Delaney Schick

Over the last couple of years, with pandemics and vaccines at the forefront of the media, we have all asked the question: what sources can we trust? Who can we trust concerning our health and medical decisions? Most of us, including myself, probably look to the internet. Just this morning, I woke up with a swollen, red eye, and the first thing I did was Google my symptoms. According to a report by The Telegraph, there are over 1 billion Google searches per day concerning health-related content. That’s a lot of people trusting Google to give them the answers. But how many of us know how to decipher if what we are reading is a trustworthy source or not? Social media, news outlets, and even politicians have blurred the lines of reliable sources when it comes to making health-related choices for ourselves and our loved ones. Nowadays, it is more important than ever to know how to make an informed and educated decision. As a registered nurse, I have learned a lot over the years about trustworthy sources in the medical world. With all of the information that exists at our fingertips, it is fundamental to know how to differentiate between what is trustworthy and what is not. What is a Trustworthy Source? Let’s start with sources we can trust. As I said, most of us are quick to use Google as an initial tool to find answers to our questions. Google is not the enemy– it can give us great sources– but we have to know how to cipher through the bad to find the good. If you find yourself researching and come across an article, the University of Washington Library suggests using a SMART check. A SMART check asks: Source: Who or what is the source? What are their credentials? Motive: Why do they say what they do? Authority: Who wrote the story? What is their reputation or mission? Review: Is there anything included that jumps out as potentially untrue? Two-Source Test: How does it compare to another source? If you can answer these questions with answers that support a credible source, then you’ve most likely found yourself a trustworthy article. Examples of trustworthy sources in the medical field include the National Institute of Health, MedlinePlus, Center for Disease Control and Prevention, medical institutions (universities or hospitals), and peer-reviewed journals. Commonly used, WebMD is also a reliable source and provides great resources. However, it is important to note that even WebMD states on every page of its website, “WebMD does not provide medical advice, diagnosis or treatment.” It is important to remember that no Google search, published article, or WebMD post can replace seeing your primary care provider. They are our formally trained experts. Even if they do not have the answer to your question, they have access to and knowledge of credible research and resources. What Sources NOT to Trust? Now that you know how to find a trustworthy source, there should be red flags associated with articles or posts that cannot pass a SMART check. The NIH recently posted an article about what to ask before trusting a website. They said to be wary of websites that offer “quick and easy solutions” or “miracle cures” for your health problems. Sources that are not credible may include authors with no credentials or expertise in the field, posts that do not have linked supporting sources, blog posts that are sharing opinions rather than facts, and out-of-date publications. Do not be quick to believe the first thing that shows up on a Google search or a sensationalized post made by a social media influencer. If you read something that sparks your curiosity, double and triple-check it with credible sources and research. It’s Your Choice Asking questions is one of the most powerful tools we have. When we know how to find informed and educated answers to our questions, we help stop the spread of misinformation. Controversial health topics will inevitably remain a part of our everyday news consumption, but it is important to be equipped to decipher what is true and what is not true. As we have learned, sometimes it takes quite a bit of digging before we know if a source is trustworthy or not. Ultimately, it is your choice what you consume and believe, but keep researching, asking questions, and not believing everything you read. References Dr. Google will see you now: Search giant wants to cash in on your medical queries How do I know if my sources are credible/reliable? National Institutes of Health MedlinePlus Centers for Disease Control and Prevention WebMD NIH: Online Health Information: Is It Reliable?

As a Neuro ICU nurse, I used sternal rubs as a go-to method when a painful stimulus was necessary to test a patient's motor response. Thankfully, with some research, I realized it might not be the best practice. Although it is not wrong, in this article, there are other more effective and safe methods. In this article, we'll cover: The proper way to perform a sternal rub Why we sometimes use it for the Glasgow Coma Scale When not to use a sternal rub Alternative central pain stimuli techniques What is a Sternal Rub? A sternal rub is a firm rub on someone's sternum is a method used when testing an unconscious person's responsiveness. A "painful or noxious stimuli", the purpose is to elicit a response from a patient unresponsive to more gentle interactions. This method is one way to test someone's motor response. After a patient doesn't respond to more innocuous stimuli such as voice, gentle rubs or the like, a healthcare provider can perform a sternal rub. Some indications for sternal rubs include brain injury or an overdose. With these conditions, sternal rubbing may be a valuable technique to employ. Sternal rubs are one part of a common neurological assessment called the Glasgow Coma Scale. What is the Glasgow Coma Scale? The Glasgow Come Scale (GCS) is the most objective system used in healthcare to rate someone's level of consciousness. It's used in the field by EMTs and paramedics, in the hospital upon admission, and in a hospital unit with every nursing or provider assessment. The scale assesses 3 areas: eye-opening, motor, and verbal responses. The parameters are scored as: Eye Opening Response Spontaneous--open with blinking at baseline (4 points) To verbal stimuli, command, speech (3 points) To pain only (not applied to face) (2 points) No response (1 point) Verbal Response Oriented (5 points) Confused conversation, but able to answer questions (4 points) Inappropriate words (3 points) Incomprehensible speech (2 points) No response (1 point) Motor Response Obeys commands for movement (6 points) Purposeful movement to a painful stimulus (5 points) Withdraws in response to pain (4 points) Flexion in response to pain (decorticate posturing) (3 points) Extension response in response to pain (decerebrate posturing) (2 points) No response (1 point) The average healthy person with no deficits is going to score a 15. One area we often use the GCS is with patients with brain injuries. The lower the number, the more severe their head injury is. The categorization depends on severity: Severe Head Injury: GCS score of 8 or less Moderate Head Injury: GCS score of 9 to 12 Mild Head Injury: GCS score of 13 to 15 As a healthcare provider, you perform a test for each area to determine the score. If someone does not respond to voice or touch, then use painful stimulation. Often, that stimulus is a trapezius squeeze, mandibular pressure, supraorbital pressure, or a sternal rub. Steps to Perform a Sternal Rub Correctly It's vital to ensure a sternal rub is appropriate in the situation. It should not be your first move on someone who appears unconscious because it is extremely painful (just try it on yourself; it does not take a lot of pressure to cause discomfort). There are other things you should try first. For example, a good place to start is with a gentle shake and saying, "Hey, are you okay?” If they do not respond to voice or touch, move on to a painful stimulus. Try peripheral stimuli first. You can apply pressure to the bottom of their nail bed with your thumb and index finger. Pay attention to their hands and feet because they are often the first— and possibly the only—response you will get from a subconscious person. It's important to note that a peripheral stimulus response does not mean the same as a central stimulus response in a patient. You may only get a spinal reflex response if you apply pain to someone's periphery (hands, lower legs, feet, or nail beds). A sensory nerve tract sends the pain signal to the spinal cord. The spinal reflex immediately responds via a motor nerve tract that travels to the muscle of the extremity experiencing pain. If intact, this will cause the patient to respond by withdrawing from the pain. Because the impulse stopped at the spinal cord, it was never transmitted to the brain. Therefore, a positive peripheral response only indicates that the peripheral nervous system is intact. To be accurate, you must also check their central nervous system. One method to check the central nervous system response is to provide a painful central stimulus, often a sternal rub. To perform a sternal rub with accuracy, follow the steps: Assess the sternum. You don't want to sternal rub someone with a presternal abrasion or a fresh sternotomy scar from cardiovascular surgery. If either is present, perform another type of central stimuli (trapezius squeeze, mandibular pressure, or supraorbital pressure). Make a fist and firmly rub your knuckles up and down the person's sternum. There is no need to rub using all your strength; firm pressure is appropriate. The goal is to not leave a bruise. Apply pressure and rub the sternum until you elicit a response. Do not rub for more than 30 seconds. Look for responsiveness. Again, watch the person's hands or feet for movement; it may be a small, slight movement. On the contrary, the person may respond more appropriately and reach toward you to stop the pain. When to Avoid a Sternal Rub In many cases, you can avoid sternal rubs altogether. Some say it is the least recommended painful stimulus because it does not distinguish if the person is localizing or withdrawing from pain, which is vital to note when scoring a person on the GCS. As mentioned before, try other stimuli first. Start with the least invasive and transition to more invasive methods if necessary. Avoid sternal rubs if The person is intoxicated or sedated. Alcohol is a central nervous depressant. Certain drugs like benzodiazepines, barbiturates, and some sleep medicines also depress the central nervous system, depressing their response to a stimulus. There is a presternal abrasion, or you will leave a bruise. Another team member recently performed it. Collaborate with your team to determine what response they saw or whether they performed it correctly.= The person recently had open heart surgery with a sternotomy. Assess the chest to see if the person has a long midline surgical scar down their chest. Irritating that incision could cause anything from infection to wound dehiscence. The person has polytrauma or suspected rib fractures. What Are the Potential Risks of a Sternal Rub? Sternal Rubs Can Cause Bruising or Abrasions There is a case study of a 50-year-old male in the hospital for an intracerebral hemorrhage. On admission, his GCS was 5 (Eyes-1, Motor-3, Voice-1). Knowing that, providers most likely performed sternal rubs or painful stimuli on him multiple times daily. Unfortunately, he developed a 7cm by 1cm abrasion on his sternum, directly caused by excessive sternal rubs. Always assess the sternum beforehand. Watch Out for Combative Patients As you have learned, sternal rubs induce a lot of pain. For some people, they can elicit a response so significant it might involve their hand or arm coming at you and causing an injury. Even in a subconscious state, this type of painful stimulus can cause purposeful or non-purposeful harm. Infections or Worsened Injury Avoid sternal rubs when there is an incision, abrasion, or injury to the chest. The last thing the patient needs is for their providers to worsen their condition by blindly sternal rubbing them, which could irritate an incision or open wound on or near the sternum. You don't want to have to page the cardiothoracic surgeons if you see a sternotomy scar start to dehisce. And you definitely do not want to feel some already broken ribs cracking when you could perform a trapezius squeeze instead. Bottom Line Use your clinical judgment to decide if a sternal rub is necessary. Because it is such a common practice, knowing the risks that come with sternal rubs is crucial. Now you understand the risks and when to avoid sternal rubs altogether. You also have learned alternative methods for central painful stimuli, such as the trapezius squeeze, mandibular pressure, and supraorbital pressure. Painful stimuli are sometimes necessary when scoring someone on the Glasgow Coma Scale. Ensure you take the appropriate action to get an accurate response without causing more damage. STAFF NOTE: Original Community Post This article was created in response to a community post. The comments and responses have been left intact as they may be helpful. Here's the original post: References Mistovich, J. (2017, May 16). Misinterpreting the results of a sternum rub. EMS1. Retrieved February 21, 2023, from https://www.ems1.com/ems-products/patient-handling/articles/misinterpreting-the-results-of-a-sternum-rub-Zk7mSQgBWXfyvygq/ Whitehead, S. (2022, November 10). Test for unconsciousness: The sternal rub. TheEMTSpot. Retrieved February 21, 2023, from https://www.theemtspot.com/test-for-unconsciousness-the-sternal-rub/#So_how_do_we_do_it_properly Jain, S., & Iverson, L.M. (2022, June 21). Glasgow coma scale - statpearls - NCBI bookshelf. National Library of Medicine. Retrieved February 21, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK513298/ Centers for Disease Control and Prevention (n.d.). Glasgow coma scale. Retrieved February 21, 2023, from https://www.CDC.gov/masstrauma/resources/gcs.pdf Emergency & Mobile Medicine Learning Network. (2006, July). Beyond the basics: Patient assessment. Retrieved February 21, 2023, from https://www.hmpgloballearningnetwork.com/site/emsworld/article/10322699/beyond-basics-patient-assessment#:~:text=Since the sternal rub does Naalla, R., Chitirala, P., Chittaluru, P., & Atreyapurapu, V. (2014, April 7). Sternal rub causing presternal abrasion in a patient with capsuloganglionic haemorrhage. BMJ Case Reports. Retrieved February 21, 2023, from https://casereports.bmj.com/content/2014/bcr-2014-204028 Emergency & Mobile Medicine Learning Network. (2008, August). Beyond the basics: Interpreting altered mental status assessment findings. Retrieved February 21, 2023, from https://www.hmpgloballearningnetwork.com/site/emsworld/article/10320935/beyond-basics-interpreting-altered-mental-status-assessment-findings National Cancer Institute. (n.d.). NCI dictionary of cancer terms: Central nervous system depressant. Retrieved February 21, 2023, from https://www.cancer.gov/publications/dictionaries/cancer-terms/def/central-nervous-system-depressant