Why Be an Acu Safety Nerd, Part 2

Acupuncture is basically safe. It’s so much safer than other forms of medical intervention that you should hardly have to even think about it. Right?

Except for the times that you do have to think about it. Those times often involve elements that are out of your control (for example, a pandemic; more about that shortly). At which point you can take the attitude of, “Acupuncture safety is not a thing! I shouldn’t have to deal with this!”, but... that’s not helpful.

I’m going to argue that an attitude of “I am a safety nerd and acupuncture safety is an interesting thing” -- is helpful, even in the face of things you can’t control.

Several years ago, I had a conversation with a patient at our clinic who was convinced that an acupuncture needle had broken off in their body. They were so convinced that they had actually gone to the emergency room and gotten X-rays, which hadn’t shown anything. The ER doctor hadn’t encouraged them, in fact he’d been scornful and dismissive. He had made an incision in the place the patient thought the needle was, poked around in an excruciating manner, and finally sent the patient home with a referral to a specialist along with insinuations that they were delusional. Despite this experience, the patient was still sure there was a broken needle in their body.

Knowing that it’s 99% certain that a single-use, stainless steel acupuncture needle manufactured in the 21st century would not, in fact, break off in a patient’s body, I could have easily responded along the same lines as the ER doctor. I could have said, flatly, “no way”. I was feeling all the adrenaline you would expect an acupuncturist having this conversation to be feeling (though it helped that I hadn’t treated this patient myself), and I knew the conversation had the potential to get unpleasant. Instead of insisting that broken acupuncture needles are not a thing, I told them I was sorry that they were in pain and had had such a bad experience in the ER. Then I said something like, “So actually, I’m kind of a nerd about acupuncture safety and adverse events, and I’d like to get as much information as possible from you so that I can understand what happened.”

And then I let the patient talk, while I did some deep breathing. They told me more details about the sequence of events that made it pretty much impossible there was, objectively speaking, a broken needle lodged in their body. I asked questions. I talked about the history of acupuncture needles and how they’re manufactured, and the patient asked questions. I talked about how pain can change the nervous system and affect perception. A couple of times we both actually laughed, and at the end of the conversation neither of us was upset. Over the course of the next month, the patient kept coming in for treatment but eventually stopped talking about the broken needle. Best of all, this person remained a regular patient for years; they were managing chronic pain and acupuncture was one of the few things that reliably helped them.

The broken needle incident didn’t ruin their relationship with the clinic, and I believe that’s because I chose to be a safety nerd at a critical moment. The beauty of being a nerd is that you’re so curious, so interested, that you can’t simultaneously be defensive or dismissive or hostile or resistant. I was so busy being an information sponge in that conversation, I wasn’t worried about being right. Also, I suspect the patient thought I was sort of a dork, but that’s okay; I was a sympathetic, unthreatening dork.

And I’m glad I had this experience before COVID hit, because it taught me some perspectives on safety that came in handy:

1. Safety practices have to take into account that often enough the world and all the people in it are just bizarre. Humans will do weird things, say weird things, think weird things. They will make mistakes. Safety isn’t about keeping all that stuff from happening, because you can’t. Safety is about what you do in the face of it.

2. Safety involves tolerating uncertainty -- also limited, ambiguous, and changing information. Was there a chance that the patient actually had a broken needle in their body? Yes, given what they said had happened (particularly the location and the needling depth) there was a vanishingly small chance. No acupuncture needle company would swear that it would absolutely never happen. Knowing this, I was able to say to the patient sincerely that the experience they were describing represented a highly unusual event, a real outlier, so of course we’d want to learn as much about it as we possibly could.

Our conversation stayed friendly because I didn’t treat the uncertainty as a threat, and I didn’t try to get rid of it. The ER doctor, in order to do his job, had to figure out if there was objectively a needle in the patient’s body; fortunately, my job didn’t require that. I could hang out with some mystery, there at the convergence of the neurobiology of pain and the structural integrity of acupuncture needles, and encourage the patient to hang out there too. (Which they apparently did until the pain resolved or changed, or their relationship to it changed.)

Navigating safety policies during COVID has, of course, required hanging out with way more mystery than that.

3. Because of uncertainty, “safe” vs. “unsafe” is often not a useful binary. There is no absolute safety. You can make things safer, if you work at it, but you’ll never make them completely safe. Similarly, safety isn’t about right and wrong -- that would be ethics or moral philosophy, which is different from safety. We would all like safety to be simple, but it isn’t simple. It’s complex (and fascinating!).

4. Safety depends upon communication to the point that you could argue that safety is mostly about communication.

Whether or not the patient actually had a broken needle in their body, they had in fact had an adverse event: they now had an incision and new pain to go with it. I was pretty sure the post-ER pain was worse because of how the ER doctor had treated them; pain is responsive to social context. My interaction with them similarly had the potential to make their experience even more negative than it already was.

Also, see above: safety involves tolerating uncertainty -- along with limited, ambiguous, and changing information. In that context, clear and careful communication is everything. (More about this in future posts.)

5. What’s better than a list of safety “don’ts” is building a culture of safety. And one good foundation for a culture of safety is, you guessed it, encouraging everybody to be a nerd about it.

By the time I was having the broken needle conversation with the patient, no list of safety dos and don’ts was going to help me. It was way too late -- as it generally is, once something actually happens or somebody thinks something happened, which honestly in acupuncture practice is more common. What helped me was an orientation toward openness, listening, empathy, and gathering information, as opposed to scrambling to figure out what went wrong and who to blame for it.

Similarly, as my clinic has been navigating COVID, the safety dos and don’ts were a starting point (“don’t come to work sick and don’t treat anybody who’s having symptoms” is a great foundation) but they weren’t nearly enough, especially for the long haul. It helped us tremendously to accept that we were going to have to make safety decisions based on limited, ambiguous, and changing information; there was no alternative. But we chose to adopt the attitude that safety information was so compelling, we weren’t going to complain. No, we were into it. The whole situation is hideous, but that doesn’t keep it from being interesting (especially once you detach from the binaries of safe/unsafe, right/wrong, etc.).

We’ve successfully nerded our way through the pandemic so far, to the point that a lot of our organizational systems are in better shape now than they were before COVID. I don’t mean to imply it’s been easy, because of course it’s been hard -- but it would have been harder if we’d been fighting the process of complying with an avalanche of new safety demands, as opposed to nerding out on them.

The vast majority of acupuncturists in practice are self-employed small business owners. Running a small business is something of an endurance test in the best of times. It seems like one thing we could collectively do to support these small businesses is to investigate the kindest, most expansive definitions of safety practices, the ones that give us more energy rather than drain us of the little that we have, the ones that help us stay curious and open. Maybe even hopeful.