The next thing I was aware of was coming too, lying on the floor at the bottom of the steps.  I don’t know how long I‘d been there or why it happened.

I didn’t feel any pain but could see that I had broken either my right leg or ankle, and that I needed medical help. I was on my own.  The loft ladder was between me and the telephone.

I somehow managed to move the ladder while supporting my right leg and ankle with my left foot.  I squiggled along on my side about two meters to the phone.  Dialled 999 and told the operator what I had done. Then said that I had Addison’s disease and would need an emergency injection of hydrocortisone immediately the ambulance arrived. I kept stressing this.

By now I was feeling very poorly. The operator kept on the line until the ambulance arrived, my husband getting to the door at the same time. The ambulance control had contacted him for me and he let them in.

I was now in a lot of pain, shaking uncontrollably, and feeling exceedingly nauseous and cold . Once again I explained to the ambulance man and the student who came with him that I had Addisons and needed an emergency injection.  They said they did not carry hydrocortisone and that it would be given when I got to the hospital.  Instead, they gave me Entenox gas for the pain.  I  don’t think they had any idea that Addison’s can be life-threatening in an emergency.

It was more than ten years since I had last worked as a nurse and I was in no state to give myself an injection.  My husband didn’t know how to and the ambulance crew said they were not allowed to.  So I insisted that I swallow 100mg hydrocortisone with some water before we left in the ambulance. By now my thinking processes were getting slower and I was drowsy from the Entenox. But I realised that I had to stay with it, to make sure I received the correct treatment for my Addison’s as well as my leg.

When we got to Accident & Emergency 20 minutes later, the steroids I had kicked in a little. The doctor told me that I would need an x-ray and examination. I told him that I must have immediate treatment for my Addisons.  But he simply said it would be checked later - after the x-ray.   It was about 20 minutes later, after the x-ray, that the medics started trying to take some blood from me.

By this time I was becoming more and more scared as nobody was taking any notice of my requests for intravenous fluids and hydrocortisone. My blood pressure was down and still moving. Five attempts to take blood had failed.  It was apparent to me that my system was shutting down.

I began demanding as loudly as I could to have the prescribed emergency treatment for Addison’s.  I had none of the necessary paperwork with me, other than my SOS pendant. But the hospital did have my records.  I just kept shouting as loud as I could: IV hydrocortisone and IV fluids, and my hospital number.

A French Canadian doctor overheard me.  He came to my cubicle and asked why I needed it. I told him I had Addison’s disease. He immediately authorised the fluids and six hourly intravenous hydrocortisone.  So approximately two hours after I arrived at the hospital and about three hours after the fall, I got the treatment I needed to stabilise my Addison’s.  He also managed to take the bloods that were required.

Shortly afterwards a nurse from Accident & Emergency came and asked me the reason behind my demands, as her mother has Addison’s.  Yet she (the nurse) had never heard of the emergency procedures I had requested.   This highlighted to me how little training most medical staff receive about Addison’s. 

I then had a temporary cast put on my leg, and was moved to the surgical assessment ward.  The staff were brilliant; not once did they forget the fluids or the six hourly hydrocortisone. I had trouble-free surgery on the Monday where my leg was plated and my ankle pinned.  It just took a little longer to stabilise my blood pressure afterwards. The next day I was moved to an orthopaedic ward where the staff once again watched my blood pressure, which was now climbing back to all of 70 over 50! 

Wednesday came and there was now a dilemma for the staff. No one knew how to reduce the steroids, which had amounted to 400 mg hydrocortisone per day over nearly five days. I was drinking normally and the IV line taken down. Luckily I was able to work out how to switch to a tapering oral dose for them and draw it up in a chart. I was also able to contact my endocrine nurse who okayed the reduction chart I had given the staff. By this time my husband had managed to bring in my  folder containing all the information on Addison’s downloaded from the ADSHG website.  I left this at the side of my bed, and it was “borrowed” continuously by the staff until I took it home. I was in hospital for 12 days altogether.

Since this happened, I’ve made sure I am prepared for any future emergencies.

I’ve had a refresher course on how to self-inject and my husband has been shown how to do it for me.  I take extra medication with me everywhere.  When I go out my bag now contains: my steroid card, the emergency letter, a small amount of oral medication and the injection kit.

As I write this, my general health is back to normal although it did take a while.  I am still wearing a heavy-weighted boot that the hospital gave me.  In a few more weeks I hope to be able to get into my Doc Martins - as recommended by the Orthopaedic Consultant.  I need to strengthen my ankle, so have some serious walking ahead of me.

Jackie

July 2004

Falling off a ladder -The doctor’s view

Jackie knew exactly what treatment she needed for her Addison’s, to deal with the challenge of a severe physical injury and to prevent her body going into a state of shock.  She kept her wits about her and was able to insist on getting the extra medication she needed.  Jackie deserves our congratulations for the clear-headed way she dealt with what must have been a frightening situation.

Provided you can swallow and keep medication down, oral hydrocortisone is sufficient in an emergency; you do not need to rely on getting an injection.

For anyone who is seriously injured, you need to take immediate action:

• Get help from others.

• Take an extra 20mg hydrocortisone immediately and more as you need it.

• Give yourself an injection of 100mg hydrocortisone if you feel seriously unwell.

• Arrange hospital admission to treat your injuries and stabilise your Addison’s.

What Jackie had not appreciated was that she would have to rely on the assistance of people who had no knowledge of the potentially life-threatening nature of an Addisonian crisis, or did not understand how quickly someone with Addison’s can go downhill.

Everyone with Addison’s can take steps to help ensure they get the right treatment in an emergency:

• Wear a MedicAlert bracelet.  This is more easily recognised by medical staff than other types of emergency jewellery.

• Carry the ADSHG emergency letter with you.  This lists the correct hospital treatment.  

• Ensure your partner is trained in how to give an emergency injection and knows where you keep your injection kit and spare medication.

• Ensure your partner has a copy of the ADSHG emergency letter and is able to explain your condition to medical staff. They need to be able demand the correct hospital treatment on your behalf, if you are too weak to do so:

1.      An injection of 100mg hydrocortisone

2.      Intravenous fluids

Reading about this kind of serious injury and the delay in getting the right treatment can be alarming.  It may help to know that there is around a 3 per cent chance in any one year that someone with Addison’s will get sick enough to need hospital admission.  This is higher than your chances of being injured in a car accident, so you do need to be prepared.  

Most recent thinking on how to come down from the high doses of steroids Jackie needed during her four days of post-operative recovery, is that a taper is not strictly necessary.  It should be possible to drop straight back to your normal oral dose.  But every individual needs careful monitoring during this time and some cases do vary.

Professor John Wass

The Churchill Hospital, Oxford, UK