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July 9, 2012

Through a Glass, Darkly

Author Affiliations

Author Affiliation: Department of Internal Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.

Arch Intern Med. 2012;172(13):985-986. doi:10.1001/archinternmed.2012.2765

For now we see through a glass, darkly; but then face to face: now I know in part; but then shall I know even as also I am known.—1 Corinthians 13:12

“Do you have any questions for us before we go to the bronchoscopy suite, Dr Bryant?”

Without corrective lenses—removed at the request of my bedside nurse, prior to administration of general anesthesia—the world is a series of blurred polygons that vaguely resemble familiar objects. To my left, the tall trapezoid that I recognize as the attending anesthesiologist is engaging me in a preoperative dialogue that is at once familiar and alien. To my right is a slender rectangle that I know is my wife. Though I can't see her crying, I can hear faint sobs and recognize the square box handed to her across my gown-covered chest—hospital-issued facial tissue.

“No, I just want to get the process started.”

Today is Friday. During the afternoon on Tuesday I had requested of my pulmonary clinic preceptor a chest radiograph for evaluation of pleurisy. For several months I had ongoing right-sided chest pain after an episode of pneumonia; that day the pain grew so severe that I could no longer ignore the symptoms with ibuprofen and rest. On Wednesday evening, I was lying on my back in the computed tomographic (CT) scanner, listening to the instructions from an automated voice telling me when to breathe as my chest races through a whirring digital donut of lights and sounds; I am struck most by how no one had ever mentioned to me the warmth that comes over the body with administration of intravenous contrast. By Thursday, I am a vessel of dread as the radiologist and interventional pulmonologist confirm what I have already viewed myself—“aggressive appearance of the right cardiophrenic adenopathy with chest wall invasion and sternal erosion.”

“Andrew, at this point, I would recommend a bronchoscopy for tissue diagnosis.”

As a second-year pulmonary and critical care medicine fellow, I had authorized consents for hundreds of patients for this same procedure. Although I could quote the risks and benefits from my sleep, this was the only opportunity I had to hear the discourse in such a unique fashion, as if for the first time.

“There is a risk of bleeding and infection. . . . ” I reflected on every biopsy I had ever performed and tried to recall the few cases in which bleeding was significant enough to cause worry. My mind drifted to the case of a young lady with acute chronic renal failure caused by lupus nephritis—a chest CT angiogram performed to rule out pulmonary embolism had prompted pulmonary consultation for incidentally noted mediastinal lymphadenopathy. Despite prophylactic administration of desmopressin for uremic bleeding, I feared the wave of crimson would never cease, as I placed the bronchoscope to the bronchial wall in an effort to tamponade the bleeding.

“ . . . As well as collapsed lung. . . . ” One of my mentors had glibly told me that if I did not eventually have a bronchoscopy complicated by pneumothorax, then I was simply “not doing enough bronchoscopies.” The credo was undoubtedly of little consolation for the young man in his twenties who became acutely short of breath a half-hour after transbronchial biopsy, his chest radiograph revealing a thin line demarcating partially aerated lung from empty space. I apologized profusely while placing a small-bore chest tube into his side, barely hearing his calm voice as he told me, “Don't worry, these things happen.”

“And, finally—though rare—there is a risk of death.” Although it is the ultimate procedural risk, this portion of the consent process had always been the easiest for me to discuss, reminding my patients that the risk of dying in an automobile accident on the way to the hospital is much more likely than coming to harm associated with bronchoscopy. However, today my thoughts float toward every car accident I have seen either on the side of the road or read about in the news since having moved to Nashville, Tennessee, only 5 years ago. Suddenly, the risk seems more prevalent than I had lent credence to in the past.

“You may feel a bit of a burning sensation in your left arm—that is just the Propofol infusion. Then, it is ‘night-night.’”

I contemplated the risk of dying for one last time, staring up at a plastic mask placed gently across the bridge of my nose, before going to sleep.

When I awoke, the world was still a myopic blur. My wife and friend were beside me, asking me if I knew where I was, and how I was feeling.

“Well, your lab work indicates that you are not pregnant.”

The postanesthesia care unit nurse laughs at her joke. She is a friend from the hospital, and I would later learn that she had requested to care for me that day. Even in my partially inebriated state, I was pleased to hear that my α-fetoprotein and β-chorionic gonadotropin hormone levels were normal, virtually ruling out concern for a germ-cell tumor. My wife tells me that she was told the procedure went well, and they were able to get an adequate amount of tissue to make a diagnosis. My only concern at the moment is when I will be able to replace my contact lenses. When I finally am able to do this, the first thing I see is my wife's beautiful smiling face, and I know that everything will be just fine.

“Well . . . at least I can see clearly, now.”

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Article Information

Correspondence: Dr Bryant, Department of Internal Medicine, Vanderbilt University School of Medicine, D-3100, Medical Center North, Nashville, TN 37232 (

Financial Disclosure: None reported.