By Debra Johnston, M.D.
 
One of my favorite parables describes the difference between heaven and hell. In both places, hungry people sit at tables laden with delicious food. In hell, people suffer and starve because they cannot eat with the long utensils provided. In heaven, people are happy and thrive because they use the utensils to feed each other.
 
Many cultures and religions have some variation of this story. It illustrates a universal truth: we depend on each other. The current pandemic has starkly illustrated this interdependency, and it does not sit comfortably with our American culture of self-reliance and rugged individualism.  
 
As a physician, I depend on nurses, techs, therapists, and pharmacists. I depend on hospitalists to care for patients too sick to stay home. Hospitalists depend on intensivists to care for the sickest. Doctors depend on nurses providing hands-on care at the bedside, respiratory therapists adjusting ventilators, technicians operating machines which substitute for failing organs. And we all rely on those who sterilize equipment, launder sheets, clean rooms, repair machines, and prepare food.
 
Two years into the Covid 19 pandemic, those of us who remain in healthcare are tired. We have enough beds, and ventilators, and protective equipment, but the human infrastructure is struggling to keep up.
 
Unfortunately, we cannot simply hire more people. Becoming a physician requires 11-plus years of higher education. Most care team members have at least two years of specialized schooling which is only the beginning; learning is an ongoing process. Health systems may accelerate some of the administrative hurdles to get more people to the bedside, but we cannot accelerate the time it takes to know what to do there.
 
The upcoming tsunami of Omicron Covid patients threatens to swamp our health care systems. Not only are more people in need, but their needs are far more intense. In addition to Covid patients, people with other illnesses and victims of accidents still need health care services. As my colleagues and I anticipate the coming surge, we wonder how we will meet it. Who will die that with more support, might have lived?
 
Like the people in the parable, we need each other. Those who are eligible, please get your Covid shots and boosters. Vaccinated people are less likely to need a hospital bed, and less likely to carry the virus to someone more vulnerable. Get your flu shot. Influenza infections are skyrocketing, too. Wear a high-quality mask in public, to protect yourself and others and avoid spending long periods of time in crowds.
 
We all depend on each other to stay safe. Like those diners in heaven, please use the available tools and do your part for the person across the table.
 
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.
 
Imagine a condition with symptoms that present differently in each person who has it and no currently approved lab test can definitively confirm the diagnosis. Imagine that the symptoms can flare up and then mysteriously disappear, including fatigue, low grade fevers, joint pain, and mouth sores. All these symptoms overlap with multiple other conditions further complicating a diagnosis. Imagine that the best available method for diagnosing this ailment is a manual checklist of eleven criteria and if the patient suffers from at least four, they receive a diagnosis on a scale of definite, probable, or possible.
 
What if I told you this condition is caused by an attack on the body by its own immune system and the main way to treat this is by suppressing the immune system we each depend upon to help protect our bodies from infection. The course of this illness can range from mild to rapidly progressing to organ failure and death. This condition is real and has a most appropriate name which means “the wolf” in Latin. The condition is systemic lupus erythematosus (SLE), a condition which evades diagnosis and is difficult to treat.
 
Lupus mainly affects women between the ages of 15 and 40, particularly women of color. For many busy young women with lupus, symptoms are often brushed off by family, friends, and unfortunately sometimes by health care providers who may view the patient as being “tired” or “over worked.” Routine wellness lab tests, which serve as an alert system for other illnesses, provide no indication of lupus. Patients who persist and find someone to further investigate their symptoms may be misdiagnosed with a myriad of other conditions sometimes resulting in unnecessary medications, treatments, and further suffering.
 
Work is underway to better understand lupus. The trigger that causes the immune system to start attacking itself is not known, but scientists suspect it involves a combination of genetic and environmental factors.
 
Research and awareness are making a difference. In the 1950s, the 5-year and 10-year survival of SLE patients was less than 50 percent. Since then, that number has improved to over 90 percent. This increase in survival rate stems from improvements in our ability to diagnosis lupus earlier and to provide better treatments once diagnosed. But we must do better. Early diagnosis of lupus requires patients and health care providers working together to persist in finding this “wolf in sheep’s clothing.”
 
If you or a loved one has a concern about lupus or other autoimmune conditions, talk with your doctor and see if a consultation with a rheumatologist would be beneficial.
 
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 Joy Falkenburg, M.D.
 
What does it mean to practice humanity in medicine? The phrase is used as a tagline and in book titles. Humanity and compassion in medicine is touted as something to aspire to, a noble accomplishment. But in reality, the biomedical model of health, the business model for healthcare, is not set up to support it. Algorithms and best practices set forth by insurance companies and Centers for Medicare and Medicaid do not account for the time required to establish meaningful human interaction between patient and caregiver.
 
This conundrum can be frustrating. Understanding the nuances of each individual patient and each situation cannot be rushed. Yet opting to practice ‘slow medicine’ can have negative ramifications; constantly running behind schedule, having more work than you can handle and knowing that there are more critical and needy patients waiting to be seen.
 
Thankfully, the benefits far outweigh the frustrations. Medical professionals who choose to share in the human condition with patients are better able to care for the whole person in a way that is nurturing and fulfilling to both parties. When we are successful in this effort to see our own fear and our own death and our own vulnerability in our patients, we will meet them and treat them with an open mind and open heart. We will listen actively, without bias or judgement and we will do what is best for them in this moment in their life.
 
Regardless of our profession, experiencing a sense of powerlessness can creep into us and lead to isolation and avoidance. We can lose connectedness with our own emotions and our own self. Striving to have an awareness and acceptance of grief, pain and knowing when to accept our inability to change circumstances can help us avoid feelings of helplessness.
 
Being a doctor helped create who I am as a person. I am grateful for all the patients who have enriched my life and taught me lessons of humility, joy, interconnectedness, and impermanence.
 
My patients and my experiences have indeed opened my mind and my heart. In my exam rooms, my patients and I collaborate in a communion of sorts. We share and connect as we learn about and better understand each other. That is what it means to practice humanity in medicine.
 
Perhaps these words by one of my favorite authors David Whyte say it best, “Put down the weight of your aloneness and ease into the conversation. Pay attention to everything in the world as if it is alive. Realize everything has its own discrete existence outside your story. By doing this, you open to the gifts and lessons the world has to give you.”
 
Joy Falkenburg, M.D., a family medicine physician in Custer, South Dakota, is a contributing Prairie Doc® columnist and guest host this week on the Prairie Doc® television show. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central. 

By Kelly Evans-Hullinger
 
With 2022 nearly upon us, so too is the tradition of the New Year’s resolution. Merriam-Webster defines the New Year’s resolution as “a promise to do something differently in the new year.” I would argue that in practice, the resolution is less of a promise and more of a hope or intention.

My resolution for 2021 was to read 20 books by year’s end. I failed. I could blame my kids, work, other hobbies, but honestly I blame my phone! In my defense, I was in good company as a flopped resolver; less than half of New Year’s Resolutions are estimated to be successful.

An estimated 74 percent of adult Americans set a personal goal each year, the most common category being to improve health and wellness. If you are a regular at a gym or fitness center, you have witnessed the phenomenon of the January influx of attendees that typically trickles back down to baseline by March.

Whatever your resolution, there are some ways to increase your odds of being successful in following through in 2022. One tip is to make your goals follow the SMART mnemonic: Specific, Measurable, Attainable, Relevant, and Time-sensitive. Let me elaborate, using my failed 2021 goal as an example.

Specific: “Read at least 20 books this year” is specific, but I could have done better. Had I explicitly listed each book title up front I would have avoided time wasted searching for books throughout the year.

Measurable: My goal was easily measurable; just count the books. If your goal is not measurable there is no way to know whether you are on track to reach it.

Attainable: I did not set a goal to read 50 or 100 books in a year. I know people who read that much, and I admire them, but that was not realistic for me. Setting an unattainable goal may set you up to quit in the early stages.

Relevant: I set this goal because I enjoy reading, and I know I am a happier person when I spend my downtime with my nose in a book. Choose a goal that you care about, and maintain enthusiasm.

Time-sensitive: Most New Year’s resolutions will have a time frame of one year. But setting smaller time-sensitive goals can be helpful. I ought to have made a sub-goal to read two books per month to keep on pace.
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The New Year might be a great time to commit to a positive change in your life. I hope the SMART approach will help you (and me) succeed this year!

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 Jennifer May, M.D.
 
Food intolerance and food allergy are common these days. When I was a kid, no one asked about nut allergies or gluten sensitivities when inviting you to a birthday party. You could bring homemade snacks to school. Peanuts were served to everyone on airplanes. Today, we are constantly reminded to be aware and take precautions to help prevent exposure for those who are intolerant or allergic. 

Understanding the difference between allergy and intolerance is important. Allergies can result in life threatening reactions, whereas food intolerances are not life threatening but can be very problematic. Food allergies and intolerance have many overlapping symptoms making diagnosis difficult. 

Food intolerance is very common and is estimated to affect 20 percent of the world’s population. Food intolerance occurs when the body has a chemical reaction to eating a particular food or drink. Most food intolerance reactions involve the digestive system, skin, and respiratory system. Many of us have mild intolerance, say to dairy, but other common triggers are gluten, caffeine, and eggs.

Food allergies can be more serious and result from an inappropriate immune system response. Nuts, for example, are harmless yet the immune system can identify them as toxic. Even a small exposure can lead to a life-threatening reaction known as anaphylaxis. 

Thankfully, we have new approaches to manage food allergy. Today, we better understand how exposure to a broad variety of food in infancy can reduce risk of developing allergy as we age. Another option available is immune therapy for peanut allergy.

On the other hand, managing food intolerance requires an understanding of what food or ingredient triggers symptoms, then we focus on avoidance. We do not have immune therapy for food intolerance.  

Both food intolerances and allergies are becoming more prevalent. For example, between 2007 and 2016 there was a 377 percent increase in treatment of diagnosed anaphylactic reactions to food. Why are more people having challenges with food? It is not clear. Maybe it is our environment, our diet, or both. No specific cause has been identified.

Our world has changed and our treatments for food allergies and food intolerance have changed as well. It seems we will continue to have special dietary requests for a long time to come, so getting the right diagnosis is our most important first step. 
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Jennifer May, M.D. practices rheumatology in Rapid City, South Dakota. She is a contributing Prairie Doc® columnist and guest host this week on the Prairie Doc® television show. 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 Matthew Owens, M.D.
 
Emergency medical services (EMS) in rural America are in a state of crisis. Difficulty recruiting emergency medical technicians (EMTs) and the financial constraints of EMS agencies are the major causes of this crisis.

The majority of South Dakota is considered a medically underserved area (MUA), indicating too few primary care providers, high infant mortality, high poverty or a high elderly population. Most of the MUAs are also designated as rural or frontier, increasing the likelihood of prolonged transport times to hospital-based medical care. Rural and frontier MUAs are historically served by volunteer EMS services.  Seventy three percent of EMS agencies in South Dakota utilize volunteers. In 2016, 32 percent of volunteer agencies reported missing calls due to staff shortages. These conditions have led to a disparity in mortality rate for traumas for rural residents.
 
An ad hoc group comprised of the University of South Dakota School of Medicine, South Dakota State Medical Association, Northeast and West River Area Health Education Centers (AHEC), Sanford Academic Affairs EMS Outreach, and Community Memorial Hospital in Redfield has received funding through the U.S. Department of Labor, and Substance Abuse and Mental Health Services Administration to combat the EMS crisis in South Dakota and improve health outcomes for rural residents.   
  
For many students, grant money is available to cover costs of the EMT training available at Sanford EMS Outreach. The synchronous online classes can be completed by the student at home, while the hands-on portion may require weekend travel. 

In addition, members of the ad hoc group developed the Dakota Responder class curriculum, the goal of which is to train more people. Through a unique collaboration with Agtegra, a farmer-owned grain and agronomy cooperative with more than 6,300 members-owners in eastern North and South Dakota, the Dakota Responder classes will initially be made available to Agtegra employees. Those who attend the classes will be trained to provide emergency care for serious bleeding, opioid overdose, and use of automatic defibrillators. Agtegra employees located in rural areas of the Dakotas are well-positioned to provide life-saving care until EMS personnel arrive on scene.   

Ultimately, the goal is to increase the number of trained EMTs to staff rural EMS centers and improve emergency response times. To encourage this endeavor in your community, share this information with your neighbors and contact your legislators and county commissioners to urge their support for local EMS centers where you live. 
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Matthew Owens, M.D. practices family medicine in Redfield, South Dakota. He is a contributing Prairie Doc® columnist and a guest this week on the Prairie Doc® television show. 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.
 
As a family physician living on the upper Great Plains, I have many patients of Norwegian and German descent. Thus, I am familiar with some diseases that are prone to affect people of northern European ancestry. One such example is Dupuytren’s contracture. 
 
Dupuytren’s contracture is a gradual thickening of the connective tissue of the palm of the hand. It may begin innocently as a nodule in the palm or joint stiffness, which are common for anyone. However, with Dupuytren’s contracture, over time the fingers curl inwards and cannot be straightened. Cords can become visible in the palm of the hand. This is often a slow progression over several years and may or may not become painful. It can make it harder to grasp objects and use the hand in general. 
 
Sometimes called the “Viking Disease,” Dupuytren’s contracture most often affects men of northern European descent over the age of 50. Other risk factors making a person susceptible to this disease can include smoking, alcohol, manual labor, and being thinner. It would seem being a fan of the Minnesota Vikings may be a risk factor, but that is probably just coincidence. 
 
The condition is named after Guillaume Dupuytren, a French military surgeon who was skilled in anatomy. He described the condition well and was the first to perform a successful operation for it in 1831. Interestingly, Dupuytren gained prominence from treating Napoleon Bonaparte’s hemorrhoids. 
 
Although a steroid injection or physical therapy may be helpful, in general, Dupuytren’s contracture cannot be cured, only treated. For a long time, surgery was the mainstay treatment, especially for more advanced cases. Surgery can involve cutting the fascia, the affected layer of connective tissue. A less invasive procedure involves using needles to weaken the thickened cords of fascia.
 
In the last decade a new treatment became available. Injecting the enzyme collagenase weakens the bonds in the collagen of the fascia, releasing the contractures. Extracted from the bacteria Clostridium histolyticum, the collagenase offers an effective nonsurgical option for treatment. 
 
I am not sure what my Norwegian and German ancestors would have thought about injecting an enzyme from a bacterium into their hands. However, patients today appreciate regaining the use of their hands for daily activities and to clap and cheer for their favorite football team.
 
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 Jill Kruse, D.O.
 
The holiday season is here, and many wonderful activities are happening. As you hustle and bustle, be aware that accidents and injuries can occur. When you see a doctor, they record a diagnosis code explaining the purpose of the appointment. Some codes describe the actual injury and others describe what happened during the injury. For example, Y93.2 is the code for “activities involving snow and ice”.  So, if you went sledding, crashed into a tree, and broke your left femur or thigh bone, your medical chart would show these codes: S72.8X2A “other fracture of left femur, initial encounter for closed fracture,” W22.0 “striking against stationary object,” and Y93.2.

With this in mind, let’s have some fun and review codes that would be used for mishaps from popular holiday songs and movies. For the grandma who was run over by a reindeer, we would use codes W55.32XA and V06.00xa defined as “struck by other hoof stock, initial encounter” and “pedestrian on foot injured in collision with other nonmotor vehicle in nontraffic accident”, respectively. The song does not specify injuries received from this accident, but there is mention of drinking too much eggnog. Therefore, we might verify the diagnosis of R78.9 which is “finding of alcohol in blood.” 

In the holiday movie A Christmas Story, Ralphie wants a Daisy Red Ryder BB gun. His mother warns that he will end up with S05.90XA “unspecified injury of unspecified eye and orbit.” Of course, that doesn’t have the same ring to it as “You’ll shoot your eye out!” Don’t forget Ralphie’s classmate who gets his tongue stuck to the frozen flagpole. His injury would be noted as T33.90 and S00.502A which are “superficial frostbite to unspecified sites” and “unspecified injury to oral cavity, initial encounter.” Ouch!

I hope that Santa can avoid E73.0 and W13.2xxA which are “lactose Intolerance” and “fall from, out of or through roof, initial encounter.” Either of those situations would make Santa less merry and bright. And let’s hope the jolly old elf has seatbelts in his sleigh because if Rudolph gets anxious in the fog and makes a sharp turn, Santa might have a V00.221A, “fall from sled, initial encounter.”
  
May your stockings stay safely hung by the fireplace without X02.0XXA “exposure to flames in controlled fire in building or structure [fireplace], initial encounter.” No one wants their holiday ruined by Z63.1 “problems in relationship with in-laws”. And hopefully your children don’t have any Z62.891 “sibling rivalry” issues.

My wish for all of you is a peaceful, silent night, preferably not due to H83.3 “noise induced hearing loss” from all the carolers at your door. And, in the New Year, may you only need to come to the clinic for Z00.00 “encounter for general adult medical examination without abnormal findings.”

Happy Ho, Ho, Holidays and stay healthy out there people!

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 Kelly Evans-Hullinger, M.D.
 
I love Thanksgiving. I love preparing the food all day and enjoying it while sitting around a table with some of the people I love most. And there is one holiday tradition that I have grown to adore. As we sit down to eat, we share one thing we feel grateful for this year.

Practicing gratitude has been shown to improve aspects of mental health and our sense of well-being, and it isn’t hard to understand why. Saying or thinking “I am grateful for…” feels really good and doing so regularly can help shape our outlook on the world and our place in it. I know this, and still, I fail to follow through with regularly practicing gratitude like some experts recommend.

There is no time like the present, right? Let’s try it. Here are some things this Prairie Doc is feeling particularly thankful for this year:

I am thankful for my health, thankful to be alive. As I grow older, and as I continue to walk with my patients as they encounter disease and sometimes death, the simple wonder of being alive and feeling well has never felt so clear. None of us will avert death but feeling gratitude for life does make each day a little sweeter.
I am grateful for my family and friends who have sustained me through difficult times and shared in my joy. I am on the receiving end of hugs, snuggles, and the hilarious and warm actions of my children, who give me laughter and hope every day.

I am incredibly grateful to be a physician. I feel fortunate to have a profession that gives me meaning and connects me to people and my community. I am indebted to my colleagues and mentors, including my Prairie Doc cohorts and the original Prairie Doc, Rick Holm, who generously shared so much with me about being a physician.

There. That felt good. I hope you’ll try it too, around the Thanksgiving table, privately in a journal, or however it works for you. Let’s make a habit of practicing gratitude.
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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.
 
Obesity affects approximately 40 percent of American adults, and I’ve been one of them for nearly as long as I can remember. There are innumerable schemes that promise effortless, or nearly effortless, weight loss, and many diets that claim to be the best approach. 
 
Most of us recognize that if something seems too good to be true, it probably is. It’s much simpler to identify the miracle potion advertised on our social media feed as snake oil, than it is to sort through all the conflicting and seemingly changeable advice on what makes a healthy diet. Should we be cutting out fat, or cutting back on carbs? Is there a particular combination of foods or spices or supplements we should be eating to be slim and trim and healthy?
 
In truth, obesity is a tenacious disease, and many people successfully lose weight with any of a multitude of diets. Many people are also unsuccessful with those very same diets. 
 
Between my second and third years of medical school, I had a month without work or structured academic obligations to study for the important Step 1 board exam. Every morning, I would get up and exercise for an hour before I hit the books. I would prepare healthy meals, and snack on carrots and celery while I read. I was determined to lose some of my excess pounds and set a good example for my future patients.
 
At the end of that month, I’d lost two pounds. This was not at all what I had anticipated. I was frustrated, angry, and hurt. I felt that my efforts had failed. I felt that “I” had failed.
 
Let’s think about what “success” means. Although we may want to get down to our ideal body weight, very few people with obesity actually achieve that goal, especially without surgical help. From a medical perspective, loosing just five to ten percent of your body weight improves your health in a variety of ways. More importantly, the lifestyle changes that can lead to that weight loss have health benefits of their own. 
 
With the wisdom of nearly 30 years in medicine, I realize that by focusing on the scale, I hadn’t seen something even more important. Eating fruits and vegetables reduces the risk of heart disease, strokes, cancer, and many other chronic diseases. Daily exercise strengthens hearts and bones. In short, even without weight loss, exercise and a healthy diet are good for you.
 
Experts may debate the nuances of the “best” diet, but there are some fundamentals which can bring success with or without the loss of pounds. Eat a variety of produce, and lots of it. Watch the sodium. Minimize processed foods. Avoid added sugars and trans fats. Your diet isn’t something you are “on” or “off”. Your diet is the way you nourish your body every day, and success is the choices you make that support your health.
 
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.