Scott,
Great post, but one issue is this statement “We used to have a lot of problems with IO (recognized) failure until we stopped letting residents put them in and made it an attending and critical care paramedic only skill.”

Just because residents may not be initially as adept at placing IOs, it doesn’t mean they shouldn’t be placing them. Like any procedure, if not done as a resident, that skillset won’t be there as an attending–when he/she is expected to be the final authority and definitive proceduralist.

Keep in mind that that particular critical care transport medic at one time was a novice in this procedure and may have had one or two failures.

[…] From EMCrit: […]

its a bit off topic but Jeff raises a good point. Medicine has always been an apprentice model of training and mastery. You cant simulate everything . Bruce Lee once said, you can try to teach swimming on dry land as much as you want, but nothing beats getting into the water!
Patient safety and quality care issues challenge us , responsible for training the next generation, as Scott says. Personally I take the view point that teaching and supervising someone to perform a life saving skill is a favourable balance of the patient safety vs training needs equation…in general but its a case by case anaylsis. Our teachers did this for us. that is the tradition. that is the discipline.

To help protect my IOs (even in adults) I place a roll of tape over the top of it so the roll lies flat to the skin. I then secure it with long strips of tape the te skin. That way the tape takes the knocks rather than the IO.

Thanks, Rebecca, for these excellent tips. Your comment about some folks suggesting proximal humerus is the preferred site is right on target. I’m one of those folks. Because of the lower intramedullary pressure there, you achieve simultaneously a 5x greater flow rate (vs prox tibia) AND less patient discomfort. Your target is much bigger, so despite more overlying soft tissue, I think with training that proper placement is actually easier at the humeral site. If you’re running a code (and you believe that epi works), humerally administered epi will get to the heart in about 0.5 seconds, just as if it had been given through subclavian or IJ central line. The only downside of the humeral site is that if you let the patient (or the CT tech) range the patient’s shoulder, it has a high rate of becoming displaced.

Here are my two bits on the whole IO experience. My background is in Prehospital medicine and ER as a nurse in a level one Adult and Peds Trauma center. The errors that I have seen in practice come back to lack of quality education prior to deployment of a new device. Also, needle choice and site choice is key. Not all peds pts get the 15mm needle most get the 25 mm needle. Pushing the needle through the skin until you hit bone and then looking for a black line is a must. If you see a black line then give gentle pressure and let the driver do all of the work. Like previously mentioned, stop when you feel a pop or lack of resistance, in young children there might not be a big sensation of either. Hard flush with a 10cc fluid bolus to open up the medullary space to facilitate fluid delivery. It is key to remember that children less than 1 year of age have very small tibias and if we fail to stabilize the IO with an appropriate dressing we will have failure due to the fluid pushing back on the needle (non-expanding closed space… Read more »

So, to weigh in on this as a lowly resident and EMCrit fan since MSIII:
I can see how folks would prefer not to let residents put in lines, IOs, etc. It creates a potential problem for care of the individual patient – but saves our future patients a great deal of suffering. Everyone has a first.

I’ve noticed a truly distressing tendency for non-military-trained PAs to bar residents from procedures, and I understand that some folks are very results-oriented. As medical professionals, though, shouldn’t we work together to pool our knowledge rather than to create silos of care? This may just be my experience with our local culture.

Residents are incredibly aware of the problems of medical training – that we might cause problems for our firsts. It galls us. We read, and simulate, and try our hardest.

But the truest way to learn is by BEING in the situation.

The Hippocratic oath puts first a recommitment to passing on the craft, even before “do no harm”. Creating “no residents” rules is a flawed approach.

[…] https://emcrit.org/misc/how-to-secure-an-io-in-a-peds-patient/ […]

Kevin Guenard’s post mentions something of incredible importance that deserves repeating – in *many* pediatric patients, the pink EZ-IO needle (labeled for 3-39 kg) is not long enough to penetrate flubber and enter the intramedullary cavity. We have had several infants in whom the pink needle wasn’t long enough, but older children in whom it is. Opening the needle set to find out the device isn’t of appropriate length for a given patient is wasteful – I’m at a point that I really don’t see the point in carrying the 15 mm needle set. Kevin I wonder what your thoughts are on this? We have seen a few EZ-IO cannulae put through the tibia in kids. I think the key here is not avoiding using the driver, but rather, not pushing – simple advance the needle to the bone, trigger the driver, and let it do the work. I’ve tried several different ways of securing the IO cannulas and I actually like that the EZ-IO does not have an adjustable flange. I usually take a big central line Tegaderm and put it straight down over everything and “tent” up the side where the extension set comes out from under the… Read more »

i am reading this all 6 years post original publication.
the comments and discussions are all so appreciated.
very very cool
tom