# Intraosseous access in cardiac arrest.



## Smash (Aug 28, 2011)

Another IO thread for y'all, this time with a snazzy poll (I hope; never tried that before)

I'm interested in finding out how people utilize intraosseous (IO) access in cardiac arrest.  I'd like to know if it is routine, only used if IV access is difficult or prolonged, or never used at all.

Most importantly, I would like to know your rationale for whichever option it is you chose, so please add a post as well as a vote.  

Many thanks,

Smash


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## MrBrown (Aug 28, 2011)

IO access is in the Clinical Procedures for patients who have a life threatening need for medicine or fluid where IV access has been unsuccessful

If Brown can't put a drip into some bloke in cardiac arrest, it is reasonable to attempt IO access.

Brown remembers way back to Mobile Intensive Care Officer training in 1992 where it were proclaimeth that drugs in cardiac arrest have little effect 

Gosh Brown is so torn


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## Shishkabob (Aug 28, 2011)

I drop an IO first thing on a cardiac arrest, not even attempting to look for an IV.


I do an IO first because it's faster, easier, and I can get it done in seconds and move on to the next thing I have to do.  Being the only ALS provider on the vast majority of the arrests, I don't have time to waste attempting IVs when I can just drill in to the tibia and be done with it and move on to the plethora of other things I need to get done.



Infact, in all the arrests I've done, I've only ever done a single IV, and that's because the patient was too obese and the IO wasn't long enough.  I was actually kind of shocked that I was able to get an IV on that one, let alone first try...


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## MrBrown (Aug 28, 2011)

Linuss said:


> I do an IO first because it's faster, easier, and I can get it done in seconds and move on to the next thing I have to do.  Being the only ALS provider on the vast majority of the arrests, I don't have time to waste attempting IVs when I can just drill in to the tibia and be done with it and move on to the plethora of other things I need to get done.



What plethora of other things do you have to do?

Circulatory access for drugs and fluid is at the bottom of our cardiac arrest procedure, above only intubation.


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## Shishkabob (Aug 28, 2011)

You mean like every single other thing that has to be done in arrest before you're able to actually call it?  I'm going to assume you've done atleast one cardiac arrest, therefor I won't get in to a list of what is done on them.




No reason to spend attempt after attempt trying to get an IV, or looking for a suitable site, when you can just pop an IO in and be done with it, regardless of supposed of efficacy (or lack) of medications.


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## MrBrown (Aug 28, 2011)

Linuss said:


> You mean like every single other thing that has to be done in arrest before you're able to actually call it?



Brown finds it interesting that you mention needing to do lots of things as a reason to use an IO as there are really not a lot of things you have to do at a cardiac arrest.

- CPR
- Defibrillation as appropriate
- Ventilation
- Adrenaline 

... in that order

Even if there are only two of you all that you need to do is have somebody do CPR while you put on the defibrillation pads. Ventilation is not a priority and can be left until the first two minutes of CPR (and first shock if necessary) has been delivered, although there is time to shove in an oral or laryngeal mask airway between getting the defibrillation pads on and the first two minutes of CPR being delivered.

If the local redneck yahoo volunteer firefighters have shown up as well more the merrier, get them to do CPR while one Ambulance Officer secures an airway and if you are that set on getting a drip, that frees you up to do that.


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## Shishkabob (Aug 28, 2011)

I initially had a list but took it out because I thought you've actually done a code, soooo...apparently codes are run differently down south...


(Not in order)
Establish an airway
Establish a line
Monitor the monitor
Shock if needed
Give medications
Gather a history
Get a BGL and check other reversible causes
Confirm patency of airway, and if necessary move on to the next step, like intubation
Make sure ventilations are correct and adequate
Make sure compressions are correct and adequate
Talk to the family
etc etc etc

And that doesn't even include getting ROSC.  It's by no means "hard", especially once you've done a couple, but it is still quite a bit that needs to be done, especially in the opening part, before you even think about calling it.



Again, it takes seconds to do an IO... even if your disagree with the evidence on medications in a cardiac arrest, there's no reason to not get a line, or even get one early on.  The evidence still backs up giving medications to reversible arrests, and you can't give the medications without having a line.


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## MrBrown (Aug 28, 2011)

Mate, it seems like you are making this way more complex than you need to.  



Linuss said:


> Establish an airway



Can be done in five seconds; if you do not carry the LMA then shove an oral airway in.  One of your redneck volunteer firefighter/EMTs can do this



Linuss said:


> Establish a line



At some point, most cardiac arrests in Brown's experience this is not done until the second cycle of CPR or later as adrenaline is not given until at least the end of the second cycle.



Linuss said:


> Monitor the monitor



This is a semi valid point; nobody Brown knows sits there and stares at the monitor



Linuss said:


> Shock if needed



Only done once every two minutes



Linuss said:


> Give medications



Only done once every three, four or five minutes depending on the flavour of your operation.  We give adrenaline every four minutes so every second cycle 



Linuss said:


> Gather a history



Grandpa fell down .... 



Linuss said:


> Get a BGL and check other reversible causes



Last time Brown checked hypoglycaemia did not cause cardiac arrest, but your point about Hs and Ts is valid.



Linuss said:


> Confirm patency of airway, and if necessary move on to the next step, like intubation
> 
> Make sure ventilations are correct and adequate



What makes the Ambulance Officer or redneck volunteer firefighter/EMT ventilating the patient incapable of doing this?



Linuss said:


> Make sure compressions are correct and adequate



Now that is very important!

A cardiac arrest here might get three or four people (a normal crew + an IC or two crews where it would be nice if one was an IC but not essential).   While somebody does CPR, we put in an LMA and then put the defibrillation pads on.  At the end of the first cycle, check monitor and shock if required, go back to doing CPR.  At some point about now somebody is going to shove in a drip and give some adrenaline.   Repeat the pump-shock-adrenaline routine until you decide to cease resuscitation and go back to the station to watch telly.

We have been running cardiac arrests without intraosseous access since 1972 and have not found the little bit of time it takes to get a drip in to be that much of a problem.


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## usalsfyre (Aug 28, 2011)

I choose the IO (and BIAD for that matter)option on pretty well all of my cardiac arrest. Why? Because it gives me loads more time to focus on ensuring compressions are effective and to get a history (i.e. search for reversible causes). In our system an airway must be established and ACLS must be in progress before we reach an outcome, one way or the other.

Most of you know I'm not big on being scared of a lawsuit. But the reality in the US is you must follow some sort of standard, even if it's not "protocol". At the moment that standard includes medications for cardiac arrest. I don't like it, I think it's a waste of time, but my opinion doesn't matter in this case. My kids like to eat and have a roof over their heads. As such, I continue to sling cardiotoxins around per advised in the appropriate ACLS algorithm


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## usalsfyre (Aug 28, 2011)

MrBrown said:


> What makes the Ambulance Officer or redneck volunteer firefighter/EMT ventilating the patient incapable of doing this?


Crap, half our paramedics can't do this effectively!

Typical first responder trying to ventilate a patient vs good airway control are two different things. If we didn't insist on blowing patients gastric systems full of air in arrest that'd be one thing, however the AHA decided in their INFINITE wisdom to keep the most difficult, least proven part of CPR for healthcare providers.

An aspiration makes these folks course a hell of a lot more complicated should their be an aspiration. BIADS have helped, but not fixed the problem.


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## MrBrown (Aug 28, 2011)

Brown did not say medication should not be given in cardiac arrest just that the notion of "ZOMG WTF we have so many important things to do so lets forego putting a drip in and shove in an IO!" is a wee bit odd to Brown and our collective experience as there is plenty of time to put in an IV between the start and end of the second CPR cycle.

Oh and WTF is a BIAD?


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## Shishkabob (Aug 28, 2011)

I'll combine your first few comments with a single response


MrBrown said:


> Can be done in five seconds; if you do not carry the LMA then shove an oral airway in.  One of your redneck volunteer firefighter/EMTs can do this



What the hell is with the redneck volunteer comments?






> At some point, most cardiac arrests in Brown's experience this is not done until the second cycle of CPR or later as adrenaline is not given until at least the end of the second cycle.





> This is a semi valid point; nobody Brown knows sits there and stares at the monitor





> Only done once every two minutes





> Only done once every three, four or five minutes depending on the flavour of your operation.  We give adrenaline every four minutes so every second cycle





> Grandpa fell down ....




You make it sound as if all that will just *poof* happen, without any effort being done.   I don't know about you, but my patients don't call 911 with a King airway already in place when I arrive.


Establishing an airway, putting in a line, watching the monitor, giving medications, gathering a history: All stuff that has to be done.  None of it is done prior to my arrival, and I'm the only person qualified at doing any of it.  On top of that, no it's not "OMG GET THIS DONE", but there's no point in working a cardiac arrest if you're going to spend 15 minutes doing what can be done in 3.





> Last time Brown checked hypoglycaemia did not cause cardiac arrest, but your point about Hs and Ts is valid.


Last time I checked, hypoglycemia not only COULD cause a cardiac arrest, but was also one of the Hs.

Not to mention, HYPERglycemia could cause acidosis which could cause cardiac instability.  





> What makes the Ambulance Officer or redneck volunteer firefighter/EMT ventilating the patient incapable of doing this?



So you're saying I should NOT make sure things are running smoothly?  

Ever hear of the EMT student that makes up numbers because they can't obtain a BP?  







> A cardiac arrest here might get three or four people (a normal crew + an IC or two crews where it would be nice if one was an IC but not essential).   While somebody does CPR, we put in an LMA and then put the defibrillation pads on.  At the end of the first cycle, check monitor and shock if required, go back to doing CPR.  At some point about now somebody is going to shove in a drip and give some adrenaline.   Repeat the pump-shock-adrenaline routine until you decide to cease resuscitation and go back to the station to watch telly.




And I'll reiterate what I said before: I'm the only Paramedic on scene for most of my arrests.  I'm the only one actually able to do more than squeeze a bag and push on a chest.  

Sounds to me like you're spoiled with having multiple advanced level providers who each can work with eachother and split the tasks.  Not always the case here.   I like having a second Paramedic on scene with me in an arrest, but that's not always possible.






> We have been running cardiac arrests without intraosseous access since 1972 and have not found the little bit of time it takes to get a drip in to be that much of a problem.



Funny, we've been backboarding patients without cause since the 70s... doesn't mean it's better.





I'll reiterate it: Codes are not hard to do, however that doesn't mean there isn't a lot to do, a lot to keep track of, and that I am often the only advanced provider on scene capable of doing the stuff.


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## epipusher (Aug 28, 2011)

absolutely love the I.O. Our protocol is humerus only.


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## Cawolf86 (Aug 28, 2011)

We use an IO if we aren't successful in gaining peripheral access and the patient has no prior access (port/picc/etc).


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## boingo (Aug 28, 2011)

Interesting point of view Brown.  It is without a doubt faster to place an IO than an IV in the vast majority of patient, it is relatively large (15g) access, hard to dislodge (unlike an IV) and is so easy a caveman (firefighter, volunteer even) can do it.  

Gathering a history should be more involved than "Grandpa fell down", PMH, meds, etc...are all vital to establishing possible cause and very well may help direct your care beyond Adrenaline every 4 minutes.  

I quite often place an IV instead, but if any doubt, the IO goes in.  I have no idea how many arrests you have worked since '72, but I can assure you I can remember pleny where IV access was difficult to near impossible, and I do a lot of them.  Your mileage may vary.


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## dixie_flatline (Aug 28, 2011)

Linuss said:


> And I'll reiterate what I said before: I'm the only Paramedic on scene for most of my arrests.  I'm the only one actually able to do more than squeeze a bag and push on a chest.
> 
> Sounds to me like you're spoiled with having multiple advanced level providers who each can work with eachother and split the tasks.  Not always the case here.   I like having a second Paramedic on scene with me in an arrest, but that's not always possible.



Yeah, this is a big factor I think. Every code I've been on had at least 2 ALS providers and 5-7 BLS providers - and once it's a working code the EMS captain for that shift shows up.  I was on a full code a couple months ago with 4 paramedics (granted, that was kind of a mess).  For the most part our medics seem to just drop normal lines rather than use the EZ-IO.


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## ah2388 (Aug 28, 2011)

As much as I would like to disagree with Linuss...I can't say I disagree in this instance.

Senor Grandmaster El Bingeroso McMasterofMedicine Brown,
You mention employing assistance from 2 ambulances, 3 or 4 WELL TRAINED individuals including an absolute minimum of 2 "ALS" providers.  In the rural situations which Linuss is describing, it is not uncommon for 1 ambulance to cover entire counties, or large scarcely populated areas.  While this often times will make ROSC nearly impossible, with few codes actually being worked, the ones we do arrived at quickly leave a paramedic, an EMT, and usually several firefighters who are trained no further than the first responder level.

We could debate for hours about how the US system has a number of significant flaws, specifically the lack of division between fire suppression and EMS.  The bottomline is, it's the reality here.  These "redneck volunteer firemen" are unpaid, and joined the department in an effort to assist there rural community with an essential function for the protection of property.  They did not join the community to assist on medical calls where they are often treated like 3rd world citizens by "paragods and ambulance driver's."  With that being said, there is a huge training issue or lack there of in a lot of these people.  Ignoring that, THEY ARE ALL WE HAVE.  As such, while all the tasks Linuss listed are performed reasonably well by 1 provider, having worked in  systems with multiple ALS providers similar to the system you described, it is certainly challenging to work a code effectively with only 1 person on scene with a reasonable level of training.

In conclusion,
I think that Linuss has a point here, establishing access quickly, with a tool that secures itself checks off one more thing off the list.  In this situation,establishing access can often be one of the most time consuming things to do on a full arrest.  To Linuss, don't be so defensive brother, if you know for yourself you are practicing good medicine, and have found a system that works for you...state so, backing it up with evidence you believe to be reasonable.  Getting defensive about this type of thing would be like throwing blood in the water near the GBR...watch out for those brownsharks


Hopefully this wasn't long winded and made some sense, I am coming off a 48 without much sleep and I desperately need another nap

-Adam


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## epipusher (Aug 28, 2011)

the patient has "access", regardless of the route. is that not the most important thing?


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## Lady_EMT (Aug 28, 2011)

MrBrown said:


> If the local redneck yahoo volunteer firefighters have shown up as well more the merrier.



I hardly appreciate your continuous references to us "dumb hick volunteers." I may be a volunteer in a rural setting, but I do a damn good job of doing what I need to do during a cardiac arrest. 

If you want to talk about volunteers, please do it in a more respectable fashion. 

Back on topic, I can't do IOs as I'm not a medic, but from what I've seen, they have their pros and cons. They seem quick, easy, and a good way to bypass the searching for IV access, but from what I've heard they're also very costly, so it's almost worth looking for IV access. 



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## usalsfyre (Aug 28, 2011)

Lady_EMT said:


> but from what I've heard they're also very costly, so it's almost worth looking for IV access.


This is an extremely poor reason to choose an IV over an IO. It's not a cost that's passed to the patient, they are there to use, so why are you worrying about it? If your service can't afford to pay, then they have no business playing.


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## DESERTDOC (Aug 28, 2011)

Give a cursory glance at the patients neck looking for an EJ while I am at the head.  If not, IO it is.

Always IO for PEDI code, no glance given, expressed or implied.  

IO's for peds and adults are fast and mostly effective.


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## Lady_EMT (Aug 28, 2011)

usalsfyre said:


> This is an extremely poor reason to choose an IV over an IO. It's not a cost that's passed to the patient, they are there to use, so why are you worrying about it? If your service can't afford to pay, then they have no business playing.



Not my opinion. But many paid medics in my area take that account. 


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## usalsfyre (Aug 28, 2011)

Lady_EMT said:


> Not my opinion. But many paid medics in my area take that account.


And we wonder why the rest of healthcare doesn't consider us professionals...

Sorry, glad you came back and clarified the point.


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## abckidsmom (Aug 28, 2011)

I think since the advent of EZIO, we have stopped looking for iv access at all in arrest, and go right for the drill.  We could certainly take a second to look, cause I really believe that iv is quicker if you see an obvious site.

Brown, dear, you really need to realize that rural or not, good medics are rednecks too.  Probably oughta find another stereotype, one that matters.  K?

Anyways, I am too lazy to go on, I wills just say thanks to usuals for saying what I thought more intelligently.  Im just typing this on my redneck phone, so im a little slow tonight.


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## socalmedic (Aug 29, 2011)

I always look for an IV first. if i can get a 20 or larger i will go IV if all i find is 22-24 size veins then they will be getting an IO. I have had no problem gaining IV access and using a proper ETT for my airway as the only paramedic on scene.  I use the IO and the King as they where intended, BACKUP, and yes i will admit freely that i have had to use both. but not before at least attempting IV/ETI.


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## MrBrown (Aug 29, 2011)

abckidsmom said:


> I
> Brown, dear, you really need to realize that rural or not, good medics are rednecks too.  Probably oughta find another stereotype, one that matters.  K?



Brown was taking the piss


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## usalsfyre (Aug 29, 2011)

socalmedic said:


> I use the IO and the King as they where intended, BACKUP, and yes i will admit freely that i have had to use both. but not before at least attempting IV/ETI.


Convincing evidence besides your personal belief is needed. 

We've had this discussion before. The "tube of shame" BS needs to go away, ETI is NOT a "gold standard", an airway that delivers effective ventilation while providing reasonable protection from aspiration is.

15 years ago MAST were a "gold standard" too. How much time was spent off the chest attempting an ETT? Were you making sure compressions were of good quality while fishing around for a line?


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## ah2388 (Aug 29, 2011)

socalmedic said:


> I always look for an IV first. if i can get a 20 or larger i will go IV if all i find is 22-24 size veins then they will be getting an IO. I have had no problem gaining IV access and using a proper ETT for my airway as the only paramedic on scene.  I use the IO and the King as they where intended, BACKUP, and yes i will admit freely that i have had to use both. but not before at least attempting IV/ETI.



Another thing you may consider is that the EZ IO has a way of securing itself reasonably well.  From your post I feel its reasonable to assume that you have been doing this for a minute..with that in mind, how many times have you yanked an IV out of a pt's arm while transferring them onto a spine board or into your ambulance?


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## ah2388 (Aug 29, 2011)

usalsfyre said:


> Convincing evidence besides your personal belief is needed.
> 
> We've had this discussion before. The "tube of shame" BS needs to go away, ETI is NOT a "gold standard", an airway that delivers effective ventilation while providing reasonable protection from aspiration is.
> 
> 15 years ago MAST were a "gold standard" too. How much time was spent off the chest attempting an ETT? Were you making sure compressions were of good quality while fishing around for a line?



I think we can both agree that it is likely that compressions are neglected during attempts at ETI, however...assuming that this isn't the case, do you see any issues with ETI>King?


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## DesertMedic66 (Aug 29, 2011)

ah2388 said:


> Another thing you may consider is that the EZ IO has a way of securing itself reasonably well.  From your post I feel its reasonable to assume that you have been doing this for a minute..with that in mind, how many times have you yanked an IV out of a pt's arm while transferring them onto a spine board or into your ambulance?



That's the main reason I like to have a board under the patient before any lines get connected. People get a little crazy with shears and like to cut cords that we need (defib, leads, O2, any cord that is seen could be cut). I know it's not always possible to get a board under the patient before things start getting attached.


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## ah2388 (Aug 29, 2011)

firefite said:


> That's the main reason I like to have a board under the patient before any lines get connected. People get a little crazy with shears and like to cut cords that we need (defib, leads, O2, any cord that is seen could be cut). I know it's not always possible to get a board under the patient before things start getting attached.



This is a good tip.


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## usalsfyre (Aug 29, 2011)

ah2388 said:


> I think we can both agree that it is likely that compressions are neglected during attempts at ETI, however...assuming that this isn't the case, do you see any issues with ETI>King?



Nope, and if I get a ROSC I tend to pull the King and intubate the patient if they have anatomy that is amicable to it. However, I've also used Kings on calls from start to finish, and can say in my limited, anecdotal experince I haven't seen anymore of an aspiration issue from a King than a ETT.

I think alot of the vitrol against BIADS is long on fear and short on fact.


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## the_negro_puppy (Aug 29, 2011)

There are merits for both IV and IO but Brown does have a point about things to do in a cardiac arrest. Only ICP's have IO here so for us (paramedic/paramedic) or paramedic/student we don't have a choice until/if an ICP can attend. Having recently practiced running arrest scenarios, I can get an LMA in 2 minutes while partner applies pads and does compressions. Defib at 2 minutes, and get IV access in a few more minutes and have 3 shocks in and first amount of adrenaline by 7 minutes. I know this is vastly different to real arrests where more time is spent moving patients, suctioning airway etc

Having said that we dont intubate or use anto-arrhythmics or sodium bicarb at our level so Linuss does have a point in that he has more things to consider with a less skilled partner (EMT-B) who is only good for compressions andventilations.


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## MrBrown (Aug 29, 2011)

the_negro_puppy said:


> Having said that we dont intubate or use anto-arrhythmics or sodium bicarb at our level so Linuss does have a point in that he has more things to consider with a less skilled partner (EMT-B) who is only good for compressions andventilations.



None of which we really use anyway; some arrests get intubated depending on the flavour of Intensive Care Paramedic you get but most have an LMA shoved down their gob

How you describe is pretty much how it works out in the real world here; somebody places an LMA pretty quick and starts ventilations while the other Ambulance Officer puts on the pads and does compressions.

It takes about 5-7 minutes for somebody else to get to the job and by this stage unless a family member is up to doing CPR we're not going to get past two to three rounds of CPR, a couple of shocks and an LMA but the evidence for doing more than that earlier on is pretty um, you know not there?


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## Shishkabob (Aug 29, 2011)

usalsfyre said:


> 15 years ago MAST were a "gold standard" too. How much time was spent off the chest attempting an ETT? Were you making sure compressions were of good quality while fishing around for a line?



I can honestly say my first ETI of a cardiac arrest was while I still had the FFs pump on the chest, and I got it first shot!  I love the bougie.


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## lawndartcatcher (Aug 29, 2011)

Our ALS service is taking part in a CCR pilot program (45% survival vs <5% national rate). Anyone in cardiac-caused arrest immediately gets (in this order):
     1) CPR
     2) O2 via NRB
     3) Defibrillator attached
     4) IO in a lower extremity (per the doc leading the study).

We don't bag or intubate cardiac arrests until we've done at least 3 cycles of CPR / shock / Epi; the NRM and chest compressions allow enough oxygen to diffuse into the lungs that you can maintain adequate SPO2. Because everyone else (including our exceedingly professional and well-trained volunteer EMT-Bs, thank you very much Mr. Brown) is busy up at the head / torso, using the EZ-IO in the lower extremity means we're not bumping into each other.


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## socalmedic (Aug 29, 2011)

usalsfyre said:


> in bold



*Convincing evidence besides your personal belief is needed.* dont have it, the OP asked what I do and I posted that. where I am the king is a rescue airway and is listed as such, to boot it can only be used after two failed attempts at ETI. as you requested in the past I am still trying to get my docs report on our trial of IO/KING as front line in an arrest which was never used again after the trial for reasons that have been previously discussed. I haven't forgotten to get the report for you, it should be out in February as we are apparently using 2011 data for the stats in addition to 2009 data.

*How much time was spent off the chest attempting an ETT?*
None, only once have I paused compression for sake of intubation.

*Were you making sure compressions were of good quality while fishing around for a line?* absolutely, doesn't take but a few second of concentration to get a line, the rest of the time getting ready, line striped, tourniquet on... i can watch everything that is going on. besides my EMT partners are pretty good at thumping the chest. 

*@ah2388* never have I had a line pulled out during transfer. as fire... said I put them on a LSB very early on. and i keep all the wires and lines on one side of the patient which makes rolling easy. once on the board the monitor gets placed on the legs (which is right where the IO would be...) with the wires neatly under all the straps. iv bag becomes the only thing not strapped to the same unit as the patient. I also use a saline lock for all IV starts so I can detach the bag when needed for transfer. at the hospital the IV gets detached, and the whole LSB/patient/monitor/wires package gets moved to the hospital bed and they place their pads and take mine off. IV gets re-attached after my monitor and wires are out of the way.


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## MrBrown (Aug 29, 2011)

lawndartcatcher said:


> (including our exceedingly professional and well-trained volunteer EMT-Bs, thank you very much Mr. Brown).



Somebody really needs to learn what taking the piss means 

What you describe is more-or-less towards our priorities here: rapid and continued CPR and defibrillation.  

It is nice to put a drip into the bloke and give him some adrenaline but by far CPR and defibrillation take priority.


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## Shishkabob (Aug 29, 2011)

MrBrown said:


> It is nice to put a drip into the bloke and give him some adrenaline but by far CPR and defibrillation take priority.



And neither of which I typically do on an arrest, and neither of which is delayed while doing an IO which takes seconds, in the leg, away from the chest.


Which brings me back to wondering why you are against IOs in the onset.


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## MrBrown (Aug 29, 2011)

Linuss said:


> And neither of which I typically do on an arrest, and neither of which is delayed while doing an IO which takes seconds, in the leg, away from the chest.



So if you have somebody else doing your CPR and defibrillation, why can't you take the time to put an IV into this patient? 

You've never put an IV into some blokes foot?



Linuss said:


> Which brings me back to wondering why you are against IOs in the onset.



Brown is not against IO as a means of circulatory access in a cardiac arrest; but it should not be first choice because there is really no valid reason you cannot at least attempt an IV first, shove a 14ga. into his external jugular if you have to.

We have been running cardiac arrests without intraosseous access since the Mobile Intensive Care (Life Support Unit) pilot project was introduced in 1972 and have not found it to be such a problem that we needed to introduce intraosseous access in the adult patient any sooner than when we did (2009).

The following is the advice of the Medical Directorate of the London Ambulance Service regarding intraosseous access (source)



> The EZ IO should never be used ...where there is an appropriate alternative route for a drug ... for patients in cardiac arrest the EZ ;IO should only be used when two attempts at peripheral access and one attempts at external jugular vein access has been unsuccessful.



Brown supposes that the consensus view here, in AU and the UK is that its just not that important and to routinely drill an IO into some blokes leg is a bit of overkill.


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## Tigger (Aug 29, 2011)

MrBrown said:


> Brown is not against IO as a means of circulatory access in a cardiac arrest; but it should not be first choice because there is really no valid reason you cannot at least attempt an IV first, shove a 14ga. into his external jugular if you have to.
> 
> Brown supposes that the consensus view here, in AU and the UK is that its just not that important and to routinely drill an IO into some blokes leg is a bit of overkill.



I guess I don't see why an IV needs to be considered first? What's the difference beyond the difference in size (15/14ga)? Access is access right?  I haven't heard of any weakness in the IO tibial route in terms of a delay in medication effect.


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## Shishkabob (Aug 29, 2011)

MrBrown said:


> Brown is not against IO as a means of circulatory access in a cardiac arrest; but it should not be first choice because there is really no valid reason you cannot at least attempt an IV first, shove a 14ga. into his external jugular if you have to.



So, you're against it being first simply because you CAN do something else first instead?

That's not a defendable view.  




How is it overkill?  It's a peripheral line, with complication rates equal to, or less than, IVs.  Put the needle on the drill, attach the line and you're done, moving on to something else.   There is no legitimate reason not to do an IV over an IO in a cardiac arrest.


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## MrBrown (Aug 29, 2011)

Linuss said:


> So, you're against it being first simply because you CAN do something else first instead?



Sure, you even said it yourself; you have somebody doing your CPR and defibrillation and that is the most important thing.

There is no reason you need to drill an IO into somebodies leg when you can put an IV into their foot, external jugular or arm on the opposite side of the person doing CPR.  

Drugs in cardiac arrest are just not that important.

Just because you have the flash whiz-bang technology doesn't mean you have to use it.  We haven't been using it for almost four decades and have managed just fine.  It is not routinely used in Australia or the UK either.

Yes, you "can" do it but we "can" do a lot of things too .... doesn't mean they are necessary.

Brown has never been to a cardiac arrest where an IO has been placed, or where Brown has wanted to place one.  Even with two Ambulance Officers present, the focus is on CPR and defibrillation not using flash toys to do something which probably is not going to make jack crap of a difference anyway.

If you honestly can't get a drip into some bloke after two attempts then it is reasonable to put an in an IO.


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## Shishkabob (Aug 29, 2011)

MrBrown said:


> There is no reason you need to drill an IO into somebodies leg when you can put an IV into their foot, external jugular or arm on the opposite side of the person doing CPR.



And again, that is not a valid defense of using an IV over an IO.  I'm still waiting on one.


An IO is typically faster, more secure, and easier when compared to an IV.  I see no reason not to use an IO over an IV in a cardiac arrest.


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## usalsfyre (Aug 29, 2011)

MrBrown said:


> Brown has never been to a cardiac arrest where an IO has been placed, or where Brown has wanted to place one.



So then you're admitting you have no experience on which to base an educated opinion on. You're going totally off of your personal perception that the intraoseous route is much more invasive than an IV line, and can't make any claims on whether it would work better for your services situation or not as it's not a routine procedure. 

I've worked without IOs, I've worked in systems where they were backups and I work in a system now where per the medical director and clinical department they are the preferred access in cardiac arrest. I will say this, it is much easier, faster and more secure FOR ME to place an IO in an arrest patient. In addition it keeps the line out of the work area and there's never a chance of someone asking to pause compressions for "just a second". The same with BIADS. 

I've heard the same arguments presented here against 12 leads ("they don't change MY treatment, treat the patient and not the monitor"), any sort of BIAD ("a real paramedic will get a tube"[ignoring of course the hypoxia and trauma caused by crappy laryngoscopy]), IV pumps ("they taught me how to count drips back in medic school, I don't need a stinking pump) and ETCO2 ("it's wrong most of the time, I put tubes in for 20 years without it"). You occasionally still hear it about SpO2. ALL of these devices have value in patient care depending on the organizational set up. They all increase the efficacy of the care delivered in some way. 

Until an organization has evaluated a device or treatment for themselves it's shortsighted to condemn others who have incorporated device. It's also a good way to end up eating crow, as you never know what you may be doing next year. That said, I've been guilty as sin of doing this before, even with the specific devices and protocols discussed here.


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## MrBrown (Aug 29, 2011)

Linuss said:


> An IO is typically faster, more secure, and easier when compared to an IV.  I see no reason not to use an IO over an IV in a cardiac arrest.



Speed is not an argument here, you have somebody doing your CPR and defibrillation, that is what is important.  The bloke is already dead, drugs do squat, IO needles cost $200, an IV cannula costs $2, just because you have a flash toy to play with doesn't mean you have to use it.

If Brown had the choice between an IV and an IO, with just one other Ambulance Officer on scene and nobody else for the duration of  the arrest, Brown would put an IV in.  Why? What difference is the couple of minutes going to make that it might take for you to get a shock or two in before you can get an IV in place? It's not.


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## MrBrown (Aug 29, 2011)

usalsfyre said:


> So then you're admitting you have no experience on which to base an educated opinion on. You're going totally off of your personal perception that the intraoseous route is much more invasive than an IV line, and can't make any claims on whether it would work better for your services situation or not as it's not a routine procedure.



More invasive or not is not the argument.

Are you wrong for doing it? No most certainly not.

Perhaps it is just another example of the collective "the good old ambo trick of more is better is always not true" cognition.


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## usalsfyre (Aug 29, 2011)

MrBrown said:


> Speed is not an argument here, you have somebody doing your CPR and defibrillation, that is what is important.  The bloke is already dead, drugs do squat, IO needles cost $200, an IV cannula costs $2, just because you have a flash toy to play with doesn't mean you have to use it.
> 
> If Brown had the choice between an IV and an IO, with just one other Ambulance Officer on scene and nobody else for the duration of  the arrest, Brown would put an IV in.  Why? What difference is the couple of minutes going to make that it might take for you to get a shock or two in before you can get an IV in place? It's not.



Because your dealing with at least two well trained ambulance officers and rarely have to manage a scene. I may be dealing a monosynaptic window licker of partner, if I'm lucky I get an old man from the local FD who has a CPR card and a desire to help. Speed is not important getting drugs on, it's important in my ability to "manage" the care being provided.  

Again, you can't base your experince limited to your one system and declare everyone else as inferior for using a treatment that has been found to fit better in their situation. I'm arguing in my system it works well. I believe it would work well in certain other models as well (I REALLY believe this of BAIDS due to extensive experince of watching long periods with no compressions due to ETI attempts both in and out of the hospital).

Have you ever known me to be one of advising people to play with cool toys "just because"?


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## MrBrown (Aug 29, 2011)

usalsfyre said:


> Because your dealing with at least two well trained ambulance officers and rarely have to manage a scene. I may be dealing a monosynaptic window licker of partner, if I'm lucky I get an old man from the local FD who has a CPR card and a desire to help. Speed is not important getting drugs on, it's important in my ability to "manage" the care being provided.



We still have holdovers from the day whose total education consists of a six week Proficiency Ambulance Aid Certificate ... so not all are well trained, Brown has seen some absolutely terrible arrests with such piss poor CPR the Ambulance Officer in question should be forever condemned to Hell Station 

Brown's favourite was "oh this bloke is in asystole, with some PVCs!" um .... yes, oh look mandatory Bachelors Degree in 2014 FTW!



usalsfyre said:


> Again, you can't base your experince limited to your one system and declare everyone else as inferior for using a treatment that has been found to fit better in their situation. I'm arguing in my system it works well. I believe it would work well in certain other models as well (I REALLY believe this of BAIDS due to extensive experince of watching long periods with no compressions due to ETI attempts both in and out of the hospital).



Brown has never declared anybody as inferior, each system is a creature unto its own operating modality and praxis limitations bearing in mind vastly different political, funding, educational, cultural and operational differences.

You blokes are not "wrong" for drilling an IO into some blokes leg but its just difficult for the brain box to contemplate it as being necessary to do in place of putting a drip in.

Then again, we say funny words like adrenaline, bloke and shav and think Sprinters make good ambulances so what do we know? 

*Brown gets Brown's large cowboy hat, Garth Brooks T-Shirt and hip pouch full of suxamethonium ... can Brown come play wild west frontier ambo now? 

/taking the piss



usalsfyre said:


> Have you ever known me to be one of advising people to play with cool toys "just because"?



Brown really likes playing with the red lights weeeee! 

/taking the piss


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## ah2388 (Aug 30, 2011)

I have no idea what taking the piss means..

/taking the piss


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## Pelagic (Aug 30, 2011)

MrBrown said:


> Brown gets Brown's



Would you stop talking about yourself in the third person FFS. Whatever clinical efficacy your statements may or may not have, doing that constantly has my "cock" meter pegged.

Taking the piss is an English colloquialism that means to rib someone or wind them up


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## MrBrown (Aug 30, 2011)

Pelagic said:


> Would you stop talking about yourself in the third person FFS. Whatever clinical efficacy your statements may or may not have, doing that constantly has my "cock" meter pegged.



Brown speaketh in the fourth person, Brown does not technically exist and is a kinda cross between a delusion and sort of comical character/alternate personality created by Brown's creator.

And what the bloody hell are you talking about, nothing Brown says has any sort of clinical efficacy


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## Lady_EMT (Aug 30, 2011)

Pelagic said:


> Would you stop talking about yourself in the third person FFS. Whatever clinical efficacy your statements may or may not have, doing that constantly has my "cock" meter pegged.
> 
> Taking the piss is an English colloquialism that means to rib someone or wind them up



You'll get used to it  though Brown may have a lot of opposing ideas, from what I've seen he knows what he's doing. If you stick around, you'll notice that you won't even notice he speaks in the third person. 

There's a lot of pros and cons to the IO argument. I just think that it's a new technology that people can either love or hate. As long you get access, that's all that matters. Do what you're comfortable with. 


---
- This post brought to you by Tapatalk


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## Shishkabob (Aug 30, 2011)

"new technology"? 

Ha. Not even close 


EMS may lack in a few things, but we're ahead of much of medicine in others.


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## socalmedic (Aug 30, 2011)

Lady_EMT said:


> You'll get used to it  though Brown may have a lot of opposing ideas, from what I've seen he knows what he's doing.



Rob sounded like he knew what he was doing too... Just saying.


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## silver (Aug 30, 2011)

socalmedic said:


> Rob sounded like he knew what he was doing too... Just saying.



I thought this was appropriate http://www.wusa9.com/news/local/story.aspx?storyid=125578&provider=top

btw whose first post would so blatantly "attacks" an esteemed member of the community?


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## the_negro_puppy (Aug 30, 2011)

socalmedic said:


> Rob sounded like he knew what he was doing too... Just saying.


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## epipusher (Aug 30, 2011)

as i stated previously, access is access.

/thread


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## Smash (Aug 30, 2011)

epipusher said:


> as i stated previously, access is access.
> 
> /thread



Seriously?  /thread?  This isn't /b/, we aren't all twelve year olds and nobody "wins" threads here.

"Access is access" is complete rubbish, unless you are actually suggesting that an IO is identical to a peripheral IV which is identical to a EJ cannula, which is identical to a femoral cut-down, which is identical to a subclavian central line?


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## usalsfyre (Aug 30, 2011)

Smash said:


> "Access is access" is complete rubbish, unless you are actually suggesting that an IO is identical to a peripheral IV which is identical to a EJ cannula, which is identical to a femoral cut-down, which is identical to a subclavian central line?


(Since access is access, usalsfyre is telling his medical director he's going to start placing IJ PA lines)


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## silver (Aug 30, 2011)

usalsfyre said:


> (Since access is access, usalsfyre is telling his medical director he's going to start placing IJ PA lines)



What do you mean, all your 911 ALS patients don't get Swan lines???


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## Hunter (Aug 30, 2011)

usalsfyre said:


> (Since access is access, usalsfyre is telling his medical director he's going to start placing IJ PA lines)



IJ PA lines?


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## Hunter (Aug 30, 2011)

and as far as what I learned is that IV and IO are basically the same to deliver meds, as far as how long it takes for the meds to reach their target.


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## usalsfyre (Aug 30, 2011)

Hunter said:


> IJ PA lines?


It's a form of central catheter that enters through the internal jugular vein and part of the catheter threads through the right side of the heart and into the pulmonary artery. Rarely placed outside of CVICUs, and even that's getting rarer.


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## Smash (Aug 30, 2011)

My next handover:  This is Mavis, she is an 84 year old resident of a nursing home.  She fell this morning in the shower, resulting in a suspected fractured right NOF, with marked rotation and shortening.  I have done a femoral cut-down and administered a total of 100mcgs of fentanyl......


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## Shishkabob (Aug 31, 2011)

Smash said:


> My next handover:  This is Mavis, she is an 84 year old resident of a nursing home.  She fell this morning in the shower, resulting in a suspected fractured right NOF, with marked rotation and shortening.  I have done a femoral cut-down and administered a total of 100mcgs of fentanyl......



Probably get the same reaction I did when I brought in a patient I gave fentanyl and Ativan to. 

Nurse: "But, that's conscious sedation!? "
Me "yes, yes it is"


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## DESERTDOC (Aug 31, 2011)

Seeing hospital staff's reaction to what Paramedics really do when we use our brains and do what they deem to be exotic, is like watching someone who has never seen fire.


For some reason they seem stunned when therapies work that are initiated by a Paramedic, yet do not bat an eyelash when it is ordered for them to do.


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## systemet (Aug 31, 2011)

DESERTDOC said:


> Seeing hospital staff's reaction to what Paramedics really do when we use our brains and do what they deem to be exotic, is like watching someone who has never seen fire.



I think they're sometimes surprised because our scope of practice / medical control guidelines, allow us to do a lot of acts in a relatively austere environment that are typically done in a far more cautious manner by far more experienced providers (usually physicians) in the hospital.

There's a reason, for example, that ER often calls anesthesia to help manage difficult airways.  It's not that the ER fellows aren't *great* at intubation / airway management.  It's because its safer and better for the patient.

My experience has been, that sometimes we're not as well aware of the risks that the procedures we perform entail.  EMS isn't about doing the best medicine possible, unfortunately.  It's about doing the best medicine possible when performed by a paramedic with limited support, in the prehospital environment.



> For some reason they seem stunned when therapies work that are initiated by a Paramedic, yet do not bat an eyelash when it is ordered for them to do.



I would politely suggest that may be either (i) more aware of the risks than we are, or (ii) less in touch with the idea that EMS is about doing what's best for the patient when the best isn't readily available.

Just my opinion.


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## MrBrown (Aug 31, 2011)

Brown thinks its time for the revival of intracardiac adrenaline!


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## DESERTDOC (Aug 31, 2011)

systemet said:


> I think they're sometimes surprised because our scope of practice / medical control guidelines, allow us to do a lot of acts in a relatively austere environment that are typically done in a far more cautious manner by far more experienced providers (usually physicians) in the hospital.
> 
> There's a reason, for example, that ER often calls anesthesia to help manage difficult airways.  It's not that the ER fellows aren't *great* at intubation / airway management.  It's because its safer and better for the patient.
> 
> ...



Personally, I am well aware of what the possible negative outcomes, risks etc of the therapies I provide.  The people I have worked with know their :censored::censored::censored::censored: inside and out.  That said, some systems are stronger than others, just like some Paramedics and EMT's are stronger than others.

Woe unto the clinician who is not acutely aware of all possible negative and positive outcomes and or effects of his or her treatment.

I think they cannot fathom that what we do works and seem to struggle giving credit where it is due, because it was not done in the ED for them to see where the patient started at and where they are now.


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## MrBrown (Aug 31, 2011)

DESERTDOC said:


> I think they cannot fathom that what we do works and seem to struggle giving credit where it is due, because it was not done in the ED for them to see where the patient started at and where they are now.



Gosh you blokes seem to have such a strained relationship with hospital, everbody likes the ambos here


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## systemet (Aug 31, 2011)

DESERTDOC said:


> Personally, I am well aware of what the possible negative outcomes, risks etc of the therapies I provide.  The people I have worked with know their :censored::censored::censored::censored: inside and out.  That said, some systems are stronger than others, just like some Paramedics and EMT's are stronger than others.



Agreed, there's a range of skill / competency levels amongst providers, and some systems seem to perform better than others.

BTW, I'm not trying to suggest that you're a bad clinician.  I've got no information to form a basis for that judgment.  

I just think that sometimes, as a group, we're a little cavalier when it comes to medical procedures with a potential to cause serious harm.



> Woe unto the clinician who is not acutely aware of all possible negative and positive outcomes and or effects of his or her treatment.



I guess.  It's best to know when you do something difficult / dangerous and screw up, that it was at least worth doing in the first place.



> I think they cannot fathom that what we do works and seem to struggle giving credit where it is due, because it was not done in the ED for them to see where the patient started at and where they are now.



I don't know that I've really had this problem.  The way I see it, I do my job as best I can, they do theirs.  That's the minimum we should expect.  If we're all doing what we were paid to do today, and we're being mutually respectful, then I don't think I need any credit.

I've had situations where the patient's condition has changed as a result of my treatment.  One that comes to mind was a near-death anaphylaxis patient who was extremely bronchospastic, unconsious, severely hypoxic and seizing, who we gave over a 1mg of epinephrine (some of it IV), and intubated.  It wasn't until the epinephrine started wearing off, that they realised quite how sick the patient was.  I can forgive them for that.  He didn't look that sick once he was intubated, and no longer hypoxic.  

I've had situations when I've felt that the physician or nursing staff were being rude.  But everyone has bad days.  These were exceptions to the norm.


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## usalsfyre (Aug 31, 2011)

systemet said:


> I just think that sometimes, as a group, we're a little cavalier when it comes to medical procedures with a potential to cause serious harm.


Agree completely. I think it's very commonly because 1). we (as a group) often haven't seen one of whatever procedure we're performing go really badly 2)when it goes very badly it's not reviewed in an eduational setting 3) we rarely get to follow up on a patient and 4)*EGO *. I've met a disturbing number of paramedics who think they're that much better than the next guy, or even a physician who's specialty is something like airway control simply because they do it in an austere environment.


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