Anatomy of a Safety Incident #2

As noted previously, acupuncture schools have an accreditation mandate to teach safe practice, emergency procedures, risk management, and safety protocols. One of the relevant ACAOM standards, “The student must demonstrate the ability to manage inappropriate patient behavior” (Master’s Level Competency under Patient Care Domain 5: Case Management) isn’t specifically tagged as safety, but in my experience, there’s a lot of overlap.

Soon after my clinic, WCA, re-opened after lockdown, we had an epic safety incident. A long time patient, let’s call her K, got into a heated discussion with the staff person at the front desk about having to wear a mask. She grudgingly agreed to put one on, but took it off once back in the treatment room. The acupuncturist who approached her reiterated that she needed to wear a mask. K complied and said angrily, just give me my treatment so I can get out of here. The acupuncturist got two needles in before K ripped off her mask again, saying that she couldn’t breathe.

And then things really deteriorated as other patients in the room got involved in the conversation, saying that they would be uncomfortable if she didn't wear a mask. One of them stated she was immunocompromised. In response, K made comments regarding her doubts about the virus; also, something to the effect of “fuck you, you scared sheep”. At that point the acupuncturist said, “I’m sorry, I don’t think this is going to work today”, removed K’s needles, and told K she needed to leave. K refused to go. The other patients continued chiming in; the words “I’ll kick your ass” were uttered for the first time in our historically peaceful treatment room. The acupuncturist then pulled everyone’s needles out of concern for everyone’s safety (without counting, obvs) and got ready to ask for backup. At that point K left the treatment room.

Out in the lobby, the staff person at the front desk noticed that K seemed to have an altered perception of events, saying that she was doing everything that staff asked her to do and that she was just standing up for herself. The front desk person told her she needed to leave; K wanted to know if she couldn't come back (was she 86ed from the clinic?) The front desk person responded, that’s not what I'm saying but you do need to leave now, today, and try again another day.

At the time, K had been receiving regular treatment (multiple times a week) at WCA for many years to address multiple chronic conditions including PTSD. She had said that acupuncture was the only thing that controlled certain severe symptoms and WCA being closed for 4 months was a hardship. Her experience includes suicidal ideation and major frustration with “falling through the cracks” in the conventional healthcare system.

For what it’s worth, K does not fit -- at all -- what many people would think of as the profile of an anti-mask protestor.

In the blizzard of internal emails that followed this incident, another acupuncturist wrote, “I understand that we likely need to terminate this patient, and this may already be known, but WCA has been a lifeline of sorts for them so they are likely to take it very hard. It sounds like they realized this at the end of the awful interaction, that they could potentially be terminated and they didn't want that to happen, so switched course. Yes, a little too late, but just wanted to bring that to light, if it wasn't already clear.”

An administrative staff person reached out to K by email:

“We are required by the state to have everybody wear masks. You can request a medical accommodation from us. We’re not required to grant your request if it represents a fundamental alteration to our business, it’s an undue burden, or it threatens other people’s safety.

According to (the acupuncturist you saw) she had to pull everybody’s needles because she was concerned about their safety, yours, and hers. It was a very bad scene. You scared a whole bunch of people. I’m not saying that to scold or argue, it’s just what we’re dealing with now: a big mess.

We’re not going to tell you what to believe about the virus. You have been a part of our community for a long time and we take that seriously. I reached out to you because I wanted to understand what happened, but we need to know that the understanding goes both ways. So please understand our position.

WCA runs on a shoestring and we can’t survive without lots of people coming in and paying for treatments. Nobody is subsidizing us, we have to earn our money. If we violate the state’s directives about having everyone wear masks we could be shut down -- and when we’re shut down, we still have rent and bills to pay. Equally important, though -- if lots of people don’t feel safe getting treated in our clinics, they will stop coming and stop paying us and we won’t survive. That’s just our reality.

Again, we are not telling you what to believe about the virus. But if you yell at other patients in our treatment room, and threaten them, we’re going to go out of business. We can’t operate under conditions like that under normal circumstances, let alone now. We have to think first about basic safety and patients getting threatened in the treatment room by other patients is not something we can live with. So what do you suggest that we do about this situation?”

K wrote back and described the situation from her point of view, including details that the acupuncturist who treated her confirmed. She said that when she came into the clinic, she felt stressed about having to wear a mask, but the real problem was that she felt like the other patients were ganging up on her, bullying her, and discriminating against her. One patient told her that she needed to go back to school or read a book because she was obviously uneducated. Another patient said, there’s something wrong with you, and told the acupuncturist that she should call the police to deal with K. Another flipped her off. K didn’t remember anything about threatening to kick anyone’s ass.

Let’s review the list of common trauma triggers in healthcare settings, according to Laurie Lockhart MS:

authority figures
sensory cues of past events
lack of power/control
feeling threatened or attacked
caught by surprise
feelings of vulnerability and rejection
sensory overload

This incident checks off almost every item on that list, (unfortunately) thanks to the other patients. There was a collective “ohhh” from the WCA staff on the email thread as everyone saw what happened in a different (trauma-informed) light.

And right after that K sent another email, apologizing sincerely, taking responsibility, and promising nothing similar would ever happen again (though reiterating that she did not threaten to kick anyone’s ass). She added that it was very hard for her to function without acupuncture and humbly asked that WCA continue to serve her.

An acupuncturist wrote to other staff, “This situation may be the universe throwing stuff our way to test us as we re-open, but it's also a reminder of how important it is that we DID re-open and how much acupuncture can help folks. To mess up (really big) and then plead to come back because they need it so greatly, is no small thing.”

A discussion ensued about how to possibly accommodate everyone’s need for safety while continuing to offer at least some acupuncture to K. Solutions were proposed and the administrative staff person wrote back to K:

“We really appreciate your apology, it helps a lot, and I think we have a plan to move forward.

First I want to say that we believe you that your perception of what happened is different from other people’s. In stressful situations where there’s a lot of adrenaline dumping into our systems, our brains process things in complicated ways and memories can be tricky. The important thing from our perspective is to be clear that we can’t have interactions like that happening in our clinics, it’s just a complete no-go for us and so we had to have a big conversation among the staff about whether or not we can continue to serve you at WCA. As I said you’re an important part of our community and it’s a priority for us to figure it out. Here’s what we’re asking from you in order to move forward:

that you agree nothing like this will ever happen again (you already did this in your last email)

you agree to wear a mask at WCA

you (comply with some convoluted arrangements about scheduling which were inconvenient for
K and temporarily limited her access to some degree)

Thank you for being honest and helping us work something out.”

K responded, agreeing to all conditions. There were no further safety issues of any kind in her treatments and her relationship with WCA is currently just fine, with full access restored.

This incident demonstrates some core parts of the community acupuncturist job: using professional judgement and knowledge of trauma informed care to address safety issues that inevitably come up in the clinic. COVID-19 was just one element in the overall safety mix. It also highlights the importance of relationships in navigating safety issues. Without the long relationship between K and multiple WCA acupuncturists, as well as the acupuncturists’ trust in each other (and each others’ judgement), this situation would likely not have been salvageable.

Boundaries and empathy don’t have to be in an either/or opposition to each other; creatively making safety (even out of bad situations) allows them to be both/and. A major benefit of trauma informed care is not expecting either patients or practitioners to be perfect. We expect that people will sometimes be triggered and also that they will sometimes make mistakes. Expecting and tolerating and learning from triggers and mistakes makes us safer.