July 24, 2006

Red Flag Cases That Need Referral

By Bruce H. Robinson, MD, FACS, MSOM (Hon)

The growing acceptance of traditional Chinese medicine across America opens up opportunities for you to expand your practice and increase your earnings. This is best facilitated if you have some grounding in Western medicine and are thus able to interact professionally with medical doctors, nurses and other therapists.

The vast majority of patients have their own physicians, but a great number of them also need your care. When you have a patient with lupus or diabetes, you need to understand some of the ramifications of having such a disease from the Western medical viewpoint, even though you might not be expected to be an expert in Western disease management. Having such a knowledge base is best for the patient and will bring you more referrals from Western doctors, who will see you as a resource for them, rather than a strange competitor they don't really understand or trust.

As you see more patients who are quite ill, it becomes ever more critical for you to recognize potential "red flag" cases and refer them to a Western doctor they will see that day or, in the case of a severe emergency, to a nearby emergency room. I am frequently asked by licensed acupuncturists to review with them the most flagrant red flag cases that need urgent referral.

Understanding Referral Cases and Keeping Current with Western Medical Advancements

Many factors have led to our present litigious society, which appears so ready and willing to sue a health care professional. It is based on an underlying malpractice mentality that is held by many American patients today. It's due to a deep erosion of consumer confidence in the medical practitioner and a regrettable loss of that special covenant relationship that once existed between patient and doctor, one which actually promoted the healing process.

Various media sources - magazines, radio, television and the Internet - barrage Americans with stories of medical misadventures, often with tragic consequences, and tell of enormous awards by sympathetic juries to malpractice victims. Insurance companies are seen as having "deep pockets" for someone who has been mishandled, especially when so many patients feel "ripped off" by outrageous medical fees and prescription costs, with a small bottle of Viagra tablets, antibiotics or heartburn mediation often costing as much as $200. TCM practitioners are increasingly exposed to this feeding frenzy for an injured patient to have just and fair restitution when something goes wrong.

Moving together with these deep concerns for every practitioner is the need to keep current with medical advances, such as the recently accepted treatment of developing strokes with the anti-thrombin agent rtPA (recombinant tissue plasminogen activator). Wherever possible, every patient experiencing a stroke must be given the chance to receive this treatment. The window of opportunity for this potentially life-saving anticoagulation is only three hours. All practitioners must know about this, because the accepted legal doctrine is that failure to provide the best available treatment constitutes malpractice. There are many other new therapies in Western medicine that are important to know about. A full discussion is beyond the scope of this article, but these new therapeutic approaches are covered in advanced Western medicine training programs available to licensed acupuncturists.

Red Flag Cases

Here is a list of the more common conditions that require immediate or prompt referral to a Western medical doctor or treatment facility. Remember that when urgently referring a patient to a hospital, a practitioner must make direct voice-to-voice contact with the person who will receive the patient.

  • sudden chest pain (coronary artery occlusion, spontaneous pneumothorax, pulmonary embolism, dissecting thoracic aneurysm);
  • persistent cough (could be benign, such as postnasal drip or even acid reflux, but might be lung cancer, lymphoma, heart failure, pleural effusion, etc.);
  • severe abdominal pain (appendicitis, ruptured duodenal or gastric ulcer, acute pancreatitis, Crohn's disease or ulcerative colitis with intestinal rupture or abscess, acute cholecystitis, acute diverticulitis, or many other conditions);
  • upper GI or lower GI bleeding (bleeding duodenal or gastric ulcer, ulcerative colitis, gastrointestinal cancer, bleeding from intestinal polyps or vascular malformations, esophageal or gastric varices, or many other conditions);
  • new onset of severe headaches (always worrisome; could be any number of severe neurological conditions, possibly a brain tumor);
  • impending or actual gangrene of a finger, toe or foot in a patient (advanced arteriosclerosis, diabetes mellitus, Raynaud's disease or syndrome, or many other possible causes);
  • tender swelling in a calf or thigh (impending or actual deep thrombophlebitis, with the risk of potentially fatal pulmonary embolism);
  • redness in the whites of the eye, especially with pain and alteration of vision (may be benign, but could be uveitis, glaucoma, or a foreign body in the eye);
  • change in level of consciousness (impending or actual stroke, diabetic coma, intracerebral bleeding from ruptured cerebral aneurysm or trauma, brain tumor, hydrocephalus, others);
  • pain with weight loss (possible cancer, often missed by practitioners in the early stages when it can still be cured);
  • suspicious breast lumps; abdominal masses; axillary, neck or groin masses (may be cancer);
  • vaginal bleeding after menopause, or excessive bleeding before menopause (may be benign, but might be cancer, large fibroids, endometriosis);
  • new onset of neurological symptoms such as weakness, numbness, visual changes, sudden mood swings, irrational or reckless behavior (could be a degenerative disease, brain infection, stroke, cancer, etc.);
  • fever of unknown origin;
  • frequent episode of dizziness or light-headedness (may be benign, but might be an impending stoke, heart trouble, or possible brain tumor);
  • unexplained weight loss or failure to thrive in a normal fashion.

This list is necessarily incomplete and cannot take into account every conceivable urgent clinical situation you might encounter. Cancer in any form is best treated in conjunction with a Western physician or hospital, and a TCM practitioner who takes on the role of primary provider of a cancer patient can expose himself or herself to medical liability. Of course, there is much Chinese medicine can do to improve the outcome of Western medical cancer treatments and reduce the morbidity of such modalities as chemotherapy and radiation. I personally believe every cancer patient needs Chinese medical treatments as well as the Western medical therapy they are receiving.

It's good to remember the old adage, "If in doubt, check it out." Talk with a Western doctor if you are uncertain about what is going on with one of your patients and are concerned it might be serious or even potentially life-threatening. Your patients will bless you for doing so.

Click here for previous articles by Bruce H. Robinson, MD, FACS, MSOM (Hon).


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