How to MacGyver an IO

Responding to a cardiac arrest a few shifts ago resulted in a peculiar problem with an IO. We were at post and the call was a block away at a small, private residence. Getting out of the unit, we could hear hysteric crying through the open front door. I instructed my Paramedic Intern to grab the airway bag and Zoll as I grabbed the house kit.

Quick stepping through the front door, the distraught daughter began rattling out a history before we could even ask. The patient, her father, an obese man in his 70s, had gone to the bathroom and had been straining during a bowel movement, when he stopped breathing. The daughter called 911 within 30 seconds and we had arrived only minutes after the arrest, he still had a shot.

Grandpa Jack was found still sitting upright on the toilet, blue as a blueberry in his face, and still with a somewhat strained expression. We heave him to the floor, trailing his oxygen bottle behind him, and drag him to the living room. Grandpa Jack is huge, over 350 pounds with a shape that isn't round, or pear, or any other body shape I've seen before. He's simply big. Puffy arms and hands told me venous access would be a problem. A wide, short neck told me airway access would also be complicated.

I directed the firemen to start CPR, my intern to get to work on an airway, and I set to work on venous access. The Zoll quickpads were applied and he was in PEA at 40. Again, I studied Grandpa Jack's arms for a workable IV site as the fire department EMT-Intermediate stuck him in the hand. The EMT turned to me right away, "I think we're gonna have to go IO on this."

"Yeah, I know." The IO package was already in my hand and I was working my way around to the patient's feet.

My company has not in-serviced our new EZ-IOs yet, so they aren't on the units. Instead, I dug around the pediatric supplies and pulled out a pediatric IO. We use a 15g Baxter IO, and really, it's designed for pediatric use, not bariatric. I've heard tales of other paramedics in my company using our ped IOs on adult patients with less than stellar results. Some have told me that the IO has even broken during insertion, but I was undaunted.

Grandpa Jack's legs were just as puffy as his arms and his tibial tuberosity was difficult to palpate on the left. I knew it was there though, so I sunk in the needle expecting to hit bone and meet resistance. Instead, I sunk the IO to its flange into fatty tissue. "No good on the left," I said, "too much fatty deposit."

His right leg is better and I can clearly palpate the site. I swab it down, then again sink the needle, immediately contacting bone. I'd never done an IO before, so this was an entirely new experience for me, and while I was a little worried about fouling it up, I started to apply pressure. Using the twisting motion and straight down pressure, I sunk the IO slowly into the tibia, finally feeling the tell-tale lack of resistance. It took easily a minute of constant pressure and twisting to get placement.

I'm in! Great! I'm thinking. Without taking my hand or eyes from the upright IO, I ask the fireman for a syringe. With my free hand, I grasp the hub of the catheter and give a pull. No give.

Maybe a little twisting action, I think. Again, grasping the hub, I twist the catheter a little left, then a little right. Come on, you bugger. No give.

Removing my trauma shears (yes, I had them with me today), I dig into the hub with the blade. Again, I pull, then twist, then pull a little more. No give.

Back a few posts, in My Pockets, I wrote about what I carry with me when I'm at work. What I left out is that I occasionally (as in maybe once a month) wear a leatherman tool on my belt in a little holster with a mini-mag light. It's a knock-off leatherman, a generic multitool with pliers, a knife, and screwdrivers among other things. And it's here, as I struggle with a stubborn IO catheter, that I wish today was that one day of the month.

"I need a leatherman. Any of you guys have a leatherman?" I look at all the firemen in the room. We're over five minutes into the arrest without IV access and I'm uncomfortable with that.

"Guys, I need pliers. Get me pliers right now." My voice had a little edge to it.

"What king of pliers?" The fire lieutenant asks me.

You've got to be kidding I'm thinking. "Needle nose or regulars, it don't matter. I just need pliers."

The LT reaches into his bunker pocket, pulling out a well used leatherman. He flips it open, and hands me the needle nose set. Grasping the hub, I pull up on the catheter and hear a very satisfying shink as the catheter slides clear of the needle. It reminded me of a kung-fu movie, the sound the katana makes as it is pulled from its scabbard. Next, the syringe is attached and marrow is aspirated. I flush the IO, push the first epi, then attach the macro lines which drips steadily and triumphantly, if a little slowly, into the patient's leg.

*****

We transport Grandpa Jack with a combitube after a failed ETT attempt. We never established a patent IV so the IO was used throughout the code. Grandpa Jack never improved from a PEA. He was turned over to the ER where they continued to work the code for another 30 minutes. I have to admit that I felt a little bit of paramedic pride. The IO set was the primary access used during the resuscitation as the ER staff was unable to obtain IV access.

The ER doc called the arrest after the staff went above and beyond in their resuscitation efforts.

EMSDailyNews.com picked up this entry and ran it on July 13th. Thanks for the plug.