I hate tuna salad. Hate is a pretty strong word for something I've never tried, but the odor has always deterred me. Tuna sushi or sashimi is fabulous, but cooked tuna, especially from a can, disgusts me. Adding mayonnaise and eggs to the fishy smell creates a stronger emetic than ipecac.
I remember once I went to Florida with my family and some family friends - I was probably about 15; overly awkward with stork-like legs, braces, and short frizzy hair. One night my mother's friend cooked her specialty. She had been bragging about it all week: Tuna Salad Casserole. The horribly fishy, eggy, mayo odor was overly exacerbated by being baked in the oven. Unfortunately, the cloying smell permeated every inch of the two story house for hours. I thought I was going to have to sleep on the porch. Maybe I did.
One of the few things I detest more than tuna salad is turfing work; you know - passing the buck. I was always incredibly annoyed by residents that simultaneously sucked up to attendings while pushing their own work off on younger residents and support staff. I must admit when I was pregnant with both of my children I was unable, or unwilling, to perform fetal autopsies, but rather than dumping them on other residents like some of my precedents, I always traded them for a complex surgical specimen, like a Whipple. A Whipple is a pancretoduodenectomy, which is the treatment of choice for pancreatic cancer (an often futile, but sometimes successful and at least life-prolonging surgery). The procedure is named after the surgeon that pioneered it, and can involve removal of as much as the distal half of the stomach, the gallbladder, the pancreas, regional lymph nodes, and part of the common bile duct, or fewer of the aforementioned parts. It is extremely difficult to orient, dissect, and ensure proper margin evaluation, and the dissection often necessitated, as a resident, calling Dr. Styles for help. I think it's pretty funny that when you google image a Whipple, Mr. Whipple of Charmin fame comes up right alongside Netter images of retroperitoneal body organs.
When I was a fellow in cytology, I trained performing fine needle aspirates in clinics all over UAMS and the VA. I stuck needles in all sorts of strange places: sole of the foot (very painful!), breast, behind the ear, soft tissue masses in the leg, under the tongue, etc. Occasionally we got called to the head and neck clinic at the cancer center in order to perform a needle near a stoma that was created post-laryngectomy. 99.9% of the time - don't quote me, that's just a pretty accurate ballpark figure - the larynx is removed for squamous cell carcinoma. After removing the larynx, the bottom portion of the windpipe that connects to the lungs cannot be hoisted all the way up to the pharynx (upper airway). Therefore, the open-ended trachea, which soon bifurcates into the right and left main stem bronchi leading into the lungs, is attached to a surgically created opening in the neck, called a stoma. People with a stoma still eat through their mouth (the esophagus is not affected), but they now breathe through this hole in their anterior neck.
Sometimes cancer will recur as a lump near the stoma. Often the lumps are just fibrotic scar tissue, kind of like a keloid, but the surgeon needs to know if it is cancer or not, so they call us to perform a fine needle aspiration. I don't love this site, because it is always awkward both palpating a nodule directly adjacent to someone's airway and sticking the needle in as you are watching them breathe through this tiny, artificial, surreal, alien-like mouth-hole.
One day my attending pathologist, an extremely pleasant 40ish female, and I were wandering through the Cancer Center on our way to perform a needle on a lump near a stoma site. It was early in my fellowship, and she asked me if I was OK to do it by myself, but assured me that she would remain in the room. I laughed internally, because many of the other attendings were already sending me ahead of them on my own, and I was feeling a little babied, but in a good way. She was a very maternal attending. I told her I was fine, and sauntered ahead of her in search of the patient. A nurse pointed to a chart on the door, and my knock was answered with a loud chorus, "Come in!"
As I walked into the small exam room, the odor of tuna salad slammed into me before I was able to ascertain that there were five people crammed into the tiny exam room, lining the windowsills and perched on the counter below the supply cabinet, in addition to the patient. One of them smiled cheerily and said, "I hope you don't mind, we all got lunch while we were waiting. Would you like some tuna salad?" Each and every one of the family members, including the patient, had a Styrofoam box full of the dreaded concoction. I automatically went into odor distress mode - shutting off my nose for mouth breathing only. I turned to the patient, an elderly female who was still munching away, and gave her my procedure explanation and consent spiel, which was considerably longer at the beginning of my training than it is now. As I leaned over to allow her to sign the consent, I could feel the tuna salad breath from her stoma on my neck.
I entertained then quickly rejected the idea of deferring the procedure to my attending and leaving the room. I dabbed the tiny nodule directly adjacent to her stoma with an alcohol pad. It took a little extra alcohol to clean the stoma site - the air that goes in and out of a stoma is dry, because it is not moistened by the mouth. The dryness causes thick, mucous secretions to collect around the stoma site, necessitating frequent cleaning and maintenance. As I leaned in with the needle, a tiny fleck of tuna salad escaped the stoma; in must have fallen down her airway instead of her esophagus. It was too much for me - I had reached my limit. I turned around to my attending. "Could you please take over? I suddenly need to use the restroom." It was all I could think of.
I left the room, ran down the hall, and went into the scope room and closed the door. I took deep inhalations of tuna salad-free air through my nostrils and felt the blood returning to my brain. I felt foolish and mortified that I wimped out, but incredibly relieved that I had escaped. I don't remember what the diagnosis was, but I do remember that my attending was really cool about the whole episode. I spent the rest of the year trying to make her life easier, as penitence.
Last Sunday, when I returned with Sicily from visiting my best friend from medical school, Ike looked down at my legs, startled.
"What happened to you in Jonesboro?"
Sicily and I were greeted the morning before in the driveway by Alyssa, her husband, and their beautiful two year old daughter Ainsley, whose golden curls are so amazing they almost took my breath away. I can't believe it has been two years since I have been to see them. I am remembering her a lot this summer, since I am the woman of honor (that is what I finally settled on, as opposed to matron, thanks to the help of Dr. Styles) in my sister-in-law's wedding, and was the same for Alyssa about three years ago.
As we walked in the house, their 2 year old, 30 pound dog Miles, all muscle, greeted me a little too enthusiastically. They had taken him to the vet the day before, but concerns over possible eye trauma had trumped their remembering to get his nails cut, and I was the unfortunate by product. I ultimately regretted my loud reaction more than the aesthetics and pain; I set up a cycle of fear for Sicily throughout the weekend, which she ultimately couldn't shake. Not that she didn't put forth every effort - she was so brave and even became friends with Miles at one point until the cooing that was so effective in lulling Ainsley into a happy state of co-existence with my daughter sent the dog into an ecstatic frenzy, which in turn sent Sicily running into a bedroom and slamming the door, screaming my name in terror.
No amount of rationalization on my part could get rid of her fears. I held her until she calmed down and then tried to explain that Miles was just excited, that he wouldn't hurt her. That he hadn't even MEANT to hurt me. I even compared the dog's manic state to Sicily's actions in the pool earlier as she tried to entertain Ainsley - Sicily was rushing away and toward Ainsley on the steps, yelling HILARIOUS, a tactic that had delighted my brother-in-law's 5 month old a few months earlier, but was currently causing Ainsley to react with confusion between excitement and sheer terror. Sicily got it all, appeared to understand with my assurance that she wouldn't be left alone with the dog, then stared at the long red cuts on my legs that were already forming blue and purple outlines. When I tried to open the door to the bedroom, she rushed into the bathroom and slammed the door. "No mom, I'm not ready yet. Make him go outside for a little bit, please."
Alyssa understood, and the perfectly harmless dog went outside for a couple of hours. Alyssa and Chris had apologized profusely to me earlier, but I waved them off. "I am more worried about what this will do to Sicily for the weekend. Don't worry about me. Cuts and bruises are edgy and cool. I can make up fascinating stories about what people do in Jonesboro on the weekend for fun, and brag about my participation."
As I was trying to talk Sicily out of her fear, and getting slightly frustrated, I had to check myself. Our gut fear reactions are good for us, evolutionarily protective, even. And she had witnessed the dog cause trauma to me, so she had good reason to be worried. She didn't have the same experience as their two year old, who had been living in the house unharmed for two years. She only had a few hours under her belt, and she had every right to be wary and demand protection from the adults around her.
On Monday morning during a break, I called Alyssa to tell her: "Sicily wouldn't wash her hair last night and wore the french braids you did for her to school today!" I also told her that when I went in to wake Sicily up for school, she had picked out the picture of Ainsley from the 100 or so kid pics I had cut from Christmas cards that year and pinned to the billboard right outside of her room, and fallen asleep with it next to her. It almost melted my heart. Alyssa reported that Ainsley wouldn't go to bed without the stuffed bear that Sicily had made earlier in the year and gave to her as present, and Ainsley sadly noted Sicily's absence in the seat next to her on the way to day care Monday morning.
Alyssa was my benchmark in medical school. We studied hard together, and she always did a little better than me, which frustrated me but kept me going. Now she is an ophthalmologist with a state-of-the-art building filled with high tech equipment, providing an endless source of entertainment for the kids and I when she got called in to see patients over the weekend. As I think back on our friendship, we have shared lots of fears, most of which have melted away. But we are still here for each other. Hopefully we can set up the same relationship for our daughters.
I said earlier, that I started swimming for the first time in 10 years, but really, when I think about it, it's been 20 years. I'm that old.
But I was proud of myself, because I had been swimming 10 lengths, or 20 laps, in the 50 metre pool. Until I bragged to my father last Friday.
I went to their house with the kids, for turkey tacos and a swim.
"Dad, guess what? I started swimming again."
"How much are you swimming?"
"That's about a third of a mile. Do you mean 10 lengths?"
"No, 20 lengths. 10 round trip."
"Oh, that's 2/3rds of a mile. Even better. What stroke?"
"Mostly breast stroke. A little freestyle. Maybe 4 lengths. Some backstroke."
"Breast stroke is a lazy stroke."
My dad swam in Memphis, growing up, and held some state records in the butterfly. He went to Iowa, a big ten school, on a swim scholarship. He swam alongside Mark Spitz. When he realized he probably wouldn't make it to the Olympics, he applied to med school to escape the draft. He was accepted, I understand, days before he got drafted to the Vietnam War. So he didn't have to go. Which is why I probably exist on this planet, today.
Damn it, I am NOT lazy. So when I went to the Racquet Club earlier this week, I swam 24 lengths. I added a bunch of freestyle, which really gets my heart rate up. I asked my kid's swim instructor, James, how many lengths was a mile.
I had only done 1200. So today after work, I was determined to do a mile. And I did. 12 laps breast stroke, 12 laps freestyle, and 6 laps modified backstroke - no arms. Just kicks. I had my arms extended above me, like a rocket ship. Or an enema. You pick.
When I was finished, my legs were like jelly. I had one of those awful cramps in my toe - the lack of electrolyte cramps that occur from overdoing it. Despite the fact that I was late picking up Ike to host a party, I had to lay down on a chair and rest for ten minutes, before I was able to walk again.
Hopefully I can impress my dad. If not, I will push it even harder next week.
I have this technophobe hang-up that most everyone I know can do a million more things on the computer than I can. Last fall, I was writing in Google Documents, but I started getting these weird middle of the night e-mail messages that made me think it was being infiltrated by space aliens - then my dad told me not to put anything on the internet I wouldn't want read. Good advice. I really hadn't, but decided to get it all out of there anyway. Yet in the process of pulling everything off I lost some of it, because I can't find where I put it on my computer. I wanted to blog about one of my partners a couple of weeks ago, and use parts of something I had written previously, but it's gone. Oh well. I printed her a hard copy and she's going to look for it when she is off next week.
So anyway, I opened up my Google Reader tonight to check my blogs (Happy Birthday HB's wife! See you Friday night at the big homecoming party!) and my brother had somehow infiltrated it. He is the one that helped me get set up in Google Reader last winter, so I could just follow all new blog entries with one glance, and also all of my pathology journal articles and abstracts. It's pretty cool having the American Journal of Forensic Pathology (no, I don't practice, but still fun to follow) right next to Arkansas Blog. So now Michael is sharing all this stuff with me, articles and such, and is commenting on them. Not really a blog, just following someone who shares and comments. Something new. How I came to follow him, I have no idea, but some of what he shared is pretty hilarious. I thought I'd steal one if his finds to entertain. Maybe he can comment and let me know how he snuck in. And I'm going to try my hand at this link thing again, until I get it right.
The other morning, John found a sheet on the floor with thumbnail pictures from a trip I took long ago, during residency. I made a mess the night before, looking for an old picture of our house before it was remodeled thirty years ago, and I guess I didn't get it all cleaned up. He keyed in on a tiny photo, pointed to it, and asked, "Mommy, did I have a rocket ship birthday party one time?"
I cracked up on the inside when I looked at the picture. It was of Dr. Woods and Dr. hmm . . . let's call him Dr. G. He spent a year in Chicago doing a gastrointestinal fellowship, and he also coined my pregnant nickname "Big Belly Betty," which caught on quickly. Dr. Styles especially loved that nickname. Anyway, Dr. Woods and Dr. G were posing next to a person dressed up like a giant Fleets enema with a comic happy face and a long orange tip. I took the picture at a sanctioned field trip -- the three of us traveled to Conway to see the giant colon. It was on display at a school gym - a massive colon replica complete with cancer and hemorrhoids. I got a picture of Dr. Woods next to the hemorrhoids. Love that pic. Despite being pregnant with Jack, I crawled through the colon to view all of the bigger than life-sized wonders I normally peered at through the microscope. I remember they gave away a calendar - colon cancer survivors in bikinis. There were some amazing-looking women who had survived colon cancer. My favorite part of the trip was eating Stoby's cheese dip at one of my old college restaurants. Maybe because I was pregnant, and I loved food so much. Or maybe just because I love cheese dip. I found someone dressed up like a colon polyp in the bathroom at the gym and got my picture taken with her - she looked like a red velvet Hershey kiss with cool, black-framed glasses. Very polypoid.
I didn't tell John any of this, but I did tell him that it wasn't a rocket ship birthday party. I pointed to another picture with me in it, and told him that he was in my belly, then. He looked surprised, then hugged me and grabbed his backpack for school.
The picture above is of a giottos rocket blaster - a wonderful surprise free gift I received with my $12,000 microscope (I am still paying off that scope). It costs $8.34. I know this because I love it so much I bought it for all of my partners and some of my pathology friends last Christmas. It is an amazing tool that uses only air, not chemicals, to blast the dust off of your scope (so you can't kill yourself by huffing it, like dust-off). I deliberately leave my protective covering off of my scope because I love to use it so much, and it looks cool. Dr. Woods thought it looked like an enema, so I warned everyone in my group not to lend theirs to him, in a note I tied to it with green and red ribbons. It has so many other uses - dusting computer keyboards, entertaining my son on rare visits, and attacking the flies that like to migrate from the hall to my office.
So anyway, rocket ships and enemas. That's what I've been thinking about this week. Now you can draw some of your own comparisons.
I feel like I have been on a rocket ship today - in addition to work, I decorated my mother-in-law's hospital room with flowers, candy, National Geographic magazines, and crossword puzzles. She had her hip replaced today, and is doing well. In post-op, status post morphine, she smiled and told me she was in "la la land." Good for her!! I was also in the final stages of ordering cupcakes, party platters, and buying plenty of Diet Hansen's for Sicily's second annual cupcake and pool party tomorrow - this year she picked the invitations (mom! she looks like me! brown hair!), made the guest list, and spent many mornings on the way to school composing the poem on the invite. "Mom, I just love summer breeze. It sounds so good. I love saying it. Summer breeze. It has to have summer breeze in it." Her rhyme attempts were often comical, but ultimately lovely. I also ordered invitations for a bridal luncheon I am throwing for Annie in August. WHEW!!
I flew out of town this July 4th, with my family, to visit my sister, her husband, and her two sons - Joshua is five and Matthew is two. She was extremely excited to take us to the new gym/pool they had recently joined.
"You won't believe it. It's like the Athletic Club on steroids."
My first indication that something was awry was on the way to the pool Saturday morning at 10:30. My brother-in-law Chris and I were towing Sicily and Matthew in his pristine Land Rover; we had just picked up sandwiches at a deli for lunch and packed them in a cooler. Sicily was cooing to Matthew in the back seat in her most high, beautiful melodic voice that was geared toward little kids. This voice always cracks me up because I remember her perfecting it on John when she wanted something from him. "John? Don't you want me to have the last bite of your macaroni? Don't you? And that cookie? Can I have it, please?" Her voice was so pleasantly hypnotic, he couldn't help agreeing with her in spite of the meaning of her words, and was often left cookie-less and confused by what had just happened. By the time he realized her con, it was too late.
Chris and I were sharing stories about the aquatic feats of our offspring, and I told him about how John had recently lost fear when he turned four and was barreling off the diving board ramp, cannon-balling into the deep end. I stick close by to assure that his rudimentary swim skills will get him to the ladder, but it is impressive. Chris replied incredulously,
"You have a diving board at your swimming pool? That must be a really old pool. We don't have one at our pool, they are too dangerous these days."
Well, yes, it had been around since I was little, but I hadn't realized that diving boards had gone the way of trampolines that weren't encircled by heavy mesh curtains. I guess that's Arkansas for you.
When we arrived, it was indeed the Athletic Club on steroids. The lobby was a giant whirlwind of granite tile and cherry wood, with a large restaurant that boasted everything from smoothies to grilled fish. Chris directed Sicily and I to the women's locker room ("I'll meet you on the other side!"), which contained endless wooden lockers and mirrored walls with granite counter tops. The ceiling was at least twice as high as my 10 foot living room. There were so many corridors leading off of the main hall I worried about getting lost, but we stuck to the straightest possible path and eventually landed in an enclosed swimming lap pool area. I noticed smugly to myself that even though there were a few more lanes, the lap pools were only half as long as the one at my club. Chalk one up for Arkansas.
We exited the lap pool area and there was the large recreational pool with three sectioned areas - a child's play area with beach-angled entrance, the water slides, and more lap pools. An army of red-suited teenage lifeguards flanked the pool, most of them casually talking. They greatly outnumbered the patrons - children and adults combined. Sicily pulled me frantically toward the water slide area - her aunt had bragged about them the day before and her anxious anticipation had built itself into a frenzy. On the way one of the lifeguards complimented me.
"Hey, I like your swim suit. Where did you get it?"
I smiled at her. "Thanks, I got it in Arkansas."
I looked over toward the water slides and there was yellow tape wrapped around all of the poles near the bottom. POLICE LINE - DO NOT CROSS. I wondered in alarm what had happened there.
The life guard glanced casually in the direction I was looking and said, "Are you all headed for the water slides? They don't open for ten more minutes."
I asked, "Is everything OK with the water slides?"
She peered at me, clearly confused by my question. "We never open the water slides until 11:00."
I decided not to ask the more obvious question. Just then Sicily, who had walked ahead, started trotting toward me in a slow canter. The lifeguard looked as alarmed as if she was racing toward us at breakneck speed. She shouted, "SLOW DOWN! No running allowed, " then turned to me with an accusatory voice. "You should really keep an eye on her. Running is not allowed by the pool." I shrugged, "She's six. She forgets. I'll remind her." I walked over toward Sicily, and glanced down at a large painted sign on the concrete. I told her "No diving here Sicily - it's too shallow." We had been practicing diving at our own pool, and I suddenly worried that she might dive in.
The lifeguard, who was still clinging like a parasite, announced in an authoritative voice, "There is no diving allowed at this pool anywhere. Period. No diving." I looked at her. Despite her previous compliment, I was beginning to get annoyed.
"No diving? Why not?"
She replied."It is one less liability for us to worry about." I glanced at her and then scanned the pool, looking at the endless supply of bored lifeguards, and decided if there was anything they needed, it was more things to worry about, not less. I told Sicily we had five more minutes until the water slides opened, and we headed back toward the others to check in.
By the time the water slides did open a few minutes later, I was engrossed in conversation and Sicily impatiently wandered over by herself. I wasn't worried no matter how deep the water was - she has been adept in the water since the middle of last summer. But I did keep an eye on her - sometimes her short height fools the lifeguards and they like to have eye contact with me before they let her proceed. Surely these lifeguards weren't worried - at least two manned the line at the bottom, there was one on top to staunch the flow of children, and one in the water at the bottom, which was no more than five feet deep, to monitor the emerging kids. Still, as I watched Sicily shoot down into the water, the lifeguard at the bottom began to look around so wildly that he reminded me of that girl on The Exorcist, and despite the fact that she was swimming gracefully and effortlessly to the side of the pool, I began to wave my arms frantically in order to assure him that yes, I was aware that my child was on the water slide, and I was watching. What was he so worried about? He was close enough to her that he could easily help her out if she was in trouble, which she was clearly not. Even though he was far away I could make out his stern glare and he must have given an invisible signal to another lifeguard. She came over to remind me that I needed to keep and eye on my child at all times. I nodded until she turned away, then shook my head in disbelief.
My sister noticed, and laughed. "Yeah, there are a whole lot of rules here. I break them every time. I am still learning. Last week I learned that we can't eat food on the lounge chairs, only at the tables."
A little later, John wanted to try the water slides, and I checked on the rules with my sister. "No, there's no height rule. You walk with them, go down first, and then catch them." He was very excited since he is not yet tall enough at our pool - it has recently become a battle every visit. So we climbed the steep, three story wire steps to the top and I made sure John was clear on the rules. He still wanted to go, so I went first. As I went down, I almost caught air on one curve - it was an open tube with water shooting down it, and almost twice as long as our pool slide. I wondered how he would fare. Too late now. I waited at the bottom for him, and the lifeguard stationed there looked at me in frustrated recognition.
"Ma'am, we usually don't allow people to wait on their children at the bottom. You need to move to the side."
"But it's his first time," I said softly.
"OK, just this once." I was beginning to understand the feeling of a prisoner who was let out into the courtyard to smell the fresh air for five minutes.
John didn't like the slide. He didn't cry, but was clearly stunned and shaken, and I gathered him into my arms and assured him he was brave. He looked like he had seen a ghost. If I almost caught air on that one curve, I'll bet he was very airborne.
"No mommy, I wasn't brave."
"John, just because you don't want to do it again doesn't mean you aren't brave. You were very brave to try that big kid slide." I was ashamed of the part inside of me that was slightly grateful that I wouldn't have to battle him over riding our own pool slide for the rest of the summer.
We walked back over to Sicily, who had decided she wanted a picture of herself coming down the slide. I grabbed the camera and enlisted John and Joshua as my sentinels at the bottom of the slide to alert me that it was her turn at the top of the tunneled slide (there were two). I aimed my camera toward the bottom of the slide while they excitedly posted me of her progress. "She went up another step! She's getting higher! She's almost to the top!" I felt a tap on my shoulder.
As I looked around, a face smiled at me broadly - all mirrored sunglasses and crew cut, sort of like a lifeguard version of Tom Cruise. "I'm sorry, we don't allow cameras at this pool. We like to protect our members from exposure." Exposure from what? I replied, a little sharply, "You sure do have a lot of rules at this pool." He nodded in assent, and walked away.
As I walked over to my sister, I announced loudly, "I found out another rule! No cameras! I'll bet you didn't know that one." Sara laughed, "No, I didn't." Her neighborhood friend, who had recently arrived, responded gravely, "I think they are worried that someone might take pictures of the kids in their bathing suits and use them for, you know, child pornography." She said the last two words in a whisper, and I didn't reply, because I didn't really trust what I might say, and I didn't know her very well.
So tonight after I swam my laps and the kids had their 6:30 lesson, I watched Sicily practicing her shallow dive, and I watched John race to the diving board without warning (except from me) and garner momentum down the slide for his cannonball ("Mommy, did I touch the clouds? I didn't feel it, did I reach them?"), and I was happy that my pool wasn't on steroids.
The pool may have been a little strict, but the weather was amazing and the weekend was fabulous. Sara and Chris have the best sushi joint on the planet, and the view of the fireworks at the cul-de-sac down the street from their house left John speechless. Not to mention her friend from work, who threw a fabulous July 4th cookout. We miss them so much already!
I interviewed this week with a freelance journalist, who is writing a piece about medical personnel blogs. I almost didn't do it - I am happy with my readership, and am scared of exposure. Back in April, the last time I checked my google analytics, I was getting a staggering, for me, steady 15-25 hits a day. I think. Maybe my memory has inflated the numbers.
I almost posted the e-mail interview last night, but decided to wait until the article comes out in August, in fairness to the journalist profession. Can't wait to share. It was my writing effort, this week.
I am amazed at how much more stamina I have in the water than on land. The Racquet Club lap pool is my new favorite haunt. I look incredibly cool (HA!) in my silver bathing cap and mirrored goggles. I forgot what it was like to have goggle raccoon eyes, for thirty minutes after swimming exercise.
Hope everyone has a wonderful July 4th weekend, with lots of fireworks.