By Richard P. Holm, MD
 
Starting in 1805 through 1858 the Dakota Indian people living in Minnesota were, by U.S. government treaties, gradually cut out of their traditional hunting areas. In 1861, crops failed, winter was severe, meager federal payments were late and Dakota children were starving. By August of 1862, desperation moved some of the Dakota Indians to attack white homestead farmers and families and the state militia responded. War was on.
 
After six weeks of fighting the Dakota warriors surrendered and 303 men were sentenced to death by hanging. President Abraham Lincoln commuted many but left 38 Dakota men to hang in Mankato, Minnesota just after Christmas 1862. Those commuted were shipped to prison in Iowa where more than a third died as conditions were so poor.
 
Although many Indian people did not go to war, white hatred of all Indians grew like a prairie fire. Within a year, a $25 bounty was paid for the scalp of any Dakota Indian found free within the state. Lives were lost on both sides of that war, but the Dakota Oyate (Oyate means people) lost their lands and their culture. Pride and family traditions were severely compromised affecting many generations to come.
 
First introduced by mental health expert Maria Yellow Horse Brave Heart, Historical Trauma Response is a societal diagnosis now used by psychologists and historians. It refers to the cumulative, transgenerational, traumatic experience which causes long-lasting injury to communities, cultures and descendants, like that of the American Indian. Another example of HTR is the African American slave experience.
 
Experts state that HTR may cause smoldering animosity between groups as well as poverty, alcohol abuse, violence, depression and suicide behaviors. How can this be treated without compromising a culture’s traditions? Do ancestors of immigrant Europeans have a societal responsibility to right a wrong? Does smoldering animosity block the path to healing?
 
I believe prejudice hurts all of us. Hate poisons the well, even if it is “inherited hate” that came from more than 200 years of conflict and violence. It is time for European descendants to free ourselves from the bonds of historical bigotry and better understand the perspective of the Indian people. It is time for people of all races to stop hating and find ways for cultural healing through spiritual kindness to each other.
 
Lakota leader and mystic Black Elk said, “The bison were the gift of a good spirit . . . and from the same good spirit we must find another strength.”
 
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 SDPTV most Thursdays at 7 p.m. central. 

By Richard P. Holm, MD
 
For years I cared for a young gentleman with recurrent leg swelling associated with redness, fever, pain and open sores between his toes and lower legs and the rash of athlete’s foot. Once again, the emergency room doctor admitted the patient, and started him on intravenous antibiotics while the nurses put on support hose and encouraged him to elevate his legs.
 
There are two types of blood vessels making up “the vascular system.” Going away from the heart, blood is pumped through arteries providing oxygen and nutrients to almost every cell in the body. Coming back to the heart, blood travels through veins, oxygen depleted and loaded with waste. When venous blood passes through the kidneys, liver and lungs, waste is removed.
 
When arterial flow is blocked, pain, loss of muscle strength and open sores develop. In contrast, when venous flow is blocked, swelling and congestion occur which can also reduce arterial flow. Most dangerous, poor venous flow can result in blood clots.
 
Reversible causes for arterial blockage include regularly eating too many calories, not getting enough exercise, smoking and failing to connect enough with people and nature (which is entirely under-rated). Others may talk about pills and supplements, but the plain truth is that nothing comes close to these healthy lifestyle habits in preventing premature obstruction of arteries.
 
A list of preventable or treatable causes for vein and venous obstruction with swelling in the legs is long. It includes congestive heart failure, inherited varicose veins, jobs that require prolonged sitting or standing in one place and leg trauma, all of which injure vein valves, make edema worse and increase the risk for clots. Clots developing in veins are dangerous. They can move to the lungs, threaten life and worsen swelling.
 
My young patient had a combination of foot fungus (athlete’s foot) and bacterial infection growing in toe cracks and leg sores. He also had venous insufficiency (the valves in the veins were destroyed) and new blood clots, possibly triggered by the fungal and bacterial infections. His condition was complicated, indeed! We elevated his feet even higher, increased the pressure of his support hose and added medicines including a low dose diuretic, an anti-fungus medication and an anticoagulant. His leg swelling resolved and stayed that way, especially because he wore 20 pound below-the-knee compression hose.
 
Bottom line: The vascular system makes up an incredibly complex organ system. Please take measures to protect blood vessels by understanding the values of a healthy lifestyle and, when needed, wearing firm below-the-knee support hose.
 
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 SDPTV most Thursdays at 7 p.m. central.            

By Richard P. Holm, MD
 
In 40 years of practice, I have seen how the final moments of one’s life can be inspiring or agonizing, no matter the manner of death. As I see it, the fear of death is a greater enemy than death itself. This has brought me to make the following recommendations for approaching our final moments.
 
Be prepared
Scientific advances, along with health care providers’ driven desire to save lives, have wrought lifesaving techniques that sometimes cause suffering (an unintended consequence). To correct this, making an advanced directive (living will) can help prevent great suffering. Going without is like arriving at the airport with no plans as to where you are going. Remember, a written advance directive is a tool to encourage discussions about end-of-life expectations. When you reach your end-of-life situation, do you want antibiotics, intravenous (IV) fluids, feeding tubes, resuscitation? (I don’t.) Speak to your family members about your wishes now in case you later lose your memory and ability to speak for yourself.
 
Also, there has been a growing emphasis and payment for hospice and palliative (comfort) care. Why not welcome these added financial benefits from Medicare and insurance if you or your family member qualifies? (These you control and can be stopped at any time.) When death is imminent, comfort care can be a blessing as it brings less emphasis on intervention which might cause suffering. Talk to your doctor and family about your choices.
 
Dehydration can be our friend
When a person has a terminal condition, is no longer wanting or able to take oral feedings or fluid, I see it as cruel to force artificial fluids through IV or feeding tube means. Without fluids, the patient’s internal pain relievers (endorphins) turn on while setting the stage for living only about ten more days. Dehydration does NOT cause suffering. Considering the prolonged suffering that can result from artificial fluids, dehydration can be our friend.
 
Reconciliation brings harmony
As we get closer to our own time of death, it is prudent to say to those who matter, this wisdom phrase, originating from Hawaii, called “Ho’oponopono,” and made popular by Dr. Ira Byock. “I am thankful for you, forgive me, I forgive you and I love you.” This can help restore harmony with others and with oneself.
 
Bottom line: The fear of death can keep us from making important plans for an advanced directive and hospice, can trap us on a feeding tube and can keep us from finding harmony with the ones we love. A good death requires the courage to be prepared.
 
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 SDPTV most Thursdays at 7 p.m. central. 

by Richard P. Holm, MD
 
Over a six-month period, a 78-year-old businessman with a clever wit and superb leadership skills became less able to talk. He gradually became more confused and lost his ability to learn new things. In the end, he lost his capacity to swallow well and started inhaling some liquids and food until finally pneumonia gently shuffled him off this mortal coil.
 
Dementia is a progressive deterioration of intellect, memory and social skills which, by definition, interferes with normal activities and relationships. It is an umbrella term which includes various types and causes. Alzheimer’s disease and vascular disease (caused by small and large strokes) make up the lion’s share of dementias. Other rarer forms of dementia include frontotemporal dementia, Lewy body dementia, traumatic brain injury and various combinations of any of these conditions.
 
Classic Alzheimer’s accounts for more than 60 percent of dementias. Early symptoms include recent memory loss or loss of the ability to learn a new thing. Until very late in the disease, people with Alzheimer’s usually retain the capacity to walk normally. Gait abnormalities, by comparison, are usually found with most of the other causes of dementia. It is important to note that some people can have gait abnormalities without dementia. (Try to walk a mile a day, if you are able.)
 
The prevalence of dementia increases with age. Five percent of those aged 71 to 79 have dementia, while the incidence increases to 38 to 50 percent in those 90 or older. This also means more than 50 percent of the very old DO NOT HAVE DEMENTIA.
 
Your care provider should evaluate and treat, if apropos, some often reversible or temporary causes for dementia-like symptoms. These include depression, low thyroid, certain infections, multiple sclerosis, low blood sugars, too low or too high sodium or calcium, chronic alcohol use, malnutrition (along with vitamin B1, B12 and D deficiency), dehydration, bleeding under the lining of the skull of the brain, poisoning from heavy metals or pesticides, smoking, high levels of carbon monoxide (check your furnace), low levels of oxygen, moderate to severe sleep apnea, brain tumors, any major medical illness and, last but not least, side effects from certain medications (especially tranquilizers like Ativan or Xanax). Look at that list again and make sure those conditions are considered when you or your loved one is first being evaluated for dementia.
 
Beware of scammers, who are thick as thieves, looking to sell you false treatments. For more credible information about dementia, go to medlineplus.gov. There is no changing the devastating nature of dementia but knowing all about it can 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 SDPTV most Thursdays at 7 p.m. central.             

By Richard P. Holm, MD
 
A dear physician friend of mine who practices in Florida developed renal (kidney) failure a few years ago at the age of 60. He was initially treated with peritoneal dialysis which involves repeatedly flushing special fluid into the abdominal cavity, letting it sit for a bit to remove poisons and then draining out the contaminated fluid, usually three times a week at night. Later, he moved to hemodialysis where blood is drained from his arm into a filtering machine where the blood is cleared of the same poisons and then pumped back into his blood stream. This is done usually three times a week taking four hours at a sitting.
 
It must be a burden to be required to do dialysis three days a week or more for something that most of us take for granted. Since a transplanted kidney is much cheaper than dialysis and is better on the body than dialysis, it would be preferable for most people to get a transplant. However, finding a transplant organ can be difficult. In the past year my friend has had at least four scheduled transplant dates, only to be turned down at the last minute. How frustrating that must be!
 
The National Kidney Foundation notes that more than 120,000 people in the U.S. are currently on the waiting list for an organ and 100,000 of these are for kidneys. Six thousand living and 12,000 cadaver kidneys are transplanted each year in this country while 20 people die every day waiting for an available organ.
 
Organs that are commonly transplanted from living or cadaver donors include kidney, liver, heart, lung, pancreas and even small intestine. Tissues include cornea, skin, heart valve, vein, tendon, ligament and bone. A healthy living donor may be related, or not, to the recipient.
 
It is a courageous and altruistic act of loving kindness to donate an organ so another person may live. To explore becoming a living donor go to organdonor.gov. This gift of life has remarkably minimal risk to the donor and, depending on the organ donated, usually means just a few days in the hospital. While you’re thinking about it, TALK TO YOUR FAMILY about your intentions and mark “yes” as a potential donor on your driver’s license.
 
Please consider organ donation, a most precious gift to someone in need, like my friend in Florida. It takes courage but you will save a life.
 
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 SDPTV most Thursdays at 7 p.m. central.             

By Richard P. Holm MD
 
I appreciate how the old prayer goes, "Bless the food before us, the family beside us, and the
love between us..."
 
A few years back, our youngest son, had a break-in at his home and they took his computer with
all his pictures as well as his original created songs. They also got away with my old film-dependent
camera with a bunch of undeveloped pictures my son had taken. He decried that it wasn't the loss of the computer or the camera, it was the loss of memories and ideas contained within. He was
dismayed that he dreamt he caught the thieves breaking into his house and in his dream, he choked them and hit them with a baseball bat.
 
It brought back the memory of advice one of my patients gave me one day, "If you want to
destroy your enemy, make them hate." I know how self-destructive hate can be. In that sense,
the thieves got my son twice, once for the robbery and once for the deep anger they instilled in
his heart.
 
Maybe once a year I watch a family self-destruct as children of a dying parent return from afar to
criticize the choices that the local family had made, often demanding more aggressive care
when the parent is at the end and it is time to let go.
 
I have seen lawyers at the bedside of a borderline-competent patient working a change in the
will, giving more land to one child than another, resulting in the blackest of disharmony between
kids that had grown up together as family and who will never speak to each other again.
 
I have seen widows and widowers remarry and find joy once again after the sad death of a
spouse, only to have children selfishly scrambling for the spoils of the inheritance, leaving
someone in the equation without their fair share. Truly there is nothing more heart-breaking than to see such destructive behavior among family members.
 
But this does not always happen. In fact, more often than not, the death bed of a parent brings
some great moments of joy. One family I remember in particular, surrounded their dying mother
with harmonious hymns in that hospital room as they had the family reunion that hadn't occurred in many years. Families most often come together around a dying parent or sibling joyously sharing of family memories while supporting and loving the one leaving.
 
Our son found a way to let go of the loss and anger following the robbery and moved on to new
equipment and even better creativity.
 
It isn't the material stuff in front of us, it is the family beside us, and the love between us.
 
Richard P. Holm, MD is 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 SDPTV most Thursdays at 7 p.m. central.               

By Richard P. Holm MD

“Every once in a while, my heart seems to be jumping out of my chest, I get a weak feeling and short of breath,” the patient explained. When I listened with my stethoscope, his rhythm was different than the usual lub-dub, foot-tapping, sounds, which are regular as a band marching through town on a summertime parade. Instead his heart had the irregular rhythm of popping corn, chaotic and unpredictable, and I couldn’t tap my foot to it.

As predicted, the EKG showed the rhythm of atrial fibrillation, with the atrial rate running at three to 400 beats per minute, and the ventricular rhythm chaotic, as the experts say, irregularly-irregular at about 150 beats per minute. Atrial fibrillation, or A Fib, is the most common abnormal heart rhythm condition. It afflicts about one percent of the total population, more than two million people in the U.S., and eight percent of all those older than 80 years of age.

There are many causes for A Fib, including long standing high blood pressure, coronary artery blockage, sleep apnea, too tight or leaky heart valves, too much or too little thyroid hormone, blood clots to the lung, an inherited conduction system or wiring condition, excessive amounts of tobacco, coffee, alcohol, or amphetamine, a viral infection involving the heart, stress of any kind, or just an old and weak heart.

There are two main reasons we need to do something about this rhythm abnormality. Most devastating can be the clots that can form in the atria since they are not emptying effectively, resulting in something like 10 to 25 percent of all strokes to the brain. Second, the ventricles are not efficient pumps when atria are fibrillating and even worse so when the ventricles are beating at 150 beats a minute.

So, with A Fib we must slow the heart down, thin the blood to prevent strokes, and sometimes even bring the rhythm back to normal when we can. While we are at it, in each case, physicians need to study why A Fib happened. It is a complex and interesting condition, and there is a lot of debate about what kind of blood thinners to prescribe, what kind of rhythm-control drugs to use, and when to use surgery and pacemaker treatments.

But the bottom line about A Fib is that good treatment by your general or cardiology physician can prevent problems and allow a normal life, even with the heart rhythm as irregular as popping corn.

Richard P. Holm, MD is 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 SDPTV most Thursdays at 7 p.m. central.

By Richard P. Holm, MD
 
Before my junior year in high school, I returned from a Boy Scout canoeing trip to discover my sister had been killed in a car crash. I will never forget the sadness of the moment when I walked into the house that was filled with what seemed like half the caring and wonderful town of De Smet to find my mom and dad there grieving. It was near the end of that summer, but the beginning of a long period of mourning for my family and me.
 
There were lessons that came to me after my sister’s death. I realized how important support from a community could be. Consolation came from our friends, neighbors, church community, as well as people we barely knew. It seemed more about their presence and not their words. I noticed there were people who had trouble themselves dealing with such loss, and they sort of disappeared.
 
Also, I realized that a funeral is not exactly a time of closure for a family, but really just the beginning of a time to accept reality and forge ahead with the difficult changes that life can and does deal out. It took me years to think about my sister and relish in her memory rather than cringe from the pain of the loss. In that sense, I know I will never have closure and that’s good.
 
Some 14 years after her death, while I was on the faculty of a medical school in Georgia, I found myself having to advise medical students how to talk to patients or family about sad news. I reviewed the medical literature on the subject at the time and concluded that there is no right way to do it except to be 100 percent honest and to say whatever is needed with compassion.
 
Through the years those guidelines have sustained me while I have had the burden of sharing awful news. 
 
Bottom line, it is being there, more than words that consoles. Never worry about what to say, just show up, be honest, and care.
 
Richard P. Holm, MD is 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 SDPTV most Thursdays at 7 p.m. central. 

By Richard P. Holm, MD
​
In the U.S., there are almost five million people with mild to moderate dementia, and studies show that about 70 percent are at home, either alone or with a caregiver, often a spouse. If people with mild to moderate dementia can stay home safely, this would save Medicare and Medicaid a great deal of taxpayer money. More importantly, this would provide those people affected with dementia their preferred environment. Indeed, it is important to allow all people the chance to stay at home whenever possible.
 
A 2013 Johns Hopkins report studied more than 250 people with dementia living at home and found that 99 percent of the demented and 97 percent of their caregivers had at least one unmet need. The foremost unmet need was defined by safety issues such as poor lighting in walkways which increased the risk of falling. Other needs that were not being met in this study included not performing regular exercise, poor follow-up with health care providers, not having prepared legal and estate planning and not receiving help with medications and some activities of daily living. Researchers found that those with lower income, with depression and with borderline rather than severe dysfunction had significantly more unmet needs.
 
When there were at-home caregivers for these folks with early dementia, the caregivers were often not aware of these deficiencies. In addition, the needs of the caregivers were often ignored or unrecognized. Remarkably, at-home caregiver stress and depression were some of the strongest predictors for an earlier move of the person with dementia to the nursing home.
 
Methods to enhance a person’s chance of staying at home are not difficult. Preparation for legal issues and estate planning should be done early and BEFORE the loss of memory. Other methods include providing raised toilet seats, grab bars in the bath and bedroom, properly tacked down carpets, good nighttime lighting in walkways and proper day and nighttime footwear. Researchers also advise providing enhanced support for caregivers with education about community support available such as social services, occupational therapy and caregiver support groups. In addition, screening and treatment of any caregivers’ depression, should be provided. This would go a long way in helping people stay at home as they age.
 
Bottom line: Most of us, and our families, are not prepared for the possibility of dementia as we age. If we prepare, we greatly improve our chances for staying at home.
 
For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow
Prairie Doc® on Facebook, Instagram and Twitter featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPTV most Thursdays at 7 p.m. central.               

By Richard P. Holm, MD
 
We have all had to deal with bullies throughout our lives, and I have had my share. One fall day, coming home from school, I saw two guys from my third-grade class beating up on a smaller kid and was moved to step in to help. I was chagrined but not surprised when the victim ran home, and I became the new target. The beating I took that day was minimal, however, the sense that I did the right thing by standing up against bullies has propped up my self-worth my whole lifetime.
 
Bullies and abuse are everywhere. While in medical school, I was in an Atlanta emergency room when a woman came in with a broken nose and other broken bones and bruises that were explained away as the result of a fall, when we knew full well the injuries were inflicted by her spouse. Since coming to this prairie town 38 years ago, I have seen several cases of parents who physically and emotionally abused their children, and of adult children who physically and emotionally abused their parents. I remember numerous cases where women came into my office, explained their husbands were physically beating them, and despite my recommendations to escape and seek shelter, they stayed married to the scoundrels.
 
The American Psychiatric Association defines domestic violence and abuse as control by one person over another in any relationship. Control is the operative word. The means of this control can result from physical, sexual, emotional and economic abuse, including threats of isolation.
 
The number of American troops killed in Afghanistan and Iraq from 2001 through 2012 was greater than 6,000, and the number of American women murdered by male partners during that time was about 12,000. The Center for Disease Control estimates that in the U.S., one out of every four women and one out of every seven men will have experienced severe physical violence from a bully in their lifetimes.
 
The National Coalition for the Homeless estimates ten million children are exposed to domestic violence every year, and that people exposed to such hostility as children are three to four times more likely to become abusive or be abused than people raised in families without it.
 
Sometimes it’s right to stand up to a bully, and when there is danger, it’s right to escape and get help. And it’s always right to save your children from a lifetime of abuse by not allowing it in your family.
 
For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow
Prairie Doc® on Facebook, Instagram and Twitter featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPTV most Thursdays at 7 p.m. central.