I just got home from a home visit with an 87 year-old woman. This is the first time I’ve seen her in 15 years. She had pain from a removal of a small skin cancer that has not been healing. She’s had many of these removed and this one has been problematic. She is thin and very dry looking with a red tongue with insufficient moss. She has had high blood pressure for 7 years. She is on 3 different blood pressure meds and has been told she has a sodium imbalance. She is on tramadol for pain and was also given a recent prescription for prednisone. She hated the feeling of the prednisone so stopped it the day before I saw her. Her surgery was near LI 5 but her main pain was around SI 12. Her blood pressure is not managed well and is generally 180/90. She feels unwell the higher it is.
So, I decided to do SI+ on the R first (pain, pain location and surgery on the left). I got the needles in and she said she felt like her BP was going up. I took them out and decided on spleen + R because of her dryness, surgery on LI channel, she is interested in EVERYThing, I got the first needle in and she had the same experience. I decided not to do more. We took her BP and it was 198/91.
I’ve never had this happen before. I wonder if it could be related to being on a narcotic? Anyone have experience with narcotics thwarting treatment. I feel that I maybe didn’t have the best treatment idea but I can’t see how it was so wrong either. @KristinWisgirda
Thanks for sharing your experience.
This is significant indication of SI excess. You really want to see strong K excess signs before using SI+ in someone so elderly.
Interesting that her pain occurred on SI12 after surgery.
This sounds like an adverse reaction and the patient really needed K+. My best guess is of why someone so dry reacted poorly to Sp+ too is that her system was still reeling from the SI+ stimulation without the K+ needed to counterbalance.
I have very limited experience with Saam and narcotics but have had success despite them.
Please let us know what happens if you get to treat her again.
Thank you so much Kristin for your insight. I will try to go back tomorrow keeping your suggestions in mind and let you know.
Reminds me of the similarily elderly man (and he was a VERY vital man for his age) I posted about here many months ago who had strong pain and my first treatment was SI+ . . . and a few hours later, his wife called me to say he had become really weak . . . I drove to their house immediately!! and did a Kid+ treatment - he felt a lot better, but nevertheless, within 12 hours, he was in the hospital having suffered a minor stroke . . . in people this age, as Kristin says, we have to take it as essential that they are SI XS implicitly, it seems.
Thanks Daniel, I have not heard this about SI+ yet, only about the caution with pregnancy. What a way to learn! That must have been an upsetting situation. I think I am going to take the intro mentoring class that starts next week again!
Daniel graciously posted about this experience here. It is the second case.
There are also a number of other discussions of SI+ use in the elderly on this forum.
I just went to visit my patient and she’s doing okay. She said she slept better last night than she had for a while. I did Ki+ just with my finger on the point with tonification or dispersion technique depending on the point. Then I held St 41. She had some good digestive sounds, settled and the pain in her hand improved. Toby had told me that the reaction could have been temporary. I’ve seen this quite a bit - where there is a short exacerbation and then things get much better. I didn’t feel like I wanted to wait to see if the wave would break or grow though. Maybe the fact that she slept so well is an indication it may have helped? At any rate I am relieved she okay. After reading Daniel’s story, I didn’t sleep well last night.
When I think back into my acupuncture career, which has been long, I can’t recall situations where someone got worse so quickly and intensely or even at all. This makes me respect the power of the 4 needle technique of Saam immensely. It has strong power to heal and strong power to throw people off by being “all in.” I think most of the acupuncture we all learned in school was so unfocused and not “all in” with anything and we all, or maybe just I, got used to an idea that the worst you could do was to not help someone. With Saam, as it is with herbs, this is just not true.
May we take a moment to bow down to Saam’s power with humble respect and commitment to learn it well. Amen!
Glad to hear your patient is is doing OK. That is scary. Great that she felt the positive with sleeping so well. (I find that maybe I didn’t touch a patient’s main complaint, but they slept great that night at least they feel satisfaction from the session.)
Sorry I didn’t follow this connection on ST41 and the pain in her hand. Maybe you are pulling up your vast acupuncture wisdom and not Sa’am?
My experience is that if someone is going to have a negative reactions it is after the first or second treatment when the wheel is really out of true. I always have new patients check in with me and there have been a couple of times where someone emailed me that they feel awful after a session. If I know I diagnosed properly then I have told them to wait at least until the next day and if you still feel lousy to come in. I explain that it can be a good thing, especially if I know the Dx was correct and they really feel lousy - I trust they will be feeling better than before the treatment.
I have experienced this a few times myself with subtle body/energy work where I feel awful afterwards which I see as my body self correcting with new proprioception. (One very significant time when I saw Jean- Pierre Barral 20 years ago) As you said this Sa’am 4 needle flavor gives such a powerful message to the tissue that very occasionally people can feel like crap afterwards.
I looked through my notes to find examples and only came up with this one although I have a couple of others in the back of my faltering memory storage…
36 yo female who had incessant burping. First treatment was ST+ and it worked great. Second treatment 3 days later I felt her tension and she was wound tight. I treated LR+. 3rd treatment she reported that after the 2nd treatment she felt awful for about an hour and was going to cancel but then all of a sudden she felt great and has been feeling so much better since. “Is that normal.?” she asked.
I am still working on seeing the face as Toby says that is how you can determine the efficacy of a treatment. I don’t have that sensitivity yet - I hope someday soon it will become obvious.
Humility . . . .
BUT - WHAT this also makes me wonder about a LOT . . . those patients who just do not respond to Sa’Am treatments - really in any significant way - given that we KNOW it is such a powerful push to the body . . . what is going on there?
There are aspects of this discussion that could be misleading to new Saam practitioners.
Toby and I have reviewed this case based on the information presented here and through other avenues. Toby’s conclusion is that the reaction to SI+ was adverse based on the reported patient’s reaction and despite the patient sleeping better last night. A stronger adverse reaction was prevented by the SI+ needles being removed.
It is totally scary when a patient has an adverse reaction. This is made worse because we are responsible for introducing this powerful quality into the patient’s system. The correct response to an adverse reaction is to needle the counterbalancer. This teaching is fundamental to Saam practice and is its prime safety mechanism.
No information has stronger clinical weight than a patient’s reaction to our treatment both on the table and in the long run. Of the two, the primary guide to whether a patient is experiencing an adverse reaction is on the table. If the patient is feeling unwell on the table, it is almost always an adverse reaction. This should be our first assumption waiting to be proved wrong by a skillful evaluation of the complexion. There are rare cases of the patient having brief discomfort on the table but improvement in the complexion during the discomfort indicates that it is not an adverse reaction. The information presented with this case does not point to this last scenario. We all could improve in our evaluation of the complexion. I look forward to learning more and honing this skill.
George, how do you know that you have diagnosed correctly? Is it because the patient has settled well on the table? I have had cases where the patient settles well on the table but has unusual sensations after the treatment that resolve after a few hours or a day or so with the net result being improvement. If the net result is not improvement than I have to assume I was wrong in my evaluation of the patient settling. This has definitely happened to me. Evaluating settling can be tricky and I don’t always get it right.
This is definitely an important point that needs clarification. If a patient seems to settle on the table then what exactly constitutes an adverse reaction?
I had a patient get a headache the morning after the treatment (the night before) which went away after a couple of hours and then they had a good week. I’ve had other patients who felt exhausted after the treatment and felt fine the next day. Someone else felt irritable and reactive after the treatment and was also fine the next day.
Are these adverse reactions? Are these acceptable reactions but should still cause us to think twice using the treatment again at another time?
I know that there are not clear cut answers but perhaps it is a subject that needs more attention - What exactly falls into the parameters of an adverse reaction?
In the case I mentioned she was tight bilaterally from TW15-GB21 and her left side let go immediately. Her pulses also evened out and relaxed, in addition to her calmly sinking.
I gauge the treatment multiple ways: l I look for a pulse that evens out between depths, left/right, relative strength and overall quality. That seems like a low hanging fruit.
I also use channel palpation on the corresponding channels checking prior tight/painful points - oketsu release on SI+, abdomen releases for confirmation of the correct conformation.
How a patient settles is of course important. With the masks I have trouble with the face changes as it challenged me even before Covid.
My diagnosis experience in the clinic with hands on a patient is a different experience than diagnosing a case on this forum or on a Zoom class. In both there is the cerebral aspect of going through the wheel of channels and logically coming to a diagnosis. However having the patient in front of me and touching the patient gives so much information a written word cannot. I find that quiet place offers significant clinical weight and I wish I could have those experiences of treatment clarity all the time. So when it comes through I use that information and have a knowing trust in my diagnosis.
I agree that getting worse on a table should be seen as an improper channel choice at that moment in time and corrective action needs to be taken. I have had to do this several times where I need to counterbalance then often do a treatment to address the concern. I explain to my new patients before needling what to expect and I give everyone a bell to ring if they do not feel right on a table or have a worsening of their main complaint. For more Sa’am seasoned patients if I am doing a ‘dark horse’ channel I’ll also explain if they feel so and so symptom that is uncomfortable to ring the bell. (for example - doing KD and feeling a tightening of muscles etc) If I don’t have a high degree of confidence I then stay with them for a bit or check back in in a few minutes.
The seldom occurring unpleasant reaction after treatment that turn into a positive are after they have left the office, not on the table. In my personal experience of being a receiver (of other modalities, not Sa’am) and the 2 or 3 I’ve had with Sa’am those seemingly unpleasant reactions happen after the treatment ends. The unpleasant symptoms are followed by a positive improvement compared to before the session. It seems rare and in my experience it seems if big shifts are going to happen it will be in the first or second session when there is a lot to correct. As you said if there is not a net improvement or a worsening of symptoms then it is an adverse reaction.
And of course I tell my patients I want to see improvement every treatment. If there is not an improvement then I evaluated or treated (bad needling) incorrectly for what they needed in that moment.
To your point about adverse reactions here is a current case that I had an adverse reaction but thankfully is doing extremely well now thanks to Sa’am:
I am treating a 2017 concussion patient who has had stabbing sharp pain on the left side of her head several times a day almost daily as well as insomnia since the fall. She said she was fine before this and a busy yoga teacher. SI+ on the first treatment seemed to bring some relief to the duration and intensity of the occasional sharp stabbing. I went with LR+ for the second, she settled, I checked in with her and she said she felt good with the needles. She reported feeling relaxed after the session.
However the next day she contacted me that a couple of hours after the treatment her pain moved to her right side (it was never on the right) as it went from a sharp occasional left sided headache to constant dull right sided headache. She said she’d rather have the occasional stabbing. (I was like ‘shit’ as she is in my only on Wednesday office so couldn’t see her for another week and her driving 45 minutes drive to my regular office was out of the question). However she did say she slept better after the treatment. In the back of my mind I was thinking I’d have to drive to Cambridge on my off day to treat her SJ+.
But thankfully the headaches improved by Sunday and lessened, but she still said the next Wednesday (Jan 27) she wasn’t sure what was worse, a dull headache lasting hours or a sharp stab or a few minutes? I could now see I treated incorrectly even though there was change - the overall net result was not improvement. This was also the days after the Qiological eye webinar and I saw the clouded dullness. I obviously treated SJ+ and Feb 3rd she reported “This week has been much better - almost headache free most of the time…Vision is pretty good - Amazing how the vision shifted”.
it is such an art tuning into what our patients need in each particular moment. Sa’am is such a beautiful healing modality and knowing we have the ability to correct mistakes is just amazing, really amazing. I am so grateful.
or as grandma said . . . ‘the proof is in the pudding’
WORSE now with masks!! I have made ‘listening’ my new primary settling assessment avenue - after the needles are in, I continue in a light dialogue with the patient for a few minutes and in my evolving experience, if they are settling, there is often quite a sudden and marked shift in the tone, camber, quality, pace of their voice . . . .
It’s always great to learn from reading other cases that go right as well as wrong. I am in constant awe and have such a respect for this style. I just had someone today who from all indications seemed to be pointing to SP+. Dry, skinny, busy. I checked in on her after 5 and she was having heart palpitations and seeing scary faces. Definitely took those needles out and treated LI+. Settled immediately.
I have been wondering something. I follow what Toby taught in class that if the patient has an adverse reaction take the needles out and treat the counter balancing channel on the opposite side. But if I have done a treatment and the patient reports back that after the treatment there was an aggravation of symptoms, suggesting perhaps an adverse treatment, then at their next treatment I will treat the counterbalancing channel but stay with the original side rather than the opposite side. Is this wrong?
Yes I would stay with the original side if it is the next day or beyond. But if it is truly an adverse reaction and their complaint symptoms are worse and not just different or moved I would get them in ASAP, not wait until the next treatment.
Yes. I do have them back ASAP. But there is always is that patient no matter how much you explain to them how this style is different and if symptoms are aggravated or any else is off please let me right away and they still don’t and have rationalized in their heads it’s probably due to some other thing and couldn’t be possibly the acupuncture. I’ve even learn to be a lot more inquiring at my 5 min check in. The woman I mentioned in my first post above, who had the palpitations, when I checked in on her at 5 min she first said she was good and relaxed. And as I prodded a little bit she said she had palpations but can get them sometimes so she didn’t think it was an issue except they were quite strong… And then another pause and “oh and weirdly I’m seeing scary faces”. Definitely the needles came out and tx was countered.
I’ve found I do a lot more digging now in addition to paying attention to the face especially as they are masked.
Oh weirdly I’m seeing scary faces…
As you point out here @Shanlarson the patients will often come up with all kinds of reasons for adverse things they are experiencing. In part it is that desire so many patients have to please their doctor.
I’d like to hear more about how how you’re digging for more information from your patients and what you are attending to, so as to determine if the needles are right or not. Yes, complexion is a gold standard, but hard to use in a masked situation.
It is hard to ask questions of how a patient feels without leading them. I’ve started asking “are you feeling more relaxed or energized?” Giving them a choice between two “positives” helps me to better understand their internal state without leading them with the choice of something positive or negative.
As to treatments where they get worse and then better. If the getting better means they go back to their usual level of discomfort or suffering, then I’m chalking it up to mistreatment. If they get exponentially better, and the issue basically resolves, then the treatment was right and body needed to “right itself” and sometimes that requires a bit of a “healing crisis,” which while it does happen, I don’t think it happens that frequently. Too often “healing crisis” is a CYA for mistreatment.
So yes, teasing these reactions out is very important.
This is from Toby regarding what side to needle after mistreatment, which is not what I stated:
My teacher didn’t make many mistakes so I don’t have exact documentation of which side to put the counterbalancing needles on. I have been putting them on the opposite side, when I need to right away and also for return visits. This seems to work well.
yes the seeing faces is interesting. I’ve had patients mention it a few times over the last couple of years I’ve been doing SAAM. Sometimes good faces with a good treatments but a couple that come to the top of my head where it’s an adverse treatment and the patients have seen scary faces or melting faces and they mentioned it on their own without being prompted by me at all.
I think I’m similar to you Michael. Often I ask if they notice a calming feeling and sense of relief, like how you feel when sink into a relaxing chair or if it’s more buzzy, excited like sometimes how you feel with a smidge too much coffee. I suppose that might be a bit leading but I find usually they can relate and will tell me.
There are those people though who either want to please or want to tough through it. I find I need to convince them it’s not about if “they can handle it”. I think they have been so use to going to a massage, physio, IMS, etc and they have to breathe through it/ get through it. No pain no gain attitude. They are the ones who usually are kind of curt at my 5 min check in and say they are “fine” which usually makes me ask more questions.
I really want to improve my assessing complexion skills but it’s kind of hard with mask just looking at their eyes and forehead.