Which is more accurate in estimating GCS score:sternal rub vs the nipple cripple

[La Fiera]

After failing to respond to a fairly rough sternal rub, an attending I was working with reached over to my patient and twisted the patient's nipple as hard as he could. Surprisingly, the patient not only withdrew, but clearly localized the pain.
So, is squeezing one's nipple more likely to ellicit a more sensitive response, thereby improving a patient's GCS score?? Should we go around twisting nipples to avoid intubations?
Should we get a med student to do a randomized control trial?
It might not fly with the ethics committee.

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[southerndoc]

I've actually had good success with putting a lot of pressure on the coracoid process. You can do this with family watching. The family usually doesn't like to see a physician doing a sternal rub or a nipple twist, but if you just grab the persons shoulder and press the coracoid process between your thumb (on the coracoid process) and your fingers (on the back of the shoulder), you can create a lot of agony for the patient -- enough to wake up the fakers and those with altered mentation. The family just thinks you're grabbing their shoulder out of compassion.

 

[BADMD]

I'm with southerndoc. You've got to be kind of sly when inflicting pain on the patient to assess responsiveness. I've found pressure just above and behind the angle of the mandible works well...and you can look like you are adjusting the person's head for a more comfortable position.

 

[spyderdoc]

I usually do the fingernail press. Doesn't look so cruel to the family. Doesn't leave a mark. I do like Southerndoc's method as well...

 

[DrQuinn]

I do the house key between the fingers. slide it in there, compress the two fingers together, then rotate the key. Hurts like the dickens.

Of course, it would look odd to the family....

Q

 

[southerndoc]

I usually do the fingernail press. Doesn't look so cruel to the family. Doesn't leave a mark. I do like Southerndoc's method as well...

Can't take credit for it. It's the Krochmal method.

 

[roja]

Learning to arouse patients is something that gets better with experience. I can't tell you the number of times someone is 'unarousable' and I have seen them barely putting any pressure on the sternum and say in a quiet voice "mr x... mr x".

I use a variety of methods: sternal rub, fingernail press, pen along sole of the foot. Accompany with a LOUD firm voice.

The 'problem' with all of these is interrater reliability. There is alot of variability in how two people will 'arouse' someone.

I believe there was a study a while back that showed the only decent consistancy between different examiners was nasopharyngeal stimulus (stick a long qtip up the nose).

This is pretty annoying and works well.

 

[WilcoWorld]

Great thread with a lot of good tips. I think I'll try Southern Doc's method next time I'm in front of family, as it seems the most subtle.

To respond to the OP: One advantage of the nipple squeeze is that the areola is dark & will thus show less bruising - it's never good to make it look like you're beating patients up. Also, if I'm ever somnolent in your ED (let's hope I'm not), I'd much rather get awoken with a titty twister then get an ET tube.

 

[dchristismi]

From now on, it's Q-tips up the nose!

(I am a fan of the fingernail smash, but might try the coranoid process trick next time.)Usually the family is not at bedside when I'm doing these things... at least at this job.

 

[knowwareman]

wow... i didn't even know about the coracoid process one. just tried on myself, ouch!

 

[EM2BE]

wow... i didn't even know about the coracoid process one. just tried on myself, ouch!

True it's a good one now that it has been mentioned. We had to locate the coracoid process on each other in lab in 1st year - it was painful!

 

[Chronic Student]

Putting pressure superior and medial to the orbit (around V1) works, as do sternal rub, finger smash, good ol' pinch, jaw pressure, nipple squueze, squeezing the anterior part of the axillae in-between your thumb and forefinger, etc.

Just don't pinch the old folks with really fragile skin. It will tear. Trust me on this one.

I really know how to irritate people!

 

[southerndoc]

I heard water boarding will awaken the fakers.

 

[GeneralVeers]

I use the Vulcan Nerve Pinch on them.

 

[WilcoWorld]

I use the Vulcan Nerve Pinch on them.

Wait, wouldn't that put them down?

Oh yeah, I guess that's what I want to do with most fakers after I've discovered what they're up to.

 

[Substance]

I believe there was a study a while back that showed the only decent consistancy between different examiners was nasopharyngeal stimulus (stick a long qtip up the nose).

This is pretty annoying and works well.

Seconded:

I saw a patient who appeared to be "seizing". The attending looked at me, said "watch this", and proceeded to roll some paper towel up into a little point. He then unflinchingly jammed the paper towel spike up the patient's nose. The patient winced and slapped his hand away.

 

[GeneralVeers]

Seconded:

I saw a patient who appeared to be "seizing". The attending looked at me, said "watch this", and proceeded to roll some paper towel up into a little point. He then unflinchingly jammed the paper towel spike up the patient's nose. The patient winced and slapped his hand away.

Do you also waterboard the patients in your facility?

 

[tybalt]

Putting pressure superior and medial to the orbit (around V1) works, as do sternal rub, finger smash, good ol' pinch, jaw pressure, nipple squueze, squeezing the anterior part of the axillae in-between your thumb and forefinger, etc.

Just don't pinch the old folks with really fragile skin. It will tear. Trust me on this one.

I really know how to irritate people!

One of the attendings at my hospital does this... certainly isn't the most gentle of ways to arouse -- I thought his eyeball was going to pop out

 

[lucky_deadman]

Seconded:

I saw a patient who appeared to be "seizing". The attending looked at me, said "watch this", and proceeded to roll some paper towel up into a little point. He then unflinchingly jammed the paper towel spike up the patient's nose. The patient winced and slapped his hand away.

I've seen a few docs use ammonia ampules for psuedo-seizures. When people were able to withstand the ampule being under their nose, one went up each nostril. Haven't seen anyone able to fake it through this.

 

[GeneralVeers]

I've seen a few docs use ammonia ampules for psuedo-seizures. When people were able to withstand the ampule being under their nose, one went up each nostril. Haven't seen anyone able to fake it through this.

I find that the simple "Force Field" technique works for most of the fakers and doesn't constitute battery. Just drop their hand/arm over their face, and it will magically move aside easily missing the vital parts of the face and neck.

 

[bartleby]

What do you think that it would look like if family or a staff member walked in while you're doing the nipple pinch (on a man, let alone a woman)? Whenever you can stimulate the patient in a way that will avoid leaving a mark, you're much better off. Pressure on the coracoid process, as a poster mentioned above, is great in the presence of family (it looks like you're giving them a reassuring shoulder squeeze), and is quite irritating.

 

[AmoryBlaine]

Seconded:

I saw a patient who appeared to be "seizing". The attending looked at me, said "watch this", and proceeded to roll some paper towel up into a little point. He then unflinchingly jammed the paper towel spike up the patient's nose. The patient winced and slapped his hand away.

Hey, it's cheaper than Ativan.

I like the trick of crushing a toe/finger against a reflex hammer, pen, or the handle of shears. This seems to be a NSurg trick from what I've seen.

That's said, anyone who thinks a good vigorous sternal rub is not sufficiently irritating needs to have one performed on them.

 

[crewmaster1]

Rumor has it that someone in our residency accidentally ripped off someone's nipple a couple of years back and had to call plastic surgery! The patient was still unresponsive.

I have been told that it is important to make sure the pain is applied to a central location (mastoid, coracoid, chest wall, superior orbital wall) and not to extremities because of the neuro reflexes.

 

[Substance]

Do you also waterboard the patients in your facility?

Yes.

 

[GoBuckeyes913]

I heard water boarding will awaken the fakers.

The ED where I'm rotating at right now uses these mini ammonia packets to wake the fakers. I've never seen them before, but it sure as hell works. I took a whiff to experiment and it felt like I was inhaling fire.

 

[GoBuckeyes913]

I've seen a few docs use ammonia ampules for psuedo-seizures. When people were able to withstand the ampule being under their nose, one went up each nostril. Haven't seen anyone able to fake it through this.

Whoops! skipped over this one, sorry didn't meant to be redundant!

 

[Tiger26]

The ED where I'm rotating at right now uses these mini ammonia packets to wake the fakers. I've never seen them before, but it sure as hell works. I took a whiff to experiment and it felt like I was inhaling fire.

After reading this, my first thought was to mention waterboarding sarcastically (well, sort of sarcastically), but then i realized i got beat to it

 

[howelljolly]

Seconded:

I saw a patient who appeared to be "seizing". The attending looked at me, said "watch this", and proceeded to roll some paper towel up into a little point. He then unflinchingly jammed the paper towel spike up the patient's nose. The patient winced and slapped his hand away.

Not a bad idea with the paper towel. The cotton swab up the nose becomes a problem when the patient jerks their head and you're left with a tiny fragment of wood in your hand, while the rest of the device is lodged in the patients nasopharynx.

I like the pen against the nail.

You can also press on the glabella.

Ive seen some pretty nasty abrasions from sternal rubs through shirts.

 

[leviathan]

I find that the simple "Force Field" technique works for most of the fakers and doesn't constitute battery. Just drop their hand/arm over their face, and it will magically move aside easily missing the vital parts of the face and neck.

I've never tried that on a faker, but I told an unexpecting student to fake unconsciousness, and she let her hand drop on her face!