Monday, 15 June 2009

Addison's Disease/Adrenal Insufficiency

Ok here we go.

What is it?
Addison's disease was discovered by Dr Addison in 1855. It is a rare condition affecting mainly, but not exclusively, people between the ages of 20-50.
Right, we should all know that we have 2 kidneys. On each kidney sits an Adrenal gland. The adrenal gland is a bit like a Cadbury's creme egg. For example the chocolate is the cortex and the soft fondant centre (yum yum) is the medulla. Cells in the cortex produce hormones called Aldosterone and Cortisol. Together they help to control/regulate the blood pressure, regulate salts in the blood stream and help regulate the immune system. They also help balance the effect of insulin in regulating blood sugar and helps the body respond to stress. The cells in the medulla produce adrenaline and noradrenaline which have various actions throughout the body.
Now in Addison's and adrenal insufficiency the adrenal glands produce little or none of the above hormones. I think I'm right in saying that Addison's is known as primary insufficiency. Now just to complicate things there is a secondary insufficiency. Lying under our brain we have the Pituitary gland. This produces a hormone called ACTH which controls the amount of cortisol produced in the adrenal glands. With me so far? Good.

There are many reasons why we may fail to produce these hormones:
Primary Insufficiency:
Addison's ( >80% of cases), surgical removal, trauma, Infections (TB/HIV etc) and cancer. There are more.

Secondary Insufficiency:
Congenital, trauma, surgery, radiography, cancer, long term steroid use for other conditions and tumours of the pituitary gland. Again there are more.

What ever the cause these patients require life long steroid treatment. They do this by taking oral steroid tablets every day.

What's a Crisis?

Basically anyone who has the above conditions and for whatever reason are unable to keep their oral steroids down or is affected by other factors that increase the body's natural demand for cortisol such as trauma, stress etc. If someone is having surgery then the surgeon usually has to ensure the patient will have enough steroid cover for the procedure. This helps the body cope with the extra stress.

There are many causes of a crisis such as infection/ tummy bugs, stress, trauma and any form of serious illness. If patients vomit or become unwell then they usually double up on their own steroid tablets and if necessary give themselves a hydrocortisone injection. Not everyone is given a home injection kit though. A lot of sufferers manage their condition extremely well even if they start to feel a crisis coming on. Once they feel better then they will slowly wean themselves off the higher steroid doses and back on to their normal dose.
Sometimes people become very ill very quickly and are unable to keep their tablets down. That's when they need an injection. That's when we come in.

People may feel weak, dizzy, have a low blood pressure, rapid pulse and sometimes a low blood sugar. People can have seizures and become unconscious. If left untreated death will occur. It is a potentially life threatening condition. On the outside it could be just someone vomiting but when you find out they have Addison's (and understand the problems that causes) it changes the game somewhat. Be aware, not every one will present with the classic signs of shock. If they can't keep oral steroids down they need Hydrocortisone. The aim is to prevent a crisis not just to treat it when it comes along.

There are some good websites that explain the condition far better than I have. All you have to do is GOOGLE ADDISON'S DISEASE and go from there.

It's amazing reading some of the patients's stories from a few years ago and you will see that back then hardly any ambulance staff knew anything of Addison's. We didn't have Hydrocortisone (HYC) back then. Well we do now which is a step in the right direction.

Some advice though. Make sure you have a medic alert bracelet or some other obvious means of letting us know that you have this condition. If you are an Ambulance Technician (and you can't give HYC) use common sense and ring A/E to get permission to administer it IM. You may just save someones life. Actually I don't know why Techs can't give it nationally, it comes under the same drugs act that covers Glucagen, Adrenaline and Narcan (which enables techs to give these drugs in the first place) All UK Paramedics can now give it IV/IM and where I work via the IO route.

Hope this has helped. I'm waffling now so I'll sign off. Byeeee.

Adrenal Crisis

I've had a busy week. Cardiac arrest, sudden death, diabetic hypo, countless falls and an imminent birth (That we managed to get to hospital just in time. It was close though, she wasn't budging initially but as soon as I opened up the mat pack she shouted "No, not here! I didn't want this!" "Well you've two choices, take some really good breaths on this gas and air and let's get you down to the vehicle or we'll have to deliver here. Your choice." I said. With that she gulped the gas and air and made it to the truck. We were only 2 minutes from the hospital and were there in no time. They had called the midwife but she refused to come out. I phoned maternity and requested one to come out as birth was imminent but then cancelled her as we were en route.)

I was on the car over the weekend and Saturday was spent mostly going to calls but being stood down again. Then 25 minutes towards the end of my shift in comes a call, Sick person, Cat B. "Bugger!" It's not far and en route I get an update. Female with a histroy of Addison's Disease. I'm greeted by the woman's kids who show me into the front room. My patient has been vomiting for 24 hrs plus, unable to keep her oral steroids down and had already given her self her own Hydrocortisone injection 5 hours earlier. She was not good. I needed to get some more steroids into her but her veins were non existent. I tried twice but there was nothing. The ones in her hand were like trying to cannulate an electric cable, tough. I gave up and gave her an IM injection instead. She did say that she had terrible veins and that they always had trouble at hospital. She did ask me to put an IV in her ankle as that is what they usually end up doing in A/E. I said I'd rather not if I can help it. She also had severe abdo pain radiating into the back so I gave her some gas and air. No sign of a crew so I called up control. "Nothing assigned to you yet, why, did you need one then?" "Er yes please, bearing in mind this lady is suffering from an Adrenal crisis and it is potentially life threatening." "OK, we'll get one running." They took ages and my patient was pleading for me to have another go at getting a line in. She wanted some anti-sickness meds and as her BP was low I needed to get some IV fluids going. Her sugar was OK (this can be low in a crisis) and she had good oxygen saturations. The crew arrived and after a little bit of banter (she was in remarkably good spirits despite her condition) we got her onto the truck. Now she was lying down I had a look at the vein in her ankle, it was a beaut. "Right I'll have one attempt and that's it." I said. "Please do, I'd rather you got one in now." She said.

And in it went, 4 vials of bloods, some IV Metoclopramide (she was already taking the oral version) and some IV sodium chloride and they were ready to go. I gave a pre alert to A/E and off she went. The vast majority of my on scene time was taken up waiting for the crew to arrive. I finished 45 minutes late, at time and a half mind you, and it was for a genuine patient so I didn't mind. It didn't help that I left my house keys at home and had to wake my wife up at 1.15 am to let me in. Whoops.

For those non-medical types and trainee techs etc that might read this blog my next post will be a brief overview of what Adrenal crisis and Addison's disease is about. Stay tuned.

Tuesday, 9 June 2009

Is it me....................what do you think?

This call occurred a couple of weeks ago and I still find myself questioning one of the decisions made by the DR at A/E.

Our first job of the night was to a child who had fallen from a rope swing that his dad had just put up in the garden. We arrive on scene to be greeted by a panic stricken father who leads the way round to the back of the house. On the floor is a small boy lying on his side, conscious and breathing (always a welcome sight in any ill or injured kid, I'm sure you will all agree) and covered in the customary emergency layers of blankets. A quick assessment reveals that his ABCs are good. However he has bony tenderness in the centre of his neck (C-spine), he also has some thoracic bony spinal tenderness. It is causing him great discomfort despite his mum having already giving him some oral paracetamol solution. He has no neuro deficit and all his limbs are moving. Because of the 'mechanism of injury' we need to be very careful and immobilise him. We pop a collar on him and keep him chatting. Despite the pain he is very compliant and I offer him some oral morphine to ease the pain of which he is grateful. Next we roll him onto a vacuum mattress for comfort and suck the air out. On to the trolley, into the truck and of to hospital with mum. Dad follows in the car. On the way I do the usual observations which are normal for his age and I find out that mum is a paediatric nurse at the local hospital.

Now, back to the mechanism of injury; the swing is my height-over 6' and according to dad the swing managed to unhook it self when the kid was at full height. He landed on grass but his back took the full brunt.

I phone the hospital and speak to one of the Jr DRs, as I know they were busy, just to let them know what we have and how long we will be. We arrive 10 minutes later with a child who is now relatively pain free. This is the bit I'm stuck on. After releasing him from the vacuum mattress I take control of the head and direct the log roll while the DR examines his back.
"when I press you tell me yes if it hurts, OK?" says the DR
"OK" says the child
Pressing on the neck soon generates a yes and another yes and another. Now onto the thoracic spine and another yes etc. The DR then says "I think he'll be OK" and asked the boy to move his head left and then right, no problem. However when the DR asks him to lift his head up off the trolley he can't because it is too the middle of his neck and back! The DR still says "I think he will be OK".
Dad shakes my hand and both parents thank us, we book in the patient and are off on the next job.
What I don't understand is why didn't the DR refer him for an X-ray? Yes I know kids have soft bones, yes he landed on grass (which wasn't that soft) and yes he probably will be OK. But if there is CENTRAL bony tenderness over any part of the spine, child or adult, then surely that warrants an x-ray. Again I know x-rays shouldn't be dished out 'willy nilly' but if the mechanism is there.................................

I'm sure/hope he was fine. I should really follow it up (too busy that night) and have a chat with the DR.

This is no way a dig at any A/E DR just my curiosity. I'm pretty sure if it was one of the more senior DRs then investigations might have been slightly different. I don't know.

Sunday, 7 June 2009

At the end of a night shift...........................

For me it was a rotten end to a night shift. I was fortunate enough to go home to my wife and family. The driver of this car was less fortunate.


Wednesday, 3 June 2009

The Fall

Another 999 call. A fall in a retail park
"It's probably some old dear who has tripped over in one the shops" I joked.
About 3 minutes later we pulled into the retail park.
Jokingly I said "Nah it's probably someone who's fallen through the roof"
Before we knew it we had an update on the radio "Cardiac arrest, young male fallen approx 40ft through the roof"
Now on scene, ambulance doors swung open. I grab my Para bag, response bag and drugs kit. My crew mate grabs the suction and critical hemorrhage kit. Through the doors we are confronted by a crumpled heap. Above him is smashed ceiling panels and about 40-50ft above that is a smashed skylight.
The patient isn't in cardiac arrest but he's not far from it. Massive head, facial and chest injuries are obvious. We needed to act fast if we were going to give him any chance of survival.
By now a RRV Paramedic from base had arrived and we quickly set about suctioning the airway and then moved the patient onto his back. He wasn't breathing adequately and his radial pulses were virtually non existent.
First thing to sort was airway. I had a quick look with my laryngoscope but saw nothing but blood so I suctioned some more then started to assist his breathing with a BVM. Another look, more suction and then in with an ET tube. Airway was now secured. Next was breathing. It was quite evident that there was significant blunt chest trauma. One side of the chest was higher than the other, breath sounds were diminished and it was hyper resonant. I opted to insert a wide bore IV into the chest to allow the air to escape. Radial pulses started to get stronger. All the while my colleagues were getting other kit sorted. My crew mate then took over ventilations while my self and the RRV Paramedic both got big IV lines into the arms. At this point various other colleagues turned up including a local Basics DR. He just wanted to know how far we had got and then we reassessed ABCs. Next thing we know HEMS are en-route and within minutes they are walking through the door. The HEMS DR gave some RSI drugs to make sure the patient was properly asleep while the HEMS Paramedic performed a thoracostomy on the damaged chest. This made a huge improvement with ventilations, my needle decompression improved things as well but the thoracostomy really did the trick. Next we started some Hypertonic saline. Epistats were also inserted as there was significant bleeding from the severe maxillofacial injuries. A pelvic splint was also applied just as a precaution and a rapid ultrasound of the chest and belly was carried out to detect internal bleeding. Now with everything in place and all the best possible treatment it was time to load the patient into the aircraft. Many shoppers were filming us as we walked through the car park, probably out of morbid curiosity. When the helicopter lifted off there were even more people filming on their phones and as soon as the helicopter vanished they had all practically disappeared. The young lad was flown to the Royal London by passing all the local A/E units as it is the UK's main trauma centre.
We had to give our details over to the police, which is the norm in these situations. Next was the task of clearing up which was now like a war zone. Police asked if we could check over the patients work mate who was in a state of shock so I went over and had a chat with him. He was just dumbstruck.
After a quick debrief in the car park we were back on base restocking.

I've since found out the poor lad died this morning.
Everything that could be done was done right there and then. We gave him a chance.