By Richard P. Holm MD
 
It was a Boy Scout canoe trip into the Minnesota Canadian boundary waters in the summer of 1965 when a gangly group of DeSmet Scouts discovered the sun again after two days of chilling and soaking rain. Taking our noon break from canoeing all day, we found a solar exposed, very large, warm, and welcoming rock on an island and stretched out on its warm surface We took off our shirts and dried our soaked socks while reveling in the renewing rays of the sun.
 
At that moment I could feel the wonderful power and force of ol’ sol beaming into me. I remember thinking how the sun’s radiation was the visible energy source for life on this earth, and I wanted more of it. It must be a natural instinct to want exposure to the rays of the sun. Think how people seem to gravitate to the beach for sunbathing, and how sad some get in the days of the winter solstice when there’s not enough of it.
 
Recently, we have become more aware of the importance of enough vitamin D which our bodies manufacture when rays of sun come in contact with our skin. We can also get this important vitamin from the oil of deep-sea fish (such as cod) who live in very dark waters gathering their vitamin D by eating falling phytoplankton who mostly live on the sun-soaked surface water. The fish store their plankton-source vitamin D in their livers, and it is that cod-liver oil source of vitamin D that supplemented children for many years. Now we can take fish oil capsules, flax seed oil (another vitamin D source) and vitamin D3 supplements which all work to do almost the same thing as laying out on a warm rock in the boundary waters. Still, we know that just about 50 percent of people don’t get enough vitamin D.
 
The flip side of all this sun and vitamin D talk is that one can get too much of both. One should not take more than 5,000 international units (IU) of vitamin D per day, and one should avoid too much sun. We know that excessive sun (or tanning booth) exposure causes premature skin aging with wrinkles, sagging, brown spots, rough skin, not to mention skin cancers.  You hear and read everywhere the following words of advice: use sunscreen, wear protective clothing and avoid tanning booths.
 
But after two days of a soaking cold rain, it should be okay to lay out on a warm rock.
 
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​By Richard P. Holm, MD
 
Understanding the story of acute appendicitis brings us to understand other causes for a belly ache or abdominal pain. Like many other causes of abdominal pain, appendicitis is a blockage of a smooth muscle tube (SMT). We have a lot of SMT hollow transport tubes in our bodies including: esophagus, stomach, small and large intestines, kidneys, ureters, bladder and urethra, bile ducts, pancreatic ducts and gallbladder, fallopian tubes, the uterus and even the aorta and blood vessels.
 
When anything blocks the forward-moving squeezing of one of these SMTs, people have cramping spasm-like pain that lets up and comes again later with nausea or vomiting adding to the misery of the situation. Patients usually can’t find a comfortable position and are all over the bed, moving and anxious.
 
While appendicitis is a blockage where the appendix and the large intestine meet, other examples of smooth muscle tube blockage include blocked colon with cancer, blocked kidney or ureter with stones, perforating aortic aneurysm with obstructed flow, infection of the gallbladder with gallstone obstruction and blocked fallopian tube with an ectopic pregnancy.
 
When appendicitis is just beginning, the pain is around the belly button. As appendicitis worsens, pain moves from the belly button to the lower right abdomen and intensifies until either the blockage is resolved (usually with surgery or antibiotics) or the appendix ruptures, spilling fecal material and infection out into the abdominal cavity. This causes severe infection and inflammation especially affecting the smooth lining that surrounds the abdominal cavity. The lining has plenty of nerves and thus, this causes a new and exquisite type of pain.
 
Now we have peritonitis (inflamed peritoneum) which causes the patient to stop moving, to become still, almost frozen to the table or bed, not wanting anyone to touch him. This is a dangerous situation and requires emergency intervention. Other examples of pain from peritonitis include perforated stomach ulcer or ruptured: diverticula, gallbladder or ovarian cyst.
 
Clues as to what is causing either blocked SMT or peritonitis pain come with location of pain, the history of the progression of the illness, and the physical examination. Laboratory and X-ray may also help. People with non-dangerous belly pain, often have recurrent constipation, menstrual symptoms or bladder infections and should seek help at the outpatient clinic. In contrast, some clues to bring one to the emergency room should include progressive, unexplained, severe abdominal pain, shaking chills and blood in the urine or stool.
 
Understanding how a blocked SMT or peritonitis happens with appendicitis, helps, in turn, to explain the many possible causes of a belly ache.
 
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By Richard P. Holm MD
 
Mr. D, a diabetic patient of mine, came into the clinic with exercise induced leg pain. Iniitally the pain would go away if he stopped exercising, but now it was coming on after walking less than a block. He said, “the pain is meaner and lasts longer after I stop.”
 
The diagnosis of Mr. D’s condition is claudication, a condition where arterial flow to the legs is blocked. I immediately called the vascular specialist for an urgent appointment. Two weeks later the patient returned to the office after having had his blocked arteries dilated with a balloon followed by the placement of stents to hold them open. Happily, he told me he could once again walk for miles without pain.
 
His vascular doctor had started artery dilating meds, lipid meds, and daily baby aspirin. I renewed my encouragement for Mr. D to eat fewer calories, exercise daily, keep his blood sugars controlled, and the most important advice, “Stay away from sitting long on that darn couch. It’s like smoking.”
 
The narrowing process, called atherosclerosis, can be the result of genetic tendencies, diabetes, smoking, high blood pressure, high blood lipids, and even normal aging. Arteries usually narrow gradually, but atherosclerosis can sometimes trigger a clot and a sudden complete blockage resulting in a sudden, and devastating event.  It can occur in coronary arteries of the heart, cerebral arteries of the brain, renal arteries of the kidneys, and peripheral arteries of the legs. And, in general, when it’s happening in one, it’s happening in all.
 
Narrowing of blood flow can deprive muscles, skin, ligaments, and nerves downstream of precious blood flow and oxygen, resulting in an aching and agonizing hurt that would bring anyone to their knees. When it happens in the legs, like what happened with Mr. D., the pain symptom is called claudication and the condition is called peripheral artery disease or PAD.
 
PAD affects five percent of all people over 50, but more than 30 percent of all diabetics in the same age group. There can be a curve ball with diabetes or with aging, as these people sometimes lose feeling in their legs and feet due to nerve destruction, setting them up for PAD without pain. The presenting sign then would be painless sores on the feet which won’t heal. This is especially treacherous because, without good blood flow, the healing is very slow and the patient, having no pain, is not as motivated to do the work required to heal ulcers.
 
Leg pain that goes away with rest may not sound so bad, but peripheral arterial disease is one of the most formidable challenges in modern medicine. 

By Richard P. Holm, MD
 
Vaccines protect people from illness with minimal risk.
 
Smallpox has been around for many millennia. For thousands of years, the virus caused a deadly illness that killed more than 35 percent of adults and 80 percent of children who contracted the disease. That is until the smallpox vaccine was discovered in 1796. Noting that milk maids rarely got smallpox, British rural physician Edward Jenner found that deliberate infection with the milder cowpox disease provided substantial immunity to smallpox. After decades of improvement to the vaccine and a campaign lead by the World Health Organization, global deaths from smallpox were reduced from two million per year in 1967 to zero in 1977. Human smallpox infections were virtually eliminated from this world because of vaccinations.
 
Another example of clever manipulation of the immune system is the story of a pneumonia vaccine. In a 2003 study, researches noted there had been a huge drop in hospitalizations of the elderly for pneumonia, with 12,000 fewer yearly deaths—especially in those older than 85. This is the result of routine childhood pneumonia vaccination. Although we now encourage two different pneumonia vaccines for those older than 65, the authors of the study claim that it was the routine vaccination of children that was responsible for the reduction of pneumonia in the elderly. Thus, herd immunity profoundly protects immune deficient adults by reducing their exposure to sick kids.
 
There have been dangerous and untrue rumors that vaccinations in children are responsible for autism. Despite the natural human wish to find something to blame for this condition, autism appears in similar rates in children who are given and not given vaccinations. Don’t get me wrong, some vaccines carry risks, but it all depends on the specific type of vaccine and what disease it is treating. Most vaccines are incredibly safe.
 
Take for example the vaccine for Dengue fever, where the risk of side effects is significant. With Dengue vaccine, ten children are saved for every one child who is harmed. Compare that with the measles, mumps, rubella (MMR) vaccine series given in the U.S. which has mild temporary side effects including fussiness, mild fever, injection-site soreness, affecting one child in four. There is temporary mild joint pain, rash, mild glandular swelling, and loss of appetite affecting one in 50, and high fever and platelet problems affecting one in 25,000. Much better than Dengue vaccine. The benefits of the MMR vaccine far outweigh the risks. That is why we routinely give people the MMR vaccine and only give people the Dengue vaccine if they have a high chance of exposure.
 
Vaccination, a clever manipulation of our immune system, protects us from the scourges of the future.

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By Richard P. Holm, MD
 
The U.S. is rated as the tenth wealthiest country in the world. The financial Web site 24/7 Wall St. clarifies that there are two reasons we are not considered wealthier: 1. We have the world’s largest gap between the rich and the poor, which continues to grow 2. We are the only developed nation in the world without universally available health care. The second issue of health care goes hand in hand with poverty. Poverty, not ethnicity, is strongly associated with mental health problems, crime, overcrowding, malnutrition and illness. Poverty also affects children more than others. All of us would be better off if poverty was reduced.
 
The U.S. Census defines poverty depending on the number in the family. For a single person, poverty means a yearly income below about $12,500 and, for a family of four, that number is about $24,000. In 2016, the U.S. Census found about 13% of our general population is in poverty. When we break that down by ethnicity, 28% of Native Americans, 27% of single parent families, 26% of African Americans, 23% of Hispanics, and 21% of disabled people live below the poverty line. Again, experts clarify that some of the most major problems in our country are associated with poverty, not ethnicity.
Contrast this with the growing billionaire class. A Forbes Magazine study stated that the rich are getting richer in a way not witnessed since the first gilded age a century ago. Josh Hoxie, co-author of the Forbes report, said “So much money concentrating in so few hands, while so many people struggle, is not just bad economics, it’s a moral crisis.” For example, the wealthiest 400 people in the U.S. now have more money than the total of the lowest 64% of the U.S. population.
Poverty is a U.S. humanitarian shortcoming within our own borders which, I personally believe, is the core issue about which our political leaders should give their greatest attention. I don’t claim to have the answers to poverty, but our country could do better in making available to all: affordable health care, satisfying jobs with living wages, and quality and affordable pre-school and higher-education. I believe political leaders should be intensely studying the issue of poverty and how to support people in need while encouraging opportunities for rewarding work. All of us, rich and poor alike, could personally try to attack this problem, especially locally.
 
Addressing poverty will also address mental health problems, crime, overcrowding, malnutrition and illness; especially the way these issues so severely affect children. Helping all people caught in the trap of poverty will immeasurably raise all boats and make everyone in our society safer and happier.
 
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By Richard P. Holm MD
  
His wife almost had to force him to come to the emergency room. She said he was unusually irritable. Although he typically kidded with me, this evening the smile was gone. He complained of a tearing strain and pain into his back (along with a throbbing abdominal discomfort). On exam he had a pulsating abdominal mass and upon listening with the stethoscope I could hear a repeating and prominent whoosh. My patient didn’t have a back strain but rather a dissecting abdominal aortic aneurysm.
 
The aorta is the largest blood vessel which extends out the top of the heart feeding oxygenated blood to virtually every cell in the body. It is a multi-layered, high-pressure hose that arches upward and around, sending tributaries to neck and brain, arms and then down through the chest past the diaphragm. Once it reaches the abdomen, the aorta sends branches everywhere, including the bowels and kidneys before finally splitting into the two femoral arteries providing blood for the legs.
 
We measure the continuous pressure exerted within the aorta in millimeters of mercury, and has, on average, a systolic pressure of 120 and a diastolic pressure of 80. In a hypertensive person, this can be much higher. After years of increased pressure, and, especially after years of smoking, the walls of this mighty vessel can weaken and blood flow can split into one of the layers of the vessel, dissect the layers apart. A weakened aorta can also suddenly rupture, causing immediate death. Most victims are or were smokers and about two-thirds are male. The U.S. Preventive Services Task Force recommends that men aged 65–75 years who have ever smoked should get an ultrasound screening for abdominal aortic aneurysms, even if they have no symptoms. In my practice I listen, especially to every past smoker, male or female, for an abdominal whoosh.
 
More than 15,000 Americans die from this condition each year with the incidence tripling over the last 30 years due to the aging population and the history of smoking in that group. The death rate would be markedly less if proper screening occurred. My patient did not die; he made it to surgery and within hours a new lining to his aorta was provided.
 
Now, something like 10 years later, he is still alive and joking with me. 

By Richard P. Holm, MD
 
There is an epidemic of obesity in the United States. As people get older, their risk for diabetes and diabetes-associated complications will expand like their waistlines. The average weight of 5’9 men in 1960 was 166lbs. It is now 195lbs. The average weight of 5’4 women in 1960 was 140lbs and is now 166lbs. The CDC estimates that 69% of American adults over the age of 20 are either overweight or obese. Complications of diabetes associated with obesity include premature aging of blood vessels, nerves, kidneys, and the immobility that goes with weighing too much.
 
With this looming potential for catastrophe, we should first ask the question: “why is this epidemic happening?” Is it because of genetics? Adoption and twin studies show that we usually end up being about the same weight as our biological parents, not adoptive parents. This, however, doesn’t explain why rates of obesity are increasing. There must then be environmental factors to explain this upward trend. Is it the lack of activity of today’s youth? Is it the food that pregnant mothers eat which nourishes their babies in the uterus before birth, or the way we feed babies in the first months after birth? Is it high calorie starchy fast food? We simply do not know why this epidemic is occurring.
 
Still, there must be something we can do. Repeated studies show, even with the best weight-loss programs, only 35% of individuals will lose significant weight. Furthermore, over the following year, only 10% of them will be able to keep it off. Over the next five years, almost all of them will return to their original weight. Nothing seems to work short of surgery, which is dangerous and not always effective—at least 50% of those people will regain their weight as well. We can therefore infer that weight loss programs are either ineffective or potentially very harmful, especially if people are shamed or criticized into trying them.
 
My recommendation is to take or give NO CRITICISM of individuals who are overweight, especially if they have or are predicted to have diabetes. The value of each individual has nothing to do with weight and all to do with your heart. What remains most important is that obesity may not go away but diabetes gets better when we eat right (a balanced, low calorie, healthy diet with lots of vegetables) and exercise daily (like a brisk walk one to three miles a day). We should all forget about weight as the goal. Lifestyle should be the goal, along with loving yourself the way you are.
 

By Richard P. Holm, MD
 
It was a number of years ago and I was working in the emergency room when a severely compromised 20-year-old woman with cerebral palsy came in battling a lung infection. She was moderately mentally handicapped and had muscle spasticity of all her muscles which hampered her ability to cough and clean out her lungs. This was not her first time with pneumonia, and it wouldn’t be her last. What was most remarkable about her situation was the love and support she had from her entire family, not just mom and dad. Her three siblings were also part of this wonderful caregiving team. They joked with her, encouraged her, reassured her, and loved her. It was beautiful to see. The story turns sad as eventually, months later, the patient succumbed to an infection despite aggressive treatment. However, the compassion and joy I saw that day, like rays of light emanating out of her caregivers, left me happy inside.
 
Caregivers come in all shapes and sizes and from all walks of life: male and female, spouse, adult child, parent, grandparent, friend, or hired assistant. They can provide care at home, in assisted living centers, in nursing homes, or in some other institution. They might be doing this job out of obligation, duty, financial responsibility, love, compassion, or sometimes as a job for pay. Many people develop the need for a caregiver after trauma, illness, stroke, or after reaching advanced age. Others require help from birth. The needs of the compromised individual can also vary. Sometimes they require a lot of help with everyday activities, including bowel and bladder care or even help with feeding and hydrating. Sometimes the person only needs someone to check in on them every day or give them a kind word every once in a while.
 
After my Dad died, I found myself calling my mom for about five minutes every morning while I was on the way to work. I know she cherished these short, pleasant conversations. After several years of this, when a stroke took this pleasure away, I came to realize how much I grew from and enjoyed those daily conversations. It had been a mutual gift we were giving each other.
 
The following lessons for caregivers might be helpful:
1. Practice listening
2. Be kind, honest, and respect your patient’s choices as much as possible
3. Seek alternatives if you’re feeling burned out
4. Realize the value you receive by the giving of yourself
 
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​

Every physician and care provider who has been practicing for a while can tell you stories of people who were hospitalized with an unknown illness and cured by simply reducing the number of medicines they were taking. A daughter once brought her increasingly confused and failing elderly father into the clinic to see me. He had been living in a Minneapolis nursing home and was taking a “shoebox” of medicines prescribed by multiple different VA providers. The daughter asked if there were any changes that might help. She was elated when I dropped the pill count down from twenty to six.
 
In two weeks, he returned to the clinic remarkably improved. Following a move to Brookings, he enjoyed something like three good years of life in an assisted living center, his daughter’s family nearby, until a quick death came following an infection. The daughter told me that after stopping all those pills, her father went from a zombie to rejoining the living world again—reading newspapers, hanging with new friends, playing pinochle, attending church, and going out to dinner with his family.
 
Medications are overprescribed in this country, and there are many reasons for this culture of pills. Care providers are being pressured to follow health care protocols which are basically recipes for care. These recipes are an attempt to improve quality but often do the opposite and encourage adding unnecessary pills. Other causes include excessive prescribing by the specialists that are also seeing the patient, the time limits that care providers are allowed with patients and their overzealous wish to satisfy their patient, the pharmaceutical industry’s excessive promotional efforts including their direct-to-public advertising (which is not allowed in most other countries), and the patient’s desire for an easy pill rather than a tougher lifestyle change. Health care protocols, physicians, the pharmaceutical industry, and patients are all to blame for the burden of polypharmacy that has taken hold of our country.
 
Medications intended to be helpful can sometimes be harmful. It should be a careful, well trained, and considerate care provider—not a protocol or an advertising campaign—that determines when a new medicine should be started. Please DO NOT stop any medicine you are presently taking. However, every time you see your care provider, start with the statement that you are not seeking another medicine unless it is necessary, and ask if there are any medicines that can be stopped.

For the last two years, as I have been wrestling with my own health problems, I have experienced superb care provided by emergency room (ER) docs, hospital docs, and (after I was sent home) outpatient care providers. This included my primary care internist in Brookings, my teleconferencing oncologist from Sioux Falls, and my surgeon from Rochester. I’ve experienced and benefited from the perspectives of several scopes of practice. There has been a great deal of change from the way we used to do it, and I think we have to embrace the change.
 
When moving to South Dakota in 1981, I was not surprised to learn that those of us in the “Brookings Clinic” shared call and the responsibility of the ER, took care of our own patients in the hospital and saw people in our outpatient clinic Monday through Friday. This was a lot of work, but it taught all of us to know and appreciate the constant changing face of medicine and gave physicians an “up-close-and-personal” relationship with our patients.
 
Then, over time, hospitals throughout the state started hiring docs who worked exclusively in the ER. In Brookings, that change made our home lives better, but we lost some of our ER talents in exchange. Next, maybe 15 years ago, we obtained the electronic Intensive care unit (e-ICU) which gives our ICU patients the advantage of the extra eyes of a remote ICU specialist, allowing sicker people to stay in rural hospitals. However, the biggest change in the last few years involves how those patients admitted to hospitals are now being cared for by hospital care specialists (hospitalist).
 
Presently, when patients go home, there is a hand-off that must occur between the care of the hospitalist and the patient’s own primary care provider in the outpatient clinic. It is this hand-off which many believe could be better and is the center of an ongoing debate among doctors. I would advise patient and family to watch-dog this transition to make sure the hospitalist spoke with their outpatient care provider.
 
Scientific evidence-based studies have shown that the best overall care happens when it starts with an established outpatient primary care relationship. The best (and least expensive) health care would happen in this country if EVERYONE had a designated primary care provider who would hand-off and receive from the hospital team when necessary.
 
Change is happening, and the benefits far outweigh the risks if only each of us could find and establish a relationship with a primary care provider.