Introduction
This is the second of a series of vignettes in which young people with AI have unrecognized or unacknowledged symptoms of low cortisol and the results of their ignoring these situations.  Our goal is to help you recognize your own symptoms of low cortisol and circumstances that deplete your cortisol levels so you can adjust your activities accordingly.  In the rush of daily life, it is too easy to lose track of time, especially when we are not on our usual schedule, and miss an all-important dose of our medication.

The consequences and risk of missing a dose, however, can be serious.  At best, we feel really, really lousy, and it takes a day or several to get back to our baseline.  At worst, we could end up in a life-threatening adrenal crisis and be unable to advocate for ourselves. 

To prevent serious ramifications from missing a dose, it is important to be attuned to what our particular low cortisol symptoms are, be they foggy thinking, muscle and joint pain, clumsiness, or some combination.  Becoming symptomatic should cause us to think about whether we missed a dose or need to take a small booster dose.


Ariel's Story
Ariel was five minutes late for work.  Again.  Ms. Preston, the office manager, scowled at her as Ariel sat down at her desk and turned on her computer.  Upon opening her email, the top message instructed her to report to the branch manager’s office.  Ariel sighed and put her head in her hands. 

She’d already received a second warning about tardiness, but she felt that the administration was nitpicking. As she told them at the last counseling session about her attendance, for her to get to work on time, she would have had to take a bus that got her to the office almost half an hour early. Since no one could enter the office until opening time, she would have to wait outside in the cold and weather.  She almost always worked overtime and often worked through lunch.  She was the highest producing member of her unit, and she had received a recognition award the previous month.   
The previous night, Ariel had been out late celebrating her birthday with friends.  She had, perhaps, drunk a little more than she should have, but how often did you have a birthday, anyway?  Ariel had felt queasy when she woke up that morning, so she skipped breakfast.  Unfortunately, she also forgot to take her cortisol and fludrocortisone.
Ariel went to the branch manager’s office and was stunned when she was informed that she was being terminated for repeated tardiness after multiple warnings.  She suddenly felt a dizzy, sinking feeling.

When she woke up, she was lying on the floor of the branch manager’s office, and he was splashing water on her face. She blinked at him, but she could not process what was happening and why she was on the floor. Ms. Preston stood over her and scolded her for being melodramatic. Although Ariel wore a medical alert necklace, it was under her turtleneck sweater, and she had not told anyone in the office of her diagnosis of adrenal insufficiency. 

​The branch manager and Ms. Preston pulled Ariel to her feet and accompanied her out the door of the office and the building.  Ms. Preston handed Ariel her purse and told her the staff would be mailing her belongings from her cubicle.  Ariel leaned against the building, unsure of where she was and what was happening.  She slid down the wall and sat on the sidewalk.  Fortunately, a medical professional happened to walk by, and recognizing a person in distress, called EMS. The paramedic found her medical alert necklace, and as soon as she arrived at the ER, the doctors gave her IV cortisol.


Questions

• How many cortisol-consuming stress events can you recognize in this scenario?
  • [ANSWER: staying out late, overindulging in alcohol, skipping breakfast, missing medication, being late for work, getting fired, fainting, being put outside while disoriented.]
• How many symptoms of low cortisol can you identify in this scenario?
  • [ANSWER: queasiness upon awakening, dizziness, sinking feeling, loss of consciousness, disorientation.]
• What actions might Ariel taken when she felt faint?
  • [ANSWER: pulling out her medical alert necklace to let the administration know she needed medical attention.]
• What could Ariel have done to prevent some of these cortisol sapping events?
  • [ANSWER: Maintaining a regular sleep schedule, not skipping meals, taking medications on time, not overindulging in alcohol, making sure people that regular contact with her knew of her diagnosis.]

Introduction
In the rush of daily life, we all push through periods when we don’t feel well. However, it is important for those of us with adrenal insufficiency to be cognizant of the difference between feelings associated with normal fatigue or illness and an episode of low cortisol requiring an updose.

Most of us have been taught that having a cold or flu puts stress on our bodies and that requires additional cortisol, with instructions to double or triple our replacement steroid dose within the protocols. That said, it is equally important to be able to recognize that emotional and injury-related stresses also deplete cortisol levels, and it is crucial that we adjust to accommodate for these situations.

To help our members recognize these situations, NADF is pleased to present a new feature we are calling “A Day in the Life". We hope these interesting and realistic vignettes of ordinary or extraordinary events will help you to think about your own daily routine and recognize yourself in these some or all of these stories. You are welcome to share your own story with us and tell us how you handled those not-so-average days. We hope you enjoy reading and reflecting!


Benjamin’s Story
True to form, Benjamin went to bed at 10 pm and got up at 6 am, completed his 30-minute morning run, and ate his high protein breakfast along with his morning fludrocortisone and hydrocortisone. He drove to school and studied in the library until classes started. His first class was English, which was always his worst subject.

Ben prided himself of never getting a lower grade than A-, just as he prided himself on his strict physical regimen. Although his diagnosis of adrenal insufficiency had annoyingly disrupted his sense of control, he approached it as a challenge to be conquered rather than an impediment to his command over his body and mind. He refused to allow his life to be altered, and he refused to let anyone outside his immediate family know about his diagnosis. Every morning after he got in his car, he took off the medical alert bracelet his parents made him wear, and put it back on every evening before he went back into the house.

During first period, Ben’s English teacher handed back the midterm exams, and he was enraged to see that she had given him a grade of B-. Because he had another class immediately after English, he could not approach her to protest the grade until later in the day. Nonetheless, this distressing disappointment gnawed at him throughout the morning.

Ben’s last class before lunch, gym, was one of his favorites. As he changed in the locker room, Ben found himself feeling slightly nauseous, but told himself it was just hunger. Besides, in gym class they were practicing running and jumping hurdles, which as a member of the track team, was one of the things Ben was best at. Just as Ben went into a jump, however, a couple of classmates were horsing around and bumped him, altering the trajectory of his landing. He heard a sickening crack before he felt the pain in his leg. As he rolled moaning on the floor, he could barely breathe for the pain.

When EMS arrived, his blood pressure was 80/40, and his heart rate was 130. Ben was clammy and could barely speak.  The paramedics braced his leg and started an IV.  Fortunately for Ben, they took him to a medical center that had his medical records on file so eventually the clinicians were made aware that Ben had adrenal insufficiency. Unfortunately, Ben was already in crisis, and was vomiting, disoriented, and had seriously low blood pressure.

​Questions

• How many cortisol-consuming stress events can you recognize in this scenario?
  • [ANSWER: running for half an hour before taking his steroid replacements, high emotions around getting the “bad” grade on the test, and the severe injury in breaking a leg.]
• How many symptoms of low cortisol can you identify in this scenario?
  • [ANSWER: nausea, vomiting, disorientation, low blood pressure.]
• What actions could Ben have taken to improve his situation?
  • [ANSWER: wear a medical alert bracelet or necklace at all times, inform responsible adults of his diagnosis, take his medication before putting the physical stress of running on his body, acknowledge his adrenal insufficiency and accept the compromises needed to manage it, put less pressure on himself to be perfect.]
• What could Ben have done to prevent his injury from leading to an adrenal crisis?
  • [ANSWER: wear a medical alert bracelet or necklace at all times, inform responsible adults of his diagnosis.]