NZASA Inc - Codes of Safe Practice for Acupuncturists
Consent
Written consent is strongly recommended. If treating a child under 16 years parental or guardian's consent should be obtained. Consent should be based upon the consumer being given an explanation about the proposed treatment, the needling technique and the possible side effects and outcomes following acupuncture.
Safe Acupuncture Practice
Recognise and comply with "Contraindications and Precautions"
- Prohibited Areas for Needling
- Scalp area of infants before fontanelles have closed.
- Nipples and breast tissue.
- The umbilicus.
- External genitalia.
- Vulnerable Points That Require Skill & Care
- Orbit of eye:
Jiangming BL 1
Chengqi ST 1
Qiuhou Extra 7 - Certain neckpoints:
Tiantu CV 22 front neck
Neck-Futu LI 18 side of neck over great vessels
Tianyou SI 17 near baroreceptors - side of neck
Yamen GV 15 over spinal cord
Fengfu GV 16 over brain stem - Points over lung tissue unprotected by bone or cartilage e.g:
Zhongfu LU 1
Jiangjing GB 21
Dazhu BL 11 - Liangmen ST 21 : lies over gallbladder on right side. Needle may be inserted superficially or horizontally to prevent damage to gallbladder.
- Shanzhong CV 17: a small percentage of population may have a hole in the sternum.
Tianzong SI 11 : a small percentage of population may have a hole in the scapula. - Ah Shi points close to vulnerable structures.
- Avoid puncturing certain pathological sites: e.g. varicosity of veins; inflammatory areas; areas of unhealthy skin; infection; lymphoedema.
- Penetration of knee joints
- Penetration of inner ear
- Penetration near or over major nerves, arteries, veins and over pelvic, abdominal and internal organs generally.
- Orbit of eye:
- Special care should be taken when treating consumers with the following conditions:
- Pregnant women do not use forbidden points during pregnancy e.g. Sanyinjiao SP 6, Hegu LI 4.
- Diabetics care should be taken when needling diabetics because of the danger of poor peripheral circulation.
- Pacemakers do not treat consumers with pacemakers with electro-acupuncture.
- Confused or Psychiatrically disturbed great care must be taken with consumers who are unable to understand the procedure. Parental consent should be obtained for children. The use of a consumer advocate is advised.
- Bleeding disorders
- Care with insertion and removal is required with naturally occurring Haemorrhagic diseases e.g. Haemophilia, Von Willebrands
- Drug induced, e.g. Warfarin
- avoid needling into joints
- apply pressure on each point after needle removal.
- Unstable epileptics care should be taken with needling. If a seizure is triggered then appropriate resuscitation techniques apply including the use of Rhenzhong CV 26 or/and Yongquan KI 1.
- Consumers taking Western medication acupuncture's homeostatic action may change the consumer's response to drug treatment. Research literature suggests that some drugs interact with acupuncture, making it more or less effective. Many Western drugs have now been analysed using Traditional Chinese energetic properties. It would be prudent for practitioners to be aware of the action of common Western drugs on body systems from a Western and Chinese perspective.
- High blood pressure whilst acupuncture treatment is commonly used for treatment of high blood pressure some care should be taken.
- Drunkenness generally, consumers who are drunk should not be needled.
- General care should also be exercised when needling the following types of consumers: Very old, dying and debilitated, emotionally upset (or in a state of shock), or consumers who are sweating profusely.
Be competent to carry out correct management of needle accidents, complications and reactions according to guidelines of safe practise:
Painful Needling
Needle insertion should be relatively painless. If there is unusual pain then the needle should be removed.
Bruising or Haematoma
Cause: Injury to blood vessel.
Management: Apply pressure with swab to area after needle withdrawal. Disperse the bruise or haematoma with laser or moxibustion.
Prevention: Avoid puncturing blood vessels.
Fainting
Cause: Apprehension; tiredness; hunger; general weakness;anxiety/fear; needle phobia; excessive stimulation with needles.
Management: Remove needles immediately. Lie patient down and raise legs. Reassure patient. Acupressure Rhenzhong DU 26, Yongquan KI 1.
Prevention: Explain procedures before treatment. Treat in a lying position. Insert only a few needles on first visit. Use gentle stimulation on first visit.
Bent needle
Cause: Unskillful manipulation; needle striking hard tissue; sudden change of patient's posture; unexpected contraction of muscle causing spasm.
Management: Relax area; return posture to original position if this is the cause. Gentle needle manipulations with slow removal following the direction of the bend. Never remove with force.
Prevention: Good initial positioning. Skilled needle manipulation.
Stuck Needle
Cause: Muscle spasm; entanglement of needle in fibrous tissue during manual stimulation; patient changing position once needle in situ.
Management: Relax patient; alter posture slightly. Massage skin around the needle lightly, leave a while, gently free needle by moving needle gently in different directions, then remove. Put 1-2 needles around stuck needle and gently remove.
Prevention: Good posturing of patient. Avoid muscle tendons during insertion. Avoid over-enthusiastic manual stimulation.
Broken Needle
Cause: Usually poor needle quality.
Management: Remove with forceps if possible. If this is not possible the imbedded needle must be removed surgically. Mark the exact area with a radioopaque object, e.g. paperclip stuck to skin. Immobilise area if possible. Refer for x-ray and further treatment.
Prevention: Use quality needles with shaft and handle made out of the same stainless steel. Do not insert needle fully up to shaft/handle junction.
Drowsiness
Some consumers may feel very relaxed and even sleepy after treatment. They should be advised not to drive until they have fully recovered. Suggest they bring a support person or driver and tailor appointments for the end of the day so they can go home and rest.
Infection
The skin should always be carefully examined for infection prior to treatment and medical advice should be sought if needed. Very thin and fragile skin should be needled with care.
Pneumothorax
If a pneumothorax is suspected (signs may include chest pain, tightness, dry cough, shortness of breath on exertion) a chest x-ray is essential to confirm or exclude. It is the responsibility of the practitioner to ensure that the consumer is referred for a chest x-ray and medical advice. It is important to note that the symptoms of a pneumothorax may not be present for several hours or days following acupuncture treatment.
Forgotten Needle
Cause: Tiredness, distraction, inattention, or lack of checking procedures.
Management: Systematically check and re-check that all needles have been removed at the end of a treatment.
Prevention: Development of habitual and systematic checking procedures.
Needle Stick
- Washing wound well
- Encourage bleeding
- Blood test for Hepatitis B and C and MV status from operator and consumer. (If consumer is shown to be HIV +ve, the practitioner should urgently seek advice re antiviral drug therapy treatment, according to the current recommendations.)
TRANSMISSION OF VIRUS PARTICLES
Dr. M H Anderson BSc MBchB Dobs DavMed D1H FRNWGP MFOM
Viruses consist of nucleic acid (either DNA or RNA) surrounded by a protein coat. Some viruses can have a lipid coating outside the basic structure. They are total parasites, the aim being to get their nucleic acid, which contains the genetic code for further virus replication, into the host cell. Once inside the cell, the virus takes control of the cells and turns it into a virus factory, producing more virus particles until the cell is destroyed, and the viruses move to other cells and continue the process. The most successful viruses are those that don't destroy their host too fast, so that there is plenty of time to spread to other hosts, thus ensuring survival of the virus species.
Acquired Immunodeficiency Syndrome (AIDS)
The success of the Human Immunodeficiency Virus (HIV) is due to it specifically attacking the T lymphocyte, part of the host's defence system. This leads to an inability of the host to defend itself against infective organisms that normally would not cause harm. Not everyone infected with HIV will develop AIDS. Some may have persistent symptoms known as AIDS related complex (ARC). It is currently estimated that 30-40% of those infected by HIV will develop the serious, fatal disease known as AIDS.
HIV viruses can be found in most body fluids, but in number too low to be infective to others. However, it is recognised that HIV can be transmitted via seminal fluids, vaginal and cervical secretions, breast milk and blood.
In an acupuncture context, it is the blood born transmission that puts individuals at risk: the HIV virus can survive up to 24 hours outside the body in dried blood, and up to 2 weeks if moisture is present. (In refrigerated products, such as blood transfusion, HIV can survive indefinitely; hence the need for a good screening programme for donated blood).
Hepatitis A, B, C, D, E (So far!)
The primary site of injury is the liver, due to the immune response they engender (rather than a direct cytotoxic effect on hepatocytes).
From an acupuncture point of view, Hepatitis B and C are the most important ones to consider, as they are transmitted via a percutaneous route.
Hepatitis B: This is a double stranded DNA virus, which replicates via an RNA intermediate. The main source of the virus is the worldwide reservoir of over 400 million carriers (HBAg+).
Hepatitis C: This is an RNA virus frequently associated with chronic Hepatitis.
(Hepatitis A and E are transmitted by the enteric route and do not cause chronic Hepatitis. Hepatitis D requires a pre-existent Hepatitis B infection and can worsen the severity of chronic Hepatitis B).
In the USA, 1,000 health workers contract Hepatitis B each year. Not only is it highly contagious, it is highly resilient. While HIV has been shown to live 24 hours in dried blood, Hepatitis B can survive for at least a week in dried blood.
More recently, Creutzfeldt-Jacob Disease (CJD) has received publicity, following outbreaks of "Mad Cow Disease" in the UK. If transmitted to humans, it causes diseases known as the spongioform encephalopathies, so called because the brain becomes riddled with holes. You may have noticed in the reports that no one ever used the words "virus" or "infection". This is because the "causative agent" is a protein ... no nucleic acid.... that is called a "prion". These prions multiply by causing normal protein molecules to convert into dangerous ones simply by inducing the benign molecules to change their shape.
The worrying part of this is that prions may cause a range of diseases that we haven't recognised yet, may be transmitted by blood, and it appears that they are not denatured by temperatures that would normally sterilise instruments.
(The use of the PAANZ Manual for Section D of the Codes of Safe Practice is acknowledged)