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A sky-high crisis


Nick Willson

  • At 17, Duncan wasn’t sure that he really wanted to go on holiday with his mum and dad, but cheap flights from Newcastle and the promise of an escape from some particularly dreary Scottish weather meant the three of us were off for a relaxing week in Tenerife. We reflected on how chilled we felt as we waited in the airport lounge for our return flight, not realising what was ahead.

An eventful start to the flight
We had no sooner boarded the plane and got our seats when Duncan asked to go to the toilet. As you can imagine I was grumbling, as mums do, that he should have gone before we left. Unfortunately, this was to set a precedent for the rest of the trip and it was soon evident that a window seat was not going to be an option.

 

He started to feel quite unwell and tired, and was slumped over the folded down plane seat table, despite him taking an increased oral dose of hydrocortisone after toilet visits and being encouraged to drink to minimise the effects of dehydration. I rummaged around my handbag for the loperamide tablets, only to discover that whilst I had the tablet box, the blister strip that should have been inside wasn’t there.

 

 

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Duncan with his dad in Tenerife


The cabin crew noticed that Duncan wasn’t looking good and asked if he was feeling sick, which he wasn’t at this point, and discretely gave him a couple of loperamide capsules. The toilet trips continued much to the annoyance of the passenger in front, who deliberately put his seat back so that Duncan couldn’t rest his head and who complained loudly when John, Duncan’s dad, asked politely if he wouldn’t mind putting his seat up.

 

An unplanned diversion
Duncan’s condition continued to deteriorate and we explained to the cabin crew about Addison’s disease and what could happen if he was to have an adrenal crisis. They put a call out over the tannoy for any doctors or nurses on board, but with no success. They asked advice from their Medilink ground staff and were told that they would not have permission to divert. If I am honest, I wouldn’t even have thought about diverting the plane at this stage if it had not been mentioned by crew. I just wanted to get to Newcastle asap.

 

About 90 minutes into the flight, Duncan vomited and we administered more oral hydrocortisone in the vain hope that he would be able to keep it down. No such luck. John took Duncan to the back of the plane and administered his emergency hydrocortisone injection. At this stage Duncan was very floppy and couldn’t keep his eyes open, so when asked again about diverting the plane, we made the decision to divert to the nearest UK airport, Cardiff, and to be met there by an ambulance. The cabin crew got Duncan some oxygen and managed to clear a couple of seats so that he could lie down at least until it was time to land.

 

Back on the ground
When we landed at Cardiff we were met by a full response team including a helicopter. Apparently they had been told that there had been a cardiac arrest. I got a little upset when I overheard one of the team flippantly comment, ‘He’s ok, he’s just had some kind of crisis or something’. I appreciate that I was going to be a bit sensitive to comments like this after the worry of the flight, but the cabin crew also picked up on it and thought that it was a bit unprofessional. When I spoke to the paramedic later, he tried to explain that they thought they were coming on to revive a dead body and that the comment had been made because there had been a de-escalation of the emergency. John is a police officer and the last thing he would want is to have emergency services involved unnecessarily, but we were 30,000 feet in the air with a fairly unresponsive 17-year-old and, quite frankly, we didn’t know if Duncan’s condition would have been much much worse by Newcastle.

 

Duncan was hooked up to a drip in the ambulance and taken to Accident and Emergency at the local hospital, where he was admitted. He was met by a junior doctor and a lovely nurse, who was kind and keen to get Duncan settled. Duncan was comfortable and hadn’t vomited again, but he was still struggling to keep his eyes open. John and I felt that the doctor didn’t know much about Addison’s disease and gave the impression that a fuss had been made about nothing. John’s stomach started to play up a bit and when the nurse realised that there was a strong possibility that the root of all this was a diarrhoea and vomiting virus, we were asked to gown up and use infection control measures. The doctor took bloods from Duncan but we were then left in a small triage room overnight.

 

Confusion over medication
At around 1am, a different nurse came in with a glass of water and said that Duncan should be sipping water and if he could drink the water without vomiting then he could go home. I thought that this was very strange. He couldn’t keep awake, his blood pressure was low (110/45mmHg), he was still on a saline drip and as far as I knew the only hydrocortisone he had received was from his emergency shot. Also we were a long way from home in Scotland, our car was in Newcastle and our cases were ‘presumably’ in Newcastle too. When I challenged the nurse, she went to check. Another nurse came back with a list of accommodation for Cardiff city centre. When I said that in previous crises Duncan was in for a few days and had to prove that he could take oral meds before he could be discharged, I was told that that was because he would have been under child services before and that is why more checks would have been done. Welcome to adult services!

 

 

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Duncan with his Mum in Tenerife


Duncan woke up when all this was going on and I managed to get him to sit up and told him that he was to try to drink something because he was getting discharged. Have you ever tried to get accommodation for three people in a city centre in the early hours of a Saturday morning? Needless to say five hotels later and nothing.

 

A short while later the original nurse came back and said that there had been a mix up and that we were ok to stay. At this point I asked about the intravenous hydrocortisone and referred to previous experiences and advice given by the ADSHG. She checked Duncan’s notes and said that hydrocortisone had been given by ambulance staff at 7.30pm, 7 hours previously, and went to check whether more should be given. Duncan was given more hydrocortisone intravenously and everything settled. In the morning Duncan was much brighter, still had diarrhoea but no more vomiting and was able to eat some bread and jam.

 

I asked if he could take his oral meds as usual and was advised that he could. When the doctor on call came round to see Duncan, he said that he could go home. He said that there had been a query over whether he had a crisis or not because electrolytes and potassium levels were ok and he suspected that it was a virus, as indicated by his still raised temperature. I understand this point and don’t think there is any doubt that it was a virus, but the seriousness of the potential dangers of said virus on someone with Addison’s seemed to have got lost a little and perhaps a full blown crisis was only avoided by the prompt treatment.

 

A wake-up call
Anyway with lots to think about, we were set on our merry way to arrange car hire back to Scotland, with instructions to go to the nearest A&E should Duncan’s condition deteriorate en route. Thankfully, despite being desperately tired, there were no further incidents … phew! The experience has been a bit of a wake-up call for Duncan about wearing a MediAlert etc. as he realises that he was so out of it that he would have been unable to get the help he needed without someone else being there. We’d like to pass on our thanks to the Thompson flight crew, paramedics and medical staff at the hospital, who despite some confusions, looked after Duncan throughout this experience.

 

Carol (Duncan’s mum)
June 2016
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A sky-high crisis - The doctor's view

 

A remarkable story and I’m delighted to see a good outcome for what must have been a very frightening experience for Duncan and his family at the time. What can we learn from this?

 

One of the key points is early recognition of potential adrenal crisis. Duncan and his family were clearly well educated about appropriate adjustment of hydrocortisone treatment during illness (‘sick day rules’) as they recognised the need for an additional dose of hydrocortisone tablets as soon as he became ill, along with the need to increase his fluid intake. Infection is one of the commonest precipitants for a crisis and it was especially unfortunate that Duncan was struck down by diarrhoea and vomiting whilst on a flight. Vomiting in particular can present a challenge as hydrocortisone tablets may not be absorbed, which is why it’s so important for patients to also carry an emergency hydrocortisone injection supply. Every local endocrine centre should be able to supply this and it’s important that you check the expiry date so that supplies can be updated in a timely manner.

 

Duncan and his family should be commended for carrying the emergency hydrocortisone injection with them on board and for the early administration of this as soon as the vomiting started. Whilst early hydrocortisone injection can be lifesaving, it’s still critical that this is followed by a medical review, especially if there is no symptomatic
improvement.

 

A decision to divert a plane is not one to be undertaken lightly but was entirely appropriate here given Duncan’s deterioration. I was pleased to see that the paramedic staff had recognised the potential for an adrenal crisis and given appropriate treatment in the form of intravenous hydrocortisone and fluids. This is the cornerstone of management and it’s critical that treatment is commenced as soon as the diagnosis is suspected. There have been instances in the past where treatment hasn’t always been given quickly by ambulance crews and I know this is an area where the Addison’s Disease Self-Help Group has campaigned hard.

 

Patients and families, nevertheless, need to be aware that Addison’s disease is not always a familiar diagnosis to paramedic, nursing and medical teams. It’s helpful, therefore, if staff are informed of the disease and the importance of intravenous and additional oral therapy as part of crisis management. We would also encourage patients to carry a steroid emergency card with them at all times. This should include details of their local endocrine team who can be contacted by emergency teams if necessary. Medical jewellery is also important; Duncan was fortunate that he had family members with him during his crisis but wearing a bracelet or necklace detailing the condition and treatment can be lifesaving when no-one else is around to relay these clinical details.

 

Dr Aled Rees
Consultant Endocrinologist, University Hospital of Wales
June 2016

Edited by webmaster



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