what did I see?

weavers · Feb 5, 2012

they drilled an intraosseous catheter into her femur. Its for instant IV access. Its hard at the best of times to get an IV stick on an elderly person. Maybe they injected atropine, it speeds up the heart and then they probably gave her IV fluids.

gfoster6993 · Feb 5, 2012

that was the most amazing thing I have ever seen. I just didn't understand how an IV worked in a bone. I thought it had to be in an vein. I have a lot to learn....I know that. If I am more interested in that kind of stuff, should I consider just doing EMS classess or getting my RN? Will I learn all that in RN school? If I get my RN, what all kinds of classes would I have to do in order to work for the EMS? I'm just undecided at this time. But thank you so very much for writing me back. I'm always willing to learn new things.

ClearBlueOctoberSky · Feb 5, 2012

If you are interested or just want to know if EMS is for you, talk to your local Fire Department/Ambulance Service for the opportunity to do a ride along. I am not sure where you are, however most services welcome these as an opportunity to either educate or recruit.

I live in Denver, and here, our EMS protocols are completely different than Nursing. In fact, EMS is regulated by an entirely different Agency: the Colorado Board of Health. In fact as a Paramedic, you are allowed to do things a RN and definitely a LPN (at least in Colorado) normally wouldn't be allowed to. For me, it was the most difficult concept to grasp as I went through LPN school. I let my Paramedic license lapse during school, and while it made me sad to begin with, after having the time to think, I am now glad that I will never be placed in a position where I might get in trouble by either board, or be in a position of conflict.

If you decide, you would first start out as an EMT Basic, then progress to either Intermediate level or Paramedic, depending on where you are, and what they term the different levels. A good resource would be to go to your state Public Health website and search for either EMS or Prehospital Services. (At least in the State of Colorado, that is where ours are.)

Good luck and no matter what you decide to do, one or the other or both (and I know several Paramedics that are also Nurses), the important thing is to enjoy what you do.

suanna · Feb 5, 2012

I've never seen an IO line in a hospital or inserted one. I've gotten NO training in 25+ years of nursing in IO insertion or care. It is the new hot thing in ACLS so I'd expect to see them in ER from time to time, but I think the IO line is being pushed by the company that makes that handy gadget you saw the paramedics use. For me and my patients- stick in a femoral line until a PICC can be placed. I can't imagine how the incidence of osteomyelitis isn't going to go through the roof with frequent "quasi-sterile" deep bone penatrations as a theraputic intervention. My guess- by the time you get out of school this fad will have passed and we will be back to the more traditional med/fluid administration routes. An IO has ALYAYS been an "optional" intervention if IV access can't be established, it just wasn't commonly used or taught until the last 4-5 years.

gfoster6993 · Feb 5, 2012

do they do IO lines on everybody for instant IV access in emergencies? I have seen a lot of codes where I work and this is the first time I have ever seen this. The paramedics didn't even look for an IV access to begin with, they just did this "IO line" as soon as they got there. Thank you all so much for your information.

ClearBlueOctoberSky · Feb 5, 2012

Suanna,

Using IO's to establish a much needed IV in a critical patient isn't a fad. It has been around for years. It is now being used more than the past because of better techniques.

IO's are used primarily by Paramedics in the field when you aren't able to get the PIV and you need to have a line. I can't really speak for the ER, however, I know that it is rarely used by the ER Staff here in Denver.

I understand that sterility and hygiene are important, and I will be the first to admit that the back of an ambulance isn't the cleanest place to be. HOWEVER, infection control and how clean your patient is kind of takes a back seat on the to do list when you are intubation and attempting to stabilize a patient that is lying in the middle of a field full of cow patties, in the middle of a highway, on top of a mountain, or in a muddy ditch. In these instances, you scrub them down with as much alcohol, or Iodine that you might have and hope for the best while trying to make sure your patient lives through the transport to Life Flight or the ER.

As for the ART Lines, sure they are the better treatment, however, no where in the US (that I know of) do Paramedics have the scope of practice, training, or equipment to establish one. They just aren't practical in the Pre-Hospital environment.

ClearBlueOctoberSky · Feb 5, 2012

do they do IO lines on everybody for instant IV access in emergencies? I have seen a lot of codes where I work and this is the first time I have ever seen this. The paramedics didn't even look for an IV access to begin with, they just did this "IO line" as soon as they got there. Thank you all so much for your information.

With the Denver Metro Protocols, we are supposed to attempt twice to secure a PIV. With experience, you learn which patient's you aren't going to waste the time on trying to do that, and go straight to the IO. Again, like I said, I can only speak for Denver. Every city and region has different protocols.

suanna · Feb 5, 2012

Suanna,
Using IO's to establish a much needed IV in a critical patient isn't a fad. It has been around for years. It is now being used more than the past because of better techniques.
IO's are used primarily by Paramedics in the field when you aren't able to get the PIV and you need to have a line. I can't really speak for the ER, however, I know that it is rarely used by the ER Staff here in Denver.
I understand that sterility and hygiene are important, and I will be the first to admit that the back of an ambulance isn't the cleanest place to be. HOWEVER, infection control and how clean your patient is kind of takes a back seat on the to do list when you are intubation and attempting to stabilize a patient that is lying in the middle of a field full of cow patties, in the middle of a highway, on top of a mountain, or in a muddy ditch. In these instances, you scrub them down with as much alcohol, or Iodine that you might have and hope for the best while trying to make sure your patient lives through the transport to Life Flight or the ER......

Thus my point. Punching a non-sterile invasive device into the bone marrow seems like a great way of setting up a very difficult infection. Not that PIV isn't a bad thing to get germy, I just don't know how much more or less dangerous a contaminated bone marrow is vs a contaminated vein. Getting a patient to where they are going isn't the goal- saving thier life is. If you manage to transport to a hospital but the patient dies of sepsis or loses thier legs-kidney-gut.... to infection and dies a mos later in an ECF I don't know that that counts for much of a save. There have been lots of treatments that have been "around" for years, but I would love to see some evidence based follow-up that says an IO is more effective than a femoral venous line or the old stand-by intratracheal med delivery. IO sounds great as long as it ends up with greater long term recovery to discharge. In this area (NE OHIO) IO as a first choice of access has only been taught for 3-4 years. I still won't be shocked to see it go the way of "high dose epi". One more therapy that gets the patient in the door but the discharge is still to the funeral home.

ClearBlueOctoberSky · Feb 5, 2012

Suanna,

You need to understand that the IO is used for emergency access. Once the patient is at the ER, more definitive means of IV access are used. The IO is only left in place for 24 hours, if that long.

Here are some articles that might interest you:

Intraosseous Devices for Intravascular Access in Adult Trauma Patients

Intraosseous Infusions: A Review for the Anesthesiologist with a Focus on Pediatric Use (Please note that with this article most complication studies were done before the standard use of the B.I.G and the EZIO system, which lessens the complications of fracture and misplacement. The rate for Osteomyelitis was only .6% in a study population of 4359 attempts of IO. It further states that the primary reason for osteomyelitis was due to infusion of hypertonic solutions.)

The Use of a Powered Device for Intraosseous Drug and Fluid... : The Journal of Trauma and Acute Care Surgery (This is an abstract, I'm not a member, however maybe you know someone who may access the full article for you.)

http://www.emsworld.com/article/10324117/intraosseous-infusion-not-just-for-kids-anymore

The take home point is this: This access is not a long term access. It used only to stabilize the patient until that patient is delivered to definitive care. The chance of the patient being as you say it discharged to the funeral home from having a field IO done is far less than the mortality rates from cardiac arrest and multi-system trauma are.

In my experience, far better to deliver a patient that has a beating heart to the ER, than one that doesn't.

mazy · Feb 5, 2012

I learned a little bit about IO in nursing school and thought it was fascinating.

But when I think about the patients I work with in LTC; how fragile they are -- especially in terms of their bone health -- as well as their ability to bounce back from some of the more aggressive interventions, I do find it a little, I guess I would say, intimidating to hear that technique was used.

I also would want to know more about that patient's cor status and quality of life concerns, because in LTC you are really dealing primarily with quality of life issues -- even for the full COR patient -- because in LTC a lot of full COR patients are also very medically fragile.

I would want to take into consideration how such an intervention would play out in the future for an elderly patient who is much more prone to developing complications that younger patients might not experience.

I have seen occasions where we sent full-cor patients out to the hospital and they came back to us on hospice after receiving a battery of aggressive interventions that of course, the hospital had to do, because some people want the whole nine-yards.

But their bodies just can't handle it, and so they come back and die and it is NOT pretty. Usually quite awful to be honest. So I would want to be very mindful of those concerns when performing an IO on an LTC patient.

ClearBlueOctoberSky · Feb 5, 2012

I don't know where the OP is from, all I know is from my own experience and the protocols for my area.

You are correct in that the medical fragility should be taken into account. But for EMS it also depends on what the cardiac rhythms were, patient presentation, and surrounding circumstances as well as their local protocols they are operating off of.

Here in Denver, our protocols for field pronouncements are very liberal, and most Paramedics will consider calling the COR, rather than working if the medical history is one that seems to not support quality of life. However, if you have ROSC during the COR, or if you have a patient that is a pre-cor and they don't have DNR directives or Advanced Directives in place you still need to transport and provide resus support, even if it means placing an emergency line such as an IO.

As far as other regions, it may be in their protocols that they have to work and transport, period.

As a Paramedic, you are also taught to advocate for your patient, something that I always took seriously. Sometimes, though, Paramedics/EMTs either don't think about consequences of the patient outcome because they get "caught up in the moment", or their proverbial hands are tied due to SOP and protocols.

I'm not saying this is the right way to do it, but sometimes you have no choices.