Adrenal insufficiency: improving paramedic practice

Adrenal emergencies in the pre-hospital field are rare but when encountered the outcome can be fatal if it is not recognised and treated rapidly (Schulman et al, 2007). The greatest challenge for pre-hospital clinicians is to recognise this elusive condition; the signs and symptoms may be non-specific early in the presentation, and the diagnosis may not be suspected or immediately clear. Coupled with the vague nature of the presentation a gap in paramedic education means that the care provided to patients with acute adrenal insufficiency is not always optimal (McBride, 2012). These factors combined suggest that much can be done to improve the response to this group of patients. To improve practice a project was undertaken to address this gap in paramedic education.

The prevalence of adrenal insufficiency in the UK is 110 to 120 per million and rising (Simmons–Holcomb, 2006). Chakera and Vaidya (2009) observe that Addison's disease has an incidence of 4.7–6.2 per million people in western populations. While the total number of individuals with adrenal insufficiency is low, all of these patients are at risk of adrenal crisis, with 42% of patients experiencing at least one crisis per year (Hahner and Allolio, 2009). Preuss (2001) specifically considered the prevalence of adrenal emergencies as a presenting condition to an emergency department and describes this as a rare event. To date no data was sourced that identified the level of exposure paramedics have faced in terms of this condition. Difficulties in diagnosis are well documented with 60% of patients having seen two or more clinicians before the diagnosis was made (Postiglone, 2013). This diagnostic complexity is likely compounded by the relative rarity of this condition and also the varying signs and symptoms that this condition presents with.