Night shift asthma attack: no first aider, an out-of-date inhaler
02:10 at an injection moulding plant with 40 staff across three shifts. On paper there is one qualified first aider per shift - in reality the night-shift first aider is on annual leave and no cover was arranged. A 34-year-old machine operator with known asthma has been coughing at her station for an hour. She is now sitting bolt upright, leaning forward, and can only speak two or three words between breaths. The wheeze is audible from a metre away, her respiratory rate is about 32, and her lips look pale. Her own reliever inhaler is in her locker, roughly 150 m away along the production hall. The first aid point holds a salbutamol inhaler that expired 14 months ago, no spacer, and a partly used oxygen cylinder. The first aid room is unlocked, but the accident book has no entries for six months. The ambulance ETA is 25 minutes and she keeps saying "I'm fine, I just need to sit down".
1. It is 02:15. Set out your management of this patient over the next ten minutes.
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Recognise this as a severe, potentially life-threatening asthma attack: inability to complete sentences, respiratory rate around 32, audible wheeze, upright tripod posture, pallor. She cannot self-triage - "I'm fine" is not reliable in a hypoxic patient.
0–2 minutes
- Call 999 immediately. Do not wait to see whether an inhaler works. The 25-minute ETA is the driving constraint.
- Sit her upright, leaning slightly forward, and loosen tight clothing. Do not lay her flat - that worsens the mechanics of breathing.
- Send someone to her locker for her own inhaler at once.
- Reassure her calmly, keep the area quiet, and stay with her - panic increases oxygen demand.
2–10 minutes
- Give the reliever as soon as it is in your hand: one puff at a time, up to 10 puffs, either with a spacer (five breaths per puff) or, without one, with a good technique and 30–60 seconds between puffs. Repeat every few minutes if there is no improvement.
- Give oxygen if you are trained and the cylinder is in date, aiming for 94–98% saturation.
- Reassess continuously: how many words she can say, respiratory rate, wheeze, colour, level of consciousness.
- Prepare for deterioration: if her breathing becomes slow, irregular or she stops responding, move to rescue breathing and CPR.
- Have someone wait at the gate for the ambulance; 25 minutes is a long time and the crew must not lose time finding the unit.
2. Should you use the expired inhaler? Explain your reasoning.
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Yes - provided it is the only bronchodilator available at that moment and the canister is intact, undamaged and still has contents. Then replace it with her own in-date inhaler the second it arrives.
The reasoning is a comparison of risks, not a rule about dates. Expired salbutamol may have reduced potency, and a metered-dose inhaler that has been stored in a warm workshop may deliver less propellant. The realistic harm is therefore a weaker dose than expected. The realistic harm of withholding a bronchodilator from a patient who cannot speak in sentences is a preventable respiratory arrest within the next quarter of an hour, with an ambulance 25 minutes away.
Practical points: shake the canister and test-fire it once, check the dose counter if fitted, and give it through a spacer if one can be improvised or found, because a spacer markedly improves delivery to the lungs in a patient too breathless to coordinate an inhaler. Do not use a damaged or contaminated device. Note the batch and expiry in the record, and tell the receiving crew, so they can factor it into their assessment.
A secondary judgement: this device should never have been in the kit expired. That is an arrangements failure, and it belongs in the incident report.
3. What failures in the workplace first aid arrangements does this incident expose, what would you change, and what must be recorded?
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Failures exposed
- No cover for absence. The designated first aider was on leave with no nominated replacement on a night shift - the arrangement existed only on paper.
- No equipment checks. A reliever inhaler 14 months out of date shows no scheduled inspection, no named person responsible, and no log.
- Unsuitable kit for the risk profile. No spacer, and an oxygen cylinder of unknown status, in a plant with known asthmatic workers.
- No reporting culture. An empty accident book for six months in a 40-person plant is not evidence of safety; it is evidence that incidents and near misses are not being recorded.
- No effective emergency plan for a remote night shift - nobody was tasked with meeting the ambulance.
Changes: review the first-aid needs assessment with shift patterns, lone working, distance to hospital and the actual hazards; nominate and train a deputy per shift, with agency or supervisor cover for leave; introduce a monthly kit check with a signed log and named owner; add a spacer and confirm oxygen cylinder status; train all supervisors to recognise severe asthma; introduce near-miss reporting.
Record: date, time, location; casualty details; what was observed at each time point; every treatment given including the out-of-date inhaler with batch and expiry; oxygen if used; who was informed; the 999 call time and ambulance arrival; the arrangements failures; and the handover given to the crew.