Why We Do This, Part One

Recently I got the following email from a punk:

"Last Thursday I treated someone whose CC was a feeling of jitteriness, something like brain fog, or another kind of head fuzziness that seemed hard for her to describe-- like she couldn't relax, and wasn't sleeping well. I needled DU20 and SSC, along with ML10, an mian, and the 8Es for insomnia type stuff. There wasn't anything unusual about the treatment in the moment. Later that night, the receptionist gave me a note with the patient's name saying that she had a follow-up question about her treatment. We weren’t able to connect until Friday morning. She said that after her treatment and for the rest of the evening, she felt this tight band around her head. She said it wasn't a headache, but a feeling of tightness above her eyes. She also reported feeling more calm, and that she slept well Thursday night. By the time we spoke, around 11am Friday, the feeling had subsided completely.

I fumbled my way through using a lot of words to say that I don't really know why that happened. I reasoned aloud that I hadn't put any needles in her forehead directly, as a way to rule out some sort of causation from the puncture itself. I felt conscious to not appear too defensive, and also wanted to get clarity that she was okay, and not experiencing anything that felt like an emergency. It sounded like mild concern turned to curiosity, especially since by the time we spoke, the feeling was gone. So I guess my question is; is any sort of interaction like this, where a practitioner has to have a follow-up conversation with a concerned patient considered an adverse event?

It's hard to not display an element of self-defense here, because of the feeling that there’s very little connection between where i put the needles and her reaction to them. Like, how can it not be my fault in some way? But, I can also dispel that notion because there wasn't any quantifiable harm, or injury. I feel confident that we both left the conversation without feeling like something WRONG had happened. But days later, I still feel like I shouldn't discount the interaction completely, and am obviously still thinking, WTF, why did that happen???

One of the last things she said was that she was going to talk to her other (private) acupuncturist about it-- the one she's been seeing for years. There wasn't any attitude in her saying this, and quite frankly I was like, good, please do that, I'd like to know what she says! I thanked her for the call, and told her I was new to practicing, and appreciated the opportunity to interact with patients like this, and that I was glad she was feeling better today. I'm sure there is a whole script of things I should have said differently, but overall it felt like an okay call. Though as I said, I am still not sure if it does or doesn't constitute an AE."

I love this question because it gets right to the essence of why we have an Adverse Events Reporting Database. It’s something that the rest of the acupuncture profession has wondered about too: why would we want to keep track of such minor events? Why put any energy into this kind of thing once you’ve reassured the patient and everyone’s moved on? Is something really an adverse event if there’s no lasting damage and nobody ends up in the hospital?

For our purposes, YES: Any sort of interaction like this, where a practitioner has to have a follow-up conversation with a concerned patient, IS considered AERD material. Because we had to put the line somewhere and “follow up conversation” is exactly where we put it! It doesn’t matter whether the patient wants to talk to you about the tiniest of bruises, the kind you can barely see when you squint, or pain that caused them to go to the emergency room in the middle of the night. If a patient’s concerned enough to want to talk to you about it, we want to keep track of it. Why?

First, a core aspect of community acupuncture is that we want to validate people’s experience. We believe that patients are authorities on their own bodies. In our clinics, they shouldn't have to “prove” to us whether their concerns are valid.

This is very different from how the rest of the healthcare system operates, especially when it comes to pain, which is the main thing we treat. Any time you show up to work as a punk, the odds are high that more than one person on your shift has had their pain dismissed or minimized by another healthcare provider. Maybe they’ve been told it’s “all in their head”, maybe they’ve been told they’re malingering and don’t actually want to get better, maybe they’ve even been accused of “drug seeking behaviors”.

As Dilip Babu MD said to a class of POCA Tech students recently, “When a patient tells you they’re in pain, believe them.” Because, unfortunately, other people in their life probably haven't believed them.

This position of “we believe you when you say you’re in pain” is core enough to what we do and who we are that we never want to move away from it -- never. (Not even for tiny bruises.) One of the best things about being a punk is the integrity of the job. So when we were deciding how to define adverse events for ourselves, we decided to be consistent: an adverse event happens if a patient said it happened. If they said it happened, we want to keep track of it, because one of the purposes of the database is to understand people’s reactions to acupuncture. We want to get a sense of what kinds of things cause concern for patients.

Second, we also want to get a sense of what kinds of things happen, because nobody has really tried to do that systematically and in detail. We know that things happen as a result of acupuncture (or in conjunction with acupuncture) that we can’t explain, both good and bad, and as practitioners we have to live with that. Before we had the AERD, I remember a punk telling a story about a patient who got a black eye right after a treatment. This can happen if you needle, say, BL 1 or ST 1, which are right beside the orbital bone. However, the punk hadn’t needled any of these points; the closest point that they needled was GV 24, right on the hairline. Nothing else had happened to the patient that could explain the black eye and the punk was pretty sure that the needle at GV 24 was, in fact, responsible. The patient didn’t need any medical follow up. The question of course was HOW did a needle on the hairline cause a black eye? We don’t know! But as a practitioner, I want to know that’s a possibility in case it happens to one of my patients.

Similarly, I have no idea why a patient I was treating for the side effects of chemotherapy happened to have a visit, in the chair, from his grandmother (who had long ago passed away) to tell him that everything would be okay and he would recover (which he did). How did a treatment for nausea result in a vision of a dead person? Does ST 36 cause visions of dead people? Even though the outcome was positive, I guess I could have defined this as an adverse event because my patient was quite shaken up and I certainly didn’t intend for it to happen (this is many years pre-AERD). Sometimes, with acupuncture, the connection between what you did and what happens next is not at all obvious to you.

If we’re going to practice “energetic medicine” we need some kind of routine and some kind of container to deal with unexpected outcomes that we can’t explain or anticipate. It’s better for punks to not be at a loss when we have a “WTF, why did that happen?” moment, because those moments are just an unavoidable part of the job. The AERD is the container we’ve chosen, and reporting to it is the routine, but they’re not much good if we don’t use them.

Finally, it’s about communication. Of course a lot of punks could come up with something to say to a patient when they a) have a distressing reaction to a treatment or b) something inexplicable happens, and if both the punk and the patient felt okay afterwards then the punk could just move on with their day and forget all about it. And that’s what most punks are going to do.

But that doesn't help anybody else! And you know who needs help the most? The acupuncturist or acupuncture student who gets freaked out when something like this happens to them because nobody ever led them to anticipate the “WTF, why did that happen?” moments. They’ve got no framework for AEs, and so they start wondering if maybe they’re a terrible practitioner, or maybe they just don’t know enough and they should take out more loans and go back to school for a transitional doctorate. People who are at risk of making bad decisions when they don’t have enough support and enough context are the ones who need us to share this kind of information. It represents a species of generosity that our particular profession really needs. You never know who you might help.