# A theoretical question : the lesser of two evils ...



## AUSEMT (Apr 10, 2012)

Theoretical question for the wise ones out there:

You have a pt. who is in extremis and you need access To admin fluid and meds.
Problem is, 
1. They are undergoing dialysis and your chances of getting an IV in are about the same as dispatch giving you an extra meal break, 0%.
2. They have severe osteomyelitis.

Your options are:
1: cannulate the pt.'s AV Fistula
2: Insert an IO needle, possibly rendering permanent damage and disability to the limb.

What would you do?


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## Medico (Apr 10, 2012)

If they are nearing death as your scenario suggests, I would drill after an attempt to locate vein for IV. My protocols won't allow me to use a fistula.


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## Aidey (Apr 10, 2012)

Fistula, but I'm biased as I worked dialysis for a while and am perfectly comfortable using fistulas/grafts/catheters. As for drilling, you should be able to drill in a limb without infection, unless they are a multi limb amputee.


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## medicdan (Apr 10, 2012)

Aidey said:


> Fistula, but I'm biased as I worked dialysis for a while and am perfectly comfortable using fistulas/grafts/catheters. As for drilling, you should be able to drill in a limb without infection, unless they are a multi limb amputee.


Do your protocols allow you to access fistulas and grafts? Do you have needles long enough?


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## Veneficus (Apr 10, 2012)

AUSEMT said:


> Theoretical question for the wise ones out there:
> 
> You have a pt. who is in extremis and you need access To admin fluid and meds.
> Problem is,
> ...



3. EJ.

Impossible IV access? Don't know what that is... I would opt for a basilic or cephalic vein (proximal to the antecubital fossa in order to mitigate normal anatomical variants of the vessles of the distal extremity) if EJ is not in the protocol, they are in there, you just have to find it.

If forced to use an IO, the sternum or posterior illiac crest is the adult sites of my preference. 

If really pressed with none of the above options, a fistula is fine, they are relatively close to the surface and the whole point is repeated vascular access.


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## Aidey (Apr 10, 2012)

My protocols allow the use of fistulas/grafts/indwelling catheters when the pt needs immediate treatment. I've accessed all 3 over the years. Adenosine works great through a PICC line, lol. 

Fistuals/grafts usually do not need longer or special needles. The majority of needles used are 15g butterfly needles. I've found a 16g works perfectly fine. I would probably never go smaller than an 18g because a smaller needle may have issued getting through the scar tissue. If you ever encounter a pt who says they have a buttonhole fistula DO NOT TOUCH IT unless you know exactly what you are doing. Those do take special blunt needles and you can ruin years of work by poking them with a normal needle. Obviously if they are dead you have to do what is necessary to treat them, but expect to get a very angry phone call from a nephrologist. 

Also, if you have the long depth needles the EZ IO can be used in at least 9 sites. Bilateral ankles, tibas, humeri, iliac crests and the sternum. If I want to use it in the ilium or sternum I have to call for orders, but the chance of me ever needing to resort to those sites is slim.


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## Veneficus (Apr 10, 2012)

Aidey said:


> Adenosine works great through a PICC line, lol.



Probably way better than it does through a peripheral line  That had to be awesome. 



Aidey said:


> If I want to use it in the ilium or sternum I have to call for orders, but the chance of me ever needing to resort to those sites is slim.



That is unfortunate as those are considered the ideal locations in adults.

Posterior illiac has less risk for complication than anterior, but in my opinion, if you need an IO the patient has crashed or is going to in short order without intervention and there should be no restrictions on using it as a first resort or location.

From anecdote, I am convinced an IO as a first resort in smaller peds who are in real danger is life saving and recommendations of 90 seconds, failed IV attempts, etc that delay the IO are absolutely a bad idea. 

But alas, I will never be an EMS medical director, so the best I can do is try to exert my will through a willing one


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## Aidey (Apr 10, 2012)

It was fun. The FFs had been looking for an IV for 10 minutes and she looked crappy. They had a collective panic attack when I did it. The ED doc told me I took all the fun out of it for him. 

Even with the long depth needles I'm not sure how many people we could do iliac IOs on due to body size. I doubt it would work on anyone who is more than slightly overweight. Why don't you like the tibial or humeral sites?


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## Veneficus (Apr 10, 2012)

Aidey said:


> It was fun. The FFs had been looking for an IV for 10 minutes and she looked crappy. They had a collective panic attack when I did it. The ED doc told me I took all the fun out of it for him.
> 
> Even with the long depth needles I'm not sure how many people we could do iliac IOs on due to body size. I doubt it would work on anyone who is more than slightly overweight. Why don't you like the tibial or humeral sites?



In the ideal world, you should still be using a bone that produces red marrow. In the older adult that is the sternum and possibly the illiac.

I have found that with a little practice (usually my practice was bone marrow biopsies) the posterior illiac even on larger bodies is very easy.


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## johnrsemt (Apr 10, 2012)

One of my partners and I transported a patient for about 150 miles that had no arms,  just had hands coming out of the shoulders.  And his legs had issues.

  On the way back we talked about where to stick him if we had to.   Didn't do BP during transport due to the no arms, and leg issues.    We were very happy that he stayed stable during transport


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## Veneficus (Apr 10, 2012)

johnrsemt said:


> One of my partners and I transported a patient for about 150 miles that had no arms,  just had hands coming out of the shoulders.  And his legs had issues.
> 
> On the way back we talked about where to stick him if we had to.



So what did you come up with?


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## TheLocalMedic (Apr 11, 2012)

I had a patient like the one initially described, all scar tissue and bones so fragile that the pt had broken a femur the week before after just trying to stand up.  Ended up with an EJ and a 21 gauge butterfly that I managed to slip into a nice little vein in the pt's temple.  The doc cracked up when he saw the line coming out of the guy's head, but you gotta do what ya gotta do in a pinch, right?


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## Melclin (Apr 11, 2012)

Just find some access. +1 on the "they're in there" idea. 

Not knowing where you work, I can't comment on the possibility of doing the following. Lets say for arguments sake you just simply couldn't get IV access.

I would consult via the clinician for advice on appropriate use of the fistula, given that I know precisely f**k all about them or cannulating them. 

To me, drilling them has inherent danger associated with it. The only danger associated with the fistula is that you're (READ: I) not familiar with them. So get familiar with them. How about pulling out your iPhone and googling it. Hop on the phone to the clinician (or whatever oversight you have available). Ring the hospital ED and ask for a chat with one of the docs. There are a few options around for "just in time learning".


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## johnrsemt (Apr 11, 2012)

We didn't come up with much;  my partner was in the back and didn't really check him out to see if he had any EJ's  (pt was un cooperative, and not a nice person for that long of a transport).
  But the only place I could think of would be an EJ.  We didn't have protocols for or equipment for Adult IO's at that time.   Now I would drill him in the tib.

   I always tried to get partners to think of things like that;  where would you stick a patient like that; what would you do if the patient went downhill.
   Partners at the time would tell others and me that they didn't like that,  but as they went on in EMS they would tell me that it actually did help them out.


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## MSDeltaFlt (Apr 11, 2012)

EJ then IO.  Moot.


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## Aidey (Apr 11, 2012)

Veneficus said:


> In the ideal world, you should still be using a  bone that produces red marrow. In the older adult that is the sternum  and possibly the illiac.
> 
> I have found that with a little practice (usually my practice was bone  marrow biopsies) the posterior illiac even on larger bodies is very  easy.



Fair enough. 

It does seem like it would be easy, mostly  because it is a large area to hit. How long are the bone marrow  aspiration needles you are using? I was under the impression that the  adult needle is usually 3-4 inches long. The long depth EZIO is about  1.75 inches (45mm).


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## Veneficus (Apr 12, 2012)

Aidey said:


> Fair enough.
> 
> It does seem like it would be easy, mostly  because it is a large area to hit. How long are the bone marrow  aspiration needles you are using? I was under the impression that the  adult needle is usually 3-4 inches long. The long depth EZIO is about  1.75 inches (45mm).



honestly I don't know how long the needle is, it is one of the manual IO needles, but it looks rather long.

I have not used an EZ-IO in my career, only trained with it. I have used the manual needles in EMS and never had any issue with them.


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## socalmedic (Apr 12, 2012)

my protocol allows accessing fistulas and indwelling catheters in extremis, however now that we have the EZ-IO those days may be long gone. hell I used to have a Huber needle just in case I needed to use a Porta-Cath.


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## Aidey (Apr 12, 2012)

I prefer to access and indwelling cath over using IO. Why put an extra hole in someone if you don't have to?


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## socalmedic (Apr 12, 2012)

I have to agree with you, however the medical director would prefer that we try IO prior to any artificial or indwelling device. note that we are limited to proximal tibial IO only.


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## Trashtruck (Apr 12, 2012)

Look for an EJ. Then IO.
In the past, we weren't allowed to do IO's on conscious people. We are allowed to now, though(sucks for the pt).


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## Solomon Paramedic (Jun 4, 2012)

The answer for you depends which state you are in, Aus protoclos don't usually recommend usuing a fistula most services here frown on it, having been a phlebotmist it doesn't really matter. If you can't find a view look a bit harder there are  plenty even if you have to use a 24g. 

As far as the IO the protocols here only allow for Tib and Humerus so either/or, the coroner takes a dim view of sitting back and not acting when it is in the scope of your protocols. 

Do you have other options? Tubed, nebs with assisted chest compression?

Anyways as others put itgo with what you have got, people die from not breathing infection is slow, and fistulae can be replaced.


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## Doczilla (Jun 4, 2012)

Someone mentioned a sternal I.O , are systems using those now? Before I got in the army my system had it, though it was frowned upon as "barbaric". They're all about it in the army, but thats only because the "sternal notch" area is generally well protected by body armor and makes for fast access when limbs are chewed up. 

Ive had decent results with them, crappy though if you need a dedicated line for RSI and a line for resuscitation. E.J. is money. I feel bad for the whiskeys because they dont get taught to. 

Next in line for me is a cutdown, they get pretty fast with a little practice.


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## the_negro_puppy (Jun 4, 2012)

Foot, ankle?


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## Doczilla (Jun 4, 2012)

Saphenous on the ankle is a gimme, though I've done AC before.


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## Christopher (Jun 4, 2012)

Veneficus said:


> I have not used an EZ-IO in my career, only trained with it. I have used the manual needles in EMS and never had any issue with them.



If you've ever used a power drill, you can use an EZ-IO. The only real failings I've seen are:


Because it is "so easy to use" people often lack in training on the basics...like identifying landmarks
Even if they know where to go they view the 3 needle sizes as "absolutes" and may not realize the Long needle perhaps is required for a pediatric patient
Providers seem hesitant to use them on conscious/semi-conscious patients because it is a "drill"

I love the EZ-IO and it has made life far less stressful, or if they are stressful it's made it shorter in duration, in emergent situations with poor intravenous access.


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## Doczilla (Jun 4, 2012)

Drilling is more humane than manual pressure, who here has bent an I.O needle?


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## Solomon Paramedic (Jun 5, 2012)

Here in Oz we can't go with sternal at all so we are limited with the 2 long bones. EJ is usually last resort and then mostly in arrests since it is a decent size. Depending on where you operate the EZ-IO is quick enough to use without too much pain. I use the B.I.G. and if the pt is conscous we can give 1% lignocaine anyway.


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## Shishkabob (Jun 5, 2012)

Protocols allow a; alternative access outside of peripheal IVs and IOs if meds are needed in an actual emergency.  

It's inserted wherever I can get it.


Life > limb.  Life > fistula.


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## HawkMedic (Jun 8, 2012)

Listening to some of the posts; I wish we had more in our protocols! We have peripheral IV's; EJ's; IO in the long bones, and the humerous. It would be cool to do a sternal or Illiac IO. We can't access fistala's or ports/ PICC's without medical direction so its basically a waste of time you might as well just try the EJ, or IO. We do have EZ IO which has been awesome compared to the manual IO's.


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