Snoring, Gurgling, and a Gasp Every Six Seconds
A neighbour calls at 07:05: 'Come quick, Bob collapsed in the garage.' Bob is 62. He is on the concrete floor and does not respond when she shouts his name or pinches his shoulder. 'He's breathing, though - I can hear it,' she says. Asked to describe it, she says it is a snoring, gurgling sound followed by a gasp every five or six seconds. His face is gray, his lips are pale blue, and his chest barely moves. She is alone with him, has no first aid training, and is on a cell phone on speaker. She is crying and says, 'I can't do CPR, I don't know how.' The garage door is open and the light is on.
1. The caller says he is breathing. How does the EMD decide whether that is true, and which questions produce the answer?
Read the worked answer
The question is not 'is there any breathing?' but 'is there effective breathing?'
Ask:
- Is he awake? Does he respond when you shout or pinch his shoulder?
- Watch his chest for me - is it rising and falling normally, the way yours does right now?
- Is he breathing regularly, or only once every few seconds with a big gasp?
- Put your hand near his mouth - can you feel steady air?
- Is it a snoring or gurgling sound?
Interpretation: occasional gasps with a snoring or gurgling noise and no real chest rise is agonal respiration. To an EMD this is not breathing - it is a patient in cardiac arrest and the highest determinant, dispatched as such immediately.
What not to ask: Is he dead? and Can you find a pulse? Lay rescuers cannot reliably find a pulse, and the attempt burns the only two minutes that matter. Do not wait for a pulse check before beginning instructions - the breathing description has already answered the question.
Framing to the caller: What you are hearing is not normal breathing. I'm going to tell you exactly what to do, and I'll stay on the phone with you the whole time.
2. Write the pre-arrival instructions you would deliver, in order, with the framing you would use for an untrained and reluctant bystander.
Read the worked answer
Framing first, in one or two sentences - she has already said she cannot do it, so address that before the mechanics:
I know this is frightening. I am going to stay with you and tell you every single thing to do. You cannot make this worse, and anything you do is better than nothing.
Sequence:
- Put the phone on speaker and set it on the floor next to him.
- Turn him onto his back if he isn't already.
- Kneel beside him. Put the heel of one hand in the centre of his chest, on the breastbone, and your other hand on top. Lace your fingers together.
- Keep your arms straight, shoulders over your hands, and push straight down hard - about two inches. Then let the chest come all the way back up.
- Push about twice a second. I will count with you - keep going with my voice.
- Don't stop. Don't stop to check on him. I'll tell you when to stop.
Delivery rules: one instruction per sentence, wait for confirmation, repeat the count out loud continuously, correct hand position verbally rather than criticising. Confirm whether local protocol directs compression-only or conventional CPR with ventilations; if ventilations are included, give them as a separate, clearly counted step.
Continue until responders take over, or he begins breathing normally, or the caller is physically unable to continue.
3. Ten compressions later she says, 'He just gasped - I think he's breathing again,' and later, 'He's moving and opening his eyes.' How should the EMD respond at each point?
Read the worked answer
To the gasp: do not stop.
That gasp is not breathing - keep pushing, right on my count.
A single gasp or snore during compressions is common and is not a return of circulation. Stopping for it costs perfusion and is one of the most frequent errors in telephone CPR.
Stop only for a genuine sign of life: breathing normally and consistently on his own, or purposeful movement and response to voice. Superficial or irregular gasping does not qualify.
When he does meet that bar:
- Stop compressions.
- If he is breathing normally and there is no suspected spinal or head trauma, roll him onto his side into the recovery position so the airway stays clear.
- Keep the phone at his side, monitor the breathing, and tell her to call back the moment the breathing changes or stops - compressions resume if it does.
- Nothing to eat or drink; keep him warm; do not let him stand up or leave.
- Update the responding unit with the change in condition - a patient who was in arrest and is now breathing changes the crew's preparation.
Also confirm access before ending: garage door open, light on, she is at the door to wave them in.