# No more sternal rubs??



## RobertAlfanoNJEMT

Apparently according to my crew chief/assistant Cheif we are no longer allowed to perform sternal rubs as a painful stimuli. He tried to explain to me why we cannot but it still didn't make sense. I'm not sure if this is something from our medical director or a new state protocol, but nonetheless if someone could explain why it is not recommended I'd appreciate it.


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## DesertMedic66

Its been phased out in my area now for around 4 years. We still have plenty of people doing it however. I believe it had to do with some patients (trauma) possibly having a Fx sternum and it may also look inappropriate if you are doing it to a female patient.


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## Flying

Some people don't respond to a sternal rub very well (I don't find it painful, for example), you may end up bruising the person's chest with nothing to show for it, not good for female patients in public view...

Go to the trapezius squeeze. http://emtlife.com/threads/sternal-rubs-trap-squeezes-motor-bikes.12366/


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## SpecialK

Bollocks, good hard sternal rub I reckon ...


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## akflightmedic

The programs I taught for and in practice at the services I worked for, we had discontinued the sternum rub as far back as early 2000s. Was surprised to see this thread actually.

There are far better ways to assess painful stimuli than a sternum rub. Additionally, it was an abused practice as well, yes whether you admit or not, there are several sick folk among us who get off on inflicting pain to drunks, ODs, and fakers. And the rub does not need to be repeated, yet it often is...draw your own conclusions.


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## MrJones

Flying said:


> ...Go to the trapezius squeeze. http://emtlife.com/threads/sternal-rubs-trap-squeezes-motor-bikes.12366/



Meh. Take the barrel of your pen and squeeze it hard against the patient's thumbnail. Guaranteed to wake the dead. Well, not quite, but you get the idea.


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## joshrunkle35

Eye flick 

*sarcasm*


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## STXmedic

MrJones said:


> Meh. Take the barrel of your pen and squeeze it hard against the patient's thumbnail. Guaranteed to wake the dead. Well, not quite, but you get the idea.


You can get activation of reflex arcs with peripheral pain stimulus. If you're just trying to wake them up, then no big deal. But if you're trying to truly assess neuro status, then reflex arcs can throw off your assessment.


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## MrJones

STXmedic said:


> You can get activation of reflex arcs with peripheral pain stimulus. If you're just trying to wake them up, then no big deal. But if you're trying to truly assess neuro status, then reflex arcs can throw off your assessment.



Possibly so, but not in my experience....


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## STXmedic

MrJones said:


> Possibly so, but not in my experience....


Oh? You get definitive neuro findings on all your patients that you perform painful stimulus on? That's impressive, especially considering the vast majority of paramedics can't even name the cranial nerves. When an unconscious patient withdrawals from your peripheral pain infliction, what finding do you look for that tells you it's not a reflex?


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## COmedic17

Pinch their trap and put ammonia salt under their nose. 


It's my go-to for when drunks won't wake up.


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## MrJones

STXmedic said:


> Oh? You get definitive neuro findings on all your patients that you perform painful stimulus on? That's impressive, especially considering the vast majority of paramedics can't even name the cranial nerves. When an unconscious patient withdrawals from your peripheral pain infliction, what finding do you look for that tells you it's not a reflex?



Public Service Announcement: If you would like to discuss a topic - especially a point of disagreement - with me it is important to do so calmly, respectfully and without obvious snark or sarcasm. Why, you ask? Because responses such as the one quoted here are destined to go unanswered.


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## Akulahawk

I have removed one post from this thread. Keep this discussion civil or this thread will be closed and offenders may end up taking a break for a while. There's at least one or more other posts here that are bordering on the edge of civility but remain because they still contribute to the discussion, for now.


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## COmedic17

MrJones said:


> Public Service Announcement: If you would like to discuss a topic - especially a point of disagreement - with me it is important to do so calmly, respectfully and without obvious snark or sarcasm. Why, you ask? Because responses such as the one quoted here are destined to go unanswered.


Is this a fancy way to say " I don't know how to answer that question, so I will just refuse to answer it..."?


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## STXmedic

Akulahawk said:


> I have removed one post from this thread. Keep this discussion civil or this thread will be closed and offenders may end up taking a break for a while. There's at least one or more other posts here that are bordering on the edge of civility but remain because they still contribute to the discussion, for now.


Aww, I thought it was actually quite reserved...


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## Akulahawk

STXmedic said:


> Aww, I thought it was actually quite reserved...


While this particular post is civil in tone, keep the discussion on topic. It would _really_ not be good for discussion if this thread were placed on moderation because of posts like this that do not further the discussion.


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## Carlos Danger

I will still use a sternal rub, but I am gentle about it - I actually use my fingertips instead of my knuckles.

Most people find it extremely noxious even with considerably less pressure than what it typically takes to cause a bruise. The only time it causes problems is when people do it really hard, or over and over.


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## Kevinf

I had both a classmate and a coworker that have scars from when they got a sternal rub when the rubber didn't remove their ring. Both of them women and neither happy about the scars on their chests. I stick with a trap pinch myself.


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## COmedic17

Kevinf said:


> I had both a classmate and a coworker that have scars from when they got a sternal rub when the rubber didn't remove their ring. Both of them women and neither happy about the scars on their chests. I stick with a trap pinch myself.


....I'm just trying to imagine in my mind how it would be possible for a ring to get in the way while doing a sternal rub... Since a ring def wouldn't be on the knuckles used..... And if it was, I wouldn't think you would be able to bend your finger all the way...


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## RobertAlfanoNJEMT

akflightmedic said:


> The programs I taught for and in practice at the services I worked for, we had discontinued the sternum rub as far back as early 2000s. Was surprised to see this thread actually.
> 
> There are far better ways to assess painful stimuli than a sternum rub. Additionally, it was an abused practice as well, yes whether you admit or not, there are several sick folk among us who get off on inflicting pain to drunks, ODs, and fakers. And the rub does not need to be repeated, yet it often is...draw your own conclusions.


I used it for example on a paralyzed pt found at a bar who'd helped himself to a nice cocktail of mixed opioids and alcohol. I knew we were no longer supposed to do it but I couldn't exactly deliver painful stimuli to his lower extremities, plus it was working he'd come awake enough to speak to me for a few seconds when I'd do it.. I think my crew Cheif was inferring that sternal rubs can cause some cardiac issues which I don't really understand how, unless you are doing it so hard that you knock the heart out of rythem. Nonetheless when we got in the back there was no need to continue sternal rubs because when the paramedics started a 20 gauge IV he was awake and screaming like they had dug a knife into his arm! He may have had some nerve damage from his accident, but I have never seen someone respond so verbally to an IV. He screamed right in my ear all the way to the ER


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## RobertAlfanoNJEMT

COmedic17 said:


> ....I'm just trying to imagine in my mind how it would be possible for a ring to get in the way while doing a sternal rub... Since a ring def wouldn't be on the knuckles used..... And if it was, I wouldn't think you would be able to bend your finger all the way...


Simple solution to that is that EMS professionals should only be wearing a watch to work..


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## joshrunkle35

COmedic17 said:


> ....I'm just trying to imagine in my mind how it would be possible for a ring to get in the way while doing a sternal rub... Since a ring def wouldn't be on the knuckles used..... And if it was, I wouldn't think you would be able to bend your finger all the way...



I would think the same thing. If a ring is touching, you're already doing it wrong.

I've done sternal rubs on unconscious/unknown, only after other methods fail, and I'm not really opposed to it, other than how it looks to uneducated bystanders.


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## akflightmedic

RobertAlfanoNJEMT said:


> Simple solution to that is that EMS professionals should only be wearing a watch to work..



Agreed! Do not want those pesky wedding bands interfering with any mojo.


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## RobertAlfanoNJEMT

So pretty much what I've taken from what you all have said is that it looks bad to bystanders who don't know what you are doing and it can leave some awkward bruising. If those are the only contradictions then I'm going to keep doing it.


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## gotbeerz001

RobertAlfanoNJEMT said:


> So pretty much what I've taken from what you all have said is that it looks bad to bystanders who don't know what you are doing and it can leave some awkward bruising. If those are the only contradictions then I'm going to keep doing it.


If your boss says to discontinue a practice and offers an alternate method, you should probably just do what they say.


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## akflightmedic

RobertAlfanoNJEMT said:


> So pretty much what I've taken from what you all have said is that it looks bad to bystanders who don't know what you are doing and it can leave some awkward bruising. If those are the only contradictions then I'm going to keep doing it.



Aside from the above comment...add on the fact that it is almost always an unnecessary method. There are better ways. Just because we can, does not always mean we should.

One of my favorite quotes and seems rather applicable here is "Training will show you 1000 ways to skin a cat. Education will show you the cat did not always need to be skinned."


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## COmedic17

RobertAlfanoNJEMT said:


> Simple solution to that is that EMS professionals should only be wearing a watch to work..


...or they should be wearing whatever they feel like as long as it doesn't interfere with performing their duties.


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## akflightmedic

I personally think I would look rather silly if I showed up wearing only my watch.

Lt. Dangles

Paramedic Beaux Dangles


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## Carlos Danger

akflightmedic said:


> I personally think I would look rather silly if I showed up wearing only my watch.



They don't call me "big guy" for nuthin'...


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## Jim37F

They told us about sternal rubs in EMT school, they also said those were no longer allowed by the county, for pretty much the same reasons others here listed. However our instructor decided to show us the "proper" way to do one anyhow, as in rocking your knuckles across the sternum (applying pressure with each one), vs the apparently more common technique where people simple rubbed their knuckles across the sternum like they were trying to cause an Indian burn, which in our instructors opinion, that faulty technique is what caused the problems to get it banned.

At least for us on the BLS side, the only two officially approved techniques for testing painful stimuli response is the finger nail bed press and (I'm forgetting the technical name) placing a pen between the patients knuckles and squeezing them together. I've seen Paramedics here also use trap squeezes and other techniques as well, so that might only be BLS restricted to those two.



akflightmedic said:


> I personally think I would look rather silly if I showed up wearing only my watch.


Why is your watch that silly looking?  Just need to go full whacker and get your badge tattoo'd on your chest and you'll be good to go, it's your summer uniform option right?



Remi said:


> They don't call me "big guy" for nuthin'...


The real question is are they looking below or above the waist?


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## akflightmedic

Remi said:


> They don't call me "big guy" for nuthin'...



WillieDoo Disease....when your belly sticks out further than your WillieDoo.

Had to change name to WIllie due to censorship of the abbreviated name of Richard.


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## Tigger

RobertAlfanoNJEMT said:


> So pretty much what I've taken from what you all have said is that it looks bad to bystanders who don't know what you are doing and it can leave some awkward bruising. If those are the only contradictions then I'm going to keep doing it.


Yea I mean leaving some "awkward bruising" is totally fine, especially when there are other ways that don't, right?


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## RobertAlfanoNJEMT

Tigger said:


> Yea I mean leaving some "awkward bruising" is totally fine, especially when there are other ways that don't, right?


It's not that I am intending to leave the awkward bruising but I'm not hyper analyzing everything I do to the smallest degree.. In the heat of the moment if the first thing that comes to my head as a source of painful stimuli is a sternal rub, I'm not worried about what kind of bruising they will have, I'm worried about determining their LOC and what to do with that information.


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## gotbeerz001

RobertAlfanoNJEMT said:


> It's not that I am intending to leave the awkward bruising but I'm not hyper analyzing everything I do to the smallest degree.. In the heat of the moment if the first thing that comes to my head as a source of painful stimuli is a sternal rub, I'm not worried about what kind of bruising they will have, I'm worried about determining their LOC and what to do with that information.


Or maybe practice a way that accomplishes both objectives so that it's readily available "in the heat of the moment".


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## Chimpie

RobertAlfanoNJEMT said:


> In the heat of the moment if the first thing that comes to my head as a source of painful stimuli is a sternal rub, I'm not worried about what kind of bruising they will have, I'm worried about determining their LOC and what to do with that information.


That's what education, training and practicing is for. So that "in the heat of the moment" you natural reaction/response is to do what is right per your protocols, not per your feelings.


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## COmedic17

RobertAlfanoNJEMT said:


> In the heat of the moment if the first thing that comes to my head as a source of painful stimuli is a



Throat punch


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## Tigger

RobertAlfanoNJEMT said:


> It's not that I am intending to leave the awkward bruising but I'm not hyper analyzing everything I do to the smallest degree.. In the heat of the moment if the first thing that comes to my head as a source of painful stimuli is a sternal rub, I'm not worried about what kind of bruising they will have, I'm worried about determining their LOC and what to do with that information.


Turns out that's not how being a professional works. You don't get to choose what you think is best in the face of contradictory evidence. 

Also you should be worried about a causing unnecessary bruising, there's that whole "first do no harm thing."


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## Kevinf

COmedic17 said:


> ....I'm just trying to imagine in my mind how it would be possible for a ring to get in the way while doing a sternal rub... Since a ring def wouldn't be on the knuckles used..... And if it was, I wouldn't think you would be able to bend your finger all the way...



Presumably the provider in question used his hand in a closed fist and just ground down his MCP knuckles instead of the more distal ones. 

I have had partners that wear rings, though the women with rocks on them tend to turn them inward when gloves go on.


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## Bullets

I prefer supraorbital pressure, i get decent response from that and nothing damaging



COmedic17 said:


> Pinch their trap and put ammonia salt under their nose.


You still use ammonia inhalants?!


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## OnceAnEMT

First learned sternal rub 3 years ago, and learned at the same time that it was phased out. I've never done it, but even today nurses in the ED still do, usually giggling away. The docs don't, interestingly enough. I've given up on saying the whole "You know, there are other ways to do that...".

We'll bust out ammonia salts if a doc wants it, with high confidence that this patient just doesn't want to wake up. Never seen it fail when appropriately used (ie, dead people don't wake up).


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## Jon

RobertAlfanoNJEMT said:


> ..I think my crew Cheif was inferring that sternal rubs can cause some cardiac issues which I don't really understand how, unless you are doing it so hard that you knock the heart out of rythem...



Ok... First, it's "Chief" (I before E except after C, etc, etc), and "Rhythm".

Secondly - Lets talk commotio cordis. Are you familar with the term? What does it mean? What is involved in "knocking a heart out of rhythm"???


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## NUEMT

'A little research into the topic showed that patients who presented with ALOC had been sternal rubbed (SR'd)  once by medics, then by nursing staff...again by docs.. then by every resident and or medic student in the ed..... and so on..  repeated rubs caused trauma.....this equals bad pt care.  Uhh... do no harm.  Even little harm.

I myself use it solely on possible arrests.

I would also say that I am trying to do away with and resist any notions (even joking ones)  of punitive medicine.  It's not what I practice and it's not tolerated around my patients.  I always think to myself, "if that was my family, would I be ok with this?"


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## coolidge

What is the difference between doing a sternal rub vs a trapezius squeeze in what they are measuring?  Thanks


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## NUEMT

coolidge said:


> What is the difference between doing a sternal rub vs a trapezius squeeze in what they are measuring?  Thanks


No measuring application. Merely doing it to guage alertness.


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## ExpatMedic0

Some how this has slipped by me, I've never been told to avoid a sternum rub expect for the obvious contraindications. Is there any recent evidence base for suggesting its no longer appropriate for clinical practice? Is there an actual professional medical body who condemns the practice ? Everyone's entitled to their anecdotal evidence and opinions on why alternative methods maybe preferred...I am just curious


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## Carlos Danger

ExpatMedic0 said:


> Some how this has slipped by me, I've never been told to avoid a sternum rub expect for the obvious contraindications. *Is there any recent evidence base for suggesting its no longer appropriate for clinical practice? Is there an actual professional medical body who condemns the practice ?* Everyone's entitled to their anecdotal evidence and opinions on why alternative methods maybe preferred...I am just curious



Good questions.


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## ERDoc

I still use it when necessary.  I don't think there is going to be much literature out there for either side.


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## medicsb

I don't really get the controversy.  Are people using brass knuckles for sternal rubs?  I've tried multiple techniques, and personally I find the sternal rub to be the most reliable.


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## ExpatMedic0

I regularly use it, Iv'e never been questioned by other medics or ED staff and I have never read any literature stating it should be avoided (aside from obvious contraindications) . I was actually really surprised to see this thread and many of the replies. "Different strokes_ (or painful stimuli) _for different folks" I suppose.


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## SandpitMedic

Sternal rubbing for the win.


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## zzyzx

Personally, I use sternal rubs. That said, a known downside of sternal rubs is that you have to do the sternal rub for a significant of time before some people will respond.


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## Fry14MN

COmedic17 said:


> ....I'm just trying to imagine in my mind how it would be possible for a ring to get in the way while doing a sternal rub... Since a ring def wouldn't be on the knuckles used..... And if it was, I wouldn't think you would be able to bend your finger all the way...



I wear a ring on my left hand(not ring finger). I'm left handed so I use my left had for a sternal rub and I've never had it get in the way but its also flat. I could maybe see if he or she has some huge blingin' rock of some kind but if it's that big I would think that would be removed before shift. And not to mention using gloves would be a hassle.


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## Melbourne MICA

For RobertAlfanoNJEMT: The sternal rub is abused by everyone from my observations. It was never intended as a means to wake patients. In fact, pain stimulus applied to the sternum as part of the Glasgow coma score assessment NEVER in fact, included  a full handed knuckle rub. The idea in the GCS is application of a painful stimulus to the sternum should illicit a response from the patient to reach across and remove the stimulus. This indicated a higher or lower level of brain function. This makes complete sense when you consider the next part of the assessment is to determine if the response (or level of functioning brain activity) is unilateral perhaps suggesting stroke as a differential cause of the unconsciousness. You can see that if, with each test, as they get more and more narrowly defined, there is still no response then the level of unconsciousness is worse and expressed by the falling GCS score. The stimulus itself is commonly defined as equivalent to the tip of a pen applied firmly to the sternum. Application of anything more than a pen tip level of pain is both unethical and clinically misleading because it gives an overestimate of conscious state in terms of the GCS by rousing the patient from what may well be deep unconscious due to a serious neuro event. In particular, over stimulus may have ramifications in causing a pain induced rise in HR, BP, M.A.P. and subsequently I.C.P. - a really undesirable thing to do if the cause of unconsciousness is a cerebral bleed.   The classic example of this explanation is an event I witnessed involving a a stream of nurses who 1 by 1, attended a young unconscious male in the Ed brought in by paramedics who probably did the same thing, assumed a drug overdose, and applied brutal sternal rubs one after the other in order to wake him up - reason being if they couldn't, under ED policy (of which I was aware having visited this ED many times), he would need to go to ICU and obviously take up a bed. The prejudiced, judgmental and basis of this approach to patient care (I actually interceded and complained at the time as I was writing up my paperwork nearby) was completely rendered a farce when it was discovered he in fact had a neuro-bleed not a drug overdose. I really don't think I've seen a better example of the whole knuckle rub abuse scenario. Perhaps that's why its been withdrawn by so many services or maybe some EMT's have been sued? I hate anecdotal orthodoxies and Ambos are so willing to adopt them it seems. Piss poor practice and no benefit to patients if you ask me.


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## RobertAlfanoNJEMT

Melbourne MICA said:


> For RobertAlfanoNJEMT: The sternal rub is abused by everyone from my observations. It was never intended as a means to wake patients. In fact, pain stimulus applied to the sternum as part of the Glasgow coma score assessment NEVER in fact, included  a full handed knuckle rub. The idea in the GCS is application of a painful stimulus to the sternum should illicit a response from the patient to reach across and remove the stimulus. This indicated a higher or lower level of brain function. This makes complete sense when you consider the next part of the assessment is to determine if the response (or level of functioning brain activity) is unilateral perhaps suggesting stroke as a differential cause of the unconsciousness. You can see that if, with each test, as they get more and more narrowly defined, there is still no response then the level of unconsciousness is worse and expressed by the falling GCS score. The stimulus itself is commonly defined as equivalent to the tip of a pen applied firmly to the sternum. Application of anything more than a pen tip level of pain is both unethical and clinically misleading because it gives an overestimate of conscious state in terms of the GCS by rousing the patient from what may well be deep unconscious due to a serious neuro event. In particular, over stimulus may have ramifications in causing a pain induced rise in HR, BP, M.A.P. and subsequently I.C.P. - a really undesirable thing to do if the cause of unconsciousness is a cerebral bleed.   The classic example of this explanation is an event I witnessed involving a a stream of nurses who 1 by 1, attended a young unconscious male in the Ed brought in by paramedics who probably did the same thing, assumed a drug overdose, and applied brutal sternal rubs one after the other in order to wake him up - reason being if they couldn't, under ED policy (of which I was aware having visited this ED many times), he would need to go to ICU and obviously take up a bed. The prejudiced, judgmental and basis of this approach to patient care (I actually interceded and complained at the time as I was writing up my paperwork nearby) was completely rendered a farce when it was discovered he in fact had a neuro-bleed not a drug overdose. I really don't think I've seen a better example of the whole knuckle rub abuse scenario. Perhaps that's why its been withdrawn by so many services or maybe some EMT's have been sued? I hate anecdotal orthodoxies and Ambos are so willing to adopt them it seems. Piss poor practice and no benefit to patients if you ask me.


I can agree with most of what you are saying and you actually gave a solid explanation and reason so thank you!


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## Melbourne MICA

RobertAlfanoNJEMT said:


> I can agree with most of what you are saying and you actually gave a solid explanation and reason so thank you!


 You're welcome. Good practice is so easily sidetracked by orthodoxies that catch on and develop a life of their own. They are rarely balanced, evidence based behaviors, rather a mob mentality. When combined with our prejudices and biases the end result is bad practice. Young guy unconscious becomes scum bag druggie who deserves all he gets..........What if he was a hard working honest white collar professional who just overdid it on this particular occasion.?


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## NoahW5394

Just my 2 cents as a forum ride along 

I first head of the sternal rub in cert training. Our instructor was a police officer and AHA first aid guru. He said that the manuvar had been banned for several years and was now considered assault. 

I can see why it would be a go to, but simply as a trained civilian, I would never try this on a female. Would look like I had something other than her safety in mind...


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## akflightmedic

NoahW5394 said:


> I can see why it would be a go to, but simply as a trained civilian, I would never try this on a female. Would look like I had something other than her safety in mind...



If you think the sternal rub might be deemed inappropriate based on gender, then you are doing it wrong...very wrong. There is absolutely zero change of misinterpreting your intention of a sternal rub when done in the proper situation and performed properly.


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## NoahW5394

akflightmedic said:


> If you think the sternal rub might be deemed inappropriate based on gender, then you are doing it wrong...very wrong. There is absolutely zero change of misinterpreting your intention of a sternal rub when done in the proper situation and performed properly.



Can you explain the proper way to do a sternal rub?


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## akflightmedic

Knuckles to sternum with small circular motion....if you think someone is going to confuse you in uniform leaning over an unresponsive victim while rubbing their sternum with the sexual violation of a female, then either you are doing it wrong or need an anatomy lesson.


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## NoahW5394

akflightmedic said:


> Knuckles to sternum with small circular motion....if you think someone is going to confuse you in uniform leaning over an unresponsive victim while rubbing their sternum with the sexual violation of a female, then either you are doing it wrong or need an anatomy lesson.



You may have mis understood, I have no uniform. But that aside, I do see your point, plus it's not like it would ever be done on a person who wasn't obviously unconcioius or near unconcioius. Thanks for the reply


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## Carlos Danger

Melbourne MICA said:


> Application of anything more than a pen tip level of pain is both unethical and clinically misleading because it gives an overestimate of conscious state in terms of the GCS by rousing the patient from what may well be deep unconscious due to a serious neuro event. In particular, over stimulus may have ramifications in causing a pain induced rise in HR, BP, M.A.P. and subsequently I.C.P. - a really undesirable thing to do if the cause of unconsciousness is a cerebral bleed.



I think this is really over stating the "problem" with sternal rubs.

Certainly it can be abused. So can any other method of painful stimulation. And perhaps it isn't a useful component of a detailed neuro exam, but it is certainly convenient way to assess a general level of consciousness.

Why is it unethical to cause pain with a sternal rub, but not unethical to cause pain with a trap squeeze or a pen on the fingernail?


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## DrParasite

NoahW5394 said:


> I first head of the sternal rub in cert training. Our instructor was a police officer and AHA first aid guru. He said that the manuvar had been banned for several years and was now considered assault.


I call BS on this statement.  Can you provide any court cases where EMS personnel have been criminally charged for administering a sternal rub?  Can you provide any judicial decision where a judge deemed a sternal rub to be equal to assaulting a person?  How about a text book from AHA or one of the EMT publishers clearly stating that sternal rubs are no longer permitted?

If might be your instructors law enforcement opinion that a sternal rub should be considered assault, and I have heard they have fallen out of favor because you can cause harm if the person has a fx sternum, but I have never heard anything about them being banned and to administer one is considered assault.


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## DrParasite

Melbourne MICA said:


> The classic example of this explanation is an event I witnessed involving a a stream of nurses who 1 by 1, attended a young unconscious male in the Ed brought in by paramedics who probably did the same thing, assumed a drug overdose, and applied brutal sternal rubs one after the other in order to wake him up - reason being if they couldn't, under ED policy (of which I was aware having visited this ED many times), he would need to go to ICU and obviously take up a bed.


I think the bigger issue there was if one person didn't succeed, the next in line did the exact same thing expecting different results.


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## RobertAlfanoNJEMT

akflightmedic said:


> Knuckles to sternum with small circular motion....if you think someone is going to confuse you in uniform leaning over an unresponsive victim while rubbing their sternum with the sexual violation of a female, then either you are doing it wrong or need an anatomy lesson.


To clearify the sternum is higher up, so when doing it your hand should not be in the woman's breasts, also you should not be lifting your hand when you do it so it won't look like you're rubbing her breast.. Plus who would assume you are doing that?? What kind of creep sees a female faint and automaticly runs over and feels up her breast


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## akflightmedic

Not sure why you quoted me since I said essentially the same as you...


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## ERDoc

RobertAlfanoNJEMT said:


> What kind of creep sees a female faint and automaticly runs over and feels up her breast



You haven't been doing this job very long, have you?

I have to agree that multiple sternal rubs by multiple people is overboard and bordering on assault, but used properly it can be very helpful.


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## Handsome Robb

I've never heard that sternal rubs had fallen out of favor. 

I generally do a trap squeeze or if I think someone may have the potential to wake up and be angry and hostile towards me I'll use nail bed pressure with a pen so I'm not directly over the top of them. 


Sent from my iPhone using Tapatalk


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## vc85

I was told not to use eternal rubs because they are ineffective. Supposedly the nerves to that area don't go directly to the brain

They said to do a trap squeeze as the nerve runs directly to the brain


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## NomadicMedic

vc85 said:


> I was told not to use eternal rubs because they are ineffective. Supposedly the nerves to that area don't go directly to the brain
> 
> They said to do a trap squeeze as the nerve runs directly to the brain



Yes. 100% true. The sternum is innvervated by the splenic nerve, which goes directly to the spleen, bypassing the brain entirely. 



It's worth looking at the types of painful stimuli you're using to determine responsiveness and WHY you're doing it. You really don't need to inflict a whole slew of painful stimuli to a simple unconscious person right off the bat. 

Central stimulus, like a trap squeeze, sternal rub or my wife's favorite, supraorbital pressure, is a solid way to measure if a patient flexes or withdraws from pain. Peripheral stimuli (like nail bed pressure) may just trigger a reflex reaction. 

If you're just trying to wake someone up, an intoxicated person, for example... A shake and a loud "HEY!" usually does the trick.


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## akflightmedic

HEY! HEY! Are you OK??!!


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## NomadicMedic

Well, how many times have you seen an EMT or a first responder put in the knuckles to somebody who's just passed out after drinking?


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## Carlos Danger

vc85 said:


> I was told not to use eternal rubs because they are ineffective. Supposedly the nerves to that area don't go directly to the brain
> 
> They said to do a trap squeeze as the nerve runs directly to the brain



And this is why not taking anatomy seriously is a problem.


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## vc85

Hey don't shoot the messenger 

This is what one of our agencies training officers said was told to him by an MD at a major EMS conference.

Now, putting on my computer science hat for a minute, it is a shorter distance from the brain to the trap than to the sternum so propagation delay is reduced. Not that it would make any difference in a ems setting. But maybe that is what the doctor was getting at?


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## Flying

vc85 said:


> Now, putting on my computer science hat for a minute, it is a shorter distance from the brain to the trap than to the sternum so propagation delay is reduced. Not that it would make any difference in a ems setting. But maybe that is what the doctor was getting at?


Peripheral vs central nervous system. Stimulating different parts of the anatomy will have varying effects because there are multiple incoming (afferent) pathways, each of which terminate differently.


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## DesertMedic66

"Sir! Sir! Can you hear me? You, go activate the 911 system" is usually what I do


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## NomadicMedic

"...and bring back an AED"


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