"I Remember..."

Once Upon A Time

Donald C. Zavala, M.D.

In 1969 I was accepted for a pulmonary disease fellowship at the University of Iowa Hospitals and Clinics, Iowa City, Iowa. The acceptance in itself was a miracle since I was 45 years old, and had spent the last 17 years practicing internal medicine in El Centro, California, a desert farming community located in Imperial Valley, just north of the Mexican border. A simple phone call to my old friend in Iowa City, Dr. George Bedell, took care of the problem. It was as if there had been no lapse in time. I gave up my practice, sold my home, uprooted my three children and traveled over 2000 miles with my family to Iowa. My wife firmly supported my decision, and the children looked at the move as a big adventure.

Upon our arrival in Iowa City, Dr. Bedell, Chief of the newly created Pulmonary Division, greeted me warmly, then made a good news/bad news announcement that left me in disbelief. First, the bad news: (1) the pulmonary division consisted of himself, period; (2) I was the first pulmonary fellow in the program; (3) there was no lung clinic, no pulmonary ward or intensive care unit; (4) the pulmonary function laboratory consisted of a lone Collins spirometer; and (5) he was leaving the next day on a month’s vacation. Now for the good news: (1) he graciously offered my family (and my hound dog, Pele) to stay at his home; (2) in his absence he gave me freedom to carry out whatever I wanted to do at the University Hospitals; (3) the pulmonary refer service WAS ACTIVE; (4) getting home by 6:00 p.m. to have dinner with my family was a welcomed novelty; and (5) there were no night or weekend calls at the hospital.

I was eager to learn as much as possible about anything new in the field of pulmonary medicine, so in the fall of 1969 I attended a national otolaryngology conference in Atlanta, Ga. One of the speakers was an unknown physician named Shigeto Ikeda from the National Cancer Institute, Tokyo, Japan. He gave a talk on a novel diagnostic instrument, the flexible fiberoptic bronchoscope. The large audience could scarcely understand a word spoken…in fact, no one paid much attention to the presentation. The physicians were all “rigid” bronchoscopists! However, I was mesmerized by Dr. Ikeda’s slide presentation and was convinced that this instrument had a great diagnostic future. Little did I realize at the time that this unique tool would revolutionize pulmonary medicine.

When I returned to Iowa City, Dr. James Clifton, Chief of the Department of Medicine, informed me that a trip to Japan to work with Dr. Ikeda was out of the question. But acting upon his suggestion, I gave a talk to a group of elderly ladies who were members of the Iowa Lung Association and received a check for $3600.00 to buy the new instrument.

In January 1970, the day came when a special package (box within a box) arrived from the Machida Company in Japan. The instrument was a clever bit of engineering, but nothing compared to modern fiberoptic bronchoscopes. No biopsy tools were available, flexion at the distal tip was limited and the suction/biopsy channel was extremely small. Fortunately, the light source was adequate and although fiberoptic vision was compromised by a “chicken-wire” effect, visual acuity was sufficient to identify mucosal changes and the bronchial anatomy. The language department at the University of Iowa sent over an interpreter to help me read the instructions, which were in Japanese.

The next scenario began in the dog lab. My animal model was a homeless, tri-colored collie that I named “Hannibal” in memory of the brave soldier from Carthage who took his army with elephants into Spain and across the Alps to fight the Romans. I immediately observed that dogs have bronchial anatomy different from humans. One of the main variations is the presence of a cardiac lobe. It took me a long time to figure out why Hannibal willingly followed me to the laboratory, happily wagging his tail. He would jump up on the table and wait to be bronchoscoped. Finally, the mystery was solved. The dog liked Demerol! After a shot of the drug he would get a silly look on his face, glassy-eyed, and start to drool.

My work was done late at night in the gastrointestinal laboratory where fluoroscopy was available to map out the tracheobroncial tree and (later) to develop the technique of transbronchial lung biopsy. For my assistant, I trained my oldest daughter, Cathy, who was a senior in West High School, Iowa City (she is now a physician). I fully realized that I must proceed with UTMOST caution. One mistake would cost me my fellowship. At least I could return to my practice in El Centro, so went my reasoning. After pre-medication, Hannibal was transported to the G.I. laboratory on a gurney covered with a sheet. My major concern was that the dog would bark. On one occasion a meticulous nurse in charge of the laboratory found a few dog hairs and reported the incident to the Chief of Medicine. When summoned to his office, I knew that something had gone badly wrong! Dr. Clifton faced me with a stern look, then broke out in a smile and said “Don, you’ll have to be more careful and clean up ALL the dog hairs.” Later, I used the same dog to develop the technique of transbronchial lung biopsy and removal of small foreign bodies from the airways.

Keep in mind that in those early days, circa 1974-1975, it was absolutely forbidden to remove a foreign body from the tracheobronchial tree with anything other than a rigid bronchoscope. Many surgeons and otolaryngologists would consider the new flexible fiberoptic procedure to be malpractice, so I said very little about the foreign body work until the time came for publication. But back to Hannibal. You will be glad to hear that after my work was finished with this fine animal, he lived out a good dog’s life on a friend’s farm doing the things that dogs like to do, such as chasing rabbits.

After working 6 months, I felt confident enough to carry out fiberoptic bronchoscopy on a patient. The first opportunity came in July 1970, when a 56 year-old male smoker, lawyer by profession, arrived in our medical ward. He had undergone rigid bronchoscopy under local anesthesia for a small right upper lobe density with negative results. After a detailed explanation of the procedure and demonstration of the fiberoptic instrument, the patient appeared to be favorably impressed. At last, my very first case! As I was leaving the room he called me back with this question, “How many people have you done with this new instrument?” I replied, “No people, just a dog.” “A dog,” he yelled in dismay! “You had better come back tomorrow. I need time to think.” Apparently the probability of having lung cancer was too much for him to endure, because the next day he agreed to let me perform the bronchoscopy “after-hours.”

Everything went according to plan. After preoperative medications using IM morphine and atropine, local anesthesia of the oropharynx and larynx was achieved with 4% lidocaine. For control of the airway (in the event of unexpected bleeding) an endotracheal tube, with lubricant added was passed into the trachea by sliding it over the shaft of the pre-inserted fiberscope and then secured externally with tape. Thus, ready access was provided to the endobronchial tree. As the carina, right and left mainstem bronchi, and bronchial orifices came into view, I felt like I was standing on the moon for the first time. A few squirts of 1% lidocaine into the mainstem bronchi controlled bronchospasm. The lesion was easy to locate in the RB-1 bronchus. Biopsy was carried out by back-loading a self-made brush (stiff hog hairs mounted on the end of a wire) through the tiny biopsy channel and gently rubbing the lesion under fiberoptic vision. Prior to brush biopsy, a dilute solution (1: 10,000) of epinephrine was squirted on the tumor to lessen the chance of hemorrhage. Smears were made on glass slides, placed in a jar containing alcohol-ether and sent to pathology. The next day the pathologist called to say that the specimens were the best “sputum smears” he had ever seen and that the patient had a well-differentiated squamous cell carcinoma. I never revealed that the smears were from a brush biopsy via the flexible fiberoptic bronchoscope. A few days later the lawyer had a right upper lobectomy. He was still alive and doing well five years later when I reviewed his outpatient medical records.

At this point, it became evident that in order to help establish flexible fiberoptic bronchoscopy as a medical (not surgical) procedure, more cases needed to be reported. So cautiously I started to bronchoscope patients and began publishing in 1973. Finally in 1975, an article titled “Diagnostic Fiberoptic Bronchoscopy: The Techniques and Results of Biopsy in 600 Patients” was published in Chest (68, 12-19, 1975). Phone calls flooded the office asking for more talks and seminars than could possibly be handled. Over the ensuing 20-plus years it was a source of satisfaction to train a succession of pulmonary fellows in the gentle art of flexible bronchoscopy. An endotracheal tube was used when biopsy was anticipated, and the transnasal route was used for bronchial lavage. When carrying out transbronchial lung biopsy under fluoroscopic guidance, the tip of the fiberoptic bronchoscope was wedged into the appropriate segmental bronchus to contain any bleeding.

Morphine and atropine were the standard preoperative medications. Before retiring in 1992, two bronchoscopy rooms were necessary to handle the heavy work load involving patients and research.

Currently my wife, Julie, and I are enjoying life on the Hampton Plantation, St. Simons Island, Georgia. This year I celebrated my 81^st birthday and am looking forward to shooting a golf score that equals my age. Looking back, I realize that I was extremely fortunate to be at the right place at the right time and to recognize that something unique was occurring. But times do change, and given the same situation and circumstances, there is no way that I could do today what I did over 30 years ago. I find it difficult not to be teaching, laying hands on the sick and investigating some curious phenomenon.

Dr. Zavala is Emeritus Professor of Medicine, University of Iowa.