Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What Does the Hand Drop Test Tell Us?

 

Why do we use the hand drop test?

Because somebody has told us that it is a good idea, but are they right?

Well, consider where the question is coming from and whether you have ever seen any research to demonstrate that patients who fail the hand drop test have no physical illness.
 

Samuel Johnson described patriotism as “the last resort of a scoundrel.”12 (Ambrose Bierce disagreed, believing it was the first resort.4) The medical analogy to these definitions of patriotism is psychogenic illness or hysteria, a diagnostic haven to which uncertain physicians all too often repair when signs and symptoms seem anatomically or physiologically senseless. Unfortunately, the diagnosis of psychogenic illness or hysteria often tells one more about the physician’s lack of knowledge than the patient’s disease.[1]

 

That is just criticism of the diagnosis after a thorough assessment, while the hand drop test is often the first refuge of the all too certain paramedic.

The hand drop test is raising the patient’s hand over the patient’s face and letting go. If the hand does not fall on the face, it is considered a failure and the patient is considered a faker.

If the hand hits the face and causes injury, what is that called?

Sick enough to deserve a paramedic, or just a well disciplined faker?
 


Image credit.
 
 

[youtube]S06nIz4scvI[/youtube]
 

Peter Canning points out what should be an obvious flaw in the hand drop test, as with any other good patient/bad patient test.
 

There is a second more valuable lesson than the Hand Drop Test, a lesson that comes later and often comes painfully to your own performance as a paramedic. And that lesson is just because a person is aware enough to move their hand to avoid their face, doesn’t mean they can’t also be really sick.[2]

 

Are these patients really faking?

How much are these patients able to control what they are doing?
 

These patients are correctly described as having a psychogenically driven unresponsiveness to distinguish their apparent alteration in level of consciousness from those caused by organic pathologies. Psychogenic used in this context indicates that the pathogenetic mechanisms are caused by a primary functional psychiatric disturbance and in no way implies that the state is self-induced and under volitional control.[7] [3]

 

 

In a series by Slater, almost half of a group of 61 patients diagnosed as suffering hysteria were eventually found to have an organic disease that explained their “hysterical” symptoms.17 Slater concluded that “the diagnosis of hysteria is a disguise for ignorance and a fertile source of clinical error. It is, in fact, not only a delusion but also a snare.” For reasons not fully understood, “hysterical” symptoms appear to be especially frequent in patients who have neurologic disease.[1]

 

According to Dr. Eliot Slater,[4] our desire to jump to the diagnosis of unworthy may apply more to us than to our patients.
 
 

At Life in the Fast Lane, the hand drop is only mentioned as the very last assessment in a full medical workup of a possible pseudocoma – and he stresses to make sure to not injure the patient.[5] At Crashing Patient, Dr. Scott Weingart does not even mention the hand drop test, except that Chris Nickson’s entire article is republished as a part of the page on Complete Neurologic Evaluation.[6]

Do we get bonus points for not treating patients who have at least a partial psychological cause of unconsciousness?

Does the hand drop test improve our care of the unconscious patient?

Footnotes:

[1] The Diagnosis Of Stupor & Coma
By Fred Plum, Jerome B. Posner
Oxford University Press,
1982 – Medical – 377 pages
Psychogenic Unresponsiveness chapter at Google Books.

According to Bartleby.com the quote should be last “refuge” –

Respectfully Quoted: A Dictionary of Quotations. 1989.

NUMBER: 1306
AUTHOR: Samuel Johnson (1709–84)
QUOTATION: Patriotism is the last refuge of a scoundrel.
ATTRIBUTION: SAMUEL JOHNSON.—James Boswell, Life of Johnson, entry for Friday, April 7, 1775, p. 615 (1970).

“In Dr. Johnson’s famous dictionary patriotism is defined as the last resort of a scoundrel. With all due respect to an enlightened but inferior lexicographer, I beg to submit that it is the first.”—Ambrose Bierce, The Devil’s Dictionary, at entry for patriotism, The Collected Writings of Ambrose Bierce, p. 323 (1946, reprinted 1973).

H. L. Mencken added this to Johnson’s dictum: “But there is something even worse: it is the first, last, and middle range of fools.”—The World, New York City, November 7, 1926, p. 3E.

[2] Street Lessons #5 The Hand Drop Test
Posted by medicscribe on May 23, 2013
Street Watch: Notes of a Paramedic
Article

[3] Psychogenic unresponsiveness.
Hurwitz TA.
Neurol Clin. 2011 Nov;29(4):995-1006. doi: 10.1016/j.ncl.2011.07.006. Epub 2011 Sep 1. Review.
PMID: 22032670 [PubMed – indexed for MEDLINE]

[4] DIAGNOSIS OF “HYSTERIA”.
SLATER E.
Br Med J. 1965 May 29;1(5447):1395-9. No abstract available.
PMID: 14286998 [PubMed – indexed for MEDLINE]

Free Full Text in PDF format from PubMed Central.

[5] Eye Movements, Coma And Pseudocoma
July 16, 2010
by Chris Nickson
Life in the Fast Lane
Article

[6] Complete Neurologic Evaluation
Crashing Patient
Article

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