Medicine is Clumsy, Don't You Be
All medical systems have clumsiness in them. If the technique isn't, the practitioner is. Everyone in every form of medicine is striving to improve. That is why we call it practice. While we may balk at the 100,000 deaths that will happen in the U.S. this year from properly prescribed pharmaceuticals, countless patients have already died over the past two and a half thousand years by taking deadly herbal prescriptions, receiving moxa that backfired and acupuncture that proved fatal.
Why do we know how deeply we can insert needles at each point? Because somebody before us blew it. How many acupuncturists have inserted into brain stems thereby paralyzing patients, into kidneys causing internal bleeding, and into lungs, ending breath? How many have suffered as TCM's primitive system evolved into the streamlined methods we use today. We are among the oldest medical systems in history and stand on the shoulders of those who have come before us. But we have no right to sneer at other systems finding their way towards "Do No Harm". Nor can we let up on self-scrutiny. We must avoid the clumsiness that stems from our human nature and ignorance. And we must be humble and educated enough about other systems of medicine to know when they have something to offer that we don't.
Here are a few important examples of good intention blended with medical clumsiness. Hopefully, you will find value in them.
My "complex ankle reconstruction" surgery, though more difficult than the surgeon had anticipated, was successful. He was brilliant and while some of his techniques were long a part of his repertoire, others (that my insurance wouldn't cover) were cutting edge. In a few hours, he turned me life in a new direction.
Immediately after surgery, I was using Moxa, taking herbs and nutritional supplements, getting Reiki and acupuncture treatments and pleased with my progress. I was off pain medication in four days, had good energy and was excited that the modalities I was using were providing great results quickly.
My cast was changed six days after surgery, a normal protocol. But something wasn't right. I felt trapped with my ankle; literally torn apart, put back together, encased in fiberglass and burning in a new place. I went back to the hospital to learn that the cast tech did not cover a small, surgical incision point and the cast was rubbing against it. It was a small mistake that made life harder at a time when life was already extremely hard. When you are that vulnerable, every pain counts. Every little slip-up feels big. And in medicine, patient misery does matter.
A different cast tech corrected that mistake but made another, far graver one. When I called the surgeon several days later, he told me, after listening to my worsening symptoms, that the cast had been put on too tightly and that I should come in ASAP to get it removed. The excruciating pain, which did not respond to multiple pain medications, was caused by the cast's pressure on the surgical site. The wound could be infected and the healing process may have been compromised. Excessive pressure on my newly severed nerves could further damage them. Permanent problems result from casts that are too tight.
David, a friend and ER doctor, later told me that the casting process is a "crap shoot." It has to be tight right after surgery to inhibit movement, but it can't be too tight. Problems like this happen in his ER all the time, he told me. It's an art form that cannot be perfected, even by those who spend their lives committed to doing it well.
Four weeks post-op I developed gastritis as a direct result of using medications to minimize the cast related pain and inflammation. My stomach was so irritated that, at a time when nutrition was paramount, I couldn't eat at all and lost a half-pound every day for three weeks, 9% of my body weight. "Maybe you have duodenal ulcers from the medications you were given," my gastroenterologist said matter of factly. "Why would I be given a drug that can do that?" I asked him. "Your gut is not your surgeon's field." he responded.
As I write two months later, I still have pain, burning and hypersensitivity to touch in my foot from that cast and have only repaired my stomach enough to eat gentle foods and a few nutritional supplements. My energy level isn't what it was before the gastritis, my weight is still down and my herb intake is far below what I would like. One minor mistake led to another and side effects snowballed, permanently altering my entire surgical healing experience. What long-term ramifications will come from this? "The energy to repair surgical wounds is supposed to come from herbs." my herbalist has told me. "If it comes from the body it can shorten your life."
At 92, Eleanor's energy and enthusiasm for life were amazing. She did and came and went in ways most people a decade younger are not capable of. Though healthy, her internist kept a close eye on her high blood pressure and she received regular medical care.
Last spring, she had a "spell" of spinning feelings while driving and had to pull over. While the "spell" ended, it re-occurred several times in the weeks that followed. Then her energy vanished. She went to her internist for tests. Then she went again ... and again to ENTs, cardiologists, hematologists, and vascular specialists. Everyone said she was "great." For four months she felt wretched, endured two hospital stays after "spells," and spent a fortune on tests. Finally, Eleanor was diagnosed as having a virus.
"Why do they say you have a virus?" I asked. "Because they don't know what else it could be." She muttered in exasperation. "Are your doctors going to treat this virus?" I asked. "They cant," she moaned. "There are no medications for it!"
I gave Eleanor an acupuncture treatment after that conversation and she immediately felt 40% better. The next day, I gave her virtually the same treatment and got no results whatsoever. When this happens, I consider two possible etiologies. The first is that a disease agent is so virulent that in the span of 24 hours my patient has dramatically worsened, requiring a much stronger or different treatment to be effective. The other is that there is no disease agent and something is wrong biochemically. I believed the latter to be the case and, having the luxury of a house call practice, spent the afternoon watching her. I saw the amount she drank vs. her frequency and volume of urination. The balance wasn't right. I studied her medications and called her pharmacist to inquire about possible problems showing up after a decade on the same blood pressure drug combinations. "Impossible," he said. In other words, I got nowhere. I called a friend in pharmaceutical manufacturing to get a more realistic assessment.
We determined that Eleanor's blood pressure protool was no longer her best option or appropriately dosed. A legitimate cause for the dizziness and fatigue was the potassium it drained from her body. It was worth exploring if she needed to have the simple balance of sodium and potassium regulated. These two minerals carry nutrients into and out of our cells. They are among the most basic of our biochemical balance points. If this ratio gets too far off, a person can die. Eleanor was close to that point.
I gave her Gatorade. She drank a mouthful and her cheeks got pink instantly. I put her on 16 ounces for the afternoon and her energy and color dramatically improved. I called her internist, told him what I had determined, prescribed and witnessed and asked about prior evaluation of her electrolytes. Other than blood chemistries being taken when she was feeling well enough to go into the office, her symptoms were almost abated, no follow up tests had been done.
All those specialists, months of testing, years of potassium draining meds and no one checked the essential biochemical yin/yang of the body when she was having symptoms. Aghhhhhh! She was re-admitted to the hospital, put on an electrolyte IV and re-evaluated for her meds. Problem solved.
What happened to the virus diagnosis? It floated away once I figured out what the problem was. The multiple MDs on the case had not identified a virus as a causative factor. But they needed to give the patient an answer and had no other, the internist told me. "And they are all excellent physicians," he said, sounding somewhat confounded by the mis-steps he and his colleagues had taken. I believe him. But sometimes, clumsiness is unavoidable, even from the best.
Jenna was in her late 40s when she came to me for back pain relief. It had vanished from six acupuncture treatments given to her about eight months earlier and she had been very pleased. But it had come back stronger now and she had moved to a new city so she couldn't see the same practitioner again.
She lay on her belly as I palpated her back. "The pain comes from that hard knot near my spine," she said. Do you feel it right by my rib? That must be the muscle spasm or something, because that is where it all radiates from." I moved my hands lightly over her skin and asked, "What did my colleague do when he saw you eight months ago?" "I told him where the lump was and where the pain was and he worked around it on my back. He also put some needles in my hands and feet. It felt great."
Suddenly I had that heavy sensation that comes when immanent danger is in front of me. It was a combination of dread and sadness that seeped into my hands as I brushed my fingers over the tissue irregularity she was speaking of. "Have you seen a physician about this lump?" I asked quietly, not wanting my voice to reveal my concerns. "No!" she said emphatically. I hate doctors and avoid them if I can."
Without giving Jenna a treatment I asked her to sit up and told her she had to see a doctor right away. I would not administer any treatment until she had a diagnosis as to what the "lump" was. I stressed that it was medically irresponsible to treat this "lump" or any secondary pain radiating from it before any one had diagnosed the cause of the problem.
Testing revealed that Jenna had vertebral bone cancer, which, over the several months prior to her diagnosis, had become metastatic. Her chances of survival were far lower because of all those pleasant, pain free months given to her by the previous acupuncture treatments.
Medicine and those who practice it are clumsy. All medical systems and all practitioners, even those who are well educated, devoted, even gifted, have clumsiness in them. You cannot control that. But you can control yourself and your choices. That is the point! If you look back honestly, can you see that you might have contributed to that mess? With your best intentions, what health problems did you miss? Whose injuries or diseases might you have covered up with pain or symptom relief? Whose disease states might have worsened by your misdiagnosis? Which patients would have been better served had they gone to a physician or practitioner in a different area of medicine for diagnosis before coming to you for treatment or visa versa?
Never, Never, Never
Never treat a condition you don't have a diagnosis for. Ever! Why not use CEU education to get really good at diagnosing according to our classical theories? Or take classes to learn when our theories are not what is needed for an accurate diagnosis or appropriate treatment. The best thing you can do to lessen the inherent clumsiness in your practice is to learn how to be diagnostically savvy, including when you must refer out.
Clumsy But Not Knowing It?
Did you know that you can make patients worse years from now if you don't take the long, true, slow road to healing today? Yes, sure you can tonify, make them feel better and leave that pit of dampness or deficiency, heat or stagnation waiting until later. If you aren't a good enough diagnostician you wont even know it's there. I've seen this happen multiple times. Patients will love your work because you offer faster relief. But it will catch up with them and years down the road they will be way worse off for it. This is not a threat, it's part of TCM theory. We must address syndromes in the proper order based upon accurate diagnosis and, if we skip steps, we are not doing our patients justice. We are creating good feelings, not good results.
Know Your Limits
I've made lots of mistakes in my 44 years of practice, several of which I have shared with you (so you can avoid them) in this column. But being arrogant about the capabilities and scope of TCM is not one of them. I strive to know when a patient needs someone else to evaluate or treat him or her. I ere on the conservative side if there is any chance that a problem could be better assessed or addressed by a different kind of medicine.
It is your obligation to step aside with grace and, in some cases, insistence. Don't let patients who love alternatives in medicine shy away from the mainstream out of fear or the " I hate doctors" line. Your patient may have had bad experiences before but that doesn't mean sending them to it now for diagnosis or treatment is wrong. And it doesn't mean they can avoid the clumsiness inherent therein, just as I couldn't when I got my miraculous, miserable surgery and recovery process. I hope you take this subject as seriously as I do.