A baby choking

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Scene 1 · Opening

20.50. The night light is on, the door is ajar, you are putting washing away in the hallway.

He was playing on his own in his cot. Now he is making no sound at all, and there is a pen cap lying on the rug.

Scene 2 · What you find

His eyes are open and he is not crying. His chest is not rising.

He is not coughing either, and that is exactly what tells you how serious this is.

What do you do with the first second?

• Right move : I shout for someone to call 15, and I start straight away without leaving him.
  No cough, no cry, no breathing: this is a serious blockage : No cough, no visible breathing movements, going floppy: the national health insurance guidance says to call 15 or 112 and to start the actions immediately. You get someone else to call, you do not go off to call: your place is here.
• Mistake : I put a finger in his mouth to hook out whatever he has swallowed.
  You have just pushed it further in : The health insurance guidance says it in plain words: do not put your fingers in his mouth. A finger groping blindly pushes the object further down and blocks him more. What brings it out is the pressure of air, not your hand.
• Not the best choice : I go and wake the neighbours upstairs, they have got three children.
  They are sleeping beautifully, and the stairs are long : Three children do not add up to a first aider. You are the only person in the room, and you are already the right one.

Scene 3 · The position

It is all in the position. The guidance describes it step by step, and it takes three seconds to get into.

How do you hold him?

• Right move : I sit down, I lay him face down along my forearm, my hand under his head, head lower than his chest.
  Head lower than the chest, hand under the jaw : The guidance asks you to support his head with your fingers either side of his mouth, without pressing on his throat, to lay him along your forearm face down, and to tilt him so that his head is lower than his chest. Then one to five blows between the shoulder blades, with the heel of your open hand, firmly.
• Mistake : I put my arms round him and do the fist under the ribs, the way you would for an adult.
  Abdominal thrusts are not for him : The guidance reserves abdominal thrusts for an adult or a child. With a baby, it is chest compressions that take over from the back blows. His belly has nothing to compress, and it holds organs you can damage without effort.
• Mistake : I pick him up by the feet, head down, and shake him.
  Above all, not by the feet : It is written into the public guidance in those words: whatever you do, do not hang him up by the feet. His neck cannot hold his head, nothing comes out, and you have added an injury to a choking. The right position exists, it is simple, and it fits along your forearm.

Scene 4 · The compressions

Five blows. Nothing has come out, and he still is not breathing.

The guidance moves straight on, with no pause and nothing to think about.

Five blows, no effect. What now?

• Right move : I turn him face up along my forearm, head still lower, and I press the middle of his chest with two fingers, five times.
  Two fingers, in the middle of the chest : Your forearm against his back, your hand holding his head, turn him face up, rest your forearm on your thigh, keep his head lower than his body, then the pads of two fingers in line with the breastbone: one to five deep compressions, releasing between each one.
• Mistake : I press on his tummy, under the ribs: that is where the air comes back up best.
  For him it is the chest, never the belly : The fire and rescue services sum the rule up in one line: compressions on the belly for an adult or a child, on the chest for a baby, a pregnant woman, or whenever it is impossible to get your arms round the abdomen. This is not a matter of comfort, it is the difference between a useful action and one more injury.
• Mistake : I put him flat on the mattress and slap his back, I will have more force.
  Flat, nothing comes down : The whole technique rests on the tilt: his head has to be lower than his chest, and his jaw has to be held. Laid flat on a mattress he has lost the slope that brings the object out, lost the support for his head, and the mattress swallows your blows.

Scene 5 · The cycle

Five blows, five compressions. Still nothing.

Nobody ever told you how many times you would have to start again, and that is the real question in this one.

You are a cycle and a half in. What do you do?

• Right move : I start the cycle again, blows then compressions, and I stop only if he coughs, if he screams, or if the crew arrives.
  You repeat the cycle, and there are three signals to stop : Repeat the cycle of back blows then compressions, and stop the moment a cough, a scream or crying appears, the moment breathing comes back, or the moment the object is thrown clear. Keep alternating until then, or until help arrives.
• Mistake : I stop: I have done what it says, I will wait for the crew.
  Two rounds are not a limit : The public guidance says to carry on alternating blows and compressions until the airway clears or until help arrives. Nothing stops after a set number of rounds: what stops the action is air getting through again.
• Mistake : Something has come out: I get the call cancelled and put him back down.
  Nobody knows what is still in there : In every case hospital is essential, either to take the object out or to make sure all of it has come out. What came back out is not necessarily all of what went in, and a fragment that has gone down into a lung cannot be seen from outside.

Scene 6 · He stops responding

On the third cycle he goes limp on your arm. His head rolls, his arms hang, he no longer reacts at all.

The syllabus has one line for exactly this moment, and only one.

He has just lost consciousness. What do you do?

• Right move : I lay him on his back on a firm surface, get someone to confirm help is coming, and start resuscitation with five rescue breaths.
  On the ground, the call, and resuscitation : The syllabus runs exactly this way: ease the casualty to the ground, have someone alert the emergency services or do it yourself, and carry out cardiopulmonary resuscitation. In an infant it starts with five rescue breaths, your mouth sealing his mouth and nose, then the compressions. And at the end of each cycle of compressions, you look into his mouth for the foreign body.
• Mistake : I keep going with the back blows and compressions, only harder: it was about to work.
  That manoeuvre has just ended : Back blows and choking compressions are the moves for a conscious infant. The moment he loses consciousness, the syllabus changes line: to the ground, alert, and cardiopulmonary resuscitation. That is what takes over, and it is what checks his mouth for the foreign body at every cycle.
• Mistake : I hold him against me and drive to the emergency room, it is five minutes away.
  Five minutes with no first aid at all : An unconscious infant who is not breathing needs air now, not a car ride. Resuscitation starts where he is, and the emergency service you called can help you carry it out by giving instructions over the phone. On a car seat, nobody is doing anything.

Scene 7 · He screams

At the second set of compressions you see the pen cap on his tongue. You take it out, and he is howling.

It is the best sound this room has ever produced.

He is breathing. What do you do with these three minutes?

• Right move : I stop everything, I hold him sitting up against me, I comfort him, and I stay on the line with 15.
  Sitting up against you, and not another move : Once the air is back, the baby is kept sitting up and no further manoeuvre is done. You settle him however he is most comfortable, you comfort him by talking to him, you loosen his clothes and you follow what the crew tells you.
• Mistake : His breathing is still noisy: I give him one last blow to finish the job.
  One blow too many can undo all of it : The moment he coughs, screams or breathes, the manoeuvres stop. The public guidance says to do nothing at all until breathing is back to normal, because any manoeuvre risks shifting the object and blocking him further. Noisy breathing means air is getting through.
• Mistake : I put him flat back in his cot, he will drop off again.
  He stays sitting up all the way to hospital : The public guidance is explicit: the baby has to be kept sitting up, including during the journey. Laid flat, whatever is left in his airway slides back down, and nobody is there to see it coming.

Scene 8 · The crew

Blue light in the courtyard, footsteps on the stairs. You open the door with one hand, the other holding him sitting up against your shoulder.

They take his blood pressure, they look at his throat, they take him in anyway. That is normal, and it is written down.

You gave five blows and five presses with two fingers. That was everything there was to do, and you did it.