# Sternal Rubs/Painful Stimulus



## Sasha

A couple good articles on sternal rubs and painful stimulus. I know a lot of people don't like sternal rubs, and I know I generally don't do a sternal rub for 30 seconds. 

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


> When assessing a patient who is not alert and does not respond to verbal stimuli, a painful stimulus may be applied to the body. The sternal rub is the most common stimulus practiced out in the field. However, it is possible to misinterpret the patient’s response to the stimuli depending on the duration the pressure is applied.
> 
> Response to the stimulus is used to make assumptions about the integrity of the brain and its function. If the patient responds to the pain with what is interpreted as purposeful movement, it is assumed that the brain received the impulse, was able to interpret it, and responded with some degree of a correct response.
> 
> If the patient does not respond, it is assumed the brain either did not receive the impulse or was unable to interpret the stimulus. If the brain is unable to interpret the painful stimulus and send out a correct response, one would think that its integrity is compromised and the patient is at grave risk for losing vital functions. Thus, a patient who does not respond to a painful stimulus would be thought to be critically ill or injured.



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


> Emergency medical service personnel often work under conditions that can be best described as “extremely uncontrolled.” Under these conditions, patient assessment is expected to be conducted in a rapid manner, in order to collect as much history and physical exam information as possible.
> 
> This information is used during the critical thinking process to develop a differential field diagnosis. Further assessment and emergency care is based on the differential field diagnosis; thus, the information collected must be as accurate as possible. Inaccurate information can lead to improper care. However, the results of the exam may not always provide the most accurate information.
> 
> Last month’s column discussed the possible misinterpretation of a sternal rub response in a patient with an altered mental status. In addition to the sternal rub, there are a few other situations where the results from a physical exam conducted on a patient with an altered mental status may be misinterpreted.


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## BLSBoy

I prefer the eyelid flick first. If no response, then go to sternal rub. 5 sec, max. No response, then yea, priority. 
Why?
Most normal pts would NOT have such a reaction to that. 
Other stimulus such as foot flick (run a pen up the instep), watching pain when you start an IV can judge. 

I kinda disagree with the 30 sec rub. That seems overbearing and could cause further injury to the pt.


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## CaLiEMT

i was taught to put a pen light between the fingers and squeeze. Any one ever try that?


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## Lifeguards For Life

CaLiEMT said:


> i was taught to put a pen light between the fingers and squeeze. Any one ever try that?



There are two different types of painful stimuli: central and peripheral. Central stimuli are applied to the core of the body; whereas, pain applied to the extremities is considered peripheral stimuli. In 1974, neurology professors Graham Teasdale and Bryan J. Jennett suggested using fingernail pressure as a form of peripheral painful stimuli to determine if a response is present. A central painful stimulus is then applied to assess for localizing, or the patient's ability to attempt to remove the stimulus. More current literature suggests caution when applying and interpreting the results of peripheral stimuli. When pain is applied to the fingernail bed, lower legs or elsewhere in the periphery, it might elicit a spinal reflex response. That is, the pain impulse travels via a sensory nerve tract to the spinal cord, where it is immediately turned around by a spinal reflex and sent out via a motor nerve tract to the muscle of that extremity, causing the patient to move. The movement may be withdrawal, where the patient pulls the finger or distal extremity away from the painful stimulus, which is interpreted as localizing the pain. Since the impulse was never transmitted to the brain and interpreted by the cerebrum, what appears to be purposeful movement is not a positive indication of cerebral function, but only an indication of intact peripheral nerve tracts. Thus, be skeptical of withdrawal or localizing effects when painful stimulus is applied to the extremities.


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## Sasha

CaLiEMT said:


> i was taught to put a pen light between the fingers and squeeze. Any one ever try that?



The pen thing is periphereal stimulation. Stick to the core.


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## Lifeguards For Life

Sasha said:


> The pen thing is periphereal stimulation. Stick to the core.



SASHA!


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## VentMedic

Even patients with brain death will have responses from the spinal reflexes including a painful stimuli to the plantar region. However, if the response is interpreted as purposeful or there is some grimace in facial expression, all you may have done is a coma score to determine the level of cognitive function and not really if the patient is faking being unconscious.


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## Sasha

Lifeguards For Life said:


> SASHA!



You sniped me. With a much better post. Stupid phone. Boo for forgetting laptop.


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## RyanMidd

We were taught the core vs peripheral idea, but the actual "painful/tactile stimulus" was up to us.

Trap-pinch always seemed a little more humane, both for the patient, and for onlookers.


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## Shishkabob

Why not just give a noogie?


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## Pyromedic

Pinch the finger seemed better, less chance for bruising.


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## Lifeguards For Life

Pyromedic said:


> Pinch the finger seemed better, less chance for bruising.



bruising is the least of their worries


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## EMSLaw

We were told repeatedly in my EMT-B class that the sternal rub is no longer considered best practice, and we should pinch the neck or earlobe or the skin over the clavicle instead.


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## MSDeltaFlt

I hardly ever use a sternal rub anymore, not because I'm afraid of it causing bruises, but because it just doesn't work. Trap pinch either. Pts who want will tolerate all kinds of painful stimuli.  I've left bruises on pts who would get discharged because they had no illness or injury.  They just didn't want to respond to anything. 

However, if you try to piss them off, you will generally get a response.  The way I do it is to gently to moderately tap on the eyes, nose, and mouth.

I've lost count how may times doctors preparing to intubate a pt due to no response from sternal rubs/trap pinches would rethink their strategy after I would mess with the pts' faces like that.


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## Two-Speed

I've only ever seen a sternal rub done on a post-dictal frequent-flyer with a history of being uncooperative, abusive to paramedics, and oftened faked being unresponsive, so the doc used the rub to see if he was conscious or faking or not...End result, doctor almost got punched in the head.


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## VentMedic

Two-Speed said:


> I've only ever seen a sternal rub done on a post-dictal frequent-flyer with a history of being uncooperative, abusive to paramedics, and oftened faked being unresponsive, so the doc used the rub to see if he was conscious or faking or not...*End result, doctor almost got punched in the head.*


 
If the intent was to abuse the patient,  the doctor should have expected it.


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## Two-Speed

VentMedic said:


> If the intent was to abuse the patient,  the doctor should have expected it.





The intent was to check for consciousness, because he very well could have been out like a light, he seemed rather unconscious and unresponsive to everyone in the room.  I most certainly wouldn't have posted the story if the doctor had done it to abuse the patient. 

But like I said, the patient had a history of abuse to paramedics and ER staff, so it was expect he would react like that.


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## VentMedic

Two-Speed said:


> The intent was to check for consciousness, because he very well could have been out like a light, he seemed rather unconscious and unresponsive to everyone in the room. I most certainly wouldn't have posted the story if the doctor had done it to abuse the patient.
> 
> But like I said, the patient had a history of abuse to paramedics and ER staff, so it was expect he would react like that.


 
You still don't know the INTENT of the doctor.  Your post also confirms whoat might have been the actual INTENT.


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## Two-Speed

VentMedic said:


> You still don't know the INTENT of the doctor.  Your post also confirms whoat might have been the actual INTENT.



I think we should probably agree to disagree on this one.  I will admit that I didn't know the intent the doctor had, but I'm giving him the benefit of the doubt due to the pt's  perceieved level of consciousness.  If I knew for a fact it was abuse, I wouldn't have posted it.


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## Sasha

Two-Speed said:


> I think we should probably agree to disagree on this one.  I will admit that I didn't know the intent the doctor had, but I'm giving him the benefit of the doubt due to the pt's  perceieved level of consciousness.  If I knew for a fact it was abuse, I wouldn't have posted it.



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.


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## MasterIntubator

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


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## Lifeguards For Life

MasterIntubator said:


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



haha. ouch


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## VentMedic

MasterIntubator said:


> 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.


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## Two-Speed

Sasha said:


> 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.


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## NomadicMedic

VentMedic said:


> 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.


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## 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.


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## 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.


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## 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.



n7lxi said:


> 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...


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## 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.


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## 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."


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## VentMedic

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


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## MasterIntubator

agreed


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## 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.


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## VentMedic

BLSBoy said:


> 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.


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## 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.


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## reaper

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


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## VentMedic

reaper said:


> 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.


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## 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?


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## NomadicMedic

bunkie said:


> 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.


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## R.O.P.

n7lxi said:


> 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?


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## reaper

Have seen way to many unresponsive pt's come in with bloody noses, from it!


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## Seaglass

R.O.P. said:


> 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?



Several reasons. For one, being hit by your own dropped hand can actually hurt. I heard of one guy who did it on a patient who was wearing a big heavy watch, which cut him. Even if it doesn't leave a mark, it can still be considered abuse. There are painful stimuli that don't carry that risk. 

More importantly, even if patients don't hit themselves, EMT's are likely to treat them as fakers even when that may not be the case. For instance, people with certain problems may not be able to consciously control that limb, even though they won't hit themselves. They still need help. 

It also can't really tell fakers from not--some fakers know the trick, and will let themselves be hit. In that, it's not different from most other tests which assess responses which are well within a patient's control. 

Most importantly, do you want to be the one who says "not a stroke" and doesn't transport to a stroke center when maybe you really didn't drop the hand directly over their face? I sure don't. 

Past a certain point, as Bledsoe says, it doesn't matter if they're faking. They're still going. I'm going to assume the worst case and let the ED sort it out...


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## Lifeguards For Life

BLSBoy said:


> 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.





> Although it’s not an EMS story, another highly publicized case points out the problems with ammonia inhalants. In Panama City, Fla., a 14-year-old boy was admitted to a community juvenile boot camp after stealing his grandfather’s car. The boot camp was designed to get young offenders on the right track before they end up in the prison system. The teenager, Martin Lee Anderson, wasn’t keeping up on the initial morning run that the detention officers were monitoring.
> 
> When he fell down, several detention officers and a boot camp nurse began to break ammonia inhalants, hold Anderson down and cup the inhalants around his nose. They continued this until they used at least five or six inhalants—over a five to six minute interval—all caught on videotape. Anderson never got up. CPR was started, and he was taken to a community hospital, where he died.
> 
> It was later determined Anderson had sickle cell trait—a condition that decreases the amount of oxygen carried in the blood. After the incident, Florida Governor Jeb Bush ordered the state’s attorney in Tampa to investigate. Although the initial autopsy in Panama City found that Anderson had died of “natural causes,” the second autopsy in Tampa found that Anderson died of asphyxia due to repeated ammonia inhalation. Florida ended up paying the Anderson family $5 million.



Clinical Alert: Is My Patient Faking?
Bryan E. Bledsoe, DO, FACEP
http://www.jems.com/news_and_articles/articles/jems/3303/clinical_alert_is_my_patient_faking.html


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## RescueYou

Me personally...
Central- sternum or spinal rub, but not for 30secs. 
Peripheal- pin in the instep, pinch the anterior part of the wrist

Checking for consciousness: I flick the eyelids or if you're pretty sure they are faking, take their hand and drop it over their face. No conscious pt will hit themselves in the face unless they're a frequent flyer...it's also funny to talk to your other EMT and be like "hmmm...unconscious...looks like it's time for an IV (or OPA), etc"


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## reaper

Spinal rub?


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## RescueYou

reaper said:


> Spinal rub?



I haven't used it but once...
Pending no spinal injury of course...

You can rub your knuckles up and down the spinal cord in the thoracic section and get a painful response sometimes.


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## VentMedic

Finally...I can log in again!



RescueYou said:


> Me personally...
> Central- sternum or *spinal rub*, but not for 30secs.
> Peripheal- pin in the instep, pinch the anterior part of the wrist


 


RescueYou said:


> I haven't used it but once...
> Pending no spinal injury of course...
> 
> You can rub *your knuckles up and down the spinal cord in the thoracic* section and get a painful response sometimes.


 
What about osteoporosis? Even a young man or women can have calcium depletion to make bones brittle for a variety of reasons. Or the young asthmatic or COPD patient who has been on corticosteroids? 

What happens when YOU make them a spinal injury patient?

Are you going to charge extra for the chiropractic adjustment? Talk to any Chiropractor, Neurologist or Physical Therapist who will confirm it takes very few pounds of pressure to do serious damage especially on an unconscious patient. On an older person or one who's albumin level is low, which includes many drug and alcohol addicts, you may also have damaged the tissue covering the spine which will result in a lengthy hospital stay even if they were fakiing being unconscious. 




RescueYou said:


> Checking for consciousness: I flick the eyelids or if you're pretty sure they are faking, *take their hand and drop it over their face. No conscious pt will hit themselves in the face unless they're a frequent flyer*...it's also funny to talk to your other EMT and be like "hmmm...unconscious...looks like it's time for an IV (or OPA), etc"


 
Is this like tossing the person suspected of being a witch into the deep end of the lake? If they swim they are a witch and if they drown they must be innocent. Now that you have broken the nose or caused possibly permanent damage to the eyes of a NON-faking patient, are you satisfied with your assessment? Not only is the patient unconscious but now they have injuries caused by YOU. Also, if that patient becomes apneic, you have just damaged one route of establishing an airway be it NPA or NTI.

I seriously doubt if your medical director or employer's attorney will want to stand behind you and the union rep will probably disappear as well.


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## RescueYou

*Everyone's a critic*



VentMedic said:


> Finally...I can log in again!
> 
> 
> What about osteoporosis? Even a young man or women can have calcium depletion to make bones brittle for a variety of reasons. Or the young asthmatic or COPD patient who has been on corticosteroids? *omg. take a general impression. dont do it unless u can ensure the pt has none of those things. family can b of great assistance and this can be used if they lose consciousness en route b/c u shud hopefully already have the SAMPLE done. simply listed spinal rub as an option. *
> 
> What happens when YOU make them a spinal injury patient? *if you rub them that hard, you are insane. if they have calcium depletion, u can just as easily break a rib or even crack the sternum up front. *
> 
> Are you going to charge extra for the chiropractic adjustment? Talk to any Chiropractor, Neurologist or Physical Therapist who will confirm it takes very few pounds of pressure to do serious damage especially on an unconscious patient. On an older person or one who's albumin level is low, which includes many drug and alcohol addicts, you may also have damaged the tissue covering the spine which will result in a lengthy hospital stay even if they were fakiing being unconscious.
> 
> 
> 
> Is this like tossing the person suspected of being a witch into the deep end of the lake? If they swim they are a witch and if they drown they must be innocent. Now that you have broken the nose or caused possibly permanent damage to the eyes of a NON-faking patient, are you satisfied with your assessment? Not only is the patient unconscious but now they have injuries caused by YOU. Also, if that patient becomes apneic, you have just damaged one route of establishing an airway be it NPA or NTI. *it's one thing to hold their arm straight up and drop it...it's another to hold it 1/2in or 1in up from their face. wont do hurtful damage but if they are faking, they are going to make sure their hand lands above or below their face. try dropping your hand on your face. i wish i could watch. *



and that's all i'm going to say b/c i've done all of the above and never had a problem before.


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## VentMedic

RescueYou said:


> and that's all i'm going to say b/c i've done all of the above and never had a problem before.


 
Your patients have been lucky you have not seriously injured them.

And you're not even a Paramedic yet.



> *try dropping your hand on your face*


 
I am not unconscious. Again, you may be doing harm to those who need your help the most which is those who are unconscious.




> *if you rub them that hard, you are insane. if they have calcium depletion, u can just as easily break a rib or even crack the sternum up front. *


 
Which is also part of this discussion about sternal rubs. Read Dr. Bledsoe's article which has been linked in earlier posts.



> *omg. take a general impression. dont do it unless u can ensure the pt has none of those things. family can b of great assistance and this can be used if they lose consciousness en route b/c u shud hopefully already have the SAMPLE done. simply listed spinal rub as an option. *


Can you post the EMT book that advocates a spinal rub?

If the patient is unconscious, how do you know for sure they do not have a spinal injury? Did they fall to ground? Are you certain you can take the word of the bystanders who may have been guilty of horseplay or foul play that injured the patient?

What's with the chat room shorthand?  Do you use that in your PCR?


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## reaper

VentMedic said:


> Your patients have been lucky you have not seriously injured them.
> 
> And you're not even a Paramedic yet.
> 
> 
> 
> I am not unconscious. Again, you may be doing harm to those who need your help the most which is those who are unconscious.
> 
> 
> 
> 
> Which is also part of this discussion about sternal rubs. Read Dr. Bledsoe's article which has been linked in earlier posts.
> 
> 
> Can you post the EMT book that advocates a spinal rub?
> 
> If the patient is unconscious, how do you know for sure they do not have a spinal injury? Did they fall to ground? Are you certain you can take the word of the bystanders who may have been guilty of horseplay or foul play that injured the patient?
> 
> What's with the chat room shorthand?  Do you use that in your PCR?



:beerchug:


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## AnthonyM83

Isn't the Glascow Coma Scale meant to be used with painful stimuli above a certain central nerve tract/level?

Also, EMT's are taught to use NPA's and OPA's very freely with unresponsive or semi-responsive patients. Since this is going to be done anyway, you can often get some useful information from their response...


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## LondonMedic

AnthonyM83 said:


> Isn't the Glascow Coma Scale meant to be used with painful stimuli above a certain central nerve tract/level?


Central stimuli above the shoulders if I remember right to identify any purposeful localisation - I use supra-orbital pressure.


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## Jeffrey_169

I must say I agree with EMSBoy on this one. I would not perfrom a sternum rub for more then a few seconds. It is extremely painful and it has proven to be effective.


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