Waited to call 911 when O2 sat dropped to 45%??

[taylor_made2008]

A friend of mine has volunteered at a nursing home for awhile now and the other day there was an incident. I'm still at the student level and don't know enough yet to answer her questions.

There was a frail elderly woman, who had a normal O2 sat (low 90s I think). Apparently they tried to feed her some oatmeal or something and she couldn't swallow it very well and may have coughed or choked (sorry I can't remember). About 30 min to an hour later, an LVN found her (not sure if it was just a regular vitals check or if she was unresponsive or what), but her O2 sat had dropped to 45%.

They waited 3 minutes to call 911. The RN administered 15L to try to bring the O2 up herself with a rebreather mask. It only got to 60-something after 3 min so THEN they called 911.

Both of us think 911 should've been called immediately, while still giving her O2. I mean, wouldn't that make sense? Isn't there some ethics code or something?

Also, my friend asked if 15L was too much. I thought it was probably appropriate for the situation, but I thought the order had to come from a doctor. She didn't think one had been called, but she didn't know for sure.

Thanks for your help

[MendedHeart]

Oxygen is one of those things you get an order for later. It can be put on if needed. I would have had someone else call 911 and I would have worked on oxygenation

[meanmaryjean, DNP, RN]

Three minutes isn't very long if you are setting up oxygen, re-positioning the patient, calling for assistance in all of the above.......

[jadelpn, LPN, EMT-B]

Depends on the policy of the facility. But if it became apparent that the resident choked on something, suctioning right away would have perhaps been a thought. IF that is something that can be done. Then an immediate call for a swallow evaluation, as if this was new for the resident, it needed to be followed up on. If when checking the patient for vitals, and the O2 levels were 45%, then it would be best to call 911, institute BLS for choklng protocol, again with the suctioning and oxygen. Which a non-rebreather may or may not have been the best choice if there was food pocketed in the patient's mouth. When BLS arrived, they could have made other emergency choices--an OPA, NPA, or if a paramedic, an advanced airway.My thoughts of this are why someone who was choking to the point of a potential airway obstruction (or aspiration pneumonia) was not checked or interventions started until 30-60 minutes after the incident? At that point, 3 minutes isn't going to make a world of difference.

[BrandonLPN, LPN]

I would say 3 minutes from the moment the LPN took the resident's SPO2 to the time 911 was called is very fast, all things considered.

In that 3 minutes, the airway was likely checked, the resident repositioned and O2 applied.

Heck, you're not even giving the LPN time to check the resident's code status. Or to make sure the pulse oximeter sensor is functioning. I can't tell you how many times CNAs have came running to me telling me MR Smith's O2 sats are 60%, only for me to point out to them that his fingers have poor circulation and they need to give it a minute. Or tell them that they can't check SPO2 on the hand while the automatic cuff is inflating.

3 minutes is really quite fast if you stop and think about it.

[canoehead, BSN, RN]

Three minutes sounds reasonable to me. They are expected to do an assessment of the patient, look for reversable problems, make sure the transfer is appropriate (any DNR/do not hospitalize orders). Some nursing homes need to get hold of the doc and/or the family before calling for transport. Without knowing anything else about what happened, they seem quite on the ball.

[taylor_made2008]

Thanks everyone. I have more info.

When the paramedics came, they found oatmeal lodged in her trachea, and one paramedic told someone he had to “force” the breathing tube through the food. This doesn’t sound like a “teaspoon” of oatmeal (what the staff said) that was given within an hour or so. But, I’m not a doctor. Someone (I think a C.N.A.) said the patient was experiencing decreased alertness the day before.

[psu_213, BSN, RN]

When the paramedics came, they found oatmeal lodged in her trachea, and one paramedic told someone he had to "force" the breathing tube through the food. This doesn't sound like a "teaspoon" of oatmeal (what the staff said) that was given within an hour or so.

It seems realistic to me that the resident tried to swallow the oatmeal, didn't get it all the way down and over the next hour began to aspirate it. Also, she could have been silently aspirating several bits of the oatmeal.

The problem is, we are going based on 2nd and 3rd hand information. We weren't actually looking down that laryngoscope. Just because the paramedic had to "force" the tube through the oatmeal, we do not know if it was "a lot" or not so much oatmeal. Was there really any sizable amount of oatmeal or was he or someone else who told the story being overly dramatic about it? Was the oatmeal in the back of the mouth or further down in the airway? Had it been aspirated when she ate or did she have an emesis later and aspirated that?

Whatever the case, I don't think that we are ever going to have enough info to full explain what happened, let alone pass judgement on it.

[LadyFree28, BSN, LPN, RN]

It seems realistic to me that the resident tried to swallow the oatmeal, didn't get it all the way down and over the next hour began to aspirate it. Also, she could have been silently aspirating several bits of the oatmeal.

The problem is, we are going based on 2nd and 3rd hand information. We weren't actually looking down that laryngoscope. Just because the paramedic had to "force" the tube through the oatmeal, we do not know if it was "a lot" or not so much oatmeal. Was there really any sizable amount of oatmeal or was he or someone else who told the story being overly dramatic about it? Was the oatmeal in the back of the mouth or further down in the airway? Had it been aspirated when she ate or did she have an emesis later and aspirated that?

Whatever the case, I don't think that we are ever going to have enough info to full explain what happened, let alone pass judgement on it.

this.....that is all.

[JustBeachyNurse, LPN]

Besides most medics would SUCTION the oatmeal rather than forcing food further into the airways & lungs pretty much turning a possible aspiration/choking into an aspiration pneumonia. Third hand stories are nice & exciting often more dramatic than reality.

Plus 3 minutes is actually pretty quick to activate EMS as many others have stated.

[taylor_made2008]

This is why I'm not an RN yet. There's so much to consider! Thanks again everyone!

[OCNRN63, RN]

Besides most medics would SUCTION the oatmeal rather than forcing food further into the airways & lungs pretty much turning a possible aspiration/choking into an aspiration pneumonia. Third hand stories are nice & exciting often more dramatic than reality.

Plus 3 minutes is actually pretty quick to activate EMS as many others have stated.

​That was my first thought...wouldn't you try to clear the obstruction first?