Neuro ICU - "how to test for pain response in comatose individuals

Dear all

I am a coma care communications trainer and counselor in a neurosurgery ICU in a large state hospital in Africa. It is an under resourced and highly stressed environment.

We work following minimal signals from people in altered states of consciousness - acknowledging and helping amplify these signals.
Our aim is accompaniment and completion of inner process which will hopefully lead to an easier death process (we have one of the highest global rates of AIDS deaths) or recovery process from TBI.

Many of our patients are inidentified young men and women who have entered ICU through violent attacks. It is important for me that their experience of hospital is not one of secondary violence.
Those that have recovered and can remember their experience say how important it was in their recovery and rising to consciousness that they were treated kindly and positively and that they " distanced themselves" when they were treated harshly.

The nursing staff in our unit test for response to pain in the Glasgow coma scale through nipple squeezing.
I want to challenge this practice and would like advice on how this is approached in other hospitals.

With thanks
JW

In my institution we were told that nipple twisting is inhumane and we are not allowed to use it. We use the sternal rub and trapezius squeeze as mentioned above. We also use pencils and sqeeze them over the toe or fingernal where the half moon is near the cuticle.