Sternal Rubs/Painful Stimulus

[reaper]

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

 

[Seaglass]

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...

 

[Lifeguards For Life]

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

 

[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"

 

[reaper]

Spinal rub?

 

[RescueYou]

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.

 

[VentMedic]

Finally...I can log in again!

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

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.

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.

 

[RescueYou]

Everyone's a critic

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.

 

[VentMedic]

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?

 

[reaper]

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:

 

[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...

 

[LondonMedic]

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.

 

[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.