The Advair Incident

 I never meant for this blog to be about funny patient stories, but since I have nothing else to talk about today, wth, here goes. Names have been changed to protect the clueless. . .

A few years back I was doing a fellowship in pulmonary medicine in the midwest. Having grown up on the east coast, I was used to verbose patients with a million complaints, who are not shy about questioning your diagnosis or asking questions about exactly how, when, and where to use their medications. However, out in the midwest, things are a bit different. Patients on the whole, tend to be more stoic, and and more often than not tend to keep complaints to themselves.

I was seeing a middle-aged woman with copd as a follow up appointment. Her copd was just enough to make her mildly short of breath. I had prescribed an advair inhaler at her last visit, and was seeing her back to see how she was doing. She apparently had not noticed any difference at all, though she didn’t seem too concerned about it. I asked about other risk factors, did an exam, and then spoke with my attending, who also came in to see the patient.
We went over every detail of her various occupational exposures, and asked her several times to confirm that she was in fact using the inhaler as prescribed. We asked about pets at home, about her recreational activities to see whether she was going to any smoky casinos. We obsessed over her seasonal allergies, and a multitude of other minutia, finally coming up with a plan to look at her cardiac function. Ultimately we ordered a battery of tests, lab work, imaging, etc. . .the patient was agreeable to all of them, and my attending went to see another patient.
As I was wrapping up the visit, she asked about whether she could get a refill of her advair inhaler. I thought it was probably not worth it since it did not seem to be helping. She had her inhaler on her and showed me that the counter showed only a few puffs left. And then I did something that I don’t always do, and in retrospect, I’m not sure why I even did it then; I asked her to demonstrate to me how she was using it. She then took the round inhaler, opened the side slot, and correctly pushed the lever forward to load the medication. “Good!” I said, “then what do you do?”.

She then closed the inhaler and promptly tucked it away in her purse!“Wait. . . you take a puff off it right?!”, I said, half expecting the ultimate answer, but thinking it was impossible, no one could possibly be this dense “No, that’s it, I turn it, then I just put it away.”
I stared at her, incredulous, a moment passed, then another. Down the hall the respiratory therapist was chiding a patient to blow harder into a spirometer. The patient returned my stare blankly, not knowing the thoughts going on in my head neuro-psychiatic eval for dementia? No, she is obviously with it. Mental retardation? No, too high functioning. . .
Finally, my brain and mouth reacquainted themselves,  my lip quivering with excitement at the Moby Dick of medical tales that would surely make the drab tales my attendings rehashed ad nauseum seem like childrens’ stories, “well Mrs. Jones, you need to actually take a puff off of it before you put it away. So why don’t you just use it that way, and we will hold off on all these other tests to see if it works?”

The patient was then sent on her way to check out. I hussled to the physician work room to blab about the whale I just speared. As I went to dictate, however, a thought struck me, if she uses that inhaler, she’s gonna get a full months supply of salmeterol in one puff. . .                  “SH(#$&$(@tT!!!”
I ran up to the check out desk and looked around the waiting room, no, not there. I ran to the elevators, and there she was, just about to board. I asked for her inhaler, put in my pocket, and told her to have a nice day.