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.                

Richard P. Holm, MD
 
My patient was in severe pain, suffering from an obstruction in his gastrointestinal tract as a result of spreading cancer. I knew that morphine, one of the opioids, would provide immediate and merciful relief, and it did. We are thankful that we have something that can palliate pain and provide comfort for severe acute pain, especially for patients at the end of their lives. That’s good!
 
In contrast to the good that opioids can do for certain acute pain, we know they are not very effective for musculoskeletal or neuropathic pain and fail terribly in helping long term pain and chronic pain syndrome. Despite this inadequacy, opioids are still being over-prescribed for most post-operative musculoskeletal pain.
 
Also, our bodies quickly develop tolerance to opioids, thus continually requiring increased doses to get the same effect. In addition, withdrawal symptoms from opioids can be significant making it difficult to stop taking opioids once hooked. It is estimated that about 75 percent of those taking illicit opioids got started from a prescription, more than 100,000 people are regularly using heroin and about 12 million people are taking non-prescribed illicit opioids. That’s bad!
 
It gets worse. Opioids have an insidious potential for overdose which depresses the drive to breathe so much as to suffocate people to death. In the U.S., it is estimated that about 70,000 people die each year from opioid overdose. In comparison, 83,000 die from diabetes, 56,000 from influenza and pneumonia, 47,000 from suicide and 40,000 from motor vehicle crashes. That’s very bad!
 
Ultimately, care providers need to prescribe opioids very judiciously and people must be careful when taking prescribed opioids. AND people need to avoid dangerous illicit forms. We do have an antidote to opioid overdose called naloxone (or Narcan®). If given soon enough, it displaces the opioid from the brain pain receptor and the victim starts breathing again. Thus, every ambulance and emergency room have multiple doses of this lifesaving reversal agent readily available.
 
Unfortunately, in response to this opioid epidemic, the drug manufacturer of naloxone, which costs 50 cents to six dollars to make, raised its price up to $4,000 for a dual pen auto-injector. Fortunately, a generic version will be available soon with a two-pack of auto-injectors for $180. Until then, we pay the higher price. That’s ugly!
 
Bottom line: If we hope to find help for this crisis, we need to understand the good, the bad and the ugly about opioids.
 
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                                                      
 
This week I spent some time exploring the origins of the word, kind: It comes from Old English gecynd (YEH’-kund) or cynn (kyn), meaning nature, race, family. Another Old English word kyndnes (KIND’-nes) means “nation,” which I interpret as a subtle and ancient nod toward kin, kinship and our common bond in support of our country. Modern dictionaries define the word kindness as the quality or state of being generous, helpful, caring and giving. Synonyms include tactful, good hearted, neighborly, forgiving and gracious.
 
Sometimes I only understand something when I explore it’s opposite or antonym. For example, I had to think about mental illness to better understand mental health; about hate to better understand love; about depression to better understand joy. The antonyms of kindness are words like mean, cruel, malicious, spiteful, malevolent, even despicable.
 
Where is the intersection of kindness and medicine? In years past, admission committees for medical school have searched hard to find the very smartest college graduates and they were able to do it. Certainly, physicians need the intellect to understand the complexity of human health and continue a lifetime of learning. However, we have realized that searching for students by intellect alone might graduate medical students who don’t always develop good bedside manners and a capacity for compassion. More recently, some of the best medical schools have added kindness and compassion programs to their curriculum.   
 
I didn’t have the benefit of such a program when I went to medical school, however, over my 40-year medical career, I’ve learned to recognize the healing power of kindness in medicine. I’ve seen it in the nursing staff caring for folks living in a small-town long-term care facility. I’ve heard it from medical providers, nurses and technicians caring for people in clinics, ERs, hospitals and in hospice programs. I’ve heard it from kind supportive friends who have offered or driven me for chemo; from jolly laughing buddies who raise my mood; from my care team as they gently hook me up for my next infusion; from our kids who call to check on me; and from my loving wife who is at my side warming me when I’m chilled, picking up my burdens with unending daily kindnesses as I struggle through these side-affects. It’s a good thing she doesn’t love me for my hair.
 
I am happy that our medical schools are teaching young doctors that people deal with illness so much better when it comes with a generous dose of kindness.
 
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.                

​Prairie Doc® Perspectives for week of December 1, 2019
How to Live 40 Percent Longer
By Richard P. Holm, MD
 
“Doc, I’ve started on this new diet and I wonder what you think,” said my patient. Then I hear about the patient’s latest weight loss plan. There are so many plans out there...the Noom® plan, the Shark Tank diet, the keto diet, the Mediterranean diet, the paleo diet, the sugar-free diet, the low-carbohydrate diet, the one day a week fast. Some diets increase the intake of water, of fiber, of antioxidants and the list goes on. Many of these new plans are variations of a low-carb plan, which I like. I also have found that a weekly fast seems to work for some people.
 
About 20 years ago, two huge studies compared the low-carbohydrate diet with the low-fat diet. Both studies showed the same thing. People liked the low-carb diet better and with it, they lost more weight easily and initially. After one year, however, most people from both groups regained the weight they had lost. Similar studies through many years showed the same thing, no plan seems to keep the weight off long term. The two questions commonly left unanswered are, is it good to eat less, even without weight loss; and how important is exercise in all this?
 
The most powerful studies have shown that when people eat 40 percent less than what they would eat if they had no limit, they live about 40 percent longer. It is the calorie count that matters, not weight loss. Add to this the multiple scientific studies that show if an overweight person is fit and in good condition then their risks of death are no greater than for a thin person who is in good condition.
 
When people ask me, I recommend starting with three to seven days of calorie counting and exercise measurement before any changes are made. The calorie goal depends on one’s height and age, but an average sized middle-aged woman or man needs fewer than 1800-2000 calories per day for maintenance and at least one mile of walking per day. By the way, I think a balanced diet with plenty of vegetables and fewer carbohydrates makes the transition easier to tolerate and is especially good if one is diabetic or pre-diabetic. The most important point remains…fewer calories.
 
Bottom line: Setting a goal to “lose weight” puts you at risk for disappointment. For heavy and thin people alike, your best chance for success is to be mindful of your calorie intake and exercise regularly. Then, love yourself as you are.
 
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
 
Of the 40 million people with hearing loss in the U.S., 25 percent of those, or 10 million, have lost their hearing as a result of exposure to excessive noise. But how much noise is too much?
 
Measured as decibels (dB), the acceptable manufacturing noise standard is to allow a daily exposure up to but not over 85 dB in an eight-hour period. More than that can cause permanent injury to our hearing. This is likely due to wear and tear on the tiny hairs that vibrate when sound is introduced. It’s like a line of kids walking across one path on the grass day after day. A little is good, too much kills the grass.
 
The average conversation, for example, is usually around 50-60 dB, street noises at 70-80, and an operating lawnmower at about 90. Noise levels above 90 come from surprising places like screaming babies, convertibles driving at 60 mph, marching bands, leaf blowers, hand and hair driers, and those noisy electronically amplified concerts. Single loud sounds like gunfire at about 150 dB can also be damaging, but the time exposed to lower volumes are the most significant and unrecognized danger we face daily.
 
A recent social trend has created a new threat. Tuning out the world with ear buds, while turning up the tunes for hours, can be like riding on the two-cylinder John Deere tractor with no cab all day while cultivating corn. Those old two-cylinders were loud, and so it can be with ear buds! Ear bud volumes at 100 dB for as short as 15 minutes can damage hearing. Again, it’s the volume multiplied by time that makes it so bad. One study showed that 97 percent of third graders had documented exposure to hazardous sound levels. Another showed that 12.5 percent of 6 to 19-year-olds in the U.S. already had hearing loss directly attributed to noise exposure.
 
What’s more, if the volume is too loud, ear buds can be even more dangerous as they may prevent us from hearing the noises that help us avoid danger. For example, walkers, runners, and bicyclists need their ears to hear when a truck might be coming from behind.
 
Of course, it isn’t just noise that can reduce our hearing. Infections, trauma, and even medications like antibiotics, chemotherapy drugs, or pain medications can do it too. Seek medical help if you notice your hearing is changing.
 
The bottom line: Protect your ears by avoiding exposure to too much noise, get help if your hearing changes and beware of ear bud risks.
 
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.