The Greatest Lesson of All
Posted by David FlemingComment

Fleming Official PhotoAs I ponder the last six months, I cannot help but see how lucky I am to have been diagnosed with multiple endocrine neoplasia (MEN) type 2A during the last semester of the didactic portion in the Interservice Physician Assistant Program (IPAP) at Joint Base San Antonio–Fort Sam Houston. As genetic testing isn’t a common part of an annual physical exam, the diagnosis started as an incidental finding in an informal training exercise.

A colleague of mine is completing an emergency medicine fellowship at San Antonio Military Medical Center (SAMMC) and asked if I could invite some other PA students to visit her in the emergency department to act as subjects for Focused Assessment with Sonography for Trauma (FAST) exams practice. I have accompanied fellow students on a few occasions, but on this last visit, we found what looked like a cyst on my kidneys. This was in mid-December.

On January 5, I returned to classes, and a week later, sent a Relay Health message to my primary care manager. While I figured it would be something that we probably needed to work up, I sent the message hoping that I wouldn’t have to go in for an appointment, as I was a busy PA student who just wanted to finish my last semester so I could move on to assigned clinical rotations at Nellis Air Force Base, north of Las Vegas. Needless to say, he told me to come in for a physical exam and a referral to radiology for a more thorough ultrasound. Lucky for me, he was able to work me into his schedule that week.

After getting a physical exam, I was referred to a surgical center for a renal ultrasound. After getting the ultrasound, I got a call from my provider saying that I needed to go back for a CT. Once that was done, I got another phone call, this time a little more concerning. While I can’t recall the exact date or much of what he said, I can vividly recall “about the adrenal glands” and the need to work up for something more nefarious like “metastatic cancer” or even the very rare “pheochromocytoma.”

It was a Saturday when I called my dad asking him about his adolescent thyroid cancer. For as long as I can remember, he had taken levothyroxine (Synthroid), and I, as a youth, needed to get yearly blood work to make sure I didn’t have thyroid cancer like he had. While he couldn’t remember the exact type of cancer, he ended the call by saying, “But you know what? They kept testing me for a pheochromocytoma.”

Over the next seven weeks, I just kept going to class, taking tests and had a number of follow-up appointments and imaging modalities, including a thyroid ultrasound. While most didn’t know of my condition, I finally told my wife about what was going on and told her that I was leaning towards this probably being a “pheo” and not metastatic cancer. I tried to minimize what was going on because she was completing a civilian physical therapy studies program and had enough on her plate. I told her that there was no reason to worry about things that we can’t control.

Finally, in mid-March, I got an appointment with my endocrinologist. He reviewed the imaging modalities, said that my 24-hour urine sample showed huge levels of catecholamines and was confident to diagnose me with bilateral pheochromocytoma; he told me that I’d need to stay in the area to complete my medical treatment, probably for another four to six months. Later that day, I came back, and he completed the fine needle aspiration (FNA) of my thyroid and sent those cells off for further evaluation.

After the endocrinologist visit, I knew that I was going to have to stay in San Antonio. Besides that, he introduced a new variable into my “focus on what we can control” mantra: an irreversible alpha-blocker called phenoxybenzamine, needed preoperatively for surgical resection of pheochromocytomas.

I had another six weeks of classes, and after taking my first pills, I wondered how I was going to stay awake. After a couple of days, I guess that I started getting used to the meds (or started drinking more caffeinated beverages). I kept trying to “focus on what I can control,” and then, about 10 days later, I got put on atenolol, and that made me even sleepier! I would initially take the meds at night and then started to take my pills in the morning with some caffeine.

“I had another six weeks of classes, and after taking my first pills, I wondered how I was going to stay awake. I kept trying to ‘focus on what I can control.’”

During the last few weeks of school, I had a couple of follow-ups with the endocrinologist and the general surgeon. The endocrinologist told me that the results from the FNA said medullary thyroid cancer. So, on top of bilateral pheochromocytomas, I was diagnosed with medullary thyroid cancer. With that, I got some blood work done, and the genetic testing came back saying that I had MEN 2A. It wasn’t a shock, but more of a relief.

If I were to say that my medical conditions were painful or burdensome, I’d be lying. When people asked about my diagnosis with pheochromocytomas, they ask about headaches, palpitations and sweating. To be frank, yes, I had those, usually in sporadic episodes but not together. The symptoms weren’t all that noticeable. I just felt like all of the other stressed-out PA students. And as for the thyroid cancer? I wasn’t hyper or hypothyroid. My thyroid panels weren’t bad, and I didn’t think I had any problem.

Thanks to our friends, especially those with whom I worked and went to church, I was able to finish classes, get my apartment packed up and move closer to SAMMC. I graduated on a Friday, and the next Wednesday, went in for the bilateral adrenalectomy.

I wasn’t really sure what to expect, but I started to realize that I’m a terrible patient. Shortly after surgery, I was in the ICU asking when I could get the heck out of there. The great part about having no adrenal glands is that if I feel tired and worn down or know that I’m going to experience some physical or emotional stress (e.g. exercise), I just take a 10 mg hydrocortisone pill and I’m cool as a clam.

My main purpose for getting back on my feet was to get ready for my next surgery, the thyroidectomy. I knew that I had about a month to a month and a half before they were going to remove the thyroid, so I figured that I should get on my feet and try to get back into better shape to help with the next surgery’s recovery time.

I had surgery scheduled in June and started preparing myself physically and mentally. In the days leading up to my surgery, I weaned off of the NSAIDs, kept doing moderate exercise and even took a couple of road trips. The surgery date rolled around, and we arrived at the hospital ready to start the morning. I felt that this surgery was going to be a breeze compared to the last one, but as it turns out, the anticipated two-hour procedure lasted a bit longer. After a couple of hours, I was able to see my wife and went off to the ward for the evening. I was able to head home after a couple of nights in the hospital and start the recovery process there.

Since that day, I’ve been at home, trying to get my neck muscles and trapezius to stop spasming, my shoulder to stop hurting and to get back to my activities of daily living. While my voice isn’t completely back (I still talk in a relatively low voice), I am getting better day by day.

Academically, I remain on medical hold, while I recover and the Air Force determines if I am “fit for duty” now that those pesky adrenals have gone away. Apparently, those guys are important, and the military gets concerned about people on chronic steroid therapy. Come what may, I continue to “focus on what I can control.” I can feel sorry for myself or be envious of my former classmates who are immersed in their clinical rotations, but no, that’s not going to get me anywhere.

I focus on improving my health and preparing for my upcoming Air Force fitness assessment. I focus on following up with my providers and getting better medically. And, I focus on reviewing study material in the hopes of keeping my mind fresh when it comes to the study of medicine, with the ultimate goal of passing the PANCE and becoming a licensed PA.

Officer Trainee (OT) David Fleming is a recent graduate from Phase 1 (the didactic portion) of the Interservice Physician Assistant Program (IPAP) at Joint Base San Antonio−Fort Sam Houston, Texas. Prior to his arrival at IPAP, OT Fleming served in the Air Force for approximately four years in the civil engineering field as an electrical power production journeyman.

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