This article is taken from the Winter 2011 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members.
For details of how to become a member, click here.
Learning about lymphoedema - a GP's view
By Dr Graham Easton MSc MRCGP MAcadMEd
Deputy Director of Primary Care Education Faculty of Medicine, Imperial College London, Charing Cross Campus
|
Dr Graham Easton, GP and interviewer on our new British Medical Journal (BMJ) Learning educational module for doctors, explains how his view of lymphoedema has changed. |
 |
I was a bit wary when I was asked to help make an educational video, part of the LSN’s BMJ Learning module for GPs about lymphoedema. In my mind, lymphoedema was really at the fringes of my GP skills – a "specialist" type of swelling often caused by surgery or radiotherapy for breast cancer, and best managed by expert doctors or nurses. We certainly didn’t dwell on the lymphatic system at medical school, and as a junior doctor it wasn’t something I had to grapple with. I suppose there is also an unfortunate tendency for doctors to engage with conditions that are easy to treat: and sadly there are no pills or operations to cure lymphoedema. But I see lymphoedema differently now, and hopefully the video will persuade some of my GP colleagues to take another look too.
Swelling, particularly in the legs, is a big part of our job. It’s common in the elderly, the obese, and the immobile. But when I see someone with leg swelling – and I suspect I’m not alone in this – my main focus is to exclude a serious cause. I want to make sure it’s not a deep vein thrombosis (DVT), heart failure or liver disease for example. To be fair, that’s what we are trained to do, and it is important. But once I’ve ruled those things out, I admit there’s a tendency to disengage. Raise your leg, wear a stocking, see the nurse…
What I’ve learned through the Lymphoedema Support Network (LSN), and interviewing Professor Peter Mortimer for the video, is that my work needn’t stop there. In fact, that’s where it starts. The lymphatic system is a physiological miracle, doing a vital but unsung job of draining fluid from the tissues back to the main circulation. There’s a lymphatic component to most types of chronic swelling. Taking a careful history from the patient can help pinpoint the nature of the problem and whether it’s predominantly lymphoedema or not. For example, lymphoedema tends to develop gradually compared to the more sudden onset of a DVT or heart failure. It’s not usually painful unless there’s cellulitis, and it doesn’t tend to get better just by elevating the affected limb. Several medications can cause chronic swelling – the worst culprits are probably the calcium channel blockers (such as amlodipine) often prescribed for high blood pressure. I’ve learned a lot about how to examine for lymphoedema too. For example, I will be testing for "Stemmer’s sign", in which the thickened skin in lymphoedema means it’s impossible to pinch a fold of skin at the base of the second toe. There are characteristic skin changes too from thickening to reddening.
But the most important change for me is feeling less impotent about being able to help. From now on, I’ll make a point of offering the patient an explanation for their swelling – not simply saying it’s not life-threatening. Secondly, there may not be drugs or surgery, but proper compression stockings, exercise and specialist massage can make a world of difference. Thirdly, I am lucky in having a specialist lymphoedema clinic close by, but GPs who don’t have that luxury can get details of nearest services from the LSN, or get support from local district nurses or tissue viability clinics. Meanwhile, I can offer practical advice to patients about using the affected limb as much as possible to keep the muscle activity going; keep the weight stable; keep the skin clean and moist; and avoid injections, needles or blood pressure readings from the affected arm. I’ll try to avoid using diuretics, and although cellulitis is a recognised complication of lymphoedema and needs appropriate antibiotic treatment, redness of the skin on both legs doesn’t always mean infection.
So I feel I have learned a lot making the video; I hope doctors watching it will feel the same. It’s impossible for busy doctors to know everything about every condition they may come across, but with luck they might feel more able to help the next patient they see with chronic swelling.
|
