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.