Needling Deficiencies and Inconsistencies

I have been a practitioner of acupuncture and TCM for more than 22 years and have needled thousands of patients during this time. In addition to being a practitioner, I also design, import and distribute acupuncture needles throughout North America. I make it my business to know everything there is to know about needles, their manufacturing standards and quality.

I have watched how acupuncture has grown over the last 20 years from a practice that was considered illegal to one that is currently being performed in virtually every area of health care. My goal, and I am sure that we all have the same goal, is to see acupuncture and TCM fully integrated into our health care system. For that to happen, the practice of acupuncture has to undergo scrutiny from every aspect of our society, including related health care disciplines, regulatory bodies, educational bodies and the end-users themselves, the patients.

As you know many of the risks involved with acupuncture have been clearly identified, and practitioners in general are very cautious about them. However, there is a process that occurs during needling with thin and/or longer needles that introduces a risk factor that is not being dealt with consistently within our profession. What happens in this case is that once a longer, regular gauge or thin needle has been tapped in below the dermis, the remaining length of the needle will bend and bow as it is being inserted. At this point, effort is required to either counterbalance the bowing by increasing force in different directions, or by using a sterile cotton swab to stabilize the shaft.

The problems with this process are twofold: when you try and counterbalance the bending and bowing with different movements, it slows the insertion process down and can increase discomfort for the patient; and if you stop the needling process and go and get a sterile cotton swab or a shorter tube, efficiency is reduced.

Currently, schools teach students correct needling procedures, and Clean Needle Technique training is required for all licensure in both Canada and the U.S. However once out in practice, many practitioners take shortcuts with true Clean Needle Technique. I have witnessed all kinds of needle insertion deficiencies over the past 20 years. Deficiencies that are done behind closed clinic doors when no one else is watching. These include using non-sterile cotton swabs, using leftover shorter tubes that are lying around on the desk top that may or may not be contaminated, and some simply just touch the shaft of the needle with their fingers in efforts to stabilize it during the insertion process.

What I find interesting is the degree to which people let themselves take risk. The reality is that however small of a risk touching the shaft introduces, it is there, and we as health care practitioners are expected to do everything we can to reduce risk to our patient. However, a number of practitioners daily disregard this information and still continue to touch the shaft of the needle. I am not saying that all practitioners do this. However, we are all human and we often take shortcuts to reduce time and make choices that may not be up to standard sometimes.

When I ask practitioners about this, a number of them brush it off and say there is no problem, that there really is no increased risk with touching the shaft, as it is being done every day in thousands of clinics and no alarm bells are ringing. Journals are not flooded with articles on needle infections, so why make a mountain out of a mole hill?

The reality is that over the last 20 years, acupuncture has moved from an unregulated technique whose practice was limited to a few hundred practitioners and their patients, to one in which thousands of practitioners are treating tens of thousands of patients. That means each day, a growing number of patients are being needled. Statistically, with growing numbers, the potential for needle-insertion error increases as does the potential for needle infection. With acupuncture techniques now being practiced in practically all levels of health care, we need to take note of the growing expectations of professionalism and the increased scrutiny of everything we as acupuncture and TCM practitioners do.

Fundamentally, TCM and energetic medicine is all about looking at trends and probabilities. It is what we do when a patient walks into our clinic. We assess their health status by interpreting the signs and symptoms presented. From this analysis, we get a relative interpretation of their current condition and a sense of the trajectory the condition is trending. Once we have a diagnosis, we then make adjustments using acupuncture and herbs to change the trajectory of the patient's condition to a more stable, healthier one. Similarly, when we look at our profession as a whole and view it within the context of the growing numbers of acupuncture sessions being performed, we will know through our knowledge of yin and yang, that as something is veering in one direction we need to insert adjustments to stabilise the system. If we fail to make these adjustments the potential for problems increases.

That means as acupuncture is increasing in popularity, we as practitioners need to increase our vigilance with our needling techniques, our clinic procedures and the selection of instruments that we insert into our patient's body. We need to do that to avoid unintended consequences from occurring.

Our medicine is about preventing health problems, but our philosophy as a whole can be applied to any aspect of our life, be it clinic procedures, how we manage our money, or trends within our profession. What we as acupuncture and TCM practitioners do is all about preventing negative situations before they arise. That is why I am now writing about it, raising the red flag, saying let's be vigilant.

How is it then that I keep on hearing practitioners scoff at these concerns about needle quality or needle-insertion techniques? Many practitioners buy the cheapest needles to save cost, not really thinking about the needle metal, how clean or how well-made it is. I can guarantee that when you really know what goes into making cheap acupuncture needles you would not want to use them again. With regard to needle-insertion techniques, as I mentioned before, I have heard many practitioners casually reflect how touching the shaft of the needle is not really a problem and they themselves have been doing so for years with no issues. This is akin to them telling me that when there is a lightning storm they would not bother seeking cover, because the chances of getting hit are just so slim. So why worry? Fair enough if you are taking that risk yourself, go ahead. But doesn't that change if you drag someone else out into that lightning storm, blindfolded? Would you not be responsible for that person too? So why take the risk involving someone else? When practitioners break clean needle protocol that is what they are doing. Unknowingly the patient is being dragged into a situation that they are unaware of.

The reality is that problems do happen and infections do occur. Sometimes they are little arrhythmias around the needle that last for days, or a bit of pruritis that goes away after a few days and the patients don't formally complain. Or in the case of poor needle quality, black tattoo marks from poorly cleaned needles that are left behind after the needle is removed.

In my discussions with malpractice insurance companies, I have been told that patients do complain and practitioners have been sued. We don't hear about these cases as they are not published to protect the practitioner and their future earning potential. Insurance companies handle these cases and they are out of the public eye. Think about it, if you were a patient, would you want to go to a practitioner who was sued for not using proper clean-needle technique after it was made public in the news? Probably not. So these cases and settlements are kept private. For all the denial that goes on about potential risk, all it takes is one case. If we as a profession are not doing everything we can to protect ourselves from having that one case, then we are setting ourselves and our patients up for potential problems.

The bottom line is that the potential for infections do exist, but thankfully, like lightning strikes, they do not occur often. However, with the growing number of treatments being offered, the small number of issues we now have is bound to increase. To be preventative about this, we need to alert ourselves now and make the appropriate adjustments in the way we needle, implement the extra vigilance needed to ensure greater risk management for our practice and our growing patient loads. Doing so will not only help us protect our patients, but also help us continue to move our profession into the mainstream of health care.