The sternal rub is a technique historically used by healthcare professionals to assess a patient’s level of consciousness in emergency settings. Its application involves intentionally causing pain to gauge a neurological response, an action that, outside of a medical context, could easily be considered physical battery. Clarifying the status of this procedure requires understanding its specific clinical role, the legal principles that permit its use, and the ethical shift causing its decline in modern medicine.
The Clinical Purpose of the Sternal Rub
The sternal rub is classified as a central noxious stimulus, applied to the core of the body to provoke a response. This technique involves using the knuckles of a closed fist to rub firmly across the patient’s sternum, or breastbone. Its purpose is to test the “P” (Pain) response within the AVPU scale, a rapid neurological assessment tool. The AVPU scale assesses if a patient is Alert, responsive to Voice, responsive only to Pain, or Unresponsive.
The technique is reserved for patients who are not responding to less invasive stimuli, such as a verbal command or a gentle shake. Observing the patient’s reaction provides insight into their level of brain function. A patient who withdraws from the pain suggests a higher level of neurological function than one who exhibits only a non-purposeful motor response. The resulting information helps medical personnel quickly determine the severity of altered mental status and guide immediate treatment decisions.
Is the Medical Procedure Itself Illegal?
The sternal rub, when performed appropriately by a trained healthcare professional on an unresponsive patient, is not illegal and does not constitute battery. Battery is legally defined as an unauthorized, harmful, or offensive physical touching. In a medical emergency, the law allows for a professional exemption based on the doctrines of emergency and necessity. These doctrines permit medical assessment and treatment without explicit consent when a patient is unconscious or unable to communicate their wishes.
The justification is that a reasonable person would consent to a necessary diagnostic procedure in a life-threatening situation. This principle operates on the understanding that the procedure is medically necessary to gather information for the patient’s benefit. Since the intent of the professional is diagnostic and therapeutic, the action falls within the accepted standard of medical care. Using the sternal rub as a diagnostic tool in an emergency setting is considered a lawful and necessary action to determine the severity of a neurological condition.
Why the Technique is Falling Out of Favor
Despite its traditional use, the sternal rub is increasingly discouraged by modern medical protocols due to several limitations and negative outcomes. The technique is highly painful and has a significant potential to cause physical damage, often leaving behind bruising or abrasions. This visible marking can later be misinterpreted as a sign of abuse or neglect, creating complications for the patient and the care team.
The sternal rub is considered less reliable and less specific than other central painful stimuli. Alternatives, such as the trapezius squeeze or supraorbital pressure, are generally preferred because they are less likely to cause lasting marks and may offer a more nuanced assessment. The wide variation in the pressure and duration applied by different practitioners also leads to a lack of standardization, which can result in inconsistent and potentially unreliable neurological assessment results. This medical shift is driven by a focus on patient dignity and the availability of more specific, less traumatic diagnostic methods.
When the Use of Force Constitutes Abuse
The legality of the sternal rub depends entirely on the context and the intent behind its application. The action crosses the line into civil or criminal misconduct, such as assault or battery, when it is used on a patient who is conscious and able to communicate. An action intended for assessment becomes an illegal touching when performed on a person who can verbally refuse or is responsive to less aggressive stimuli. The law requires a patient’s express refusal to be respected unless a life-threatening emergency overrides that refusal.
The application of a sternal rub as a punitive measure or a form of intimidation is unequivocally illegal. Using the technique to “test” a patient suspected of faking unconsciousness, or applying excessive force that results in injury, falls outside the scope of medical necessity. In these situations, the professional exemption is voided because the intent is no longer diagnostic, but disciplinary or malicious. The context shifts the action from a sanctioned medical procedure to an unauthorized and harmful touching.