The Ability of Paramedics to Accurately Locate Correct Anatomical Sites for Intraosseous Needle Insertion

Introduction Intraosseous (IO) access is an alternative to peripheral intravenous access, in which a needle is inserted through the cortical bone into the medullary space using either a manual driver or an electric drill. Although studies report high success rates of IO access, failures are often attributed to incorrect site placement due to failure to adhere to anatomical landmarks. This study was designed to evaluate the ability of paramedics to locate the correct anatomic location for IO needle insertion. Methods Participants were paramedics who were recruited at Pennsylvania’s annual statewide Emergency Medical Services (EMS) conference. After completing a demographics survey which included information about their training and practice environment, they were asked to identify which IO sites were permitted for IO placement using the EZ IO® drill and to place a sticker at those locations on a human volunteer. A transfer sheet was utilized, and the distance between the participants' sticker and the location as marked by a physician board-certified in both Emergency Medicine and Emergency Medical Services was recorded. Descriptive statistics and t-tests were calculated from the records. Results Of 30 paramedics who participated in the study, 25 (83%) had been in practice for more than five years (range: 1-37 years), 13 (46%) reported running more than 20 calls per week, and 23 (79%) reported that they only or mostly provide 9-1-1 EMS response. Ten (36%) participants were currently certified in PHTLS, and 16 (57%) had previously been PHTLS certified. All participants reported having been trained in IO insertion. Seventeen (57%) reported having utilized an IO ≤10 times in the field, and 13 (43%) reported >10 field IO insertions. When asked to identify appropriate IO insertion sites for the EZ IO drill, 26 paramedics (90%) correctly identified both the proximal humerus and proximal tibia. The average distance from the landmark for the humeral insertion site was 5.06 cm, with a statistically significant difference in the means for those who did and did not rotate the arm internally before identifying the humeral IO insertion site (p < .01). The average distance from the landmark at the tibial insertion site was 4.13 cm. Conclusion Although a high percentage of paramedics were able to verbally identify the correct location for IO placement, fewer were able to locate the insertion site on a human volunteer. Our results suggest a need for hands-on refresher training to maintain competency at IO insertion, as it is a rarely utilized procedure in the field.