By Jennifer May, M.D.
 
“Doctor, I need an x-ray.” As a rheumatologist, I hear this statement many times from patients who believe imaging will help determine the cause of symptoms, such as back pain or knee pain. It seems simple, take a picture, and find out what is wrong. However, radiology is not always black and white.

Radiology is the medical specialty that uses medical imaging to diagnose and treat disease. Radiologists are physicians, trained in interpreting various types of imaging such as x-rays, CT scans, MRIs and more.  Rheumatologists often depend on imaging to help manage diseases such as rheumatoid arthritis. However, the rheumatologist, radiologist, and patient must work as a team to determine which type of radiology will be most effective for each specific clinical situation.  

For example, an x-ray of a patient with knee pain tells us about the bones, cartilage (space between the joint), and degree of joint fluid present. But it tells us little directly about tendons, ligaments, or muscles because these soft tissues do not show up on a basic x-ray. Therefore, an x-ray may not be the most informative option and performing one may not change the treatment plan. 

Radiology offers a wide range of tools for physicians and patients today. What began with x-rays has evolved into a broad field that includes both interpretation and intervention. Interventional radiologists perform various minimally invasive procedures using medical imaging guidance, such as x-ray or ultrasound. Interventional radiology can treat problems with blood vessels such as blockages or clots and place stents to open them up. They can insert medicine directly into tumors, perform biopsies and other procedures. Additionally, patients generally tolerate interventional radiology procedures much better than major surgery.

With this in mind, when a patient presents their specific set of symptoms, I consider the wide spectrum of radiological tools and talk to the patient about which are most likely to help us find the information we need to improve their particular situation. Sometimes the right tool is an x-ray, but other times it is not. 

Once the information is gathered, physicians and radiologists work together to interpret the data and make a diagnosis. At that point, we are better prepared to make treatment decisions and determine if the patient needs medicine, injections, a brace, physical therapy, or referral to specialist. 

Without a doubt, radiology is integral to good medicine, but it’s not always black and white.  

Jennifer May, M.D. is a contributing Prairie Doc® columnist. She practices rheumatology in Rapid City, South Dakota and serves on the Healing Words Foundation Board of Directors, a 501c3 which provides funding for Prairie Doc® programs. 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, MD
 
My friend broke my nose at an after-prom party in high school. It was nothing deliberate, such as fighting over a girl. Rather, we bumped heads while wearing those big round air-filled sumo wrestler suits. Besides hurting a lot, I remember thinking, “I’ve never been so aware of my nose before.” I was overly cautious of anything that could come close to my nose.
 
I think we sometimes take our noses for granted. Despite being right between our eyes, it’s not our noses, but our heart, lungs, and other organs that get most of our interest. We brush our teeth daily. We get our eyes checked regularly. We adorn our ears and fingers with rings all the time, but the nose is generally ignored. 
 
Sure, there are some famous noses and some people are more aware of the size of their nose than others, but mostly, outside an occasional bloody or runny nose, we don’t pay it much attention. 
 
During annual preventive physical exams, I usually look around for any suspicious spots that could be cancer. One of the most common areas is on the nose. The nose sticks out and is susceptible to getting more sunlight and thus can be prone to getting skin cancer. If you notice a new bump on your nose that won’t go away after a month or two, you should get it checked out. Better yet, be proactive and put sunscreen on your nose as well as your ears, cheeks, neck, arms, and legs and anywhere else that will be in the sun. It’s best to keep your nose out of it (the sun, that is) and wear a wide-brimmed hat.
 
Of course, we cannot talk about our noses without expressing appreciation for our precious sense of smell. Smell helps our brains taste all those amazing flavors and when food goes bad, we depend on our nose to warn us before we take a bite of something that we want to thumb our nose at.
 
I can’t imagine going through summer without the smell of flowers, apple pie, a campfire and fireworks. With Covid-19 around, the smell of peanuts at a crowded baseball game or cotton candy at the fair will have to wait for now, I guess. If you lose your sense of smell talk to your doctor. It could be from allergies or a cold, but it could also be something more serious like the coronavirus.
 
As much as we’d like to see everyone’s nose again, the right thing to do is as plain as the nose on our face. Let’s not get our noses out of joint. Let’s keep our noses to the grindstone, continue to be mindful of social distancing and wear masks that cover our mouths and our noses!
 
Andrew Ellsworth, 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 streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.        

By Jill Kruse, D.O.
 
A few years ago, I spoke at a conference for women physicians. My talk opened with a simple question.  What organ does the heart supply blood to first? It was a deceptively simple question, but the room was silent as they all pondered what they thought was a trick question. Various answers came in, but they were all wrong. Everyone else tried to guess what the most important organ would be that would receive the blood first. They tried to deduce which organ was physically the closest to the heart.   

The next slide in my talk was a picture of the heart from an anatomy textbook and there I showed the answer. The heart feeds itself first. The very first blood vessels that branch off the heart at the aorta are the coronary arteries. These are the blood vessels that feed the heart and are the ones that, when blocked, cause a heart attack.  

This was not a talk about anatomy, and it wasn’t a lesson in physiology. It was a conference on self-care.  No one has ever called the heart a selfish organ. We call someone who is generous and kind as someone who has a “big heart”. The heart’s sole purpose is to supply oxygenated blood to the entire body, and it beats constantly from before we are born until the moment we die. The only way it can do this is by taking care of itself and making sure its needs are met first. Yet when we think of taking time for ourselves or saying “no” to someone’s request because we do not have the time or energy to help, we often feel selfish. 

When the heart does not have enough blood flow to an area, or there is a blockage in a vessel, it causes pain. Sometimes people ignore this pain and push through. Sometimes the pain goes away, only to come back later when the demands on the heart grow stronger. If the area of the heart is starved for blood for long enough, that part of the heart dies. If a large enough area of the heart dies, then the heart cannot effectively pump blood to the rest of the body and the person may die of a heart attack. 

We need to follow this example in how we treat ourselves. We need to take care of ourselves – emotionally, physically, and spiritually – before we can take care of others. If we ignore this and take care of our needs last, our ability to care for not only ourselves, but others will suffer. Be like the heart, tirelessly giving and kind to the entire body, but most importantly ensuring that the giving and kindness applies to you first and foremost. 
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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 Richard P. Holm, MD
 
In recent years, I’ve learned of wonderful aspects of Native American culture, especially the sacred medicine wheel or hoop of life with variations in colors and meanings according to each tribe and nation. The circle is a universal spiritual symbol, but the Native American medicine wheel has complexity and power for me, a person who has cared for the elderly throughout my lifetime on the prairie.
 
For centuries, the Native American medicine wheel has given bearing, a sense of position, an objective and simultaneous understanding of both the infinitude and the limitation of life. The wheel brings a conscious spirituality that recognizes and accepts all things. For me, it closes the gap between the cynical scientific part of me and the inclusive spiritual part. By spiritual, I mean that part of our soul that savors music, art, poetry and the divine; the part that grows to love all things living and nonliving.
 
In the following verse, I’ve taken the liberty to express my interpretation of the sacred circle:
 
First we get down on our knees and feel the soil, sacred Mother Earth, the world around us, the animals, plants, prairies, lakes, mountains, the environment of our planet from where all food and sustenance comes; earth is foundation.
 
Then we stand and raise our arms to sacred Father Sky, the sun, stars, clouds, rain, wind, air and breath of life, light and dark; from where all energy flows and ebbs; sky is infinity.
 
Then we turn and bow east, symbolized by the color red, the rising sun, springtime, birth, the very young, a sense of innocence and hope for the future.
 
Then we bow south, symbolized by the color yellow, the full sun, summer, early adulthood, a sense of unconquerable power and the courage to fight for justice.
 
Then we bow west, symbolized by the color black, the setting sun, autumn, mature adulthood, a sense of gravity to protect freedom and face vulnerability with honest eyes.
 
Finally we bow north, symbolized by the color white, nighttime, winter, old age, wisdom to savor friendship, family and the circle of life, release from fear of change and death, and a sense of empathy from having walked in another’s moccasins.
 
We pray in harmony as love consoles. O sacred hoop of life, please touch our souls.
 
This essay is a composite of works written by the late Richard P. Holm, M.D. who died in March 2020 after a battle with pancreatic cancer. He was founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. Dr. Holm’s legacy lives on through his Prairie Doc® organization. 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.                                                                                                                                   -0-

By Kenneth A. Bartholomew, MD
 
By now everyone with a television or internet connection has heard of the “Opioid Crisis in America”.  Deaths from accidental overdoses of opioids each year have now surpassed deaths from automobile accidents.  Depending on whose numbers you read, these deaths range from 50,000 to 70,000 each year, versus 38,800 from vehicle accidents in 2019.  Just how did we get here?
 
I have been practicing long enough to have witnessed the progression of this problem.  In medical school in the 1970s, we were taught to be cautious and limit the prescribing of morphine and Tylenol with codeine because they had the potential to be addicting.  We saw occasional problems with overuse and addiction, but not that many.
 
In the 1980s and 1990s, there were multiple articles published in medical literature that showed patients in emergency rooms and hospital wards were not receiving enough pain relief.  This was doubly damning because almost every article showed that people of color were provided less pain relief for surgical pain or trauma pain than Caucasians.  Multiple essays followed.  The unstated implication was that we were bad doctors, not doing a good job of relieving pain.
 
Enter the federal government and the Law of Unintended Consequences.
 
The Joint Commission, the body in charge of hospital accreditation, made pain the “Fifth Vital Sign”.  It was mandated that every patient, every day, often multiple times a day, be asked how their pain level was doing (and quantify it on a one-to-ten scale).  The use of pain medications accelerated.
 
Add to this the fact that in the search for better pain-relief drugs, oxycodone was approved by the FDA in 1995 and the continuous-release version, oxycontin, came on the market the following year.  Fentanyl, many more times more powerful was approved in 1998 for cancer pain.  These drugs are far more addicting than codeine, a fact then unknown to most doctors and allegedly covered up by the drug company.  With this perfect storm of mandates and new drugs, the number of prescriptions skyrocketed – we did not want to be seen as bad doctors by the Joint Commission watchdogs.
 
Needless to say, the addiction rate skyrocketed as well.  These drugs, some claim, can ‘turn on a switch’ in the brain after only a single dose.  One addict stated, “It was the first time in my life my body didn’t hurt.  I wanted that feeling to last.”  And he did almost anything to get the drugs, which ruined his life and almost killed him.
 
In contrast, we look at several European countries that did not “mandate” Draconian pain relief measures. Their post-operative patients receive mostly Tylenol and ibuprofen and their satisfaction scores are essentially identical to those of the U.S.
 
What I think we should learn from this forty-year unfolding of the “Opioid Crisis” is that doctors should be doctors and politicians should be politicians, and the Law of Unintended Consequences will continue to bite us in the backside unless we take the time necessary to know and understand history.
 
Ken Bartholomew, M.D. is a contributing Prairie Doc® columnist. He practices in Pierre, South Dakota and serves on the Healing Words Foundation Board of Directors, a 501c3 which provides funding for Prairie Doc® programs. 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.
 
At the bottom right hand corner of my driver’s license there is a small heart and the word “donor”.  The print is small and easy to miss among all the other information contained.  That one word, I would argue, is the most important piece of data there.  Displayed next to my height, weight, and eye color, I proudly declare that when my organs are no longer of any use to me, I want to give them to someone in need.  This is a personal decision and, according to United Network for Organ Sharing, donation is supported by all the major religions.  It is also a decision that can impact up to eight other lives. 

Donation of my organs, cornea, and tissues is a gift that will cost me and my family nothing.  There is no cost to the donor’s family or estate, and it doesn’t affect funeral plans or prevent a viewing.  When I die, my organs, tissue, and corneas will be available to people in dire need of them.  I don’t want my body to be like an Egyptian pharaoh’s tomb filled with treasures that could be better used by the living.  The ancient Egyptians removed the organs from the body before they mummified someone.  These organs were placed in Canopic jars and buried.  Let my Canopic jars be living, breathing people who need them to live their life to the fullest.     

Right now, there are more than 113,000 people waiting for lifesaving organ transplants.  Of those people, 8,000 will die each year waiting for an organ that will not come in time.  The thought that I can lower that number when I die brings me a sense of pride and joy.  Organ donation is the ultimate way for a physician, and anyone else, to help someone be healthier.  Organ donation is truly giving the gift of life. 

I have seen this gift of life personally.  My cousin’s husband, his mother, and his sister all had heart transplants due to a genetic condition.  He had a heart transplant on December 29th, 1999 and a kidney transplant on March 31st, 2005 giving him an additional 20 wonderful years of watching his three children grow.  A significant gift for someone who was not sure that he would live much beyond his wedding.  Before his kidney transplant, he was dependent on a dialysis machine three times per week.  The organ donations have changed his life and the lives of his family.  I hope that I can change the life of someone else through my gift of organ donation and I hope you will consider donating as well. Find out more at www.organdonor.gov.
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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.        

Prairie Doc® Perspectives for week of May 31, 2020

By Richard P. Holm, MD
 
The medical history books reveal secrets of circulation and blood pressure that rival the best novels of intrigue. Years ago, before people had figured out how blood circulates, second century Greek scientist Galen, had the idea that blood moved from the right side of the heart to the left through unseen pores. That idea was not questioned for more than 1,000 years until a series of people in the mid-1500s finally broke with the old idea.
 
After great debate among leading thinkers of the time, English scientist and physician, William Harvey, and several anatomists and scientists finally convinced local medical leaders, and later those of the world, that blood pulses through the body on a great circular journey. It was fear of change that made the acceptance of this discovery so difficult.
 
Harvey, and other scientists, proved that venous blood is almost “sucked in” as it returns from the outer reaches of the body through gradually larger veins and eventually flows into the right ventricle of the heart. From the right ventricle (right lower part of the heart), blood is pumped into the lungs where hemoglobin gathers oxygen and releases carbon. From the lungs, oxygen rich blood flows to the left atrium (left upper part of the heart), to the left ventricle and is pumped out into arteries to feed almost all the cells of the body with oxygen.
 
From each tiny cell the blood picks up carbon waste, and the blood is drawn back to the right heart and lungs once again. Continuous circulation happens because the heart pump squeezes and relaxes, repeating the process some 80 times a minute from birth to death.
 
In my mind, the marvelous truth about the circle of blood flow is pure evidence of the beauty of both evolution and intelligent design. Circulation, like the rhythm of life, is a regular and recurring pulsing; a succession of surges over time like the flow of seawater and fish meeting the shore on an estuarial tide, the birth of lambs and calves, bursting forth on an early springtime prairie pasture or even the seventy to ninety-year life-cycle of humans, moving with joy, sorrow and grace from birth to natural death.
 
This essay, written by the late Richard P. Holm, MD, is an excerpt from his book “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. Dr. Holm was founder of The Prairie Doc® and his legacy lives on through his Prairie Doc® organization. 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, MD
 
Life is about balance. We balance our time, our budgets, our work, and our family. If you concentrate too much in one area, you will soon be wanting in another. Additionally, our bodies are constantly working to keep our blood pressure, blood sugar, and temperature in balance. 
 
Covid-19 disrupted our balance, both in our lives and for some, in our bodies. It overwhelmed some communities with too many people who became sick. Other communities banded together (or rather, apart) to slow the virus and protect the most vulnerable. 
 
Thankfully, many areas have been successful at slowing the spread and flattening the curve, avoiding the tidal wave of sick people filling the hospitals. However, this came with a great cost to the balance in our economy, our social interactions, and our normal way of life. It revealed and magnified numerous problems. It exposed disparities in healthcare, and it provoked supply chain issues, food chain issues, unemployment, poverty, and misinformation. 
 
People have many needs in addition to safety. People often need work not only for money for food and shelter, but also for fulfilment and purpose. People often need other people because we are inherently social creatures that thrive from being there for others, providing words of encouragement, or a caring shoulder to lean on, or an embrace.  
 
Living with Covid-19 around us require a new balance that may change over time. While it would be wonderful, reducing cases to zero is probably not realistic for a while. Meanwhile, our communities need economic activity and we need social interactions. Thus, some people are venturing out more and businesses are reopening. Some places are doing this more cautiously than others. We need to get creative and adjust our expectations of normal for a while. Our elders and those with high risk conditions may not be safe or feel safe, so we should do what we can to help them. Washing hands, wearing masks and being mindful of the distance between us are not perfect but are still the best forms of protection for now.
 
No one knows what the future holds. Perhaps reopening the economy will increase our cases of Covid-19, and perhaps not. Perhaps the virus will dissipate over the summer months. If it re-emerges in the fall, will we be ready? Will we plan and use this time to prepare? Will we again work together to protect our fellow man? Let’s use this time wisely and find our new balance.
 
Andrew Ellsworth, 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 streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.        

By Richard P. Holm, MD

One summer during my college years, another premed student and I got a job at the Swedish Hospital in Minneapolis, as nurses’ aides. At that time, the guys were called orderlies, but we were part of the nursing department. We were taught how to clean patients’ private parts without making the patient feel self-conscious, and how to place urinary catheters mostly in old men with prostates that had overgrown and were blocking urinary flow.
 
We all have those private areas, let’s not pretend otherwise. The waste disposal parts are as important to us through our lifetime as our hearts, except not quite as romantic. Try switching metaphors and famous poems simply don’t have the same pizazz. For example, try E.E. Cummings’ “I carry your colon with me,” or William Wordsworth’s “My urinary tract leaps up when I behold a rainbow in the sky,” or Douglass Cross’ “I left my bladder in San Francisco.”
 
Romance aside, we are happy when our urinary tract is working well, draining the urine, removing waste and water. The kidneys collect and concentrate the urine, they deliver this yellow fluid through the ureters, the tubes from the kidneys to the bladder. The bladder is a bag to collect the urine until it is convenient to be emptied.
 
It seems like a simple, straight-forward system. However, trouble could be around the next corner. Conditions like urinary tract infections, kidney stones, bladder control problems, and prostate troubles are not uncommon through the course of a person’s life and can vary from causing short-term discomforts to long-lasting conditions.
 
One of the barriers to treatment for many people is the human problem of stigma and shame. It does not feel good to admit to anyone, even a loved one or a medical professional, that you’re having troubles “down there.” Let me reassure you: this is a common human condition. Shame is an enemy to a healthy, functioning body. I would instead say “join the club!” and remind you that you are not the only one with such a problem.
 
I am no longer the young orderly helping the old men in the Swedish Hospital with their issues. I now find myself amazed at the magnificent function of the human body, identifying more with those old guys than I do with the young staff. All of us have bladders and urinary tracts about which there is nothing to be ashamed.
 
Richard P. Holm, MD wrote this essay in February 2020. He passed away in March after a battle with pancreatic cancer. He was founder of The Prairie Doc® and author of “Life’s Final Season, A Guide for Aging and Dying with Grace” available on Amazon. Dr. Holm’s legacy lives on through his Prairie Doc® organization. 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 Mark E. Bubak, MD
 
Growing up decades ago, we all knew kids and adults who were held back by their asthma. They sat out gym classes and sporting events, missed school or work over and over again, were up in the wee hours of the night fighting to breath, or seemed to make their own chest noises all the time. They got nicknames like Wheezy.
 
Jump ahead now to 2020. Although we still continue with our traditional allergy avoidance and immunotherapy programs, inhaled corticosteroid inhalers, and long and short acting airway muscle relaxing agents to treat asthma, we now have entered what is being called “The Biologic Era” of asthma treatments.
 
Biologic treatments are not the traditional chemical drugs we have been using for decades. Rather, biologics are antibodies similar to those we use to recognize and fight off germs. When designing biologics for asthma patients, scientists replace the recognition portion with a component that targets “problem signals” from our immune system. One family of signals or targets, known as interleukin proteins, come from T cells and tell other cells what to do. The allergy antibody IgE is another target. When the particular biologic is given, it circulates through the patient until it finds its target, and then binds to that target. The result is to change the way our body works, decreasing parts of the allergy or immune reaction that causes us to have the asthma.
 
All these therapy choices can be overwhelming. We now want to personalize each asthmatic’s program with the goal of “control,” meaning hopefully, no asthma. It all starts with talking to your doctor to establish an understanding of your history followed by a physical examination. You and your doctor might then decide on several options including, allergy testing, blood counts, IgE levels, nitric oxide breath measurement, x-rays, CT scans, and pulmonary function tests as indicated to determine what type of asthma you have. Armed with the knowledge obtained, your allergy doctor can prescribe the best combination of treatments to achieve control.
 
And as an added benefit of control, we can hopefully eliminate the use of that old nickname, Wheezy.
 
Mark E. Bubak, MD practicing in Sioux Falls, South Dakota is a contributing Prairie Doc® columnist. He is certified by the American Board of Allergy and Immunology to care for adults and children with asthma and allergies. 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.