Ahhh the embattled sternal rub. Revered, reviled … the sternal rub is the Ann Coulter of medical interventions. Abrasive, annoying, loved by many, hated by many more. The subject of the usefulness of the sternal rub is bound to cause controversy in any EMS forum.
In other words … it’s a great subject for The Spot.
Like many controversial assessments and treatments, the sternal rub (sometimes referred to as the sternum rub) got its bad-boy reputation more from its misuse than from its own shortcomings. Never-the-less, the technique does have its shortcomings.
Like so many other tools, it has its place when used appropriately and it has its potential for misuse. So let’s make sure you understand its uses and limitations.
If you’ve never encountered this technique, the sternal rub is a test for unconsciousness. It’s a popular form of painful or noxious stimuli designed to illicit a response from a conscious or semi-conscious person. Establishing an unresponsive patients ability to respond and remove noxious stimuli is perfectly medically appropriate.
Note that on your Glasgow Coma Score, establishing best eye response and best motor response both require the ability to administer and observe the patients reaction to pain. Having said that, I’m not the biggest fan of the sternal rub. i think there are other more appropriate tests like the face flick and the hand drop that, when done correctly, render more valuable information.
To perform the sternal rub, the care provider makes a fist and places his knuckles against the patients mid-sternum. Applying firm downward pressure the provider then rubs up and down across the sternum. To the uninitiated, this is surprisingly uncomfortable. With even a moderate pressure, the sternal rub is unbearable to most folks.
On the surface (pun intended) the stenal rub seems simple enough. Fairly benign body area … fairly simple technique. What could be the problem?
There are several:
We tend to overuse it.
Recall the last time you performed the sternal rub and the patient did not respond at all? What was your reaction? Did you begin aggressive airway management? Did you call for rapid transport? Or .. did you do it harder? … And then maybe a little harder? And then one really good one just for good measure?
And then the nurse at the hospital did the same thing. And then the intern did the same thing. And then the resident and on and on. And by the time the patient regained consciousness they had a big bruise and a sore chest for the next week. We overuse the technique when we think people should be responding but they don’t. Perhaps one reason we overuse it is because we know …
Especially people who are drunk or sedated. People who’ve had it done to them multiple times and the odd person who just has a really insensitive sternum. Because of these outliers we tend to keep trying the technique just a little more aggressively to see if this isn’t just one of those people who doesn’t feel it that much.
Some reports state that many patients don’t reposnd until pressure has been applied for 30 or more seconds. I’m not comfortable with applying the rub for that long or that hard to see if I can illicit a purposeful movement. That makes the results difficult to interpret.
For the record, any painful stimuli that leaves marks on the patient is inappropriate. If the patient arrives at the hospital with marks from your assessment, you did it wrong. No excuses.
It’s not a first line technique.
To many folks walk up and start in on the sternal rub as their first line assessment of unresponsive patients. No gentle shake and shout, no face flick or loud verbal stimuli. Just one good sternal rub. If the patient wakes easily, your patient rapport is pretty much shot after a good sternal rub. This is also a good way to get hit or grabbed because …
It places your arm in a bad spot for combative or dangerous patients.
It’s tough to do a sternal rub from above or out of the way. You pretty much have to offer up your whole forearm to the patients grasp. Beware and be ready to defend yourself if you come out of nowhere with a good hard sternal rub.
So how do we do it properly?
If you rub your knuckles firmly across your sternum you’ll discover that this move hurts. You don’t need to lay into someone with everything you’ve got. Give a good firm rub and then be done with it. Pay attention to the patients hands. For your own safety and because that might be the only response the patient is able to make.
I’d suggest keeping the sternal rub farther down on your assessment checklist. Remember to use less aggressive forms of stimuli first (i.e. noise, shaking, flicking, pinching.) Don’t just walk up to some poor dude and start in on him with this move.
The appropriateness of the sternal rub lies entirely in the hands of the care provider using the technique. When dons properly by someone who understands its benefits and limitations, it can yield valuable information. When done poorly, it is at best useless and at worst abusive.
Hopefully you’ll always use the sternal rub with caution, good intentions and respect for the patient.