By Francine Arneson, M.D. and Kyle Arneson, M.D., Ph.D.
 
When patients and their families are asked to meet with palliative care specialists, it commonly triggers a wide range of emotions. Some may feel uncertainty about having an additional care team involved when they already have multiple appointments, and many fear what the referral may mean in regards to their current treatment plan and ultimately to their life trajectory. 

Along with these complicated emotions, patients and their families often admit to being unsure why their doctors feel the need to involve palliative care. By contrast, when a patient is referred to a cardiologist, oncologist, or surgeon they tend to understand why. The concept of palliative care has been utilized for decades by many clinicians but has only recently evolved into its own specialty. Recognized through research and clinical trials, palliative care has shown to help patients live well with serious illness by enhancing quality of life, extending prognosis, and ensuring patient centric care and comfort.

Palliative care is delivered alongside best standard medical care by an interdisciplinary team, consisting of doctors, nurses, social workers, chaplains, pharmacists, and others to meet the multidimensional needs of individuals. Ensuring that medical decisions align with the patient’s personal values and enhancing the patient’s quality of life remain the focus of specialty palliative care. Palliative care also aims at minimizing suffering.
Suffering is a scary word, but most people facing a difficult diagnosis will experience some element of suffering. Many first think of suffering as physical distress such as pain or shortness of breath. However, in palliative care, a much broader view of suffering is taken. It includes not only physical symptoms but also the emotional, spiritual, and practical toll illness places on our sense of self and our loved ones.  

Palliative care commonly addresses suffering in those who are not having physical symptoms, but have anxiety or depression, overwhelming feelings of guilt, remorse, fear, or discord regarding faith. Palliative care will discuss how illness impacts a person’s independence and appearance and focuses on how illness impacts relationships with loved ones. Palliative care provides that extra layer of support to ensure that all medical care is based upon individual choices and values.

As we attempt to maintain a sense of self through complicated illness, these topics are vitally important but are rarely addressed in normal health care settings. Specialty palliative care strives to ensure that the medical plan of care is based on diagnosis but is also optimized to incorporate the patient’s personal values and beliefs, based on goals and life experiences.

So, although many people are initially hesitant when a palliative care referral has been made, ultimately most people deeply appreciate the benefit of excellent symptom management and the patient centric support that is provided throughout a relationship with the palliative care team.
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Francine Arneson, M.D. and Kyle Arneson, M.D., Ph.D. are contributing Prairie Doc® columnists. They practice palliative medicine and radiation oncology, respectively, in Sioux Falls, South Dakota. Francine is the featured guest on the show this week. 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 Mandi Greenway, M.D.
 
“Doc, what’s this scaly rash on my arm? Do I have ringworm again?” A lot of the rashes I see in my dermatology clinic are red and scaly. In fact, what first drew me to dermatology as a profession was watching a dermatologist distinguish between seemingly similar red, scaly rashes all day. It intrigued me at the time, and I wanted to be just like her.
 
I can always tell when my patient is a farmer, because they usually treat any rash as ringworm before coming to see me. How does ringworm happen and why are farmers so familiar with it? Ringworm, first of all, is not a worm. It is actually caused by a fungus that infects our skin and causes a circular rash wherever the fungus came in contact with our skin. Without treatment, the circle will continue to expand and enlarge, forming concentric rings. The rash usually itches and is bothersome.
 
There are several families of fungus that can cause ringworm (tinea corporis in medical speak). They can be spread directly from other people, animals, or soil. The most severe infections typically happen when we get ringworm from animals. Growing up on a farm, I am very familiar with how much farmers interact with their livestock and pets. Farmers are accustomed to diagnosing ringworm on their animals and often will treat themselves if they see a similar rash. I’m pretty sure every farm family has had at least one member who has come down with this common infection at one time.
 
But all that is scaly, and circular is not ringworm. I remind my patients, especially farmers, that there are lots of different rashes that can look similar. It is not always in your best interest to try to self-diagnose and treat.
 
Nummular eczema is a type of eczema that forms red, scaly, circular patches on our skin. Granuloma annulare is another rash that forms raised rings on the skin. These are both treated differently than fungal infections and make up the most common rashes that are misdiagnosed as ringworm.
 
There are other, less common, rashes that can signify underlying medical conditions inside your body. Even though ringworm is a common, non-dangerous skin infection, if your rash doesn’t improve with over-the-counter antifungals you should always check with your doctor.
 
Mandi Greenway, M.D. is a contributing Prairie Doc® columnist. She practices dermatology in Mitchell, South Dakota and is the featured guest on the show this week. 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.
 
Examples of accelerating scientific progress abound in human history. Mendel’s experiments with plants demonstrated inheritance in the mid-1800s. Over the next 100 years, researchers across the world built upon each other’s discoveries, until Watson, Crick, and Franklin finally identified the structure of DNA. The human genome project was launched nearly 40 years later, and within 15 years, the entire human genome had been mapped.

Da Vinci famously conceptualized human flight during the Renaissance, but it took 400 years of research and experimentation before the Wright brothers flew at Kitty Hawk. Only 54 years later, the Russians launched Sputnik 1, and 12 years after that, Armstrong and Aldrin walked on the moon.

In 1846, ether was used for surgery for the first time. Surgeons could operate on patients without inflicting excruciating pain from the knife. Advances in the understanding of antisepsis taught surgeons to wash their hands and their instruments, and survival rates after surgery steadily rose. The first appendectomy happened in 1880. The first kidney transplant was in 1953. Today, surgeons can repair heart valves without opening the chest, and address spina bifida while an infant is still in the womb. Death as a result of surgery is uncommon in all but the direst of circumstances.

Hundreds of years ago, the Chinese blew pulverized smallpox scabs into the noses of susceptible individuals, and eventually variolation, the deliberate, controlled exposure of an individual to smallpox was practiced throughout the world. Smallpox contracted naturally carried a death rate of about 30 percent. Variolation improved the odds significantly: only one to two percent of people died. In 1796, Jenner started inoculating children with cow pox, thus conferring immunity to smallpox, and the modern vaccine era began. 

Since the late 1800s, vaccines against many once terrible diseases have been developed. As technology has advanced, it has been easier to identify the organism that causes a disease. It took almost 15 years to determine that polio was caused by a virus rather than bacteria, and another 40 years to learn that there were in fact three different strains of the polio virus. It took only two years to identify HIV.

Science accelerates, and science rises to new challenges. Basic science advancements are translated into new or improved technologies faster than ever before. Researchers across the world can collaborate, replicate, build upon, or as importantly refute, each other’s findings. 

We have tools today that even da Vinci could not have imagined, and they enable us to do things that would have seemed like magic to previous generations. Science fiction author Arthur C. Clark once wrote, “any sufficiently advanced technology is indistinguishable from magic.” Thankfully, understanding how these technologies developed helps us appreciate the difference.
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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.
 
My daughter recently brought home a monarch caterpillar. We cared for it in a container making sure it had a supply of fresh milkweed leaves and kept its cage clean. It seemed perfectly content to munch on leaves all day. After a few days it hung upside-down from the lid of the cage and we waited for it to form a chrysalis, and eventually convert to a butterfly.

We used the time lapse video capability of our cell phone to capture the transformation. Watching the video, the change seems easy, quick, and effortless. There does not appear to be any major effort or pain involved for the caterpillar. However, after researching the subject, we came to appreciate the significant process the caterpillar undergoes which is not apparent to the naked eye of the observer.

Unless we take time to learn about the butterfly’s makeover, we may tend to minimize it as an uncomplicated process. Literally everything about the caterpillar changes. Its old body is completely broken down for the new one to form. Enzymes are released to break down the caterpillar skin and hormones allow new body parts to be formed. To the spectator, it looks easy, to the caterpillar, it is a monumental task.   

This got me thinking about how change is difficult for people, and how important it is for us to support each other as we attempt it. Many changes in life are painful and complicated, especially those we make to improve our health, or our physical, emotional, or spiritual wellbeing.

Breaking old habits and creating new, healthier behaviors involves a transformation. It requires that we learn new ways of thinking and practice positive self-talk which is sometimes uncomfortable and challenging work. Quitting smoking, walking every day, choosing different healthier foods, and avoiding junk food are changes that offer long-term benefits. The work may not seem worth it in the short-term. You may want to give up, especially when others do not seem to notice your struggles or understand how you are feeling inside. You may miss the way things were before you embarked upon your journey.

Look to the butterfly for encouragement to continue your transformation. Change may feel like a struggle, but when your wings emerge and you take flight thanks to your healthier habits, the change will be its own reward.
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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.

When the Declaration of Independence was signed on July 4, 1776, the American colonies still needed to win the Revolutionary War to truly gain their independence from the British Empire. The war continued another seven years until September 3, 1783. One of the deadliest threats to the Continental Army, however, was not the British Army, it was disease, especially smallpox. 

Boston had an outbreak of smallpox in 1775 from British Redcoats arriving to fight the rebellion. George Washington knew very well the dangers of smallpox after having had it himself as a young man, which left scars on his face. To keep his soldiers safe, Washington did not allow anyone from Boston near his troops. Washington wrote to John Hancock, the president of the Continental Congress, that he would “continue the utmost vigilance against this most dangerous enemy.” Later, when the British withdrew from Boston, Washington allowed only soldiers with immunity into the city. 

Most of the Continental Army had never had smallpox while most of the Redcoats had. This put the Americans at a big disadvantage. An attempt by the Continental Army to take Quebec failed in part because of heavy losses due to smallpox. In fact, General John Thomas died of smallpox in July 1776. 

This was before the advancement of vaccinations. However, there was a procedure known as variolation, an early form of vaccination which involved exposing a cut on the recipient’s arm to a small dose of the virus, hopefully just enough to trigger immunity without causing severe illness or death. The procedure was illegal in many places including Washington’s home state of Virginia.  

Washington knew they could not afford to lose more soldiers to smallpox. Thus, despite push back from the Continental Congress, Washington ordered this primitive form of vaccination for the entire army, and by the end of 1777 more than 40,000 soldiers had received it. Infection of the army dropped from 20 percent to one percent and lawmakers repealed bans of variolation for smallpox across the colonies.  

George Washington’s efforts at quarantine and primitive vaccination helped protect the Continental Army from disease which helped them eventually defeat the British Army and earn independence for the United States of America. 

The war on Covid-19 may take several years as well. History shows how vaccination can be a great weapon against disease. Unfortunately, many remain unvaccinated, and hundreds in the U.S. continue to die each day. We need to rally both nationally and locally, to unite our efforts so we can gain our independence from Covid-19.

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 Philip Meyer, D.O.
 
For most of us, seeing the doctor means making a trip to the local clinic to see our primary care physician in person, but an increasing number of patients are seeing their doctor remotely by telehealth, using two-way video telecommunication technology.

The popularity of telehealth services soared during the COVID pandemic much like Zoom and similar technologies. Historically, patients and health care providers alike have been reluctant to adopt it, but federal health policy changes have removed many of the barriers to telehealth access and have promoted its use in both primary and specialty care.

According to the National Institutes of Health, twenty percent of us live in rural America where less than ten percent of physicians practice. I personally have known patients who live more than one hour from their primary physician and more than three hours from a medical specialist. Taking time off work and the travel expense required cause many patients to delay seeking care until their acute illness becomes complicated or their chronic condition deteriorates.

Thankfully, as telehealth services have grown, time and expense of travel to a specialist have decreased and access to care has increased for many. Rural emergency physicians and hospitalists utilize telehealth services for additional support and expert opinions for issues ranging from acute trauma and cardiac arrests to coordination with critical care specialists regarding the optimal management of a patient’s ventilator. Although not every specialty is available, the advent of telehealth has afforded many outpatients the opportunity to stay in their hometown and see a specialist.

While my patients and I have had many positive experiences with telehealth, none exemplifies the power of a remote video connection better than one of my first encounters with a critically ill COVID patient in my local ICU last Fall. Moments after placing a call to my telehealth affiliate, I was video chatting with a critical care specialist in Seattle – America’s first COVID epicenter. I was in my central South Dakota rural ICU wearing my PPE standing beside my patient who was now on a ventilator struggling with a disease I had never seen or treated and in the room with us virtually, but 1300 miles away, was a specialist with six months of experience treating dozens of patients like the one before me.

There will never be a replacement for in-person health care and a physical examination is required for proper diagnosis in most cases, but I urge you to keep an open mind to seeing a physician remotely by telehealth when necessary and consider the power it can add to your overall health care.
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Philip Meyer, D.O., a hospitalist in Pierre, South Dakota, is a contributing Prairie Doc® columnist. He appears as a guest during On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB Thursday, July 1 at 7 p.m. Central. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook. 

By Kenneth A. Bartholomew, M.D.
 
The liver is one of the most amazing but underrated organs in our bodies. We cannot live without it, and, unlike the kidney, we cannot bypass it with a dialysis machine. Lose your liver and you lose your life.
 
The liver is essential for digestion, but also detoxifies our blood, filtering, breaking down, and disposing of chemicals we cannot use. While there are many toxins that can harm the liver cells, it has an amazing ability to regenerate itself. It can suffer immense damage, nearly die out, then recover and allow many more years of life.
 
To help us discuss liver damage, we look at ‘hepato’ from the Greek ‘hepar’ or liver. Thus, the words ‘hepatocellular’ meaning cells of the liver, and ‘hepatitis’ referring to inflammation of those cells. Hepatitis can cause cirrhosis (liver scarring), liver failure, liver cancer and death.
 
The classic forms of hepatitis (yellow jaundice) are caused by the hepatitis viruses, A, B, and C.  Hepatitis C is particularly aggressive but thankfully there is now a drug that can kill this virus.
 
Toxins and chemicals can also cause hepatitis, the most common being drinking alcohol and acetaminophen (Tylenol). The combination of both is especially toxic. Other commonly used medications that can damage the liver include aspirin, cholesterol drugs called statins, anti-seizure meds like phenytoin (Dilantin), ketoconazole, some antiviral drugs, and anabolic steroids. If you take these prescription meds, do not stop. Instead talk to your doctor if you have questions.
 
Unknown to many people is the fact that even some herbs and supplements, used excessively, can cause liver damage. Comfrey, black cohosh, aloe vera, cascara, kava, and chaparral are just a few; even vitamins taken in quantity have poisoned the livers of children who mistook them for candy.
Regrettably, in our obese society, fatty liver is fast becoming one of the most common forms of liver damage. Fatty infiltration of the liver cells causes inflammation. NASH (nonalcoholic steatohepatitis) is the worst form of this. There is no medication; the only known cure is significant weight loss.
A simple blood test can reveal if your liver enzymes are in the normal range or if they are showing inflammation. The liver may be underrated, but please do not ignore it. Schedule your annual exam and talk to your doctor about your liver. Catch problems early and you might prevent long-term complications.
 
Kenneth A. Bartholomew, M.D. is a contributing Prairie Doc® columnist. He practices in Pierre, South Dakota and serves on the Healing Words Foundation Board of Directors, a 501c3 which provides funding for Prairie Doc® programs. 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 been spending a lot of time talking with patients about the COVID-19 vaccine. Sometimes we celebrate being fully vaccinated. Some patients are skeptical about how serious COVID-19 infections actually were. And others are not convinced they can trust the vaccine.
 
When I talk to the first group, we chat about our plans to reunite with people and activities we love. With the second group, I share stories of my firsthand experiences as a doctor during this crisis. We talk about interpreting death rates, how death certificates are filled out, or how health care is reimbursed.
 
I particularly enjoy the conversations with the third group, many of whom share some of the same questions I had. I did not believe, at the beginning of the pandemic, we could possibly have a vaccine by the end of 2020. How could a vaccine for a brand-new disease be developed so quickly?
 
There are two lessons beautifully illustrated by the lightning-fast development of the COVID-19 vaccines. The first is what can happen when money is no object. The typical process of drug development involves a relatively small investment for initial testing, investing a little more only if those results are encouraging, rinse and repeat. With the COVID-19 vaccines, all needed funding was available almost immediately.
 
The second lesson is the importance of past research. Other coronaviruses caused outbreaks of SARS (severe acute respiratory syndrome) in 2003, and MERS (Middle East respiratory syndrome) in 2012. Researching these deadly infections taught us how coronaviruses invaded human cells, so we knew that the spike protein was a good target for a vaccine. Developing a vaccine for Ebola taught us how to safely edit the genes of a less harmful virus and use it to teach our immune systems to fight a more serious infection. Thirty years of mRNA research led to clinical trials of mRNA-based cancer therapies, and investigation of mRNA vaccines for influenza, rabies, and Zika. All this research and technology was used in COVID-19 vaccine development.
 
Chinese scientists published the genetic code for the virus in January 2020. Within days, using all that previous knowledge, researchers began production of vaccines. When the clinical trials began, the pandemic was raging, and many trial participants were exposed to COVID-19 over a short period of time. Trials could proceed faster than usual because when lots of people are getting sick, it doesn’t take as much time to determine if a therapy, including a vaccine, is effective.
 
Were the COVID-19 vaccines developed in record time? Yes. Because money was no object, and because 30 years of scientific research and development left us poised to succeed.
 
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.

I was sitting in my beach chair on vacation soaking up the sun when I overheard the couple next to me sounding concerned. They were throwing out lots of big medical terms but were very confused and said that they did not understand anything that they read on this MRI report. I turned to them, apologized for eavesdropping, and introduced myself as a physician. I offered to “translate” what the radiologist report said, and they gladly accepted. 

Their problem was not a lack of information. They had access to the patient portal and were able to download the MRI report and the physician’s notes. All this information was written in medical terms, acronyms, and shorthand with a few words in Latin and Greek sprinkled in. What they lacked was clarity and understanding.

So, I sat there on the beach and translated the report into layman’s terms. The family was grateful, and I was happy to help ease their minds. This was not what I had planned to do on this beautiful day at the beach, but it was rewarding to be able to use my knowledge and skills to help them get some clarity. However, it was disheartening that they had to rely on help from a stranger who happened to overhear their discussion about arteriovenous fistula.   

The medical record is written by doctors to communicate to other doctors and is full of terms and jargon that are not used by most people. Having access to this information is good, but when taken out of context or the relationship of a visit with a physician, information can cause more confusion and unnecessary anxiety.

To quote Takeda Shingen, “Knowledge is not power, it is only potential. Applying that knowledge is power. Understanding why and when to apply that knowledge is wisdom!” Years of medical school, residency, and continuing medical education help doctors gain knowledge, understanding, and hopefully, the wisdom to communicate effectively with our patients.

A worthy health care team welcomes and encourages questions, eager to give you the best information possible. We want you to know what is going on with your health, and to fully understand what all the labs and tests mean.
If you ever feel like this family on the beach, my recommendation is to contact your physician or health care provider and ask for more time to discuss your health status. Doctors on the beach everywhere will thank you, as we relax and enjoy our time with our family knowing that your family is well taken care of.
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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.
 
My last conversation with Grandpa was over the phone. He was sick and dying. I was 1,200 miles away in residency, learning how to be a family physician. I was not going to make it home in time to see him one last time.
 
We did not know exactly what was wrong. Sure, he could have had more tests and been admitted into the hospital, but that was not what he wanted. Thankfully, a family friend and physician had talked to my grandparents about their end-of-life goals. This discussion helped Grandpa realize what was important to him, like his faith and being with Grandma, and what was not, like spending time in doctor’s offices and hospitals. 
 
Even though I was a physician in training, I supported his choice. He was in a peaceful place, listening to music, talking with Grandma and other friends and family. 
 
Most people want to die at home. However, only 20 percent do. When it comes to dying, some advance planning may make a world of difference. 
 
It does not require an official document or appointment with a lawyer to make plans for how you would like to spend your final days. It does not even necessitate a visit with your doctor, although all the above may help. The most important thing is talking to your loved ones about your wishes and goals of care.  
 
How do you know when to have this talk, how to bring up the topic, and what to say during the conversation? How and when do you say “enough is enough” when it comes to searching for a cure, a surgery, a treatment, or spending a few more nights in the hospital? Discussing these questions may not be easy, but it is more productive and less stressful to have the conversation now rather than during a crisis.
 
Start with scheduling an appointment with your doctor for the sole purpose of talking about your end-of-life goals, expectations, and values. Then, together, adjust your care plan accordingly. Revisit these discussions periodically with your family and your healthcare providers. 
 
It was tough not being there with Grandpa, but he was at peace, so I was at peace. This past year, many others have had to say goodbye remotely or did not even have the chance. This is a reminder for us all to have meaningful conversations, to tell our loved ones how much they mean to us, and to cherish the time we do have together. 
 
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.