I had to be stitched on the outside and inside of my mouth, split my nose open, and got two lovely black eyes.  I was not a pretty sight, and still bear the scars.

Anyway, that was the least of my problems.  

I am not long diagnosed, only got my emergency injection kit recently and had never used it before.  So my partner and I were a bit dubious about giving me the injection and waited for the ambulance crew.  By the time they arrived I was mostly unconscious and being sick.  I was also very confused. 

The ambulance crew took the injection kit but didn't tell my partner that they couldn't inject it without a doctor’s permission.   If they had explained this, he would have injected me there and then.  Instead, they took me away in the ambulance with my unopened injection kit.

By the time I got to hospital my blood pressure was so low that I nearly died.

It was really scary how quickly it all happened.  Three hours from being okay to being nearly dead.

I was in hospital for a week, and am better now.

Unfortunately, on my post-hospital visit this week, the consultant stopped me from driving because she wants to investigate why I passed out in the first place, and why I was out for so long. So I've now got to have a brain scan, ECG, a chest x-ray, blood tests, and until those results come back - no driving.

Pam

August 2002

Things that go bump in the night -The doctor's view

Pam and her partner did the right thing in ringing for an ambulance promptly, as her physical injuries needed urgent treatment in addition to the need to stabilise her Addison’s. 

If Pam and her partner had been trained to follow the general rule about when to use the emergency injection - as soon as you have vomited twice - she would have used her injection kit before the ambulance crew arrived.

This case highlights how important it is for the patient’s partner or a companion to be thoroughly trained in how and when to give an emergency injection.  Even if it is a near neighbour, there needs to be someone who knows what to do if you, the Addisonian, are vomiting, seriously injured, or otherwise extremely ill.

This case also reminds us that, for many patients, it is not until several months after they begin treatment that their blood pressure and general health stabilise.  In those early months, patients may be more vulnerable to a crisis if they become ill or are injured.  All Addison’s patients need to be confident about using their emergency injection from day 1 of their treatment.

For many Addison’s patients, it also takes some months after beginning treatment to be able to recognise the early warning signs of steroid insufficiency and to know when illness or physical stress requires extra medication.  It may be the case that before going to bed, Pam had some indications she was becoming unwell.  Had she, perhaps, been feeling light-headed and dizzy, nauseous, or had diarrhoea?

John Wass

Professor of Endocrinology,

The Radcliffe Infirmary,

Oxford

Things that go bump in the night -The Ambulance Service View

Pam’s case shows clearly what can happen when an Addisonian does not receive immediate intervention at the onset of a crisis.

Both Pam and her partner should have been thoroughly trained in when and how to use the injection kit when it was issued.  The hydrocortisone injection should have been administered at the onset of vomiting, before the ambulance arrived.

The ambulance staff would have had no knowledge of Addison’s disease, so the benefit of the emergency kit would have been lost on them.  Because it is such a rare condition, ambulance staff do not receive training in adrenal insufficiency.

Paramedics work within strict guidelines on what they can or cannot administer to a patient.  They cannot generally give an injection without first radioing for approval from the receiving hospital.  

I would recommend that all Addisonians should take the following precautions to ensure they do not experience the same delays as Pam before receiving emergency treatment:

1.      Make sure your partner, companion, or even a neighbour, knows how to give you an emergency injection and where you keep it.

 

2.      Wear a Medic Alert bracelet or similar emergency jewellery. Should you be involved in an accident or begin a crisis away from the immediate family, such an alert would be of significant value to the paramedic, who would pass the information on to the receiving hospital. Many diabetics and epileptics use such a medi-alert system to good value.

 

3.      Carry a steroid card at all time.  (Or Medic Alert or other similar card).  In an emergency this card should be given to the first doctor you encounter – whether an injection has been given or not.

 

4.      Inform your local ambulance service of your condition/s. You can ask for details of your condition/s to be is recorded against your address.  If a 999 call is made, such details are then immediately available to the paramedics attending.  This will record that, for example, Pam Smith is a patient who has Addison’s disease and has an emergency injection kit of steroids at her home to prevent shock/respiratory arrest.

To find out which local ambulance service covers your area, contact the Ambulance Service Association on tel: 020 7928 9620.

Alan Donkersley

Cumbria Ambulance Service NHS Trust