​By Richard P. Holm, MD
 
Mrs. B came into the emergency room one night, years ago, with some stress related issue. After taking her history, I began to suspect there was something else bothering her. As I was beginning her physical exam she blurted out, “I know there is a breast mass but you’re not going to send me to any breast cancer doctor!” She had already decided to avoid standard treatment and her next comment explained why, “My aunt suffered because of awful unnecessary surgery and chemotherapy,” she said. I sensed there was no changing her mind and that meant trouble for my patient.
 
The story evolved as my patient’s breast cancer grew and eroded through her skin to become a weeping and tender sore. She soon sought out unconventional treatment by a non-physician from a neighboring town with an internet degree of some kind who promised to help her. The treatment involved a curious machine with flashing lights and an unusual noise which apparently indicated which group of herbal supplements the patient needed to buy in order to cure the cancer “naturally.”  
 
More women are diagnosed with breast cancer than any other malignancy, except for skin cancer. If the breast cancer hasn’t spread outside of breast tissue, then, with treatment, the five-year survival is about 99 percent. If the cancer has spread to lymph nodes just outside the breast, then, with treatment, the five-year survival is about 90 percent. Even if the cancer has spread to distant parts of the body, which happens only in about six percent of the cases, then, with treatment, more than 25 percent are still alive after five years. Since 1989, the number of people who die from breast cancer has been steadily decreasing which is the direct result of improved methods for breast cancer screening, detection and treatment.
 
My patient died less than a year from our meeting in the emergency room. I still regret not convincing her to get help from a science-based breast cancer physician. She may have lived years longer and in more comfort. Many people are now being saved who were previously lost to all types of cancers. Even when lifesaving is not possible, current cancer treatment can at least improve the quality of the time that remains.  
 
Bottom line: The fear of death and the fear of suffering keep some people from seeking medical help. Please shed those fears and seek science-based help.
 
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
 
During one of our weekly hospice meetings, the discussion turned to the burden of finding an opening in a facility for one of our patients. Mr. A belongs to the working-poor segment of our society, just above official levels of poverty and yet he cannot afford health insurance and primary care, let alone the private cost of an assisted living center or nursing home.
 
Our patient is still living at home, has no family support and is in trouble. His progressive cancer has caused an inability even to do activities of daily living such as bowel and bladder care. He now only has Medicaid and his hospice nurse and social worker is not able to find an assisted living center or a nursing home that will take him in.
 
It’s no surprise that care facilities in South Dakota find it financially difficult to accept Medicaid patients like Mr. A. Without Medicaid expansion, facilities lose money when caring for them. If a nursing home has too many Medicaid patients, it simply can’t stay afloat. This explains why nursing homes, especially in rural areas, are closing.
 
The national solution was to expand Medicaid coverage to increase payments for services using federal dollars. Some states initially elected not to expand Medicaid, for fear they would become dependent on this money. However, many states have changed their position, and to date, 36 states now accept the national funding from expanded Medicaid, including North Dakota as of 2014, and Nebraska in 2018. So far, 14 states have not expanded Medicaid, including, South Dakota, Kansas and Wyoming.
 
If Medicaid was expanded in South Dakota, more than two billion dollars of federal health care funding would come into the state, helping healthcare coverage to 55,000 South Dakotans, in turn, helping to prevent rural nursing homes from closing. This would help Mr. A, and people like him, get comfort care during their dying days.
 
Medicaid expansion passed last year in some majority Republican states indicating that this is a bipartisan issue. A recent poll revealed that approximately 80 percent of South Dakotans want Medicaid expansion. In my opinion, fearing dependence on federal money does not justify letting our rural nursing homes close or letting the working-poor go without care.
 
Bottom Line: It is time for those within the political arena to expand Medicaid.
 
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.                

Richard P. Holm, MD
 
My patient was in severe pain, suffering from an obstruction in his gastrointestinal tract as a result of spreading cancer. I knew that morphine, one of the opioids, would provide immediate and merciful relief, and it did. We are thankful that we have something that can palliate pain and provide comfort for severe acute pain, especially for patients at the end of their lives. That’s good!
 
In contrast to the good that opioids can do for certain acute pain, we know they are not very effective for musculoskeletal or neuropathic pain and fail terribly in helping long term pain and chronic pain syndrome. Despite this inadequacy, opioids are still being over-prescribed for most post-operative musculoskeletal pain.
 
Also, our bodies quickly develop tolerance to opioids, thus continually requiring increased doses to get the same effect. In addition, withdrawal symptoms from opioids can be significant making it difficult to stop taking opioids once hooked. It is estimated that about 75 percent of those taking illicit opioids got started from a prescription, more than 100,000 people are regularly using heroin and about 12 million people are taking non-prescribed illicit opioids. That’s bad!
 
It gets worse. Opioids have an insidious potential for overdose which depresses the drive to breathe so much as to suffocate people to death. In the U.S., it is estimated that about 70,000 people die each year from opioid overdose. In comparison, 83,000 die from diabetes, 56,000 from influenza and pneumonia, 47,000 from suicide and 40,000 from motor vehicle crashes. That’s very bad!
 
Ultimately, care providers need to prescribe opioids very judiciously and people must be careful when taking prescribed opioids. AND people need to avoid dangerous illicit forms. We do have an antidote to opioid overdose called naloxone (or Narcan®). If given soon enough, it displaces the opioid from the brain pain receptor and the victim starts breathing again. Thus, every ambulance and emergency room have multiple doses of this lifesaving reversal agent readily available.
 
Unfortunately, in response to this opioid epidemic, the drug manufacturer of naloxone, which costs 50 cents to six dollars to make, raised its price up to $4,000 for a dual pen auto-injector. Fortunately, a generic version will be available soon with a two-pack of auto-injectors for $180. Until then, we pay the higher price. That’s ugly!
 
Bottom line: If we hope to find help for this crisis, we need to understand the good, the bad and the ugly about opioids.
 
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                                                      
 
This week I spent some time exploring the origins of the word, kind: It comes from Old English gecynd (YEH’-kund) or cynn (kyn), meaning nature, race, family. Another Old English word kyndnes (KIND’-nes) means “nation,” which I interpret as a subtle and ancient nod toward kin, kinship and our common bond in support of our country. Modern dictionaries define the word kindness as the quality or state of being generous, helpful, caring and giving. Synonyms include tactful, good hearted, neighborly, forgiving and gracious.
 
Sometimes I only understand something when I explore it’s opposite or antonym. For example, I had to think about mental illness to better understand mental health; about hate to better understand love; about depression to better understand joy. The antonyms of kindness are words like mean, cruel, malicious, spiteful, malevolent, even despicable.
 
Where is the intersection of kindness and medicine? In years past, admission committees for medical school have searched hard to find the very smartest college graduates and they were able to do it. Certainly, physicians need the intellect to understand the complexity of human health and continue a lifetime of learning. However, we have realized that searching for students by intellect alone might graduate medical students who don’t always develop good bedside manners and a capacity for compassion. More recently, some of the best medical schools have added kindness and compassion programs to their curriculum.   
 
I didn’t have the benefit of such a program when I went to medical school, however, over my 40-year medical career, I’ve learned to recognize the healing power of kindness in medicine. I’ve seen it in the nursing staff caring for folks living in a small-town long-term care facility. I’ve heard it from medical providers, nurses and technicians caring for people in clinics, ERs, hospitals and in hospice programs. I’ve heard it from kind supportive friends who have offered or driven me for chemo; from jolly laughing buddies who raise my mood; from my care team as they gently hook me up for my next infusion; from our kids who call to check on me; and from my loving wife who is at my side warming me when I’m chilled, picking up my burdens with unending daily kindnesses as I struggle through these side-affects. It’s a good thing she doesn’t love me for my hair.
 
I am happy that our medical schools are teaching young doctors that people deal with illness so much better when it comes with a generous dose of kindness.
 
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.