rescue breathing on the toilet?

Nurses General Nursing

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After 6 years of nursing in hospice/LTC/skilled nursing today was my first code blue and I was the first responder. All I had was my young med nurse with 1yr doctor's office experience, and an OTA who originally left the patient alone on the toilet mid-seizure to discretely ask me to come to the room.

So the patient could have had a vagal response possibly, he has hypotension at times and was on the commode, unconscious. But he had his arms/hands drawn up and had been shaking like a seizure. At this point he was flaccid and drooling. He didn't come back around for several seconds* even with painful stimuli. Then he just stopped breathing, for about 20 seconds. His heart was steady at 84bpm apically. I knew he was a full code and didn't have a history of anything like this.

But I didn't know where to begin, at what point do you give up on them coming back around? You start rescue breathing right away? I don't think there was any way for me to get him on the ground, in that tiny bathroom this 240lb dead-weight, and what if he started shaking again mid-transfer and we dropped him, or hit his head? So can you do rescue breaths sitting up?

Just then he suddenly started gasping for air like I've never seen before, I'm surprised i didn't scream because it shared the crap out of me, and I was in his face! He started spewing snot and drool everywhere, I had to help him clear it so he could breath. Now all I can think of is what if I had been doing rescue breaths when THAT happened? Holy cow!

So PLEASE: what would you do, so I can do better next time?? I know it worked out but I feel like I should have started rescue breaths or been calling out important sounding directives or something to save his life...?? I did have the med nurse summon the aids while she called the supervisor who got on the phone with the doctor, so don't assume I tried to handle this ALL alone but I'm talking about before anyone else could get there... Thanks in advance!!

*seconds not minutes - oops!

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No, you didn't "work it out". The resident happened to live despite the worst efforts. Why are you wasting time having an aide call the supervisor to call a doctor? This was a life threatening emergency.

" At this point he was flaccid and was drooling, of course. He didn't come back around for several minutes even with painful stimuli."This is past the point to call 911.

You need to review your BLS.. and then learn ACLS.

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Specializes in Heme Onc.

Agreed, review your BLS. If he stopped breathing, flaccid, drooling, why are you auscultating apically. Drag his ass on the floor and start CPR...

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Specializes in Neuro/Med-Surg/Trauma ICU.

you should get him on the ground asap. since he has a pulse start rescue breathing. tell aide to call 911 and get vitals. you don't have time to listen to apical pulse, check the carotid! do you have a bag mask on your floor? if not i don't think your facility is well prepared for emergencies....

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No, you didn't "work it out". The resident happened to live despite the worst efforts. Why are you wasting time having an aide call the supervisor to call a doctor? This was a life threatening emergency.

" At this point he was flaccid and was drooling, of course. He didn't come back around for several minutes even with painful stimuli."This is past the point to call 911.

You need to review your BLS.. and then learn ACLS.

This response seems a bit harsh IMHO. Op stated that the resident didn't "come back around for several seconds" not minutes. The resident had a seizure, was never pulse less and only stopped breathing for a few seconds during the seizure. This scenario does not necessarily meet the requirements for CPR. I agree that its probably a good idea for the OP to review BLS. However, ACLS will not be particularly helpful in a LTC/SNF environment. Crash carts in these facilities are only equipped for BLS.

My first actions in this scenario would be to have someone call 911 and try to safely get the resident to the floor in case CPR become necessary. Dragging an elderly obese man to a bathroom floor sounds like a good way to cause fractures. I would only risk this kind of injury if I felt it was absolutely necessary. Many LTC facilities have total lift machines that can be used to lift an unconscious patient from a sitting to laying position. I don't know if this option was available to you but these kind of lifts are very useful tools.

I also know that LTC facilities often have asinine rules about when to call 911, what kind of situations warrant a trip to the ER, who may call a doctor...ect. Since your supervisor is probably more familiar with this resident and his situation than we are, I recommend reviewing the situation with your supervisor.

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Specializes in Neuro/Med-Surg/Trauma ICU.

i just saw this on AN homepage and i thought it was perfect for you. https://allnurses.com/general-nursing-discussion/code-blue-what-1009261.html

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Specializes in General Surgery.
This response seems a bit harsh IMHO. Op stated that the resident didn't "come back around for several seconds" not minutes. The resident had a seizure, was never pulse less and only stopped breathing for a few seconds during the seizure. This scenario does not necessarily meet the requirements for CPR. I agree that its probably a good idea for the OP to review BLS. However, ACLS will not be particularly helpful in a LTC/SNF environment. Crash carts in these facilities are only equipped for BLS.

My first actions in this scenario would be to have someone call 911 and try to safely get the resident to the floor in case CPR become necessary. Dragging an elderly obese man to a bathroom floor sounds like a good way to cause fractures. I would only risk this kind of injury if I felt it was absolutely necessary. Many LTC facilities have total lift machines that can be used to lift an unconscious patient from a sitting to laying position. I don't know if this option was available to you but these kind of lifts are very useful tools.

I also know that LTC facilities often have asinine rules about when to call 911, what kind of situations warrant a trip to the ER, who may call a doctor...ect. Since your supervisor is probably more familiar with this resident and his situation than we are, I recommend reviewing the situation with your supervisor.

I don't want to step on toes but her responses are pretty cut dry.

Been there done that is usually blunt. Sometimes it seems abrasive but nothing she said isn't true. She doesn't sugar coat things.

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Thanks for your thoughtful response LuvScience, and for yours beentheredone that, I am asking for opinions! There was absolutely no room for a lift and no safe way to get him to the ground. I've been through a hundred vagal responses and this one presented pretty much the same, we always wait it out (within seconds, not minutes). This one had a seizure component, which threw me for a loop when he stopped breathing. The supervisor didn't think I should have done anything different but I just doubted myself after the fact. It scares me that I didn't immediately go into rescue mode, I don't know when that instinct would have kicked in. So I guess this has prepared me for the next time, "better to be safe than sorry" and start rescue efforts asap. I did review BLS/ACLS, believe me! I think I'll hash it out with a couple EMS guys (on their next non-emergency trip), they usually love to tell nurses what's what!

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Specializes in critical care, ER,ICU, CVSURG, CCU.

The one thing I would have done, is facilitate an open airway, which awkward, can be done with patient setting up, if he was flaccid so was his tongue and neck muscles, I would of straighten his neck and slightly turned jaw & head laterally ....thus providing a little oral pharengeal traction, facilitating a more open airway

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Specializes in UR/PA, Hematology/Oncology, Med Surg, Psych.

Have someone call 911 right away and send in other staff to help. The sooner EMS arrives the better; and it is always ok to have a false alarm rather than wait too long to call.

Double check that your facility has a mask or carry one with you. Last time I worked in a SNF they had nothing (granted this was a long time ago) and I ended up doing mouth to mouth without a barrier and yes, coding people vomit, spit up, and have all sorts of secretions coming up :(

You will need to get that patient to the floor from the commode and you're not going to have time for someone to hunt down the lift, etc. Ease them down as best you can with as much help as possible while protecting the head. In a code situation, a broken bone is better than dead.

Also make sure this patient has suction set up in their room in case of another emergency.

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Specializes in Critical Care, Education.

To me, this is a great example of a "near miss" learning opportunity for OP's organization. I would encourage development of a "real world" resuscitation drills which include patients in the bathroom, dining room, stairway, elevator, outdoor areas, etc.

As an educator, I am always surprised at the nasty comments from my fellow ANers when anyone posts this type of thread and asks for input. I suppose I must be the only nurse who is not absolutely prepared to initiate resuscitation in every type of situation imaginable.

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Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc.
The one thing I would have done, is facilitate an open airway, which awkward, can be done with patient setting up, if he was flaccid so was his tongue and neck muscles, I would of straighten his neck and slightly turned jaw & head laterally ....thus providing a little oral pharengeal traction, facilitating a more open airway

I agree with this one and I'm betting the act of opening the airway would have resulted in immediate return of respirations. Seizures are funny things and can be game changers. Many patients stop breathing during them and for a very short period immediately after. I have picked up scads of kids who were intubated after febrile seizures because of the appearance of respiratory arrest (and/or a bad ABG obtained immediately after) when it did not really exist. I'm not sure I would have dragged this patient to the floor and immediately jumped on him given his good pulse (although I would not have wasted my time with an apical). All of us have to remember that this was the OP's first code and I'm pretty sure I wasn't a rock star at mine. So OP. what have you learned and what would you do differently? How would you handle the same scenario if it happened again?

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