# IM injections



## medicaz (Sep 28, 2005)

I delivered an IM injection to a morbidly obese patient with a compound tib/fib fracture secondary to a ground level fall exiting a vehicle. The patient was grossly overweight  with significant adiopose tissue presenting in all the conventional IM injection sites. I opted to deliver the med (demoral) into the calf area since I assumed that stie to be the best possible alternative to delivering the med intra-muscularly due to the patients physiologic  presentation. Any thoughts? By the way, the patient had a decrease in pain from a 10 down to a 5 upon arrival to the hospital.


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## Jon (Sep 28, 2005)

makes sense to me.

Nice to see someone:
A: thinking about patient's pain level
B: Thinking beyond the normal injection sites.


Finally:

Welcome.

Jon


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## Wingnut (Sep 28, 2005)

Welcome    

Sounds like you took your best option, I wouldn't have done anything differently.


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## DT4EMS (Sep 28, 2005)

> _Originally posted by medicaz_@Sep 27 2005, 11:30 PM
> * I delivered an IM injection to a morbidly obese patient with a compound tib/fib fracture secondary to a ground level fall exiting a vehicle. The patient was grossly overweight  with significant adiopose tissue presenting in all the conventional IM injection sites. I opted to deliver the med (demoral) into the calf area since I assumed that stie to be the best possible alternative to delivering the med intra-muscularly due to the patients physiologic  presentation. Any thoughts? By the way, the patient had a decrease in pain from a 10 down to a 5 upon arrival to the hospital. *


 Welcome!!

It sounds like you were definitely thinking outside the box. I am not sure I would have delivered an injection on an injured extremity.

It is kinda like starting an IV. We were always taught not to establish a line in an extremity with any type of injury (CVA,Burn,FX etc.) so I am not sure if I would have done it. By no means am I saying it is wrong, I am just curious about any restriction in bood flow to the muscular tissue secondary to the FX.

What did the ER doc say about the injection?


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## medicaz (Sep 28, 2005)

The patient was right lateral recumbant with the injured extremity presenting on top. Her back/rear end were against the vehicle she was trying to exit. I could not fit underneath the vehicle to reach the uninjured leg. I did attempt to move the injured leg to access the uninjured side, but she nearly punched me for it. So, I agree with your opinion on the injured vs. uninjured. The ER doc was fine with it. Actually, the recieving Dr.  was our Physician Advisor. He said it made sense but next time to call the ER ahead of time. The city I work for FLIPPED OUT.  They are talking about remedial training with a field preceptor! I work for a medium sized city as a firefighter/paramedic. We have 11 stations with 4 medic units. The medics are busy since we cover the whole county in addition to the city.  I have been a paramedic for about 9 years now.


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## DT4EMS (Sep 28, 2005)

> _Originally posted by medicaz_@Sep 28 2005, 10:08 AM
> * The patient was right lateral recumbant with the injured extremity presenting on top. Her back/rear end were against the vehicle she was trying to exit. I could not fit underneath the vehicle to reach the uninjured leg. I did attempt to move the injured leg to access the uninjured side, but she nearly punched me for it. So, I agree with your opinion on the injured vs. uninjured. The ER doc was fine with it. Actually, the recieving Dr.  was our Physician Advisor. He said it made sense but next time to call the ER ahead of time. The city I work for FLIPPED OUT.  They are talking about remedial training with a field preceptor! I work for a medium sized city as a firefighter/paramedic. We have 11 stations with 4 medic units. The medics are busy since we cover the whole county in addition to the city.  I have been a paramedic for about 9 years now. *


 It is not uncommon for a "City" or entity to freak out when somethign is done outside the norm. If the receiving MD had no probs you should be OK.

IF they make you do remedial, just stay quite. Don't get upset or anything. Getting hacked will only make things worse. 

I got chewed once for working a pedi-code. It was from blunt trauma and the protocol was to not work blunt trauma at the time. 

EMT's and Medics are the worlds greatest for doing stuff on the side of the road to save lives that have people in offices going "YOU DID WHAT??!!!" 

The truth is nothing is ever textbook in the field of EMS.  (With 9 years as a medic you already know that..  ) Good luck!!


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## medicaz (Sep 28, 2005)

> _Originally posted by DT4EMS+Sep 28 2005, 10:32 AM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (DT4EMS @ Sep 28 2005, 10:32 AM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-medicaz_@Sep 28 2005, 10:08 AM
> * The patient was right lateral recumbant with the injured extremity presenting on top. Her back/rear end were against the vehicle she was trying to exit. I could not fit underneath the vehicle to reach the uninjured leg. I did attempt to move the injured leg to access the uninjured side, but she nearly punched me for it. So, I agree with your opinion on the injured vs. uninjured. The ER doc was fine with it. Actually, the recieving Dr. was our Physician Advisor. He said it made sense but next time to call the ER ahead of time. The city I work for FLIPPED OUT. They are talking about remedial training with a field preceptor! I work for a medium sized city as a firefighter/paramedic. We have 11 stations with 4 medic units. The medics are busy since we cover the whole county in addition to the city. I have been a paramedic for about 9 years now. *


It is not uncommon for a "City" or entity to freak out when somethign is done outside the norm. If the receiving MD had no probs you should be OK.

IF they make you do remedial, just stay quite. Don't get upset or anything. Getting hacked will only make things worse. 

I got chewed once for working a pedi-code. It was from blunt trauma and the protocol was to not work blunt trauma at the time. 

EMT's and Medics are the worlds greatest for doing stuff on the side of the road to save lives that have people in offices going "YOU DID WHAT??!!!" 

The truth is nothing is ever textbook in the field of EMS.  (With 9 years as a medic you already know that..  ) Good luck!! [/b][/quote]
 That's pretty much what everybody is telling me. Even the Union said their hands are tied because it's the city's right. I have searched the net relentlessly and researched countless text books but cannot find any difinitive information. The only arguement I really have is that conventional IM sites are there because of the large musculature involved thus the chances of necrosis occuring is minimal with large volumes of fluid (no more then 5cc's). Like I said, this lady was frickin' huge. Her calf area was about as large as my thigh. With a 2" needle, I'm still surprised she had any relief at all! I thought for sure it was still sub-Q at best. Just pisses me off with all the chiefs we have i.e. ems officer, ems chief, an RN full time for training, battalion chief etc...and they said the same thing "YOU DID WHAT?'


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## DT4EMS (Sep 28, 2005)

Just don't fight it too hard. Sometimes it is easier to just say "I screwed up" and move on. The boss isn't always right BUT the _Boss is always right _if you know what I mean.

Even as a polce officer, there are times when we have to go "Sorry Chief" when at the time we were doing everythign we could to _do it right_......... it just came out wrong.



I'm gonna keep bumpin you up in the hopes Rid will jump in. If anyone can dig up an answer for you it's him.


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## medicaz (Sep 28, 2005)

> _Originally posted by MedicStudentJon_@Sep 28 2005, 07:04 AM
> * makes sense to me.
> 
> Nice to see someone:
> ...


 Thank you, Jon. Are you a student right now?
Kevin


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## medicaz (Sep 28, 2005)

> _Originally posted by Wingnut_@Sep 28 2005, 08:16 AM
> *    Welcome
> 
> Sounds like you took your best option, I wouldn't have done anything differently. *


 Thank you, Jennifer for the warm welcome. I was online totally freaking out because I thought what I did was really, really, really bad. I kinda just happened upon this website and decided to give it a go.  I'm wondering why nobody posted to the negetive side though...I am hoping there were no negetive thoughts out there but, you know...The only negetive I found was the possibility of injecting into a nerve or arterey. Injecting into a nerve is always a constant with any IM injection. I am confident that I avoided any arteries.


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## medicaz (Sep 28, 2005)

> _Originally posted by DT4EMS_@Sep 28 2005, 10:57 AM
> * Just don't fight it too hard. Sometimes it is easier to just say "I screwed up" and move on. The boss isn't always right BUT the Boss is always right if you know what I mean.
> 
> Even as a polce officer, there are times when we have to go "Sorry Chief" when at the time we were doing everythign we could to do it right......... it just came out wrong.
> ...


 Hey,
Thanks for the "talking down" you gave. It makes sense. This department is preoccupied with perfection. Anything outside the realm is not usually well recieved. Even though the doc was ok with it, I am destined for remedial training..........Only for 3 shifts and the preceptor is a really good guy and medic. He has been on the job for 23 years and still likes to work the medic unit. Out here, after about 8 years on the job, it is real easy to slide into an engine slot and not run as many calls. He prefers to stay online and fight the good fight.  Touche for him. We average about 14 calls a shift per unit and I am tired of it Not to mention this BS I'm going through right now.
Later,
Kevin


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## Ridryder911 (Sep 29, 2005)

If I understand this right you adminstered an IM of Demerol ( usually 1-3ml) I.M distal of a fxr site ? This is what the uproar is about ... potential poor circulation of tissue & muscle of the fxr area... I agree, I think their making mountains out of mole hills...really an I.M. is a I.M..... yes, avoidance of underlying structures as discussed. Next time you might consider the gluteus . remember the upper corner of the butt is usually not fat. the others are the deltoid in the arm..  ( you described an large obese patient ) 1 ml is not that much fluid... the other is vastus lateralis, the thigh muscle. It is hard to administer meds into obese thick walled patients.... Z-track method allows you make a Z formation with your hand pulling back tissue while doing and injecting. This method is used for deep I.M. injections.. 

If they are having potential problems with the route you took.. make them defend why it was wrong. lAlso, description of the patient (obsese) with a 2" I.M. needle , would probably get only Sub-q effect as you said.  Actually, most ER physicians are going to sub-q morphine for the duration effect... 

I wish you the best of luck.... like you described, it obviously worked. They should let you chalk this one up for experience and go on... I am sure there are other things more important....

If I can help, let me know...

Good luck,
Ridryder 911


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## medicaz (Sep 29, 2005)

> _Originally posted by ridryder 911_@Sep 28 2005, 11:02 PM
> * If I understand this right you adminstered an IM of Demerol ( usually 1-3ml) I.M distal of a fxr site ? This is what the uproar is about ... potential poor circulation of tissue & muscle of the fxr area... I agree, I think their making mountains out of mole hills...really an I.M. is a I.M..... yes, avoidance of underlying structures as discussed. Next time you might consider the gluteus . remember the upper corner of the butt is usually not fat. the others are the deltoid in the arm..  ( you described an large obese patient ) 1 ml is not that much fluid... the other is vastus lateralis, the thigh muscle. It is hard to administer meds into obese thick walled patients.... Z-track method allows you make a Z formation with your hand pulling back tissue while doing and injecting. This method is used for deep I.M. injections..
> 
> If they are having potential problems with the route you took.. make them defend why it was wrong. lAlso, description of the patient (obsese) with a 2" I.M. needle , would probably get only Sub-q effect as you said.  Actually, most ER physicians are going to sub-q morphine for the duration effect...
> ...


 Nice thought. I never considered having them "defend" not giving it there. Yes, I did give 2 cc's of demoral. Also, the anatomy lesson was a nice touch. I like to know that I am dealing with educated and rational individuals such as yourself. Thank you again for your reply (I can't believe I'm still online, I have to work tomorrow!). 
Take Care,
Kevin


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## Jon (Sep 29, 2005)

> _Originally posted by medicaz+Sep 28 2005, 11:34 PM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (medicaz @ Sep 28 2005, 11:34 PM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-MedicStudentJon_@Sep 28 2005, 07:04 AM
> * makes sense to me.
> 
> Nice to see someone:
> ...


Thank you, Jon. Are you a student right now?
Kevin [/b][/quote]
 Kevin,

I just finished school, and am waiting to have my testing scheduled. I'm a class of 1, so I seem to have been forgotten about.

Jon


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## rescuecpt (Sep 29, 2005)

> _Originally posted by MedicStudentJon_@Sep 29 2005, 07:05 AM
> * I'm a class of 1, so I seem to have been forgotten about. *


 I'm sure no one could EVER forget you, Jon.


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## Margaritaville (Oct 3, 2005)

Medicaz,

I concur with everyone else. However, you said the Doc had no problem with it. I would suggest that you speak with the Dr. and tell him of the time you are having.  I am sure he would be happy to speak with your department if he had no problem with it.

If you are ok with doing ride alongs for 3 shifts than just let it go. My only question is - What does making you do 3 shifts of ride alongs accomplish? Sounds more like punishment than re-training.

I have been an FTO and preceptor for several years. All a ride along does is show "how it looks to the student, and lets them practice their newly learned skills". That does not re-train "old dogs". I assume you already know how to ride in an ambulance and do patient care.

I just love departments that think protocols and SOP's in EMS cover every situation. Its narrow minded supervisors like that who make the rest of us look bad! You can also tell that they have not ridden in a while when they think the books have all the answers!!!!!

Good Luck and Welcome - Kevin B)


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## TTLWHKR (Oct 3, 2005)

I thought all medics were permitted to give IM injections?

I didn't have demerol on protocol, but I've given MS04 IM to a person who absolutely did not want an IV. Of course, both arms were fractured, and they didn't want anymore pain. But after feeling the burn of the morphine, he/she/it did not mind the IV's. (plural-standard trauma protocol 750NS/1000LR) And with the start of an IV, that means more pain management w/ no more needles. However, I've never given an injection into the injury site.


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## Jon (Oct 3, 2005)

The issue was the standard IM sites were innaccessible, and they gave it in a non-standard site.

Jon


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## TTLWHKR (Oct 3, 2005)

> _Originally posted by MedicStudentJon_@Oct 3 2005, 08:47 AM
> * The issue was the standard IM sites were innaccessible, and they gave it in a non-standard site.
> 
> Jon *


 Did it result in any negative effects?


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## Jon (Oct 3, 2005)

> _Originally posted by TTLWHKR+Oct 3 2005, 01:46 PM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (TTLWHKR @ Oct 3 2005, 01:46 PM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-MedicStudentJon_@Oct 3 2005, 08:47 AM
> * The issue was the standard IM sites were innaccessible, and they gave it in a non-standard site.
> 
> Jon *


Did it result in any negative effects? [/b][/quote]
 If you scroll all the way up to the top:



> *I opted to deliver the med (demoral) into the calf area since I assumed that stie to be the best possible alternative to delivering the med intra-muscularly due to the patients physiologic presentation. Any thoughts? By the way, the patient had a decrease in pain from a 10 down to a 5 upon arrival to the hospital. *



jon


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## TTLWHKR (Oct 3, 2005)

> _Originally posted by MedicStudentJon+Oct 3 2005, 12:48 PM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (MedicStudentJon @ Oct 3 2005, 12:48 PM)</td></tr><tr><td id='QUOTE'>
> 
> 
> 
> ...


If you scroll all the way up to the top:



> *I opted to deliver the med (demoral) into the calf area since I assumed that stie to be the best possible alternative to delivering the med intra-muscularly due to the patients physiologic presentation. Any thoughts? By the way, the patient had a decrease in pain from a 10 down to a 5 upon arrival to the hospital. *



jon [/b][/quote]
 I didn't read it.


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