The Complementary Therapist’s Guide to Red Flags and Referrals For Elsevier: Content Strategist: Claire Wilson Content Development Specialist: Carole McMurray Project Manager: Srividhya Vidhyashankar Designer: Miles Hitchen Illustration Manager: Jennifer Rose The Complementary Therapist’s Guide to Red Flags and Referrals Clare Stephenson General Practitioner (GP) Oxford Forewords by Sandy Fritz BS, MS Owner/Director, Health Enrichment Center Inc., Lapeer MI, USA Val Hopwood FRCP Course Director, MSc Acupuncture in Health Care Physiotherapy & Dietetics, Health and Life Sciences, Coventry University, Coventry, UK William Morris PhD, DAOM, LAc President, AOMA Graduate School of Integrative Medicine, Austin TX, USA EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2013 © 2013 Elsevier Ltd. All rights reserved. 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The Working together to grow publisher’s libraries in developing countries policy is to use paper manufactured from sustainable forests www.elsevier.com | www.bookaid.org | www.sabre.org Printed in China Preface Over the years in which I have been involved in the training of complementary medical practitioners, I have been struck by how frequently I have been consulted by students and also established therapists who were concerned about their ability to recognise whether or not the clients they were treating had an illness which merited referral for Western medical attention. Despite a rigorous grounding in the basics of clinical medicine and access to good-quality medical textbooks, it is often difficult for a therapist in practice to discern whether the unique symptoms of a particular patient, for example their headaches, their irregular bowel habit or their skin rashes, correlate with those serious conditions which require medical attention. For the practitioner in this position there is inevitably a tension between being safe and being unnecessarily over-concerned. Medical doctors also have to deal with comparable dilemmas in clinical practice. When can a patient be safely reassured and when do they need further investigation or treatment? To deal with this dilemma, doctors are trained in the recognition of ‘red flags’. Red flags are those clinical syndromes which alert the doctor to the fact that the patient needs prompt investigation and treatment for a potentially dangerous condition. Increasingly, doctors have access to excellent guidelines based on expert opinion and clinical research which offer advice on how to respond appropriately to red flags. This means that, ideally, patients are held in a safety net when they explain their symptoms to a doctor. If a red flag, such as the appearance of blood in the sputum, is presented to the doctor, then that patient, like any others who might present to a doctor with a similar pattern of symptoms, will be promptly and appropriately referred for specialist investigations and treatment according to up-to-date guidelines. It is important for complementary therapists to be aware of these medical red flags. However, in many situations, recognition of medical red flags requires particular medical expertise in examination and interpretation of medical tests. For this reason, there is a clear need for a summary of red flags designed especially for practitioners trained in the professions allied to medicine, such as physiotherapy and nursing, as well as complementary medical therapists. Such a summary should offer guidance on how to respond to those symptoms and signs of disease which can be readily discerned through routine history-taking and basic examination of the body. The guidance needs to be presented in language which does not require full medical training for comprehension. It also needs to offer clear advice on how to respond appropriately when a red flag situation is discerned. This guide has been written to meet this need. It begins with a definition of red flags as they are presented in the text. Broadly speaking, for the allied and PREFACE x   complementary medical therapist, a red flag constitutes any syndrome of symptoms or signs which indicates that the patient might benefit from or require being referred to a doctor over and above the benefit they could receive from the treatment which might be offered by the therapist. There are many self-limiting or chronic medical conditions which do not need rapid review by a medical doctor. Conditions such as tension headaches, uncomplicated low back pain, painful periods and irritable bowel syndrome can all be safely treated by non-medically trained therapists. It can be argued that with such functional conditions, the patients are as likely to benefit from treatment from a therapist as they are from seeing a doctor and, more importantly, are very unlikely to come to any harm if a visit to the doctor is delayed by undertaking another form of therapy. However, if the patient’s symptoms or signs indicate that because of the advice, tests or treatment which a doctor is trained to offer, they might benefit from also seeing a doctor for their condition, then it is only right for the allied and complementary therapist to advise the patient to also seek a medical opinion. It is good professional practice to enable the patient to do this in the most efficient way, and making an appropriate referral is part of the process of responding to red flags. This guide presents tables of red flags in three formats, designed to meet differing needs in training and practice. The first set, the A tables (in Chapter 2), order red flags in a systematic way. The A tables are ordered according to the physiological systems of the body. This format is intended for the study of red flags, and for understanding how they are outward manifestations of disordered physiological processes in the body. These tables offer some detail about disease processes, but, for an in-depth explanation of how disease might manifest in particular symptoms and signs, the student is urged to consult the sister text to this guide, The Complementary Therapist’s Guide to Conventional Medicine.1 The second set, the B tables (in Chapter 3), present red flags according to symptom keyword. These are designed for the practitioner in the clinical situation who is faced with a patient who is presenting with symptoms and signs of a medical condition. These tables are designed to help the practitioner to discern whether or not the symptoms and signs might have any features which suggest serious disease. These tables are cross-referenced to the A tables in which more explanation about disease processes can be found. The final set of tables, the C tables (in Chapter 4), present only those relatively few red flags which require a prompt and appropriate response from the practitioner in that urgent referral is merited, and first-aid treatment may be necessary. The reader is advised to commit the red flag conditions of the C tables to memory, because in urgent red flag situations there is no time to consult textbooks. These urgent red flag tables will also provide a logical structure around which first-aid training for complementary therapists can be provided. All the tables indicate with what degree of urgency a therapist needs to respond to red flags. For the large majority of red flags, a non-urgent response is merited. 1Stephenson C 2011 The Complementary Therapist’s Guide to Conventional Medicine. Elsevier, Edinburgh PREFACE xi   However, in some cases, a same-day medical assessment or emergency services call out would be best practice, and the reader is offered clear guidance when a rapid response is required. The book concludes with information on how to make medical referrals, whether this is by letter, by telephone or simply by suggesting the patient makes an appointment to see their doctor. Sample letters are provided so that referral letters can be structured in a way which is familiar to medical doctors and which enables them to gather the crucial information about a case with ease. Appropriately structured referrals have the additional benefit of being a channel of communication with local medical practitioners and can help forge good interprofessional relationships. The overarching aim of this guide is to improve the confidence, safety and professional integrity of allied and complementary therapists, so that ultimately these qualities will enhance the outcomes of therapeutic encounters with patients. Clare Stephenson Oxford October 2012 Forewords As a long time massage therapist, instructor and textbook author, I find this text a perfect companion for professional practice. The content is clear, concise and easy to use. Often massage therapy education is not comprehensive enough to assure that the student is competent in making decisions about when a client needs to be referred to a physician. The main reasons for this are the length of many massage training programs and the curriculum content. The student understands the importance of referral but simply does not have adequate time to learn all the specifics. This text solves this problem, not just for the new practitioner but also for those who have been in practice for some time and need a quick reference text. As an educator, the chapter on how to make a referral is especially important in creating a respectful working relationship among professionals. The differentiation of three categories of red flags is an effective approach in helping the massage therapist as well as other complementary practitioners make appropriate decisions about when a client is in immediate danger and when the condition presents as non-urgent but will need referral for follow-up. I also believe that this text will help physicians feel more confident about including massage and other complementary therapies in the comprehensive treatment plan for their patients because the information clearly indicates when and how to refer, and opens dialogue for the best care of the clients/patients. It is important that all health care professionals have the information necessary to work together for the good of the client/patient. Information to support clinical decision making is essential. The information in this text allows the practitioner to provide services in a safe manner because they are aware of the red flags. I am thankful to the author for considering the inclusion of complementary health care therapists into current health care systems and creating a reference to make the path of integrated health practice smoother. Sandy Fritz BS, MS Owner/Director Health Enrichment Center Inc. Lapeer MI, USA (2012) Using any kind of medicine is a chancy business but complementary medicine is thought to be generally benign. However, any practitioner, if they are honest, will tell you of patients where they have had doubts, sudden sinking feelings or nagging little puzzles about the safety and advisability of treatment when dealing FOREWORDS xiv   with a patient even though they may have a clear Western diagnosis. Those of us trained in Western medicine expect to feel secure in our abilities but often complementary therapy takes us out of our comfort zone. This book answers a long unarticulated need. An authoritative guide to the theory and use of the red flag system is almost as good as having a wise advisor by your shoulder in clinic. It means that we can concentrate on helping the patient recover with less anxiety that we might somehow be making their condition worse. The logical arrangement of the text is really helpful and designed to prioritise the information in a very practical way. While it would be ideal to have plenty of time to sit down and think about all the issues, this book will allow a hasty consultation and guide the reader to the relative urgency of the most important symptoms quickly. The distinction between “high priority” and “urgent” is helpful to consider. That the summary tables, A and B, are presented in different ways is an innovative design, allowing for those who think first in physiological terms to integrate with those who may focus primarily on organ systems (TCM practitioners). Even more important for quick reference is the inclusion of first aid suggestions in the C group of tables. The section on communicating with medical practitioners is brief and vital for sensible inter-professional communication at any time. To sum up, this is a book I would have been very grateful for as a student physiotherapist and will still find invaluable as a practising acupuncturist. Dr Stephenson has gently inserted an extra layer of protection for all our patients. Val Hopwood FRCP Course Director MSc Acupuncture in Health Care Physiotherapy & Dietetics Health and Life Sciences, Coventry University Coventry, UK (2012)