​Prairie Doc® Perspectives for week of September 19, 2021

By Kelly Evans-Hullinger, M.D.
 
It is September, fall is in the air, and what we might call “respiratory season” is nearly upon us. Respiratory season refers to the colder months in which we spend much of our time indoors, maybe October through March. Normally, this season correlates with when we see high rates of typically seasonal respiratory infections such as influenza and respiratory syncytial virus or RSV.

Living through the COVID-19 pandemic has given us knowledge we can use to greatly decrease the spread of all respiratory infections. During the 2020-2021 respiratory season, rates of influenza were at historic lows in South Dakota and across the country due to the measures we took to decrease the spread of COVID-19. So, what are the lessons learned?

First and foremost, we should learn that when we are sick with respiratory symptoms, we should avoid spreading our illness to others. It remains essential that anyone experiencing symptoms of cough, fever, or cold symptoms be evaluated and consider testing for COVID-19, influenza, and possibly other infections to ensure avoidance of spread.

Second, if you are sick, even if you have tested negative for COVID-19, try to avoid spreading germs to others. We should especially avoid contact with those most vulnerable to respiratory illnesses – this includes the very young and the very old and those who have suppressed immune systems or chronic lung disease. If you must be around others, keep distance when possible, cover your mouth and nose when coughing or sneezing, and at best, wear a mask to keep those respiratory droplets out of the air. I now cringe to think of years past, when I would power through my common colds and see patients without a mask. I know I can do better in the future.

Finally, vaccines remain one of our best tools for infection prevention. Of course, vaccination against COVID-19 is crucial and has proven to be highly safe and effective. But let’s not forget other respiratory vaccines. It is time to think about getting your annual influenza vaccine. And if you are 65 years old or more, or if you have any medical problems increasing your risk for bacterial pneumonia, you should ask your healthcare provider about a pneumococcal vaccine.

We have the tools to keep ourselves and others healthy during the respiratory season. I, for one, hope that lessons learned during a respiratory viral pandemic might help us all do better in the future.
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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. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc® a medical Q&A show celebrating its twentieth season of truthful, tested, and timely medical information, broadcast on SDPB and streaming live on Facebook most Thursdays at 7 p.m. central.                     

​By Debra Johnston, M.D.
 
What I remember most is the silence.
 
She was 19 years old, just starting her first semester of college. She had been transferred to our level 1 trauma center, intubated and in a medically induced coma. I was a third-year medical student, being introduced to the realities of medicine. Our team was clustered around her in the procedure room adjacent to the ICU while my senior resident inserted the central line we would use to quickly administer large volumes of medicine and fluids. 
 
ICUs can be busy, noisy places. This ICU was a large open room, with rows of beds surrounded by all the equipment needed to care for critically ill and injured patients. The sounds of machines whirring and beeping, of doctors and nurses and all the support staff, accompanied us in that little windowless procedure room.
 
The neurosurgery team solemnly filed through the door, eyes grim. They’d reviewed her CT scan. The pressure of the blood accumulating inside her skull had forced the base of her brain downward, into the space usually occupied only by the top of the spinal cord. We stared at each other in silence. We’d already lost the battle.
 
During the next few days, I watched her 20-year-old sister support their parents as we walked through the process of declaring brain death and deciding on organ donation. Other than the silence, the sister’s grief, and her courage, are my most potent memories.
 
Over the years, I’ve seen many lives irrevocably altered by brain injuries. Children thrown from their bicycles. Soldiers caught in blasts. Women battered by their partners. Seniors who slip and fall. Some patients fight to regain skills that were once effortless. Some succumb to their injuries or the consequences. The lucky ones sometimes don’t even realize how close they came to having their lives upended.
 
Our ability to help has improved significantly in the nearly 30 years since I stood at that young woman’s bedside. People survive injuries that would have previously been fatal. People recover enough to rejoin the community, instead of finishing their days in nursing homes. Nevertheless, too many still die, over 50,000 Americans every year. Nevertheless, survivors spend months relearning basic skills with the help of skilled therapists. Nevertheless, millions live with varying degrees of disability, despite aggressive rehabilitation.  
 
As with so many things, the best treatment is prevention. Buckle your children into their car seats. Use your seatbelt. Wear your helmet. Keep the guns locked up. Learn how to reduce the risk of falls, especially for the young, and the old. It’s much better to protect that fragile brain, than to try to put it back to rights.   
 
Debra Johnson, M.D. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc® a medical Q&A show celebrating its twentieth season of truthful, tested, and timely medical information, broadcast on SDPB and streaming live on Facebook most Thursdays at 7 p.m. central.                     

By Jill Kruse, D.O.
 
The kidneys may be called the Rodney Dangerfield of the body, as they often “don’t get no respect.” The National Kidney Foundation estimates that one in three adult Americans are at risk for kidney disease, yet these organs are mostly ignored unless they develop stones or stop working.

When healthy, kidneys work continuously at their main job of filtering blood to remove unwanted products and help produce urine. Kidneys clean approximately 200 liters of blood each day removing up to two liters of toxins, waste, and water in the process. Perhaps less well known is the fact that the kidneys are essential for many other functions in the body as well, including managing blood pressure and preventing anemia.

Kidneys release the hormone renin which is part of the complex renin-angiotensin-aldosterone system, or RAAS, instrumental in helping regulate blood pressure. RAAS regulates sodium and potassium absorption in the kidneys and balances fluid and electrolyte levels in the body, all of which have a direct impact on blood pressure.

When treating patients whose blood pressure does not respond to medications, heart doctors will examine RAAS function. They may also order an ultrasound of the kidneys. Sometimes this reveals a narrowing of the artery going into the kidneys which may be responsible for treatment-resistant high blood pressure.

Kidneys also secrete a hormone called erythropoietin which acts on bone marrow to help the body produce red blood cells. Without this hormone, people can develop anemia.

Vitamin D is converted to its active form by the kidneys allowing the body to use the vitamin to its advantage. Thanks to the kidneys, vitamin D helps balance calcium and phosphorus absorbed from the foods we eat. Without enough calcium, people can develop weakening of the bones and muscles.

Kidneys complete these and many other functions so efficiently that a healthy person can donate one and the remaining kidney will do the work of two. They work hard to help us, so let’s do our fair share to help them. If you have diabetes, work to control it as best you can because high blood sugars can damage your kidneys. And one thing all of us can do for our kidneys is to stay hydrated.

There is no doubt that kidneys deserve more respect. Talk to your doctor about blood tests or urine tests to check your kidney’s health and functionality. Kidneys…let’s show them some respect!

Jill Kruse, D.O. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc® a medical Q&A show celebrating its twentieth season of truthful, tested, and timely medical information, broadcast on SDPB and streaming live on Facebook most Thursdays at 7 p.m. central.                     

​By Andrew Ellsworth, M.D.
 
This summer I attended the celebration of life service for Dr. Rick Holm, the original Prairie Doc who founded this newspaper column, a radio show and a television show now entering its twentieth season. He died from pancreatic cancer in March of 2020 during the early days of the Covid-19 pandemic and thus there was no public service at the time.
 
Many friends and family gathered to celebrate Rick. We sat on lawn chairs, shared tales, and sang songs in a beautiful park on a gorgeous evening. We recalled stories of him being notoriously late, knocking over wine glasses with his large hand gestures, and mistakenly eating potpourri thinking it was trail mix. Themes emerged of Rick’s amazing ability to accomplish so much in a day, his skill for active listening, and his passion for finding the best in people. 
 
His children shared memories of their dad, including their family bedtime prayer “Help us to be kind and honest and respect people’s choices, and help us to be better people tomorrow.” Rick crafted that prayer from the Hippocratic Oath, the promise that doctors make when they complete their training and before they begin their careers. The oath emphasizes the medical ethics principles of beneficence (to do good), and nonmaleficence (to do no harm), and the importance of patient autonomy (to respect people’s choices). 
 
Listening to the Holm bedtime prayer, I realized how the oath had taken on new meaning for me this past year as I observed people choosing to get vaccinated for Covid-19, or not. As a primary care physician, I know Rick would have recommended vaccination for all who are eligible. He was a proponent of preventative care and vaccines help prevent disease. Rick would have listened with kindness to the concerns of each patient. He would have explained with honest science how the vaccine works and how the risk of a severe reaction from the vaccine is greatly outweighed by the benefits of being vaccinated, such as reducing the chance of serious illness and complications from Covid-19. 
 
Just as my colleagues and I promise to do, Rick would have cared with beneficence for his patients that were sick with Covid-19, even if they refused the vaccine. He would have respected their choices and held their hand with no maleficence, no judgement, or condescendence. At the same time, he would have celebrated with a Snoopy dance those who choose to get vaccinated, those who choose to quit smoking, to start exercising, and to eat healthier. As we carry his legacy into another decade, we continue the message of The Prairie Doc, “Stay healthy out there, people!”
 
Andrew Ellsworth, M.D. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc® a medical Q&A show celebrating its twentieth season of truthful, tested, and timely medical information, broadcast on SDPB and streaming live on Facebook most Thursdays at 7 p.m. central.  

By Dr. Luke Mortimer, M.D.
 
I recently saw a patient I hadn’t seen in more than 18 months. This patient had previously come to me somewhat routinely for arthritic knees. Together, we constructed a conservative treatment plan to help increase activity and prolong the life of those knees. Unfortunately, the Covid-19 pandemic put a dent in our plan. Prior to the pandemic, this patient had been a borderline diabetic with some other medical comorbidities. Upon their return, we found a lot had changed. The patient had gained 30 pounds, decreased activity, and could not move about very well. We had to revise our plan based upon the patient’s current condition. I have observed, over the last few months, this scenario is not unusual.

With the pandemic, many people simply stopped moving and as a result their joint related complaints skyrocketed. This inactivity created a significant increase in pain and discomfort in those with underlying arthritis. As patients continue to return to society and have a difficult time picking up where they left off, what do we do to help them get back to their normal?

First, identifying the significance of their medical and orthopedic issues is key. Those with more combined orthopedic and medical issues may require a multidisciplinary approach amongst physicians. Success is more likely if the patient and orthopedic surgeon work together with the primary care physician to assist in management of weight, diabetes, cardiac and other issues that need specific attention. Great communication amongst providers is essential to maximize the benefit for the patient.

Second, developing a plan that will assist in overcoming these issues is the next goal. This may involve cautious use of anti-inflammatories or corticosteroid injections to help decrease inflammation. It may involve viscosupplementation or “gel” injections to assist with lubrication. Physical therapy to focus on getting specific muscle groups to unload the joint while also allowing increased movement may be a great place to begin. Walking, water walking, water aerobics, elliptical machine, bike riding, or hiking are great examples of low impact activities that promote good joint health. The overall goal is to get patients that stopped moving back to an active lifestyle. As many of my patients and colleagues say, “motion is the lotion”.

We all know the pandemic has been difficult and affected us all in different ways. Getting outside, increasing activity, and developing goals to help people get moving again is paramount for overall health. A good conversation and developing a plan with your local health care team is a great way to begin your return to wellness.
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Luke Mortimer, M.D. is a contributing Prairie Doc® columnist. He practices as a board-certified orthopedic surgeon in Rapid City and Spearfish, South Dakota and Gillette, Wyoming. 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.    

​Prairie Doc® Perspectives for week of August 15, 2021

By Debra Johnston, M.D.
 
“First day of school! Wake up! Come on. First day of school,” the little fish shouts at his dad in the opening scene of Finding Nemo. The first day of school is an important transition for students of all ages, and it is often a challenging one. That is particularly true this fall as we start yet another academic year marked by the pandemic.
 
Parents have an important role in preparing their children for a successful school year. First, start adjusting the schedule. Many families relax the rules during the summer and may be in the habit of staying up late and sleeping in. Make sure your child has time to adjust to their school year routine before that first day. Second, develop good habits by acting ahead. Having the backpack ready and clothing laid out the night before saves scrambling in the morning and reduces the risk of forgotten items. Invite your children to help decide if they want school lunch or a sack lunch and let them help pack their lunch boxes. 
 
Back to school checkups for your children provide a valuable opportunity to talk to the doctor about physical, developmental, and social changes. Additionally, children may need immunizations: boosters for tetanus and pertussis, or shots to protect them from HPV, meningitis, and Covid. 
 
The Covid vaccine is available to those age 12 and over, and I urge parents to schedule those shots if your child is eligible! Although in general children are less likely than adults to end up in the hospital with Covid, we do see previously healthy children become seriously ill and suffer complications. The jury is still out on whether the Delta variant is more dangerous to children than previous variants, but we do know this variant is more contagious, which means more people fall ill. Infected children can spread the virus to other people who may be more likely to develop serious illness. There are still many people who are not eligible for the vaccine, who have chosen not to get the vaccine, or whose vaccine may not be as effective as hoped due to underlying health conditions.
 
Many children feel nervous about the start of school and those jitters may be worse this year due to the pandemic. Talk to your children about their concerns. Help them work through “what ifs”: What if I forget to wash my hands? What if I start coughing during school? What if I forget my homework? Most adults have had practice dealing with these experiences in the moment, but we, too, can benefit from mental rehearsals. Become familiar with your school district’s plan for controlling and responding to the pandemic so you can help your child with changing conditions. 
 
With a little preparation, we can reduce stress, set our kids up for a successful year and help them be as excited as Nemo to start school!
 
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.
 
It is often said that laughter is the best medicine, yet I have never written a prescription for a funny movie, or a television comedy show, and I have no clowns or rubber chickens in my office. On the contrary, doctors are often expected to be serious and professional. Perhaps we are missing a great opportunity to help heal. What if more doctors were like Dr. Patch Adams, who is known by the medical community for his quest to inject humor and laughter into the treatment of patients? 

In medicine we work to cure disease. To cure means “to eliminate all evidence of disease.” However, there is a second goal that we also have and that is to heal. To heal means “to become whole by strengthening the mind and spirit to improve the quality of life, even if, or when, no physical cure is possible.” Laughter helps us heal. There have been multiple studies on what happens to the human body when we laugh. Research has been done on the importance of laughter from children to the elderly and no matter the age, laughter is the best medicine. 

Due to the mind-body connection, laughing can aid your brain in producing chemicals that help your heart work better and pump more evenly. Laughing can assist in reducing pain by causing the body to produce its own natural painkillers. A deep belly laugh benefits and enhances your intake of air, which stimulates the lungs and muscles. Laughter helps boost your body’s immune system to help you prevent and fight off infections. It can also lower your stress level and give you more energy. 

According to the American Heart Association, research has shown that laughing can decrease stress hormones, reduce artery inflammation, and increase your HDL (good cholesterol). Who knew that a laugh could do so much good? A study on adults age 65 and older in Japan showed that even after adjustment for high cholesterol, high blood pressure, depression, weight, and other risk factors, the frequency of heart diseases among those who never or almost never laughed was 1.21 times higher than those who reported laughing every day. In the same study, the risk of having a stroke was 1.60 times higher for those who almost never laughed compared to those who were full of mirth.

So, I will leave you with a few “treatments” to help improve your health today. Why did the pillow go to the doctor? Because he was feeling all stuffed up. Why did the cookie go to the hospital? He was feeling really crumby. Does an apple a day keep the doctor away? Only if you aim it well enough. Did you hear the one about the germ? Never mind; I don’t want to spread it around. Laughter is one medicine for which there is no maximum dose. Laugh often and well for a happy and healthy life. 
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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 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.