Diesel Or I/O?

This is, in part, me telling a story and in part me asking for feedback.

We were away from our usual area when the job came down, by some luck we were on the corner of the road that the call was from, “GP surgery – three month old baby – dehydration”. We were so close to the job we reached the surgery before they had finished making the call.

Into the surgery we walked and one of the receptionists led us through to the room where the patient and her parents were.

As I walked into the consulting room my heart skipped a beat and my stomach turned over – this child was incredibly ill.

She was so ill I had to carefully check that she was still breathing.

My crewmate got the child out to the ambulance (where most of our equipment is) while I listened to the GP as he gave me a history of the child. Small for her age she had been vomiting for a few days, now she was severely dehydrated. This is why she looked like one of the babies they show on the news when there is a drought or famine in another part of the world.

I actually jogged back to the ambulance – this was a child that needed to be in hospital as quickly as possible.

A 'capillary refill time' is a good measure of how poorly a child is, you press on the nailbed of the child's finger and see how long it takes the blood to flow back. In a healthy child this is less than two seconds. In this child it took five seconds for the colour to run back to her finger. Her fontanelles were sunken and she was not responding as a child her age should.

We thought about starting treatment on the child immediately, but as the hospital was six minutes away we instead decided to make a run for it.

It's not often I blue light someone into hospital with sweaty palms, but this was one of those occasions. I had a very real fear that this child was going to die in the back of the ambulance.

Straight into resus went the child, to be surrounded by doctors and nurses who could start treating her.

—–

About twenty minutes later we'd finished up our paperwork and my crewmate went back into the resus room. We thought that they would have started treatment, but it would seem that they hadn't even managed to start rehydrating her.

I checked with one of the top paediatric nurses at our regular hospital – she agrees that the child was incredibly sick and needed access for re-hydration immediately.

—–

There is a problem working for the LAS, something that I'm going to elaborate on in a short while, and that is that there is little further training and no clinical feedback on the jobs that we do*. As this was a 'strange' hospital, I don't have an easy way to find out the outcome of this job, or if what we did as an ambulance crew was the right course of treatment.

There are two ways that we could deal with this child – we pick her up and the only medicine we use is diesel. Which means that I drive her quickly to where the experts are – the doctors, nurses and other clinicans at the hospital. In this case this is what we did.

The second option is that we spend a little long out on the street. We could have tried to get some fluids into the child immediately. Why we didn't do this was due, in part to our lack of experience.

There are two ways we could have got fluids into her – the first was to place an IV line into a vein – this is incredibly tricky with a small child at the best of times, let alone one that was so dehydrated as her veins would have been collapsing.

The other way would be via an IO needle. This is a large metal needle that you punch through the skin and into the bone marrow of the shin. The needle is then left sticking perpendicular to the surface of the skin and secured in place. (You can take a look here for some images )

The problem with this is two-fold. Firstly you are stabbing a tiny baby in the bone. I make no qualms about this, but it's something that fills me with no small amount of fear.

But what causes this fear? Quite simply this is the second problem – In over ten years of emergency medicine I have seen this procedure carried out twice. Once when I was an A&E nurse and once as an ambulance worker. In this country at least it is a very rare procedure. My crewmate (who would have to actually do this as she is the paramedic) has never seen one done before outside of the classroom that she sat in about six years ago. Due to this lack of experience and training we don't have the confidence to perform this sort of intervention.

So we had to balance it out as to what to do – are we going to do something that we are barely trained for and have no experience of, or do we 'scoop and run' thinking that the hospital would do it straight away?

Of course, we had hoped that the hospital would have gained that blood system access straight away, so when they didn't it had both me and my crewmate wondering if we had done the right thing. If we'd put that needle in on the side of the road, would the child now be getting the fluids it desperately needed?

So I'd like to ask those of you who have experience of such things – what would you have done? Would you have done as we did, no treatment and a six minute journey to hospital, or would you have 'stayed and played' on scene for maybe twenty minutes doing something that you don't feel trained for?

I don't feel ashamed to say that it has given me a crisis of self reflection, and of confidence.

—–

Sometime in the next two weeks I'm going to highlight the problems with training in the LAS – then offer a solution, so this post isn't really about our training. You will have plenty of chances to comment on that when I do those posts…

—–

*Not strictly true – there is always the coroner's court.

43 thoughts on “Diesel Or I/O?”

  1. Run. A very big theme of every JRCALC treatment guideline is “do not delay removal to hospital, if necessary [do whatever] en route]”. I may not have the exact words, but the gist's there.With a 6 minute journey time, getting the pt to definitive care is, IMHO, the best possible treatment you could have given. Why nothing was done quickly at the receiving hospital is not (sorry, can't think of a better way to phrase this) your fault.Maybe the fast-bleeped paed Reg was hurtling towards Resus but hadn't quite got there?

  2. As a paramedic working in the state of washington in the USA, I have to say a few things. Knowing that the system I work in is different from yours, I will say that here, my EMT partner is not responsible for that decision-I am, since I am the medical authority on scene (between me and my EMT partner). Secondly, the EZ-IO drills are CAKE and the best thing to be put on ambulances for this exact reason-virtually painless (it was done on me in training) and instant access, regardless of patient condition, age, etc. I am guessing from what you wrote that the EZ-IO is not on your rigs in London yet, which is something that maybe you guys can lobby your supervisors for because of the huge benefit to having them. Regardless, don't let this cause so much second-guessing on your part-you did the best you could with the equipment you had on hand. If your partner felt her inexperience was an issue since she hasn't done many peds IVs, don't you guys have a training dept that provides yearly in-services to keep those rarely used skills functioning? If so, maybe she should be proactive and attend some of those refreshers for just this type of reason. That is one thing about working in this field, you never ever know what each day is going to bring, so you have to constantly be on your game-working to keep those skills effective and ready for the rare call that comes your way. Beyond fluid boluses, there wasn't much else that could be done in the field for the child, so getting her to the emergency room fast is always a good call.Also, since I am writing for the first time, I wanted to let you know that as a medic in a completely different country with totally different emergency systems, it is great to read your blog.

    I really enjoy it. Thanks.

    Tresa

  3. Scoop & run: I doubt you could have got an I/O in & saline running in 6 minutes in the cramped conditions we work in in the back of an ambulance.

  4. To be fair to the GP, they were still on the phone to Control when we arrived – we were around 200 yards away when we go the first few details through.The GP knew how sick the child was – I think we both saw it in each other's eyes…

  5. I'd have done the same. One of the great strengths of pre-hospital medicine is recognising when the best thing for the patient is the hospital, and it sounds like that was the case in this job. Getting IV access in a paed is *hard* – an ill paed with dehydration must be much, much worse. Even if you did get a line, it'd probably blow/fall out en route, and wouldn't really achieve much (plus how long would you fart about calculating paed drug doses).Meanwhile, 6 minutes away is a paed anaethetist who's job, day in day out, is to do exactly that. S/he'd be so much better for the kid right now. So use the one remaining tool in your armoury, and hoof it there.

  6. I can really relate to your dilemma. Reality is that we don't come across enough sick kids to feel comfortable treating them. In addition our various providers do not adequately prepare us for the challenge. I would have done the same in the hope that the time to definitive treatment would be short. Down in NZ, we have just started using the EZIO drill which is pretty user friendly compared to the Cook's needle. Only used it in adults so far with success. Nonetheless those little bones still freak me out!

  7. If you went with your first instinct, then that was the right thing to do. Your training, experience and human nature did that for you. It's only on reflection that you questioned yourself. You took her to the place where there was backup, experience and support for any further problems she might encounter.Right choice.

  8. Diesel every time, no questions of qualms, any poorly child needs to be surrounded by the paed teams in resus, I do see why you are questioning yourself, but be assured I think 99.9% of all ambo staff would put on the ole lead boot and keep the thumb on the air horn until pulling up at the doors

  9. As a Paediatric SHO (in a different country) who still occasionally volunteers for the local ambulance service, my answer is load and go. IV cannulation in anyone is easier in the controlled and well lit emergency department. Plus, there'll be more than two people, so you can simultaneously have more than 1 person attempting venous access (who is likely to be more used to sticking lines in kids than you are) as well as someone else doing the initial assessment. Not a criticism of your skills, but just a reflection of reality.Diesel, every time.

  10. As an anaesthetist who get called to these sorts of things not infrequently, I have a very low threshold for inserting an IO needle in little ones. They are not the easiest things to learn to do, but are certainly life saving. I certainly wouldn't expect the paramedics to try this, although would not criticise them for doing so.I think diesel is definately your best bet, unless you know there will be a significant delay in getting there.

    From the story, the delay in starting care for this child once in hospital seems worrying – was a senior doc/paed present, or was it just juniors flapping around?

  11. With my grand total of no relevant experience or training, I think you must take the child directly to the hospital (assuming she'll survive the trip) rather than attempting experimental or half-remembered procedures that technically fall outside your remit and your expertise, in the back of the ambulance. As you say, the hospital is the place with the people who have the appropriate training, experience, equipment and facilities, not just in terms of treating the child, but also for looking after the parents.That twenty minutes later, the child was still not receiving treatment, is not your responsibility. It's a problem, certainly, but not a professional failing on your part – you had a reasonable expectation that the A&E staff at the hospital would jump right to it with all machines a-bing-ing and make a much better job of rehydrating the kid than you and your colleagues would have been able to.

  12. I don't have any medical experience, but as a lay person I am wondering why after 20 minutes the A & E staff had not started doing anything? Surely you shouldn't have to make decisions about how to do your job based on the worry as to whether they'll do theirs?After all, I bet you can hardly say to a coroner that you made a decision to do something 'because you were afraid A&E wouldn't do their job properly' can you?

  13. Those of us in this field are well aware that paeds 'drop-off' very quickly, they do not compensate like adults so with a 6minute run time you without question did the right thing. Working in a field where blame must be appointed should the inevitable happen, we work with the constant knowledge that as well as saving lives we must also cover our own backsides should the proverbial hit the fan which is why most people waste time with the stay and play attitude because they know that if the finger gets pointed its their job on the line if they cannot justify why they did not carry out a procedure that they have been trained for. Unfortunately our industry makes us guilty until we can prove our own innocence – where there's a blame culture has a lot to answer to

  14. 100% scoop and go. I work as a Tech in rural Scotland and sadly we often do not have the choice, our travel time can be hours. In your situation there is no benefit to invasive procedures with such a short travel time. I am a firm believer in Diesel and you and your partner should have no doubts that you made the best call.

  15. An IV on a dehydrated baby? I have seen a whole ER department fail to get a blood draw from a plump hydrated infant. It seems to be really tricky when you are dealing with kids, and the only thing that makes a difference is practice, practice, practice. The people who are best seem to be those in paediatric hospitals that do these procedures a dozen times a day, every day.You were right to go to the ER – had they promptly and successfully helped the baby you wouldn't have thought twice about your decision.

  16. I'm another American paramedic posting for the first time (long time reader). Let me start by saying I don't think you did anything expressly wrong on this call. You accurately recognized an acutely ill child, gathered essential information, and expedited your transport to an appropriate facility with a fast transport time. My familiarity with the British ambulance system is limited at best, you acted as any reasonable BLS crew in the states would have done. In fact, many ALS crews (at least one paramedic) would have acted similarly. That being said, I've always learned to be aggressive in treating patients for exactly the same problem you ran into- the A&E staff had not yet “fixed” your patient after arrival. I learned the hard way several times that arrival at the hospital and the time it takes to address your patient's life threat are often separated by quite a while. That could be a reflection of the abilities of the hospital to which you've taken your patient or it could be a reflection of Murphy's Law (what if there is already a working trauma/code in resus or if the A&E is beyond swamped and there simply isn't a bed available for some time). For these reasons, I probably would have started the IO if I were in your position. That being said, IOs are very common in the US (both manual and drill) and I have trained with them extensively and used them clinically fairly frequently. I think they are a fantastic tool that it not as “scary” as I first thought. Still, you did a good job because you accurately recognized that the infant really needed a hospital more than the back of your ambulance. Similarly, great blog, really interesting read for a fellow EMS professional.

  17. Having no medical experience whatsoever, I still think you did the right thing. I am a mum, and I once watched an experienced paeds doctor take 12 minutes to draw blood from my perfectly healthy infant, who was a red-faced, snottery, squalling mess by the time he'd finished. In fact, it was a contest as to who was the reddest, her or the doctor!What happened after you delivered her to A&E is their responsibility, although I do think it reflects on your dedication that you were so concerned at the delay.

    Take a deep breath, and repeat after me, “I did the right thing”. Keep repeating it until you convince yourself.

  18. Diesel. Everytime.We have a different problem up here. I've just completed my basic paramedic training (now need to wait for clinical placement, which doesn't include paediatrics by the way). We were briefly shown how to IO access on a disembodied small limb, all very unrealistic.

    But the real crux is that our service will not purchase the kits to put on the vehicles. Because they are not used very often they are not considered cost effective.

    Price of a child's life anyone?

    In your case being so close to hospital I'd run everytime. Unfortunately up here north of the border there are some huge distances to cover in areas. IO in these situations may be invaluable.

  19. Interesting problem. I frequently have the same dilemma – whether to tube a patient in the pre-hospital arena, or run to the hospital and let them do it there. I am about finished writing a blog about just one scenario. The bottom line is, every time I have thought to myself, “I'll wait until we get to the hospital< " I have regretted it. There is this misplaced thought that, once the patient has been delivered to the safety on the resus room, everything will go smoothly. This is often not the case, and the fact that there are so many people, with no team leader, is usually the cause.Of course you did the right thing. You have little experience in IO insertion, and your colleague has less. For you to have tried to get an IO in, and possibly failed, would have taken far too long, and 6 minutes is not a long time. However, given the alternative scenario, of having the experience and confidence to get a line in a child, the answer has to be "don't delay the line."

    Great blog, great inspiration to the rest of us.

  20. Hello, I'm an Advanced Care Paramedic in Ontario, Canada. I have been lucky in my career to never have had to place an IO in a child, ever! I thought a lot about your call and how I would have handled it myself, had it been me in the “hot seat”.My standing orders allow for the placement of an IO in a “pre-arrest” child (which from your description seems to describe this infant!) without needing to look for IV access first…

    After much thought I think that I would do a rapid eval. for IV access and if nothing is seen/palpated I would then make one IO access attempt on scene prior to transport.

    my rationale for this is based on the small amount of time needed to assess for, and access an IO as well as the potential benefit to the patient by starting a fluid bolus early.

    Should the patient deteriorate further, having the IO in place will increase survivability by allowing early drug administration.

    While I agree that a short transport time is a mitigating circumstance unexpected delays can and will occur. I believe that it's best practice to anticipate at least 3 steps ahead and be prepared for possible deterioration…

  21. google the ez-io drill. at my service there is never a need to walk into an emergency department without access for meds or fluid.

  22. These calls are inherently tricky and I've done a few myself. What works on one patient won't necassarily apply to the next. My experience with dehydrated paeds has been to scoop and shoot and try establish IV/IO access en route to definitive care. At least you're intervening whilst at the same time making haste to definitive care.If you don't mind my asking, does the LAS have access to the right kind of fluids for these patients? In South Africa, we usually only carry NaCl or Ringers Lactate, when these patients need fluids like Neonatalyte, etc., to avoid the risks of exacerbating the dehydration.

    After my first bad experience where the child arrested after three months of negligible care at a rural state facility, I made a point of practicing my IV/IO cannulation by volunteering at a paed ICU. It's given me a little more confidence and experience when the need has arisen to perform the skill in make-or-break situations. Once you have a rapport with the staff at the unit, I think you'll be inundated with requests to cannulate the kids.

  23. It does indeed come down to experience – My crewmate has no qualms about intubation (of course, we don't have to RSI – so for us it's less of a quandry) If we'd done more IO's, or had recent training in them, then we may well have gone for it.

  24. I don't know if you have the sexy drill types – but ours are the manual ones. As an advanced care paramedic I would assume also that you feel more confident in your training, is that right?If we had felt more confident, then yes, we'd have gone for it, as it is a possibly failed attempt would have taken us longer than six minutes.

    But yes, I agree with you about three steps ahead – unfortunately I don't think we have the training for it.

  25. I've seen them on video – doctors drilling into each other and it does look brilliant.Sadly the LAS only has the old manual ones. Which doesn't do wonders for your confidence…

  26. We only have NaCl or 10% Dex. I've never even heard of these special fluids – never seen them in hospital either, but then it has been *years* since I did a paed rotation.As for getting experience – I'd love to work on the baby transport vehicle as you get loads of experience there – but because I'm on a disciplinary for my sickness I'm not even allowed to apply.

  27. Here in Italy it's really different because we have no paramedics, only volunteer rescuers (alone on the ambulances) and a few specialist crews (cars with a driver, a nurse and a medic in each). In my town (Genova) there are only 6 such crews, so you often do without them. And most rescuers have not even AED training.Anyway, in most cases you arrive on the scene long before the specialist crew and you have to assess the patient's situation with no specialist medical training. If the patient needs specialist care and the medic hasn't arrived yet (if the medic is coming in the first place), assuming that he isn't already in arrest (then you begin bls procedures) and that you can carry him/her safely enough before treatment, you usually follow a scoop and go policy.

    If you're lucky and the medic is on his way you usually arrange a rendez-vous on the road to the hospital.

    Now, to your case, in your situation and with your training I would probably have done the same. After all 6 minutes are not eternity.

    Once I was carrying a severe trauma patient with a nurse on board, we were 10-12 minutes away from the hospital, SpO2 was falling fast. He had his mouth tightly shut, he was unconscious and the nurse couldn't intubate him with the ambulance running (italian streets are usually in a very bad shape, so ambulances are never really steady environments). That said, the nurse ordered us to just run as hell and hoped he would make it. And he made it, though just in time.

  28. I second these comments. Particularly with the EZIO, access is less painful than being stuck (possibly multiple times) with a smaller (prob 24ga) catheter, and you have a MUCH better route. Chances are if the child was as sick as you describe, they needed some fluid and fast. You didn't state what the child's vitals were, but given your field impression of 'sick/not sick', it sounds like this kid was in some trouble. That being said, you have to evaluate not just your transport time, but the likely time to DEFINITIVE care. 6 minutes of driving, a bit of time for transfer, and how long in the worst case until the ER gets vascular access ? It has been my experience that hospitals really don't use the IO as much as they could, opting instead for the 'IV Team' or going for an A-line. So the bottom line is – how much could change in your patient in the 10 or so minutes until treatment may be started at the ED ? As we all know, kids can go downhill fast. From my perspective, I'd take a serious look at getting access ASAP since you just don't know, and the sooner the better in a pedi.

  29. Every year we attend a mandatory CME with our base hospital where we practice IO's on chicken bones and Portex surgical airways on pig tracheas! All fun, although I have never had to place an IO on a pt (yet) I don't think that it would deter me from one attempt if it was indicated.Is there any mechanism in your service to request additional training, or to suggest CME topics?

    In Canada an Advanced Care Paramedic is equivalent to the EMT-P level…

  30. No medical professional here, just a mom who had a similarly dehydrated 9-month old from vomitting and rushed him to an ER in Boston, MA and then watched in frustration as a number of docs tried and failed to put an IV in his arm, inside the elbow bend, where you would put an IV in an adult. It seemed crazy to me, but what does a mom know?My baby was crying and moaning as they jabbed him repeatedly until finally, someone decided to call a pediatric nurse from upstairs and she came in and put the needle in the back of his tiny hand, quickly and efficiently and he calmed down.

    Sounds like you did the right thing above, but as many mention above, the handoff between ambulance and hospital seems dangerously obstructed by paperwork and delays.

    And as for doing good deeds, remember how immensely relieved parents are when you arrive on the scene. Your job is hard but being a parent is sometimes even harder. At least you know what to do and are trained to do it.

    Mysteriously, that pincushion baby is now 14 years old, well hydrated, full of vim and vigor and taller than me … and I'm fairly tall. So all's well that end's well, so far.

  31. Firstly, I'd like to say that I think you did an EXCELENT job. Those runs always have a bit of “Pucker Factor” but I think you did quite well. While I have not one single problem with your treatment I do have some insight into your situation.I am a medic in the Midwest US. Over the last 5+ years, IO's have been getting huge here. At first they were just for pedi's in arrest. With my current department, we have what's called the EZ-IO (look it up). It is basically a power drill with a needle on it. It's an AMAZING tool. Only used it once myself on an adult in arrest, but I have trained a lot with people who use them constantly and it is quickly becoming the standard.

    Most protocols I know of use some IO device for any arrest at any age. The consensus is that the 30 seconds time and 95+ succuss rate is better than the 1-3min and 60-70 percent success rate of an IV. While the IO is a bit more 'brutal', the patients that need it are far beyond that point.

    I have also seen video and heard 1st-hand stories of IO training. EMT's recieved IO's and relate the pain level to that of an IV.(Think about it, there aren't many nerves in the bone) They state most pain come from the pressure used to bolus the saline. My current protocol allows for a bolus of 100mg Lidocaine (Xilocaine) for that reason.

    In the end, I would say that in your situation I most likely would have started the IO. BUT, I certinly have NO problem with a “Diesel Bolus” either. I applaude your recognition of the severity of the child and it is certinly a testement to you, that you are agonizing this much over a run. And THAT is what makes a good medic!

    Stay safe out there!

    Chris Turner

  32. Many thanks for the EZ-10 info l have started to hand the info round. We sometimes have animals in that are to collapsed to get an iv in especially at the emergency practice l work at a lot and that would be ideal. Pity it won't go under 3kg but it may be adaptable, am thinking of puppies, kittens etc.Not a lot else you could have done under the circumstances. And once at a & e l guess wading in and snarling at the staff is frowned on. We sometimes do IP fluids but do not know if that is done or not in humans.

  33. I assume that by your surprise you weren't aware this child was likely to be so ill. If that's the case I don't blame you. You should have been told how ill this patient was. “3 month old – dehydration” rather understated the point. Whether this is a failing of the G.P not recognising a serious illness in a child, or your control staff not conveying the message to you properly is a matter for serious discussion. I think, sadly, it could be the former. You recognised an ill child straightaway; because you know what one looks like. The question is did anyone else? Personally, I think you made the right decision.

  34. In that case I take it back – to a degree; we know they are sometimes contributory factors. However, the fact I think you made the right decision still stands. It is unreasonable to expect a Paramedic to perform an intervention they have probably never done before in 3, 4 , 5, maybe more, years. There should be regular training for this; especially if the Service deemed it so important as an intervention. The reality is most people are not going to keep paying for courses to refresh on a procedure they hardly ever perform. So with both those in mind, diesel seems like the most appropiate measure most times.

  35. I, too, happen to think you made the right call. The distance just didn't warrant stay and play.Here in Holland we have been using the EZ-IO for a couple of years. We use it as primary method of access in both adult and pediatric resucitations. Why in adult resuscitations? It's been proved to be quicker method of administration than a peripheral IV line, as long as it's placed in the upper humerus. I almost always use the EZ-IO unless there's an obvious external jugular vein that's good access. That also makes it a far more familiar procedure that I would have no qualms about using, even if it were on a child. It is not a painful procedure, however, the administration of fluids and/or medication certainly is. One of the ways around this is to administer a small bolus of lignocaine before anything else.

    Carl.

  36. We are lucky enough in secamb to have had the EZ-IO (with lidocaine if needed) available for a number of years now. We also have many staff experienced (including myself) in using it in adults & kids. As in any poorly sick child diesel is one of the best treatments however the EZ-IO allows me to gain access within 60 secs with minimal fuss and in the back of a moving vehicle. A 3 way tap attached and age/weight related fluid bolus administered before arrival at A/E whilst on the run. I wouldn't want to attempt using a barbaric cook needle though! I do feel sorry for you guys up in LAS. The EZ-IO is a revolutionary piece of kit and has changed prehospital paeds care it's just a shame that you don't have it.

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