Late Thursday morning and a Code was called to the hospital residences, where patients and relatives visiting from interstate can live on campus for a few days. The residence are located in a building on the opposite side of the main hospital to the emergency department. Walking at ‘code pace’, it takes only a couple of minutes to get over there.

Entering the foyer of the residence, we turned left passing the small  plastic TV that always seems to be showing Dr Phil.
The fact that the Code was up on the third floor, and that we were pushing a crash cart that carried our defibrillator, drugs and intubation equipment left us with little choice but to use the slowest lift in the known universe.
It is quicker to fly from Vladivostok to Auckland than to elevate to the top floor of our hospital residence. In fact it is so slow that they have installed  food vending machines on the inside.

In a rush of unconsidered stupidity, I decided to leave the doctor and nurse waiting at the lift and scoot up the stairs to see what was going down.
Scampering out onto the third floor I could see down the length of the corridor to where a cleaner was frantically waving me in to an open door.

A large man was laying on the floor of the small room, crumpled into the  space behind the door. His wife was sitting on the bed holding a ball of red wool against her mouth like a handkerchief.
The man was blue. The ball of wool snaked down to a small cabled jumper hanging unfinished from a knitting needle that had somehow become wedged between two of the mans toes. He had very long uncut toenails.
Stepping over the man to kneel beside him I remember feeling the warmth of the in-floor heating under my knees and the cool clammy skin of the man. I could see from his glazed, half open eyes that he had a good head start on us.
Opening his airway, I drew my face down real close as if listening to something intimate he might whisper. For a few moments, there was nothing in the world but the cold breathless vacuum that hung between us.
I was so close that as I turned my head to face him, I could feel his coarse bristles rub against my cheek. His lips were dry and cracked and caked with something white.

At this point two things became evident. Firstly, my friends with the crash cart were not even within earshot. Perhaps they were fogged in at New Delhi.
Secondly, I am a total idiot. Hanging off the side of the crash cart is a bag/valve/mask device. The reason it hangs off the side of the trolley is so you can grab it in a hurry in order to manually ventilate a patient. Which is exactly what I needed to do, and exactly where it continued to be hanging.

I did not want to put my mouth on this mans mouth, so I felt for a pulse.
Nothing. OK, lets move along.
I began chest compressions. Center of the chest. 100 per minute. Basic life support. Which is a great oxymoron really, because it feels the total opposite of basic when you actually find yourself trying to squeeze blood from the stone of a dying mans heart.
Thirty compressions later, I am supposed to give two more breaths. Looking across at his wife I could see that she knew it too.

No sign of the team. I bobbed forward, squeezed his nose between my thumb and first finger, placed my other thumb between his chin and lower lip and opened his mouth.
I drew a deep breath and sealed my mouth firmly over his. I could taste nicotine and toothpaste.
The moment I blew into him, he vomited violently.

The contents of his stomach shot up his gun barrel oesophagus, into my mouth, out my nose, and with all probability, up my Eustachian tubes and out my ears.
Jolting upright I already had a mouth full of bacon and eggs and soggy toast and cold coffee and stomach acid.  Suppressing the urge to swallow, all I could do was let it all wash back out onto the mans chest.
A few seconds later, and I had a second mouthful, this time Muesli, some more soggy toast, orange juice and Vegemite.

So when the crash cart arrived, there I was. CPR in progress. An ocean of vomit. His breakfast. My breakfast.

In retrospect, I should have grabbed the bag/valve/mask, and I might have used a sheet to put across his mouth, and I could have been carrying one of those small disposable face shields on my key chain. But what it was, was a messy, smelly, unpleasant and ultimately sad resuscitation attempt. Sometimes, that is the way it goes.

Something to think about. Would you be prepared to give mouth to mouth during a resuscitation attempt?
The risk of infectious transmission is small (but not non-existent), and there are no reported cases of anyone getting HIV or Hepatitis following mouth to mouth. What is your own back-up plan?
Then there is the whole mouth to lunch scenario, which believe me is no fun at all.
My personal advice is that if you find yourself needing to ventilate a patient and you are without a bag/valve/mask or pocket-mask or similar device…skip it completely and concentrate on quality chest compressions until assistance arrives. In the hospital setting, such equipment is never far away.
Unless, of course, the elevator gets fogged in.

[Original photo credit: assbach ]

22 Responses to “mouth to mouth regurgitation.”

  1. Not my experience, my brother’s. He was assisting in an intubation, no mouth to mouth, the pink frothy secretions can up after BMV, stomach contents flew out and covered him. He had secretions and stomach contents in his mouth ,nose and eyes. His shift ended at 12 and ,at 2am there were paramedics at the door of his house to “escort ” him back to work stat. The patient died, full blown hepatitis, unfortunately my brother who negative that night , tested positive a week or so later…he has hep c. He was exposed during a routine code. Never give mouth to mouth without protecting yourself first. My brother is a respiratory therapists with four daughters, this happened almost twenty years ago. He’s glad they treated him so quickly, otherwise he would be one of the many exposed unknowingly. I truly love what I do, but as the years pass, I find myself injured more and more, I’m not married or in a relationship where someone could care for me if I got hep c or HIV. I had a needle stick on Christmas , from a patient who was hep ABC , and HIV positive. His “friends didn’t think we needed to know that..they thought he may get different treatment….I had six months of hell. Patients are not open about their conditions and I will remain human and make mistakes( needle stick).
    My brother required multiple meds , infusions and liver biopsies, (several times required repeats because not enough specimen was obtained). Currently I work in an SICU, so when there’s CRP, there’s always blood , from brains ,chests etc. puts us in a very scary position. But I only get angry when the family keeps ” secrets” from their nurses and therapists and docs.

  2. …… says it all about getting to a code too quick ….. if the bystanders (NOK) are looking that sad and needy invite them into sharing the action …… would you kiss a stranger in the street any longer than a peck on the cheek …. I think not !!!!! well done Ian …. glad I had finished dinner before reading this blog !!!!!!

  3. Just when you thought you’d heard all of the permutations of disgusting code possibilities another one comes along.

    Ugghhhhhhhhh. That is seriously foul amigo, seriously foul. A great post nonetheless!

  4. I gagged just reading this lol! It makes me thankful that I work in an ASU :)

  5. DRABC – Number One- DANGER. So easy to overlook this one even though it’s so simple. I’d assume that the risk of swallowing someone else’s bodily fluids (or splashing in the eye) is dangerous enough to preclude giving rescue breaths until adequate equipment is at hand.

    Of course, in the heat of the moment, you’re trying to save a life. And there isn’t a whole lot of leeway as far as time goes!

    Another point is how efficient are chest compressions going to be if there is minimal to no O2 in the blood stream. So you are madly circulating blood that has almost distributed the last of it’s oxygen supply, particularly if it’s been 5 – 10 mins already.

  6. I have been told by our educatior RN to never I repeat NEVER give mouth to mouth to a stranger unless it’s a child and then its completely up to you! It’s something i’m going to stick by, if the poor person is in arrest and they have a relative or friend near by then he or she can give them mouth to mouth while I stick to compressions! The way I look at it, if their not breathing, their deady bones already and anything I do is a bonus, and I’m damn good at compressions! If no one else is around, I’ll make the decision at the time and I will never feel guilty for not giving MTM if i chose not to.

  7. Have had to do this twice in public, with very old men. Did not think twice in either occasion. I feel it is better walking away with a mouth full of vomit (on the first occassion) than the look of dissapointment in the families face because people did nothing. Saying that, I am glad the guidelines have changed, but they really should be better advertised, so the expectation of mouth to mouth is not as prevelent in the public

  8. Oh you have inspired me to go buy a keychain mask tomorrow. I never want that to happen to me. I can’t think of anything grosser than that!

  9. That is a story I’m glad you shared–1) so that I can learn without experiencing it, and 2) because. I just stumbled onto your blog; and I will definitely be subscribing (USA, California; Pediatric/Adult ER Nurse).

  10. I’ve carried a pocket shield back in the day when they were bigger than a man’s wallet and have ever since due to a near miss I still cannot talk about without flashbacks….not to mention my avoidance of fire-engine red lipstick…..and you know I luvs me my shiny red. You really do take ‘em for the team, Ian, especially since it sounds like he showed a positive room temperature sign.

  11. Wonderfully gross story.

    The latest North American ACLS guidelines back up the commenters here, and interrupting compressions for giving a breath is no longer part of the protocol.

  12. Ian… I am seriously beginning to wonder about your apparent convergent oral/medical/grossness fixation. Brains… vecuronium… vomitus… one is led to avidly speculate as to what manner of work-related substance you might next decide to sample from a gastronomical perspective? :-)

    Personally, I would be very reluctant to perform EAR in such circumstances, vomit or no vomit. In an adult arrest to the first approximation it will be a primary cardiac cause, and restoring cardiac output is more important initially than ventilation or oxygenation. There’s reasonable evidence that in the first 1 to 3 minutes of BLS, ventilation is not particularly necessary. While more oxygen is always nice, and will make one’s myocardium much happier with its lot in life, the fact is your chest compressions will produce a not insignificant amount of ventilation, and the patient’s lungs are already full of a few litres of air which, precluding a very interesting location, should have about 21% good old oxygen in it already. Hopefully by the time ventilation and supra-normal oxygenation become absolute necessities, the cavalry will have arrived with a bag-valve-mask and if you’re really lucky, a full oxygen canister.

    In kids, I would bite the bullet and do full CPR/EAR immediately and continue until ACLS equipment arrives. They’re more likely to have a non-cardiac aetiology for their arrest, the little buggers desaturate faster, and early restoration of adequate ventilation and oxygenation is much more likely to improve the probability of a good outcome, compared to an adult in the same situation.

  13. I have done it once when working as a remote area nurse on a 14 year old who had been electrocuted. I have never felt the same about chocolate ice cream, but I would do it again in the same circumctances.

  14. I have done mouth-to-mouth before. I was off duty.

    With the new recommendations for continuous compressions, I don’t see any reason to even consider mouth-to-mouth, except for suspected respiratory arrests or children. The pause for the breaths interrupts compressions.

    There may be nothing more harmful than interrupting compressions, so it isn’t as if we are depriving the patient of anything by leaving out mouth-to-mouth. Quite the opposite. We probably are leaving important treatment out by delivering breaths.

  15. I personally would not do mouth-mouth ventilation, in or out of a hospital setting (exception: for a kid i prob would try anything).

  16. What a gruesome story. Reading about the two of you losing your breakfast very nearly made me lose my dinner. Thanks.

    Anyway, MadDoc above is correct about the evidence.

    I did a sort of related blog post a while back, which you can take a look at if you like.
    http://drsamonline.com/2008/04/01/recent-medical-news/hands-only-cardiopulmonary-resucitation-cpr/

  17. Personally I would prefer to do chest compressions only and thankfully there is evidence to suggest that I’m not just a vomit averse junior.

  18. I’m with Deana. EMTs are taught to revere scene safety and not to do anything if you cannot make the scene safe for you (e.g. you don’t have the proper BSI), but perhaps standards are different for nurses. If you’re without proper BSI/PPE, go with compressions. Tell a concerned onlooker that it’s a new technique — CCR. http://www.ncbi.nlm.nih.gov/pubmed/18830073. Though I suppose if the pt doesn’t live (as it sounds likely) and it’s not in your hospital’s protocols and if the pt’s family complains, you could be in trouble. So, perhaps not.

    Well, keep your BSI in your pockets, next time.

  19. Good thing you were there. Had it been me, he would have died for sure.
    pffffft

  20. It is my understanding (maybe an incorrect understanding) is that when you are out in the field sans equipment, it is better to do proper chest compressions and forgo the mouth-to-mouth business and that there is evidence that backs this up.

    Perhaps I’m wrong?

  21. Ian, pretty much the same happened to me… well, ages ago. But I was lucky enough to actually avoid the worst part.

    The story in two words: I was on duty on ambulance when we got a call for “unconsciuos man”. Being the place quite far from our location, the driver pushed as much as he could. Nevertheless, otw we got several calls from the dispatch, telling us to “speed up”. The second the vehicle stopped I was already out and running.

    As soon as I reached the man, I realized … I had “nothing” in my hands. Did what I could do, while waiting the rest of the crew to show up with the backpacks we use to carry.
    At some point, I realized there was nothing left to check… it was due time for a couple of mouth-to-mouth ventilation.
    Luckily, it was just a couple. Then, as the backpack showed up in front of my eyes, I grabbed a ambu bag and the other stuff.

    Poor man have been 15 to 20 mins without any assistance (CPR) before we found him, you can guess the rest.

    As for me, lesson learned. Doesn’t matter what’s the call, I never stepped again out of the ambulance without the backpack on shoulders. A pocket mask at least.
    Actually, I use to carry one when I’m off duty too. And gloves.

    Keep doing the good job.
    Cheers from Catania, Italy.

  22. I carry a handkerchief with me at all times, not for that purpose but I don’t care how snotty it is it is still better than bare lips to bare lips.

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