One of the more distressing items being reported out of the developing medical catastrophe in Haiti is the lack of even rudimentary anesthesia and analgesia for the treatment of amputations and severe acute traumatic injuries.Â One possible strategy for treating patients in pain that is rapidly effective and has little mortality or serious morbidity risk is the use of battlefield acupuncture, a technique pioneered by Air Force Col Richard Niemtzow, MD, PhD in 2001.
Because Dr. Niemtzow’s battlefield acupuncture technique is most effective when using specialized small, gold-plated needles that are not always readily available, I have adapted his work to a technique I call battlefield acupressure.
But, before I describe these techniques of battlefield acupuncture and battlefield acupressure I must make a nod to the current acupuncture discourse.
Despite the fact that acupuncture has been in use for the treatment of pain for 3000 years and there is emerging literature supporting its efficacy, it currently still remains somewhat controversial and it has attracted establishment critics in the medical profession who stridently denounce it.
These clinicians point out the lack of compelling, unimpeachable level 1 evidence to support its’ use (as is similar with many other medical treatments practiced today such as the almost entire treatment rational in traumatic brain injury) and cite existing studies concluding the effect of acupuncture is no better than placebo. Some go so far as to deem it as outright quackery.
What remains inconvertible, however, is that there is emerging literature supporting its use that is apparently unread and unknown to its naysays.
Acupuncture is widely sought by the public and is provided in part by the approximately 10,000 United States physicians who have been trained in CME-approved courses to perform it.
There are dedicated CPT codes, it is judged a reimbursable procedure by many insurance companies, and is a health treatment modality that is recognized and licensed by all 50 states. The NIH has declared that it is probably of benefit in treating some conditions.
In addition, the use of acupuncture has now been adopted by major academic medical centers such as Harvard University, Johns Hopkins University, Stanford University, UCLA Medical Center, University of Pennsylvania, and the University of Maryland (where it is used in the oncology and trauma units).
It is also widely used in the Veterans Administration and throughout the United States Military, where it is now being taught to special operations forces, medics, nurses, and physicians alike for use literally on the battlefield as well as in fixed medical facilities.
And, finally, in judging whether this would be an acceptable treatment modality for Haitian patients, what is also irrefutable is the complete absence in many situations of any modern, level 1-evidenced care currently being practiced in Haiti.
As an example, some practitioners report being forced to amputate limbs on awake patients placed on bare wood tables under dirty bedsheets (i.e., Civil War era medicine), hardly the definition of level 1, evidenced-based care.
In this situation, perhaps the lack of a wide body of level 1 evidence for acupuncture use and the ongoing sometimes vitriolic charges about its’ efficacy is a nicety that the medical community and Haiti can not now afford.
In other words, to boil it down to surgeonspeak – it may work, likely won’t hurt, but maybe you gotta try something because patients are getting their legs cut off without narcotics or anesthesia.
So, to simplify the basics tenets of what battlefield acupuncture is, how it is performed, and I how I have adapted it to an acupressure technique:
Battlefield Acupuncture (Niemtzow technique)
1. As delineateed by functional MRI studies, for many people, pain signals in the body as processed by the brain seem to somehow interact with specific points on one or both of the earlobes.
2. In these patients, there are 5 main points that can be stimulated through needles or pressure on each earlobe that will partly or totally block this reflex, thus diminishing or eliminating patients awareness/experience of pain.
3. These points vary slightly in people but are close to the positions numbered in the photo below.
4. Stimulation of the points should be done sequentially as numbered below on each ear lobe. That is, point 1 on each earlobe is stimulated, then points 2 on each ear lobe, etc. (not 1-5 on one lobe, then 1-5 on the other lobe.
5. Pain control often begins within seconds after point 1 on each ear is manipulated and very likely will occur after the first two points on each ear are stimulated.
6. Stimulation is best done by using small, gold-plated, self-retaining needles that remain in place for a day or so and are left to fall out on their own.
7. Because these gold-plated needles are almost certainly not available in Haiti, conventional open-bore IV/venopuncture needles can be used – the smaller the better.
8. There are two possible techniques to stimulate the points if conventional medical needles are used.
9. Perferred method – the needles should puncture the epidermis, inserted approximately 1 mm and then left in place. Because they are not self-retaining they may fall out when the patient moves.
10. Alternately, the points can be manipulated using the 1-1, 2-2, etc. placement protocol by placing the needle 1 mm into the tissue and rapidly moving it in and out in the tissue without completely withdrawing it as in a “pecking” type motion. This should be done for 2-3 minutes at each point.
11. After both point 1’s have been stimulated, the patient should walk briskly about 15 paces away and then back towards the practitioner. By some unknown mechanism, this contributes an additive effect to the pain control by needle stimulation.
12. The patient should be queried after each point stimulation as to whether pain is diminishing. If stimulation of points 1-3 does not diminish pain, the procedure should be retried with slightly offset points from the ones listed below.
13. The effect of stimulating these points can cause a partial diminition in pain for hours to days after the treatment.
Battlefield Acupressure (Marcucci technique)
14. This is a commonsense adaption of the Niemtzow (needle requiring technique) described above. I have used it to great affect in situations where needles were not readily available. It is free, can be done in seconds, and has no significant risk for the patient associated with it.
15. It is known to all acupuncturists that stimulation of acupuncture points by pressure or heat can have profound physiological effects in some patients.
16. The points listed below can be readily stimulated to produce effective pain control in many patients by direct, sharp pressure on the point without piercing the skin.
17. Using a sharp tipped object such as a fingernail, tip of a ballpoint pen, sharped-pointed small stone, or even a wood splinter the corresponding points on both ear lobes should be simultaneously manipulated by placing and holding firm pressure on the points.
18. For instance, the practitioner stands behind the bed of the patient and uses the edge of their forefinger fingernails on point one and gives very firm pressure for 30 seconds. If this produces good pain control, very firm pressure is held for several minutes.
19. For points 1, the pressure should be placed such that it is “pointing towards the feet” and not in the direction of the skull (or stimulation of points 2-5, the pressure is placed in the direction towards the skull.)
21. If pain control continues, the practitioner then simultaneously places firm pressure on points 2 and so.
22. Because it is clumsy to ambulate the patient while keeping external pressure on these points, the patient can remain seated or in bed and instead can pump their legs as in a bicycle motion to potentiate the pain control effect of the acupressure.
23. If any degree of pain control is achieved by acupressure of points 1 and the bicycle motion, the patient should be shown how to self-administer this technique by using their fingernails to stimulate points 1, simultaneously if possible.
24. Anecdotally, it is believed that a slowly accruing analgesia effect may occur with repeated acupressure ear treatments.