Tuna Salad

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.