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!

[Jrgt312]

Thanks for your candid response, glad the "first time" is out of the way so I can be on my way to perfection now In LTC I've been through so many vagals, I guess for me it's knowing when it's truly an emergency and if it is, where to start.

I've seen what you're talking about, my DON has burst through and declared a State of Emergency before and completely humiliated me -- in the moment, although it turned out to not be an emergency, but maybe she was taking a chance because it could have saved a life? So now I think I understand that better.

Of course I will hash and re-hash all this, but only for the better. That's how we learn :) . If I kept this whole thing to myself I know it would have just eaten me up!

[NurseSpeedy, ADN, LPN, RN]

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!

Jumping into emergency mode comes with experience. It was your first code. I have seen many nurses freeze during their first code, but at least they were in the hospital and once the code team shows up they take over anyway and the assigned nurses helps where needed during the process. Only working in a LTC facility I think it's a good thing that this is your first code...that means you've sent your residents out before they get to that point-a LTC should not have frequent code blues.

Could you have handled it better, yeah, but it's done now and hind sight is always 20/20. Many others have stated how they would have handled it which offers excellent advice for the future that you can use when that next code occurs (because unfortunately, eventually, it's bound to occur).

As for consulting the EMS workers for what to do in an emergency situation, I wouldn't take that route. I only worked LTC for just under a year but I did hospital nursing for almost a decade before hand. The EMS workers were quick to judge the LTC nurses and how they handled a transfer to the ER whereas later I was on the receiving end of the judgement and I will say that it was definitely an skewed perspective. To ask them would only add to the 'granny care' view that they have with nurses at these facilities. I would consult with other experienced nurses on what you should do in the future or perhaps renew your BLS early and speak with the instructor for the course who can offer unbiased advice.

[JVoEDrn]

Don't beat yourself up to bad. Everyone here has something to say: some Bc experience, some Bc they read and had time to think it through. You did fine. You're human!

[LuvScience]

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.

Respectfully, I would like to add a little clarification about my concern. I still believe that risk of injury is an important consideration in this situation. If I come across a resident exhibiting seizure activity then my priorities are 1) maintain airway 2) prevent injury. Of course, priorities change if the resident goes into cardiac/respiratory arrest. However, if the situation actually occurred as the OP describes it then CPR was never necessary for this resident. I agree that it would have been prudent to move the resident to the floor in case CPR became necessary but seizures do not invariably lead to respiratory/cardiac arrest.

Had the staff hastily made the decision to drag their obese elderly resident off the toilet and onto the floor they may have caused serious injuries needlessly. A relatively young and healthy patient might recover well from a fracture but a broken hip or leg can spell the beginning of the end for an elderly resident.

[dream'n, BSN, RN]

A first code as a nurse can be scary as heck. Everyone feels unprepared when faced with something for the first time. Even after 20 some years as a nurse I can still get nervous about things that pop up that I don't deal with often (I just hide my fear and know my go to resources/people much better now) :)