Alternative routes for IV fluids

[AF IDMT]

Originally Posted by swatsurgeon

The sternum is not FDA approved and shouldn't be based on the length of the needle. The original sternal IO (not the FAST1) was the one that pierced the heart a few times and was off the market quick. It was basically the peds tibia IO kit repackaged.
The tibia is first choice, humorus second due to the amount of tissue over the upper arm. The tibia in the location of insertion typically has nothing but skin over it so muscular people or obese patients can always find/hit the tibia.

We've hooked them up to high pressure bags and they do flow well.

ss

Thank you, Swat Surgeon. I think I remember an AFSOC IDMT telling me that the sternal ones were taught in a tactical medical course a few years ago, can't remember if it was OEMS or an H&K course. He said then they scared the shit out of him. I was wondering why I couldn't find as many references any more, now I know. Again, thanks for the info, sir. Back to studying.
AF IDMT

[paramedicfred]

This IO system is great. My EMS system uses it in the field. I have had to use it twice on pts. I have not used it on a pedi yet but on the adults it worked like a dream. Our system has not had an IO failure since we brought it into use over a 1 year ago. The nice "crunch" sound is gone but the FD does look funny at us when we ask for the "Black and Decker " Drill.

There was a small problem w/the little metal tips that ended up in the sternum (meant to be screwed back onto for removal) wouldn't come out. The post hospital got real testy about digging them out of guys we trained after 4-5 times. I heard at SOMA in Dec. that the redesign will eliminate the metal end.

[The Reaper]

Originally Posted by RockyFarr

There was a small problem w/the little metal tips that ended up in the sternum (meant to be screwed back onto for removal) wouldn't come out. The post hospital got real testy about digging them out of guys we trained after 4-5 times. I heard at SOMA in Dec. that the redesign will eliminate the metal end.

Good info, thanks! I can see where the hospital might be annoyed, the patient should definitely be pissed.

Great to hear from you again, don't be a stranger here.

TR

[Monsoon65]

Yowza, that looks like it would leave a mark!! As Mr Harsey said, I never knew that you would run an IV into the bone if you can't do it the normal way.

OK, where do "cut downs" fit in the whole scheme of things? Or is that something way off into left field for this thread?

Thanks!

[Surgicalcric]

Originally Posted by Monsoon65

...OK, where do "cut downs" fit in the whole scheme of things...

Cutdowns in a field setting are a last resort, meaning all other methods and/or attempts (peripheral, EJ, IO) have failed.

Crip

[Doczilla]

With availability and improved training on central venous lines and ultrasound-guided catheter placement, venous cut-downs for venous access are becoming almost unheard of in the acute care setting. The new IO systems will only make this less frequent. Cut-downs are still used to some extent for arterial access for invasive pressure monitoring in the ICU setting. As Crip said, this is absolutely a last resort, particularly because of the amount of time it takes, technical skill required, and lack of frequent practice.

Of the IO systems available (Jamshidi-type needle, EasyIO drill, Bone Injection Gun, and Fast1 sternal IO), I've used all on cadavers and all but the BIG clinically. Overall, the new systems are far and away better than the old "drive it in by hand" method, but have some limitations.

The FAST1 sternal is a decent system, but we've had some problems with placement and continued function. It requires pretty substantial pressure to place it. And there's that whole removal issue, where you have to bring the special t-bar to unscrew it from the sternum. The upside is that it is quick and ready to use right out of the package. It rattles a bit when carried, which is a potential drawback for noise discipline.

The Easy IO is just that- easy to use. It allows a bit more finesse with use, and utilizes the proximal tibia insertion site that we are all familiar with when taught IOs with the Jamshidi (though it can also be placed in the humerus or distal tibia). The drilling action means that very little pressure is applied, so there is less chance of breaking the bone or going through the opposite side of the cortex than with hand-driven needles. Of the systems out there, it is the heaviest and bulkiest when you take into account the driver unit. Previous issues with battery failure have been solved with the newer model having a lithium battery with 15 year shelf life for ~700 insertions. It comes with a small plastic handle that can drive the needle manually if there is a motor failure or if you don't want to carry the full driver, but then you could just as easily carry a Jamshidi. There is some research going on right now to develop a driver unit more compact for special operations use.

The Bone Injection Gun is the smallest and lightest of the 3 new units available, and consists of a spring-loaded mechanism to snap a needle into the proximal or distal tibia or distal ulna. We had some placement issues with this unit in a local fire/EMS system. What was found was that people were a) rocking the unit slightly off the insertion site, so it wasn't going in perpendicular, and b) inserting just off from where it's designed to be used. The BIG, when inserted in the proximal tibia, shouldn't go into the cortex at the site we are normally taught for IO (2 fingers down and one medial from the tibial tuberosity) because the bone is too thick. It needs to be inserted about one finger width medial and one proximal from the tibial tuberosity. Also, the way it is shown being held in the pictures, it looks like it needs substantial pressure. It actually doesn't, and can be held against the bone with 2 fingers and tapped with another finger to trigger insertion. Once these issues were addressed in training, they have worked very well.

As Swatsurgeon said, any IO needs to be on a pressure bag to run properly. There is substantial pain with infusion, as there are pressure-sensitive receptors in the cortex of the bone, which is often described as the worst part of the IO. A few ccs of lidocaine should go in before fluid is run to make the patient more comfortable. The systems all offer very rapid access, and I've been training our medics here to just go for the IO if they don't see a good IV site immediately available.


'zilla

[SouthernDZ]

I have used the F.A.S.T.1 and have seen the Vidacare (which they're using in SOFMSSC) used; each comes with a removal device which needs to be taped to the casualty. One of the JSOC 18Ds (we didn't own any of the cities in Afghanistan yet) removed one with a letterman; it wasn't pretty. Tape the removal device (still in the plastic) to the port.

For what it is worth, an 18D has to have the mindset that medicine isn't always pretty and with some procedures, pain just maybe "is the patient's problem" - this sounds cold and uncaring, it isn't. Proper medical care sometimes hurts; bury your emotions and do what is proper and necessary. I've inserted a chest tube on a semi-conscious patient at Baltimore Shock Trauma - woke his butt up screaming pretty quick, but he survived a tension hemo/pneumothorax.

[Eagle5US]

Originally Posted by SouthernDZ

For what it is worth, an 18D has to have the mindset that medicine isn't always pretty and pain "is the patient's problem" - this sounds cold and uncaring, it isn't. Proper medical care sometimes hurts; bury your emotions and do what is proper and necessary.

Though I think I understand what you are trying to say here, I have to disagree with the way you have presented it.
There are numerous ways to handle patients appropriately and effectively in both combat and clinical environments-with the aim of lessening their pain by providing proper medical care while accomplishing whatever it is that needs to be done. Mission or otherwise. Pain may be the patient's problem, but management of that pain is part of my job.
Sure, chest tubes hurt, so do IO's and FAST-1's. Shoot-even IV's. And yes they ALL need to be accomplished based on the patient situation..."this is going to hurt for a second, but it is going to save your life. I'll make you more comfortable in a just a minute."

So-their pain is my problem, whether they own it before I get to them, or I instigate it. I always try to inflict as little discomfort as is required to get the job done.

Medicine is a practice, how you practice it makes it an art...

Eagle

[x SF med]

Originally Posted by douthernDZ

For what it is worth, an 18D has to have the mindset that medicine isn't always pretty and pain "is the patient's problem" - this sounds cold and uncaring, it isn't. Proper medical care sometimes hurts; bury your emotions and do what is proper and necessary. I've inserted a chest tube on a semi-conscious patient at Baltimore Shock Traum - woke his butt up screaming pretty quick, but he survived a tension hemo/pneumothorax.

What part of "Primum non Nocere" does this fall under? Why is pain the patient's problem, pain can cause shock, shock can cause death, so pain and management thereof IS definitely your problem. Yes, medical procedures can cause pain, but that pain can be mitigated. "Hey TeamSergeant, blow me you whiny bastard, it's only pain, here's some more." I don't think I want your gorilla hands and mindset to care for me, or any of my former Teammates, or a child who was part of the collateral damage of an attack. You must not have had Dr. Rocky as your Primary instructor, his credo always was, "Put the Patient First". You can't always allieviate pain, but you sure as hell can manage it, and keep your patient informed.

Jumping down off the soapbox.

[SouthernDZ]

[QUOTE=Eagle5US]Though I think I understand what you are trying to say here, I have to disagree with the way you have presented it.

Which is certainly your perogative; however, I've been in emergency medicine since 1973 and I've never yet administered pain medication to a semi-conscious casualty yet and won't begin at this point. At Shock Trauma we had the most heinous injuries MIEMSS could bring our way. We would emplace two chest tubes, reintubate, perform IV maintenance, and often would incise the abdomen and cross-clamp the descending aorta prior to moving to the OR; all in less than 3 minutes.

Realizing that "pain is the patient's problem" is a coping mechanism that allows you to deal with the tragic circumstances of a life that has often been altered permanently. Especially when dealing with children.

After 23 years, 5 months and 19 days of team time, I never once allowed a casualty to carry-on in pain, when it could be prevented. It isn't always in my power to alleviate such; therefore it might be best to be dispassionate about what you have to do and soulsearch about "how you could have made it a little less painful" later. I would've loved to had that kind of time but I was a little busy trying to keep them on active duty.

With Respects

[The Reaper]

Hey, guys, it is okay to disagree with one another, let's just keep it professional and based on facts and experience.

Not implying that it hasn't been so far, just don't want to have to do any consequence management here.

TR

[Eagle5US]

Originally Posted by The Reaper

Hey, guys, it is okay to disagree with one another, let's just keep it professional and based on facts and experience.

TR

Clear Sir,

I do believe I stated my point in a matter of fact manner, that was somewhat reserved, when it came to my actual emotion regarding this subject.

But since it has been brought it:
SouthernDZ:
You do not have the keystone on MIEMSS: I too worked there in the 80's. I have also worked at University Shock Trauma in Syracuse, and at Harborview Shock Trauma in Seattle, AND on the Trauma Teams at Tacoma General, and St Joseph's Regional, and at Mary Bridge Children's oh, and here in Iraq at various locations as the only provider. Big deal. I am not the newest knuckle to bump the stairs, albeit I wasn't old enough to begin working EMS until 1982. If you want to compare resume's, trigger time, and medical experience / training, background, fine. But I don't see the point. I will stand on my reputation and credentials.

On that note, you may be impressed with your team time statement-but you should know, by now, that statements as such hold little weight in this environment. Chest pounding is not something that has been necessary on PS.com. The majority of us here have significant time in the community in one respect or another.
Sinc there is nothing in your profile, I am making the assumption that you either, are or were, an 18D-which then leads me to the conclusion that unless you progressed further in your medical education-you still have quite a bit to be able to learn. As we all do in medicine until we finally stop practicing.

If YOUR coping mechanism is that "pain is the patient's problem". I think it sucks. If it is yours, than own it fully and please do not offer it up to any new folks coming up through the course. They come here for information and need to see that others, such as myself, have the ability to disagree with your statement on "how they need to be" in order to be successful as an SF medic. THEY can decide for themselves how THEY want to qualify their handling of patient pain. I hope they choose a route other than yours. But that is, as you stated, my perogative.

As mentioned before, medicine is a practice which allows some leeway on how people do the same things differently. The way it sounds, I wouldn't approve of the way you practice if I were your patient. Glad that isn't something that I, my friends and colleagues, or my family currently have to worry over.

Originally Posted by southernDZ

Tt isn't always in my power to alleviate such; therefore it might be best to be dispassionate about what you have to do and soulsearch about "how you could have made it a little less painful" later. I would've loved to had that kind of time but I was a little busy trying to keep them on active duty.

Very dramatic statement to the unknowing or uneducated. Many of us have had the triple amputee patient with respiratory burns and an RPG round stuck in his chest with only a swiss army knife, popsicle stick, super glue, and silly puddy to treat him. That is not what this is about. Being a medical professional allows me to know what needs to be done with compassion, and actually prevents me from being "dispassionate" or having the need to soul search.

It wasn't long ago that hypotensive resuscitation was blashemous in the medical community either. Everyone is always learning.

Eagle

[SouthernDZ]

I'm certain you are correct in all of your assumptions on this matter and of your low opinion of me.

Should be the final post from me on this matter.

[SwedeGlocker]

I my opinion based on my time in ER, OR, EMS and in a remote setting is that there is always a way to offer a patient pain controll. It can be everything from a comforting hand to Ketamine IV. If a patient have pain in most cases it will be harder to threat the patient. A screming and moving patient dosnt make it easier to do invasive procedures. If the patient is hemodynamic instable the perhaps a regional block och lowdose ketamine? I does take training and experience to threat pain and to find a solutin that fit every patient but it is possibly. And dont forget Acetaminophen as the base in pain controll.