Sternal Rubs/Painful Stimulus

[MasterIntubator]

Nasopharyngeal airway and an ammonia inhalent after the initial pain receptor checks. Simple diagnostics. B) 'tiss my motto

 

[Lifeguards For Life]

Nasopharyngeal airway and an ammonia inhalent after the initial pain receptor checks. Simple diagnostics. B) 'tiss my motto

haha. ouch

 

[VentMedic]

Nasopharyngeal airway and an ammonia inhalent after the initial pain receptor checks. Simple diagnostics. B) 'tiss my motto

Ammonia inhalants are still on your truck? Use with extreme caution not only for the patient's safety but also for any bystanders (including other EMS providers) who might be in the area. You may be doing multiple intubations. As well, seizures can also be an issue. Not too long ago there were two Paramedics who did have charges filed against them for abusing their patient with multiple ammonia inhalants. I believe the final ruling in that case was that they turned in their certifications and were allowed to receive probation instead of jail if they signed an agreement never to apply for any medical certification again.

Clinical Alert: Is My Patient Faking?
Bryan E. Bledsoe, DO, FACEP
March 2008 JEMS Vol. 33 No.

http://www.jems.com/news_and_articles/articles/jems/3303/clinical_alert_is_my_patient_faking.html

But what’s the point? The patient must still be treated and transported. From my experience, it seems the purpose of these so-called “tests” is to have an excuse to skip normal patient care and treat the patient with an air of indignity. This may destroy any trust the patient has in you as a health-care provider.

Think very carefully before you do something that can be considered abuse. Even placing an NPA in someone who does not require it but just for "diagnostics" may not be thought to be of the best clinical judgment.

 

[Two-Speed]

Why? Abuse is not something that should be ignored and kept quiet. Abuse is something people need to be aware of andneeds to be reported. This is a good example of how a providers action can be misinterperted.

What I'm saying, Sasha, is there was no abuse. If there had been abuse, I would have reported it, and I wouldn't have posted the story here.

 

[NomadicMedic]

Think very carefully before you do something that can be considered abuse. Even placing an NPA in someone who does not require it but just for "diagnostics" may not be thought to be of the best clinical judgment.

Amen Vent! At my service I'm known as the guy who chewed out a "partner" who was assessing responsiveness with the "hand drop test." (That EMT is no longer employed at that service.)

In King County, "noxious stimuli" is limited to an ear pinch or trap squeeze. I tend to like the "eyelash test"...but that's just me. In the past, when transporting an "unresponsive" patient, I've leaned over and whispered, "okay, we're in the ambulance now, you can open your eyes ..."

"Wha? Where am I?..."

Amazing! I've healed another one!

Patients that are TRULY unresponsive to pain don't flinch when I stick 'em with an 18. Most however, do. Even fakers get a ride to ER in my truck.

 

[Aidey]

Oh goodness, the nipple squeeze...I've seen an RN do that. Ouch.

I generally use the sternal rub or eyelash flick depending on the situation. On medical patients if they don't respond, they don't respond, whether they are faking doesn't have a big affect over all.

On Trauma patients it is much more important because if you activate the trauma team for a GCS of 10 post traumatic event and the pt is faking the charge RN will have your head on a pole on the front lawn.

A GCS under 13 in a trauma patient is an automatic activation. Not a full one, but they do activate part of the team.

 

[Aidey]

Oh, and Bledsoe's example of the patient with the leg jerking is a good one. I had a fire paramedic use and ammonia inhalant on a girl with CP and a hx of seizures who was having a simple partial seizure on the R side of her body. He stated she must be faking because she was still awake.

Unfortunately (or fortunately) one of their chief's stopped by as they randomly do and I never got a chance to have a discussion with the paramedic without the chief hearing it. While he would not have liked me telling him he's an idiot in private, he really would have been pissed with the chief there.

 

[Seaglass]

I agree with Bledsoe's point--fakers get transported too. I'm also pretty limited in what painful stimuli I can apply, but I don't think having more would be useful. With certain patients, simply saying "Hey, if you don't wake up and talk to me, we're going to the hospital," can be enough. So I start with that.

Amen Vent! At my service I'm known as the guy who chewed out a "partner" who was assessing responsiveness with the "hand drop test." (That EMT is no longer employed at that service.)

Not a fan of the hand drop test either. In addition to being potentially abusive, it can be misleading. Patients who are legitimately experiencing certain psych problems won't hit themselves when you do it--but that doesn't mean they can consciously control it, or that they don't need help. And I'd be a real dumb basic to say a possible stroke patient only has some kind of somatic issue...

 

[MasterIntubator]

Common sense applies to said methods, and if one does not possess such sense, maybe they should follow another field. I have seen NH3 inh. shoved in NRBs, in pts nares, etc.... and it is them that lack the sense and take it too far. ( I consider it... medicals way of weeding out the ones without such sense. ).
Gotta pick your diagnostics to match the pt, and document why you chose that method.

And yes... I still carry NH3 on the box.

 

[zmedic]

The real moral of the doc who almost got punched is to have a low threshold to restrain your patients. That patient needed restraints because either 1) they have a decreased level of responsiveness and may become combative, or 2) They are crazy and acting out or 3) they are just being jerks. In any case it's nice to put the hands in soft restraints especially when you suspect ETOH or drugs. We had soft restraints on our cots and it was really nice. Because it sucks when you are in the back of the rig alone when the 6' 4", 250lb dude decides to "wake up."

 

[VentMedic]

Let us not forget those who are in EMS with absolutely no sense at all and slam narcan.

 

[MasterIntubator]

agreed

 

[BLSBoy]

Hey Vent, wasn't it Bay County that killed a kid in Juvie with the amonia inhalants?
fcuk them, I LIKE my License and Certs.
Fakers get a ride, I'll let the ER staff use other methods.

 

[VentMedic]

Hey Vent, wasn't it Bay County that killed a kid in Juvie with the amonia inhalants?
fcuk them, I LIKE my License and Certs.
Fakers get a ride, I'll let the ER staff use other methods.

I can't remember which county but I hear their lawn service sucks as well. Something about lack of professionalism.

 

[BLSBoy]

Haha, I remember jail time, loss of licenses, jobs, etc was brought.

Only time I wanna be on the news is for something good. Not killing a pt.

 

[reaper]

It wasn't the inhalants that killed him. It was the beating and lack of medical care!

 

[VentMedic]

It wasn't the inhalants that killed him. It was the beating and lack of medical care!

That was another one which involved the guards and a nurse. I think the kid had asthma and wasn't running fast enough when they hit him with the ammonia inhalant.

We had another one at either Broward or Palm Beach County jail. Maybe both.

Hell we've had so many it is hard to keep track of all the "oops". They make ambulance chasing attorneys a good living.

 

[bunkie]

We were taught sternal rubs for initial response if the pt seemed unresponsive, if no response move on to pain pinch.
So should I be skipping the rub all together?

 

[NomadicMedic]

We were taught sternal rubs for initial response if the pt seemed unresponsive, if no response move on to pain pinch.
So should I be skipping the rub all together?

Depends on what is accepted practice where you are working.

 

[R.O.P.]

At my service I'm known as the guy who chewed out a "partner" who was assessing responsiveness with the "hand drop test." (That EMT is no longer employed at that service.)

OK, I feel like I'm setting myself up, but I have to ask...
What's wrong with the hand drop test? I mean, as long as you use another test for responsiveness as well?