedure—not even a broken bone. I was ignorant of the entire medical process from the patient’s viewpoint.
Medical schools teach early on that empathy is an essential attribute of good physicians. The concept of empathy is that through imagination, rather than literally, the physician experiences what the patient is going through. At this point I felt that empathy was no longer good enough. I needed to have a bronchoscopy. A plot began to formulate in my mind, but I would need collaborators to carry it out.
Soon after moving to Nashville in the fall of 2009, I was approached by my colleague Dr. Pierre Massion to participate as a co-investigator in a research project for which the primary aim was to develop an early detection test for lung cancer, which I agreed to do. He also asked me to perform a bronchoscopy on him as part of his research study, which I also agreed to do, but hadn’t done yet. These two thoughts came together. To accomplish my goal of understanding what it was like to have a bronchoscopy, I needed to volunteer for Pierre’s research study. So I signed up to have a bronchoscopy as a normal control for this study.
Everyone thought I was nuts: my wife, colleagues, fellows and nurses. But I was resolved to carry this out. I was uneasy on the morning of March 25, 2010, as I rode the elevator up to Vanderbilt’s Clinical Research Center. It’s not too late to walk away, I kept thinking.
It was surreal to walk into the procedure room and not go to the head of the bed, but to lie down on it, take my shirt off, get an IV started, have ECG and BP monitors attached, and be placed on oxygen. It hit home at that point. I am going to allow these people to invade my personal space and give up autonomy! This was the most important lesson I learned that day: I would be completely at the mercy of someone else.
The research nurse looked at me with concern. “Are you sure you don’t want IV sedation?”
“No sedation,” I told her. It wasn’t male bravado—I wanted to remember every detail. In most cases a desirable side effect of medications used for procedural sedation is amnesia. In my case, if I used IV sedation, there was a good chance I wouldn’t be able to recall the experience. I would be unable to explain to my patients what to expect and to really help prepare them for bronchoscopy.
Dr. Massion began the important process of topical anesthetic application. In a sitting position I first gargled lidocaine, which was very bitter, then had topical benzocaine sprayed on the back of my throat. The benzocaine smelled like bananas, but I soon realized it tasted like bananas that had been through a monkey. I could no longer feel the back of my throat, which made it difficult to swallow my saliva. What had I gotten myself into?
I was asked to lie down. A washcloth was placed over my eyes, and viscous lidocaine was placed inside my right nostril to numb it. With the Yankauer suction in my left hand to clear secretions (like at the dentist), we were under way. I was having a bronchoscopy.
Dr. Massion inserted the scope in my nostril, and I felt nothing. He advanced it to my voice box. I felt nothing. Diana from the musical A Chorus Line popped into my head.
Dr. Massion warned me as he applied lidocaine to my voice box that it might make me cough. I felt a cold sensation—it didn’t hurt and wasn’t unpleasant, but did cause a cough that quickly went away.
This process was repeated several times until my entire bronchial tree was numb. It was bizarre to hear him request instruments and supplies to perform washings, brushings and biopsies of my lungs and not feel a thing. All in all, it took 22 minutes.
Thirty minutes later I was back in the bronchoscopy suite performing a bronchoscopy on a patient with a new sense of awe and admiration for my patients and new respect for the privileges they allow me.
This article is dedicated to that delightful patient who afforded me this opportunity, for which I am eternally grateful. The nodule turned out to be an early stage lung cancer. She underwent surgery and had a portion of her lung removed, and likely has been cured of her disease.
Epilogue
Since my bronchoscopy, Dr. Massion and my nurse, Charla Atkins, as well as three pulmonary fellows, two residents and two pulmonary/ICU nurses with whom I work have all volunteered for the research study and undergone bronchoscopies.