‘A’ stands for ALERT, which is how most healthy people usually are. 

When someone unknown walks into the room, healthy people usually look to see who it is; their eyes are focused on the person, and they follow them as they move.  They'll usually speak, even if it's just to say ‘who are you’?

Being alert doesn't necessarily mean that you know or understand what's going on around you, or where you are, or what time it is, or even who you are.  Knowing all of those things is described as being 'orientated’ (or ‘oriented’, if you work in the U.S.  ‘Orientated’ is a more British/Canadian usage).

Being ‘alert’ just means that the patient is reacting reasonably to normal environmental stimuli, and you can usually tell that just by looking at them for a few seconds.

So, if you were to apply the fill-in-the-blanks sentence I gave you, we would say: “The patient is responding to normal stimulus by reacting normally”  - which is unnecessarily complicated, so when our patients are ‘normal’ we just say that they are ‘alert’, and everyone knows what we mean.


Imagine that you walk into a room and there is a patient there lying supine, with their eyes closed.  As you walk in, they don’t move or open there eyes, so you say ‘Hello Sir, did you call for paramedics’? 

At that point the patient opens their eyes and says ‘Huuuhh??’

That patient would be described not as being alert, but as ‘responding to verbal’ - which is how we often find our patients.

Although, in this case we’d be more specific and say that the patient is responding to ‘normal verbal’.  Sometimes we have to yell in someone’s ear before they respond, and those people are said to be ‘responsive to loud verbal’.

At this point you might ask “what if they wake up when you talk to them, and then they start responding normally”?

We always give the best response that the patient maintains.  So if they initially were only responsive to loud verbal, but then, once you got their attention, they became alert and stayed that way, we would say that the patient is ‘alert’.

What if they’re going back and forth?  What if they keep falling back asleep and you have to keep waking them up by yelling at them.  Would we still describe them as ‘alert’?

Remember; we always report the best response that the patient is able to maintain.  So if they can’t stay alert, then we describe the state that they keep falling back to. 

The person who keeps falling back asleep and needs us to yell at them to wake them back up would still be described as responding to loud verbal, and not as alert.


If a patient does not respond to verbal at all - no matter how loud we yell - we move on to the next step and we intentionally cause them pain to see how they respond to that.

As you can imagine, this is a very delicate area, and it requires a lot of care.  As medical professionals, unfortunately, we are going to cause pain and sometimes even harm to our patients.  What we’re trying to accomplish is to avoid all unnecessary pain and harm. 

IV’s hurt our patients.  Pulling a spinal patient out of a wildly burning car without immobilizing their c-spine will probably cause harm.  But in each case, not doing those things is likely to resulting in a worse outcome for our patients - so we do them.

If we have a patient who is not responding to loud verbal, we have to figure out exactly what their LOAs, actually are for several reasons.

First off, we want to know if they react at all.  Dead people don’t react to their environment, so if you can’t get a patient to react at all, you have start wondering if they might be dead. 

Secondly, if they’re not dead, we need to get a ‘baseline’ of what our patients LOA is to compare to later.  LOAs often change in the course of a call, and how the LOAs change is important clinical information for us as well as for the doctors we’ll eventually hand our patients to.

Finally, the way they react to pain tells us an incredible amount of information about their medical condition.

There are five specific responses that people can have to pain.  As a paramedic you need to know what these five responses are, how to recognize them, and to know what they mean.

I’ll describe them in order, going from the best response to the most worrisome. 

The first, and best one, is the most obvious: the patient responds to pain by rousing to alertness (which means that they wake up enough to obey commands, like opening their eyes or wiggling their fingers)

The second response is that the patient responds to pain by localizing the painful stimulus.

For example, let’s say that you’re pinching the nail bed on their finger - which is how I recommend you cause pain.  If they use their other hand to reach over and try to get you to stop, we’d call that ‘localizing’.  They are moving toward the location of the pain.

The next response is that the patient tries to withdraw from the pain.  Again, when you pinch their nail bed they try to pull the finger you’re pinching away from you.

Flexion (decorticate)
The third response is that they start to flex their whole body to pain.  So they pull the finger you’re pinching into towards their midline, but they pull the other hand in towards their midline too.  They also straighten their legs right out and turn their toes in towards each other.

Here’s where we start to get a lot of information from our patients. This odd posturing is due to damage to the corticospinal tracts - the pathways between the brain and spinal cord.  That specific posture is called the ‘decorticate’ (dee-CORE-tih-cat) posture. 

You can remember that deCORTICate posturing means a problem with the CORTICospinal tracts, and when they’re doing that posture, they’re pointing towards the CORe of their body!

Extension (decerebrate)
The next worse response is to see a patient extending all their limbs in response to pain.  The toes are pointed down, and they often arch their head backwards.  We call that ‘decerebrate’ (dee-SAIR-uh-bret) posturing.

http://nu.kku.ac.th/site/250262/images/decorticate.jpg April 2008.

Decerebrate posturing is caused by an injury at the level of the brainstem, and basically it means that your brain isn’t working any more.

The word ‘decerebrate’ comes from the word ‘decerebration’ which is a fancy medical way of saying that your brain isn’t working;  ‘de’ means ‘to move away from’, like ‘de-mystify’ means to move away from being mystified.  Cerebration refers to your cerebrum – the ‘thinking’ part of your brain.  Cerebration means to use your brain to think; so decerebration means ‘not thinking’, because your brain isn’t working.

Here’s an easy way to remember this.

Well if you take away ‘alert’, which is the first response, then you’ve got only four to remember.

Then, you need to remember that the first two have to do with just the arms, but the last two have to do with how the whole body responds. 

And for the first two (the arms), the first reaction (localizing) goes TOWARDS the pain, and the second (withdrawing) goes AWAY from the pain. 

For the second two (the whole body), the first reaction (decorticate) goes TOWARDS the centre of the body, and the second (decerebrate) goes AWAY from the body.


If you cause pain to a patient and they don’t respond at all, that’s as bad as it can get.  ‘Unresponsive’ is the ‘U’ in AVPU.

How to cause pain

A lot of paramedics cause pain by either pinching the trapezius muscle or rubbing their knuckles on the patients sternum.

There are two problems with this. 

The first is that when you use those techniques, it is very obvious to everyone that you are purposefully causing pain to the patient.  People don’t like to see you doing that, and some family members or bystanders can even get aggressive if you use those techniques.

The second problem is that causing pain near the patient’s midline makes it very difficult to judge their reaction using our 5 point pain-response scale.

For example, if you perform a trap squeeze and the patient lifts their shoulders and turns their head slightly toward the pain, how would you describe that response?

Decorticate, because they’re contracting towards their core? Localizing, because they’re moving their head toward the pain? How about withdrawing, because they’re moving the other side of their body away from the pain?

See?  You really can’t tell.

Here’s a better way.

On everyone’s finger there is a little crescent shape right at the base of the nail.  If you squeeze that, it hurts like stink.  The best way is to take a pen and push the side of it into the nail bed.  Try it.

No really … go on and try it!

See?  It’s tough to fake it and pretend that that doesn’t hurt.

Also, if you try, you can be kind of subtle about this and do it without most people realizing what you are doing. And since  the pain is away from the midline, it’s very easy to see what the patient’s response is.

Now, let’s continue on, hit the link below to go back to the previous page.


Assessing the patient’s level of awareness.