Dr. Ferguson is on sabbatical after nearly eight years with the Focus. If you like this essay, there are more in his book, “Well…What Did the Doctor Say?” available on line at Amazon as well as Barnes & Noble – a great Christmas gift!
The doctor-patient relationship is a sacred thing which requires periodic nurturing. It may seem obvious to many, but I had to learn that you can’t treat the condition without considering the person. Approaching a patient like Sergeant Friday on Dragnet is poor medicine. If you interact with folks, they’ll trust you with the truth and often the diagnosis.
“Doc, my feet are swollen,” said the usually stoic Mr. Jones. And before I could ask about important details he continued, “What’ll I do about ‘em?”
Some people want to know the details about their problems and others just what to do about the problem. Mr. Jones falls into the latter group, but because I believe an informed patient can better participate in their medical care I got him to listen to my circulation story.
Swollen feet are a common problem. In previous columns I’ve discussed heart disease and heart failure as a cause of swelling (edema). There are lots of other causes of edema, including advanced kidney or liver disease, severe malnutrition or vitamin deficiencies, certain medications or allergic reactions, toxemia of pregnancy, unusual endocrine system diseases and even exotic infections. You’re probably not interested in what we internists call a “differential diagnostic” list of the conditions that cause a patient’s feet to swell, but you might be interested to learn that you’re designed to swell.
Imagine your heart connected to a series of pipes (arteries) that get smaller and smaller and end in a mesh of tiny blood vessels smaller than hairs. Now, envision this tangle of tiny arteries connected to a mesh of tiny veins that then get larger and larger as they return blood back towards the heart and lungs. You may have once pulled up a plant in the yard and seen the myriad of tiny roots that similarly coalesce into larger and larger roots and then the plant stem itself.
Think of your heart as a pump pushing blood with oxygen and nutrients out to the tissues of your body, and then, on reaching the tiny arteries (capillaries), the life-giving cargo is emptied, much as a dump truck would empty its cargo. At the same time wastes are absorbed into the tiny vein capillaries and eventually returned to the heart for another cycle, after first discharging the wastes and picking up a fresh load of nutrients from the liver and oxygen from the lungs. You could envision the circulatory system as a loop with the heart at one side and the capillary beds at the opposite side.
Our blood vessels are not like PVC piping or copper plumbing. They are designed to allow nutrients, oxygen, carbon dioxide and waste to move back and forth across the vessel walls. Actually, there are tiny gaps between cells that line your vessels, and this facilitates the normal physiology of your body. And since your vessels are designed to leak a bit, the Creator designed a system to pick up the excess water and return it to the circulation. This collateral gutter system is called the lymph circulation and has the more recognizable lymph nodes as part of the system.
Mr. Jones was patient as I went through this with him, perhaps because he drives a dump truck. However, patience only goes so far. “OK, Doc, enough stories. Why are my feet swollen?”
Swelling occurs because the heart pump fails and the circulation backs up, or something blocks the vein or lymph flow, or there is too much fluid to be handled by the system generally or locally.
Have you ever been on a long car trip and taken off your shoes only to notice that your shoes felt tight when you tried to put them back on? As you sit in a car you actually bend at the waist and the knees. This can hinder or “kink” the returning venous circulation. Additionally, when you sit, there is less pumping action of the muscles to counter the effects of gravity. And if you’re overweight there is a further impediment to the returning blood flow from the legs. Add to this mix certain medications that promote swelling like ibuprofen, excessive salt ingestion, or underlying medical conditions like varicose veins, and you have a recipe for swollen feet or even a condition that we doctors call superficial phlebitis. This latter condition is not a blood clot in the deep vein system, but stagnant flow with resulting inflammation in the superficial smaller veins that can nonetheless be painful.
“So what should you do?” said the persistent Mr. Jones. I recommend you think physiologically about your body by avoiding excessive salt; and if you’re prone to edema, elevate your legs whenever possible. It’s good to get up and walk around on long trips to “pump” the veins and lymph circulation. Sometimes compression hose aid in compressing swollen veins and improving circulation. And as last resort, diuretics can be used.
“Elementary, my dear Watson, er…Mr. Jones.”