Crisis

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“Big sick” is pretty obvious in most people.  They change colour.  Breath oddly.  Sweat profusely.  They look . . . . pretty bloody sick.

This is what my patient looked like . . . pretty bloody sick.  The first thing that struck me was the amount of sweat pouring from this guy.  It really did look like someone had hosed him down and his colour was ashen grey.  Call it intuition, call it a 6th sense – but something inside me was saying this was NOT going to end with me leaving the patient at home with a “GP referral”.

. . . really did look like he'd been hosed down with waterI was aiming down the “inferior MI” front at this stage.  And with a BP of 56/24 and a heart rate of 40 everything was slotting into place for a full Right Coronary Artery Occlusion . . . that is, until I did the ECG.  Which, turned out to be the most normal sinus bradycardia I’d ever seen.  How disappointing!

“I . . . I have . . . ”  the patient, weak and almost delirious, started pulling at a wrist bracelet, “. . . I have a . . . medi . . . alert.  Hy – hy – hypo -”

“Hypoglycaemia?”  I interjected excitedly, “Hypoglycaemia!!  You’re diabetic!?  You’re having a hypo!?”  However, I’d checked the BM already and all was normal.

“No . . . hy – hy – hypo . . . I’m . . .”  He let his head drop back in exhaustion and slowly gasped for air through the oxygen mask.

Just then, one of his colleagues stepped into the room just at the same time the crew arrived.  I gave the briefest of handovers stating I wasn’t actually sure what was going on and then set about getting a line in.

The patient’s colleague – none the better for the amount of alcohol she had been drinking – started berating our progress and treatment.  Her stolid stance merely emphasized that we should already know full well what is wrong with our patient.  And the fact she was well educated, well versed and well “seasoned” did not especially help bridge the gap of misunderstanding.

She spoke . . . yet we did not understand . . .

“He’s a “hypopit” . . . HYPOPIT!! . . . blah blah blah blah blah . . . THALAMUS . . . blah blah blah . . . ADRENALINE . . . blah blah blah . . .”

We all stood and stared, wide eyed and nodding slowly.  Each of us pretending to understand but actually remaining silent and terrified of this new assailant and her long phrases.  Every now and then, certain words hit their mark – but on the whole . . . I had no idea what she was talking about.

we stood and stared, pretending to understand . . . “. . . blah blah blah . . . CRISIS . . . blah blah blah . . . HYPOPIT . . . blah blah blah . . . PITUITARY GLAND . . . blah blah blah”

On she went, gesticulating wildly and pointing enthusiastically at the patient’s medi-alert . . . until eventually her shoulders dropped and she sighed a deep sigh of defeat.

There was a long pause before she ventured her final attempt.

“Addisons!!!  You know that?  Addisonians?  He’s having a crisis”

BOOM!  And as one, we all raised our eyebrows and rolled our heads back.

“Oooooh!  Addisonian Crisis!!!  Gottya . . . why didn’t you say”

And with that, IV access was got, Hydrocortisone given and within twenty minutes our patient was right as rain.

The crew were happy as Larry.  The patient over the moon for “being saved” and his colleague relieved it was all over.

As for Addisonian Crisis – well, we’re trained in what it is and what to do but in all honesty, the condition is so rare it’s a bit like rocking horse poo in terms of coming across it.  It was certainly my first time.  And as such, was actually quite exciting.

And the patient survived too.  Which is nice.

Binder

 

4 thoughts on “Crisis”

  1. Why didn’t you look at his Medi Alert bracelet? Was it not there?

    • Yep. It was there. As far as I remember it had very little by the way of information on it . . . ie at most, “hypopituitarism” and that’s it. And by the time it was read, our rather informative colleague had arrived.

      We got there in the end though

  2. Yep. Medi-alerts don’t always give much away.

    Ta for the link on Addisonian Crisis – that’s a new one on me. Can you test cortisol levels in the field or do you just give a pre-determined level of Hydrocortisone regardless?

    • Addisons is rare Ross. And a genuine crisis is even more rare. However, we don’t test cortisol levels – we just throw as many hydrocortisone needles at them as possible and see what sticks in.

      Good thing is, the hypotension can be somewhat corrected with laying the patient suppine and raising the legs. This will have a knock on effect to the rest of the symptoms too.

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