By Richard P. Holm, MD
Joe was a middle-aged guy, smart and full of personality. He had developed Hodgkin's lymphoma a number of years back, had chemotherapy and radiation to his chest as part of his treatment, which successfully shrunk the malignant lymph nodes there, and brought him back to a normal cancer-free life.
Recently he had been waking up in the night feeling like he was suffocating. He told me he would go to the window, throw open the sash, and breath in the cool autumn air to get relief. For a week now he found that he was more comfortable sleeping in the recliner. He had also noted that he had been having trouble walking any distance and he got short of breath just coming up from the basement.
On exam, as I listened to his lungs I could hear crackles, and as I listened to his heart I noted it was beating a hundred times per minute sounding like a horse galloping. His neck veins seemed distended and there was swelling of his ankles. He wondered if there was something wrong with his lungs.
The problem was not with his lungs, but rather with his heart. Although the name for his condition is called congestive heart failure, I think the word failure sounds too doomed and guilt-ridden. I would rather it be called heart weakness instead, because we have treatment to remove the excess water, ease the load on his heart, and there shouldn't be doom or guilt about it.
Normally blood returns to the heart from veins into that mighty pump as it fills and dilates during the relaxation phase. When the heart squeezes, the entrance valves slam shut, and the only way out is past the exit valves. Repeating this cycle with relax-then-squeeze past one-way-valves, the heart pump pushes blood out to supply every cell with the oxygen and nutrients needed to flourish.
Causes for heart weakness are myriad including long standing high blood pressure, blockage of coronary arteries, a life-time of excessive alcohol or inadequate nutrition, viral infections of the heart muscle, valves that leak or are too tight, and the list goes on.
Joe's heart was weak partly from radiation injury and probably from a viral infection. Just the right balance of medications gave him relief and hope for a future.
By Richard P. Holm MD
One early morning, I was walking toward the back door on my way to work when suddenly there was a big bat flying around the breakfast room, swooping around like in a Dracula movie. As it came near me, I reactively swung at it and like hitting a Nerf ball, it was thrown across the room landing on the kitchen floor a little stunned. I closed all doors to the rest of the house, locked open the exit outside, washed my hands thoroughly, and shooed the creature out into the early morning darkness.
Bats are a marvel of evolutionary diversity with something like 47 different species living just in the U.S. and important by their contribution to our ecosystem. Experts believe that these winged animals first developed powered flight and later the ability to chirp and recognize their echo and thus their location. This capacity for radar-like-echolocation became so refined as to allow flying at night or in a cave without light. Bats eat their weight in bugs every night, carry seeds to reforest depleted wooded areas, and pollinate plants.
But one percent of these little flying mammals carry a deadly virus called Rabies. Stricken with Rabies, the victim, whether bat, dog, skunk, cat, or human, turns confused, agitated, aggressive, and infectious. Although not like a movie Zombie, which has returned from the dead, those bitten by one infected with this age-old condition, left untreated will certainly die.
So, after striking down the bat, did I need to receive Rabies Post Exposure Prophylaxis (RPEP) to protect me from coming down with Rabies? This involves four doses of Rabies vaccine over 14 days, and one injection of active immune globulin. Checking out the last 15 cases of Rabies over five years in the U.S., nine were from bat exposure, four from dogs, one from a fox, and one unknown. All but one died, and the one survivor is neurologically disabled. This left me concerned.
The CDC recommendations advise having RPEP if there has been a bite or an exposure to saliva into eyes, nose, mouth, or open wound. This was unlikely in my case and official recommendations say hand-washing is extremely important.
So I did not seek out RPEP as I did not receive a bite, the bat was acting normally, and I washed my hands well after touching the bat, although I did have a few restless and on edge nights.
Still, don’t let me bite you if I start acting like a Zombie.
By Richard P. Holm MD
The leading cause of blindness worldwide is from cataracts. That is the clouding and browning of the natural lens, which is mostly due to aging and sun-damage. It is like the difference in swimming with goggles in a crystal clear pool versus in an algae-blooming prairie lake in August. People with cataracts progressively lose their vision as their lens opacifies.
More than 2600 years ago, a physician from India was the first to write about cataract surgery. He described using a curved needle to push back completely clouded over lenses into the vitreous fluid in the middle of the eye, out of the field of vision. This reportedly would return some vision for people completely blinded in that eye by a cataract, and he called it “couching.”
The vitreous is the sack of fluid that separates the iris, pupil, and lens at the front of the eye from the retina or light sensitive nerve blanket that catches the image in the back of the eye and sends the photo message to the brain. Pushing or couching cataracts back and hopefully to the side into that vitreous would allow light through to the retina, however the vitreous would be disrupted, could possibly become infected, and there would be no lens to focus the light. Still this was better than nothing.
Couching cataracts eventually spread to China, Arabia, Africa and Europe, but it is not difficult to understand why this procedure was used only as a last resort. Other methods to remove the lens completely from the eye, without disrupting the vitreous, gradually were developed during the Middle Ages and up unto today. But until we learned how to control infection in the mid-1800s this was still very dangerous and not commonly done. Eventually very thick external glasses were devised that would replace the lost natural lens, and starting in the 1940s these removable glasses began to be replaced with lenses that are surgically implanted into the eye.
Now the surgery to extract opaque and diseased cataract lenses is much better, and keeps improving. And the lenses we implant continue to advance as well.
It is like cleaning out all that vision blocking algae, and swimming in a crystal clear pool.
By Richard P. Holm, MD
The word pneumonia was said by Hippocrates himself to have been "named by the ancients" before him. As old as it is, pneumonia is still a cause of great human suffering, but we now have better weapons to fight it.
In a small percentage of cases, especially in the immunocompromised, a bacterial lung infection can follow several days after a common cold. Symptoms then would change from a dry cough into a productive cough, creamy-sometimes-rusty-sputum, shaking chills and sweats, and chest pain. It's important to note that antibiotics for the common cold DO NOT prevent a secondary bacterial pneumonia, but antibiotics started after the bacteria grab ahold can be life-saving. It's all about the timing.
About 50 percent of pneumonia is due to the pneumococcus bacteria, now named
Streptococcus pneumoniae. Sir William Osler said in the late 1800s that pneumonia is "the captain of the men of death." Prior to antibiotics, more than 30% of all those hospitalized for a bacterial infection of the lung would die. With antibiotics, that number dropped precipitously, but still people do die of pneumonia. Mostly they are very young or very old, related of course to their undeveloped or weakened immune systems.
This July, the New England Journal of Medicine reported since 2000 there has been a huge drop in hospitalizations for pneumonia, with 12,000 fewer deaths every year especially in those older than 85. What's most amazing is it happened since the advent of routine childhood Streptococcus pneumoniae vaccination also called PREVNAR.
Although a similar and effective pneumonia vaccine, PNEUMOVAX, is available and highly recommended for those older than 65, or younger with lung disease or diabetes, it has not become routine. The authors of the study claim that it is the routine vaccination in children that's responsible for most of the reduction of pneumonia in the elderly. They call it herd immunity. Children vaccinated against pneumonia certainly are benefited, but also it profoundly protects the immune deficient adults around them.
Take home message: it is wise to have children and adults vaccinated against the dreaded Strep pneumoniae. Indeed, the "captain of the men of death" has been demoted by antibiotics and vaccinations; both modern developments of science fighting against an ancient disease.
By Richard P. Holm M.D.
The word pain has many definitions. In general, pain represents an unpleasant and harmful physical or emotional experience with a purpose. It is something to be avoided, helping us withdraw from destructive circumstances, protecting our bodies while we are healing, or encouraging us to avoid from danger. Helping people deal with pain is the most common reason people go to the doctor and I should add is also the most common reason people use alternative medicine.
It is important to realize that people have different kinds of pain.
A 50 something year old man came into my office this week with abdominal pain. It was dull, cramping, nauseating, and drove the man to stand up from his chair and walk around the room ineffectively trying to find a comfortable position. The differential diagnosis included gallstones, pancreatitis, appendicitis, or an intestinal obstruction. With testing I defined the diagnosis in order to eventually give him relief.
A 20 something year old blond woman came into the Emergency room with severe sun burn. She forgot to put on the sunscreen before she climbed into the boat, and three hours later after all that beer and fun she realized she was in trouble. Her bright red color and blisters indicated the extensive first and second degree burns and it didn’t take a medical degree to tell that she was miserable. Pain medicines and salve helped.
A 30 something year old with a ten year history of migraine headaches presented to the office with another pounding one-sided headache, and as I entered the room she was curled up on my examining table, the light was off, blinds were pulled, and her eyes were squinting and watering. I gave her a combination of pills, which helped put her to sleep, allowing the vessels and muscles in spasm to let go and give her relief.
A 70 something woman lost her husband to a month long struggle with multi-system failure starting with heart, then brain, and then the tough decision to stop life support and let go. I watched how she deeply suffered, dove back into work for distraction, and finally came to relief of pain through connectedness with family, spirit, and friendship.
The word pain has many definitions.
By Richard P. Holm MD
In 1974 in Ethiopia’s Awash Valley, a 3.2 million year-old skeleton of an ape was discovered that was different than other ape skeletons. The knee bone shape, along with pelvic architecture, indicated that this ape walked upright. As the Beatles music “Lucy in the Sky with Diamonds” was playing in the background, archeologists speculated that this could be the long sought link between apes and humans, and the upright walking individual was famously nicknamed “Lucy.” Her brain was small and ape-like but she walked upright.
This was evidence that the upright position might have come first. They speculated that standing tall allowed for the evolutionary advantage of having a better view of approaching enemy or mate and all the rest followed. Could it be that the special design of an upright knee allowed for the first big step toward the evolution of humanity? And what is so special about this design?
The knee is a hinge joint mostly held together with four ligaments. The two “collateral” ligaments run along the inner and outer sides of the knee keeping our legs from bending inward (knock-kneed) or outward (bowlegged).
The more noteworthy structures however are the two tough fibrous ribbon ligaments, which cross each other, front to back, on the inside of the knee forming an "X.” This explains why they are called the cruciate or cross-like ligaments.
The anterior cruciate ligament or ACL starts at the back of the thighbone or femur above, crosses to connect at the front of the shinbone or tibia below, and keeps the lower leg from sliding forward. The posterior cruciate ligament or PCL starts at the front of the thighbone, crosses to the back of the shinbone, and keeps the lower leg from sliding backward.
What is so ingenious is how these crossing ribbons provide for such stability, and yet at the same time, allow for the bending of the knee. So it is as Gerard Manley Hopkins the Priest poet said: “The world is charged with the grandeur of God.”