Pneumothoraxes and a Culture of Safety

Out of roughly 200 AERD reports, we have two about pneumothoraxes related to treatment in a community acupuncture clinic. (Notice I didn’t say, “pneumothoraxes IN a community acupuncture clinic “ -- more about that in a moment.)

Here’s a summary of report #197, which describes an incident that happened about a month ago: A punk needled Kid 27 on one of her regular patients. This punk happens to be trained in 5 Element Acupuncture, often uses chest points in her treatments, and has plenty of experience. In this case, however, the patient reacted immediately to the needle at Kid 27 with a feeling that something was wrong; she got anxious and sweaty and had mild shortness of breath. The punk immediately pulled all of the needles and the patient went to wait in the reception area; she has a history of anxiety and her reaction looked not unlike a panic attack. The punk advised the patient that this could be a pneumothorax and told her to go to the ER if her symptoms stayed the same or got worse. They did and she did, and by the next day she was resting at home, recovering from what was indeed a small pneumothorax. The punk stayed in communication with the patient, whom she’d been treating for the past two years. The patient wasn’t angry at the punk or the clinic, and required no further treatment. The punk and the clinic did all the appropriate documentation (chart notes, incident report), contacted their insurance, and reached out to fellow community acupuncturists for perspective.

Report #92 describes an utterly different (nightmarish) experience for the punk. A new patient, who happened to be a tall, thin young man who had recently been undergoing intensive physical training, came in with a friend for stress reduction. The punk treated him and -- as is common in this scenario -- didn’t use any points on his torso. Everything seemed to be fine. A day or two after the treatment, however, the patient landed in the hospital with a pneumothorax and blamed the acupuncture. And sued. Some details from this incident aren't readily available because once lawyers got involved, the punk couldn’t talk about it. The punk’s insurance company didn’t want to settle and chose to fight -- because the punk hadn’t needled the patient’s chest (!) and also because the patient fit the profile of someone at risk for a spontaneous pneumothorax. The basis for the lawsuit was that the punk’s handwritten chart notes said SI3, which the punk described as Small Intestine 3 on the hand, and the patient’s lawyers claimed meant Stomach 13, near the collarbone. They also claimed that the punk used extra long needles for the treatment, which of course the punk hadn’t. To make things worse, it turned out that the state where all this happened (California) requires verbal as well as written consent to treatment, and the patient claimed he hadn’t given verbal consent. It was basically the punk’s word against the patient’s.

In an online discussion about the incident in report #197, another experienced punk shared that they thought they themselves had probably had a small, undiagnosed pneumothorax as a result of a treatment in their own clinic that included Lu 1 and Lu 2. It resolved on its own in a few days before the punk decided to seek medical attention. They said, “Pneumothoraxes happen. It doesn’t take negligence for them to happen.”

And I agree, that’s the take home message: pneumothoraxes (and other adverse events) happen.

Adverse events are different from errors, but acupuncturists often confuse the two (including for political reasons, see NCASI.) A pneumothorax for an acupuncturist might represent an adverse event, it might represent an error, or (as in report # 92) it might just be a horribly timed coincidence.

Having good safety practices isn’t just about figuring out how to avoid adverse events and errors, because sometimes you can’t. Is report #197 a good reminder to needle obliquely when you’re needling over organs, and to be careful not to needle too deeply? Of course. But we also don’t know that the punk wasn’t trying their best to do both when the incident happened. Sometimes things just go sideways.

Having good safety practices is also about everything that happens AROUND adverse events and errors. I’m picturing a set of ever-widening concentric circles, like the ripples when you drop a pebble in a pond:

In the closest circle around the incident, it’s about how the punk and the patient communicate. In report #197, it sounds like the punk did a great job; in report #92, the punk didn’t get much of a chance to communicate at all. The juxtaposition of the two reports makes it really clear that having a long-term relationship with the patient makes a huge difference in how safety incidents play out. (In reading through the AERD data in general, it’s clear that safety incidents in community acupuncture clinics often happen in the context of long relationships between the patient and the clinic, and punks should be grateful they have the opportunity to create so many of those relationships.) Good communication includes acknowledging that acupuncture treatments have the potential to cause harm (all medical interventions have the potential to cause harm!) and sometimes follow-up care might be needed. This is a place where the punk can offer support to the patient.

The next set of ripples represent the communication that happens within the clinic, including incident reports and chart notes, along with the communication that happens with the clinic’s liability insurance company. This means written documentation as well as verbal conversations -- safety incidents always provide an occasion to have a safety meeting, just sayin’. This is a place where punks can offer support to each other, and also receive support from outside professionals (a major reason why we pay our insurance companies).

Finally, there are the ripples that represent people reaching out to a wider community for support. This is one of the most important opportunities for all of us to contribute to a culture of safety.

Here’s the thing about risk and community acupuncture: as a patient, the more acupuncture treatments you receive, the more chances there are for something to go sideways. Ditto for a punk -- the more acupuncture treatments you give, the more chances there are for you to experience an adverse event or make an error. It’s just math. Our low cost/high volume model creates the opportunity for broad access and deep experience with acupuncture -- as well as more chances for safety incidents to happen. (Including incidents like the one in report #92, where the acupuncturist had nothing to do with the patient’s injury.) It’s really important for community acupuncturists in particular to develop a healthy, neutral, safety-positive relationship to risk. Everyone has a different risk tolerance, and ideally everyone will spend some time reflecting on what that looks like, for them, in their practice.

However. We can’t make good individual decisions about risk unless we have better collective conversations about safety.

Another commenter in the online discussion mentioned that they believed, based on experience and research, that pneumothoraxes are more common than the acupuncture profession acknowledges. I’m sure that’s true, and there’s a vicious cycle: if L.Acs noisily complain that pneumothoraxes are only caused by all those undertrained physical therapists trying to steal our medicine, how many L.Acs will be willing to share publicly that they experienced a pneumothorax in their own practices? And if L.Acs don’t disclose when these things happen (and really, why would they? Who wants to be blamed, shamed, and second-guessed about an already very stressful event?) the rest of us are left with the impression that pneumothoraxes are less common than they actually are, which means we’re not able to make truly informed decisions about the risks we take.

This is the situation we’re trying to change with our AERD. A culture of safety is the opposite of the vicious cycle. If people feel socially safe about sharing safety data, we’ll all be able to make better informed decisions about safety and risk. The more we communicate about safety data, the safer it becomes to communicate, and the more information there is to share, which leads to better informed decisions about risk, which leads to more safety, etc. We can all contribute to a culture of safety by being supportive and grateful when people share their safety data, regardless of whether it’s an adverse event or an error or an extraordinarily unfortunate coincidence. Heartfelt thanks to everyone who’s contributed their experiences — POCA Tech students and faculty appreciate it enormously.