My First IO

I had been a paramedic for about a year when I had the chance to pop an IO into a kid for the first time. I was newly hired at my current job, working in the field training program with an instructor. My field instructor that day was a certified badass; she was an incredible medic. (I assume she still is.) We were assigned to a pediatric auto-ped on the edge of the city. 

We pulled up to find a little kid, about four years old or so, lying in the median being attended by a private ambulance crew. I was a new medic, but not so new that I couldn’t see that things were going pear-shaped. The private crew had emptied their ambulance of all the equipment. All of it. It looked like they were trying to build a fort out of EMS equipment around the kid. There was a knee-high semi-circle of monitors, kits, a bed, several backboards and scoops, and other miscellaneous BS. That wasn’t a good sign of the skill level of those medics. It wasn’t going to fly.

If you run up on a call in my city and are doing a good job when I arrive, knock your bad self out. Continue. I don’t want the call. I probably want either a nap or a meal. Sometimes both. But my agency is responsible for the EMS care in the city. If a reasonably good job isn’t being performed, then I have to take over. Which is what we did on this call.

I went to the little patient and got a brief report from the medic who was building the Great Wall of Jumpkits. He didn’t have an excess of pertinent information to give me. My partner shoved the pram in our direction, and the firefighters (who were pretty relieved to see us) rolled the kid onto a backboard and onto our bed.  We moved to the ambulance and got to work.

I don’t actually remember a lot of specifics about the patient. He was unresponsive, but had a tachy pulse, as I recall, with a scary level of pallor. I was at the head of the bed to work on an oral intubation. My partner roped off an arm to start an IV. She threw a bunch of IV catheters at one of the firefighters. That was unusual, to say the least. Firefighters aren’t usually IV starters in my system. But I was busy with a pediatric oral tube and the fireman seemed to be making the competent-appearing hand motions, so I didn’t say anything. As soon as I got the tube, my partner helped confirm the placement and exited the back of the bus. She hadn’t any luck starting an IV (which didn’t bode well for my efforts). Our total scene time was under seven minutes.

All of this makes me sound like a bit of a badass. Took over from another crew, fast scene time, quick oral tube on a pediatric patient… I am coming off sounding fairly hardcore. I’m sure this is my memory playing tricks on me. I was under a year out of medic school. I think my memory of this call is rather rosy. It couldn’t have been that smooth. I remember competence being like a lucky lightning strike. As evidence that I wasn’t as cool as this story is making me out to be, let’s turn our attention to the IO.

Like every paramedic, I was taught to place an intraosseous line in p-school. In 1998, when I went to paramedic school, IO lines were only used on pediatric patients; we didn’t place adult IOs.  We also didn’t have battery-powered drills like we have now. Back then, we used a Jamshidi needle and pushed it into a kid’s tibia while twisting back and forth. We practiced placing IOs into chicken drumsticks. My instructor explained that an IO line worked just like an IV line. Anything that went into an IV line could be run through an IO line. Cool.

A Jamshidi disposable intraosseous needle that we used to carry.
By Tirante (Own work) [CC BY-SA 3.0], via Wikimedia Commons

My partner and the firefighter had gone oh-for-four on IVs. This kid was dying and his little veins weren’t cooperating. Little dude didn’t even have EJs. So I got into the pediatric kit and pulled out a Jamshidi. I used iodine to clean the skin of his proximal tibia and started to twist the IO into his leg. It resisted and popped through the cortex exactly like the chicken drumstick in p-school. Exactly like that. Once in, it was solid. It didn’t wiggle or drift. Well, that may be a first, I thought to myself. That went exactly as advertised. I hooked the dripset up to the IO port and turned on the flow.

Nothing happened.

It didn’t flow. I used the bulb in the line to pump fluids in. Fluids flowed in when I pumped. Maybe the needle was clogged with a chunk of marrow or something. But again, there was no flow without manually pumping it in. The site wasn’t swelling or anything. His leg looked normal. But the IO wasn’t flowing. Shitshitshitshit. I was told that an IO works like an IV. This wasn’t flowing. When an IV doesn’t flow, it is bad. Thus, this IO was bad. Shitshitshitshit. It didn’t makes sense for me to pull it, but I didn’t want to leave a bad IO, either. I pulled the dripset off of it and replaced the stylet into the IO needle. Like a plug. Someone at the hospital could pull it, I figured.

I got back to work on IV attempts. Just as we were arriving at the hospital, I got a dinky 24-gauge cath into this kid’s foot that ran. I turned the patient over to the trauma center and that’s about all I recall about the call.

Apparently, intraosseous lines never flow. They always need pressure. Nobody told me that. Weird. You think that would be a specific point of discussion in paramedic school. Who knew?

Let me tell you who knew. The firefighter in the back of the ambulance with me knew. He was a paramedic and field trainer at my agency before moving over to the fire department. That is why my partner felt comfortable tossing him a handful of IV catheters.

Lesson learned. Now I make sure to hook all my IOs into a blood pump-style dripset so I can pump it. Plus I add an inflated BP cuff around the saline bag so there is even more pressure in the system. With all that, IOs flow.

So for new medics: IO lines don’t flow, but you can push fluids and meds into the bone “just like an IV.” They just have to be forced into the bone space. Here is a video of a Jamshidi being inserted into a pediatric mannequin.