I’m a believer in AEIOUTIPS for several reasons.

Unlike mnemonics like my first cardiac arrest algorithm, (Shock, shock, shock. Everybody shock. Little shock, big shock, big shock, little shock.) AEIOUTIPS has remained relevant. That helpful cardiac arrest rhyme may have helped me through my first ACLS class, but it barely lasted through my first year as a paramedic. Once someone thought up high dose Epinephrine, things got complicated.

And, unlike more well known acronyms such as DCAP-BTLS-TIC, AEIOUTIPS has actual clinical application. That means I actually run through it in my head while I’m in the middle of patient care. I have never once exposed a trauma patients chest and actually though to myself, “OK, I don’t see any deformities…and I don’t see any contusions…and I don’t see any abrasions…” You see my point.

So what is this AEIOUTIPS acronym? It’s an acronym to help you remember the most common causes of altered mental status (AMS). This is useful when your patient is anything less than alert and oriented and you can’t figure out why.

Let’s face it, some differential diagnosis jump out at you. It isn’t tough to figure out what’s really  wrong with the dude that got hit by a car. The COPD patient who’s tripoding and breathing 30 shallow breaths a minute isn’t much of a mystery either. But the confused or unconscious patient can be a real puzzler.

The next time your patient has an altered mental status and you find yourself puzzled by what’s going on, manage the basics and run through the AEIOUTIPS acronym in your head.

A is for alcohol.

It’s first on the list for a reason. Alcohol plays a roll is a large percentage of the altered mental states that we encounter. Sometimes it’s obvious. Other times it isn’t. Does the patient have an odor on their breath? Does their environment suggest alcohol consumption?

E is for epilepsy (and other forms of seizure).

Could the patient have had a seizure? Inquire about the patients medical history and check their prescription medications. Do you note any oral trauma or urinary incontinence? Look closely for repetitive focal movement. Was the onset of altered mentation sudden?

I is for insulin.

Check the refrigerator (Insulin), the medicine cabinet and the patients body (Medicalert tags) for evidence of diabetes. Could the patient be hypoglycemic (or possibly hyperglycemic). Don’t forget a routine glucose check on all of your altered mental status patients. The ones we can’t figure out tend to always get their blood glucose checked. It’s when we are convinced that the cause of altered mentation is something else on the list that blood sugar can sneak up on us. Most of us have at least one good story about the stroke or the seizure that turned out to be a hypoglycemic event.

O is for overdose (and oxygenation).

If medication bottles are present, does the pill count add up? Is there evidence of drug use at the scene? We discussed alcohol, but don’t forget about other substances that can cause mental status changes. Consider opiates (and check those pupils). Hallucinogens, deliriants and inhalants also produce altered mentation to varying degrees. They account for some of our more unusual mental status presentations.

Also consider an acute hypoxic event. Airway patency, lung sounds and skin should be evaluated early. If the patient is on home oxygen ensure that the supply is uninterrupted.

U is for uremia (or underdose).

Does the patient have a history of renal failure or renal disease? Have they been urinating? Look for signs of increased toxins (mainly nitrogen) in the blood like jaundice, recent fatigue, dehydration, unusual thirst and peripheral swelling.

Some folks also add “underdose” or non-compliance to medication to the U category. Medication non-compliance can contribute to altered mental states, but the true cause of altered mentation will, most likely, be found somewhere else on this list. Is the patient taking their prescribed medications?

T is for trauma.

Could there have been an unreported traumatic event? Could the patient have been assaulted? Could there have been a previous head injury that lead to the current change in mental status? (Think lucid interval.) Your assessment should include a through look at the head as well as a search for causes of occult bleeding in the chest abdomen and pelvis.

I is for infection.

Is there a source of infection? Has the patient been ill recently? Is the patient immuno-compromised? Are they in a high risk category for sepsis such as kids, the elderly, and patients taking chemotherapy and immuno-suppressive therapies? Feel the patient skin. Take a temperature if you have that ability. Pay close attention to the blood pressure. Most of our sepsis patients will show some degree of hypotension before they become noticeably altered.

P is for psychiatric (and poisoning).

This is one where non-compliance to medications can be an important precipitating factor. Does the patient have a history of psychiatric events? Could the current presentation be a simple episode of catatonia or some sort of psychosis? Psychiatric disorders can precipitate some unusual, what-the-heck-is-going-on type presentations. If you feel like you’ve ruled out everything else, consider an acute psychotic episode.

Also consider the possibility of poisoning, both intentional and unintentional.  Consider the environment where the patient was found. Could the patient have had contact with a poison. Consider that ingestion is only one potential route for poisons. Chemicals like organophosphates can be absorbed through the skin and carbon monoxide is inhaled.

S is for stroke (and shock).

Not just occlusive stroke, but anything that might put pressure on the brain. This includes lesions, tumors and spontaneous hemorrhage. Do a thorough neurological evaluation and look for motor deficits in the patients response to stimuli. Note muscular weakness in the face and take a good look at the pupils.

While we specifically addressed hypovolemic shock and septic shock, consider other causes of shock like cardiogenic and anaphylactic shock. Pay close attention to the patients hemodynamic stability and consider an underlying shock state.

AEIOUTIPS takes a little practice. Your first few times working through the acronym will feel awkward. But with a little time and patience, the memory tool can become a trusted friend during some of your more challenging calls. I’ve talked through these nine points out loud with my partner on the way to the hospital when an altered patient us both scratching our heads over what was going on.

While I may not always nail the cause of altered mental status, I rarely find an altered patient who falls outside of the AEIOUTIPS list.

Now it’s your turn. Did you learn the AEIOUTIPS acronym in school? Do you use it during patient care?

Read more EMT awesomeness:

LCES for EMTs

The Ultimate EMS Protocol

The SOAP Reporting Breakthrough

Understanding OPQRST

Learning DCAPBTLS (A Word of Advice)

I imagine it was probably my first Prehospital Trauma Life Support class back in 1990 that I first heard of the three collision rule. Since then, it has remained a useful tool in examining the mechanism of injury after auto accidents. If you haven’t heard of it, please allow me to elaborate.

The three collision rule states that, in any auto accident, there are three collisions that occur and the keen EMT needs to be aware of all three. The next time you walk up to a vehicle accident, instead of imagining two large objects colliding with each other, imagine three separate collisions occurring with each respective vehicle. All of them have implications for the alert EMT.

Collision Number One: The Exterior of The Vehicle Strikes Something

Take a quick walk around the vehicle and consider the elements of Newton’s second law (force is mass times acceleration or deceleration). Ask yourself the questions that apply to that equation. How heavy is the vehicle involved? How fast was it traveling? How fast did it stop? All of these will contribute to the force involved in the initial impact, but speed really is king. Force increases proportionally as the weight of the vehicle increases, but speed has an exponential influence on collision forces.

Several things can give us clues about how fast the car was traveling at impact.

First, pay attention to the posted speed limit in the area of the collision. Cars traveling through a 25 mile per hour residential neighborhood will collided with one fourth the kinetic energy as a car driving through a fifty mile per hour commercial district. Second, look for skid marks and other indications of attempts to slow the vehicle before impact. Third, look at the vehicle itself. Keep in mind the older cars are designed to resist impact forces and newer cars are designed to absorb impact forces while keeping the passenger space intact.

In modern cars, passenger space intrusion and axle displacement are significant findings. Also note airbag deployment within the passenger space and if the headrest height is in proportion to the driver. Now we can move inside the vehicle.

Collision Number Two: Stuff Within The Vehicle Moves Toward The Point of Impact

This includes the vehicle occupants. Everyone inside the vehicle will move in the direction of impact until they are stopped by their seat belts or the inside surface of the vehicle. Both of these options can create injuries. Keeping that in mind, it’s useful to know where the patient was sitting inside the vehicle and whether or not they were restrained.

Also peak around for other heavy objects that may have struck the patient during the crash. Groceries, car seats, tool boxes and the bowling ball from last weeks league game can all become deadly projectiles during a run-of-the-mill vehicle accident. In much the same way, oxygen bottles, med kits and ECG monitors can all add complications to a run-of-the-mill ambulance accident. I digress.

Collision Number Three: Stuff Within The Patient’s Body Strikes The Inside of The Patient’s Body

Excuse my overly technical use of the word stuff, but there’s a lot of stuff inside the average patients body and it all behaves differently when it’s forced to go from fast-forward to stopped-dead. Solid organs like the spleen and the liver fracture and bleed. Hollow organs like the stomach rupture. Vessels like the aorta tear. Lungs rupture or become punctured.

This is all part of the third collision. And if you’ve paid attention to the first two collisions, much of it is predictable. Certainly you can’t predict all the injuries suffered in an auto accident, but you can get pretty good at guessing what injuries you might find based on a thorough investigation of the mechanism of injury.

There you have it. The three collision rule. The next time you walk up to a car accident, count the number of cars and multiply by three.

What do you think? Do you know the three collision rule? Do you think about it? Is it useful? Leave a comment and join the discussion.

Read More Stuff:

Understanding Kinetic Energy and Trauma

Doctors Watching EMS Care on Cameras?

The C-spine Immobilization Controversy

The Ultimate Guide to EMT Vital Signs: Respiration

What Motivates Us Really?

]]> http://theemtspot.com/2010/11/03/the-three-collision-rule/feed/ 5 http://theemtspot.com/2010/06/08/the-ultimate-guide-to-emt-vital-signs/ http://theemtspot.com/2010/06/08/the-ultimate-guide-to-emt-vital-signs/#comments Tue, 08 Jun 2010 20:32:12 +0000 Steve Whitehead http://theemtspot.com/?p=3207 Part 3: The First Rule of Vital Signs

This is probably a good time to bring up the number one rule of vital signs. Remember the movie Fight Club? Everyone knew the first rule of fight club was to never talk about fight club. Now let me give you the first rule of vital signs. Burn it into your memory.

Never lie about vital signs.

Oh, I know. You think you’d never lie about vital signs. You’re an honest person right? Why would you lie about something as silly as vital signs? And yet, it happens…a bunch.

There you are deflating that blood pressure cuff. Everyone’s looking at you, waiting for your report, and you hear . . . . (wait for it) . . . (wait for it) . . . nothing! everyone is waiting. And you did see the needle bounce right around 120 and stop bouncing right around 70. The BP must be normal right? Couldn’t you just make it up and save face?

Don’t do it. It’s hard to admit when you just don’t hear the BP or can’t feel the pulse, especially when you think it’s something you’re doing wrong. It’s easier…and very tempting, to fake it. Don’t do it. You only have to make up incorrect vital signs once to completely blow your credibility.

Report a 120 over 80 blood pressure to your partner when it’s really 60 over nothing just one time and your credibility as a caregiver is shot. Tell the hospital the patient has a strong pulse at 84 bpm when it’s really weak and irregular at 136 bpm just one time and it will be a long time before they trust your hand-off report again. Medicine is harder when your colleagues don’t trust you.

Everyone has had the experience of not being able to feel a pulse, or hear a lung sound or a blood pressure. Practice your vital signs. Take them diligently and then tell the God’s honest truth about what you find.

Now it’s your turn: Have you ever been tempted to lie about the vital signs? Have you ever done it? What happened?

Read more EMS stuff:

Medicine Between The Frames

Beyond the 1-10 Pain Scale

You Can’t Give Away What You Don’t Have

Waiting Is Serving

Self Destruct

As much as we practice this skill in EMT class, I often wonder why so many EMT’s have such bad head-to-toe skills out on the street. It seems that, once we get out on the street, the systematic, thorough head-to-toe assessment falls out of favor and quickly gets replaced with the faster, more direct focused assessment.

That works just fine most of the time. If it didn’t, I figure it probably wouldn’t be such a universal phenomenon. (For the record, have you ever worked somewhere where this wasn’t the case? Neither have I.) The downside is that when the patient arrives who really needs a, honest-to-goodness, rapid, complete head-to-toe, we’re not up to the task.

I happen to believe that patient assessment skills are one of the defining qualities of a talented EMT. Here are seven tips to keep your head-to-toe in top form.

1. Do head-to-toe assessments frequently.

I mean more frequently than you’re doing it right now. You have a lot more opportunities to do a a good head-to-toe than you’re currently taking advantage of right now. Drop the surprised expression. This is just you and me talking here right?

That infant in the car seat involved in the fender-bender could have used one. That trip and fall at the mall would have been prefect too and so would that dude punched in the bar fight. You let them all go without a top-to-bottom physical exam. The more you do head-to-toe exams, the more comfortable and efficient you’ll become.

2. Be systematic.

It’s called a head-to-toe for a reason. No, that doesn’t mean that you need to start at the head every time. (In fact, with kids, I recommend starting at the feet.) But you do need to have a system and stick to it. If you make up your physical exam each time you do it you’re never going to be smooth. When an emergency is in full-swing, the assessment won’t come naturally.

People tried to teach me this lesson for a long time and I don’t know why I was so slow to learn it. I guess it just seemed silly to force myself to do the assessment the exact same way every time. I’m glad I finally relented. Now I understand. If you want to be efficient when it counts, you have to be systematic.

3. Pay attention to the patient’s facial expressions during your assessment.

Sure we ask the patient if it hurts, but you’ll pick up on a lot more if you pay attention to the patients face. Are they distressed or relaxed? Are they paying attention or distracted? Do they wince or grimace during palpation? There are many reasons why a patient might try to conceal their discomfort and if you are in the habit of only looking at the body part you’re checking, you’re going to miss some stuff.

4. Interact with the patient.

I don’t just mean, breathe deep, does this hurt, yada, yada. That’s the patient interview. But it isn’t real interaction. Talk to people while you’re assessing them. Family doctors have mastered this skill, and for good reason. There’s a wealth of patient assessment information to be gained by just talking with folks about what happened, where they were going and whatever else is on their minds.

You don’t need a fancy mental status exam to figure out if people are oriented and responding in context. Just talk to them. If their brain isn’t working right you’ll figure it out.

5. Visualize the structures beneath the skin.

This requires you to know your anatomy. If you’re palpating parts of the body and you can’t visualize the structures beneath the skin, go back to your anatomy text book or try to find a cadaver lab to attend.

It’s a worthwhile skill to be able to visualize what lies beneath the patients skin and it’s essential when we are calculating the possibility or probability of injury and developing a differential diagnosis.

6. Feeling, really feeling, is harder than you might think.

Of course, we feel the patients body. Palpation is feeling. What else would we be doing? Actually most of what’s going on is looking and asking. Things that we see like bruises and abrasions are rarely missed in a proper physical assessment. Pain and tenderness is also pretty easy to pick up on. Push, “ouch”, got it.

But things that we need to feel. Things like crepitus or masses, or fever or coolness or rigidity. Those things tend to get missed. we miss them because it’s easy to go through the motions of palpation, but it requires some mental energy and practice to really feel for abnormalities.

It’s also something we never really get to practice until were doing real-deal patient assessments. In class we get in the habit of looking and pushing but you can’t really feel abnormality on a mannequin. They feel hard and plastic every time. When you’re palpating a human, focus on what you’re feeling.

7. Be confident.

Have you ever watched an ER physician do a physical exam? Pay attention the next time you get an opportunity. Watch not only the types of assessments they do but the manner in which they move from one assessment to the next, interacting with the patient, describing the needed behaviors or responses.

ER physicians do thousands of patient assessments and it shows. They don’t need to think about the next step in the process. They just do it. It’s the same way a short order cook doesn’t need to think about the ingredients in your Denver omelet. It’s the same way a professional baseball pitcher doesn’t need to think through the steps to throw a slider. They have reached a level of unconscious competence.

When you’re working on your head-to-toe technique, strive for that level of unconscious competence. Where you are confident in your ability because you know what comes next without ever needing to think about it. At that level of ability you can really focus on what you’re seeing, feeling and hearing.

I said it at the beginning but it bears repeating. Your physical assessment skills are one of the defining qualities of your patient care ability. When I’m evaluating a new EMT or paramedic, one of the first things I want to see them do is perform a complete head-to-toe assessment.

Performing that skill well, with calm confidence, is one of the hallmarks of a good EMS provider. It is an essential, foundational skill that speaks volumes about your ability. Could yours use a tune-up?

Now it’s your turn: Have you ever known a really good EMT who couldn’t do a near-perfect head-to-toe assessment? Have you ever known a really bad one who could? What are your tips for mastering this skill? Other readers would like to know. Leave a comment and help make this post even better. 

Read More Goodness:

Test For Unconsciousness: The Hand-Drop

Five Big Trauma Scene Mistakes You Can Avoid

5 Assessment Findings That Should Concern You

The EMT Code of Ethics

Beyond The 1-10 Pain Scale

One of Scott’s observations is that comic books require imagination on the part of the reader because, in all great comic books, the action occurs between the frames. The artist only shows you snapshots of action and dialogue. Most of the story takes place in our heads. The real story is the stuff that we invent that happened in-between the frames.

Medicine works in much the same way. We assess, we ask our questions, we do our head-to-toe and we make a guess (educated) about what’s going on. Then we make a change, and the medicine begins, after we make the change, not before.

Then we do the in-between stuff. Loading the patient on the pram, shoring up the splinting, carrying the bags back and forth, making a phone call to the doc. And the medicine works … or it doesn’t.

And then we start the next frame. The action starts all over, but make no mistake, the medicine happened while we were doing other things. Just off the boarder of the frame.  Between one action and the next, while were busy doing the in-between-stuff, the medicine happens.

Don’t miss it.

Now it’s your turn: Do we forget to focus on the medicine that happens in-between our interventions? Is it important to remember that the medicine happens in-between interventions or is it just a matter of semantics.

Related Articles:

The Art of The Pulse Check

The Art of The Nasopharyngeal Airway

Understanding OPQRST

Beyond the 1-10 Pain Scale

The Ultimate EMS Protocol

I’ve gone live with the book and newsletter sign up and it appears that everything is running smoothly. I’ve already had a half dozen sign-ups and the link has only been posted for a few minutes.

Thanks for your patience. This writing project took me nearly six months to finish. I had an idea of what I wanted this book to be and I wasn’t willing to stop until I’d succeeded.

The result is The Non-Conformists’ Guide to EMS Success. This is no pamphlet or power point slide show. This is 48 pages, almost 16,000 words, and chapter after chapter of compelling ideas designed to challenge the way you think about your job, your leadership, your life, and your role in EMS. And it’s all free.

If you’re ready to stop listening to me talking about it and get the book for yourself, just click the newsletter sign-up at left. The EMT Spot practices a strict, double opt-in, anti-spam policy. We’ll never reveal your e-mail to anyone, ever.

You’ll receive an e-mail confirming that you really did sign up for Splatter and the e-book. Once you click the confirmation link you’ll received your welcome edition of Splatter and the .pdf version of the e-book will be attached. It’s as simple as that.

The newsletter will also have an opt-out link at the bottom if you’d rather not be on the newsletter mailing list. (But I hope you’ll decide to stay)

I also hope that after you’ve read the e-book, you’ll come back here and post a comment, or send me an e-mail, letting me know what you thought about it.

I look forward to your comments, I look forward to providing you a behind the scenes look at the web site in the monthly newsletter and I look forward to continuing to provide you with quality content right here on the blog. Thank you for stopping by.

Now it’s your turn: Will you be signing up for the e-book and newsletter? Why or why not? If you’ve read the book, what did you think? Leave a comment before you go.

My first E-book is scheduled for release on January 21st, one week from today. The e-book will be free and it will be available right here at The Spot.

The Book is called The Non-Conformists Guide to EMS Success. This book is the culmination of two decades of EMS experiences, mistakes, failures, trials, and errors that lead to my ultimate success. My goal was to write something that would be useful to EMTs at any stage in their career. And I didn’t hold anything back. This is my road map to finding true success and fulfilment in EMS work.

I started at the beginning and kept typing until every ounce of useful information was on the screen. Over 15,000 words and 50 pages later I closed the largest writing project I’d ever undertaken. And now you can have it for free.

The book release will also coincide with the launch of Splatter, a brand new bimonthly newsletter for regular readers of The EMT Spot. Splatter will be the behind-the-scenes, insiders guide to The Spot. You’ll get the e-book and the newsletter all in one go. And it’s all going to happen right here. So mark your calendars. I’ll see you back here in a week for the ribbon cutting and the cake.

I’d like to teach you how to take a pulse in three seconds or less. Yes it’s possible.

I am, quite possibly, about to contradict everything you learned about taking a patients pulse in your EMT class. Hear me out on this one.

In general, I think we overemphasize the importance of coming up with a set of numbers that represent the patients vital signs and we underemphasized the importance of placing the patients vitals in context for their condition. The pulse is a prime example of this dynamic at work.

The patients pulse holds a wealth of clinically significant information. The exact heart rate isn’t one of them. Sometimes, we get this misconception lodged in our brain that the purpose of feeling the patients pulse is to determine how many times their heart is beating each minute. We will dutifully devote 15 seconds, 30 seconds … yes some even advocate taking a full minute to make sure this number is perfectly accurate.

I disagree. You can determine everything you need to know about the patients pulse in three seconds and then move on. The next time you kneel to take a patients pulse, consider these four, clinically relevant findings instead of staring at your watch.

1. Estimate the heart rate.

That’s right, just take a guess. The more you practice this, the better you’ll get. You should be able to guess the patient’s heart rate to within four beats-per-minute in either direction. That’s as close as you need to get. Get in the habit of grabbing a pulse and estimating the rate before you look at the monitor or count it off a watch. You’ll be surprised. This isn’t as tough as it might seem.

2. Is the patient’s heart rate to fast or to slow?

Start thinking like Goldilocks. You know … from the nursery rhyme? Everything was either too much or too little or just right. Once you have an estimated idea of the pulse rate ask yourself, “Is that too fast for this patient, too slow for this patient or just right? Knowing whether the pulse is too fast or too slow in the context of this particular patient is much more important than having an exact number.

3. Is the patients pulse strong or weak?

Imagine the heart as a pump (it is) sending a wave of pressure through the arteries and out to your gloved fingers. Is it a strong pump or a weak one? Does the pulse bound strongly or is it thready and weak? This is significant.

A quick note on weak pulses; don’t spend to long searching for a pulse you can’t find. We tend to doubt ourselves when we are unable to find a pulse so we keep searching, and searching … and searching. If you can’t feel a pulse, check quickly at the brachial artery and then grab your blood pressure cuff.

If you find that the blood pressure is adequate you can always come back and search around for that pulse, but don’t delay the continued assessment of a possibly hypotensive patient to search for a pulse.

4. Is the patients pulse regular or irregular?

Does the pulse have a nice regular cadence to it or does it occur irregularly. An irregular pulse will present in gallops and pauses. It can be subtle or obvious. In some cases, an irregular pulse is not clinically important finding. In some cases it could be medical emergency. Note the regularity or irregularity of every pulse you check.

What I’d really like you to take away from this is that the exact heart rate is pretty low on the clinical significance scale. We tend to spend far too much of our time, energy and focus on obtaining a highly accurate heart rate and not enough time or focus on the things that are very significant about the patients pulse. Is it too fast or too slow? Is it strong or weak? Is it regular or irregular? There will be time later to get the heart rate nailed perfectly. And if there isn’t … it probably wasn’t that important anyway.

So what do you think? How much time do you spend taking a patients pulse on scene? Do you agree or disagree with my thoughts on the importance of that task? When is it very important to have an exact heart rate? Is it ever? Leave a comment and let me know.

Related Articles:

 The Art of The Nasopharyngeal Airway

Remembering The Glasgow Coma Score

Understanding Combative Head Injuries

Describing Pain

Six Techniques to Nail The IV Every Time

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 …

Some people don’t respond to it.

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.

Related Articles:

Test For Unconsciousness: The Face Flick

Test For Unconsciousness: The Hand Drop

Remembering The Glasgow Coma Score

Understanding Combative Head Injuries

Describing Pain

What Is Blood Anyway?

We painted the perfect picture for you in your cardiac emergencies lecture in your EMT class. The pain felt like a pressure. It was brought on by exertion. It radiated to the left arm and through to the back. Sometimes, in your EMT skills stations, we would get fancy and have it begin at rest and radiate to the jaw. Just trying to keep you on your toes after all.

All this stuff is good to know. But we may have done you a disservice. You may be walking around with the idea that you can do a quick OPQRST and a SAMPLE and walk away with a fairly good feel for whether or not your patient is having a heart attack. You may be dead wrong.

What we may not have told you was that a large percentage of your patients suffering acute myocardial infarction won’t look anything like this. Atypical cardiac chest pain, those folks who have heart attacks but don’t quite feel like they’re supposed to feel, are actually very common. Common enough that we may need to think of a new name for them. Research says that the atypical folks may be a whole lot more typical than we think.

Did you know that the patient who is having a true myocardial infarction is 10% more likely to have pain radiate to his right arm than his left? Wrap your brain around that one.

It gets worse:

• 26% will experience shortness of breath as their primary complaint.
• 23% will complain of a burning sensation similar to indigestion.
• 6-9% will say the pain is positional or pleuritic. (Associated with respiration.)
• 5% will describe the pain as sharp and stabbing.

And when you’re done adding up all of those atypical findings, consider this:

A full 33% of acute myocardial infarction patients will have no pain at all.

You read that right – 33%. One out of every three heart attack victims don’t feel any pain. They have syncopal episodes or they have palpitations. They may get dizzy, feel weak and even fall down. They may complain of unusual sweating or an inability to catch their breath or vague nausea. But they won’t feel pain. You’ll need to figure out that their having an acute cardiac event all on your own, without the help of the single most telltale sign in the book.

The chances of having a painless heart attack increase dramatically with age. Diabetic are particularly prone to painless MI’s and females tend to have them more often than men.

When you add it all up, the atypical chest pain patients may very well be more typical than the presentation we described in your EMT scenario. The next time you encounter an acute cardiac patient with exertional chest pain that feels like a pressure and radiates to the left arm, you may want to think to yourself, “Interesting cardiac presentation … but not very typical.”

“Symptoms Other Than Chest Pain …” Circulation, 111(24) e435-e437, 2005

“Prevalence, clinical characteristics, and mortality …”  JAMA 2000 Jun 28;283(24):3223-9

“Acute Chest Pain in The Emergency Room” Arch Intern Med. 1985;145(1):65-69

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Beyond The 1-10 Pain Scale

Understanding OPQRST

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