brooks george

In healthcare we have dozens of interactions with patients every day. Most are brief—a 10-minute GP appointment, a 3-minute phone call, 60 seconds of counselling at the pharmacy counter—and often unremarkable. Occasionally, however, consultations can be so bizarre, comical, or unusual you can’t help but share them with your colleagues. There’s little point disputing that GUM physicians and A&E doctors win the lion’s share of dinner-party anecdotes (‘You put WHAT in WHERE!?’) but of the scraps remaining it appears to have fallen to me to collect stories of inhaler misadventures and misunderstandings.

I always ask patients to demonstrate their inhaler technique during a pharmacy Medicines Use Review. Patients’ techniques are mostly right and may need just a couple of pointers (e.g. ‘slow down your inhalation’, ‘hold your breath for longer’) but there have been a few doozies worth sharing.

One man was adamant that every inhaler he got was faulty, and just puffed out gas, no medicine. Turns out he was holding it upside down. One woman didn’t like the idea of putting the inhaler in her mouth, so held it 10 inches away and promptly got a face full of salbutamol.

A man in his 80s had been given a spacer device to use with his pMDI. When asked to demonstrate, he confidently removed the caps, checked both mouthpieces were clear, shook the inhaler and inserted it into the spacer. He then took a deep breath, triggered one puff and blew as forcefully as he could into the spacer device, shooting the medicine back out the top of the inhaler. At least his peak flow technique was solid.

Another woman administered her inhaler like expensive perfume, puffing it three times into the space in front of her and inhaling as she leant into the cloud. How glamorous!

As a student I was taking a patient history on a respiratory ward when a professor and his cloud of medics swarmed into the room and descended upon the bed opposite. The occupant there had been admitted with chest pain and shortness of breath.

My good woman,’ the professor began (apparently he was visiting from the 1950s) ‘I understand you’ve been provided an inhaler to aid your breathing. Would you tell me when and show me how you use it?’ 

Oh yes Doctor. See, my GP said to use it when my chest feels tight. So I take it out, shake it up, and then give it two good sprays.’ Demonstrating, she pulled down the neckline of her gown and puffed the inhaler directly into her sternum. ‘It doesn’t do much good though.

My final and favourite tale is almost certainly apocryphal, but it’s a good’un. It concerns a lady who had been prescribed a salbutamol inhaler for wheeziness secondary to pet allergies. During a home visit, her GP asked how she used the inhaler. ‘I can show you, but it doesn’t make much difference,’ the lady replied. And with that, she took out her inhaler, shook it well, lowered it down, and fired two puffs squarely into the face of her new tabby cat. True enough, the lady felt no relief. The cat, on the other hand, had never felt better. 

These stories may bring a smile to the face (and so they should!) but they reveal a simple truth; medications only work if they are used properly and appropriately. So the next time you’re contemplating doubling somebody’s inhaler, spare a thought for that poor tabby, and perhaps double-check their technique first.