People are clumsy, especially with their medications. How many times have we met patients who dropped their brand-new bottle of Xanax down the sink? Or sat in a puddle at the bus stop and dissolved all their Percocets? It’s almost like the universe has a cosmic vendetta against fun medications. These terrible accidents never seem to happen to lactulose.

Albuterol Spacer

One exception to the rule is our old friend the albuterol metered-dose inhaler (MDI). While this is definitely not a fun medication, many patients lack the physical coordination to use the inhaler correctly. Whether it’s a young child with chubby fingers or an elderly patient with arthritic hands, some patients simply can’t manipulate the MDI and end up spraying their ear, eye, chin, or the entire emergency department, while their bronchi continue to squeeze shut. These patients need a spacer to facilitate controlled inhalation of albuterol to benefit from it.

Even though spacers look like cheap plastic toys, they can be expensive (I saw one on “sale” for $60 once). Patients often balk at purchasing them, or can’t pick one up until their designated pharmacy opens. In these cases, you can build your own spacer out of two standard albuterol nebulizer kits.

Open up both kits, and take out one of the T-pieces. On both ends of the T-piece, put on a section of the ribbed blue tubing – depending on your kit, you may have to squish the tubing a little to get a fit on both sides. This leaves one opening left in the T-piece, which you should cover with tape (photo 1).

Next, take the mouthpiece from one kit and stuff it into the end of one section of ribbed tubing. On the opposite end, push in the albuterol MDI. Poke a few holes in the tubing near the MDI with an 18-gauge needle, and it’s ready to go. Spray two puffs of albuterol into the tubing, and have the patient inhale slowly through the mouthpiece (photo 2). Try not to think of similar devices you made in your friend’s basement in high school, and be sure to emphasize that the patient needs to obtain a “real” spacer as soon as possible.

Doppler Alternative

There is a tried and true tradition of inebriation and power tool usage – in particular, malt liquor seems to mix quite often with table saws, snow blowers, belt sanders, reciprocating blades, boat winches, and industrial mixers. Some of the associated hand injuries we can fix ourselves, and some of the really horrendous ones require a surgeon’s intervention. As soon as the initial assessment is done, the most immediate question is whether or not there is blood flow to the digits distal to the injury.