rescue breathing on the toilet?

[Jrgt312]

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!

[Oh'Ello, BSN, RN]

This response seems a bit harsh IMHO. Op stated that the resident didn't "come back around for several seconds" not minutes.

Its not harsh. The OP edited her post to state that it was "seconds" not "minutes" after myself and been there, done that had already replied. So... theres that.

Being unresponsive for a couple of seconds .... wouldn't even warrant rescue breathing. So what are we actually even talking about here.

[Been there,done that, ASN, RN]

Getting him on the ground was the FIRST step.This is in preparation for CPR. There are safe transfer techniques to accomplish this. Look 'em up. As another poster stated DRAG them if you have to.

The size of the bathroom and fear of fractures is NOT an issue.

Can you imagine yourself in a court of law.. explaining that you did not get him on the ground, and could not administer CPR... because you were afraid you would cause a fracture????

[RNperdiem, RN]

Easier said than done. I know how heavy 240lbs of dead weight feels and that is with other nurses helping me move someone.

The OP was in a difficult situation with no quick fix.

In ICU if I yell "I need some help in here!" (the nursing equivalent of 'officer down') I will have at least 3 people come assist me get the patient out of the bathroom, one person to fetch the crash cart, and maybe even another to fetch the doctor we always have on the unit. In LTC, skilled help is thin on the ground in emergencies except for calling 911.

[Been there,done that, ASN, RN]

Easier said than done. I know how heavy 240lbs of dead weight feels and that is with other nurses helping me move someone.

The OP was in a difficult situation with no quick fix.

In ICU if I yell "I need some help in here!" (the nursing equivalent of 'officer down') I will have at least 3 people come assist me get the patient out of the bathroom, one person to fetch the crash cart, and maybe even another to fetch the doctor we always have on the unit. In LTC, skilled help is thin on the ground in emergencies except for calling 911.

The resident needed to be placed on the floor.Two people can get a 240 lb. patient on the ground from a two foot perch. I've actually done it alone. Gravity is your real assistant here.

[NurseOnAMotorcycle, ASN, RN]

I always tell people that if you ever have the question "should I be doing CPR right now?" The answer is always Yes.

In this case, you would have YELLED for help, dragged the pt to a lying position to get ready for CPR and had another person call 911.

My first code felt as awful and weird as this one did to you. I felt like some kind of failure because the senior nurses took over like a smooth dance while I stood there not knowing exactly how to help. But because of that experience, I knew what to look for and do the next time it happened.

I would tell you not to beat yourself up about it, but I know you will anyway, so instead I'll say to remember what it looked like and what you wish you did for the next time.

For some reason people are so reluctant to yell for help (myself included!).

[canigraduate]

So, to review the situation:

Patient was in respiratory arrest on the toilet with three people (you, OTA, med nurse) available to help. Here's what to do in the future, for you, OP, and for any one else who may need this information.

First thing to do is get help. Send the least skilled person to call 911 and start the facility's code procedures. There should be a code cart. Most facilities have them in the dining room. You must tell the person you are sending out exactly what to do. It's too hard for people to think on their feet in this kind of situation, so you have to give them clear direction. Review your facility's specific policies so you know what needs to be done. When I am in a new or unfamiliar facility, I copy the policy and keep it near me so I can refer to it until I get it memorized.

After you have sent for help, establish an airway. If you can straighten the patient's head and get the airway open without moving him from the toilet, and he starts breathing, your job is done.

If that doesn't work, the next step is to get him horizontal for rescue breathing. There are still two people available, which would be enough to safely get this man on the floor. Have your helper grab a sheet or blanket off the bed and lay it on the floor in front of the toilet. Next, have your helper place the patient's arm around their shoulders, then hold the patient around the barrel of the chest under the arms. If your helper is tall enough, he/she can straddle the patient and bear hug him under the arms from the front. You grab the knees/lower legs. Or, each of you take a side and use the chair lift method. (Not the best pic, but you get the idea.)

The two of you can easily guide the patient down onto the sheet/blanket and then pull him out to where you have room to work. Start two person rescue breathing. Hopefully someone has gotten to you with the code cart by this point and you can use a bag mask.

If more people come running to help in time, use the extra people to help ease the patient down, then have them get out of the way and get things ready for EMS. If you are a no-lift facility, there should be a mechanical lift nearby that you can use to get the patient safely off the toilet.

[No Stars In My Eyes]

This wouldn't exactly be a kosher transfer in most situations, and because I am 5'8" it would work for me better than for a shorter person:

Personally, if I thought there was even the chance of a code, I'd grab the pt's shoulders, pulling forward so they'd slump over, and allow gravity to help continue the downward movement to the floor by using my thigh as a "sliding-board". Even if they landed in a heap on the floor in the small bathroom you could straighten them out just a few inches at a time, but quickly, of course. And maybe by then there would be someone else there to help you straighten the patient out the rest of the way, to be in a code-ready position.

You don't have to do an elegant textbook transfer, as long as you don't push or pull in such a way as to hurt YOURSELF. Really, it is like a previous poster so eloquently and succinctly put it: "A broken bone is better than dead."

[Jrgt312]

No doubt gravity would help. But there definitely would have been major injuries. So it's the age old risk vs. benefit inherent in being a Full Code. I did have a sobering talk with the rsd and his wife after all this to make sure they still want to be full code in spite of the risk of possible injury. Fracture is better than dead, objectively speaking, but loved ones don't always feel that way after the fact and look for someone to blame! But knowing my only chance to save them is to get them on the ground I will not hesitate next time, where there's a will there's a way...

[Jrgt312]

I think you hit the nail on the head... Initially his head was forward, the OTA tried to straighten him up and lift his head so it was level and I could face him (even though I was kneeling below him), that's when he stopped breathing. As I did a sternal rub and jostled him his head shifted forward and he started gasping for air. There was a ton of snot and drool which I cleared out manually so he wouldn't aspirate and kept him leaning forward. But I bet that's what happened with the breathing... And this is the type of answer I was looking for, a literal description of what to do first. Thanks for your response!

[Rose_Queen, BSN, MSN, RN]

No doubt gravity would help. But there definitely would have been major injuries.

I really don't get the worries about risk of injury. Pretty much any injury can be fixed and healed. Dead is dead, and can't be fixed. A patient isn't breathing? Well, if they ain't breathing they are probably going to go into cardiac arrest at some point. That's where fear of injuring a patient goes out the window. After all, if CPR is done correctly, most likely there will be broken ribs. Prioritization.

[JVoEDrn]

When you came in and saw that he was seizing you should have immediately started the bls algorithm! You should have directed the aid/nurse to get the AED, BVM, and call 911----not the doctor who will not do anything for you.

While they are doing that you are timing his seizure. Once the seizure has stopped you do a carotid check for 10sec max, if there's no breathing you bag him and give him rescue breaths 3-5secs for two minutes or until he starts on his own. If he snots/vomits/aspirates you're turning him or suctioning him.

This is basic bls despite the difference in scenario and you may need a refresher....

What matters is that you stay up on your skills so that next time this happens you know what to do.

[JVoEDrn]

Also you don't need to be lying down to start cpr. yes it's more effective but if it's out of the question you work with what you got.