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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...