# Something Weird



## rockwood (Jul 1, 2010)

I'm a new emt... The other night my unit was called on a car wreck. No one was seriously injured and we got out patient into the ambulance without any trouble, the pt's vitals were fine 130\80 and a strong pulse around 80 or 90, and the patient was talking to us and responding to out questions and the pupils were fine, and then we re-took vitals and found that the patient's bp had dropped to 70\50 and at that same time the monitor showed us that the patient's pulse had dropped to around 60 and the patient when unresponsive after a few seconds, but after a sternal rub the patient came back and everything went back to normal. We were all weirded out by this and didn't really know what happened. It seemed like the patient passed out for a second. 

Does anyone know what could cause this?


----------



## Shishkabob (Jul 1, 2010)

Could have been a syncopal episode caused by a vasovagal stimulation of some kind.


----------



## mycrofft (Jul 1, 2010)

*HJAver you extricated him yet or waiting for our feedback?*


The sternal rub didn't affect the VS, that was coincidental or in errror.
Manual or machine VS's?


----------



## usafmedic45 (Jul 1, 2010)

> Could have been a syncopal episode caused by a vasovagal stimulation of some kind.



That's what it sounds like.  To the OP, this is one of the reasons we don't do rectal exams on trauma patients in the field.


----------



## rockwood (Jul 1, 2010)

well the sternal rub must have woken the paitent back up, i was just wondering what would cause someone to faint like that


----------



## usafmedic45 (Jul 1, 2010)

rockwood said:


> well the sternal rub must have woken the paitent back up, i was just wondering what would cause someone to faint like that


Actually more than likely, the sternal rub had nothing to do with waking him back up. Once people vagal down to the point of syncope, generally the stimulus goes away and the patient rapidly comes back to consciousness.


----------



## MrBrown (Jul 2, 2010)

Could be any one of 500 different things


----------



## lightsandsirens5 (Jul 2, 2010)

MrBrown said:


> Could be any one of 500 different things


 
Start listing them Brown........

I'm going to go with the majority opinion here and say they vageled out somehow.


----------



## mycrofft (Jul 2, 2010)

*Or the sternal rub did wake him up, but only because he was already recovering.*

Sometimes vitals are like cell phone snapshots, they can be taken at moments flattering or terrifying but a repeat will clear it up.


----------



## Fox800 (Jul 2, 2010)

Also, don't do sternal rubs. Ever. Unless you like being sued.

Pinching the trapezius, or a properly applied ammonia inhalant works wonders. Notice I said PROPERLY.


----------



## mar7967 (Jul 2, 2010)

Fox800 said:


> Also, don't do sternal rubs. Ever. Unless you like being sued.
> 
> Pinching the trapezius, or a properly applied ammonia inhalant works wonders. Notice I said PROPERLY.



I have been an EMT a little over a year...what is wrong with sternal rubs? That is what they teach in class (and yes, I know what they teach differs from how things are done in the field), but how can you get sued over a sternal rub?


----------



## Fox800 (Jul 2, 2010)

mar7967 said:


> I have been an EMT a little over a year...what is wrong with sternal rubs? That is what they teach in class (and yes, I know what they teach differs from how things are done in the field), but how can you get sued over a sternal rub?



Bruised sternum, broken ribs, etc. It's just not a good idea. There are much better alternatives.


----------



## Shishkabob (Jul 2, 2010)

Fox800 said:


> Bruised sternum, broken ribs, etc. It's just not a good idea. There are much better alternatives.



If you break a rib doing one, you're probably either doing it wrong or it's not your fault due to a bone problem. 


It's better to do something else that actually has an affect on the cns rather than the pns such as a trap squeeze.


----------



## mar7967 (Jul 2, 2010)

Linuss said:


> If you break a rib doing one, you're probably either doing it wrong or it's not your fault due to a bone problem.



My thoughts exactly


----------



## PrincessAnika (Jul 3, 2010)

it was once suggested to me to take a pen, put it perpendicular to the pts fingers, between the base of two of the fingers, and push the knuckles just above the pen together around the pen.  try it on yourself.  if it doesn't wake up the pt they most likely are truly out.

oh, and anybody ever uses an ammonia inhalant on me better have the intubation kit ready....you can't properly apply an ammonia inhalant to an unresponsive pt unless you know for sure and 100% certain they don't have any reactions to it...and how do you know that unless you ask them?  (i have asthma, btw, and ammonia inhalants are one of my bigger triggers - i accidentally broke one doing a rig check and had to use one of the neb setups -- and that was 2 ft away from my face AND i threw it out of the truck right away AND there was a strong breeze blowing away from the truck)


----------



## 8jimi8 (Jul 3, 2010)

Linuss said:


> If you break a rib doing one, you're probably either doing it wrong or it's not your fault due to a bone problem.
> 
> 
> It's better to do something else that actually has an affect on the cns rather than the pns such as a trap squeeze.



quoted for truth


----------



## 8jimi8 (Jul 3, 2010)

PrincessAnika said:


> it was once suggested to me to take a pen, put it perpendicular to the pts fingers, between the base of two of the fingers, and push the knuckles just above the pen together around the pen.  try it on yourself.  if it doesn't wake up the pt they most likely are truly out.



please do not brutalize your patients. use a trap squeeze.


----------



## Fox800 (Jul 3, 2010)

Linuss said:


> If you break a rib doing one, you're probably either doing it wrong or it's not your fault due to a bone problem.
> 
> 
> It's better to do something else that actually has an affect on the cns rather than the pns such as a trap squeeze.



Have fun explaining the sternal bruising. Pen trick, trap pinch, pen on knuckles > sternal rub.

The ol' OPA or NPA is a great tool for unresponsiveness, too. It also assists in airway patency.


----------



## 8jimi8 (Jul 3, 2010)

Fox800 said:


> Have fun explaining the sternal bruising. Pen trick, trap pinch, pen on knuckles > sternal rub.
> 
> The ol' OPA or NPA is a great tool for unresponsiveness, too. It also assists in airway patency.



except when it fills with vomit!


no one mentioned corneal reflex.  Great way to assess acceptance of an OPA too.


----------



## Fox800 (Jul 3, 2010)

8jimi8 said:


> except when it fills with vomit!
> 
> 
> no one mentioned corneal reflex.  Great way to assess acceptance of an OPA too.



Then you probably should have pulled it at the first sign of your patient not tolerating it.

Might I suggest an NPA w/lidocaine surgical jelly before an OPA, if you think your pt. might be "lightly" unconscious or faking, as opposed to jumping straight to an OPA?

It's uncanny how well it works.


----------



## 8jimi8 (Jul 3, 2010)

Fox800 said:


> Then you probably should have pulled it at the first sign of your patient not tolerating it.
> 
> Might I suggest an NPA w/lidocaine surgical jelly before an OPA, if you think your pt. might be "lightly" unconscious or faking, as opposed to jumping straight to an OPA?
> 
> It's uncanny how well it works.




I think you misunderstood what i meant.  My point was to assess corneal reflex before attempting an OPA.  Corneal reflex (-) pt should accept an OPA.


----------



## Fox800 (Jul 3, 2010)

8jimi8 said:


> I think you misunderstood what i meant.  My point was to assess corneal reflex before attempting an OPA.  Corneal reflex (-) pt should accept an OPA.



Sounds good.


----------



## PrincessAnika (Jul 3, 2010)

8jimi8 said:


> please do not brutalize your patients. use a trap squeeze.



since when does squeezing someone wake up a faker?  unless you are pinching, which leaves bruises....whereas the pen trick (from medic class - also can take the pen and push it against the base of the pts fingernail and "scrape" it off the finger) does not leave bruises and you don't have to apply very much pressure at all, to illicit any type of response if you are going to get one......i didn't realize that was considered brutalizing a pt.


----------



## 8jimi8 (Jul 3, 2010)

PrincessAnika said:


> since when does squeezing someone wake up a faker?  unless you are pinching, which leaves bruises....whereas the pen trick (from medic class - also can take the pen and push it against the base of the pts fingernail and "scrape" it off the finger) does not leave bruises and you don't have to apply very much pressure at all, to illicit any type of response if you are going to get one......i didn't realize that was considered brutalizing a pt.



pushing something hard against a small bone is a great way to break it.  Have you ever had anyone squeeze your trap?  There is no way someone can fake through it.  Do a corneal reflex, again there is no way that someone can extinguish their involuntary response.  You won't break any bones doing a trap squeeze or corneal reflex.  The first time you break someone's finger, or pull their nail off, will be when you believe me?


----------



## Fox800 (Jul 3, 2010)

PrincessAnika said:


> since when does squeezing someone wake up a faker?  unless you are pinching, which leaves bruises....whereas the pen trick (from medic class - also can take the pen and push it against the base of the pts fingernail and "scrape" it off the finger) does not leave bruises and you don't have to apply very much pressure at all, to illicit any type of response if you are going to get one......i didn't realize that was considered brutalizing a pt.



It's not brutalizing, unless you're doing it wayyyyyyyyy wrong. I learned the pen trick from my first partner, one of the best paramedics I know, been working for 20+ years.


----------



## PrincessAnika (Jul 3, 2010)

8jimi8 said:


> pushing something hard against a small bone is a great way to break it.  Have you ever had anyone squeeze your trap?  There is no way someone can fake through it.  Do a corneal reflex, again there is no way that someone can extinguish their involuntary response.  You won't break any bones doing a trap squeeze or corneal reflex.  The first time you break someone's finger, or pull their nail off, will be when you believe me?



i never said push HARD.....and anyone squeezes any muscle on me i bruise - i thought the object was not to leave marks?  i know i'm not the only one who bruises easily....to clarify, i get so much as poked in the arm and i bruise...lol


----------



## 8jimi8 (Jul 3, 2010)

Fox800 said:


> It's not brutalizing, unless you're doing it wayyyyyyyyy wrong. I learned the pen trick from my first partner, one of the best paramedics I know, been working for 20+ years.



Sorry i watched a neurologist doing it...  the patient didn't respond, so he did it harder... then harder... I was like... dude... let the propofol wear off.  The patient had blood blisters under her nails when he was done.

Sometimes you see one example and then extrapolate it to everyone.  My bad!  Please accept my apologies.  I haven't taken a class that has taught me about that technique yet and my only example was that neurologist... brutalizing the poor patient.


----------



## Fox800 (Jul 3, 2010)

8jimi8 said:


> Sorry i watched a neurologist doing it...  the patient didn't respond, so he did it harder... then harder... I was like... dude... let the propofol wear off.  The patient had blood blisters under her nails when he was done.
> 
> Sometimes you see one example and then extrapolate it to everyone.  My bad!  Please accept my apologies.  I haven't taken a class that has taught me about that technique yet and my only example was that neurologist... brutalizing the poor patient.



Damn...you'd have to be doing it HARD to make that happen.


----------



## alphatrauma (Jul 3, 2010)

Fox800 said:


> Damn...you'd have to be doing it HARD to make that happen.



That's what _she_ said.


----------



## Fox800 (Jul 3, 2010)

alphatrauma said:


> That's what _she_ said.



Snap. From Virgin-ia.


----------



## Sandog (Jul 3, 2010)

Fox800 said:


> Also, don't do sternal rubs. Ever. Unless you like being sued.
> 
> Pinching the trapezius, or a properly applied ammonia inhalant works wonders. Notice I said PROPERLY.



I was also taught not to do a sternal rub.


----------



## Fox800 (Jul 3, 2010)

Sandog said:


> I was also taught not to do a sternal rub.



There are varying degrees of Bad Idea. You might be able to get away with doing a sternal rub on a 20 year old male passed out drunk, doing a sternal on a 70 year old woman in a nursing facility who is genuinely comatose (and on warfarin, which you hadn't asked about yet) is a Very Bad Idea Indeed(TM).


----------



## Sandog (Jul 3, 2010)

Fox800 said:


> There are varying degrees of Bad Idea. You might be able to get away with doing a sternal rub on a 20 year old male passed out drunk, doing a sternal on a 70 year old woman in a nursing facility who is genuinely comatose (and on warfarin, which you hadn't asked about yet) is a Very Bad Idea Indeed(TM).



You have my full attention.


----------



## Fox800 (Jul 3, 2010)

Sandog said:


> You have my full attention.



Just throwing out a hypothetical. This hasn't happened in my presence, but I'm sure it easily could, and has happened somewhere out there. I'd like to witness hospital staff biting off the heads of an EMS crew who brings in a pt. with a bruised sternum.


----------



## Sandog (Jul 3, 2010)

Fox800 said:


> Just throwing out a hypothetical. This hasn't happened in my presence, but I'm sure it easily could, and has happened somewhere out there. I'd like to witness hospital staff biting off the heads of an EMS crew who brings in a pt. with a bruised sternum.



Agreed, Taking AVPU one step too far is not a good idea  I opt for less evasive methods.


----------



## reaper (Jul 3, 2010)

Funny, In 20 years I have yet to bruise a sternum or break a rib. Biggest thing is no one is ever taught how to do it correctly. You do not need to actually rub the sternum, all that you need to do it roll your knuckles on it. it is painful and does not do any damage.

There are many methods to test response and all can be bad, if done wrong. Learn the right ways and not injure the Pt's.


----------



## Sandog (Jul 3, 2010)

Reaper, you got a job, pull that tongue back in...


----------



## Sandog (Jul 3, 2010)

Reaper, you know that was a joke, right?


----------



## zmedic (Jul 3, 2010)

I'm not sure corneal reflex is the best thing to test, nor reflexes in general. You are looking for where the person is on AVPU and trying to get their GCS (and maybe wake them up). Someone can be in a coma and various reflexes are intact. If someone said the patient was responsive to pain based on a corneal reflex I would argue that all they have shown is that a corneal reflex is intact. Trap pinch is useful for seeing if the patient is faking or can be aroused, but one nice thing about more peripheral stimuli like the fingernail is that you can distinguish between withdrawing to pain and localizing to pain. Again, not a super important distinction pre hospital but nice to keep track of in the Unit.


----------



## PrincessAnika (Jul 3, 2010)

8jimi8 said:


> Sorry i watched a neurologist doing it...  the patient didn't respond, so he did it harder... then harder... I was like... dude... let the propofol wear off.  The patient had blood blisters under her nails when he was done.
> 
> Sometimes you see one example and then extrapolate it to everyone.  My bad!  Please accept my apologies.  I haven't taken a class that has taught me about that technique yet and my only example was that neurologist... brutalizing the poor patient.



ah well then yeah i can see that.  you dont have to do it hard for it to test or pain response tho.  take one fonger and press on another one on yourself, then slide the pressing finger off the nail -- thats all the pressure you need to do it properly.  if it doesnt work try once more but you dont keep going over and over again....that neuro should have to have that done to HIM.  idiot.


----------



## akrall83 (Jul 3, 2010)

Fox800 said:


> Just throwing out a hypothetical. This hasn't happened in my presence, but I'm sure it easily could, and has happened somewhere out there. I'd like to witness hospital staff biting off the heads of an EMS crew who brings in a pt. with a bruised sternum.



I've seen it. 97y/o female. Brand new EMT-b did a sternal rub and caused a massive skin tear on her chest. Thin skin and bad technique don't mix. Not the method I would have personally gone with, but as a phlebotomist I was not in a position to say anything. The medic, the nurse, and the doctor all took care of that though.


----------



## usafmedic45 (Jul 4, 2010)

> I'd like to witness hospital staff biting off the heads of an EMS crew who brings in a pt. with a bruised sternum.



I've seen it too.  I've also fired someone for being excessively forceful in regards to sternal rubs and overzealous in choosing when to use them.  The straw that broke the camel's back on this was a little old lady (family friend of mine actually) who ended up with a large skin tear and associated bruising and bleeding.  The EMT in question had to be escorted out of my office by the police.


----------



## Prophet (Jul 14, 2010)

has anyone tried the "drop test" where you pick up there arm and drop it on there face.  If it falls to the side they are faking it, if it falls smack on there face they arent.  Heard about it from an emt who goes to a lot of prison calls.


----------



## alphatrauma (Jul 14, 2010)

Prophet said:


> has anyone tried the "drop test" where you pick up there arm and *drop it on there face*.  If it falls to the side they are faking it, if it falls smack on there face they arent.  Heard about it from an emt who goes to a lot of prison calls.



This particular method has been called into question recently... and is now generally frowned upon.


----------



## Prophet (Jul 14, 2010)

I figured as much.  I was just curious if anyone else was actually doing that cuz it sounded like a lawsuit in the making. 
"Woh, what happened, I passed out...  why is my lip busted open?"


----------



## PrincessAnika (Jul 14, 2010)

alphatrauma said:


> This particular method has been called into question recently... and is now generally frowned upon.



agreed.  i've also seen pts playing the system who are able to pass the arm drop test with flying colors.  not reliable - there are much more reliable ways to test for playing the system....


----------



## MediMike (Jul 31, 2010)

Who wants to hear what the new guy has to say? Hahaha...

The trap squeeze has been called into question in many areas due to the risk of damaging the brachial plexus

Sternal rubs when performed PROPERLY are still acceptable in most areas (to my knowledge)

The pen between the fingers is a bad idea, a couple years ago some medics tried it on an elderly female with osteoperosis, had a lil' trouble explaining why the diabetic came in with fractured fingers

Pen + Fingernail on the other hand (hah! Get it? ) works quite well in my experience, but once again when performed PROPERLY.  You don't have to smash the poor patient's finger in half with it.

Sidenote...the hand drop technique will indeed prove "fakers"...but when that patient is wearing a big heavy watch and you're a brand new EMT...I wouldn't advise it


----------



## Jay (Jul 31, 2010)

Fox800 said:


> Then you probably should have pulled it at the first sign of your patient not tolerating it.
> 
> Might I suggest an NPA w/lidocaine surgical jelly before an OPA, if you think your pt. might be "lightly" unconscious or faking, as opposed to jumping straight to an OPA?
> 
> It's uncanny how well it works.



In Pennsylvania, NPA's are not indicated for use on a trauma patient, e.g. post-MVA. In this case if there was a question about airway, I would have used an OPA simply out of concern for the potential head trauma. Since the patient was A&O and would obviously have a gag reflex, airways are out anyway.

As for sternal rubs, same thing, what kind of trauma could be irritated from doing one? For one, you can take a piece of broken rib and push it into the lung causing a very bad situation very fast, or what if there is a AAA? Then it ruptures and again in a very bad situation.

Being that the BP dropped I would have been thinking shock, possibly that the patient was decompensating on me. I also didn't see any mention of O2 use which would have been my first precaution because of the many "what if's" that were unaccounted for any may not even be recognized until the patient is at the ER getting further diagnostic testing. I also would have been doing a secondary on the ambulance checking for bruising to exclude hypovolemic shock.

Being that the patient did "wake up" still wouldn't convince me that the patient was in the clear when it comes to shock because of the quick jolt of adrenaline that the patient would have had secondary to the pain from the sternal rub especially if there were other injuries involved that were yet to be diagnosed. Vasovagal stimulation is one possibility but there are several more things to rule out the way this newbie sees it


----------



## MediMike (Aug 1, 2010)

Jay said:


> As for sternal rubs, same thing, what kind of trauma could be irritated from doing one? For one, you can take a piece of broken rib and push it into the lung causing a very bad situation very fast, or what if there is a AAA? Then it ruptures and again in a very bad situation.



Unless you're mongo fireman weighing down on that sternum like you're doing CPR I really doubt there is a chance of pushing a broken rib into a lung lol, and an AAA? Abdominal Aortic Aneurysm?  Maybe a TAA  Even then you'd have to be whompin' on that chest

As someone else mentioned, a sternum rub is designed to cause irritation, so if you're applying enough pressure to depress the chest you're doing it waaaay too hard


----------

