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As we near the end of the semester and NREMT paramedic classes begin to practice for their NREMT exams, I thought it would be time to review some of the skills that are needed for both the BLS and ALS versions of the test. I’ve been covering IO drills lately since our friend, Eric Augustus wrote such a good piece about it over at the EMS Haiku blog.
I cover all of these skills over at the MedicCast Extra site if you want to have a good place to review and download NREMT test tips for yourself.
Eric, however, was kind enough to send me this info on his use of intra osseous infusion in the field. Here is what he sent my way:
Experiences with IO
I’ve been exposed to IO for almost 20 years, ever since my first PALS class. It wasn’t until I came to my present job that I’ve ever had the opportunity to actually use it.
“My first time”
We were dispatched to a child run over. The little guy (18 months old) had been accidentally run over by a dual-axle trailer. The tires straddled the patient, and dad was unable to lift the trailer off of him and pull him out at the same time. He had to drop the trailer back on top of the kid and run for help. Help was mom.
We were about 11 miles away when we were dispatched. I put in a call for a helicopter. As we arrived, I found the patient purple from the chest up and with a broken femur. I had heard about Traumatic Asphyxia in school and knew that it was VERY BAD. I told the first responders that I wanted the patient naked and in a KED. I returned to the ambulance and called the hospital. I was convinced that he would die at any moment.
“Don’t bring him here” was the response from the doctor. We decided to bypass the local hospital, drive like hell for the nearest trauma center, and hope for a helicopter intercept. After a 7-minute scene time, we were off, driving down an old logging road, headed for the highway. I had 2 others in the back with me – my partner and a first responder. Another first responder was driving.
My partner was in charge of getting & monitoring vital signs, and the first responder was responsible for airway. Airway was not really a problem, as the patient never stopped yelling and/or screaming. After cutting all of his clothes off, I decided to stabilize his leg. We don’t carry a traction splint that small, so I folded a SAM splint in half, placed it between his legs, and used Coban to strap both legs together with the SAM splint in the middle.
I missed my IV attempts. We have to try twice before our protocols let us do IO. At that time, we used the Jamshidi IO needle. I gathered all the equipment, found my landmarks, took a deep breath, and started twisting the needle into his leg. He yelled a little louder, but I placed the needle. I managed to aspirate marrow, but had a hell of a time infusing fluid. In hindsight, I may have had the needle too deep. But, it worked and I was happy.
After finding the highway, we met the helicopter and transferred the patient. He was home in a week. Turns out that traumatic asphyxia isn’t nearly as deadly in children as it is in adults.
#2
I don’t remember this one as much. It was another child – probably 2 years old or less. The call came in as a seizure. He was lethargic (probably postictal), but had a heart rate over 200, wheezes, and a rash. It was another quick scene time. We got the hell out of there, and were headed lights & sirens for the hospital. Again, I tried for an IV but was unsuccessful. Mom was strapped into the gurney, holding her son.
I explained what I was going to do, and that it would be painful and not much fun to watch. I also explained the need for access, and how sick I thought her son was. She agreed to the procedure. I gathered all my equipment, found my landmarks, and took another deep breath. This one was a little different – landmarks were there, but it wasn’t as smooth as the first one. I got the needle in place, and felt it was stable.
Mom was not impressed. She was yelling at me by the time it was over, and almost revoked permission for the procedure. In retrospect, I will never do an IO, especially with the old Jamshidi needles, while my patient is being held in mom’s lap.
By the time I had it secured, we were at the hospital. I didn’t have time to infuse any fluids, and by the time the ED staff got around to fluids, the needle was no longer in the bone. During this time, we had IO access for adults as well. We stocked the Bone Injection Gun (B.I.G.) on our rigs, but it was never used. Personally, I found it too scary to use. It seemed too inhumane, imprecise, and very powerful. Most of my co-workers felt the same. In fact, I had the opportunity to use it, but never did, and was chastised twice by my physician advisor twice because I should have used it. One was on an adult male trauma patient, and the other a older male with a dissecting AAA.
Era of EZ-IO
We started using the EZ-IO last year. Our protocols allow its use to deliver life-saving fluids or medications if we’ve missed 2 IV’s. I’ve used it 5 times since, on 2 children and 3 adults. The first use was on a 6 year-old with terminal brain cancer, seizures, and a new onset pneumonia. He was very sick. This was not your typical 6-year old, either. He weighed well over 100 pounds.
I had just had this guy as a patient on my last shift, and knew he didn’t have any veins. He was very sick this time – obtunded and in respiratory failure. I told his mother what my plans were and we loaded him up. Before we left, I placed the needle and started fluids. The insertion was quick and precise. In fact, my partner had turned away for something, and the needle was in before he could turn back around. There was no response from the patient. The second use was on a 1 year-old with Tay-Sachs Disease and had been seizing. He was known to have status seizures, and so I wanted some access if he started seizing again. I tried once for IV access, missed, and without a missed beat, went to the EZ-IO. I remember piercing the skin and then bouncing right off the tibia. That needle is sharp! Getting my bearings again, I drove the needle in, got my marrow draw & started to flush some saline. The patient started writhing in pain during the bolus. This was the only indication of pain I’ve ever seen using the EZ-IO.
#3
The third use was on a 50’s year old female OD patient. She was obtunded with snoring respirations. The fire department was unable to place an IV, so I made the decision for IO. Once again, it was a very quick and precise placement without any patient changes. My fourth use was on another adult – a 60’s year old female with hyperglycemia. We were able to place the needle and infuse a large amount of fluid before we arrived at the hospital, shortening her stay there.
As mentioned in my blog, I just used it again the other day on a 19-year old in profound septic shock. I placed the IO in the hospital ED before we left, and was able to infuse almost 2 units of blood in the 1 hour transport to the tertiary care facility.
Wrapping Up
It’s been my experience that IO is a very useful tool, and when used appropriately, can have beneficial results to our patients. Using new technology, such as the EZ-IO, reduces the reluctance and apprehension, and increases success for Paramedics in the field (and even in the hospital, where we’ve placed 2 IO’s for the ED staff before they got the EZ-IO for themselves). Eric Augustus
Paramedic in Oregon
Thanks, Eric for that very thorough look at the IO needles in the field.
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My friend, Eric Augustus recently wrote a great post about decisions he had to make regarding getting a patient in septic shock enough fluids to make the dopamine he was giving effective. He got permission to use IO (intraosseous) access to get another line.
He writes a great tale of how this tool is going to change the way we do things in the field. For those of us who actually get to play with them, anyway. I have to say that my area is really dragging their feet on this one. The tool has proven itself in many areas surrounding our region of the state of Maryland but still we don’t have tacit approval to go ahead and get the EZ-IO system, or anything like it.
I hope that changes soon. I’m glad Eric got a chance to use his, though. Read more of his exploits and some pretty good Haiku poetry on EMS, too. Go to emshaiku.blog-city.com to check out the EMS Haiku blog.
I recently posted a new episode over at the Nursing Show on the different adventitious lung sounds heard during auscultation. If you are looking for a few auscultation tips check it out. We need to constantly practice things like how to use a stethoscope correctly.
How often do you listen to patients completely in all lung fields? Listening to breath sounds is an important part of any medical assessment. Know what it is that you are listening to is important, too. The only way to do that is to develop a habit of listening to EVERYBODY.
What do I mean by everybody? Well, I include patients in that of course. However, I also include you spouse or significant other, your kids, your partners on the ambulance, your instructors and anyone else you can convince to sit still for a quick listen. The more lungs you listen to, the more you will learn to hear when there is something wrong with one of your patients.
The next time someone you know complains of a cold or chest congestion, ask to have a listen. You might just pick up something new.
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This week’s tip is an excerpt from the “Stump the Podmedic” episode over at the MedicCast Live. You can listen to the whole 1 hour and 40 minute show at MedicCastLive.com.
Extra members will get access to the individual segments broken out by category. In this live podcast I covered topics on Pediatric Education for Prehospital Providers (PEPP), Prehospital Trauma Life Support (PHTLS), and other topics surrounding continuing education for EMTs, paramedics, and other EMS providers.
I’m always on the lookout for new ways to extend the benefits to my MedicCast Listeners. Here’s another one. Blockbuster has come on board with a special advertising deal here at the MedicCast Network. Special Promotion
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Our good friend, Chris Black sent me this link about an EMS supervisor’s truck that struck a pole and flipped over while responding to a call. Apparently, the weather and rain-slick roads contributed to the incident.
One of the problems I see when I look at articles like this is that we have so much going on when we respond in chase vehicles like this.
We are listening to dispatch for updates on the call.
We are thinking about what we are going to do when we get there.
We are talking on the radio (reaching for the mic, putting it back)
We are operating our siren, lights, maybe using the PA?
and Driving at a high speed.
Does anyone else think this is too much to keep track of? I do!
This is the answer folks: SLOW DOWN!
Remember, it is their emergency and not ours. We can’t help anyone if we don’t get there safely and if we are involved in an accident then I guarantee that our friends will divert to help us and leave the patient for second response units. Don’t make a bad situation worse. As EMTs and paramedics, our jobs as EMS providers is to provide care, not to try out for the local NASCAR qualifier!
Here are my tips for response in a chase vehicle:
Remember people can’t see you (you’re not as big as an ambulance)
Slow down to speed limit
Obey all traffic signals (even running lights and sirens)
Wait until you arrive to put on gloves or gather supplies
Talk on the radio as little as possible
Be hyper-observant of other traffic (especially when approaching the scene)
What tips do you have? Add them here to the comments area or email me and I’ll share them with the other visitors here and on the MedicCast.
Our friend, Tim Pruyn from NSW, Australia sent me some follow-up information on the snakebites episode recently. Compared to Australia’s poisonous snake situation, the U.S. has it easy. Here is what Tim had to share:
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G’Day Jamie,
Listen to both the MedicCast and Nursing Show podcasts with the snake bites interview.
Australia is home to 11 of the world’s most venomous snakes. Out of the top 25 most venomous snakes in the world, Australia is home to 20 of them (see table). According to the Australian Venom Research Unit (AVRU), there are approx 3000 snakes bite victims per year in Australia, with between 200 and 500 victims receiving anti-venom. Between 1979 to 1998 there were 53 fatalities due to snake bites in Australia. (source: Australian bureau of statistics)
World’s Most Venomous Snakes
Which snake species is the most venomous depends on the measure used. The average or the maximum venom yield from milking could be suggested, but these measures can be criticised as not reflecting the impact of a real bite. The measure generally acknowledged as best reflecting how dangerous a snake’s venom is is that of LD50. The lower this number, the less venom is required to cause death. By that measure, the most venomous snake in the world is Australia’s inland taipan (Oxyuranus microlepidotus). The table below gives the top 25 species in order, their LD50, and their distribution.
Snake Species LD50* Distribution
1. Inland taipan 0.025 Australia
2. Eastern brown snake 0.053 Australia
3. Coastal taipan 0.099 Australia
4. Tiger snake 0.118 Australia
5. Black tiger snake 0.131 Australia
6. Beaked sea snake 0.164 Australia
7. Black tiger snake 0.194 - 0.338 Australia
8. Death adder 0.400 Australia
9. Gwardar 0.473 Australia
10. Spotted brown snake 0.360 (in bovine serum albumin) Australia
11. Australian copperhead 0.560 Australia
12. Cobra 0.565 Asia
13. Dugite 0.660 Australia
14. Papuan black snake 1.09 New Guinea
15. Stephens’ banded snake 1.36 Australia
16. Rough scaled snake 1.36 Australia
17. King cobra 1.80 Asia
18. Blue-bellied black snake 2.13 Australia
19. Collett’s snake 2.38 Australia
20. Mulga snake 2.38 Australia
21. Red-bellied black snake 2.52 Australia
22. Small eyed snake 2.67 Australia
23. Eastern diamond-backed rattlesnake 11.4 North America
24. Black whipsnake >14.2 Australia
25. Fer-de-lance >27.8 South America
*LD50: mg/kg in saline by subcutaneous injection in mice
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Thanks, Tim. For the rest of you — do you have information to share here on the MedicCast? Send in your own comments or articles to share with the other listeners.
As we near the end of the semester and NREMT paramedic classes begin to practice for their NREMT exams, I thought it would be time to review some of the skills that are needed for both the BLS and ALS versions of the test. I’ve been covering IO drills lately since our friend, Eric Augustus wrote such a good piece about it over at the 
