By Mandi Greenway, M.D.

Last week I looked in the mirror and saw something I don’t usually see, a breakout of pimples. As a dermatologist I am fortunate enough to have the right tricks to keep my skin blemish free most of the time (some lucky genetics don’t hurt either). I’m also seeing a lot more acne and rosacea breakouts in my patients over the last few months. What might be the culprit? Wearing a face mask.
 
As the COVID-19 pandemic rages on, wearing a face mask is one of the most important ways we can prevent the spread of the disease. I urge you all to wear a cloth mask when you can’t social distance and when in public spaces. The data regarding face masks is clear, but our skin doesn’t always behave itself with frequent wearing. The good thing is that there are some simple steps you can take to keep your skin healthy while wearing a mask to protect those around you.
 
Skin issues from wearing masks can include dry skin, acne, and rosacea. Make sure to wash your face before and after wearing masks with a gentle cleanser. Cleansers are different than soaps and can clean the skin without removing normal oils. Apply a moisturizer that is tailored to your skin type: gel moisturizers for oily skin (or during those humid summer days), lotion for normal skin, and cream for dry skin. Try to get this moisturizer on after each time you wash your face as well as before bed. Dry lips are best treated with plain Vaseline.
 
If you’re going to be wearing a mask for longer periods of time it’s best to skip wearing makeup under the mask. Treat your skin gently and avoid harsh treatments like chemical peels or exfoliating. Some of the medicines we use to treat acne with can ironically cause more skin irritation while wearing masks, so be sure to discuss with your physician if you are having problems.
 
Lastly, be sure you are wearing the correct mask and washing them frequently. Cotton is the least irritating fabric and anyone with acne or rosacea should make sure that the layer that touches the face is cotton. Masks that fit well (snug but not tight) will be less irritating than masks that are too big and slide around on the face.
 
Hopefully, these simple tips help your skin stay healthy as you continue to wear your mask!
 
Mandi Greenway, M.D. is a contributing Prairie Doc® columnist. She practices dermatology in Mitchell, 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 Joanie Holm, C.N.P.

My name is Joanie Holm. I am a certified nurse practitioner in Brookings, South Dakota and I am the person fortunate to have been the life partner of the original Prairie Doc®, Richard P. Holm, M.D.  Rick and I were married for 40 years before his passing in March of 2020.

During those wonderful decades together, if I could point to one powerful action that strengthened our relationship with each other, with our family, our community and with our patients, it would be the act of kindness.
Thankfully, Rick was alive to see the recognition and formalization of kindness as an essential element of medical education. Medical schools across the country have started to offer courses on compassion and caring. One of the first to do so was the University of South Dakota Sanford School of Medicine.

Dr. Mary Nettleman, dean of the USD medical school, explained why the school embraced kindness as part of its core curriculum. “People want a physician who is not only competent, but also kind, so we will work to elevate this value throughout the school. By approaching this intentionally, we hope that students will learn how important kindness is in medicine and how they can incorporate it into their everyday practice. A culture of kindness can make us exceptional,” said Nettleman.

I celebrate this awareness and elevation of kindness in medical education and I salute educators for enriching their medical students in this way. 

Since Rick’s death, I have received many wonderful notes of condolence that have been very meaningful to me and my family. With permission from the author of one such letter, I share the following message which further illustrates kindness.

Dear Mrs. Holm,
I’m one of the people who knew your husband through his TV show, and I learned from him. I have cerebral palsy and sometimes it’s hard for people to understand me. One day, my mom and I were having dinner in Sioux Falls and you were seated close to us. When Dr. Holm walked by my table, I put my hand out and he stopped and talked to me. I wanted to tell him that we were praying for him and I will never forget how he made me feel. I have worked with many doctors and he was one of the best!

My dear husband practiced kindness in all he did. Regardless of our profession, may we all embrace acts of kindness and stop to hold the outreached hand of a fellow human being. 
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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 July 26, 2020                            

By Debra Johnston, M.D.
 
Sometimes, life has lessons for us that we don’t truly appreciate until much later.
 
Many years ago, when I was a very wet behind the ears new doctor, I had the privilege of being part of the care team for an elderly Native American woman. She had been transferred from somewhere in rural South Dakota to our hospital in the city in hopes of identifying her disease and ascertaining how best to help her. Her daughter accompanied her. The medical team was convinced we knew “best,” while her daughter was determined that we were not going to take a single step that might conflict with her mother’s values. The stage was set for conflict. 
 
As an intern on one of my first rotations, I just could not understand why someone would come to us for help, and then not be willing to follow our recommendations for testing and procedures that we felt would give us information we needed. We were frustrated. I didn’t recognize it at the time, but I learned a lot from that fierce patient advocate.
 
In retrospect, the most obvious lesson was the importance of acknowledging that people have different values, and those values are shaped by many things, including culture and religion. While it may be true that some values are shared across cultures, it is a mistake to assume that we can understand another person’s values and priorities through the prism of our own, or based upon what we think we know about them. 
 
Healthcare providers can best help their patients by taking time to discuss cultural values, sacred traditions, and priorities with patients. This is especially true when it comes to end of life care, but it also applies to situations such as acceptance of medical testing, preferences regarding prescription drugs versus non-pharmaceutical alternatives and culture-based healing practices.  
 
Another lesson was the importance of an advocate for the sick and vulnerable. It is extremely valuable for both the patient and the care team to have someone else present with the patient. This is a person the patient trusts to help clarify their concerns, to remember information, and to pass that information along to the patient’s loved ones. Prior to the covid-19 pandemic, few patients utilized an advocate, except in the gravest of circumstances. Now, procedures in place to protect patients, staff, and family from this dreadful virus, limit the opportunity for patients to have an advocate physically present. However, most facilities support connection to patient advocates via phone call or video call.
 
In the end, a wise chaplain arranged for a traditional healer to visit our patient in her hospital room. I was not present for the ceremony, but the senior physicians and the daughter agreed on a plan of action. We didn’t cure the patient, but we were able to offer her physical comfort in her final days, and I believe that by blending her culture and traditions with our medical ethos, we helped both the patient and her daughter find spiritual comfort as well. 
Debra Johnston, MD 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 Jennifer May, M.D.
 
“Doctor, I need an x-ray.” As a rheumatologist, I hear this statement many times from patients who believe imaging will help determine the cause of symptoms, such as back pain or knee pain. It seems simple, take a picture, and find out what is wrong. However, radiology is not always black and white.

Radiology is the medical specialty that uses medical imaging to diagnose and treat disease. Radiologists are physicians, trained in interpreting various types of imaging such as x-rays, CT scans, MRIs and more.  Rheumatologists often depend on imaging to help manage diseases such as rheumatoid arthritis. However, the rheumatologist, radiologist, and patient must work as a team to determine which type of radiology will be most effective for each specific clinical situation.  

For example, an x-ray of a patient with knee pain tells us about the bones, cartilage (space between the joint), and degree of joint fluid present. But it tells us little directly about tendons, ligaments, or muscles because these soft tissues do not show up on a basic x-ray. Therefore, an x-ray may not be the most informative option and performing one may not change the treatment plan. 

Radiology offers a wide range of tools for physicians and patients today. What began with x-rays has evolved into a broad field that includes both interpretation and intervention. Interventional radiologists perform various minimally invasive procedures using medical imaging guidance, such as x-ray or ultrasound. Interventional radiology can treat problems with blood vessels such as blockages or clots and place stents to open them up. They can insert medicine directly into tumors, perform biopsies and other procedures. Additionally, patients generally tolerate interventional radiology procedures much better than major surgery.

With this in mind, when a patient presents their specific set of symptoms, I consider the wide spectrum of radiological tools and talk to the patient about which are most likely to help us find the information we need to improve their particular situation. Sometimes the right tool is an x-ray, but other times it is not. 

Once the information is gathered, physicians and radiologists work together to interpret the data and make a diagnosis. At that point, we are better prepared to make treatment decisions and determine if the patient needs medicine, injections, a brace, physical therapy, or referral to specialist. 

Without a doubt, radiology is integral to good medicine, but it’s not always black and white.  

Jennifer May, M.D. is a contributing Prairie Doc® columnist. She practices rheumatology in Rapid City, South Dakota and serves on the Healing Words Foundation Board of Directors, a 501c3 which provides funding for Prairie Doc® programs. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.   

By Andrew Ellsworth, MD
 
My friend broke my nose at an after-prom party in high school. It was nothing deliberate, such as fighting over a girl. Rather, we bumped heads while wearing those big round air-filled sumo wrestler suits. Besides hurting a lot, I remember thinking, “I’ve never been so aware of my nose before.” I was overly cautious of anything that could come close to my nose.
 
I think we sometimes take our noses for granted. Despite being right between our eyes, it’s not our noses, but our heart, lungs, and other organs that get most of our interest. We brush our teeth daily. We get our eyes checked regularly. We adorn our ears and fingers with rings all the time, but the nose is generally ignored. 
 
Sure, there are some famous noses and some people are more aware of the size of their nose than others, but mostly, outside an occasional bloody or runny nose, we don’t pay it much attention. 
 
During annual preventive physical exams, I usually look around for any suspicious spots that could be cancer. One of the most common areas is on the nose. The nose sticks out and is susceptible to getting more sunlight and thus can be prone to getting skin cancer. If you notice a new bump on your nose that won’t go away after a month or two, you should get it checked out. Better yet, be proactive and put sunscreen on your nose as well as your ears, cheeks, neck, arms, and legs and anywhere else that will be in the sun. It’s best to keep your nose out of it (the sun, that is) and wear a wide-brimmed hat.
 
Of course, we cannot talk about our noses without expressing appreciation for our precious sense of smell. Smell helps our brains taste all those amazing flavors and when food goes bad, we depend on our nose to warn us before we take a bite of something that we want to thumb our nose at.
 
I can’t imagine going through summer without the smell of flowers, apple pie, a campfire and fireworks. With Covid-19 around, the smell of peanuts at a crowded baseball game or cotton candy at the fair will have to wait for now, I guess. If you lose your sense of smell talk to your doctor. It could be from allergies or a cold, but it could also be something more serious like the coronavirus.
 
As much as we’d like to see everyone’s nose again, the right thing to do is as plain as the nose on our face. Let’s not get our noses out of joint. Let’s keep our noses to the grindstone, continue to be mindful of social distancing and wear masks that cover our mouths and our noses!
 
Andrew Ellsworth, MD 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.
 
A few years ago, I spoke at a conference for women physicians. My talk opened with a simple question.  What organ does the heart supply blood to first? It was a deceptively simple question, but the room was silent as they all pondered what they thought was a trick question. Various answers came in, but they were all wrong. Everyone else tried to guess what the most important organ would be that would receive the blood first. They tried to deduce which organ was physically the closest to the heart.   

The next slide in my talk was a picture of the heart from an anatomy textbook and there I showed the answer. The heart feeds itself first. The very first blood vessels that branch off the heart at the aorta are the coronary arteries. These are the blood vessels that feed the heart and are the ones that, when blocked, cause a heart attack.  

This was not a talk about anatomy, and it wasn’t a lesson in physiology. It was a conference on self-care.  No one has ever called the heart a selfish organ. We call someone who is generous and kind as someone who has a “big heart”. The heart’s sole purpose is to supply oxygenated blood to the entire body, and it beats constantly from before we are born until the moment we die. The only way it can do this is by taking care of itself and making sure its needs are met first. Yet when we think of taking time for ourselves or saying “no” to someone’s request because we do not have the time or energy to help, we often feel selfish. 

When the heart does not have enough blood flow to an area, or there is a blockage in a vessel, it causes pain. Sometimes people ignore this pain and push through. Sometimes the pain goes away, only to come back later when the demands on the heart grow stronger. If the area of the heart is starved for blood for long enough, that part of the heart dies. If a large enough area of the heart dies, then the heart cannot effectively pump blood to the rest of the body and the person may die of a heart attack. 

We need to follow this example in how we treat ourselves. We need to take care of ourselves – emotionally, physically, and spiritually – before we can take care of others. If we ignore this and take care of our needs last, our ability to care for not only ourselves, but others will suffer. Be like the heart, tirelessly giving and kind to the entire body, but most importantly ensuring that the giving and kindness applies to you first and foremost. 
​
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 Richard P. Holm, MD
 
In recent years, I’ve learned of wonderful aspects of Native American culture, especially the sacred medicine wheel or hoop of life with variations in colors and meanings according to each tribe and nation. The circle is a universal spiritual symbol, but the Native American medicine wheel has complexity and power for me, a person who has cared for the elderly throughout my lifetime on the prairie.
 
For centuries, the Native American medicine wheel has given bearing, a sense of position, an objective and simultaneous understanding of both the infinitude and the limitation of life. The wheel brings a conscious spirituality that recognizes and accepts all things. For me, it closes the gap between the cynical scientific part of me and the inclusive spiritual part. By spiritual, I mean that part of our soul that savors music, art, poetry and the divine; the part that grows to love all things living and nonliving.
 
In the following verse, I’ve taken the liberty to express my interpretation of the sacred circle:
 
First we get down on our knees and feel the soil, sacred Mother Earth, the world around us, the animals, plants, prairies, lakes, mountains, the environment of our planet from where all food and sustenance comes; earth is foundation.
 
Then we stand and raise our arms to sacred Father Sky, the sun, stars, clouds, rain, wind, air and breath of life, light and dark; from where all energy flows and ebbs; sky is infinity.
 
Then we turn and bow east, symbolized by the color red, the rising sun, springtime, birth, the very young, a sense of innocence and hope for the future.
 
Then we bow south, symbolized by the color yellow, the full sun, summer, early adulthood, a sense of unconquerable power and the courage to fight for justice.
 
Then we bow west, symbolized by the color black, the setting sun, autumn, mature adulthood, a sense of gravity to protect freedom and face vulnerability with honest eyes.
 
Finally we bow north, symbolized by the color white, nighttime, winter, old age, wisdom to savor friendship, family and the circle of life, release from fear of change and death, and a sense of empathy from having walked in another’s moccasins.
 
We pray in harmony as love consoles. O sacred hoop of life, please touch our souls.
 
This essay is a composite of works written by the late Richard P. Holm, M.D. who died in March 2020 after a battle with pancreatic cancer. He was founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. Dr. Holm’s legacy lives on through his Prairie Doc® organization. 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.                                                                                                                                   -0-

By Kenneth A. Bartholomew, MD
 
By now everyone with a television or internet connection has heard of the “Opioid Crisis in America”.  Deaths from accidental overdoses of opioids each year have now surpassed deaths from automobile accidents.  Depending on whose numbers you read, these deaths range from 50,000 to 70,000 each year, versus 38,800 from vehicle accidents in 2019.  Just how did we get here?
 
I have been practicing long enough to have witnessed the progression of this problem.  In medical school in the 1970s, we were taught to be cautious and limit the prescribing of morphine and Tylenol with codeine because they had the potential to be addicting.  We saw occasional problems with overuse and addiction, but not that many.
 
In the 1980s and 1990s, there were multiple articles published in medical literature that showed patients in emergency rooms and hospital wards were not receiving enough pain relief.  This was doubly damning because almost every article showed that people of color were provided less pain relief for surgical pain or trauma pain than Caucasians.  Multiple essays followed.  The unstated implication was that we were bad doctors, not doing a good job of relieving pain.
 
Enter the federal government and the Law of Unintended Consequences.
 
The Joint Commission, the body in charge of hospital accreditation, made pain the “Fifth Vital Sign”.  It was mandated that every patient, every day, often multiple times a day, be asked how their pain level was doing (and quantify it on a one-to-ten scale).  The use of pain medications accelerated.
 
Add to this the fact that in the search for better pain-relief drugs, oxycodone was approved by the FDA in 1995 and the continuous-release version, oxycontin, came on the market the following year.  Fentanyl, many more times more powerful was approved in 1998 for cancer pain.  These drugs are far more addicting than codeine, a fact then unknown to most doctors and allegedly covered up by the drug company.  With this perfect storm of mandates and new drugs, the number of prescriptions skyrocketed – we did not want to be seen as bad doctors by the Joint Commission watchdogs.
 
Needless to say, the addiction rate skyrocketed as well.  These drugs, some claim, can ‘turn on a switch’ in the brain after only a single dose.  One addict stated, “It was the first time in my life my body didn’t hurt.  I wanted that feeling to last.”  And he did almost anything to get the drugs, which ruined his life and almost killed him.
 
In contrast, we look at several European countries that did not “mandate” Draconian pain relief measures. Their post-operative patients receive mostly Tylenol and ibuprofen and their satisfaction scores are essentially identical to those of the U.S.
 
What I think we should learn from this forty-year unfolding of the “Opioid Crisis” is that doctors should be doctors and politicians should be politicians, and the Law of Unintended Consequences will continue to bite us in the backside unless we take the time necessary to know and understand history.
 
Ken Bartholomew, M.D. is a contributing Prairie Doc® columnist. He practices in Pierre, South Dakota and serves on the Healing Words Foundation Board of Directors, a 501c3 which provides funding for Prairie Doc® programs. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.   

By Jill Kruse, D.O.
 
At the bottom right hand corner of my driver’s license there is a small heart and the word “donor”.  The print is small and easy to miss among all the other information contained.  That one word, I would argue, is the most important piece of data there.  Displayed next to my height, weight, and eye color, I proudly declare that when my organs are no longer of any use to me, I want to give them to someone in need.  This is a personal decision and, according to United Network for Organ Sharing, donation is supported by all the major religions.  It is also a decision that can impact up to eight other lives. 

Donation of my organs, cornea, and tissues is a gift that will cost me and my family nothing.  There is no cost to the donor’s family or estate, and it doesn’t affect funeral plans or prevent a viewing.  When I die, my organs, tissue, and corneas will be available to people in dire need of them.  I don’t want my body to be like an Egyptian pharaoh’s tomb filled with treasures that could be better used by the living.  The ancient Egyptians removed the organs from the body before they mummified someone.  These organs were placed in Canopic jars and buried.  Let my Canopic jars be living, breathing people who need them to live their life to the fullest.     

Right now, there are more than 113,000 people waiting for lifesaving organ transplants.  Of those people, 8,000 will die each year waiting for an organ that will not come in time.  The thought that I can lower that number when I die brings me a sense of pride and joy.  Organ donation is the ultimate way for a physician, and anyone else, to help someone be healthier.  Organ donation is truly giving the gift of life. 

I have seen this gift of life personally.  My cousin’s husband, his mother, and his sister all had heart transplants due to a genetic condition.  He had a heart transplant on December 29th, 1999 and a kidney transplant on March 31st, 2005 giving him an additional 20 wonderful years of watching his three children grow.  A significant gift for someone who was not sure that he would live much beyond his wedding.  Before his kidney transplant, he was dependent on a dialysis machine three times per week.  The organ donations have changed his life and the lives of his family.  I hope that I can change the life of someone else through my gift of organ donation and I hope you will consider donating as well. Find out more at www.organdonor.gov.
​
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.