“Traditional Chinese” Emergency and Critical Care Medicine?

I ran across this article recently with a board-certified specialist in veterinary emergency medicine recommending so-called Traditional Chinese Veterinary Medicine (TCVM) for critically ill patients.

As I’ve discussed in detail, there is some very limited evidence for a few potentially useful effects from passing electricity through acupuncture needles. However, the bulk of TCVM practice, and all of the theories behind it, is pure folk mythology and pseudoscience. It is always amazing and disappointing to see someone with an advanced scientific education treating such beliefs systems, and the therapies associated with them, as if they were in any way equivalent to science-based medicine or legitimate to experiment with on our sickest patients without good research evidence to support the claims made for them.

Such individuals would never tolerate the same near complete absence of evidence for a conventional drug or therapy. They are willing to give untested chemicals (herbs) and needle patients based solely on individual clinical experience and the belief that these practices have been used historically with success (which is often untrue).

Ultimately, it comes down to believing that a therapy is helpful based on individual clinical experience not only in the absence of high-quality evidence but in the absence of any controlled evidence or even a plausible theory. The history of medicine is one long lesson in why uncontrolled clinical observation is a very, very poor second to scientific research in evaluating the efficacy of our therapies. From bloodletting to internal mammary artery ligation, from Lourdes water to antibiotics for cats with interstitial cystitis, every ineffective therapy ever tried has appeared to work sometimes based on trial-and-error use. Either every possible treatment works for some patients, or clinical observation is an unreliable way to validate our treatments. Personally, I think the case is much stronger for the latter conclusion than the former.

I also think it is more than a question of whether or not we have clinical trial evidence. Of course we lack that for many of our treatments. But even therapies based on sound basic physiology and pre-clinical in vitro and animal model testing fail most of the time when subjected to clinical studies. Isn’t even less likely that a therapy based on Tonifying Yang or Releasing Wind is going to be truly effective? The rationale matters, especially in the absence of good controlled evidence.

Of course, in challenging these beliefs, I am immediately subjected to accusations that I am “closed-minded.” An open mind means not judging automatically and without regard to evidence, but it doesn’t mean not judging. We all have to make judgments about the safety and efficacy of the therapies we use. There is nothing inherently better or fairer about a positive judgment. If someone chooses to believe TCVM or bloodletting, or any other unscientific approach works based on the weak evidence on uncontrolled personal observation, they are not being more fair or open-minded than a critic who asks for better evidence than this before accepting such therapies. They are simply applying a different, looser standard of evidence.

I don’t claim with certainty that these therapies do not work, only that their theoretical foundations are unscientific, which makes the prior probability of their working very low, and that there is no good reason to believe they work in the absence of good-quality evidence to raise this probability. This is not being closed-minded, merely applying the principles of science and evidence-based medicine, which it seems to me have proven their worth quite dramatically compared with history, tradition, and anecdotes.

While this vet is usually careful to recommend these treatments with conventional care or instead of it only if the owner declines conventional treatment, I still can’t help feel it is unethical for a specialist to promote and legitimize such pseudoscience. We are essentially experimenting on sick patients without acknowledging this and claiming to have effective treatments when they are both implausible and not properly tested. We are giving a special pass to something to avoid the usual scientific testing we require of all our other therapies only because someone has slapped the label “alternative” on it.
Here are some examples of the comments in the article that I find disturbing:

If you have a patient that is bleeding post-operatively (post-op spay) or an unstable hemoabdomen that needs to go to the operating room, you can try dry needling Tian-Ping.

One indication for acupuncture could be in a post-op soft palate resection in a brachycephalic dog. By injecting B-12 at An-Shen to help calm a patient instead of writing an order for Acepromazine PRN

there are six typical Traditional Chinese Veterinary Medicine (TCVM) patterns for heart failure….If an owner is unwilling to do MV and the pet has collapse of Yang Qi, points for shock can be used as well.

If you have a feline patient with megacolon, and the owner is unwilling ? or it is too risky ? to place a pet under anesthesia for a de-obstipation, then enemas, lactulose, intravenous fluids and acupuncture can be used. There are 2 typical patterns for the Eastern diagnosis of megacolon, it is either Qi deficiency, or Yin and Blood deficiency. The acupuncture points would be selected based on what pattern they were exhibiting.

We treat many primary IMHAs and when they respond quickly it is great, but often we have patients that do not respond to the typical immunosuppressives. The traditional Chinese medicine pattern would need to be identified since there are different patterns. Typically for an extravascular hemolysis case, the main issues tend to be spleen Qi deficiency/blood deficiency. So selecting acupuncture points that would tonify the Qi/Blood, support the spleen, and immunomodulating points such as (LI-4, LI-10, LI-14, ST-36, GV-14) would be best. If the patient has evidence of intravascular hemolysis, clearing the heat and damp would be important and thus direct your acupuncture approach. The use of herbal therapy is becoming more popular and for a non-responding, primary ITP case Gui Pi Tang may be helpful.

the cat that is having an acute asthma attack that is not responding to typical interventions such as oxygen, steroids, and bronchodilators. Knowing LI-20, Bi-tong and Lung-hui acupuncture points can come in very handy. There are really countless uses for dry needling, aqua and electrical acupuncture in the CCU and it will likely become a more routine treatment in the critical care veterinary setting.

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19 Responses to “Traditional Chinese” Emergency and Critical Care Medicine?

  1. L says:

    On the rare (I hope) occasion that I have to take a pet to a Veterinary ER, I am interested in concrete diagnostic work, labs/x-rays/ultrasound. I can barely afford to pay for the necessary tests….never mind gobbledygook.

    If the animal is anxious or in pain I want them to have REAL medication.

  2. Carl Sagan (my hero) once said: “Keep an open mind, but not so open that your brains fall out.” By that, he meant exactly what you said here. You should be open to new ideas and therapies, but not so open that you accept them without evidence. I wish more people understood that simple principle.

  3. KP says:

    I thought that “traditional Chinese medicine” was brought to us by Chairman Mao as a way to satisfy his populace and their need for “medical care” after he got rid of most of the intellectuals (including physicians) during the Great Leap Forward. He didn’t believe in it himself and used Western doctors.

  4. Art Malernee says:

    When Nixon went to China the tv networks were showing pictures on tv of people in China getting surgery with no anesthetic just acupuncture. We all saw the pictures on tv so I thought at the time must be true. Soon after my partner was needling horses telling me how great acupuncture works for pain.

  5. v.t. says:

    There’s also not much difference between being too open-minded to implausible methods, and simply being inherently stupid. Much of this nonsense is purely made up b.s., and propagated without question by others. As they say, the stupid, it burns.

  6. sickdogeye says:

    As a board-certified specialist for 28 years, I am completely alarmed by the erosion of evidence based-medicine being taught in veterinary schools and large specialty centers…the cause of this trend is difficult to determine. Certainly product sales have an impact on our profession needing to provide “services” that can not be purchased elsewhere (food, pharmacy, flea control, etc.). The acupuncture in critical care medicine is the most alarming article promoting “alternative therapy” that I have seen. I am saddened to say that I will be glad for my eventual retirement so I am no longer exposed to this trend.

  7. skeptvet says:

    I am also deeply disappointed in the lack of concern about these things. I posted this story to the ECC board on VIN, where there are 7 DACVECCs. One, who does acupuncture an is married to a Chinese Medicine vet, responded with the usual bad arguments:

    1. I know it works because I’ve seen it for myself
    2. The only reason you would disagree is you are ignorant or closed-minded
    3. It is offensive for you to challenge my beliefs

    One other consultant took no position but suggested the conversation was inappropriate since it was about EBVM and CAVM rather than ECC medicine. And no one else responded at all. We are so afraid of offending or criticizing another vet, or so incapable of critical thinking, that no one is willing or able to acknowledge how crazy some of these ideas are.

  8. sickdogeye says:

    I am in complete agreement. There is certainly a trend, seen in our 35 doctor hospital, to not question or criticize other doctors. I emphasize to our interns, that the basis of medicine is to defend your diagnosis and therapy with evidence that supports your position. Through criticism, we learn, especially when we are incorrect (which of course we often are). Is this the effect of “millenials” in our profession”? I don’t know…I anticipate that this lack of critical thinking will begin to filter into our veterinary schools as older faculty is replaced, magnifying the problem.

  9. skeptvet says:

    Is this the effect of “millenials” in our profession”?

    I think just the opposite; it’s the vestiges of 60s post-modernism. The DACVECC who was so mad at me on VIN was a 1988 DVM grad, and a lot of the leaders of the CAVM movement got involved in those therapies when they first took off in the US in the 70s. I have no idea if the millennials will continue the trend or reverse it, but I think it’s at least 1-2 generations older than they are. 🙂

  10. Beccy Higman says:

    I like Stephen Fry on people being offended –

    “It’s now very common to hear people say, “I’m rather offended by that”, as if that gives them certain rights. It’s no more than a whine. It has no meaning, it has no purpose, it has no reason to be respected as a phrase. “I’m offended by that.” Well, so f^cking what?”

    I am offended by a lot of things, including people who sell acupuncture that has been proven to be no more effective than a placebo at best; where does that leave us. trying to work out whose offendedness counts for more?

  11. v.t. says:

    Skeptvet said: We are so afraid of offending or criticizing another vet, or so incapable of critical thinking, that no one is willing or able to acknowledge how crazy some of these ideas are.

    My question is, why do you think that is? Why shouldn’t a vet question or criticize another when that vet clearly is not practicing EBM, and putting the patient at harm or risk? The profession should be speaking up for itself, otherwise, the patient (and the paying client), has no recourse. Clients have to expect a fair amount of trust in a vet, if the vets aren’t being honest, and don’t educate the client on the method or procedure, who’s fault is that?

  12. skeptvet says:

    There are probably a lot of reasons for this reluctance. In general, most people try to avoid conflict and controversy. And criticizing the practices of others often leads to personal attacks, as you can see here, so that discourages many. And many vets may honestly not have a firm opinion on the evidence or the validity of these sorts of treatments, and they don’t feel they have the information or expertise to criticize them. Also, clients who are unhappy with the service they receive from a vet or the outcome, whether or not that vet has done anything obviously wrong, come to us fairly often to get validation for their complaints, and we rarely have enough information to honestly judge what happened. This makes vets reluctant more generally to criticize what another vet has done since we are in the habit of giving our colleagues the benefit of the doubt when we don’t have all the facts. Naturally, there is some sense of loyalty within the profession, as well, which might discourage private criticism. Be honestly, even in a closed forum like VIN where only vets are allowed, almost no one is willing to challenge CAM, so I’m not sure that really plays a very large role.

    Some of the reasons people have for not speaking up about these things may be good ones, but of course I agree that the public suffers if vets who understand why these things are not necessarily the best for patients don’t speak out.

  13. Robert Nix DVM says:

    I also think that the strong streak of professional tolerance for individuality of each veterinarian’s practice has hindered any advance of the “discipline”(holding yourself and everyone else to the same high standards that advance the integrity) that characterizes a scientific profession. It is leading to our decline because no one wants to do what needs to be done because it might harm or offend those of the group who will not measure up. Like sickdogeye, I am glad in someways that I am having to change to another profession after 23 years because I hate to see the continued decline which for which no one seems to want to take the unpopular role of restoring order and professional discipline.

  14. v.t. says:

    Thanks skeptvet and Dr Nix for your responses.

  15. kat says:

    So how do you explain why some old, arthritic dogs move a lot better and are obviously in less pain after acupuncture? How can you be so sure it doesn’t work? And why do you think humans have been doing this for thousands of years if it doesn’t work?

  16. skeptvet says:

    I have explained many times how people can be fooled into thinking a treatment works when it doesn’t. And people also practiced bloodletting, astrology, and ritual sacrifice for thousands of years, and no one claims those are effective medical therapies. The simple fact is that science works better than our personal observations to determine which treatments are effective and which aren’t, so that is the test a therapy must pass.

    If you are truly interested:

    Why We’re Often Wrong
    Testimonials Lie
    The Role of Anecdotes in Science-Based Medicine
    Why We Need Science: “I saw it with my own eyes” Is Not Enough
    Don’t Believe your Eyes (or Your Brain)

    SkeptVet’s Acupuncture Adventure: Introduction
    SkeptVet’s Acupuncture Adventure: Points and Channels
    SkeptVet’s Acupuncture Adventure: Acupuncture and the Evidence

  17. JoyK says:

    What if after 18 months the “real” medicine doesn’t work? My girl has relapsed twice on prednisone (for IMT), and it completely changes her personality

  18. skeptvet says:

    People often turn to alternative medicine in desperation when science-based medicine doesn’t have a satisfactory answer. This is understandable, but grasping at straws is very unlikely to work, and often it prolongs suffering. Few studies have been done, but in those that have implausible treatments led to higher death rates and more suffering even in cases where patients were so sick they were thought to have “nothing to lose” (e.g. end-stage pancreatic cancer). I understand why people want to try anything, but I have to be honest that there is no reason to think magic will work when science doesn’t.

    Good luck to you and your friend!

  19. v.t. says:

    JoyK, if you haven’t already, perhaps it’s time to see a specialist – there are other immunosuppressive medications that can be used (as alternate or in combination) to treat IMT (depending on if this is primary vs secondary, the latter requires finding the underlying cause, which isn’t always so straight-forward, but a specialist can help if your vet is uncertain how to proceed, or if something is being missed with diagnostics). TCM, acupuncture, etc certainly is going to do absolutely NOTHING for your baby. Please see a specialist for further direction.

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