Chapter 1 Red flags of disease
Red flags are those symptoms and signs which, if elicited by therapist, either of conventional or complementary medicine, merit referral to a conventional doctor. Referral is indicated because the presence of red flags indicates the possibility of a condition which either may not respond fully to non-medical treatment or may benefit further from conventional diagnosis, advice or treatment.
In summary, referral may be considered for the following four broad reasons:
1. To enable the patient to have access to medical treatment which will benefit their condition.
2. For investigations to exclude the possibility of serious disease.
3. For investigations to confirm a diagnosis and help guide treatment.
4. For access to advice on the management of a complex condition.
It is important to clarify at this stage that the red flags indicate those potentially serious conditions in which the patient would be in need of further tests, advice or treatment. Not all of the red flag conditions listed in this text indicate that the patient will need medical treatment. In some cases referral is advised so that the patient can have tests to exclude an unlikely but important treatable condition (e.g. a mole that might have features of skin cancer), or to obtain a medical diagnosis to guide in the future management of the condition (e.g. ascertaining the severity and cause of suspected anaemia). In other situations it may be important to refer so that the patient can have access to detailed medical advice (e.g. on the complexity of assessing coronary risk and how this impacts on subsequent choice of medical treatment).
Use of complementary medicine and red flags
There are very few examples of when complementary medicine would not be beneficial to someone who is also receiving conventional investigation or treatment for a condition. Therefore, referral in response of a patient with red flag symptoms or signs does not mean that complementary medical treatment need be discontinued, as long as the therapist is sure that the patient has given informed consent to this treatment.
The red flags as guides to referral
Red flags are guides to referral and not absolute indicators. Often the red flags described in this text specify a fixed, measurable point at which referral should be considered, for example high fever (especially if over 40°C) not responding to treatment within 2 hours in a child. Of course, in reality, disease falls somewhere along a spectrum which bridges the state of being of little concern and one of being of serious concern (see Figure 1.1). A disease does not suddenly become serious once a fixed point has passed. Moreover, what might constitute a red flag in one individual may be of less concern in someone of a stronger constitution.
Figure 1.1 This illustrates the fact that red flags have to fall at a fixed point along the spectrum of symptoms of mild to serious disease.
Bearing the potential flexibility of interpretation of red flag syndromes in mind, there may well be situations in which the clinical opinion of the therapist is that referral is unnecessary even though a red flag is present. Conversely if a nagging uncertainty persists in a clinical situation, even if the patient does not fit the criteria for any of the red flags, then it is safest to trust clinical instincts and refer. The important thing is that there is an awareness of these indicators of possible serious disease, and that in every case time has been taken to consider their relevance for patients in the clinical situation.
Prioritisation of the red flags
The various red flags merit different responses from the practitioner according to the nature of the underlying condition of which they may be an indication. To aid with decision making in the clinical situation, the red flags listed in this text are assigned to one or more of three categories of urgency.
*Non-urgent: A non-urgent referral means that the patient can be encouraged to make a routine appointment with the medical practitioner (GP) and this ideally will take place within 7 days at the most.
**High priority: A high priority referral means that the patient is assessed by a medical practitioner within the same day.
***Urgent: The urgent category is for those situations when the patient requires immediate medical attention, and this may mean summoning an on-call doctor or calling the paramedics to the scene.
The summaries of red flags which make up the appendix to this chapter indicate which category (ies) of urgency best fits each red flag. Again, this categorisation is simply a guide to the degree of urgency rather than a fixed directive on the appropriate response in a particular clinical situation.
For many of the listed red flags, the labelling indicates a range of degrees of priority (for example, */**). For these red flags, the precise level of priority depends upon other characteristics of the individual case, which should become clear according to the particular clinical situation.
How to respond to the red flags
The response to a red flag in a clinical situation depends very much upon what degree of urgency the response merits. In this book, the detail of the advice given relates to the practicalities of referral to a GP or emergency hospital department within the UK National Health Service. However, this advice is readily transferable to any national provider of medical health care, as in all there are systems whereby a generalist doctor can be consulted for non-urgent medical conditions and emergency services can be accessed for conditions requiring urgent medical assessment.
Non-Urgent Red Flags
Some red flags are indicators of possible serious disease, and yet the patient does not require urgent treatment, even if the disease actually is present. An example of this is the patient who has features of anaemia, including pallor, breathlessness and palpitations on exertion. Anaemia can have serious underlying causes, for example chronic gastrointestinal bleeding or pernicious anaemia, some of which cannot be expected to respond fully to non-medical therapies. In a case of anaemia, the patient obviously requires further investigation and may possibly require medical treatment according to the outcome of the investigations. However, if the symptoms have been developing over the course of weeks to months, the patient does not need to be seen by the doctor on the same day.
Another example of a non-urgent red flag is the well child who has symptoms which indicate occasional bouts of mild asthma. In this case referral is recommended more for confirmation of diagnosis, and so that the patient can have access to medical advice about how to manage a potentially serious condition, rather than simply for treatment. It will be obvious that in such a situation the child does not need to be seen urgently.
Most of the red flags of cancer have been prioritised as of non-urgent priority. This is because such features usually have taken weeks to develop, and 1 or 2 days’ delay is not critical in the course of most cancers. In the UK, the NHS referral system is structured so that the patient demonstrating red flag signs of cancer is seen by a hospital specialist within 2 weeks of referral by their GP, so to be seen by the GP within only a few days of referral would be ideal in order to minimise the total wait. Of course, there will be some situations in which it would be appropriate to make a high priority referral for patients showing features of cancer, either because of rapidity of progression of symptoms, or in order to allay anxiety for the patient.
Those red flags which have been categorised as non-urgent will require non-urgent referral. In these situations it can be suggested to the patient to make a non-urgent appointment with the GP. This means that the patient will be seen within the next few days. In this situation a letter of referral can be prepared, although this may not be necessary if the patient is capable of passing on the essential information verbally. If a letter is needed, it can either be taken to the doctor by the patient (most reliable approach) or can be sent by post to the practice (more likely to be delayed or go astray). A guide to writing letters of referral to doctors can be found in Chapter 5, ‘Communicating with medical professionals’.
High Priority Red Flags
Some of the listed red flags are indicators of serious disease, and these merit seeking a medical opinion on the same day, because there is a possibility that the condition of the patient might deteriorate rapidly without treatment. An example of a high priority case is the situation of haemoptysis (coughing up blood) in a man who has lost two stone in weight over the past few months (strong indicators of lung cancer or TB). In this case, the potential of serious blood loss or the possibility of contagiousness makes the referral high priority.
In high priority situations, it may be best practice to speak to the patient’s medical doctor. It is appropriate in such cases to telephone the patient’s practice to confirm a time in that day when it is most convenient to talk to one of the doctors. After discussion, if the doctor agrees with your assessment of urgency, an appropriate appointment for the patient can be made.
Alternatively, it may be more appropriate that patients make these referrals themselves, and they can be advised to request a same day appointment with their doctor.
In such situations it is good practice to give the patient a letter describing the clinical findings and concerns to take to their doctor before they leave your clinic. In a high priority case, a hand-written referral letter on headed note-paper is acceptable (see also Chapter 5).
Urgent Red Flags
In some cases the red flags indicate that the patient requires urgent medical assessment. In these cases it may be appropriate to request an emergency ambulance to take the patient to hospital. A less dramatic option is to telephone the patient’s practice to ask to speak to a doctor urgently in order to get their advice about referral to hospital. If there is some uncertainty, the doctor may choose to visit the patient first, or ask for them to come to the practice to be seen before the paramedics are called.
In those urgent cases in which it is unlikely that the therapist will meet the examining doctor, it is good practice to hand-write the reason for referral in a letter which is either to be taken with the patient to the hospital or to be given to the doctor when they arrive.
The summaries of red flags of disease
The red flags of disease are summarised in Chapters 2, 3 and 4. Each table presents information about red flags in a different way to meet the needs presented by different clinical situations. In the A tables (Chapter 2), red flags are presented according to the physiological system of the body in which the disease they indicate might have become manifest. This is the way in which information is ordered within a medical textbook. If the red flags are to be incorporated into a structured teaching programme on clinical medicine, this structure enables the red flags to be taught in a systematic way. This part of the guide also gives some explanation as to why the red flag syndromes merit consideration for referral.
However, in the clinic situation, symptoms do not arise in a systematic way. Rather, in the clinic the question ‘Is this symptom/sign serious?’ is more likely to be asked than ‘I wonder if there are any serious symptoms arising from this patient’s digestive system?’ The B tables (Chapter 3) present the red flags according to symptom keyword (e.g. headache, abdominal pain, eye problem, menstrual disorder) to enable easy reference in a clinical situation. The B tables give less detailed explanatory information, but each red flag listed is referenced to the more detailed summary given in the A tables so that more information can quickly be found if needed.
Finally, the list of red flags has been further pared down in the C tables (Chapter 4) to a summary of urgent red flags which summarise those high priority and urgent situations in which first-aid management is indicated. These tables also give some guidance on first-aid treatments. This guidance is intended to supplement the regular first-aid training which all complementary medical practitioners are required to undergo. These are the red flags that it is worth taking time to understand and to commit to memory in order to be fully prepared to act appropriately should a situation of medical urgency arise in the clinic.