By Richard P. Holm, MD
 
As I was researching the history of Native American health care, I took note of the various terms used early on by indigenous people to describe European immigrants. Initially, the references had to do with skin color. Several tribes labeled Europeans as “white skinned,” or “yellow-hided.” Some tribes still use the term “umsewah,” meaning “bleached wood.” 
 
Other tribes described Europeans as “hairy mouthed,” “hair faces” and “dog faces,” referencing facial hair on European men. Ears were also important in naming. One tribe characterized the immigrants as “ears sticking out” because they did not have long hair covering their ears as did Native Americans. Some say that the ear label referred to that tribe’s word-meaning for donkey or mule.
 
As time went on, Native Americans began to describe Europeans based not only on how they looked, but on how they behaved. A Lakota word for Europeans is “wasichu,” which means, “taker of the fat, or a greedy individual.” Recognizing the transgression over the last two centuries, I can’t blame the Lakota for choosing the label, “wasichu.”

These Native American words reflect the impact of two cultural world’s colliding and reveal a disharmony resulting from the loss of access to traditional hunting and farming lands, the loss of family and language as children were shipped to boarding schools, the loss of self-respect with isolation on the reservation and much more.  The result of all this has been decades of health disparities. For example, American Indians are 50 percent more likely than white people, to have a substance abuse disorder, 60 percent more likely to commit suicide, twice as likely to smoke cigarettes or to die of childbirth, three times more likely to die from diabetes and five times more likely to die of tuberculosis.
 
But change is coming. Revered Oglala Lakota medicine man, Black Elk, prophesized that with the seventh generation following the tragic Wounded Knee massacre of 1890, Native American people would begin to recover from the historical trauma experienced since the collision of these cultures in the mid-19th century.
 
From 1890 to 2020, that’s one hundred and thirty years. Divide that by seven and, right now, you have 19-year-olds who constitute that seventh generation. It’s time for those of us with ears sticking out and those without, people of all skin colors and cultures, to create an environment that allows all people to come out of poverty and help make positive changes in Native American health care.
 
Richard P. Holm, MD is founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.     

 By Richard P. Holm, MD
 
Standing in front of a group of De Smet Parent Teacher Association® (PTA®) members, I was to play a trumpet solo. My teacher thought I was prepared, but unfortunately, I was not. My fears brought my heart up into my throat, I became short of breath, my heart pounded and, indeed, I stumbled and had to start over again. Although my failings were likely amusing to some in the audience, they were certainly not indicating any musical skills. It was a devastating experience for me.  
 
During our lifetimes, all of us experience physical and psychological ailments. People will admit to physical trouble but don’t like to admit to psychological problems, and most of us are reluctant to ask for help. Many of these feelings increase adrenaline levels which, in turn, cause fast heart rate, shaking, shortness of breath, dizziness, diarrhea, urinary frequency, sleeplessness, headache, sweating and generalized discomfort. Sometimes these feelings of anxiety are normal, and sometimes not.
 
A reasonable level of anxiety can keep us driven to hunt for food, fix something, discover another frontier and improve what we can improve. Without stressors and the anxiety that follows, some experts believe we would become lazy, stop dealing with troubles and civilization would end. On the other hand, when feelings of anxiety expand out of proportion to the trouble we are facing, or come on easily and frequently, anxiety can sometimes interfere with a normal functioning life. Too much anxiety can be harmful to an individual.
 
We are all thrown off-balance by one kind of psychological challenge or another as we struggle through the typical encounters of daily living. Who hasn’t experienced periods of anxious moodiness that follow the reduced sunlight of winter, or anxiety following the loss of a job or facing the demands of a new job? How does anyone handle a severe illness in a child or a spouse? Who can deal with divorce without anger, disappointment and, you guessed it, anxiety? Life is often very difficult; every individual will confront stressors in different ways and sometimes we just need help.
 
Bottom line: Each of us must deal with our own physical and mental illnesses throughout our lifetime, sometimes minor, like forgetting a trumpet solo, sometimes major, like a prolonged sense of anguish after a death in the family. When our ability to live a normal life is being interrupted by anxiety, it’s time to see the doctor.
 
Richard P. Holm, MD is founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. 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 Deb Johnston, M.D.
 
Primary care doctors do a lot of different things. We diagnose illnesses from the trivial, to the catastrophic. We treat maladies both chronic and acute. We confront, and we console.
 
Of course, these are common roles in medicine, filled by many different providers. One role the primary care physician is more uniquely suited to fill, however, and one of my personal favorites, is that of guide. I’m talking specifically about the art of prevention, of maintaining wellness over the long term, and reducing the risk of diseases that might make it harder to do what you need to do, what you want to do, what you love to do.
 
Prevention is truly underutilized. We’re a lot better at looking for a problem, and a pill or a procedure to fix it, than we are at fixing what might lead to a problem in the first place. In fairness, human beings are inclined to wait for the crisis to hit before we believe it is really and truly ahead. Changing habits is hard and eating takeout pizza while watching must-see TV is a lot less work than hitting the gym and making a salad.
 
On the other hand, some parts of prevention are easy. It’s easy to get a flu shot, or a shingles shot. It’s easy to get a mammogram, or a colonoscopy. It’s easy to get blood drawn, and get checked for diabetes or hepatitis C.  
 
Of course, it’s only easy to do these things if you are aware of the benefits of doing so. This is the value of the annual checkup. From birth, to your last birthday, wellness visits have an important role. 
 
For infants and children, we monitor growth and development. For adults, we screen for diseases, and give advice on reducing risk factors that might lead to disease. Even the oldest of our old can benefit from simple tests for things such as hearing and memory. At every age, we think about safety: is that infant sleeping on her back? Is that teen wearing his seatbelt? Is that adult drinking and driving? Is that elderly person at risk for falls? Has that patient received their flu shot? 
 
Under the Affordable Care Act, most insurance programs cover prevention visits with no copay. This even includes Medicare. Everyone can benefit from these opportunities to focus on staying well, rather than treating problems. 
 
Prevention is an important part of being a primary care doctor, and an important reason to HAVE a primary care doctor. So, take your preventative action today, make a call and set up an appointment, just for that checkup. 
 
Deb Johnston, M.D. is a contributing Prairie Doc® author who has practiced family medicine for more than 20 years. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPTV most Thursdays at 7 p.m. central.      

By Kelly Evans-Hullinger, M.D.
 
It’s the dead of winter, and who among us isn’t craving the feeling of warm sunshine on our skin? I, for one, am dreaming of summer days spent outdoors, not a care in the world, basking in that delicious ultraviolet light. But alas, I must be my own physician buzzkill (maybe in this case, sun-kill), and remind myself that there is more to those rays than the pure delight I am romanticizing.

The truth is, there is technically no “safe” amount of UV exposure when it comes to our skin and the risk of skin cancer. One in five of us will have a skin cancer diagnosed in our lifetimes, and while many types of skin cancer are not life-threatening, some are. Melanoma, in particular, is a skin cancer with great potential to metastasize and ultimately take lives. Like other skin cancers, ultraviolet exposure is a major risk factor for melanoma.
I can recall one summer day when I was 13, I fell asleep on a July day watching a cousin’s baseball game. My fair-skinned back was exposed to the sun, unprotected, leaving me horrendously sunburned in the days that followed. I will never forget those next few days, one of which I spent carrying my golf bag on a hot, humid tournament day, my back covered in blisters. The thought of it now is enough to make me cringe.

And let’s not forget it doesn’t have to be a hot summer day to incur skin damage. Many of us have been surprised with a sunburn sustained while skiing or ice fishing – sun is sun, whether the temperature is hot or cold – and even on a cloudy day those UV rays make it down to Earth. And don’t get me (or your friendly dermatologist) started on the risks posed by tanning beds.

Protecting one’s skin from the sun is something we can all do to stay healthier. There are a variety of ways to do this: Avoiding sun entirely or staying in the shade, wearing protective clothing like long sleeves, pants, and a wide brimmed hat, physical sunscreen like zinc oxide, or chemical sunscreen – the experts recommend at least SPF 30 applied every 2 hours.
​
I still love summer. I love being outside for hours, sweating in the sun. But these days you’ll find me with SPF 50 applied before I leave the house and carried along at all times for reapplication. 

Kelly Evans-Hullinger, M.D. is a contributing Prairie Doc® columnist who has practiced internal medicine for the past four years in Brookings, S.D. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPTV most Thursdays at 7 p.m. central.        

By Richard P. Holm, MD
 
It’s a holy place when a patient is taking their last breath. For the most part, I’ve tried my best to give comfort at that time. There are many who have stated, “There are worse things than death.” One study in 2016, asked end-stage patients about dying and found that more than 67 percent stated that “needing a breathing machine” was a condition worse than death.
 
Mr. B was an 84-year-old retired farmer who had been struggling with chronic obstructive pulmonary disease (COPD). This condition is related to the loss of ability to exhale normally, which, in turn, is due to the destruction of tiny alveoli which are oxygen and carbon dioxide exchange units. This results in large unfunctional pockets of air which block the flow of air going out.
 
He had smoked and had extensive exposure to toxic farm dust throughout his life, and now he was on continuous oxygen therapy and couldn’t do anything without running out of breath. He had been on pulmonary rehabilitation (exercises to stay in shape), a low carbohydrate diet, metered dose inhaler (MDI) bronchodilators and repeated antibiotics for a few years. This was the third time he was hospitalized in the last two months for “exacerbation of COPD.”
 
He was suffering from a worsening of his lung disease with the added challenge of bacterial pneumonia. His oxygen levels were dropping, and survival was going to require a breathing machine (intubation). He had been intubated over several days during his previous hospitalization and this time, he did not want it.
 
His wife had died a year earlier, all siblings had passed away, but his only child, a son, lived nearby. I will never forget the conversation the three of us had that day. We talked about Mr. B’s poor quality of life. His options were either to be intubated again or to go with comfort care using an opioid. Mr. B realized death was likely, as did the son. Mr. B said, “Let’s try the comfort method.” His anxiety and shortness of breath were reduced immediately after making that choice, and over the next two hours, as the pain medicine kicked in, Mr. B slipped away with his son at his side.
 
This is very serious business, and I usually encourage people who are aware of their situation to fight on, but Mr. B was very tired of fighting for breath. He was ready to let go. In his case, “needing a breathing machine” was a condition worse than death. After his last breath, he finally found relief.
 
Richard P. Holm, MD is founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.                

By Richard P. Holm, MD
 
I came down with an unrelenting sore throat about 15-20 years ago. For years I have tried to be discreet in prescribing antibiotics in most of my patients, for fear of causing resistance in bacteria to the antibiotics. I did for me what I did for most of my patients, which was to avoid the antibiotics. However, after a week the sore throat was getting worse, it was starting to keep me from opening my mouth normally and I was running a fever. I called my friend, an ears, nose and throat doctor who practiced at our local clinic with me.
 
He squeezed me into his schedule and took a look at my throat. I noted his eyes got a little wide and then he got up and left the room, returning with a large syringe attached to a big bore needle. It was so quick I didn’t have time to resist and he placed that huge needle into my throat, stabbed the left tonsil, and came back with a syringe full of brown liquid. He smiled and said, “You have a peritonsillar abscess.”
 
I had pain localized to the left side of my throat which was made worse with swallowing and which was suspicious for peritonsillar abscess. Other symptoms that could indicate such a diagnosis include swollen tonsil or tonsils, uvular deviation away from the abscess, a mouth that doesn’t open fully, purulence of one or both tonsils, drooling, swollen neck-lymph nodes and finally, a muffled voice.      
 
Usually there are two organisms growing which makes this condition a double threat. If the infection is allowed to spread, the invasion of many layers of neck tissue can occur which leads to a progressive extension of the infection into deep tissue and possibly a dismal death. The infection can also spread to the other tonsil, which, when swollen and pushed up against the opposite swollen tonsil, can block air flow and cause death from suffocation.
 
My doctor immediately sent me down to an infusion room and started the daily intravenous dose of an antibiotic that would be repeated daily for a week. This was not the first time or the last that antibiotics saved my life. Following this experience, I looked much more carefully at every patient with a sore throat, and, although I was still careful about over-prescribing antibiotics, I prescribed antibiotics more often for swollen and ugly tonsils after that.
 
Richard P. Holm, MD is founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.          

By Richard P. Holm, MD
 
It was in London, England, 1854, when a severe diarrhea illness caused the deaths of 500 adults and children over a ten-day period and proved the value of scientific thinking. Physician-scientist John Snow mapped out the locations of those sick, and his work pointed to water from a hand pump well on Broad Street as a possible cause of the illness. He persuaded authorities to shut down the source by removing the pump handle from that well. Shortly thereafter, deaths from the illness abruptly slowed and scientists became convinced of the danger of this contaminated water.
 
Over the next years, scientists identified Vibrio cholerae bacteria as the cause of that illness in London. The original pump is still there on what is now Broadwick Street, commemorating what is thought to be the founding event in the history of epidemiology, the science of understanding epidemics, infections, and patterns of illnesses in populations.
 
The word cholera comes from the Greek word which means “yellow bile,” from an ancient and misinformed idea that all illnesses are from an imbalance of yellow bile, phlegm, black bile or blood. We know today there are many causes for infectious diarrhea including viral, bacterial, and parasitic. In the mid-1800s with the aid of the newly discovered microscope, we came to realize how to categorize bacteria, and that cholera was likely responsible for many of the pandemics throughout history. Sadly, despite all our present accumulated knowledge, human diarrhea from cholera persists today in developing countries, mostly the result of polluted water.
 
Cholera can kill within hours if left untreated. It causes severe vomiting along with three to five gallons of “rice-water” diarrhea per day resulting in severe dehydration. Unfortunately, highly infectious fecal material can too easily get into the water supply spreading the infection, especially to the very young, old and immunocompromised. More challenging is that 75 percent of people infected with cholera may not have symptoms but can still carry and spread the infection for two weeks after exposure.
 
Boiling all water before drinking would prevent the spread of all water-born illnesses. Rehydration and antibiotics are initial interventional therapy for cholera. However, too often, these preventions and treatments are not easily available in developing countries. The World Health Organization, an arm of the United Nations, estimates that, each year, three to five million cases of diarrhea and more than 130,000 deaths are still due to cholera.
 
The science of epidemiology began by discovering the water-source of a dangerous diarrhea illness and we learned how, by simply removing a pump handle, we could prevent illness.
 
Richard P. Holm, MD is founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central. 

By Richard P. Holm, MD
 
I believe that honesty is almost always the best policy. However, there are some topics people don’t want to talk about. The whys, how’s, dangers and wonders about sexuality is a topic that is still covered up today, but these issues were much more suppressed years ago. Growing up in the ‘50s and ‘60s in a small prairie town, I was immersed in conservative values. Cover up was the operating agreement for our farming community at that time.
 
To discuss, in mixed company, methods to satisfy a partner sexually or to openly talk about lesbian, gay, bisexual, transgender, queer (LGBTQ) issues would have been disturbing at that time. This is not to say that kids didn’t wonder, in private, about their sexuality, or that they did not experiment with sexual activity, but the cover up and almost denial of human sexuality was as much of the culture as was going to Sunday school.
 
One can say that our civilization is more open now and I believe this honesty is helpful in many ways. For example, in recent years, LGBTQ individuals have been making their way out of the closet. Thanks to more openness, misinformed myths have been debunked by studies showing that sexual orientation has nothing to do with harming children, being a poor parent, or abusing another. Unfortunately, unethical behavior and abuse can be found in every corner of our society regardless of sexual orientation…straight, gay and everywhere in between. Openness enhances understanding, while suppression and cover up can demonize good people and even serve to protect those who abuse others.
 
Sexual function is necessary for our species to survive but it can be much more than that. Treating each other with kindness brings mutual respect. Treating each other with honesty brings trust. Treating each other with reverence for the other person’s right to choose brings the liberty to truly love in return. That said, sexual relationships can be complicated. Sometimes hurtful activity can be unintended and may result when one party is not observant or considerate of the other person’s feelings. Conversely, it is also a form of cover up when one party fails to communicate his or her hurt feelings, thus allowing the harm to persist. Certainly, learning to change in order to accommodate our partners, along with large doses of forgiveness and open communication, can help make relationships work.
 
Bottom line: The closeness and joy of sexuality in our society and between individuals is greatly enhanced when we treat each other ethically, savor the respect, liberty and trust that follows and throw off the cover up so we can all learn and grow.
 
Richard P. Holm, MD is founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.                

​By Richard P. Holm, MD
 
Mrs. B came into the emergency room one night, years ago, with some stress related issue. After taking her history, I began to suspect there was something else bothering her. As I was beginning her physical exam she blurted out, “I know there is a breast mass but you’re not going to send me to any breast cancer doctor!” She had already decided to avoid standard treatment and her next comment explained why, “My aunt suffered because of awful unnecessary surgery and chemotherapy,” she said. I sensed there was no changing her mind and that meant trouble for my patient.
 
The story evolved as my patient’s breast cancer grew and eroded through her skin to become a weeping and tender sore. She soon sought out unconventional treatment by a non-physician from a neighboring town with an internet degree of some kind who promised to help her. The treatment involved a curious machine with flashing lights and an unusual noise which apparently indicated which group of herbal supplements the patient needed to buy in order to cure the cancer “naturally.”  
 
More women are diagnosed with breast cancer than any other malignancy, except for skin cancer. If the breast cancer hasn’t spread outside of breast tissue, then, with treatment, the five-year survival is about 99 percent. If the cancer has spread to lymph nodes just outside the breast, then, with treatment, the five-year survival is about 90 percent. Even if the cancer has spread to distant parts of the body, which happens only in about six percent of the cases, then, with treatment, more than 25 percent are still alive after five years. Since 1989, the number of people who die from breast cancer has been steadily decreasing which is the direct result of improved methods for breast cancer screening, detection and treatment.
 
My patient died less than a year from our meeting in the emergency room. I still regret not convincing her to get help from a science-based breast cancer physician. She may have lived years longer and in more comfort. Many people are now being saved who were previously lost to all types of cancers. Even when lifesaving is not possible, current cancer treatment can at least improve the quality of the time that remains.  
 
Bottom line: The fear of death and the fear of suffering keep some people from seeking medical help. Please shed those fears and seek science-based help.
 
Richard P. Holm, MD is founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central. 

By Richard P. Holm, MD
 
During one of our weekly hospice meetings, the discussion turned to the burden of finding an opening in a facility for one of our patients. Mr. A belongs to the working-poor segment of our society, just above official levels of poverty and yet he cannot afford health insurance and primary care, let alone the private cost of an assisted living center or nursing home.
 
Our patient is still living at home, has no family support and is in trouble. His progressive cancer has caused an inability even to do activities of daily living such as bowel and bladder care. He now only has Medicaid and his hospice nurse and social worker is not able to find an assisted living center or a nursing home that will take him in.
 
It’s no surprise that care facilities in South Dakota find it financially difficult to accept Medicaid patients like Mr. A. Without Medicaid expansion, facilities lose money when caring for them. If a nursing home has too many Medicaid patients, it simply can’t stay afloat. This explains why nursing homes, especially in rural areas, are closing.
 
The national solution was to expand Medicaid coverage to increase payments for services using federal dollars. Some states initially elected not to expand Medicaid, for fear they would become dependent on this money. However, many states have changed their position, and to date, 36 states now accept the national funding from expanded Medicaid, including North Dakota as of 2014, and Nebraska in 2018. So far, 14 states have not expanded Medicaid, including, South Dakota, Kansas and Wyoming.
 
If Medicaid was expanded in South Dakota, more than two billion dollars of federal health care funding would come into the state, helping healthcare coverage to 55,000 South Dakotans, in turn, helping to prevent rural nursing homes from closing. This would help Mr. A, and people like him, get comfort care during their dying days.
 
Medicaid expansion passed last year in some majority Republican states indicating that this is a bipartisan issue. A recent poll revealed that approximately 80 percent of South Dakotans want Medicaid expansion. In my opinion, fearing dependence on federal money does not justify letting our rural nursing homes close or letting the working-poor go without care.
 
Bottom Line: It is time for those within the political arena to expand Medicaid.
 
Richard P. Holm, MD is founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. 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.