By Jill Kruse, D.O.

Whenever someone is admitted to the hospital, they are asked to stipulate their “code status.” Levels of code status include full code, meaning resuscitate and intubate if required; as well as various combinations of do not resuscitate (DNR) and do not intubate (DNI). In simple terms, a code status clarifies what you want the medical team to do in the event your heart stops or if your heart goes into a rhythm that is not compatible with life.
This question is often interpreted as follows: if you are about to die, do you want the medical team to do everything they possibly can to keep you alive? We might also allow ourselves to pose and interpret the question from a different perspective: If you are about to die, do you want permission to pass away peacefully?

When discussing code status with my patients, the answer I often get is, “Of course I want to live, do everything you can to save me.” TV and movies mistakenly portray emergency lifesaving measures working most of the time. In real life, attempts to resuscitate are not as successful. A review of more than 29 different studies involving 400,000+ people over the age of 70, show that only 19 percent survived to be discharged from the hospital. The odds were even worse for those in their 80s or 90s with survival rates of 15 percent and less than 12 percent, respectively. Of those who survived, less than half returned to the same status of living they enjoyed prior to the code. Most ended up not able to care for themselves independently. 

Another common response I hear is, “Do everything if you think it will work.” Doctors are incredibly optimistic. We are trained to fight against the odds to save lives. Unfortunately, no one can predict the outcome of a code. That is like asking if a slot machine will win before we pull the lever. Sometimes we hit the jackpot and the person does fine, goes home, and everyone is happy and grateful. Other times, like most slot machines pulls, we are forced to admit the loss.

The best person to select your code status is you. There is no “right” answer, there is only your answer. Give yourself permission to make this decision with a calm, clear mind before you are in crisis or admitted to a hospital. It is not in your best interest to make a rushed decision. Nor is it fair to force it upon your loved ones in an emergency room as your health is rapidly declining.
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It is okay to give yourself permission to change your answer over time as different circumstances arise. Share your answer with your family and your doctor. Then give yourself permission to be at peace with your answer.
Jill Kruse, D.O. 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 Andrew Ellsworth, M.D.
 
Do you know anyone who had influenza this past year? Chances are you do not. Sure, plenty of people had the “stomach flu” with vomiting and diarrhea, otherwise known as gastroenteritis. Some people had colds and others had COVID-19. But cases of influenza this season have been exceptionally low.
 
Starting a year ago, when someone came to my clinic with symptoms of influenza, including fevers, chills, muscle aches, or respiratory symptoms, we tested for both COVID-19 and for influenza. At first, every COVID-19 test was negative while many influenza tests were positive. However, with social distancing, mask wearing, washing hands, and people staying home when they were sick, influenza cases in South Dakota plummeted faster than I have ever seen. 
 
The charts put out by the South Dakota Department of Health speak for themselves. Every week they send out the latest influenza statistics and compare them to past years. The number of influenza cases forms something like a bell curve or mountain which peaks in South Dakota typically during the third week of February and then tapers down again. This year that line of cases for 2020-2021 is essentially flat, and this week we saw a slight increase in cases which will hopefully only form a small bump on the chart as opposed to a mountain.
 
Usually there are well over 2,000 confirmed cases of influenza in South Dakota each year, with almost 15,000 confirmed in last year’s season. In a normal year, many more people have influenza but go unrecorded because they are not tested. For this current influenza season, many people are being tested for COVID-19 and influenza at the same time. Despite thousands of tests, there have been only 55 confirmed cases of influenza in the state through the third week of February.
 
Over the last decade, influenza claimed an average of 32 lives each year in South Dakota. The worst season was 2017-2018 when 73 people died, and the fewest deaths occurred in 2015-2016 when 9 people died. We know that this past year, COVID-19 claimed the lives of more than 1,850 people in South Dakota. COVID-19 still managed to thrive even while influenza withered. The biggest reason is because COVID-19 is more contagious than influenza. Vaccinations and past immunity to influenza also help reduce its occurrence. 
 
We cannot stress how important and helpful everyone’s efforts over this last year have been toward keeping the numbers of COVID-19 down as much as we could to “flatten the curve” and avoid a catastrophe with everyone getting sick at once. We are not out of the woods yet, but we are getting closer. As far as influenza goes, it would appear that washing our hands, staying home when sick, social distancing, and wearing masks have drastically helped to minimize the spread.
 
Andrew Ellsworth, M.D. 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.
 
Last summer we heard the prediction that by the end of 2020, we would have a safe, effective vaccine to the SARS-CoV-2 virus, which had only been discovered, of course, in December 2019, before causing countless deaths and mayhem in the world as we knew it. I must admit, I was skeptical.
 
Early in the pandemic, I learned that the fastest a vaccine had ever been developed was for the mumps virus, an effort which took four years. Even with all possible resources devoted to a COVID-19 vaccine, how could we ever do this in one year? Before I could even ponder this, however, my curiosity took me down the rabbit hole of the mumps vaccine.
 
Maurice Hilleman, to whom the mumps vaccine is credited, is something of a superhero in the world of virology and vaccine development. Over the course of his career, he was involved in the development of 40 vaccines, including an influenza vaccine in 1957 estimated to have prevented hundreds of thousands of deaths.
 
One night in 1963, Hilleman’s young daughter Jeryl Lynn awoke him from sleep. She was feeling sick.  Hilleman saw the telltale swelling of her salivary glands and knew she had the mumps. Mumps was a common childhood ailment, and while most children got mild illness including the classic swollen cheeks, it also caused aseptic meningitis, deafness, and infertility in males. Hilleman put Jeryl Lynn back to bed, then drove to his lab to retrieve a swab and culture media. He returned and awoke young Jeryl from her slumber to swab her mouth.
 
Over the next four years Hilleman cultured and tested the Jeryl Lynn strain of the mumps virus until it was safe enough to administer without the risk of illness but still effective in generating an immune response against a normal mumps virus. Jeryl Lynn was present when her younger sister Kirsten was publicly immunized with the new mumps vaccine as a small child. As a result of Hilleman’s vaccine, the United States now has only about 200 cases of mumps per year, compared to 200,000 per year before the vaccine.
 
Back to that COVID-19 vaccine. Well, my timeline skepticism was unwarranted. In December 2020, data published on two separate vaccines using mRNA technology showed without ambiguity that we did have safe, effective vaccines just one year from the start of this pandemic. How so quickly? We can give credit to a modern technology being ready for this problem and the intellectual weight of thousands of scientists around the world. I think even Maurice Hilleman, the father of modern vaccines himself, would be impressed.
 
Kelly Evans-Hullinger, M.D. 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 Debra Johnston, M.D.

I’ve learned a lot from my patients over the years. Sometimes, the lessons are learned as I walk beside them through struggles, both medical and non-medical. Sometimes, the lessons are explicitly stated, words of wisdom that stick with me through the years, and change the way I understand illness, or life in general.

The first such lesson I remember was from a middle-aged woman who had been diagnosed with type 1 diabetes only a few years prior. She came to me with blood sugars that ran critically low in the middle of the night, but sky high during the day. The situation only worsened when she tried to adjust her insulin. Back in those days, our tools for managing diabetes were far more limited, and our insulin regimens far more rigid.

After we adjusted her dosing so that the peaks and valleys of her insulin effect were a better fit for her life, we started fine tuning the control of her blood sugar. We needed to balance her insulin, with her activity, with her food. This is when she said to me, “Diabetes is the original do-it-yourself disease.”

The truth of this statement resonated with me then, and I still hear her words almost every time I see a person with diabetes 20 years later.

The stakes are high. Control of blood sugar is directly correlated with the odds of developing one of the terrible complications of diabetes, such as blindness, strokes, heart attacks, kidney failure, amputations, and nerve damage.

That control rests in part with our medicines, but the real challenge of diabetes lies in the fact that success depends on changing habits, and that is difficult indeed. People with diabetes are asked to change the way they eat, the way they move, the very way they live. They are often asked to monitor their blood sugars, which to date has meant pricking their fingers to take blood, and to make decisions based on those results, sometimes multiple times a day. Then, do it again tomorrow, and the next day, and the next day. Additionally, diabetes medications and supplies are awfully expensive!

There is some hope: new technologies are making it easier to handle the mechanics of managing diabetes, and new medicines are allowing more flexibility in lifestyle. But the burden of success still rests very much on the shoulders of the patient, to balance medicines, with activity, with food, in all the decisions he or she makes every day.  

Diabetes is no doubt, the do-it-yourself disease.
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Debra Johnston, M.D. 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 Jill Kruse, D.O.
 
Many people are familiar with the classic Abbott and Costello comedy skit “Who’s on First?” For those who are not familiar, the routine is a hilarious interaction between the two comedians as they discuss players on a baseball team while using confusing references such as “who’s on first” and “what’s on second.” The audience can see that Abbott believes he is clearly communicating the player names to Costello, but it digresses into a laughable experience of misunderstanding and frustration for both parties. The men become increasingly angry as the conversation goes on and each feel that the other is not listening. 

This situation may be funny in the world of entertainment, but it can be disastrous when it happens between doctor and patient. At times, conversation in the exam room can inadvertently go down a similar path of confusion. I recall one such experience when I was showing an x-ray to a patient. I pointed out, “Here is the fracture.”  The patient looked at me, gave a sigh of relief and said, “Thank goodness doc, I was afraid you were going to tell me that it was broken.” At that moment I realized my choice of words had not provided the clarity I intended. Thankfully, this patient spoke out which alerted me to the misunderstanding allowing me to rectify it immediately. 

Those of us in the medical field must be always mindful to ensure that we explain things in clear, everyday language. I apologize for our failures, which do happen. I also ask for your help. Doctors are human and we may incorrectly assume that our patients understand what we are saying, especially if our patients do not tell us otherwise.

Healthcare is a partnership which requires communication from both patient and doctor. It is important to recognize that not all cultures and generations feel empowered to question a doctor. Other patients hesitate to ask what they feel might be perceived as a “silly” question. In addition, patients have varying levels of education and experience when it comes to participating in medical conversations. Sometimes it helps the patient to have a family member or friend in the room to help the patient feel at ease and convey information.

Doctors strive to be sensitive to these situations, to welcome and encourage questions, then listen closely when the patient speaks. No doctor I know will intentionally or maliciously confuse a patient. We welcome your participation so both patient and doctor can best understand what care is needed. Let’s work together and keep the conversation going to make sure we both know “who’s on first” and “what’s on second” when it comes to your health.”
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Jill Kruse, D.O. 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 Andrew Ellsworth, M.D.
 
The feeling of pressure and pain in the front of the face around the eyes is all too familiar for millions of Americans. Our sinuses include four pairs of air-filled cavities above and below the eyes and behind the nose. They are helpful for humidifying the air we breathe, resonating our voices, and lightening the weight of our heads. However, the sinuses can be prone to inflammation and infection. 
 
The mucous lining of the sinuses serves as an antimicrobial barrier to infection, and little hairs called cilia help to sweep out unwanted bacteria and viruses. Disruptions to this system commonly come from allergies and viruses. If the passageways get blocked, then bacteria can grow and flourish in the moist, warm, mucous.  
 
Sinusitis is inflammation of the sinuses which can cause the full feeling behind the eyes, pressure, and pain. If left untreated, it can cause fevers and a systemic response from the body. Chronic sinusitis, lasting more than three months, can be caused by allergies, nasal polyps, ongoing infection, a deviated nasal septum, pollutants, or other conditions. 
 
One of the keys to treatment and prevention of sinusitis is keeping the sinuses open and draining. Nasal saline, a saltwater mixture, can be used to help rinse out and open the sinuses and can be just as effective as antibiotics. If allergies are at fault, a steroid nasal spray or steroid pills can be used to decrease inflammation and swelling. A nasal steroid spray can also help treat a nasal polyp, helping to shrink the polyp to aid in the circulation of air and mucous. For some people with chronic and recurring sinusitis, surgery is their best option and can provide welcome relief.
 
Try this. Hold one nostril shut as you breathe in and out of the other. Now switch to the other nostril and breathe in and out. Chances are you can breathe more freely on one side compared to the other. Wait a few hours, try it again and chances are the opposite side is more open. Congestion in our nose naturally changes sides every four to six hours. If you find that one side is always blocked, then you may want to see your primary doctor or an ear, nose, and throat specialist. 
 
Our bodies are designed for flow. The flow of air, food, blood, waste, and even mucous keeps us healthy. Next time you blow your nose, remember you are helping the natural movement of mucous, so just “blow with the flow.”
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Andrew Ellsworth, M.D. 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 was my first month in the hospital as a new internal medicine intern at a large university hospital.  Upper-level residents that I met during orientation asked me, “What is your first rotation?”  When I answered, “hepatology,” the looks I got in response told me I was in for a tough initiation.

The hepatology service included some of the sickest patients in the hospital. Each one had either end stage cirrhosis or a liver transplant, plus some acute condition requiring them to be in the hospital. They were so complicated, making clear to the newly minted Dr. Evans that a healthy liver is critical for the body to function normally.

Cirrhosis (scarring of the liver) is the undesirable result of many types of chronic liver disease. Many causes of liver disease occur at random, related to autoimmune or genetic origins. However, the most common reasons patients develop cirrhosis are alcohol related liver disease, hepatitis C, and non-alcoholic fatty liver disease, all of which might be controlled if we catch them before cirrhosis develops.

Most people know that chronic heavy alcohol use can result in cirrhosis. We don’t fully understand why some heavy drinkers develop cirrhosis and some don’t, but longstanding alcohol abuse does typically result in some degree of liver damage. Though it can be very difficult, stopping alcohol intake can, in turn, stop progression of liver damage in most patients with alcohol related liver disease.

Hepatitis C, a viral infection which in some people becomes chronic and can ultimately lead to cirrhosis, has been the most common reason for liver transplant in the United States in recent years. With major developments in treatment for this disease over the last decade, we now have highly effective and well tolerated antiviral treatments to cure hepatitis C. This virus can reside in the liver and bloodstream without causing symptoms for decades. Current recommendations advise that we screen for hepatitis C in patients who have significant risk, including all Americans born between 1945 and 1965 in addition to other high risk groups. Talk to your doctor if that includes you.

Nonalcoholic fatty liver disease (NAFLD) is increasingly prevalent and now is among the most common reasons for liver failure. NAFLD is thought to be due to metabolic factors resulting in fatty deposition in the liver. It commonly occurs along with other metabolic diseases such as obesity, diabetes, and high cholesterol. Treatment of NAFLD is focused on diet and exercise and controlling those other metabolic diseases.

That one month as a new physician on the hepatology service was enlightening. I learned so much about the importance of a healthy liver, and I continue to use those lessons regularly in primary care.
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Kelly Evans-Hullinger, M.D. 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 Debra Johnston, M.D.
 
America is grappling a difficult legacy. Our society was built by the blood and sweat of slaves, on land previously occupied by Native Americans. When we won independence, only white male property owners were fully enfranchised. Enslaved peoples were not fully counted under the constitution. Married women had no legal identity.
 
Immigrants, particularly from Ireland, southern Europe, and Asia faced open hostility. Catholic Churches were vandalized. Nearly 1000 Jewish refugees fleeing Nazi Germany were turned away in Miami harbor. Japanese Americans were forced from their homes and into internment camps.
 
We have a proud heritage of noble ideals, but we have often failed to live up to them. We have emphasized our differences, not to celebrate the rich tapestry of life they create, but to divide ourselves into “us” and “them.”
 
In the last 250 years, our society has moved in meaningful ways toward equal participation. Slavery is illegal. Women can own property. People of different races can marry. We still face the consequences of generations of discrimination, but most of us find we have opportunities our grandparents did not.
 
The LGBTQ+ community is the most recent to demand an end to discrimination. Awareness is increasing, but many people still have little information, or have misinformation, about the diversity of human sexuality and sexual identity.
 
Three years ago, a high school friend shocked me when she revealed that she was, in fact, a trans woman. I wonder how many other people I’ve met and cherished have felt compelled to hide something so important. We know that suicide attempts in the LGBTQ+ community are higher than in the general population, particularly for young people who are bullied in their communities or rejected at home. LGBTQ+ individuals are more likely to be victimized by violent crimes.
 
I often think of the saying “a rising tide lifts all boats.” It reminds me that working to improve my neighbor’s wellbeing makes my own more secure. This is especially true for the neighbors who don’t look like me, who don’t pray like me, who don’t vote like me, who don’t love like me. If their rights are threatened, it is only a matter of time before mine are, as well.
 
We can all look back in our family trees and find someone who faced discrimination for their race, religion, or class. And of course, we all have mothers and grandmothers! Let’s remember those struggles and extend compassion. We are more alike than we are different.
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Debra Johnston, M.D. 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 Jill Kruse, D.O.
 
One definition of the word murmur is “to express one's discontent in a subdued manner.” So, it makes sense that a heart murmur is often a soft-spoken signal that something may be going on in the heart. The heart does not always shout to get our attention like it does with a heart attack. Sometimes it quietly whispers to those who will listen that there might be an issue. The murmur itself is not the problem, rather, the murmur is telling us to look for one. 
 
Some murmurs are called innocent or benign. These are murmurs when the heart is normal, but the blood is flowing over the valves rapidly which causes a sound. About forty to forty-five percent of children will have a murmur at some point in their life. No treatment is needed for these murmurs and children will often outgrow them, but up to ten percent of them do persist into adulthood. 
 
Murmurs that indicate more serious issues are often associated with valve disorders in the heart. The valves are the areas that open when the chamber of the heart beats and close when the heart is between beats, to allow the chambers to relax and refill with blood. Sometimes a valve does not fully close, or it will balloon backwards and allow blood to backflow across the valve. This back flow causes a murmur. This is called valve prolapse that leads to blood regurgitation or “regurg” which requires medical attention.
 
A different type of murmur is caused by mitral or aortic valve stenosis. Stenosis is when the valve does not fully open, so the same amount of blood is forcing itself through a narrower opening in the same amount of time as it does in a normal valve. That extra pressure causes the murmur because the heart must work harder to push the blood through the valve. Over time if this is untreated it can lead to damage of the heart muscles.  
 
The most common murmur is aortic sclerosis, which happens when the aortic valve develops scarring, stiffening, or thickening. This can occur with age or after infections such as rheumatic fever or endocarditis.  This is not dangerous by itself, but if it progresses to stenosis, it can be cause for concern.
 
Often when a doctor hears a murmur, we may want to get a better look with a special ultrasound called an echocardiogram to see if we can find the cause of the noise. Once the cause is found, a follow up plan can be made.
 
When the heart whispers, we must always listen. By doing so, we may avoid further discontent, forcing the heart to raise its voice over a larger problem.  
 
Jill Kruse, D.O. 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 Debra Johnston, M.D.
 
Some health problems are much larger than the health care system and cannot be fixed by doctors, nurses, hospitals, and the rest of the traditional health care team. 
 
In our physician peer group sessions, my colleagues and I often share the agony we feel when sending people out of the emergency room, knowing that the patient is going right back into the conditions that contributed to their crisis in the first place. Perhaps they could not afford their insulin or have no refrigerator in which to keep it cold. Perhaps they are going home with the person who hurt them. Perhaps they don’t have a home to go to and are trying to care for their wound while living on the street. These situations are real, and they exist in rural areas, small towns, and big cities alike.
 
I often urge my patients to get more exercise, and we brainstorm ways to overcome the barriers they face. But options are limited for the person whose neighborhood has no sidewalks or isn’t safe to stroll through. We talk about good nutrition, and most patients know it’s best to eat plenty of fresh fruits and vegetables. But what if the only store they can reach is the convenience store which doesn’t stock healthy options?
 
Some of my patients come to me having researched their symptoms, and we talk about how to find reliable medical information on the internet. But what happens if they don’t have access to the internet? Sometimes I print out educational material, but that has no value for the patient who cannot read.
 
Almost everyone has stress in their lives, but for some people the stress is unremitting and severe. They deal with poverty and the attendant evils of housing and food insecurity, with limited education that restricts their options. They lack reliable transportation which keeps them from school or work or regular healthcare. They suffer from chronic diseases, racism and other forms of discrimination while separated from the support of family and community.
 
Research reveals that these chronic stressors have significant adverse effects on the health of not only the individual, but their descendants as well. We have a label for these stressors. They are called “social determinants” and we are increasingly aware that they play an even bigger role in a person’s wellbeing than all the things that health care providers do. 
 
Protecting and promoting the health of our patients and our communities is a sacred mission, but we need to expand our perspective beyond medicine and surgery and helping one individual at a time. Health is larger than the health care system. We each have a role to play in recognizing and reducing the impact of social determinants for the wellbeing of our entire community.
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Debra Johnston, M.D. 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.