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Acupuncture in a University Hospital
Implications for an Inpatient Consulting Service
Laeth Nasir, MD
Arch Fam Med. 1998;7:593-596.
ABSTRACT
This case series reviews my experience in providing acupuncture treatment to inpatients at a midwestern, tertiary care, university teaching hospital. I review 4 cases, including patients with torticollis, ileus, brain injury, and intractable migraine. The lessons learned from each of these cases are summarized, and the implications for the development of an inpatient acupuncture service are discussed.
INTRODUCTION
Acupuncture may have been practiced on a small scale in North America since18761; however, only recently has it become popular among large segments of the population. In China, many hospitals perform acupuncture on inpatients who have a wide range of diagnoses, in addition to carrying out traditional herbal and modern Western medical treatments. The vast majority of acupuncture in the United States is performed on an outpatient basis for chronic conditions such as pain. When acupuncture is used in the hospital, it is reported to be used primarily for the augmentation of surgical anesthesia.2 With increasing patient and physician interest, and stronger scientific evidence of the efficacy of acupuncture, this treatment modality is being carried out more frequently in conventional medical settings. A recent National Institutes of Health Consensus Panel statement3 addressed the increasing use of this therapeutic intervention, and reviewed the current scientific literature on the efficacy of acupuncture for many conditions. The panel's finding, that " . . . there is sufficient evidence, however, of acupuncture's value to expand its use into conventional medicine and to encourage further studies of its physiology and clinical value,"3 has heightened interest for this treatment modality in both the lay and professional community. Recently, it was reported that at least one hospital is experimenting with providing acupuncture care to hospitalized patients for conditions such as pain relief and anxiety control4; however, no data exist on the use of acupuncture in a general inpatient population in the United States, in whom the average acuity and severity of illness is likely to be higher than seen in hospitalized patients in developing countries such as China.
The following case-series reviews some cases from my experience as a consultant providing acupuncture to inpatients in a midwestern, tertiary care, university teaching hospital. During the past 3 years, I have provided acupuncture treatments to 16 hospitalized patients for conditions ranging from acute pain (11 cases) to anxiety (2 cases), ileus (2 cases), and brain injury (1 case). These patients illustrate both the potential and the problems encountered in integrating this unconventional therapy into the fast-paced, highly technical world of the modern teaching hospital.
REPORT OF CASES
CASE 1
An acupuncture consultation was sought from the family medicine service for a 79-year-old woman who had presented 48 hours earlier to the emergency department with severe neck and shoulder pain and spasm. Outpatient therapy was attempted initially and failed and a medical workup failed to demonstrate any serious underlying pathologic condition to account for the pain. The patient was given progressively stronger analgesic medications to control the intense discomfort. After the failure of oral and intramuscular medications to control the pain, she received a morphine patient-controlled analgesia pump. Shortly thereafter, the patient became confused and combative. Use of the patient-controlled analgesia pump was discontinued, with gradual return of the mental status to baseline. Physical therapy was begun, the option of acupuncture was offered and refused, and a neurology consultation was obtained. Magnetic resonance angiography and imaging brain scans showed no abnormalities. Results of a lumbar puncture showed no abnormalities. A small dose of intravenous benzodiazepine was recommended but resulted in a return of the mental status changes. Physical therapy was unsuccessful owing to the intense pain experienced by the patient. The patient and her family then decided to try the acupuncture treatment. Although the patient was admittedly skeptical and apprehensive prior to the treatment, to her surprise she experienced notable reduction of her neck and shoulder pain and was able to actively move her neck through about 20° rotation and lateral flexion immediately following the acupuncture treatment, which involved the placement of needles in a finger, toe, shoulder, just inferior to the zygoma, and on her forehead. A second treatment the next day resulted in enough relief in her pain and spasm that she was able to be discharged from the hospital with a nurse providing daily follow-up and outpatient physical therapy.
One of the problems encountered in geriatric patients who are hospitalized is the high incidence of medication side effects they experience. In this case, the use of strong analgesics resulted in delirium, a condition associated with a significant mortality rate.5 Following the principle of "do no harm" a case such as this requires creative solutions to avoid creating iatrogenic illness.
Most hospitalized patients offered acupuncture in our hospital have initially refused it or have been openly skeptical of its efficacy. They are understandably very apprehensive before the first treatment. This situation can be rather intimidating for a physician, particularly when many of the hospital staff may share some of the patients concerns; however, after treatment, most patients find that the procedure is not associated with notable discomfort. As is the case before any unfamiliar procedure, it is important to spend time building a degree of rapport with the patient prior to treatment.
CASE 2
A consultation was requested from the general surgery service for a 35-year-old woman, 14 days after resection of an enterocutaneous fistula caused by Crohn's disease. The patient had a long history of Crohn's disease and had been hospitalized many times for complications of the disease. The patient initially did well postoperatively, then began complaining of increasing abdominal pain and distention that necessitated escalating doses of intravenous morphine sulfate by patient-controlled analgesia pump to achieve pain relief. The high doses of morphine resulted in an ileus that led to greater distention and discomfort. The internal medicine service was consulted, but they were unable to offer any specific solution other than to wean the patient from the morphine therapy. Any attempt to do so, however, led to an intolerable increase in discomfort. Prokinetic agents were ineffective. Total parenteral nutrition was begun. When first evaluated, the patient was alert and pain free, while receiving a morphine sulfate basal rate of 7 mg/h, with 1-mg demand doses every 15 minutes which she was using regularly. Abdominal examination revealed a healing midline abdominal incision. The abdomen was slightly distended, with absent bowel sounds, and diffuse tenderness to deep palpation.
After discussing the situation with the patient, acupuncture was begun with continuous electrical stimulation of both auricular and body points. During a 6-hour period, the basal rate of morphine sulfate was lowered to 1 mg/h, with no demand doses. The patient reported feeling "as loose as a bowl of spaghetti" and more alert. She denied pain or nausea; her vital signs were stable; and her skin was warm and dry. Orders were left with the nursing staff to page the service if the continuously stimulated needles were dislodged. A call was received about 4 hours later, at 10 PM, that the patient was experiencing pain. There had been a nursing shift change, and the information regarding the needles had not been transmitted to the nurse taking care of the patient. The needles had come unhooked from the electrical stimulating device when the patient had gotten up to go to the bathroom 2 hours before and had not been reconnected. The patient was diaphoretic, anxious, and complaining of abdominal discomfort. The basal dose of morphine sulfate was increased to 2 mg/h and the patient observed for an hour, at the end of which she reported adequate pain control. Acupuncture was discontinued for the night, with the intention of completing the weaning process the next morning. A note was left on the patient's medical record to leave the basal rate untouched if possible, but if necessary, to give the patient a very small dose of an intravenous benzodiazepine if needed for sleep.
The next morning, the patient was found to be unarousable. Apparently she had done well until about 4 AM, when she awoke with abdominal discomfort and had been given 2 mg of lorazepam (Ativan) intravenously by the surgical intern on call. Immediately, the morphine therapy was stopped, and in about 30 minutes the patient awoke with abdominal pain, diaphoresis, yawning, and midriasis. Morphine therapy was restarted, and the patient refused further acupuncture treatments.
Acupuncture has been used widely to provide detoxification for narcotic addiction.6 In this case, tolerance to the analgesic effects of narcotics led to a vicious cycle of increasing ileus, distention, and further narcotic use. Acupuncture was initially successful in not only blocking the symptoms of narcotic withdrawal, but also in providing analgesia for the abdominal pain due to the ileus (and perhaps narcotic withdrawal). This case served to point out many weaknesses in the provision of acupuncture to our inpatient population. Clear communication among professionals is of paramount importance when many professionals simultaneously carry out many complex tasks to care for patients. Better communication and better understanding of the treatment by all involved in caring for this patient may have led to a better outcome. More education of physicians, nursing, and ancillary staff is important to ensure that the highest quality of care obtainable with this modality is achieved. Adequate manpower to provide acupuncture around the clock if necessary is another important lesson highlighted in this case, as well as the importance of providing adequate analgesia to patients to reduce anxiety and to build trust in the physician and treatment modality used.
CASE 3
An acupuncture consultation was requested by a surgical specialty service for a patient who was in the intensive care unit. A 32-year-old man had suffered an apparent anoxic brain injury approximately 2 weeks earlier, and was receiving mechanical ventilation. The family had heard that acupuncture was available and had requested the consultation. Review of the patient's medical record revealed a neurology consultation that held out little, if any, hope of recovery. This was echoed in a second opinion from an independent neurologist. An ethics consultation had been obtained, and the hospital chaplaincy service was involved. Physical examination revealed the patient exhibited decorticate posturing, with no evidence of neurological activity above the brainstem. When I met with the family, they related that several years ago the patient's uncle had a transverse myelitis that had been declared irreversible by many specialists, and following a course of acupuncture, he had recovered. A long discussion took place. It was pointed out to the family that there was no evidence based on the scientific literature that this course would be effective. The family was insistent, however, and ultimately it was agreed that acupuncture would be attempted. A series of treatments was carried out over several days. There was no clinical response; however, much time was spent at the patient's bedside, and a good working relationship was developed with the family. At the end of the treatment series, they were ready to move on to recognizing the irreversibility of the patient's condition.
This case raised questions regarding the ethics of carrying out a futile treatment. It could be argued that this treatment should not be attempted, based on the lack of any evidence of its efficacy in this setting7; however, the same argument could be made for continuing mechanical ventilation in this case. In this situation, the futility of treatment was balanced against its possible harmfulness, wastefulness, and the family's wishes. It is possible that the lack of a trusted primary care physician may have hindered the patient's family from moving forward in the decision making regarding their loved one. Acupuncture provided an opportunity for a grieving family to develop a relationship over time with a physician accustomed to discussing end-of-life issues. Just spending unfocused "quiet time" with the patient and/or family at the bedside is a powerful tool that physicians may use too sparingly. This quiet time, during which diagnosis or therapy is carried out, is a characteristic shared by several complementary therapies, and may be as or more beneficial than is the therapy. This case reinforces the value of spending a little extra time caring for patients and families, both inside and outside of the hospital.
CASE 4
An acupuncture consultation was sought by the internal medicine service for a 25-year-old woman who had been readmitted only hours after having been discharged from a 4-day hospitalization with a diagnosis of status migranosus. During that hospitalization, computed tomographic and magnetic resonance imaging studies of the brain had been performed, as well as a lumbar puncture. A neurology consultation had been obtained, and several medications were tried, including intravenous lorazepam, meperidine hydrochloride (Demerol), nalbuphine hydrochloride (Nubain), gabapentin (Neurontin), propranolol hydrochloride (Inderal), lidocaine hydrochloride nasal spray, oxygen by nasal cannula, ketorolac tromethamine (Toradol), amitryptiline hydrochloride (Elavil), dexamethasone (Decadron), and a morphine patient-controlled analgesia pump, all without relief. A psychiatric consultation was obtained. The patient's medical history was notable for recurrent severe migraine headaches since suffering from encephalitis 7 years earlier. She had been evaluated and treated for many years at 2 major regional subspecialty clinics without much change in her headache frequency or severity.
Although she voiced some skepticism that acupuncture could help her, she admitted "at this point, I would do anything to get this pain away." Within 1 hour of the treatment, she experienced resolution of her headache and was weaned from the patient-controlled analgesia pump. That night, she slept soundly, with only a mild return of the headache the next morning. The headache resolved completely following a second acupuncture treatment, and she was discharged home. She is receiving acupuncture as an outpatient and has had no recurrent headaches.
In my experience, acupuncture is often used as the treatment of last resort in the hospital. Whether it should remain as one is a question to be answered by the larger medical community through further research and multicenter studies. Its potential as a versatile and safe treatment should be balanced against concerns regarding its efficacy and cost-benefit ratio compared with other more familiar and readily available treatment modalities. Questions of acceptability to patients will likely vary according to personal preferences and health beliefs, experience with acupuncture and related treatment modalities, and the trust that they have in the judgment of their physicians.
COMMENT
This case-series describes some of the possible uses of acupuncture in a general inpatient population and illustrates some of the unexpected benefits and pitfalls of this procedure that may be experienced in the hospital. The cases reflect my experience in using acupuncture to treat a range of conditions. Compared with patients presenting for acupuncture in the outpatient setting, inpatients are often quite apprehensive at the prospect of receiving this therapy. This is understandable, given the unfamiliar treatments, surroundings, and severity of their illness. In contrast to the outpatient setting, where there is usually more time to build rapport and create a therapeutic alliance with the patient, physicians may often feel that they are under the gun to produce immediate results. This pressure may come from both the primary medical team and the patient, each of whom may be understandably stressed by the situation leading to the consultation.
In virtually all cases, acupuncture can be carried out without disrupting ongoing treatments. A typical treatment lasts between 10 and 20 minutes. For most inpatient indications, treatments are carried out once or twice daily. In the case of narcotic withdrawal or for postsurgical analgesia, treatment may continue for several hours.
Because of the often multifaceted problems that give rise to an acupuncture consultation, I have found that a broad range of cognitive and interpersonal skills are helpful in bridging the gap between this therapy and the highly complex hospital environment. In cases requiring follow-up, provider continuity with a generalist further promotes the transition to an outpatient setting.
As is the case with traditional consultations, any conflicting needs and expectations of patients, consultants, attending physicians, and allied health care staff needto be addressed explicitly, with clear guidelines established regarding the responsibility and end points of treat ment. Further education regarding this modality for physicians and hospital staff will increase the likelihood that this treatment is used to its fullest potential for the benefit of hospitalized patients.
AUTHOR INFORMATION
Accepted for publication March 26, 1998.
Reprints: Laeth S. Nasir, MD, Department of Family Medicine, University of Nebraska Medical Center, 600 S 42nd St, Omaha, NE 68198-3075 (e-mail: lnasir{at}mail.unmc.edu).
From the Department of Family Medicine, University of Nebraska Medical Center, Omaha.
REFERENCES
1. Helms JM. Acupuncture in the west. In: Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Berkeley, Calif: Medical Acupuncture Publishers; 1995:4.
2. Mok YP. Acupuncture, analgesia and anesthesia. Med Acupuncture. 1996;8:4-9.
3. NIH Consensus Statement Online Available at: http://odp.od.nih.gov/consensus/cons/107/107_statement.htm. Accessed January 2, 1998.
4. Villaire M. Hospital to partner with TCM college to offer acupuncture to inpatients. Altern Ther Health Med. 1997;3:30.
5. Lipowski ZJ. Delerium in the elderly patient. N Engl J Med. 1989;320:578-582.
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6. Brewington V, Smith M, Lipton D. Acupuncture as a detoxification treatment: an analysis of controlled research. J Subst Abuse Treat. 1994;11:289-307.
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7. Savulescu J, Momeyer RW. Should informed consent be based on rational beliefs? J Med Ethics. 1997;23:282-288.
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