Unconscious? (Tricks of the Trade #1)

Some people seem to think that faking unconsciousness is a good idea, either they are mentally ill, drunk, or more commonly, have had some form of argument and have decided to ‘go unconscious’. 

For some reason, benefit offices and rent payment offices are popular places, as are police cells, magistrates courts and at the checkouts of supermarkets.

The easiest, and quickest way to see if someone is faking unconsciousness is to lightly brush your finger against their eyelashes.  If their eyes flicker, then they are almost certainly faking it.  Also if they try to keep their eyes closed when you try to open them, they are definitely faking it.  Another way of checking is to hold their hand over their face, and let it drop.  People tend to be reluctant to let their hand hit them on the nose, and so the hand will instead magically drop to one side.

The other giveaway is that they open their eyes to look at you when they think you aren’t watching them…

But what happens if someone is able to wake up, yet is refusing to?

Let me quickly explain an important part of measuring someone's Glasgow Coma Scale.  The Glasgow Coma Scale is a way of measuring how deep someone's level of unconsciousness is.  (I could just quote the Wikipedia article, but if you want to know what a GCS is, then click the link).  Part of this process of assessment is how they respond to pain.

The official method of applying this pain is to push hard against the upper part of the eye socket.  This does no damage but is apparently painful.

Not to me it isn’t, and not if you are deeply drunk.

So there are other painful stimuli, one of which (my favourite) is the ‘sternal rub’, where you rub the knuckles of your hand against the patient’s breast-bone.  Some lilly-livered people think that this assessment is too close to assault, but I would ask them to consider that if we didn’t get drunks to wake up, we would be forced to undertake invasive medical procedures on them in order to ensure that their airway is clear.  If you can tolerate my sternal rub then there is something seriously wrong with you, and you need emergency treatment – but if you wake up then I have effectively ‘cured’ you.

Either way the assessment is complete.

Of course I did get a broken rib for my troubles when curing an unconscious drunk who had sexually assaulted a female pedestrian.  I also can’t see how one way of causing pain may be assault, but another isn’t.

The moral of this story is simple : Don’t pretend you are unconscious, because we will know – and don’t pretend to be unconscious when you are drunk, because it can get painful for you.

My favourite tale of how to uncover a pretender in a hospital setting was a doctor, who would loudly ask for the ‘brain needle’, to draw off some brain fluid from the unconscious patient via the ear.  Of course, he would continue, the patient needed to be unconscious because otherwise they might flinch and the needle go into the brain itself.  This was normally followed by the patient ‘waking up’ and asking, “Doctor, where am I?”.

56 thoughts on “Unconscious? (Tricks of the Trade #1)”

  1. Totally agree with the eyelid comment. I have had the misfortune to go catatonic a few times [rated GCS of 6 by a medical student friend], and have been able to feel what has been done to me without being able to respond. Had a few weak sternal rubs which didn't hurt but I wouldn't like you to demonstrate a proper one on me!

  2. Causing pain, muahahaha: an old jiu jitsu favourite is pressure on the nerves behind the windpipe – reach around the windpipe on both sides and push diagonally up. It's tricky to find, but I'm sure you medical types will have no problems 🙂 Another good one, if they're lying on their back, is to press your heel into the nerve bundle on the inner thigh a few inches above the knee.Of course the army test for “are they really dead?” – back when I was a cadet, at least – was kick 'em in the nuts.

  3. It's interesting to hear about the sternal rub thing, because when I was on placement with the ambulance service up here, I was told that sternal rubs had been banned, due to the potential for causing (and the terminology is probably wrong here) ventricular fibrillation, or some other heart related thing. They did tell me about the hand over the head thing though.Must remember some of these to try out on 'unconcious' drunk freshers.


  4. urgh… occasionally I faint (just for a few seconds, more of a “collapse” really) and I hate it most when my eyes are open again, and I'm moving, and I'm saying “I'm okay, really, I'm fine, honestly…” but I'm a little groggy, and some over-zealous first-aider who has heard about assessing levels of consciousness by testing pain tolerance starts pinching me… grrr.

  5. There is a story I've heard of a crew who went to a regular unconscious faker. They were so convinced that one of them gave the poor bloke a swift kick in the wotsits with his size 9 stee toe caps. When the patient didn't wake up and start screaming abuse at them, they decided he must be ill after all and took him to hospital.When he woke up in resus, he promptly “grabbed his plums” and accused the hospital staff of assault.

    Don't know if it's true, but it did give me a giggle.

  6. I should add though, that the good experiences have far outweighed the bad. I had one lovely lad spend the whole trip trying to talk to me in sign language!Nearly everyone is well used to epileptics and very professional. They just tell me which hospital I'm going to and let me go to sleep. It's pretty much a complete waste of time for everyone involved as I don't need the hospital at all. Doubly a waste of time when the stroke team meets us!

  7. I can think of a few more controversial tests,the A&E consultant who requests 50mls ice cold water to inject at high pressure into the ear. The ambulance tech that was suspended for checking blood sugar levels by inserting half a inch of needle between the finger and nail. Doormen who Accidentally apply steal toe boots onto the casualties fingers when kneeling down.

    I like the brain fluid test.. hehe may have to try that one!

  8. Ice cold water in the ear is (or at least was) one of the battery of tests that you do to see if someone is 'brain dead'.I wouldn't like to comment on the others that may or may not have been used by people who I may, or may not know…

  9. sit the f**k down. Even on the floor. You sit down, you might get some funny looks or some dust on your trousers but you won't graze your knees, tear your clothes, knock over display stands, fall into dog poo, or bounce off the corner of anything as you lose verticality…

  10. self-administered eye socket pushy thing not unduly painful; self-administered sternum thing definitely is. Stick with that one. Thigh hurts a bit too. But I'm not going to kick myself in the knackers.

  11. I am currently sniggering at the ammount of people worldwide who like me have been pushing their eye sockets and rubbing their sternums to see if it hurts! heheDan

  12. Yep, I did both. Can Reynolds tell how many people read each post? It'd be funny to know exactly how many people have been doing it simultaneously!

  13. Stand over them in the motor and mention to your crew mate that you can't believe it's been so long since you've seen station. Ask crew mate if anyone's looking then unzip something (near patients head) and a 5ml syringe of warm saline later the patient should be up and about and rubbing their face =)

  14. My password / log in works again!Yes, well…my brother and his mates at school in the 50s had a good one…they'd use a pencil eraser and rub it just in front of the ear where the short hairs are (embryonic sideburns). I should imagine this was as painful and difficult to endure as the chinese burns he used to practice on his little sister (me!).

  15. Ooh! I'm so totally using the 'brain needle' trick the next time some wombat tries the old 'pseudo-seizure and unconsciousness' routine.Thanks!

  16. Best one Ive found is a little pinch to the delicate skin on the upper inner arm(just below the arm pit) It is so discrete that nobody but the recipient knows you are doing it and it works a charm.Are you all trying this one at home??????

  17. Coo. How does that work then? Why does the water in the ear invoke activity but slapping them around the gob (for example) doesn't?

  18. We have one regular, who can pretty much take everyone of the previously mentioned techniques ( including the sternal rum…not a flinch ) tell her you're going to pour her vodka down the sink and she's up trying to scratch your eyes out.

  19. Oh course once you've decided that someone is unconscious your priority is to protect their airway. Few people can tollerate an OPA, and even fewer an NPA!

  20. We were taught that as a self defence escape when someone grabs you by the throat, also a similar place on the inside of the thigh/groin region to escape a headlock. Really does work

  21. Anon only speaks for him/herself. If I was prone to fainting I'd probably talk about it a lot since it must be a bit distressing and anxiety is often relieved by talking about things. Anyway it was relevant to the discussion. Don't be discouraged.

  22. Why, oh why, jusy why do people do this?!I'm worried that according to that scale I might rate as a slightly unconscious person before my first cup of coffee 🙂

    Ladycat coming in via liejournal

  23. This is known as the caloric water test. There is a primitive brainstem reflex (oculovestibular reflex) where a difference in temperature between the temperature in the ear causes the ears to drift to one side. It probably is a remnant of us being fish and turning to orient towards differences in water temperature.Check http://endeavor.med.nyu.edu/neurosurgery/coma.html

  24. The problem is if you try that on someone who's seen it before. Yes, one way out is to let go of your throat and back off. But the other is to squeeze harder until you lose consciousness. And that can also be an effective outlet for the pain.

  25. On next shift, count number of people in A&E with sore eyes/sternum / bleeding from nails and multiply to get nationwide value?

  26. My father is an ambulanceman in Scotland, I remember when I was much younger him telling me he woke the drunks up by pressing a pencil nib into the nail bed.Only tried that one on myself once…..

  27. 'causes the ears to drift to one side' ?? Does this mean the whole head turns towards the direction the ice-cold water is coming from? I'm really interested in this but don't quite understand from this description what happens as the reflex response. Please explain again! Thanks.

  28. must say that the sternal rub works for me. another one for regulars, that i have not used personally, is a bag of saline and a giving set. feed the tube out of the fly of your trousers and state loudly, “i'm sick of this B******, I'm going to piss on him”! as soon as the saline hits their face its GCS 15.Can't condone this behaviour though.

  29. yes but in all fairness, everything can be outdone by a good punch to the windpipe/adams apple in a bloke, or a good hammerfist to the gonads.Job done

  30. Did you hear about the guy that was feigning unconsciousness despite all the tests the crew did on finding him? Then took him to hospital, still no reaction whatsoever, then were about to put him in the CT scan thing and just before he went in the tunnel he sat up and was effing and jeffing, looking like giving this tiny nurse a wallop-stood right over her. So she kicked him in the nuts and let security remove him. It might be an urban myth, but as a short lady myself it reminds me of how we can get ourselves out of tricky situations 🙂

  31. Only the eyes drift not the whole head. To be more precise, they drift to the ear with the cold water and then there is a correction reflex which reorientates them forward. This produces a jerky eye movement.The path of the reflex is from the semicircular canal in the ears (which controls balance), the 8th nerve, into the brainstem, then up the brainstem, then back out to the eye muscles. It is suppressed in awake individuals by the higher brain but the reflex reappears in unconscious people (when the higher brain isn't working). If the brainstem is not working, the reflex would not be present (however, you would be able to tell as the person would not be able to breath unaided).

    Some fish have that reflex as well, when you squirt cold water at their gills, they orient towards the squirt of cold water.

  32. I have epilepsy, and experience Todd's (temporary) paralysis affecting my right side and my speech. I am sleepy and aphasic (cannot speak) after a seizure. Despite having a Medic Alert bracelet, I have had several paramedics believe I was “faking it” when I wouldn't respond to questions. On more than one occasion, the paramedic decided to repeatedly perform sternum rubs “until I talked.” I have received two broken ribs from this treatment, and a broken finger from other “pain response” tests.I will never believe that sternum rubs serve any purpose than to punish patients that paramedics believe are wasting their time.

    My complaints to HR were deemed unfounded as sternum rubs are “standard procedure.”

  33. Breaking ribs and fingers is a definate no-no, and to be honest, I'm surprised that the complaints department didn't at least send the people involved for more training.A sternal rub *shouldn't* break ribs if you are doing it right…

    And to be fair, if a crew can't recognise a post-ep fit, then they *do* need some retraining…

    And they missed a medic alert bracelet?

    Sorry to hear you've had such a rough time.

  34. They saw the bracelet, they just ignored it because “It doesn't look like any seizure I've ever seen.” Todd's paralysis is not well recognised. Paramedics often believe that it means I've had a pseudoseizure. Either that or they call the stroke team.I've had the “We'll keep up the sternum rubs/hand flexion until you stop messing,” routine performed 5 times – one of those times, the ride to the hospital took 45 minutes and they kept it up the whole way. Broken bones twice, extensive bruising the other times. Last time was a year ago, when I was at the pub with friends. Other times were pickups at high school or university. All of them accused me of trying to get out of a “math test.” Apparently people don't fake seizures for history tests? I've been verbally abused several times as well (yelling really frightens me when I'm postictal).

    Other responses from HR: Postictal confusion makes you an unreliable witness. His partner backs up his story. You can't prove you didn't sustain these injuries during the seizure itself.

    I guess five assaults over 15 years of medically refractory epilepsy and more “big white taxi” rides than I can count isn't really that bad a track record. But there's really no way to describe the sensation of being paralysed, unable to communicate, weak and disoriented and hearing your own fingers breaking while someone calls you names. I don't think it's possible for a person to be much more vulnerable than I am after a seizure. The only people who have ever harmed me in that state have been paramedics.

    I'm a little phobic now – Why on Earth did I come to this website?

  35. I guess it's the same for every profession. Lots of caring paramedics, moral policemen, foster parents who genuinely like and want to protect and look after kids, teachers who want to educate, electricians who pride themselves on doing a good safe job…and then a minority of complete and utter &(&$*% who give the rest a bad name and a shedload more paperwork.

  36. Sternum rubs are just too easy to abuse and get away with.I can move my left side and make non-speech sounds in response to pain. But nothing anyone does can make me able to get up and walk, or say my name, or stay awake. I really tried as hard as I could.

  37. I had an exboyfriend who used to be a Emt firefighter and he was telling me about the sternum rub, I had him try it on me and every time I had him do it I couldn't help but to laugh histericaly, I use to bug him to do it to me, I know it's suppose to hurt, and the bruses after words confirmed the pressure in which he was using.

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