By Richard P. Holm, MD
 
Just about 4000 years ago, Chinese writings explained the medicinal powers of what is now called cannabis or marijuana, describing its properties to help arthritis, gout, malaria, nausea and psychological stress. In the 1500 and 1600s the Spanish and English brought cannabis to the new world for medical purposes and it became a huge commercial crop for making rope. In the 1920s cannabis emerged in jazz clubs as a recreational drug. At the time, it was thought of as a better alternative to alcohol since cannabis users didn’t seem as disruptive to the community.
 
During the prohibition era of the 1930s, the U.S. Bureau of Narcotics considered cannabis as addictive and they made it illegal along with alcohol. Further, the U.S. Controlled Substance Act of 1970 defined cannabis as a ‘Schedule 1’ drug putting it in the same category as heroin and LSD, claiming there was a high abuse potential and no medicinal use. Although these claims have changed, the U.S. law remains on the books. During the Obama administration, the Department of Justice was directed to relax prosecution of cannabis rule-breakers while allowing state rules to supersede the U.S. law. The Trump administration has made very little change since.
 
Questions about cannabis remain since scientific experimentation for medicinal use has been limited due to legal restrictions. However, strong evidence points to legitimate medical uses for cannabis. Cannabidiol or CBD, one of the chemicals derived from hemp, helps those with chronic pain syndrome, children with uncontrolled seizures, those with glaucoma and finally enhances appetite stimulation and reduces nausea and malaise in cancer patients.
 
We know there is abuse potential with cannabis, just like with alcohol. Driving intoxicated with cannabis increases crashes, even if only half as much as alcohol. Also, we know excess cannabis has potential to dull and injure young and undeveloped minds. Some suggest that legalizing cannabis would allow better laws and enhanced regulation, lessening underage use.
 
Consider the tragedy of 70,000 deaths per year (and rising) from the overdose of legal and illegal opioids while there are almost no reported deaths from cannabis use, despite quite extensive consumption in the U.S. Most opioid abuse seems to stem initially from efforts to reduce chronic pain syndrome, and this condition seems to be potentially helped with medicinal doses of cannabis.
 
It is time to allow medicinal use of cannabis. It might help us reduce the deaths from opioids.
 
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By Richard P. Holm, MD
 
Addiction can be defined as the compulsive repeated use of a drug or substance (such as alcohol) or performance of a behavior (such as gambling). Dependence is different, occurring when repeated use of a drug (such as heroine) results in physical dependence which causes an unpleasant feeling of withdrawal when the drug is stopped. Addiction and dependence can occur separately, although they often run together.
 
At five-years-old, I was a thumb-sucker. I recall not being proud of it as my folks seemed progressively upset about my “addiction.” The process that finally helped me quit was when I was told I would not visit my grandma in Minneapolis until I stopped sucking my thumb. I remember many struggled attempts at quitting before I finally shook the monkey off my back. Addiction is a human condition that can affect any one of us.
 
The people in this country are currently caught in a terrible maelstrom of opioid addiction from which human beings of all ages, races and economic status seem unable to escape. Twice as many people suffocated to death from opioids last year than died of vehicular crashes. According to the website DrugFree.org, in 2010, something like 23.5 million people in the U.S. (about one in every ten over the age of 12) were addicted to alcohol, drugs, or something. Of those addicted, only one in ten would ever get help.
 
One expert stated that the financial and emotional toll of addiction is greater than the combined consequences of diabetes mellitus and all cancers put together. Think of all the lung disease and cancer that results from smoking; the cirrhosis and liver failure as well as the dementia that results from alcohol; the dental problems from methamphetamine use; and all the social consequences of addiction including accidental vehicular crashes, suicides, homicides, criminal behavior and incarceration.
 
Despite all this doomsday talk, I think we have room for hope if we realize that none of us is immune and everyone should take precautions. We should start with an open-eyed and honest approach with our youth, teaching the truth about addiction without making addictive behaviors a “forbidden fruit.” Our country desperately needs affordable addiction and mental health treatment options, available to all, without the negative stigma (and often unhelpful incarceration) that can follow. Spending for prevention and treatment of addiction would save us all significantly more than it would cost.
 
We also need more research to better understand addiction and what influences addictive behavior, even that as seemingly benign as sucking one’s thumb.
 
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By Richard P. Holm, MD
 
Did you know that an average South Dakotan male lives to 75-years-of-age, and the average woman lives to 80?  Why is that? Is it because we men are more prone to violent deaths early by going to war, riding motorcycles or driving cars faster? Nah! This accounts for only a small part of the difference.
 
I think more likely it is because men, who are genetically built larger and more muscular (likely in order to be the defender or hunter for the family) no longer need to use those muscles in this modern world.
 
Just look at most 22-year-old men, they come built almost automatically ready to fight or lift or throw or build. But instead, in this society, you find them driving a car, sitting at a desk or laying on the couch rolling through the channels looking for videos of people playing games and being physically active.
 
Even our young boys are often living through the pretend movements of action figures or computer-generated warriors, rather than actually running through fields in some sort of sport, or chase, or hunt. As men age, their activity drastically reduces while their caloric intake continues excessively on. All the while their bellies grow. I truly believe this combination of excessive calories and reduced activity accounts for the sleep apnea, diabetes, vascular disease and, overall, increased death rate of men over women.
 
But there is one more factor, which should be added here. Men are also built to deny and do what they can to avoid going to the doctor to have a check-up. Let’s face it, denial has something to do with being a man. It goes with the testosterone, guns, action toys, and channel changers. You would think a man would rather face a charging lion than the yearly physical exam. 
 
Men, please don’t just think about it, find a way to stay active, participate, don’t just watch. Prevent or lose the belly by eating smaller amounts (fewer calories) and by being more active. Also, go see your doctor every once-in-a-while. You just might live longer and feel better too.
 
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By Richard P. Holm, M.D.
 
What is inflammation? Inflammation comes from the Latin words "into the flame" like how moths are drawn to sustaining warmth of a springtime campfire and harmful self-destruction if they get too close. Inflammation is a natural phenomenon that can encourage sustaining healing but also harmful destruction, like a moth into the flame.
 
During my first years of medical school, I was honored to spend my summers with multiple doctors practicing in Watertown, South Dakota. There, pediatrician Ebehardt Heinrichs, M.D., taught me about inflammation while we were examining a young child with acute juvenile arthritis. He pointed out how her hands showed four characteristics of inflammation famously described by Celsus, a Roman who lived at the time of Jesus. Dr. Heinrichs explained, "These are the cardinal signs of inflammation: rubor (redness), tumor (swelling), calor (heat) and dolor (pain)."
 
That summer, a red, swollen, hot, and painful joint found with juvenile arthritis was not the only medical condition I saw resulting from inflammation run amok. Other destructive examples included asthma, poison ivy, psoriasis, Lupus, and rheumatoid arthritis. Those years ago, I learned that we had anti-inflammatory medications to help patients with such unfortunate conditions, although side effects were considerable. In contrast, I also saw examples of how inflammation can be beneficial in fighting off invading infections such as skin abscesses, appendicitis, tonsillitis, meningitis and sinusitis.
 
Beyond this older and established knowledge, researchers have recently learned that beneficial muscle growth comes as a response to localized mild inflammation that follows exercise. Other studies show that low-intensity training, like walking, can reduce harmful chronic inflammation. All-in-all not only can our bodies be harmed when self-destructive inflammation turns against our own cells, but our bodies can be protected and even sculpted by the yin and yang of balanced and healthy inflammation.
 
Recently, researchers have learned of another yin and yang. We know that our bodies can recognize and remove, by inflammation, tiny cancers that pop up periodically. On the other hand, certain cancers can grow because of inflammation. This later finding has allowed for even more new therapies.
 
There have been great improvements in medicines relating to inflammation, compared to what we had during those early Watertown days. We can now, more effectively and with fewer side-effects, turn off harmful targets of inflammation, cool crippling arthritis, sooth devastating rashes and even, when used correctly, shrink certain cancers.
 
Rubor, tumor, calor, dolor . . . like a moth attracted to a sustaining or harmful springtime campfire.
 
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By Richard P. Holm, MD
 
Mr. S had gained some weight. His wife noted his snoring was getting worse and he was having spells when he would stop breathing during sleep. She informed his doctor who prescribed a home overnight oximetry test. This home test showed Mr. S’s oxygen levels were dropping dangerously low during much of night. The subsequent full sleep study indicated he would benefit from a continuous positive airway pressure or CPAP device. Five years later, the patient died from a heart attack, and the doctor found out that the CPAP machine stayed under his bed and was rarely, if ever, used. One study showed, despite its benefits, only 30 percent of those prescribed CPAP will actually use it.
 
An estimated 22 million Americans suffer from sleep apnea and the majority don’t know they have it. Their sleep is interrupted by snoring, choking and prolonged spells of low oxygen levels. Their days are troubled by fatigue, sleepiness, often abnormal heart rhythms and heart failure. Their risk of stroke over five years is two to three times higher than usual and risk of all-cause premature death three to five times higher. One estimate is that 38,000 annual deaths in the U.S. will occur from heart disease due to untreated sleep apnea.
 
Making the diagnosis is challenging. In 2016, we gave a standardized questionnaire to screen for sleep apnea to 67 people who were 70-years-old or older. Following that, we tested all 67 with home overnight oximetry. Of the 67 tested, 42 percent were normal, 31 percent had mild sleep apnea and 26 percent had moderate to severe sleep apnea. Conclusions from my study were that in this older age group, the commonly used screening questionnaires for sleep apnea misses the diagnosis half the time, about one out of four have life-threatening sleep apnea and, in this older population, women and men are equally burdened by this condition.
 
Anyone with heart disease, high blood pressure, obesity, a history of heavy snoring or observed spells of apnea (and maybe anyone reaching 70) would benefit from a home overnight oximetry test and, if this test is abnormal, from a full sleep study. If CPAP is prescribed, it would be wise for that individual to make every effort to use the CPAP device, knowing that this non-medicinal therapy reduces death rate by three to five times.
 
Many premature deaths, especially from heart disease, could be prevented by first discovering the diagnosis of sleep apnea and then, when apropos, by taking the CPAP cure.
 
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By Richard P. Holm, MD
​
After 40 years as a doctor interacting with patients, in the last two and a half years the tables turned, and I’ve become the patient. Although most are good, I’ve found some doctors are detached, some are too quick, some would rather be somewhere else, some are even angry; but, when a physician who cares walks into the room, and I’m not exaggerating, the day becomes better, the pain becomes less, and hope fills my heart. Scientific knowledge is important, but the ability to convey honest concern, human thoughtfulness and compassion is equal in importance in this healing profession. So, how do we select pre-med students for that, or teach compassion in medical school?

There are studies that show those interested in humanities or taught disciplines that explore how people tick, do better in the compassion department. These disciplines include history, literature, religion, ethics, anthropology, psychology, cultural studies and the arts of theater, film, painting and poetry. Some explain that the humanities give us the very reason to learn science and mathematics.

Several studies support the value of humanities in medicine. Seven hundred medical students were surveyed about their lifetime exposure to the humanities and the results indicated that those who had more humanities knowledge had more empathy, tolerance to ambiguity, resourcefulness, emotional intelligence and less burnout. Another study found that a med student’s ability to recognize diagnostic clues increased by more than 35 percent after taking a visual arts class. Another study found practicing improv theater helped med students learn to prepare for unexpected questions and conversations. A fourth study showed how writing exercises helped med students have foresight into what a patient may be experiencing. Clearly, an exposure to the humanities makes a better doctor.

I believe that care providers who have had a well-rounded humanities education have a better chance of understanding about how it feels to face pain, nausea, loss of bodily functions or even a cancer diagnosis. Those steeped in good literature or art have a better opportunity to tap creative juices to problem solve and tolerate a life that can be ambiguous and unpredictable. Those who are knowledgeable of history, ethics, cultural ways will find it easier to know when it is time to stop aggressive care and move toward comfort.
This is a call for all students to become readers, to find time to enjoy the humanities, to exercise your caring and compassion muscles; so, when you come into the room of a person suffering, it makes their pain less and day better.

​For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow The Prairie Doc® on Facebook, featuring On Call with the Prairie Doc® a medical Q&A show streaming live and broadcast on SDPTV most Thursdays at 7 p.m. central.          

By Richard P. Holm, MD

The world of radiology began in 1895 when a European physicist Wilhelm Röntgen noticed fluorescence behind heavy cardboard when a cathode tube was activated nearby. Röntgen used his wife’s hand to demonstrate for the first time how these unknown rays, or X-rays, could penetrate the soft tissue of her hand and illustrate the bones that lay within. Röntgen generously refused to patent his discovery which allowed the explosive growth and development of a new industry.

Unfortunately, researchers were unaware of the dangers of too much X-ray exposure and during the early years harm was done, even causing death of some experimenters before safeguards were established. Over time, as technology advanced and more X-rays were utilized, interpreting the images became an increasing challenge and the field of radiology developed. Physicians trained in interpretation helped care providers make better clinical decisions.

I was a first-year resident at Emory University Hospital in Atlanta in the fall of 1975 when the hospital purchased one of the earliest computerized tomography (CT) scanners. It was called an EMI scanner named after the British company that took a huge financial risk in order to develop the technology. Electric and Music Industries (EMI) had signed with the Beatles as their recording company in 1962 and having amassed a fortune from the exponential rise of Beatles popularity, EMI was able to fund the theoretical work of Godfrey Hounsfield which took X-rays of the head from all directions while a computer compiled the results. When all other funding resources said “no,” Hounsfield’s brainchild happened, “with a little help from his friends.”

I was rotating through neurology when the results of the EMI scans started making an impact. We were amazed how they showed tumors, blood clots and lesions inside the skull. We thought it was going to change everything, and indeed it did!

Jump to the present and see how interpretive radiologists have expanded into intervention. Now, instead of simply identifying a tumor or abscess with ultrasound, X-ray, CT, or MRI, radiologists, under the guidance of an imaging modality, can pass a needle into a deep tumor and take a biopsy, drain an abscess, open-up a blocked tube and much more. Procedures that, in the past, would have required open abdominal or chest surgery, now can be done with minimal trauma and pain with quick recovery.

As a patient who has benefited under the expert image-guided hands of an interventional radiologist, I too can sing loud and clear, “I get by with a lot of help from my friends.”

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By Richard P. Holm, MD

A.P. Kalem said, “War is never a lasting solution for any problem.” However, is that statement completely true? War, through the ages, has brought great advances and solutions in medicine.

Perhaps the first innovation in medicine that evolved during warring times came with drilling holes through the boney skulls of warriors whose heads were smashed in by clubs. Once a hole was made, one could insert a finger and pull out the caved-in skull bone with the added benefit of providing an escape hole for bleeding, releasing pressure off the brain. There are museums that have 7,000-year-old skulls with healed over burr holes, and this treatment called trephination, is still done today.

During the 1700 and 1800s, the world-wide imperialism of the British came from their conquering navy. This was partially because the Brits knew lime and lemon juice with vitamin C prevented scurvy which is a life-threatening progressive condition of profound weakness, gum disease, skin ulcers and bleeding. Opposing navies riddled with scurvy had no chance against the Brits.

During the Crimean War of the 1850s, Florence Nightingale and her team of newly trained nurses showed how nursing made a difference. They cleaned up injured soldiers, provided a warm dry bed, gave healing nutrition and, in general, cared for the soldier, which remarkably reduced the death rate by two-thirds. Nursing grew from that beginning.

The Civil War brought the advancement of anesthesia with easily used ether and the education of myriads of surgeons who spread their surgical skills throughout the country after the war. Also, the Civil War generated the development of the ambulance wagon, an effective method of transferring the injured from the battlefield to a place for treatment and comfort. For example, in the battle of Antietam, every wounded-living Union soldier was off the battlefield by the end of the day.

During the Boer War and World War I, X-Ray machines became available at portable hospitals, facilitating the repair of boney injuries. The field of orthopedics evolved as surgeons had growing trauma experience along with the aid of anesthesia and antisepsis. Also, blood transfusions and intravenous fluids came to be used during WWI and brought into reality how very sick people no longer had to die from dehydration.

Civil War General William T. Sherman said, “War is cruelty . . . and at best barbarism. Its glory is all moonshine . . . war is hell.” That said, in response to the terrible injuries and illnesses of war, we have learned and improved medicine in ways to relieve suffering and enhance healing during times of both war and peace.

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By Richard P. Holm, MD
 
Ms. A. was in the bagel shop line and told the server she was allergic to peanuts. The server reassured her there were no peanuts in the bagel but was unaware some peanut butter was left on the knife from an earlier sandwich. After a few bites of the bagel, Ms. A.’s face and lips started swelling, she itched all over, slipped off her chair, vomited and fell flat losing consciousness. When the ambulance arrived the emergency team kept her flat, gave an intramuscular injection into her thigh muscle of epinephrine (also known as adrenalin), then took her off to the hospital.  

Anaphylaxis is a severe allergic reaction that can follow exposure to an allergic trigger and will happen in the lifetime of one or two out of every one hundred people. Symptoms are secondary to the release of histamine and other mediators causing a severe drop in circulating blood pressure. Triggers can be from food such as peanuts, wheat, nuts, shellfish or milk, an insect bite or sting, or a medication like penicillin. The full list is long. 
Aside from avoiding the trigger in the first place, the single most important treatment for anaphylaxis is epinephrine which is a hormone released from our adrenal glands. There are few reasons not to give an injection of epinephrine if there is a chance that anaphylaxis is happening. Our bodies make natural epinephrine when we are faced with fight or flight situations. Antihistamines like Benadryl®, Claritin® and others have no role in the prevention or treatment of anaphylaxis as they only help the itch. The single treatment for anaphylaxis is epinephrine, period. Have injectable epinephrine available and near persons at risk and use it if worried. 

To obtain a self-injector of epinephrine, you need a prescription. There are now five types available and they all work well. Ask your pharmacist to get you the least expensive one and be sure you know how to use it.  
The price for a kit with two autoinjectors runs from $375 to $600. The cost to the pharmaceutical company to purchase one autoinjector from the manufacturer was reported as approximately $30 by NBC News in 2016 after a U.S. House Committee looked at the price of autoinjectors. I believe excessive markup of the prices of medicine by drug manufacturers or pharmaceutical companies is unethical and we need to pressure our national legislators to do something about it. 
Patients with anaphylactic allergies must know what to avoid, have epinephrine available, use it when necessary, and after any reaction see their provider. 
​
Ms. A recovered fine and never went without her epinephrine rescue injector again. 
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By Richard P. Holm, MD
 
Starting sometime in the middle ages, throughout many lands, there were “bonesetters” who knew about splinting, how to treat broken bones with splints made from sticks, leather and clay. They even had a guild, a medieval union of sorts, a cohesive group of workers organized to ensure quality, consistency and education. Medical schools for physicians existed at that time, but neither bonesetters nor surgeons attended those schools.
 
In the 1700s, Nicholas Andre’, a researcher and professor of medicine at the University of Paris, formally described splinting, a technique used by bonesetters, as a method to treat boney deformities, such as clubbed feet in newborn children. He likened it to the straightening of young tree saplings. Andre’ wrote a textbook on the subject entitled L’Orthopedie. The ancient Greek word orthos means free from deformity, to straighten; and the ancient Greek word paideia refers to the art of raising a child. Together they provide for the name of a present-day surgical specialty. Literally, orthopedics means to straighten the bent bones of children.
 
Surgical methods in the 1700s and 1800s were very immature. Anesthesia was first developed during the early 1800s and ether was widely used during the Civil War. After the war, surgeons brought their surgical experience home to small towns throughout the U.S. It wasn’t until after the war that we learned of bacteria and discovered we could avoid infection following surgery. In addition, X-rays were discovered by Wilhelm Roentgen in 1895, which allowed for the marvelous and revealing image of our internal boney structure.
 
These advancements helped set the stage for expanding the focus of orthopedics from casting and making-straight the boney deformities of children. In the 1890s, Evan Thomas, a well-known bonesetter from Liverpool, England, encouraged his son Hugh to go to medical school. While learning medicine, Hugh learned from his father bone setting and casting methods, which at the time were not being taught in schools. The younger Thomas was influential in bringing this curriculum to medical schools. He later set up practice with his nephew Robert Jones, and the two worked to develop orthopedic surgical methods in treating bone injuries in construction workers, and then war injuries in military men during World War I.
 
Thus, we trace the evolution from bonesetters, and straightening the bones of children; to anesthetized yet unsterile amputations during the Civil War; to bone setting taught in medical school; to surgical repair of boney injuries in World War I; to the marvelous ever-developing field of orthopedic surgery today.
 
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