Dr. Eric Freeman writes from China
Pictures from China by Dr. Eric Freeman8/29/08 7:25 pm
Pain management and Traditional Chinese Medicine
It is hard to believe, but my time here in China is coming to an end. This past week, I have spent time learning about pain management and Traditional Chinese Medicine. I worked with Dr. Wu, a prominent pain management doc and was accompanied by Dr. Zhao, one of the residents who served as my translator. Traditional Chinese medicine consists of acupuncture, massage and using different Chinese medicine such as herbs. Apparently, the amount of training for both is the same as for an anesthesiologist. Pain management here was pretty similar to my month as a second year at Beth Israel hospital. I observed multiple trigger point injections where a combo of 0.125% bupivicaine plus some steroids was used.
More interesting to me, however, was the acupuncture. Traditional Chinese Medicine is a scientific summary of the rich experiences of the Chinese nation’s struggle against disease for thousands of years. It is one of the oldest and strongest traditional medical systems in the history of the world. Deeply influenced by the thoughts of ancient Chinese philosophy and culture, it applies dialectical thinking to research on the laws of a human being’s life activities from a macroscopic and systemic point of view.
A whole floor of the hospital was dedicated just to acupuncture. I was introduced to Dr. Liu, an acupuncture specialist. She was a very nice woman who spoke great English. Including medical school, she had almost 10 years of training under her belt just to be proficient in acupuncture. Some indications I saw acupuncture being used for included: muscle spasms, migraine, facial paralysis, low back pain, and post herpetic neuralgia.
Acupuncture points are indicated according to the specific disease and symptoms. Particularly important in acupuncture is the free flow of “Qi
There is no generally-accepted anatomical or histologic basis for these concepts, and modern acupuncturists tend to view them in functional rather than structural terms. Health is a condition of balance of yin and yang within the body. Qi is immaterial and hence yang; its yin, material counterpart is Blood (capitalized to distinguish it from physiological blood, and very roughly equivalent to it). Acupuncture treatment regulates the flow of Qi and Blood, tonifying where there is deficiency, draining where there is excess, and promoting free flow where there is stagnation. An axiom of the medical literature of acupuncture is "no pain, no blockage; no blockage, no pain."Many patients claim to experience the sensations of stimulus known in Chinese as de qi ("obtaining the Qi" or "arrival of the Qi"). This kind of sensation was historically considered to be evidence of effectively locating the desired point. (There are some electronic devices now available which will make a noise when what they have been programmed to describe as the "correct" acupuncture point is pressed).
Traditional Chinese Medicine treats the human body as a whole that involves several "systems of function" generally named after anatomical organs but not directly associated with them. The Chinese term for these systems is Zang Fu, where zang is translated as "viscera" or solid organs and fu is translated as "bowels" or hollow organs. In order to distinguish systems of function from physical organs, Zang Fu are capitalized in English, thus Lung, Heart, Kidney, etc. Disease is understood as a loss of balance of Yin, Yang, Qi and Blood (which bears some resemblance to homeostasis). Treatment of disease is attempted by modifying the activity of one or more systems of function through the activity of needles, pressure, heat, etc. on sensitive parts of the body.
Most of the main acupuncture points are found on the "twelve main meridians" and two of the "eight extra meridians" (Du Mai and Ren Mai) a total of "fourteen channels", which are described in classical and traditional Chinese medical texts, as pathways through which Qi and Blood flow.
Warming an acupuncture point, typically by moxibustion (the burning of a combination of herbs, primarily mugwort), is a different treatment than acupuncture itself and is often, but not exclusively, used as a supplemental treatment. Moxibustion is used to varying degrees among current schools of oriental medicine. For example, one well-known technique is to insert the needle at the desired acupuncture point, attach dried moxa to the external end of an acupuncture needle, and then ignite it. The moxa will then smolder for several minutes (depending on the amount adhered to the needle) and conduct heat through the needle to the tissue surrounding the needle in the patient's body. I observed first-hand the “tools” of acupuncture: filiform needles, cups, and herbs. The needles were placed in certain locations on the body and in the old times were twisted by hand. Now, due to time constraints of the physician, a stimulator is connected to the needles, eliciting a current. The cup treats localized problems, such as in a specific muscle. Fire is placed in the cup which dries the air inside. This creates a vaccum and the cup is then rapidly placed on the patient which it remains during the treatment. Circles that look like black-and-blue marks can be seen on the patient for up to a week. Finally, herbs (moxa) can also be used. The herbs were placed on top of the needle, and heated, which made the needle hot. This heat is then transmitted to the soft tissue.
Since this is a traditional Chinese medicine hospital, I am told the majority of patients will initially seek out acupuncture before ultimately resorting to invasive surgical procedures like a laminectomy, for instance.
A highlight was when I walked into the obesity treatment using acupuncture as the main treatment modality. All of the patients were women, yet in my opinion, I did not consider any of them to be obese. They were heavy set for Chinese standards. I am not sure if they first tried diet modification or ever jumped on a treadmill. Multiple treatments are necessary over a few weeks. One woman said she lost almost 5 pounds. Even in China, insurance will not cover this indication for acupuncture.
As I was walking around the acupuncture floor I sensed an interesting smell; it seemed like to be oregano. Tracing its origin, I came across a rather large open area with many people. To my left was a line to pick up medications. To my right, was the “herb pharmacy.” I was told it was all the herbs you could possible imagine, over 200 count. One must need a prescription to obtain your herb of choice. I was after all, at a Traditional Chinese Medicine hospital. I wonder if I could get some belladonna here??
Some days we would finish early in the clinic so I headed back to the OR. I would hang out in the PACU with the nurses perfecting my Chinese phrases to extubate all of the patients there. I did a case where the patient had myasthenia gravis and was to undergo a thymectomy. Dr. Cui said he thought it was best to use atracurium due to its unique pharmacology. I did not necessarily agree with him; maybe he was referring to the fact that they rarely reverse the paralysis here. I was more intrigued on using this drug for the first time. A quick search on the internet and I found the intubating dose. I gave 1/10th of the calculated dose and slipped the endotracheal tube over the fiberoptic scope easily. We strapped on the fancy twitch monitor they have and I played with it during the case. The patient did quite well.
I forgot to mention one thing about the heart cases I did last week. We did not use any anti-fibrinolytics at all. When questioning Dr. Young about this, he told me that they do have aminocaproic acid in short supply and only use it for cardiac re-do cases and for patients in DIC.
I went to a drug rep dinner the other night. Another great meal. It must have been on some anti-emetic medication as the only word I understood during the entire lecture was “5-HT3.”