Prairie Doc® Perspectives for week of May 31, 2020

By Richard P. Holm, MD
 
The medical history books reveal secrets of circulation and blood pressure that rival the best novels of intrigue. Years ago, before people had figured out how blood circulates, second century Greek scientist Galen, had the idea that blood moved from the right side of the heart to the left through unseen pores. That idea was not questioned for more than 1,000 years until a series of people in the mid-1500s finally broke with the old idea.
 
After great debate among leading thinkers of the time, English scientist and physician, William Harvey, and several anatomists and scientists finally convinced local medical leaders, and later those of the world, that blood pulses through the body on a great circular journey. It was fear of change that made the acceptance of this discovery so difficult.
 
Harvey, and other scientists, proved that venous blood is almost “sucked in” as it returns from the outer reaches of the body through gradually larger veins and eventually flows into the right ventricle of the heart. From the right ventricle (right lower part of the heart), blood is pumped into the lungs where hemoglobin gathers oxygen and releases carbon. From the lungs, oxygen rich blood flows to the left atrium (left upper part of the heart), to the left ventricle and is pumped out into arteries to feed almost all the cells of the body with oxygen.
 
From each tiny cell the blood picks up carbon waste, and the blood is drawn back to the right heart and lungs once again. Continuous circulation happens because the heart pump squeezes and relaxes, repeating the process some 80 times a minute from birth to death.
 
In my mind, the marvelous truth about the circle of blood flow is pure evidence of the beauty of both evolution and intelligent design. Circulation, like the rhythm of life, is a regular and recurring pulsing; a succession of surges over time like the flow of seawater and fish meeting the shore on an estuarial tide, the birth of lambs and calves, bursting forth on an early springtime prairie pasture or even the seventy to ninety-year life-cycle of humans, moving with joy, sorrow and grace from birth to natural death.
 
This essay, written by the late Richard P. Holm, MD, is an excerpt from his book “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. Dr. Holm was founder of The Prairie Doc® and his legacy lives on through his Prairie Doc® organization. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook, featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. Central.                                            

By Andrew Ellsworth, MD
 
Life is about balance. We balance our time, our budgets, our work, and our family. If you concentrate too much in one area, you will soon be wanting in another. Additionally, our bodies are constantly working to keep our blood pressure, blood sugar, and temperature in balance. 
 
Covid-19 disrupted our balance, both in our lives and for some, in our bodies. It overwhelmed some communities with too many people who became sick. Other communities banded together (or rather, apart) to slow the virus and protect the most vulnerable. 
 
Thankfully, many areas have been successful at slowing the spread and flattening the curve, avoiding the tidal wave of sick people filling the hospitals. However, this came with a great cost to the balance in our economy, our social interactions, and our normal way of life. It revealed and magnified numerous problems. It exposed disparities in healthcare, and it provoked supply chain issues, food chain issues, unemployment, poverty, and misinformation. 
 
People have many needs in addition to safety. People often need work not only for money for food and shelter, but also for fulfilment and purpose. People often need other people because we are inherently social creatures that thrive from being there for others, providing words of encouragement, or a caring shoulder to lean on, or an embrace.  
 
Living with Covid-19 around us require a new balance that may change over time. While it would be wonderful, reducing cases to zero is probably not realistic for a while. Meanwhile, our communities need economic activity and we need social interactions. Thus, some people are venturing out more and businesses are reopening. Some places are doing this more cautiously than others. We need to get creative and adjust our expectations of normal for a while. Our elders and those with high risk conditions may not be safe or feel safe, so we should do what we can to help them. Washing hands, wearing masks and being mindful of the distance between us are not perfect but are still the best forms of protection for now.
 
No one knows what the future holds. Perhaps reopening the economy will increase our cases of Covid-19, and perhaps not. Perhaps the virus will dissipate over the summer months. If it re-emerges in the fall, will we be ready? Will we plan and use this time to prepare? Will we again work together to protect our fellow man? Let’s use this time wisely and find our new balance.
 
Andrew Ellsworth, MD is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.        

By Richard P. Holm, MD

One summer during my college years, another premed student and I got a job at the Swedish Hospital in Minneapolis, as nurses’ aides. At that time, the guys were called orderlies, but we were part of the nursing department. We were taught how to clean patients’ private parts without making the patient feel self-conscious, and how to place urinary catheters mostly in old men with prostates that had overgrown and were blocking urinary flow.
 
We all have those private areas, let’s not pretend otherwise. The waste disposal parts are as important to us through our lifetime as our hearts, except not quite as romantic. Try switching metaphors and famous poems simply don’t have the same pizazz. For example, try E.E. Cummings’ “I carry your colon with me,” or William Wordsworth’s “My urinary tract leaps up when I behold a rainbow in the sky,” or Douglass Cross’ “I left my bladder in San Francisco.”
 
Romance aside, we are happy when our urinary tract is working well, draining the urine, removing waste and water. The kidneys collect and concentrate the urine, they deliver this yellow fluid through the ureters, the tubes from the kidneys to the bladder. The bladder is a bag to collect the urine until it is convenient to be emptied.
 
It seems like a simple, straight-forward system. However, trouble could be around the next corner. Conditions like urinary tract infections, kidney stones, bladder control problems, and prostate troubles are not uncommon through the course of a person’s life and can vary from causing short-term discomforts to long-lasting conditions.
 
One of the barriers to treatment for many people is the human problem of stigma and shame. It does not feel good to admit to anyone, even a loved one or a medical professional, that you’re having troubles “down there.” Let me reassure you: this is a common human condition. Shame is an enemy to a healthy, functioning body. I would instead say “join the club!” and remind you that you are not the only one with such a problem.
 
I am no longer the young orderly helping the old men in the Swedish Hospital with their issues. I now find myself amazed at the magnificent function of the human body, identifying more with those old guys than I do with the young staff. All of us have bladders and urinary tracts about which there is nothing to be ashamed.
 
Richard P. Holm, MD wrote this essay in February 2020. He passed away in March after a battle with pancreatic cancer. He was founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. Dr. Holm’s legacy lives on through his Prairie Doc® organization. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook, featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. Central.                                               

By Mark E. Bubak, MD
 
Growing up decades ago, we all knew kids and adults who were held back by their asthma. They sat out gym classes and sporting events, missed school or work over and over again, were up in the wee hours of the night fighting to breath, or seemed to make their own chest noises all the time. They got nicknames like Wheezy.
 
Jump ahead now to 2020. Although we still continue with our traditional allergy avoidance and immunotherapy programs, inhaled corticosteroid inhalers, and long and short acting airway muscle relaxing agents to treat asthma, we now have entered what is being called “The Biologic Era” of asthma treatments.
 
Biologic treatments are not the traditional chemical drugs we have been using for decades. Rather, biologics are antibodies similar to those we use to recognize and fight off germs. When designing biologics for asthma patients, scientists replace the recognition portion with a component that targets “problem signals” from our immune system. One family of signals or targets, known as interleukin proteins, come from T cells and tell other cells what to do. The allergy antibody IgE is another target. When the particular biologic is given, it circulates through the patient until it finds its target, and then binds to that target. The result is to change the way our body works, decreasing parts of the allergy or immune reaction that causes us to have the asthma.
 
All these therapy choices can be overwhelming. We now want to personalize each asthmatic’s program with the goal of “control,” meaning hopefully, no asthma. It all starts with talking to your doctor to establish an understanding of your history followed by a physical examination. You and your doctor might then decide on several options including, allergy testing, blood counts, IgE levels, nitric oxide breath measurement, x-rays, CT scans, and pulmonary function tests as indicated to determine what type of asthma you have. Armed with the knowledge obtained, your allergy doctor can prescribe the best combination of treatments to achieve control.
 
And as an added benefit of control, we can hopefully eliminate the use of that old nickname, Wheezy.
 
Mark E. Bubak, MD practicing in Sioux Falls, South Dakota is a contributing Prairie Doc® columnist. He is certified by the American Board of Allergy and Immunology to care for adults and children with asthma and allergies. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPTV most Thursdays at 7 p.m. central.        

By Richard P. Holm, MD
 
Mrs. R was a character. Her natural red hair had changed to gray years earlier, but thanks to the magic of her hairdresser, her hair was again flashy red, and she had a personality to match. She was a feisty, fun and full-blooded woman full of zest and pizzazz. She made me smile whenever I made rounds at the nursing home.
 
Through the years, Alzheimer’s disease took its toll on her memory, but her spirit, brightness and spark didn’t seem to fade much. Even near the end, as the family stopped the hair coloring, she gave me a charge of energy and vitality whenever we met. However, the neurodegenerative (ND) Alzheimer’s condition didn’t let up and eventually she slipped off this earthly existence gently while family surrounded her with love.
 
The image of my redheaded friend repeatedly came to me through the years as I cared for people with ND diseases. Neurodegenerative brain loss conditions include Amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease), Alzheimer’s, Parkinson’s and Huntington’s disease. These heartbreaking conditions happen because of brain cell death but we don’t know what kills the brain cells. We do know that in 2016, 5.4 million Americans were living with Alzheimer’s and we estimate 930,000 people will be living with Parkinson’s in 2020.
 
Presently a lot of research is being done to look for exposure to certain toxins as cause for ND diseases to include pesticides, fungicides, insecticides, metals like arsenic, lead and manganese, polychlorinated biphenyls (PCBs) and other human-made and natural toxins in the environment including tobacco and some antioxidants. We simply do not know the cause or causes, but we’re looking hard.
 
When a person has one of these largely untreatable conditions, we utilize tools called “Activities of Daily Living (ADLs)” to define when that person might need more help. The five ADLs include 1. personal hygiene (being able to bath, groom, brush hair and teeth), 2. continence management (being able to independently use the toilet), 3. dressing (selecting and wearing appropriate clothes), 4. feeding oneself, and 5. ambulating (being able to change position and to get around by oneself with or without an assistance device or wheel chair). Losing ability to do one or more ADLs certainly means that help is needed, if not now, around the corner.
 
Mrs. R had a great life, and although she struggled with an ND brain condition, she didn’t lose her spirit and color until the very end. Miss you, Mrs. R.
 
Richard P. Holm, MD passed away in March 2020 after a battle with pancreatic cancer. He was founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. Dr. Holm’s legacy lives on through his Prairie Doc® organization. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook, featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.    

​By Jill Kruse, DO
 
When my mom called me and said that my dad found four N95 masks in the garage and she wanted to send them all to me since I’m a doctor – That’s love.
 
When I reassured her that we had enough in clinic for now and that she should keep them, or at least keep two for her and dad – That’s love.
 
When I received the box in the mail, all four masks were there, lovingly wrapped in tissue paper with a note of encouragement – That’s love.
 
When I come home from work my children run to the top of the stairs yelling out, “Mommy’s home” – That’s love.
 
When I stop them from coming down to the landing until I can shower and change in the downstairs bathroom because I am scared that I might bring the virus home and I want to do everything I can to protect them – That’s love.
 
When a patient sends a message to local health care workers that they are thinking of us and praying that we stay well – That’s love.
 
When essential workers in any profession, show up to support their families and co-workers every day – That’s love.

When the local theater department makes masks for the hospital and uses it as a final project for students – That’s love.
 
When you order a take-out meal from a local restaurant or buy a gift card from a local small business – That’s love.
 
When you turn off the news and call a friend instead so neither of you are so lonely – That’s love.
 
When you practice social distancing, not because you are afraid, but because you do not want to add to anyone else’s risk – That’s love.
 
When teachers completely change the way they teach, with only a few days to prepare, and their eyes light up with happiness when they see their students on a Zoom meeting – That’s love.
 
When you are frustrated, angry, scared, or just don’t know what else to do, look for the love.  It is all around you. Sometimes we do not see it because we are so overwhelmed with all these other waves of emotions that try to drown it out, but it is there. It is always there. That’s love, waiting for you to find it.
 
Jill Kruse, DO, is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.        

​By Kelly Evans-Hullinger, M.D.
 
It is the year 2020, and we find ourselves in the midst of a rapidly changing, worldwide pandemic of a novel Coronavirus. This virus and public knowledge of it has spread and changed with greater speed than our scientific method can accommodate. Science, and the progression of medical knowledge, is by nature and necessity slow and methodical. This pandemic is neither. But we ought not abandon our deliberate striving for truth; not now, not because it feels too slow.

The gold standard in medical science, the randomized controlled trial (or RCT), is a relatively new development in the history of medicine. The British epidemiologist Sir Bradford Hill is credited with designing and publishing the first RCT in medical science, a study of streptomycin in treating tuberculosis, in 1948. Sure, even randomized controlled trials are never perfect, and they require large numbers of patients, time, and investment. However, their design does seek to remove variables that are sure to taint all other trial designs. They are the best we have, especially when it comes to evaluating a therapeutic intervention.

Much speculation has arisen, both in the medical community and the media, about possible drug therapies for this disease: hydroxychloroquine, azithromycin, remdesivir, convalescent plasma, and others. Why have so many physicians and scientists been less-than-fully-enthusiastic about these interventions? It is because we do not have sufficient data yet. There has not been time for any quality randomized controlled trials.

Still, if these things might help, why not just throw them at patients with severe cases of COVID-19? What do we have to lose? The truth is, the history of medicine is flush with examples of therapies that we thought would be helpful – studies in the lab were favorable, we had promising initial observational data, and expert opinion was in favor of it – but, when put to the test, they were not. In many of these cases the interventions turned out not only to be not helpful, but harmful, when they were tested in a randomized controlled trial.

We must demand a high threshold of proof before accepting therapy as effective. History has taught us that mistakes are made if we do not. We want solid evidence that an intervention helps more than it hurts before recommending we give it to everyone with this disease. Yes, even if it seems slow.

One thing is for certain: our collective scientific energy will be best spent investing in developing a vaccine for this highly contagious virus. Fortunately, there are very smart people all over the world working around the clock in this endeavor. A vaccine: now that would be a game-changer.

In the meantime, our best defense against this pandemic continues to be social distancing – so stay home and minimize contact with others. The more we flatten the curve now, the more people will benefit from the hard work of science in the future.
​
Kelly Evans-Hullinger, MD is part of The Prairie Doc® team of physicians and currently practices internal medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.        

By Richard P. Holm, MD
 
In a recent national survey, 26.9 million American adults age 18 and older reported experiencing vision loss. Of course, vision loss means blindness or the inability to see at all, but the definition also includes those having trouble seeing, even when wearing glasses or contact lenses. While not everything is preventable or reversible, early detection and intervention are among our most effective tools to prevent vision loss.
 
Mrs. E who lived well into her 90s, would come into my office, never complaining about her eyesight. However, the diagnosis of age-related macular degeneration (AMD) was obvious to me because, when she and I had a face to face conversation, she would look a foot to the left of my nose. The AMD had destroyed her central vision and she used her peripheral vision to see. AMD is the most common cause of blindness in the elderly. Risk factors include a family history of AMD, aging, smoking, obesity and hypertension. We can reduce our risk if we stop smoking, eat less, exercise and visit our eye doctor on a regular basis.
 
Almost the opposite of AMD is glaucoma, where the peripheral vision is lost, and the central vision is spared. This gradual and painless loss of vision is due to injury of the optic nerve and is commonly the result of increased pressure of the fluid within the eyeball. When glaucoma progresses, even the central vision can be lost but, if diagnosed early, treatment can help.
 
Diabetic retinopathy and cataracts are more common than AMD or glaucoma. Diabetes causes new tiny, and unfortunately very fragile, blood vessels to develop on the retina, and, when these delicate blood vessels bleed, they cause swelling, scarring, and progressive spotty vision loss. Cataracts, the leading cause of blindness in the world, cause the clouding of the lens of the eye.
 
For most of these eye conditions, there are methods to diagnose, treat and prevent the blinding consequences, yet many people skip regular eye exams. The message is staring you in the face, or perhaps a foot to the left of your nose…get your eyes checked every year. Due to the coronavirus pandemic, most non-urgent eye appointments are being deferred to the latter half of the year. Contact your eye doctor to discuss the best option for you.
 
Richard P. Holm, MD passed away in March 2020 after a battle with pancreatic cancer. He was founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. Dr. Holm’s legacy lives on through his Prairie Doc® organization. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook, featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.                                              

By Richard P. Holm, MD
 
During my lifelong practice of geriatrics, I observed many people reaching the end of their lives. Truth is, what I’ve seen is a mixed picture. The two patient stories I describe here are really a blend of hundreds of experiences.
 
Ms. A is in her late 80s, walks two miles every day, mostly outside but inside a wellness center when sidewalks are icy. She eats a balanced light diet and is connected to many friends. Ms. A is spiritually connected, and life has been and continues to be meaningful to her.
 
Ms. B is also in her late 80s, has never been much for exercise and now is unable to walk without the help of her walker. She lives in an assisted living center and has made some friends there but remains rather critical of them. Whenever her kids visit, she asks them to take her home. Ms. B had some tough times and some happy times during her life, but now, she remains rather bitter.
 
At age 82, comedian Rodney Dangerfield, who had studied the relationship between sexuality and longevity said, “I’m at the age where food has taken the place of sex in my life. In fact, I’ve just had a mirror put over my kitchen table.” Reading that made me laugh out loud, but I see Dangerfield’s comment as both funny and sad. Indeed, this thing called growing old is a mixed picture. Should we celebrate it or fear it? Does it give wisdom and meaning or just aches and pains?
 
I suggest we embrace both sides of the picture. Let’s choose to live as long and as well as our luck and genetics allows. We would all do better with regular exercise, eating less, connecting with both the earthly and the spiritual. Let’s also choose to kindly accept the fact that someday we will reach the end of our lives. We can take healthy steps by creating an advanced directive, by understanding the kinds and causes of dementia and facing the inevitable death of the ones we love. Embracing this mixed picture helps us in accepting aging processes we cannot change, avoiding suffering and savoring things that matter.
 
Bottom line lessons from Ms. A and B: Like any piece of art, we can choose how we view the picture of our own aging. Those who live with misery, anger and vengefulness will likely die that way. Those who glean meaning and joy from observation, giving to others and opening their hearts to the spiritual will find aging a grand masterpiece.
 
Richard P. Holm, MD passed away in March 2020 after a battle with pancreatic cancer. He was founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. Dr. Holm’s legacy lives on through his Prairie Doc® organization. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook, featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central. 

By Andrew Ellsworth, MD
 
When I come home from a day at the clinic and hospital, there is no better feeling than my children running up to give me a big hug. For the past couple of weeks, I have had to remind them to stop, and just do an air hug until I have had a chance to change clothes and shower. The idea is to wash away any germs and decrease the risk of getting my family sick after working with several patients and sick people during the day. Maybe these efforts are too much, or maybe they are not enough. 
 
The Covid-19 virus spreads through respiratory droplets, from talking, coughing, or sneezing, and appears to also spread via a fecal-oral route. The fecal-oral route is how the stomach flu often spreads, and many of us know how easily that circulates through families and daycares. Someone who has been to the bathroom may touch a doorknob or a serving spoon, which someone else touches before eating, and they may become infected. That’s why we need to wash our hands well and avoid touching our face and our food.  
 
Unfortunately, the virus can spread from people that do not have symptoms, or before they have symptoms which is why, I worry, I may not be doing enough to protect my family from the one person who puts them at the biggest risk: me. Some doctors and nurses are deciding to avoid their families altogether and live in the garage or the basement when they come home. I haven’t decided to do that yet, but maybe I should, or maybe I will. 
 
Pandemics and disease have separated families for longer than the history books can tell us. Before they knew the cause, our ancestors knew that if someone had smallpox, quarantine and fire were the only ways to help prevent the spread. People, houses, and entire cities were quarantined. Disease has arguably decided more wars than the battles themselves. During the 1918 influenza pandemic, soldiers from Fort Riley carried the disease to other American military bases and from there, to the battlefront in Europe.  
 
These lessons of history helped us learn about how to control disease. Advancements in infection control, medicines, and vaccinations have turned the tide and made many diseases a distant memory. For Covid-19, we do not yet have proven medications or a vaccine. However, we are learning more every day how to help those who are sick and how to better prevent the spread. In the meantime, my family and I will continue to practice social distancing and similar efforts to do our part to flatten the curve and slow the spread, to give us time to find treatments to combat this current scourge on humanity.  
 
Andrew Ellsworth, MD is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.