By Andrew Ellsworth, M.D.
 
The patient knew something was wrong. After appointments with several specialists, multiple scans, and tests, she was given a diagnosis. Still, she felt certain something was not right. I sat down with her and listened. We repeated a test she had a year prior, and this time the test garnered a different result. There was a tumor growing. She listened to her gut, she persisted and with an accurate diagnosis she got the medical care she needed.
 
Usually, it does not help to repeat a medical test. Nine times out of ten the result is the same. However, if as a patient, you get that feeling that something is amiss, seek out answers and find someone who will listen. That does not mean you need every possible test. Tests are costly. They are only a tool and using the wrong tool can cause more harm than good. 
 
Physicians are adeptly trained in the application of the tools of medicine. Throughout college, four years of medical school and another three or more years of residency training, an M.D. or D.O. invests over 10,000 to 15,000 clinical hours while learning the art of medicine. Ideally, as physicians gain experience and confidence, we learn to discern when a test is needed, and how to avoid an unnecessary test. 
 
Most importantly, a well-trained physician learns that listening to the patient history is a more powerful tool than any test. The history is the story of the patient’s current and past symptoms as told by the patient. It does not come from the chart, is not in a textbook, and cannot be determined by a blood test or CT scan. To obtain it, a physician must listen.
 
Unfortunately, physicians often interrupt a patient within the first 10 to 15 seconds of the visit. Pressures from time, from documentation, from insurance companies, and from the next patient that is waiting can contribute to the detriment of the interview. However, with careful listening and guidance from the physician, the patient will frequently provide all that is needed to reach an accurate diagnosis.
 
We can all learn more by listening. Whether listening to our bodies, our family, our friends, or even our adversaries, it is time well spent. When we take the time to listen, we are one step closer to the truth. You’ll feel it in your gut.
 
Andrew Ellsworth, M.D. 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 Kelly Evans-Hullinger, M.D.
 
Recently I saw a patient who had experienced two consecutive days of pain in his right upper abdomen. I questioned him, looking for clues of gallstones, liver mass, or maybe an ulcer in the small bowel, but his answers did not fit my expectations. The pain was located under his right ribs and radiated into his back, just as I would expect of gallbladder disease; but it was not triggered by eating, and the way the patient described the pain did not fit the profile of an abdominal disorder. Then, a lightbulb went off; I needed to look at his skin.

I examined his right back, and sure enough there it was: a cluster of red, blistering, lesions that the patient had not yet noticed. This was not gallbladder or liver disease; it was shingles.

Shingles is a skin eruption caused by a reactivation of the varicella zoster (or chicken pox) virus. In people who have had chicken pox earlier in life, the virus goes dormant in a spinal nerve. For most of us, it never again causes a problem, but in some people the reactivated virus can spread to areas of the body following the distribution of that spinal nerve, causing a painful blistered rash which looks like chicken pox.

The pain caused by shingles often occurs prior to the visible skin outbreaks making it easy to misdiagnose. In my few years of practice I have discovered shingles in patients complaining of ear pain, abdominal pain, and low back pain.

When administered early, antiviral medication can limit the duration of shingles and reduce the risk of post-herpetic neuralgia, a pain in the affected nerve distribution which lasts long after the rash resolves. At its worst, post-herpetic neuralgia can be a debilitating and life-long condition.

Fortunately, we have a highly effective vaccine that greatly reduces the risk of having shingles. The current shingles vaccine is FDA approved for people 50 and older and is much more effective than the previous version of the vaccine.

Thankfully, widespread childhood chicken pox vaccinations started in the late 1990s so decades from now, shingles may be a rare relic of the past in the United States. Until then, I will always remember to look skin deep when investigating a patient’s new pain.
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Kelly Evans-Hullinger, M.D. is part of The Prairie Doc® team of physicians and currently practices internal 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 Debra Johnston, M.D.
 
As a primary care physician, I walk with my patients as they face many of life’s challenges. Facing the diagnosis of dementia may be one of the hardest. Any chronic illness involves loss, but dementia threatens the loss of not only ability and independence, but of the very self.
 
It is important to realize that people with dementia can have rich and rewarding lives. For most patients there is an initial period where their losses are mild. There is likely time to work on that bucket list, to enjoy hobbies new and old, and laugh with loved ones, even if you are eventually playing Hearts instead of Bridge. While we grieve the loss of what was and of what we expected for the future, we can lose sight of what remains. It is a very human and very understandable response, but it can also waste precious time.
 
The early stages of dementia provide an important opportunity for patients and the people who love them to consider the future. People with dementia face the near certainty that they will eventually be unable to make decisions for themselves, decisions in keeping with values and preferences they have held all their lives. Developing an advance directive is something many of us put off for some nebulous “later.” Doing it now can ensure that our wishes are known and honored when we can no longer express them. It is also an incredible gift to give our loved ones. I’ve lost count of the number of times I have watched a grieving family clutch that piece of paper to remind themselves that “this is what mom wanted” as they make difficult decisions. 
 
Early on after the diagnosis is also a time to nurture relationships that will provide support for the person diagnosed with dementia and their care partner going forward. Professional help is available and sometimes the best option, but community support is invaluable, and irreplaceable. Family and friends can offer support and social contact, be it a cup of coffee and a listening ear, or a friendly round of golf, just like the old days. As the disease progresses, the support might be more substantial, such as a ride to the grocery store for someone who can no longer safely drive or keeping an old friend company so their spouse can go to the doctor, or get a haircut, or just take a break.
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As we have seen during the pandemic, suffering from any disease in isolation is lonely and frightening. Regardless of the diagnosis we might face, we can take the time now to make our wishes known and build up our community of family and friends. Ask for, and offer, support. As the old Beatles’ song suggests, we get by with a little help from our friends.  

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 streamed most Thursdays at 7 p.m. central.        

By Jill Kruse, D.O.

Whenever someone is admitted to the hospital, they are asked to stipulate their “code status.” Levels of code status include full code, meaning resuscitate and intubate if required; as well as various combinations of do not resuscitate (DNR) and do not intubate (DNI). In simple terms, a code status clarifies what you want the medical team to do in the event your heart stops or if your heart goes into a rhythm that is not compatible with life.

This question is often interpreted as follows: if you are about to die, do you want the medical team to do everything they possibly can to keep you alive? We might also allow ourselves to pose and interpret the question from a different perspective: If you are about to die, do you want permission to pass away peacefully?

When discussing code status with my patients, the answer I often get is, “Of course I want to live, do everything you can to save me.” TV and movies mistakenly portray emergency lifesaving measures working most of the time. In real life, attempts to resuscitate are not as successful. A review of more than 29 different studies involving 400,000+ people over the age of 70, show that only 19 percent survived to be discharged from the hospital. The odds were even worse for those in their 80s or 90s with survival rates of 15 percent and less than 12 percent, respectively. Of those who survived, less than half returned to the same status of living they enjoyed prior to the code. Most ended up not able to care for themselves independently. 

Another common response I hear is, “Do everything if you think it will work.” Doctors are incredibly optimistic. We are trained to fight against the odds to save lives. Unfortunately, no one can predict the outcome of a code. That is like asking if a slot machine will win before we pull the lever. Sometimes we hit the jackpot and the person does fine, goes home, and everyone is happy and grateful. Other times, like most slot machines pulls, we are forced to admit the loss.

The best person to select your code status is you. There is no “right” answer, there is only your answer. Give yourself permission to make this decision with a calm, clear mind before you are in crisis or admitted to a hospital. It is not in your best interest to make a rushed decision. Nor is it fair to force it upon your loved ones in an emergency room as your health is rapidly declining.
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It is okay to give yourself permission to change your answer over time as different circumstances arise. Share your answer with your family and your doctor. Then give yourself permission to be at peace with your answer.

​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 Andrew Ellsworth, M.D.
 
Do you know anyone who had influenza this past year? Chances are you do not. Sure, plenty of people had the “stomach flu” with vomiting and diarrhea, otherwise known as gastroenteritis. Some people had colds and others had COVID-19. But cases of influenza this season have been exceptionally low.
 
Starting a year ago, when someone came to my clinic with symptoms of influenza, including fevers, chills, muscle aches, or respiratory symptoms, we tested for both COVID-19 and for influenza. At first, every COVID-19 test was negative while many influenza tests were positive. However, with social distancing, mask wearing, washing hands, and people staying home when they were sick, influenza cases in South Dakota plummeted faster than I have ever seen. 
 
The charts put out by the South Dakota Department of Health speak for themselves. Every week they send out the latest influenza statistics and compare them to past years. The number of influenza cases forms something like a bell curve or mountain which peaks in South Dakota typically during the third week of February and then tapers down again. This year that line of cases for 2020-2021 is essentially flat, and this week we saw a slight increase in cases which will hopefully only form a small bump on the chart as opposed to a mountain.
 
Usually there are well over 2,000 confirmed cases of influenza in South Dakota each year, with almost 15,000 confirmed in last year’s season. In a normal year, many more people have influenza but go unrecorded because they are not tested. For this current influenza season, many people are being tested for COVID-19 and influenza at the same time. Despite thousands of tests, there have been only 55 confirmed cases of influenza in the state through the third week of February.
 
Over the last decade, influenza claimed an average of 32 lives each year in South Dakota. The worst season was 2017-2018 when 73 people died, and the fewest deaths occurred in 2015-2016 when 9 people died. We know that this past year, COVID-19 claimed the lives of more than 1,850 people in South Dakota. COVID-19 still managed to thrive even while influenza withered. The biggest reason is because COVID-19 is more contagious than influenza. Vaccinations and past immunity to influenza also help reduce its occurrence. 
 
We cannot stress how important and helpful everyone’s efforts over this last year have been toward keeping the numbers of COVID-19 down as much as we could to “flatten the curve” and avoid a catastrophe with everyone getting sick at once. We are not out of the woods yet, but we are getting closer. As far as influenza goes, it would appear that washing our hands, staying home when sick, social distancing, and wearing masks have drastically helped to minimize the spread.
 
Andrew Ellsworth, M.D. 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 Kelly Evans-Hullinger, M.D.
 
Last summer we heard the prediction that by the end of 2020, we would have a safe, effective vaccine to the SARS-CoV-2 virus, which had only been discovered, of course, in December 2019, before causing countless deaths and mayhem in the world as we knew it. I must admit, I was skeptical.
 
Early in the pandemic, I learned that the fastest a vaccine had ever been developed was for the mumps virus, an effort which took four years. Even with all possible resources devoted to a COVID-19 vaccine, how could we ever do this in one year? Before I could even ponder this, however, my curiosity took me down the rabbit hole of the mumps vaccine.
 
Maurice Hilleman, to whom the mumps vaccine is credited, is something of a superhero in the world of virology and vaccine development. Over the course of his career, he was involved in the development of 40 vaccines, including an influenza vaccine in 1957 estimated to have prevented hundreds of thousands of deaths.
 
One night in 1963, Hilleman’s young daughter Jeryl Lynn awoke him from sleep. She was feeling sick.  Hilleman saw the telltale swelling of her salivary glands and knew she had the mumps. Mumps was a common childhood ailment, and while most children got mild illness including the classic swollen cheeks, it also caused aseptic meningitis, deafness, and infertility in males. Hilleman put Jeryl Lynn back to bed, then drove to his lab to retrieve a swab and culture media. He returned and awoke young Jeryl from her slumber to swab her mouth.
 
Over the next four years Hilleman cultured and tested the Jeryl Lynn strain of the mumps virus until it was safe enough to administer without the risk of illness but still effective in generating an immune response against a normal mumps virus. Jeryl Lynn was present when her younger sister Kirsten was publicly immunized with the new mumps vaccine as a small child. As a result of Hilleman’s vaccine, the United States now has only about 200 cases of mumps per year, compared to 200,000 per year before the vaccine.
 
Back to that COVID-19 vaccine. Well, my timeline skepticism was unwarranted. In December 2020, data published on two separate vaccines using mRNA technology showed without ambiguity that we did have safe, effective vaccines just one year from the start of this pandemic. How so quickly? We can give credit to a modern technology being ready for this problem and the intellectual weight of thousands of scientists around the world. I think even Maurice Hilleman, the father of modern vaccines himself, would be impressed.
 
Kelly Evans-Hullinger, M.D. is part of The Prairie Doc® team of physicians and currently practices internal 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 Debra Johnston, M.D.

I’ve learned a lot from my patients over the years. Sometimes, the lessons are learned as I walk beside them through struggles, both medical and non-medical. Sometimes, the lessons are explicitly stated, words of wisdom that stick with me through the years, and change the way I understand illness, or life in general.

The first such lesson I remember was from a middle-aged woman who had been diagnosed with type 1 diabetes only a few years prior. She came to me with blood sugars that ran critically low in the middle of the night, but sky high during the day. The situation only worsened when she tried to adjust her insulin. Back in those days, our tools for managing diabetes were far more limited, and our insulin regimens far more rigid.

After we adjusted her dosing so that the peaks and valleys of her insulin effect were a better fit for her life, we started fine tuning the control of her blood sugar. We needed to balance her insulin, with her activity, with her food. This is when she said to me, “Diabetes is the original do-it-yourself disease.”

The truth of this statement resonated with me then, and I still hear her words almost every time I see a person with diabetes 20 years later.

The stakes are high. Control of blood sugar is directly correlated with the odds of developing one of the terrible complications of diabetes, such as blindness, strokes, heart attacks, kidney failure, amputations, and nerve damage.

That control rests in part with our medicines, but the real challenge of diabetes lies in the fact that success depends on changing habits, and that is difficult indeed. People with diabetes are asked to change the way they eat, the way they move, the very way they live. They are often asked to monitor their blood sugars, which to date has meant pricking their fingers to take blood, and to make decisions based on those results, sometimes multiple times a day. Then, do it again tomorrow, and the next day, and the next day. Additionally, diabetes medications and supplies are awfully expensive!

There is some hope: new technologies are making it easier to handle the mechanics of managing diabetes, and new medicines are allowing more flexibility in lifestyle. But the burden of success still rests very much on the shoulders of the patient, to balance medicines, with activity, with food, in all the decisions he or she makes every day.  

Diabetes is no doubt, the do-it-yourself disease.
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Debra Johnston, M.D. 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.
 
Many people are familiar with the classic Abbott and Costello comedy skit “Who’s on First?” For those who are not familiar, the routine is a hilarious interaction between the two comedians as they discuss players on a baseball team while using confusing references such as “who’s on first” and “what’s on second.” The audience can see that Abbott believes he is clearly communicating the player names to Costello, but it digresses into a laughable experience of misunderstanding and frustration for both parties. The men become increasingly angry as the conversation goes on and each feel that the other is not listening. 

This situation may be funny in the world of entertainment, but it can be disastrous when it happens between doctor and patient. At times, conversation in the exam room can inadvertently go down a similar path of confusion. I recall one such experience when I was showing an x-ray to a patient. I pointed out, “Here is the fracture.”  The patient looked at me, gave a sigh of relief and said, “Thank goodness doc, I was afraid you were going to tell me that it was broken.” At that moment I realized my choice of words had not provided the clarity I intended. Thankfully, this patient spoke out which alerted me to the misunderstanding allowing me to rectify it immediately. 

Those of us in the medical field must be always mindful to ensure that we explain things in clear, everyday language. I apologize for our failures, which do happen. I also ask for your help. Doctors are human and we may incorrectly assume that our patients understand what we are saying, especially if our patients do not tell us otherwise.

Healthcare is a partnership which requires communication from both patient and doctor. It is important to recognize that not all cultures and generations feel empowered to question a doctor. Other patients hesitate to ask what they feel might be perceived as a “silly” question. In addition, patients have varying levels of education and experience when it comes to participating in medical conversations. Sometimes it helps the patient to have a family member or friend in the room to help the patient feel at ease and convey information.

Doctors strive to be sensitive to these situations, to welcome and encourage questions, then listen closely when the patient speaks. No doctor I know will intentionally or maliciously confuse a patient. We welcome your participation so both patient and doctor can best understand what care is needed. Let’s work together and keep the conversation going to make sure we both know “who’s on first” and “what’s on second” when it comes to your health.”
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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 Andrew Ellsworth, M.D.
 
The feeling of pressure and pain in the front of the face around the eyes is all too familiar for millions of Americans. Our sinuses include four pairs of air-filled cavities above and below the eyes and behind the nose. They are helpful for humidifying the air we breathe, resonating our voices, and lightening the weight of our heads. However, the sinuses can be prone to inflammation and infection. 
 
The mucous lining of the sinuses serves as an antimicrobial barrier to infection, and little hairs called cilia help to sweep out unwanted bacteria and viruses. Disruptions to this system commonly come from allergies and viruses. If the passageways get blocked, then bacteria can grow and flourish in the moist, warm, mucous.  
 
Sinusitis is inflammation of the sinuses which can cause the full feeling behind the eyes, pressure, and pain. If left untreated, it can cause fevers and a systemic response from the body. Chronic sinusitis, lasting more than three months, can be caused by allergies, nasal polyps, ongoing infection, a deviated nasal septum, pollutants, or other conditions. 
 
One of the keys to treatment and prevention of sinusitis is keeping the sinuses open and draining. Nasal saline, a saltwater mixture, can be used to help rinse out and open the sinuses and can be just as effective as antibiotics. If allergies are at fault, a steroid nasal spray or steroid pills can be used to decrease inflammation and swelling. A nasal steroid spray can also help treat a nasal polyp, helping to shrink the polyp to aid in the circulation of air and mucous. For some people with chronic and recurring sinusitis, surgery is their best option and can provide welcome relief.
 
Try this. Hold one nostril shut as you breathe in and out of the other. Now switch to the other nostril and breathe in and out. Chances are you can breathe more freely on one side compared to the other. Wait a few hours, try it again and chances are the opposite side is more open. Congestion in our nose naturally changes sides every four to six hours. If you find that one side is always blocked, then you may want to see your primary doctor or an ear, nose, and throat specialist. 
 
Our bodies are designed for flow. The flow of air, food, blood, waste, and even mucous keeps us healthy. Next time you blow your nose, remember you are helping the natural movement of mucous, so just “blow with the flow.”
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Andrew Ellsworth, M.D. 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 Kelly Evans-Hullinger, M.D.
 
It was my first month in the hospital as a new internal medicine intern at a large university hospital.  Upper-level residents that I met during orientation asked me, “What is your first rotation?”  When I answered, “hepatology,” the looks I got in response told me I was in for a tough initiation.

The hepatology service included some of the sickest patients in the hospital. Each one had either end stage cirrhosis or a liver transplant, plus some acute condition requiring them to be in the hospital. They were so complicated, making clear to the newly minted Dr. Evans that a healthy liver is critical for the body to function normally.

Cirrhosis (scarring of the liver) is the undesirable result of many types of chronic liver disease. Many causes of liver disease occur at random, related to autoimmune or genetic origins. However, the most common reasons patients develop cirrhosis are alcohol related liver disease, hepatitis C, and non-alcoholic fatty liver disease, all of which might be controlled if we catch them before cirrhosis develops.

Most people know that chronic heavy alcohol use can result in cirrhosis. We don’t fully understand why some heavy drinkers develop cirrhosis and some don’t, but longstanding alcohol abuse does typically result in some degree of liver damage. Though it can be very difficult, stopping alcohol intake can, in turn, stop progression of liver damage in most patients with alcohol related liver disease.

Hepatitis C, a viral infection which in some people becomes chronic and can ultimately lead to cirrhosis, has been the most common reason for liver transplant in the United States in recent years. With major developments in treatment for this disease over the last decade, we now have highly effective and well tolerated antiviral treatments to cure hepatitis C. This virus can reside in the liver and bloodstream without causing symptoms for decades. Current recommendations advise that we screen for hepatitis C in patients who have significant risk, including all Americans born between 1945 and 1965 in addition to other high risk groups. Talk to your doctor if that includes you.

Nonalcoholic fatty liver disease (NAFLD) is increasingly prevalent and now is among the most common reasons for liver failure. NAFLD is thought to be due to metabolic factors resulting in fatty deposition in the liver. It commonly occurs along with other metabolic diseases such as obesity, diabetes, and high cholesterol. Treatment of NAFLD is focused on diet and exercise and controlling those other metabolic diseases.

That one month as a new physician on the hepatology service was enlightening. I learned so much about the importance of a healthy liver, and I continue to use those lessons regularly in primary care.
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Kelly Evans-Hullinger, M.D. is part of The Prairie Doc® team of physicians and currently practices internal 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.