One In A Million

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In the time it takes you to read this article, it’s highly likely that at least one Emergency Medical Dispatcher (EMD) at any one of the thousands of emergency dispatch centers across the globe using the Medical Priority Dispatch System^™ (MPDS^®) will have handled a call using Protocol 26: Sick Person (Specific Diagnosis). It is far and away the most commonly used Chief Complaint Protocol, making up around 17.85% of the 20 million cases reported to the IAED Data Center from April 2023 to April 2026. That’s over 3.5 million instances of EMDs using this protocol to triage cases of sick people over three years!

As an EMD, you are probably very familiar with Protocol 26: Sick Person (Specific Diagnosis) and have used it to handle complaints of fever, vomiting, or earaches, utilizing Determinant Codes 26-A-2I–12 (or the OMEGA-level codes if your center makes use of those). However, when was the last time you used one of the more specific Determinant Codes like 26-C-3 “Sickle cell crisis/Thalassemia” or 26-C-4 “Autonomic dysreflexia/ hyperreflexia”? When was the last time a caller reported that they had Addison’s disease or were in acute adrenal crisis? Would you know how to respond if a caller asks if they should administer Solu-Cortef to the patient?

Unlike the other more general complaints handled on this protocol, it’s statistically unlikely (but not impossible) that you’ve ever taken a call from someone suffering from acute adrenal insufficiency. The IAED Data Center shows that in the past three years, while over 3.5 million calls were handled on Protocol 26, a scant 475 were handled using Determinant Code 26-C-5 “Acute adrenal insufficiency/crisis or Addison’s disease.” Of those, over 99% of all patients were awake and breathing at Case Entry, which validates the CHARLIE-level Determinant Code.

What are adrenal insufficiency and Addison’s disease? Why are they considered a medical emergency? What kinds of treatments are available to the 1–3% of Americans who live with this condition? What should you as an EMD know when this type of call comes your way? This CDE article will help you with all these questions and more.

What is adrenal insufficiency? 

When someone says the word “cortisol,” your mind might automatically associate it with stress. Cortisol is the hormone created and released by your adrenal glands to help you manage your body’s stress response, maintaining cardiovascular function, blood pressure, and blood sugar levels. Broadly speaking, adrenal insufficiency is exactly what it sounds like: the adrenal gland is unable to release sufficient amounts of cortisol. The hypothalamic-pituitary-adrenal (HPA) axis is the hormonal feedback system that regulates cortisol production through signaling between the hypothalamus, pituitary gland, and adrenal glands. There are three main types of adrenal insufficiency.

Primary adrenal insufficiency occurs when the adrenal gland itself is unable to produce hormones, secondary adrenal insufficiency occurs when the pituitary gland is unable to stimulate cortisol secretion, and tertiary adrenal insufficiency occurs when the hypothalamus does not appropriately signal the pituitary gland to stimulate cortisol production. Secondary and tertiary adrenal insufficiency may be associated with pituitary and hypothalamic tumors, respectively, and can be jointly considered as central adrenal insufficiency. Central adrenal insufficiency is most commonly caused by prolonged glucocorticoid therapy, which suppresses the HPA axis. Suppression of the HPA axis means that the adrenal gland will not release sufficient amounts of cortisol. Common glucocorticoids associated with this suppression include prednisone, dexamethasone, methylprednisolone, hydrocortisone, etc. Approximately 80% of cases of primary adrenal insufficiency are due to Addison’s disease, an autoimmune disorder that causes adrenalitis and impaired adrenal gland function.

Symptoms

Since the MPDS is concerned with symptom-based treatment without diagnosing the patient, what kinds of symptoms do patients with adrenal insufficiency commonly experience? As mentioned before, cortisol helps maintain the body’s cardiovascular function, blood pressure, and blood sugar levels, so patients experiencing adrenal insufficiency commonly report fatigue and dizziness, difficulty standing or walking, confusion, nausea, vomiting, abdominal pain, diarrhea, and muscle or joint pain. An adrenal crisis can be triggered by extreme physical stress such as a severe infection, high fever, traumatic injury, surgery, or even dehydration. Forgetting to take prescribed glucocorticoid medications can also cause adrenal insufficiency.

While some callers might volunteer that they have Addison’s disease or are suffering from an adrenal crisis, many cases of adrenal insufficiency are undiagnosed. An adrenal crisis might be their first indication that something is amiss internally. In those cases, it is important that you as the EMD don’t diagnose the patient! Determinant Code 26-C-5 is for patients who know that they have adrenal insufficiency and report it to you directly. If a patient is suffering from any of the above symptoms without mentioning Addison’s disease or acute adrenal crisis, you will handle it based on their most pressing priority symptom.

Some callers might share that they are taking prednisone or dexamethasone for specific illnesses. Examples of such illnesses include arthritis, asthma, and gastrointestinal disorders. These individuals may not appreciate that their risk to develop adrenal insufficiency is increased.

Treatment

There are medications that patients with adrenal insufficiency can take to alleviate their day-to-day symptoms, usually in the form of oral cortisol (also known as hydrocortisone). Some patients also have access to an emergency steroid medicine that is given by injection. The brand name is Solu-Cortef, but the caller or patient might also call it corticosteroid or hydrocortisone sodium succinate. It’s an intramuscular injection, similar to epinephrine in cases of allergic reactions, and it decreases the morbidity and mortality associated with adrenal crises. A typical kit contains a syringe and a dual-chamber vial containing hydrocortisone sodium succinate powder and a diluent. It is a 14-step process, which can seem intimidating to someone unused to giving injections, but some of the steps are very quick. The hydrocortisone must be mixed prior to the injection because it does not retain its potency as a solution for long (less than 12 hours). Some patients might be confused and unable to self-administer the injection. In that case, encouraging the caller or another person to administer it is appropriate. Prompt administration of the injection—within 15–60 minutes of the symptoms appearing—is crucial in giving the patient the best possible chance at recovery.

Unlike epinephrine instructions for allergic reactions, there is not currently a specific Post-Dispatch Instruction (PDI) pathway for patients or callers with adrenal insufficiency that walks them through the process of administering this drug. Instead, you will read PDI-b: “Remind her/him to do what her/his doctor has instructed for these situations.”

A caller might be concerned about injecting the patient with Solu-Cortef, not wanting to hurt them in case it’s not a true case of acute adrenal crisis, but they should know that no harm will result from a single injection.

From the Academy side

Although the MPDS protocols are symptom-based rather than diagnostically based, there are some situations in which a patient may have a diagnosis-specific medical emergency that needs to be attended to quickly without necessarily showing priority symptoms like difficulty breathing or changes in level of consciousness.

Historically, those diagnoses have included sickle cell crisis, thalassemia, diabetes, and autonomic dysreflexia, and now include adrenal crisis and Addison’s disease. The IAED received specific requests from communication centers using the MPDS to add a pathway or Determinant Code to handle calls where the caller is reporting an adrenal crisis.

“I think that physicians who are treating these patients really need to encourage them to reach out to 911 when certain parameters are reached,” said Brett Patterson, Academics and Standards Associate and Medical Council of Standards Chair. “They need to be very clear about when it is appropriate to call 911 and get help.”

It’s not only important for the patient to have an idea of what to expect when calling 911, but to inform their family members or loved ones what to expect. The patient should be clear about their diagnosis so the EMD can take direct action and then share that information with the responding EMS agency so the patient receives the care they need for this rare condition.