Myth or Fact?

  Medical myths can assume a life of their own despite the facts. One of my favorite myths is that every patient who has a thyroid or other neck operation must have a tracheostomy tray by the bedside so an emergency tracheostomy can be done if the patient’s neck swells so much he cannot breathe.

At first glance this seems reasonable, but after reflecting on what causes neck swelling, it no longer does. Swelling that can cause shortness of breath is generally due to bleeding into the tissues of the neck. Trying to do an emergency tracheostomy at the bedside through a neck full of clotted blood would be a disaster!

The solution to the problem is simple—the sutures are taken out of the wound, the hematoma is pushed out, the pressure is relieved, and the patient can breathe. Instead of a tracheostomy tray at the bedside, all that is needed is a suture removal set. I tried for years to get that hard and fast rule changed at our hospital with no success. Nursing supervisors and others involved in the decision refused to think about the reality of the situation and change what had been many years of tradition. The situation reminded me of a quotation from the author Jessamyn West: “We want the facts to fit the preconceptions. When they don’t, it is easier to ignore the facts than to change the preconceptions.”

  Unfortunately, there are many of these traditions about lymphedema that are difficult, if not impossible, to overcome. Acquired lymphedema can occur after operations, especially cancer-related operations, radiation therapy, trauma, and infections. It is suggested that 30% to 50% of patients who have lymph nodes removed for the treatment of cancer develop lymphedema of the extremity.^1,2 Sometimes the lymphedema does not develop for several years after the operation or treatment.³ Because of the potential for preventing lymphedema, numerous recommendations have been made to minimize the chance of developing this dreaded complication. One of the more frequent recommendations is to avoid needle sticks in the affected or potentially affected extremity. This recommendation is based on the idea that needle sticks might lead to an infection resulting in lymphedema or the worsening of already present lymphedema. A break in the skin from any cause could result in problems. This dictum has been hammered into doctors, nurses, and patients since the time of Halstead, the father of American surgery. In the interest of discovering the truth about this recommendation, Cemal and colleagues³ reviewed the subject and found that little, if any, evidence was found in the literature to support it.³

  Because this tradition has been considered fact, many patients have been subjected to having blood drawn from foot veins, leg veins, or neck veins, or have had central venous catheters placed for drawing blood or receiving intravenous fluids or medications. A number of years ago, my sister, a breast cancer survivor, was told she needed a central venous catheter inserted to receive her last dose of chemotherapy because no one could get an IV started anywhere else. Of course she had huge veins on her operated arm. After much persuasion, the physicians and nurses reluctantly agreed to start an IV in the operated arm and give her the medication. Twenty years later she still has not developed lymphedema. The implications for our patients are enormous if all will accept this information.

  Other recommended preventive measures include avoiding constriction of the extremity such as having one’s blood pressure taken in the affected arm or wearing constricting or tight clothing, avoiding air travel, wearing compression stockings if air travel is necessary, avoiding extremes of hot and cold, and avoiding active exercise. Interestingly, there is no evidence to support that any of these recommendations prevent lymphedema. Contrarily, very strong evidence has been reported for involving lymphedema patients, or those at risk of developing it, in supervised, structured exercise programs. In one study, all lymphedema patients in exercise programs experienced a reduction in lymphedema symptoms as well as increased strength.⁴

  The only recommendation that was found to be overwhelmingly true was that of maintaining a normal body weight. The incidence of lymphedema in obese patients has been found to be twice that of patients considered non-obese.⁵ It was also found that even mild increases in body weight increased the chance of developing lymphedema.⁶

  Lymphedema can be a devastating disease, and we should do all we can to minimize the effect of the disease or prevent it. However, we must be able to separate the myths from the facts, so we can appropriately advise our patients. Evidence-based care is showing us that tradition in medicine might not be the best therapy for our patients. I encourage you not to allow your preconceptions to overshadow the facts.