8.2 Structured Patient Consultations & Devices Counselling

8.2 Structured Patient Consultations & Devices Counselling

Quick Reference: Practical consultation stations test a candidate's ability to deliver clear, structured, and empathetic patient education. High-frequency OSCE topics include inhaler technique demonstrations, blood glucose monitoring and subcutaneous injection technique, oral anticoagulant counselling (DOACs and Warfarin), and structured OTC symptom triage using the WWHAM framework. Candidates must physically demonstrate device operation while speaking in plain, accessible language.

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1. Respiratory Device Counselling Protocols

Inhaler technique stations require candidates to perform a physical step-by-step demonstration using placebo demo inhalers while simultaneously explaining the procedure to the patient actor.

Pressurized Metered-Dose Inhaler (pMDI) + Volumatic / AeroChamber Spacer

Pressurized MDIs release medication at high velocity. Using a spacer increases pulmonary deposition from ~10% to over 30% and reduces oral thrush risk with inhaled corticosteroids.

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|                  STEP-BY-STEP pMDI + SPACER DEMONSTRATION PROTOCOL                |
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| Step 1 | Check device & canister; remove mouthpiece covers from both inhaler and   |
|        | spacer. Inspect spacer for foreign objects or damage.                    |
| Step 2 | Shake the pMDI vigorously for 5 seconds to mix propellant and drug.      |
| Step 3 | Insert pMDI upright into the rubber ring at the back of the spacer.       |
| Step 4 | Instruct patient to sit upright and breathe out gently away from device. |
| Step 5 | Place spacer mouthpiece into mouth between teeth; seal lips tightly.     |
| Step 6 | Press canister down ONCE to release one single puff into spacer chamber. |
| Step 7 | Inhale slowly & deeply through mouth (or take 5 slow tidal breaths).     |
| Step 8 | Remove spacer from mouth; HOLD BREATH for up to 10 seconds (or comfortably).|
| Step 9 | Breathe out gently away from device. Wait 60 seconds before second puff.  |
| Step 10| If steroid inhaler: Rinse mouth with water and spit out after use.        |
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Dry Powder Inhalers (DPI: Turbohaler & Accuhaler)

Dry Powder Inhalers do not contain propellants. Drug aerosolization relies entirely on the patient's own inspiratory effort.

• Turbohaler Protocol:
  1. Unscrew and lift off the white cover.
  2. Hold Turbohaler upright. Twist grip at base fully to the right, then fully back to the left until a distinct 'CLICK' is heard (device is now loaded).
  3. Breathe out gently away from the mouthpiece.
  4. Place mouthpiece between teeth and seal lips tightly. Do not block air vents.
  5. Inhale as deeply and forcefully as possible through the mouth.
  6. Remove device from mouth and hold breath for 10 seconds.
  7. Replace cover. If corticosteroid, instruct patient to rinse mouth and spit out.
• Accuhaler Protocol:
  1. Open: Hold outer casing in one hand, place thumb of other hand on thumb grip and push away until it clicks open.
  2. Load: Slide lever away until it clicks (opens mouthpiece and loads dose counter).
  3. Exhale away from device, insert mouthpiece, seal lips, inhale forcefully and deeply.
  4. Hold breath for 10 seconds, close device by sliding thumb grip back.

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| CRITICAL COMPARISON: pMDI VS. DRY POWDER INHALER (DPI) TECHNIQUE                  |
+-----------------------------------+-----------------------------------------------+
| Inhaler Category                  | Inhalation Technique Required                 |
+-----------------------------------+-----------------------------------------------+
| Pressurized MDI (pMDI ± Spacer)   | SLOW, steady, and gentle inhalation (~3-5 sec) |
| Dry Powder Inhaler (DPI)          | FAST, deep, and forceful inhalation (<2 sec)  |
+-----------------------------------+-----------------------------------------------+

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2. Diabetes Device & Subcutaneous Injection Counselling

Blood Glucose Meter Demonstration Protocol

1. Hygiene Prep: Instruct patient to wash hands with warm soapy water and dry thoroughly. Crucial OSCE point: Explicitly warn against using alcohol wipes, as residual alcohol dilutes the blood sample and alters glucose readings.
2. Meter & Strip Preparation: Insert a fresh test strip into the meter until it powers on automatically. Verify code calibration if using older devices.
3. Lancing Device Setup: Load a new sterile lancet into the lancing device, remove the protective cap, set depth setting (typically 2-3 for normal skin), and prime the device.
4. Puncture Site Selection: Prick the side of the fingertip (lateral aspect of 3rd or 4th finger), avoiding the central pad which has higher nerve density.
5. Sample Collection & Disposal: Wipe away the very first drop of blood with a clean tissue (may contain tissue fluid). Express a second small drop, touch test strip tip to blood until drawn in by capillary action. Apply pressure to finger. Dispose lancet immediately into a yellow Sharps Bin.

Subcutaneous Insulin Pen & GLP-1 Agonist Injection Technique

• Priming ('Air-Shot'): Attach a new needle (4mm or 5mm). Dial 2 units. Hold pen point up, tap cartridge, and press button fully until a stream of liquid appears. This ensures air removal and dose accuracy.'
• Dose Selection: Dial prescribed dose (e.g., 14 units of insulin or 0.5mg Ozempic).
• Injection Execution: Select site (abdomen 2 inches from navel, outer thigh, or top of buttocks; rotate sites to prevent lipohypertrophy). Insert needle straight in at a 90-degree angle without pinching if using short 4-5mm needles. Press thumb button completely down.
• 10-Second Dwell Time: Keep the needle in the skin and hold the button for a full 10 seconds before withdrawing to prevent drug leakage.
• Post-Injection: Remove needle immediately using outer cap, dispose in Sharps Bin. Never store pen with needle attached.

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3. Oral Anticoagulant Counselling Protocols (DOACs vs. Warfarin)

Anticoagulant stations are high-risk stations testing legal, clinical, and safety counselling.

Direct Oral Anticoagulants (DOACs: Apixaban, Rivaroxaban, Dabigatran, Edoxaban)

• Indication & Action: Explain in plain terms: "This medicine thins your blood to prevent harmful blood clots from forming in your heart or legs."
• Dosing Strictness: Stress exact timing. Special requirement: Rivaroxaban (15mg/20mg) must be taken with food to ensure absorption. Dabigatran capsules must be stored in original blister (moisture sensitive) and swallowed whole.
• Patient Alert Card: Physically hand over and explain the yellow/blue Anticoagulant Patient Alert Card. Instruct patient to carry it at all times.
• Bleeding Red Flags (Immediate ER/GP Referral):
  • Unexplained, excessive, or prolonged bruising.
  • Pink, red, or dark brown urine.
  • Black tarry stools (melena) or bright red blood in bowel movements.
  • Coughing up blood or vomiting material that looks like coffee grounds.
  • Frequent nosebleeds lasting longer than 10 minutes, or severe unremitting headache.
• Drug Interactions: Warn strictly against taking over-the-counter NSAIDs (ibuprofen, naproxen) or aspirin without medical supervision. Highlight interaction with St. John's Wort and systemic antifungals.

Warfarin Counselling (Key Differences from DOACs)

• INR Target Monitoring: Explain the Target INR range (typically 2.0–3.0 for AF/DVT, 2.5–3.5 for mechanical heart valves). Review the yellow Warfarin Booklet.
• Dietary Consistency: Instruct patient to maintain a consistent diet regarding Vitamin K-rich foods (spinach, kale, broccoli). Sudden increases lower INR; sudden restriction raises INR.
• Alcohol Moderation: Avoid binge drinking as it acutely raises INR and bleeding risk.

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4. Structured OTC Consultations using the WWHAM Framework

When evaluating over-the-counter queries, candidates must structure history-taking using the WWHAM mnemonic, exclude red flags, and make an appropriate recommendation.

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|                         WWHAM OVER-THE-COUNTER TRIAGE FRAMEWORK                   |
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| W | Who is the patient?      | Is the patient present? Self, child, or elderly?   |
| W | What are the symptoms?   | Character, severity, location of chief complaint. |
| H | How long present?        | Duration, onset, acute vs chronic progression.    |
| A | Action taken so far?     | Tried any OTC meds, home remedies, or GP visits?  |
| M | Medication taken routinely| Rx meds, OTC, supplements, allergies, PMHx?       |
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Red Flag Exclusion & Referral Examples

• Cough/Cold: Cough lasting >3 weeks, hemoptysis, shortness of breath, chest pain, fever in infants -> Refer to GP.
• Headache: Sudden 'thunderclap' onset, neck stiffness, fever, photophobia, altered mental state, neurological deficit -> Immediate Emergency Department referral.
• Diarrhea: Blood/mucus in stool, severe abdominal pain, high fever, duration >48 hours in adults or >24 hours in infants -> Refer to GP.

Closing the Consultation: The Teach-Back Method

Always close interactive stations by verifying patient understanding and offering follow-up:

"To make sure I've explained everything clearly today, could you show me how you will load and use your new Turbohaler at home?"

"If your symptoms do not improve within 3 days, or if you notice any of the warning signs we discussed, please come back to see me or contact your GP immediately."