In The Emergency Department
Martha Grout, MD
Background Pain is one of the most common symptoms in patients
who present to the emergency department for treatment. Acupuncture may
be an efficient and effective modality to treat such pain.
Objective To determine whether the use of medical acupuncture is both
feasible and effective in the emergency department setting.
Design, Setting, and Patients A retrospective study of patients
treated with medical acupuncture in the emergency department of Phoenix
Memorial Hospital between August 1999 and May 2000. All included patients
had received either no prior pain medication, or pain medication at
least 1 hour prior to the treatment. Most patients treated with acupuncture
presented with musculoskeletal complaints.
Intervention Acupuncture treatments were varied, depending on
the presenting complaint. Because of the acute nature of the treatment
setting, protocols were mainly either linear or tendinomuscular meridians
with focusing points. Standard acupuncture needles were used for
Main Outcome Measure Improvement of patient pain, documented
by either the physician or the patients nurse.
Results A total of 198 cases were reviewed; 21 cases demonstrated
100% improvement, 6 cases showed no improvement. Overall, 74% of the
patients had greater than 40% relief of their presenting symptoms.
Conclusion Medical acupuncture is a viable option for treatment
of patients presenting to the emergency department, depending on the
presenting problem and the physicians patient load. Acupuncture
has the additional advantage of being a non-narcotic treatment, leaving
the patient awake, alert, and able to drive home immediately after treatment.
Pain Management, Emergency Department, Acupuncture, Alternative Medicine,
In 2000, about 10% of US residents visited hospital emergency departments
for treatment of nonfatal injuries, according to a report released by
the Centers for Disease Control and Prevention.1 Most of these patients
leave the hospital with prescriptions for pain medication, and many
of them are given pain medication while in the emergency department.
Patients who are discharged and given narcotic pain medication are not
allowed to drive themselves, thus forcing them into the uncomfortable
situation of either being medicated and requiring assisted transportation
or receiving no immediate pain relief.
In this study, I examined both the feasibility and effectiveness of
medical acupuncture in the emergency department, either as the sole
therapy or as adjunctive therapy, for patients presenting with conditions
amenable to acupuncture.
Data were collected on a series of 201 patients presenting for treatment
to the emergency department of Phoenix Memorial Hospital in Phoenix,
Arizona, between August 1999 and May 2000. This inner-city hospital
treats a largely indigent population. The emergency department at the
time of the study had 28,000 visits per year, and was staffed by 1 emergency
medicine-trained physician and 1 physician assistant. In this particular
emergency department, the physician was responsible for patients in
17 acute-care beds as well as all in-house cardiac arrests, and wrote
admission orders on almost all the admitted patients as well. The physician
assistant was responsible for patients in 5 additional fast track
The physician performed an average of 2 acupuncture treatments per shift
in the emergency department for patients who, in the physicians
judgment, might benefit from medical acupuncture. Some of the patients
were employees of the hospital who presented to the emergency department
specifically requesting acupuncture treatment. Standard allopathic diagnostic
methods and criteria were used for establishment of diagnosis prior
to the initiation of any acupuncture treatment. Approximately 10%-15%
of patients refused acupuncture, mainly because of fear of needles.
No effort was made to select every patient whose complaints were amenable
to acupuncture. Acupuncture was offered at the physicians discretion,
depending on the state of activity in the emergency department. Patient
consent was obtained for all acupuncture treatment.
Patients were eliminated from the study if there was a lack of information
on the timing of medications in relation to the acupuncture treatment,
thus possibly confusing benefit from medications with benefit from acupuncture.
Others received pain medication at least 1 hour before the treatment
and thus, were considered to have had maximum benefit of medication
so that subsequent improvement could reasonably be credited to the acupuncture
Acupuncture treatments were varied, depending on the presenting complaint.
Most patients treated with acupuncture presented with musculoskeletal
complaints. Because of the acute nature of the treatment setting, protocols
were mainly either linear treatments (e.g., LI 4, LI 5, LI 11 for a
wrist injury) or tendinomuscular meridians with focusing points (GB
44, GB 40, SI 18 for a lateral malleolus sprain). Constitutional or
French Energetic treatments were occasionally used when the patients
primary axis of symptoms and/or structural biopsychotype was easily
determined.2 Standard acupuncture needles were used for treatment (length,
25-40 mm; gauge, 30-34). Needles were retained for 20 minutes, and the
nurses were trained to remove them (cephalad to caudad) if necessary.
Pain was measured on a 110 scale (10 = worst possible pain). Patients
reported perceived change in pain following treatment. Improvement was
documented by either the physician or the patients nurse.
|Table 1. Emergency Department Patient Outcomes
||No. of Patients
||Relief Achieved, No.
||>40% Improvement Due
to Acupuncture, % of Patients
|* One of these patients returned 2 days later to show
|† Included abdominal pain, laryngitis,
leg hematoma, cat bite, scorpion sting, bladder infection, earache,
nausea, toothache, upper respiratory tract infection.
A total of 198 cases were reviewed: 21 cases had 100% improvement after
acupuncture, 6 cases had no improvement, and no patients were worse
after acupuncture treatment. A total of 75 cases were eliminated from
the study because the timing of administration of pain medication in
relation to acupuncture treatment was unclear from review of the charts;
111 cases had no prior pain medication, and 12 cases had medication
more than 1 hour before the acupuncture treatment but were still experiencing
significant pain or other symptoms.
Overall, 91 patients (74%) experienced greater than 40% relief of symptoms
with acupuncture. Musculoskeletal complaints comprised the majority
of cases treated (n=77), with 70% of those patients experiencing more
than 40% relief of their pain. Headache was the 2nd most prevalent presenting
condition (n=16), and 94% of these patients experienced greater than
40% relief of their symptoms. A miscellaneous category included patients
with complaints such as abdominal pain, respiratory tract infection,
and bladder spasms. Of these patients, 81% experienced greater than
40% relief of their complaints. The category of facial paralysis (Bells
palsy) showed no immediate relief of symptoms, although 1 patient returned
2 days later with a complete cure of his paralysis. Most patients (75%)
for whom pharmaceutical medication had failed experienced greater than
40% relief of symptoms with acupuncture (Table 1).
The average overall visit time in the emergency department is about
2 hours. The average visit time for the acupuncture-treated patients
was 1.63 hours. It does not appear that acupuncture treatments caused
any expansion of stays in the emergency department.
Medical acupuncture appears to be a viable option for treatment of selected
patients presenting to a busy emergency department. This study demonstrated
that it is possible to perform acupuncture in the emergency department
without an increase in length of stay. Relief of symptoms was significant,
with greater than 40% relief in 74% of patients treated. The advantage
of acupuncture is that patients leave the emergency department lucid,
unclouded by narcotics or other sedating drugs. Therefore, the patients
may be permitted to drive themselves much sooner than those who receive
narcotic pain medication. A further advantage is that acupuncture, in
addition to providing relief of symptoms, also promotes healing by increasing
the local blood supply and can result in more rapid resolution of traumatic
injury than treatment with pain medication and rest alone.
A MEDLINE search revealed a few articles on pain management policies
in the emergency department, but nothing on actual results of administration
of pain medication. Therefore, it is impossible to compare the effects
of medical acupuncture with those of pain medication. One study reported
on a survey of the use of alternative therapies, including acupuncture,
by emergency department patients. The conclusion was that 56% of those
patients had used alternative therapies,3 and 87% of the patients believed
that the alternative therapies were effective. However, the study did
not document any use of alternative therapies in the emergency department
itself. Another study reported on the use of Chinese therapies among
Chinese patients seeking emergency department care.4 This study concluded
that more than 40% of the Chinese patients with a Western medical physician
had also used a Chinese medicine modality, and suggested that emergency
department physicians should be aware of the medical implications of
This study suggests the need for further research into the application
of medical acupuncture in the emergency department. More specific treatments
and protocols could easily be devised, with randomized patient selection,
using specific injuries or illnesses commonly presenting to the emergency
department, e.g., ankle sprain, simple fractures, lacerations, and sore
throat, with documentation of follow-up visits and length of time to
complete healing of the original symptom or injury
This would be possible to achieve, even in a busy emergency department,
if several physicians were participating in the study or if the ancillary
personnel were trained to use specific acupuncture protocols for specific
conditions. Thus, a greater number of patients could be studied.
Mark Dietzgen, Steven Helms, Theodore Suzelis, and Valeria Wyckoff were
research associates who tabulated and calculated the data as
part of their 4th-year research project at the Southwest College of
Naturopathic Medicine in Phoenix, Arizona.
JM. Acupuncture Energetics: A Clinical Approach for Physicians.
Berkeley, Calif: Medical Acupuncture Publishers; 1995.
Gulla J, Singer AJ. Use of alternative therapies among emergency
department patients. Ann Emerg Med. 2000;35:226-228.
Pearl WS, Leo P, Tsang WO. Use of Chinese therapies among Chinese
patients seeking emergency department care. Ann Emerg Med. 1995;26:735-738.
Dr Martha M. Grout is Board-certified in Emergency Medicine and Medical
Acupuncture, with a private practice in Medical Acupuncture, and an
Emergency Medicine practice at Arrowhead Community Hospital in Glendale,
Arizona. Dr Grout is a Fellow of the American College of Emergency Physicians,
a member of the American Holistic Medical Association, and is a Clinical
Instructor for the UCLA Medical Acupuncture for Physicians Program.
Martha M. Grout, MD, MD(H)*
6137 E Mescal St
Scottsdale, AZ 85254
Phone: 480-348-9394 Fax 480-951-5930
*Send all correspondence and reprint requests regarding this article
to Martha Grout, MD, at the address listed above.