# Sternal rub... who's doing it?



## OnceAnEMT (Mar 28, 2015)

I was taught coming out of school that, "based on evidence" (which I to this day have never seen), the sternal rub is being phased out because of lasting injury to the sternum from test after all receiving providers in the chain of care have done it. I don't see EMTs in my area do it, but I see nurses and docs do it in the ED all the time (you know, when indicated). So I'm curious, who still uses this in practice? Any arguments either way?


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## Brandon O (Mar 28, 2015)

Meh. I pinch traps. A bit better diagnostically too.


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## COmedic17 (Mar 28, 2015)

I will do the sternal rub, pinch trap, squeeze finger nail, whatever is most convenient at the time.


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## teedubbyaw (Mar 28, 2015)

Trap pinch works better IMO. Don't be afraid to clamp down on them.


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## azbrewcrew (Mar 28, 2015)

Depends on the acuteness of their ETOH. If they are being toolbags they get a deep sternal massage


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## DrParasite (Mar 28, 2015)

I've been told it is frowned upon, because it can aggravate a person who has a sternal injury. 

Then again, I have been told that ammonia inhalants are being phased out of EMS too, yet they are common place in the ER.

Personally, I prefer a finger pinch than a sternal rub.


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## teedubbyaw (Mar 28, 2015)

DrParasite said:


> I've been told it is frowned upon, because it can aggravate a person who has a sternal injury.
> 
> Then again, I have been told that ammonia inhalants are being phased out of EMS too, yet they are common place in the ER.
> 
> Personally, I prefer a finger pinch than a sternal rub.



We carry ammonia


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## STXmedic (Mar 28, 2015)

I prefer the trap squeeze or forceful rotation of the lateral pectoris (okay, it's basically a "titty twister"). Many people don't impart enough force on the sternal rub, and it's midline pain which can confuse localization with withdrawal. The finger pinch can utilize reflex arcs. The two former are both central, yet lateral of midline, and are very easy to create a painful response.


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## DesertMedic66 (Mar 28, 2015)

STXmedic said:


> I prefer the trap squeeze or forceful rotation of the lateral pectoris (okay, it's basically a "titty twister"). Many people don't impart enough force on the sternal rub, and it's midline pain which can confuse localization with withdrawal. The finger pinch can utilize reflex arcs. The two former are both central, yet lateral of midline, and are very easy to create a painful response.


"Patient had a withdraw of pain from a titty twister, a purple nurple was preformed to confirm findings"


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## LACoGurneyjockey (Mar 28, 2015)

Next time I do painful stimuli I'm going with the forceful rotation of the lateral pectoris 
But around here sternal rubs are pretty much the standard painful stimuli


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## OnceAnEMT (Mar 28, 2015)

Personally I am a trap pinch kind of guy. If I think (usually know based on hx from PD or Fire) the Pt is faking I put their hand up over their face and release. I have never seen someone fake their way out of that beauty. 

Ah ammonia salts. I have seen them used once in the ED, per doc request when a sternal rub (which made its way to sternal punch) failed. I was surprised when someone actually knew they existed and gof them. It worked, too. First time I have seen it first hand. 

@azbrewcrew , hopefully joking about patient abuse is just funny to you, and not something you practice.


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## azbrewcrew (Mar 28, 2015)

Yes it was a satirical comment. Just coming off a 24 full of nothing but drunks and psychs. I take my duties as a clinician seriously


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## NomadicMedic (Mar 28, 2015)

Yep. Trap squeeze is my go to. I saw a guy's chest in the ED the day after a narcotics OD and few sternal rubs from the first responders. He was pretty torn up.


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## Brandon O (Mar 28, 2015)

The only caveat to the "Vulcan nerve pinch" is that it's not intrinsically the most noxious stimulus, so you do need to give it some good force, and if someone doesn't respond consider confirming with other maneuvers. I've been embarrassed to think a patient was totally unresponsive and have them wake up when they were moved to the ED bed or a medic gave them a pink belly or something.


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## Kevinf (Mar 28, 2015)

I've watched yelling, sternal rubs, trap pinch, lobe pinch, and nail pinch all fail on a patient who was in fact... sleeping. That's a heavy sleeper right there, he had two EMTs, an RN, and a Doc all sweating 

One of my partners has scars on her chest from where a medic did a sternal rub with his ring on years ago. I'm pretty sure she said he managed to break something as well. She's still pissed at him. So I'm not a fan of the sternal rub. Stick to soft tissue.


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## RebelAngel (Mar 28, 2015)

We don't do smelling salts. We do sternum rub for painful stimulus or hand drop test if we think patient may be faking. For babies we flick bottom of feet.


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## RedAirplane (Mar 28, 2015)

One stimulus that I was taught was: put a pen between the index and middle fingers (perpendicular to the fingers) then force the fingers together.


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## LACoGurneyjockey (Mar 28, 2015)

RebelAngel said:


> We don't do smelling salts. We do sternum rub for painful stimulus or hand drop test if we think patient may be faking. For babies we flick bottom of feet.



Any reason more places aren't using ammonia inhalants? They work like a charm provided you're not being a **** about it.


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## Brandon O (Mar 28, 2015)

LACoGurneyjockey said:


> Any reason more places aren't using ammonia inhalants? They work like a charm provided you're not being a **** about it.



They've been associated with harm. Plus a lot of people were being ****s about it.


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## TrueNorthMedic (Mar 28, 2015)

I do the trap pinch. I think it's the most effective, plus when there's bystanders around, a trap pinch can be done many times without them (bystanders) knowing what you are doing. Versus grinding away on some guys chest with your knuckles.


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## NomadicMedic (Mar 28, 2015)

The day you do a hand drop test on a legit unconscious patient and break their nose, you'll stop that nonsense.


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## Chewy20 (Mar 28, 2015)

Ishan said:


> One stimulus that I was taught was: put a pen between the index and middle fingers (perpendicular to the fingers) then force the fingers together.


 
Please tell me you're joking, or at least don't practice that in the field...Painful, sure, but if I see someone wasting there time doing that I would call them out on it


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## OnceAnEMT (Mar 28, 2015)

DEmedic said:


> The day you do a hand drop test on a legit unconscious patient and break their nose, you'll stop that nonsense.



 Probably true, but I'm not saying use it as a replacement to sternal rub or trap pinch, I'm saying use it when its already clear the patient is malingering in order to be able to say "Gotcha. Now stop playing games."

I've heard of the pen between the fingers. Read somewhere that it is too peripheral to assert the appropriate pain response, but I didn't quite get that. Trap pinch requires less resources (read: pen), so there is my go-to.


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## Brandon O (Mar 28, 2015)

I think a bit much has been made in the past of the hand-drop, although it can unquestionably be abused. Certainly though it should only be done with your other hand over the face to catch if it turns out to be positive.


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## Jim37F (Mar 28, 2015)

Ishan said:


> One stimulus that I was taught was: put a pen between the index and middle fingers (perpendicular to the fingers) then force the fingers together.


 This is one of the only two officially approved methods for testing painful stimulus response in my county. The other is the fingerbed nail pinch. I've pretty much always used the latter as it's simply, well, simpler lol (and easier to do, just grab and pinch)



DEmedic said:


> The day you do a hand drop test on a legit unconscious patient and break their nose, you'll stop that nonsense.


 Though I have seen someone do this method once before...and their hand landed smack right on their (the patient's) face. D'oh.


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## NomadicMedic (Mar 28, 2015)

Here's the thing, why do you care if they're pretending?

If they want to fake unconsciousness, more power to them. 

Vital good, all diagnostics negative, but you "think" they're faking? Leave em alone. It's a more mellow ambulance ride for you.


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## chaz90 (Mar 28, 2015)

DEmedic said:


> Here's the thing, why do you care if they're pretending?
> 
> If they want to fake unconsciousness, more power to them.
> 
> Vital good, all diagnostics negative, but you "think" they're faking? Leave em alone. It's a more mellow ambulance ride for you.


Pretty sure I've had that patient at 108. Several times.


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## Carlos Danger (Mar 28, 2015)

I do sternal rubs but I use the pads of my fingers instead of my knuckles.


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## Kevinf (Mar 28, 2015)

http://www.ems1.com/ems-products/ed...Misinterpreting-the-Results-of-a-Sternal-Rub/


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## Kevinf (Mar 28, 2015)

http://www.ems1.com/ems-products/ed...eting-a-Peripheral-Painful-Stimulus-Response/


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## Angel (Mar 29, 2015)

It depends on the situation but I've used sternal rub, trap pinch, hand drop test and another one.

Whatever is most appropriate and convenient is usually what gets done. We are another place that doesn't use ammonia tabs but the ER does.


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## squirrel15 (Mar 29, 2015)

LACoGurneyjockey said:


> Any reason more places aren't using ammonia inhalants? They work like a charm provided you're not being a **** about it.


Does popping one and asking your partner who is driving, "does this smell bad?" As you lift to their face count?


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## Handsome Robb (Mar 29, 2015)

DEmedic said:


> Here's the thing, why do you care if they're pretending?
> 
> If they want to fake unconsciousness, more power to them.
> 
> Vital good, all diagnostics negative, but you "think" they're faking? Leave em alone. It's a more mellow ambulance ride for you.


My thoughts exactly.

You want to fake unconsciousness? Sweet deal. Means I can sit back and do my paperwork. Always nice being finished with your PCR by the time you arrive at the ER minus inputting the MR number, room number and receiving staff member.

I had another crew tape ammonia inhalants to my brake pedal then color the tape black one day. Was not a happy camper when I hit the breaks coming off the freeway emergent. I have no idea where they even got them from, we don't use them.


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## Chris07 (Mar 29, 2015)

Handsome Robb said:


> Always nice being finished with your PCR by the time you arrive at the ER



I love being in that situation.


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## cruiseforever (Mar 29, 2015)

Watched an ER Dr. twist a male pt.'s nipple.  She was unable to get a response from him using some of the other methods.  When the Dr. twisted the nipple, pt. yelled out and started swearing at her.


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## Shishkabob (Mar 30, 2015)

"Doing lasting damage" is not an issue.

Some people don't do sternal rubs because it will garner no response from some people that can otherwise respond to other stimuli such as trap squeezes or eye flicking.  I still do them, and do them often as my first physical stimuli.


Honestly, some people just don't do it right.  You don't go all EMT-student on the patient and give them a massage, you pull an ER-doc and lay some weight in to it.


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## redundantbassist (Mar 30, 2015)

cruiseforever said:


> Watched an ER Dr. twist a male pt.'s nipple.  She was unable to get a response from him using some of the other methods.  When the Dr. twisted the nipple, pt. yelled out and started swearing at her.


Had a former partner that regularly used the nip twist, definitely more effective than the sternal rub.


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## Angel (Mar 31, 2015)

A nipple twist just seems inappropriate to me.


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## ghost02 (Mar 31, 2015)

Angel said:


> A nipple twist just seems inappropriate to me.



I'm with you on that one.


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## hogwiley (Mar 31, 2015)

Like someone else said, I do whatever is convenient at the time, which is usually a sternal rub. I had to laugh when an idiot partner I had tried a sternal rub on someone and then shook his hand and said ow that hurt. I told him well I guess we established you're responsive to pain anyway.


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## MonkeyArrow (Mar 31, 2015)

And with the nipple twist or the sternal rub, I'd be more than careful not to employ such pain response stimuli on females.


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## RebelAngel (Mar 31, 2015)

DEmedic said:


> The day you do a hand drop test on a legit unconscious patient and break their nose, you'll stop that nonsense.


The EMS professional that actually let's the hand fall on PT shouldn't be in EMS.


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## PotatoMedic (Mar 31, 2015)

I have been lucky in that I have only had a hand full of fake unconscious patients.  And I have decided that the next one I get gets an OPA attempt.  (You know airway management).  OK maybe not but boy will I be thinking about it.


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## NomadicMedic (Mar 31, 2015)

RebelAngel said:


> The EMS professional that actually let's the hand fall on PT shouldn't be in EMS.



But they are. And this bs continues.


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## gotbeerz001 (Mar 31, 2015)

FireWA1 said:


> I have been lucky in that I have only had a hand full of fake unconscious patients.  And I have decided that the next one I get gets an OPA attempt.  (You know airway management).  OK maybe not but boy will I be thinking about it.


I have used the NPA. No sense in unnecessarily causing them to puke.


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## PotatoMedic (Apr 1, 2015)

gotshirtz001 said:


> I have used the NPA. No sense in unnecessarily causing them to puke.


Oh!  Ethical conundrum solved!


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## Tigger (Apr 1, 2015)

FireWA1 said:


> I have been lucky in that I have only had a hand full of fake unconscious patients.  And I have decided that the next one I get gets an OPA attempt.  (You know airway management).  OK maybe not but boy will I be thinking about it.


Why would you want to do that?


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## PotatoMedic (Apr 1, 2015)

Kidding.  I do believe in do no harm, but I will admit I have thought about doing so.  I'm not a big fan of walking up to a door hearing two people talking.  Then when we are let in there is one conscious person and one obviously "unconscious."  Why?  Because the conscious person said the patient must go to Harborview (three hospitals away) only to get off our stretcher in the ambulance bay and walk away yelling thanks for the ride.


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## gotbeerz001 (Apr 1, 2015)

FireWA1 said:


> Kidding.  I do believe in do no harm, but I will admit I have thought about doing so.  I'm not a big fan of walking up to a door hearing two people talking.  Then when we are let in there is one conscious person and one obviously "unconscious."  Why?  Because the conscious person said the patient must go to Harborview (three hospitals away) only to get off our stretcher in the ambulance bay and walk away yelling thanks for the ride.


Meh. It's easier (and better) not to care too much. If someone wants to play games, just scoop, drop and cut your paper quickly.


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## gnosis (Apr 10, 2015)

I've found the supraorbital notch handy in some situations. I've never even heard of the hand drop test. Sounds kind of odd.


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## Carlos Danger (Apr 10, 2015)

gnosis said:


> I've never even heard of the hand drop test. Sounds kind of odd.



It is odd. It is based on some odd reasoning that supposes that a fully alert frequent flyer who wishes to feign unresponsiveness - and who is presumably aware of the standard tests for such - will somehow not think to allow his hand to contact his face when it is dropped from a few inches above.....even after enduring other, much more painful stimuli.


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## RebelAngel (Apr 12, 2015)

EMS did sternum rub on my 17yo daughter last night. Two sets, one from FD and one set from ambulance service. She had chest pain from it earlier but she's fine now. It was really the only thing she responded to.

We think she was having reaction to new medication, in case anyone was curious.


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## NYBLS (Apr 13, 2015)

How often is everyone having someone who is truly faking it? While I agree it does happen with how often people are talking it almost seems commonplace. Maybe you should be believing these patients are unconscious instead of trying to prove they are "faking it." Its the same workup either way.


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## medicsb (Apr 13, 2015)

I used to encounter folks faking seizures with enough regularity that it came to a point that I'd always consider that it may be fake.  Same with unconsciousness, I had enough either just not wanting to respond or just faking for one reason or another that it was something that I would consider.  

I still do sternal rubs (but have begun squeezing the trapezius) and I do on occasion do the hand drop (though I make sure to avoid the nose in case they either know the trick OR if they're actually unconscious).  I have seen and done a lot of sternal rubs and have yet to see anything that would persuade me from doing it again.  

My practice in EMS was to treat them as legit even if they failed the hand drop and I couldn't get them to "wake up", which would mean I'd place a NPA, start an IV, check a blood sugar, and ride with them to the hospital.  Usually the NPA would wake them up or they would turn their head back and forth to which I'd stop.  

I do think it okay to consider malingering, etc., and employ some tests to check for it, but ALWAYS default to treating them as if they are legitimately unconscious even if you think for sure they are malingering.


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## OnceAnEMT (Apr 13, 2015)

medicsb said:


> I do think it okay to consider malingering, etc., and employ some tests to check for it, but ALWAYS default to treating them as if they are legitimately unconscious even if you think for sure they are malingering.



Completely agree. CYA all around.


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## ERDoc (Apr 13, 2015)

I agree that in the field it may not make much of a difference if it is true/fake unresponsiveness (assuming normal blood sugar, etc), but once you bring the pt to the ER, it will help us determine what kind of work up to procede with.  I'd rather not irradiate someone who is faking it, especially if they have had multiple CTs in the past.  I wouldn't recommend using any of the above tests to see if someone is truly unresponsive or not, but if you are questioning if it is realy, then these tests can be helpful, although I would never encourage the nipple twist since there are so many other, but just as obnoxious stimuli you can use (in 24 years, I have never used it).


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## NYBLS (Apr 14, 2015)

Grimes said:


> Completely agree. CYA all around.



I don't believe its a CYA thing, I believe it is good patient care.


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## Altered Mental Status (Apr 14, 2015)

azbrewcrew said:


> Depends on the acuteness of their ETOH. If they are being toolbags they get a deep sternal massage



Ugh. That's sh*tty.


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## azbrewcrew (Apr 14, 2015)

Altered Mental Status said:


> Ugh. That's sh*tty.


Sarcasm doesnt translate well on the Internet


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## TheLocalMedic (Apr 15, 2015)

I like the hand drop test when I'm trying to work out if they're faking it.  I can't imagine that they would hurt themselves if their hand hit their face, just not enough force there to break their nose unless you're flinging their hand down on them.  Gotta be sure you do it right though, I've seen it happen where the angle of their arm will naturally allow their hand to move and miss them as it falls, so you gotta line it up right.  

We get a fair number of HP (hispanic panic) calls here where a family member is feigning unconsciousness for whatever reason, so I get to practice this one quite a bit.  

Another good pressure point is right behind the ear at the angle of their jaw.


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## Carlos Danger (Apr 15, 2015)

TheLocalMedic said:


> I like the hand drop test when I'm trying to work out if they're faking it.  I can't imagine that they would hurt themselves if their hand hit their face, just not enough force there to break their nose unless you're flinging their hand down on them.  Gotta be sure you do it right though, I've seen it happen where the angle of their arm will naturally allow their hand to move and miss them as it falls, so you gotta line it up right.
> 
> We get a fair number of HP (hispanic panic) calls here where a family member is feigning unconsciousness for whatever reason, so I get to practice this one quite a bit.
> 
> Another good pressure point is *right behind the ear at the angle of their jaw.*



Which one - behind the ear, or at the angle of the jaw?


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