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Chest Pain

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I'm well familiar with the process. That being said, if you're going this route it should be because you can't get a peripheral IV started. If you need access this badly do you really have time, more importantly does your patient have time, to wait the 6-7 minutes for this whole process to take place?

In the scenario outlined by the OP you'd be at the hospital faster than it would take to get an IO set up and actually infusing.

Firstly, if the patient crumps you're going to cardiovert immediately and how painful the procedure is is superseded by the patient's care needs.

Secondly, not all of us work 10 minutes from hospital. I don't know if you noticed but the people who suggested considering an IO are from Alberta. One hour plus transport times are not uncommon there. Personally I would probably consider going to the external jugular with this patient before IO but IO is perfectly reasonable deployed appropriately.

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I don't disagree that it can be, and in many cases is, an appropriate intervention. Nor am I arguing against proper use. I did notice that many who commented on IO use were from Alberta. While you have no real reason or way to know this, I'm not unfamiliar with hour long transport times, either. I've worked both rural and suburban/urban EMS. My preference is for rural.

My point was, as previously stated, just because you can doesn't mean you should. We in EMS seem, as an exceptionally broad observation, to be really quick to jump the gun. We don't easily tolerate being frustrated (e.g. having a hard time getting a line on someone). So if you're going to do it do it right. That is the point on which I think we both agree. We're just looking at it from different points of view.

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I haven't read the whole thread (for some reason I'm now only seeing 5 posts/page which is highly annoying) so this is more of a general statement.

With higher risk patients who need some type of venous access, either because they need a treatement, they need a treatement that can only be provided at the hospital, or have a high potential of decompensating with or without treatement, starting an IV, or in this case an IO, even though it may not be used in the field isn't always wrong. Speaking specifically of an IO in a situation where an IV is unobtainable, there isn't anything wrong with placing it while enroute to the ER so that it can be used as a bridge, if needed, until better access is obtained.

This is really where knowing the capabilities of the hospitals you transport to comes into play. Ignoring any childish debates on whether or not a paramedic is better than a nurse at starting an IV and visa versa, just figure that if you can't, and have explored all options (feet, inner wrist, EJ) that they won't be able to either.

So where does that leave you? If the patient really is that high risk, they're either getting a central line, an unltrasound guided line (deep brachial), or maybe an IO (that that's less likely).

Neither of the first two are fast; to do a full sterile prep and drape for a central line (and I think the last time I saw a non-sterile central line started, even in an emergent situation, was over 10 years ago) takes time. To grab the ultrasound and find a suitable vein and access it takes time (less than a CVC if the operator is good).

So...taking 5-6 minutes while transporting to start an IO in a comfortable manner may be more than appropriate.

When done on appropriate patients and at appropriate times.

I'd say if individual paramedics can't figure out who and when that is they should quit...but then there would be far, far, far farfarfar fewer paramedics out there.

Wait...that's a good thing...

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You are called to a residence at 2000 hours for a patient experiencing chest pain.

 

Upon arrival, you enter the residence and find a 73 year old patient laying on his bed in obvious distress. The pt. is awake and alert. Describes 9/10 substernal chest pain of sudden onset. He has a history of triple bypass surgery and took one baby aspirin prior to your arrival. Pt. doesn't take any other meds regularly. He is diaphoretic and has a rapid, strong, radial pulse.

 

He is moved to the stretcher and expediently to the ambulance. V/S are taken and reveal 122/92, heart rate 160, respirations 16 nonlabored. Cardiac monitor is placed and V-Tach is shown on 

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