A child with a severe asthma exacerbation presented to the Emergency Department (ED). So severe was his asthma attack that he required nebulized adrenaline and multiple ambulances arrived at the scene. By the time i got to see him, he looked much better, although speech was still restricted to whispered phrases and there were loud wheezes and stridor emanating from him. He was however off oxygen.
The ED nurse arrived with a spacer and Ventolin.
She handed the medication to the boy’s mother. My friend and i observed her technique as she gave the spacer to her five year old son. It was clear the technique was wrong. The kid was not getting a good seal around the spacer and the nebulized drug was just escaping from the corners of his mouth.
“How do you use this? Can you please help me?” she asked.
I was nervous. I am not exactly an expert on asthma and would really have preferred the asthma educator nurse come back and do it right, but no one was in sight. I was trained to teach adults how to use a spacer, never a child. Can’t be too difficult right?
I adjusted the spacer, tried to get the child to put his teeth around the end of the spacer and encouraged him to take deep slow breaths. But it was not working. My friend also tried to correct the technique, and we just managed the best we could. We left soon after.
I made a beeline to the wards to seek out the asthma educator nurse. I have seen her on the pediatric wards before. I was also a bit puzzled as the mother mentioned that she used a spacer at home, so why did come she look so confused? I found someone else – the charge nurse.
“Hi, i just saw a kid in the ED and i was trying to teach both him and his mother how to use the spacer. But it was not working, the child was not getting a good seal around the spacer.”
“He should be using a mask.”
“Yes, one attached to the spacer. He is only five, he will not know how to use a spacer. In fact, we encourage kids all the way up to teenagers to use the mask.”
“Erm…the ED nurse just provided a spacer and i have never seen anyone use a mask with the spacer before.”
“No, you need a mask.”
“The ED nurse probably did not know what she was doing, you should let her know.”
Now i was flustered.
“Erm…i’m just a student, i don’t think i will be correcting a nurse. But i understand we should use a mask, but if the child only has a spacer, what should we do?” i persisted.
“You got the point? That they should be using a mask?” the nurse smiled.
I nodded. And she showed me what a mask and a spacer looked like. Immediately i saw how we could have circumvented the problem. The seal would not have be so challenging for the child. But the nurse, despite her misgivings, also told me that getting the child to bite down on the end of the spacer was the best way to get a better seal on the spacer without a mask, but it will never be good enough.
Relieved that i finally got the answer, i asked her where i could get a mask. I wanted to provide one for the patient; i was really uncomfortable with the child’s technique. All the drug was just escaping instead of being deposited into his lungs. She told me that the ED should have one. And so i went back to the ED and told the ED nurse that the child was not getting his medications properly and if there was a mask that he could use. She was surprised the child did not have a mask. I was relieved. So she was unaware and not ignorant and she didn’t think i was accusing her of anything. Phew. She provided a brand new spacer with a mask and told me the patient could have it. So yay! That was good. If i told the patient’s mother she had to buy a mask, she probably would forget or not be bothered to get one, and we would be back to square one.
I seek the patient out and handed the package to her. I explained to her how to use the equipment and made her demonstrate the technique on her child. She was very grateful. I told her that in future if anyone handed her any medication with a spacer, always request for a mask.
And that day i walked away feeling like a million bucks. It felt really good to be able to help someone and to know it makes a difference. It felt good that i did not just brush the incident off but instead clarified the matter and got somewhere with it. I wish every day would be more like this.