we've all been there what did you do?

[Veneficus]

Well, why wouldn't you backboard an elderly patient with a skin tear from a sternal rub? After all, it's a trauma now!

/sarcasm

Then they are not faking, they have a real emergency!

Somebody call Brown, this will require a level 1 for sure

 

[JPINFV]

i really wanted to make a joke about anterior AND posterior LSB.... but i just can't

Maybe something along the reason why women are the best at placing an anterior and posterior LSB?

/me ducks and runs away...

 

[Aidey]

Is everyone that is referring to a sternal rub just deferring to what they learned in school?

The standard of care has been updated.

A vigorous sternal rub can cause skin tearing. Think about granny on coumadin before you start smashing your knuckles on your CUSTOMERS.

Think about peripheral vascular disease, or peripheral neuropathy when you start squeezing peoples distal extremities.

People, please stop abusing your patients. Use a trap squeeze, or just play along and take them to the ER.

Ok, to be honest it is hard to get worked up about a sternal rub when I've seen ER docs and nurses do them on a semi regular basis. Same thing with the hand drop BTW. Part of using an intervention is knowing who it is appropriate to use it on, and that means doing something else when your patient is more susceptible to skin tears.

There are some very legitimate complaints about EMS, but when we are talking about something still in common practice in the ER I don't think it is fair to put all the blame on EMS being backwards.

As far as "play along and take them to the ER", that only goes so far when you are expected to be able to tell the difference between sick and not sick. "Playing along" with a falsely unconscious patient with any sort of trauma results in some VERY pissed of trauma surgeons, ER docs and charge nurses around here. Trauma + A GCS under 13 results in an automatic trauma activation...see where that can be problematic?

We take the blame for those, and it undermines our credibility for every other trauma patient we bring in. Maybe it isn't right, but it is what happens.

 

[8jimi8]

Ok, to be honest it is hard to get worked up about a sternal rub when I've seen ER docs and nurses do them on a semi regular basis. Same thing with the hand drop BTW. Part of using an intervention is knowing who it is appropriate to use it on, and that means doing something else when your patient is more susceptible to skin tears.

There are some very legitimate complaints about EMS, but when we are talking about something still in common practice in the ER I don't think it is fair to put all the blame on EMS being backwards.

As far as "play along and take them to the ER", that only goes so far when you are expected to be able to tell the difference between sick and not sick. "Playing along" with a falsely unconscious patient with any sort of trauma results in some VERY pissed of trauma surgeons, ER docs and charge nurses around here. Trauma + A GCS under 13 results in an automatic trauma activation...see where that can be problematic?

We take the blame for those, and it undermines our credibility for every other trauma patient we bring in. Maybe it isn't right, but it is what happens.

Aidey,

I didn't at all blame EMS, I simply asked people if they are deferring to an old educational paradigm.

Every time I see a sternal rub on a patient, I follow up with that practitioner and remind them that the technique is outdated and potentially harmful.

I also, do not work (nor have ever been paid in EMS) so I haven't picked up on the idiosyncracies of transport politics.

I would not activate a trauma alert on a patient i suspected to be playing unconscious.

I have never, nor would I ever intentionally harm a patient. If I have ever needed to asses level of consciousness on a suspected unconscious, even people on their death bed have not been able to ignore my trap squeeze. I'm a rock climber, I have very strong hands, maybe that's why... But when I was the "victim" for my EMT-Basic skills class, I could NOT ignore my instructor's trap squeeze either... Even though I was supposed to be an unconscious diabetic.


so all the anecdotes aside, the point being. Sternal Rub is outdated and shouldn't be employed as a tool in modern EMS

 

[Aidey]

It isn't a matter of us saying "Trauma activation" on the patch or not. It is the hospital's own policy. If we patch in with a GCS of 13 or lower, and a CC of a traumatic injury, the hospital activates.

They have some discretion when it comes to the exact situation, but only so much. If I call in with "85 year old female, fall, obvious R hip deformity, GCS of 12, pt has hx of dementia said to be acting normal" they will do a modified activation, where they call the trauma surgeon to notify him, but the whole team doesn't come rushing to the ER.

However, the guy who robbed a convenience store, ran from the police and got tackled and is now playing unconscious will end up an activation.

There are much worse things out there being used by ER docs. Ammonia in a mask and saline in the ear are two that come to mind.

 

[8jimi8]

Do you do those things with your license? I mean what are you arguing here?

 

[8jimi8]

The hospital activating a trauma alert based on the info you give, doesn't have a thing to do with your fault. Sure maybe a trauma alert is a great way to get a conscious cold caloric, but at the end of the day are you the one abusing people?


I saw one of my intensivists use a laryngoscope on an fully awake and alert patient, but its not something i'll ever repeat... watching a guy in restraints flail and gag with his head dangling off of that hook...

I'm not trying to win anyone's points here, i'm just being an advocate for the people we are charged to care for.

 

[Aidey]

Oh go grief no, those were both things I saw ER docs do to unconscious patients. I have asthma and don't even allow ammonia in the back of the ambulance. If a FFs sets one of those things off after I warn them, I get to drive and they get to ride in the back.

The problem is that we are blamed for the accuracy of that info. If we call in a GCS of 12 and the patient is faking it, they expect that we would have figured that out and never called in with a GCS of 12.

 

[8jimi8]

I think we are on the same page here.

As usual we end up splitting hairs in the middle of the night. Don'tcha love the night shift.

 

[yotam]

Too many variables, too little time to differentiate. Your patients' reason for faking could range from a 16 y/o adolescent seeking attention from his ex-marine father or a 45 y\o lady with breast cancer that doesn't want to tell her family, but doesn't know how to go to the hospital without alarming them (given the etiology of her unconsciousness could be easily explained by low BP\low sugar\stress. True story, BTW).

So, bottom line- play the game, don't judge it. It's nothing personal, and they are not lying to you- they're lying to the man that could bring them to the hospital.

In the service I had many of those fakers, soldiers who just wanted some rest. You'd be surprised how much your endurance for pain rises when you just wanna go to bed. There is really not much to do- At most times the usual physc games don't work- just strap'em and driv'em.

 

[lampnyter]

Just to put in my 2 cents, a nasal airway isnt torture. If it is torturing the person there you are doing it wrong.

 

[8jimi8]

Just to put in my 2 cents, a nasal airway isnt torture. If it is torturing the person there you are doing it wrong.

If it isn't indicated, it is incorrect.

 

[yotam]

If it isn't indicated, it is incorrect.

We all do it... Giving 1CC seline to someone who wants morphine but really doesn't need it (or if you're riding a BLS and you don't have), or giving oxygen to an HY patient who clearly isn't in any respiratory trouble (provided it isn't an acute HY. They can actually become apneic!).

So, we all do it. I guess it's all about damage control. Never tried nasal (we don't have it here), but it certainly doesn't look pleasant.

 

[usafmedic45]

provided it isn't an acute HY. They can actually become apneic!

Who told you that? You might get a pause in breathing, but making someone fully apneic normally takes a lot more than hyperventilation + a little O2.

 

[usafmedic45]

If it isn't indicated, it is incorrect.

That wasn't his point.

 

[reaper]

If it isn't indicated, it is incorrect.

We all do it... Giving 1CC seline to someone who wants morphine but really doesn't need it (or if you're riding a BLS and you don't have), or giving oxygen to an HY patient who clearly isn't in any respiratory trouble (provided it isn't an acute HY. They can actually become apneic!).



So, we all do it. I guess it's all about damage control. Never tried nasal (we don't have it here), but it certainly doesn't look pleasant.

So do you document that on your report? That you lied to the pt and gave them something other then what you told them you were giving them?

If a pt is unresponsive to you, then a NPA is well within indication!

 

[cruiseforever]

We all do it... Giving 1CC seline to someone who wants morphine but really doesn't need it


Please do not use " we all do it", I have not given saline in place of morphine.

How do you know the pt. does not need it? Yes there are a lot of seekers out there. Unless you are in their body we have no sure fire way to judge how much pain they feel.

I believe pain is one area that we really under treat.

 

[8jimi8]

In the words of Bob Marley, "Who feels it, knows it"

I give pain medicine to drug seekers on a daily basis. Not my place to judge.

My whole dog in this hunt has been against punitive interventions.

Please people, don't take it personally, when a patient lies to you, or pretends something is wrong.

That isn't pretend, something really is wrong.

 

[Icenine]

My protocols make this very easy.

Airway- Jaw thrust (hurts like *#%)

AVPU- Usually nail bed "stimulation"

Narcan IN (If indicated)

BGL- The stick is usually not unsuspected, and the seasoned players know it's coming when you start milking the finger.

Glucagon IN (If signs and symptoms, south of 80 mg/dl)

An unsuspected anything (IN spray, NPA, etc) is a rude awakening. If you don't verbalize what you are doing prior it helps.

And I have any pt that can walk, do so at least to the front steps. This is no exception. I don't mind transporting, but don't make me kill my self.

 

[usafmedic45]

I give pain medicine to drug seekers on a daily basis. Not my place to judge.

It's also not your place to feed someone's addiction. It is your place to judge whether someone needs pain medication. If you want to claim to be a superior provider, perhaps you should not be admitting to something just as indefensible (not to mention potentially illegal) and potentially far more harmful than a nasal airway or sternal rub. Just my two cents....