By Debra Johnston, M.D.
 
I was very young when my grandfather suffered his first stroke and began his battle with vascular dementia. I grew up understanding that he was not like the other adults in my life. He would take me on long walks around the neighborhood, but it was never entirely clear who was supervising who. He rarely had much to say, and when he did, it did not make sense. He communicated mostly through gestures, and sometimes unnerved my cousins and I with his uncertain temper. 
 
With the benefit of age and experience, I appreciate now how frustrated he was, and what a herculean task my grandmother took on.
 
Medicine has made progress in the nearly 40 years since my grandfather’s death. We are better at preventing strokes and mitigating the aftereffects. We are better at distinguishing between the diseases that cause dementia. We have treatments for some of those causes, however disappointing those treatments are. We are better at addressing related challenges, such as sleep disruption and depression. We are better at guiding families as they struggle with difficult decisions, like when to stop driving.
 
Families struggle when they know Dad is not safe behind the wheel or at home, but Dad thinks everything is fine. One of the many things that dementia robs from people is the ability to grasp their condition. Some patients are skilled at hiding the extent of their impairment. Sometimes spouses fill in the gaps, so problems are less noticeable to the rest of the family. Patients can hide troubles from their doctors, too, so it is critically important that families and care teams maintain communication.
 
Just like many fully capable adults, dementia patients may fiercely resist the involvement of others in their business and many suffer for it. One of my patients hid her impairment until she was conned out of her entire savings. Another minimized his symptoms, until the family got a call from a stranger saying their father had gotten lost behind the wheel. Overruling the wishes of your adult parent can be difficult. But, when we recognize their vanishing judgement, intervening is the loving, and sometimes the lifesaving, thing to do.
 
Through much of my lifetime, I’ve watched my father worry about his own memory. This is a common concern for people who have seen a loved one struggle with dementia. I hope that someday, we will have more to offer, but there is no magic pill. For now, the best we can do is to give the same advice you hear from us on virtually every other topic: Eat a healthy diet. Get exercise. Keep your brain active. And welcome support from those who love you.
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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 Debra Johnston, M.D.
 
When I met her, she was younger than I am now. I was responsible for admissions to our hospital that day, and the ER doctor called me about a woman with intractable bleeding. It had been going on for several months, but she was embarrassed and unsure. She hid the severity of her bleeding from her husband, until the day she passed out in the kitchen. 
 
Ultimately, we diagnosed her with cancer, and she started down a difficult road of surgery, chemo, radiation, and more surgery. But they faced many hurdles beyond her disease.
 
She and her husband each had finished high school with the help of special education classes. They struggled to understand the complicated reality of her cancer, and the choices they had to make. He was on disability, but she had never worked, and she certainly was not able to now. They got by on his social security check, which was not enough to cover her medications.
 
Her family lived several hours away, and their relationship with his family was often combative. The steps into their home were rickety, and she couldn’t navigate them with her walker. They couldn’t rely on their old car to get them to medical appointments, or even to the grocery store.
 
Fighting cancer or any life altering illness or injury is hard even for those who are financially secure and have the support of extended family. For a moment, let’s put ourselves in the shoes of those who face an uphill battle just to get to neutral.
 
Perhaps we grew up with a parent who had an untreated mental illness or addiction, or who was abusive. Perhaps we face discrimination because of our race or religion or gender or sexuality or some other fundamental characteristic. Perhaps we struggle with poverty, and the attendant evils of housing and food insecurity. Perhaps we live in an unsafe neighborhood, or we cannot easily get to a grocery store.
 
How, then, do we eat right and exercise safely? How do we find and keep a good job if we have limited education or we don’t have reliable transportation? How do we communicate with a doctor if we don’t have a phone and can’t read very well?
 
All these things are part of the social determinants of health. Our health and wellbeing depend on so much more than the factors we can control. Living with chronic stress, particularly chronic stress we experience as a child, impacts our physical health throughout our lives and that stress can continue down through generations. If we genuinely want to promote wellness, for ourselves and for our society, we must put ourselves in other people’s shoes and pay close attention to these underlying issues. 
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 Andrew Ellsworth, M.D.
 
My son is a cub scout, and I am den leader. Recently our den met outside and practiced putting up tents and learned how to build a fire. With efforts to stay distanced, every scout made his own s’more, and we had such a fun time. 

One highlight of the evening was letting each scout try to light the fire. We went through a series of mistakes with the matches and thankfully no one got hurt. They were so proud to learn how to light a match and start a fire. However, it was also daunting for them. One scout specifically commented on how excited he was and how scared he was. I tried to teach safe techniques and explained how you do not need to fear fire, but you do need to respect it.  

Approaching something with respect rather than fear is helpful in so many things in life. Whether it be a wild animal, fire, or a weapon, cautious respect is usually more helpful than fear. Education and experience, without losing that caution and respect, may be lifesaving.

Those principles could be helpful as we cope with COVID-19. Depending on your situation, you may not be afraid, or you could be overcome with fear. On the one hand, fear could paralyze us and cripple our response. On the other hand, a complete disregard for measures to help decrease the spread of the virus is like being careless with fire. We all want to return to a normalcy and way of life that is healthy physically, mentally, socially, and economically. However, cases are on the rise and denial of reality and a disregard for others is fuel for the fire.

The efforts of so many people to decrease the spread such as social distancing, wearing masks, washing hands, and being careful is helping to give scientists more time to research treatments and vaccinations. Progress is being made, and so many people are united in the same goal of getting through this pandemic, safely, together. 

Recently I was visiting with a 98-year-old man. I asked him about this pandemic and what he experienced in the Great Depression and World War II. He was confident we would get through this. We will succeed if we do not let ourselves become divided, but work together, treating the virus with caution, and supporting those around us. 
 
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 Andrew Ellsworth, M.D.
 
Indeed, there is a lot we can worry about in the world today. It can be so easy to let those problems invade our thoughts as we try to get some sleep. Ideally, our bedrooms are sanctuaries of peace and quiet and places of rest. But televisions, phones, computers, and other devices bring the world and its problems to our beds, and this is not healthy. 
 
Sleep is one of the best ways to help keep our immune system strong to fight off infection and illnesses. And now more than ever, it is important to give our bodies the best chance at fighting off a cold, flu, and disease. Adults need seven to eight hours of sleep every night, while teenagers and elementary children need nine to ten hours.  
 
Regular exercise is one way to help us sleep better. It is best to exercise during the day rather than right before bedtime. We sleep better if we avoid eating large meals within two to three hours of going to bed. But this doesn’t mean we must go to bed hungry. We can reach for a small healthy snack like carrot sticks or apple slices. It can also help to keep a regular schedule and have a bedtime ritual, such as brushing our teeth after that final snack. 
 
Reduce caffeine and alcohol consumption, especially near bedtime. And when stressed, we can prepare for better sleep if we take time to relax by gentle stretching, meditation, prayer, or deep breathing. 
 
We can help ourselves by changing our behaviors, but if we experience persistent heartburn or reflux, restless legs, snoring, daytime fatigue, or use the bathroom frequently at night, it’s time to visit the doctor for assistance.
 
Finally, it helps to keep the bedroom comfortable, quiet, dark, and cool. Despite all their conveniences, consider removing those electronic devices from the bedroom. Screen time before bed, whether watching television, phones or laptops is a large and growing reason for insomnia. The bright light from screens tricks our minds into thinking it is daytime so be sure to use the night filter to decrease the amount of light they emit. And, since our bedroom is meant for sleeping, why not set a firm time to turn off all the devices for the day. 
 
“You better get up; people die in their sleep.” That’s what my dad would say when he was trying to get me out of bed as a teenager. While true, the reverse is also valid, people can die from problems stemming from lack of sleep. So, let’s get some sleep and stay healthy out there people!
 
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.
 
As a primary care physician, I commonly encounter patients who smoke cigarettes. Most people, including those who smoke, are aware of the long term health risks posed by smoking. Of course, as a physician who cares about their current and future health, I want these patients to embrace the goal of smoking cessation. As someone who has never been a smoker myself, I admit I cannot fully understand the struggle of this task. However, the data suggest that quitting smoking can be extremely difficult. I find it helpful to understand some basic psychology when it comes to smoking cessation.
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In the 1970s, a duo of scientists named Prochaska and Diclemente, after studying subjects who smoked and their likelihood of successfully quitting, developed the Transtheoretical Model of Stages of Change.  This model is widely used today to assess readiness for change when it comes to smoking and other lifestyle changes such as diet, exercise, alcohol and other substance use. The following explains each stage and how we can apply them to help with smoking cessation:

Precontemplative stage: A person has no intention of changing their behavior soon. In this case, I “plant the seed” by providing some basic education and encouraging the patient to think about it before the next visit. Pushing or forcing change at this stage is not likely to be fruitful.

Contemplative stage: A person is thinking about making a change, perhaps in the next six months, but they may not be ready for a definitive plan. I offer specific education about quitting and ensure follow up to help with planning when they are ready.

Preparation stage: A person is ready to implement change in the next 30 days. Time to cheer on my patient and set them up for success! We might set a quit date together, consider referral to the Quitline, and discuss more specific strategies, including medication or nicotine replacement.

Action stage: This is the first six months of the big change, during which patients have a high risk of relapse. It is crucial that the patient check in often with me, their Quitline counselor, and other support people. 

Maintenance stage: After the action stage, risk of relapse decreases but does not go away. I offer my patients a safe place to discuss their urge to smoke and encourage them to stay tobacco-free. If they do slip up, I remind them not to give up. I help them focus on the hard work they’ve already done and stay successful.

Quitting smoking can be difficult, but it is truly one of the best things a person can do for their long-term health. There is support out there, starting with your primary care provider. When you are ready, ask for help!

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 remember feeling jealous of my grandparents as a child. During one of our summer visits, I realized that while my siblings and I were told to brush our teeth, my grandparents would simply pop their teeth out and drop them into a glass. That seemed like a lot less work! Besides, I thought that no teeth would mean no trips to the dentist, and thus no poking and prodding of sharp instruments in my mouth. Although our dentist and his team were unfailingly caring and gentle, I was always nervous. 
 
As I recall, when I expressed my newfound enthusiasm for the convenience of false teeth, Grandma informed me that wearing dentures would mean giving up fresh corn on the cob. That was all the incentive I needed. I kept brushing.
 
Soon, I realized that a healthy smile meant something more than the ability to enjoy garden bounty. I sensed my tough-as-nails mother and grandmother each were ashamed of their smiles. Without understanding why, I could see that people were judged by the condition of their teeth. Dental health seemed to be an indication of a person’s place in society.  
 
With the benefit of age, and medical training, I learned that the impact of dental disease goes well beyond dietary inconvenience and social embarrassment. People with unhealthy mouths may suffer from malnutrition, which can be both a cause and an effect of their dental problems. Others may unfairly perceive them as less trustworthy, and less employable. 
 
Emergency rooms and medical clinics see the consequences of delayed or absent dental care. Patients seek antibiotics and pain medicines to “get them by” until they can see a dentist. These treatments may convert a raging infection to a smoldering, but temporarily bearable, one. However, they don’t fix the underlying problems.
 
There is another layer to the interplay between dental and physical health: many medical diseases and their treatments may cause or worsen dental problems. The antidepressant I give a patient might cause dry mouth, which worsens tooth decay. The medicine to prevent a broken hip may severely damage the bone of the jaw. Diabetes increases the risk for dental disease which in turn, can worsen a person’s diabetes management.
 
Additionally, research shows that poor dental health increases our risk for heart attacks and could possibly lead to premature births.
 
All in all, there are myriad reasons to take care of our teeth and gums, no matter our age. So, thanks, Grandma, for convincing an impatient child to keep brushing. 
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.
 
When you ask a physician why they became a doctor there is often a pattern that emerges. It is usually one of three things: they have family members who were doctors, they went through a significant health issue of their own, or they had a family member or close friend who when through a serious health issue. In my case, it was the latter. Sadly, there have been many such experiences with people I love but let me share with you the first I can remember. 

I was five years old. She was my neighbor, the only person who could over-rule my mother on how long I could stay at her home playing or how many cookies I could eat when we had tea parties. She was the first grown up who treated me like an adult. When she was admitted to the hospital on hospice, my mother tried to prepare me for what I would see, telling me that our friend no longer had hair. I told her that I didn’t care, I missed her, and I just wanted to see her. 

The memory is so strong that I can still smell the faint antiseptic in the air from the tile floors. The room was dimly lit with a fluorescent light over the head of the bed. My neighbor sat in the bed, her gown hanging on her frame that was now gaunt and her beautiful hair now just a memory, robbed by the chemotherapy. 
We could not stay long, children under twelve years old were not technically permitted into patient rooms at that time. I said “Hi” and gave a shy wave not knowing what else to do or say. It was enough to just be there together. My friend, that powerful woman, looked so small and frail in her bed. The woman who I knew to be so full of life was now living in the shadow of death. I did not know it at that time, but that would be the last time I saw her alive.   
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Pancreatic cancer took her away from me just a few months after the diagnosis was given. I had so many questions. Most of them started with “Why?” That was the first time I had ever been in a hospital, but it would be just one of many times throughout my life where I would be a concerned loved one visiting a sick friend or family member. The death of my neighbor started my journey to become a doctor, a journey to find answers, only to learn that there is always another patient and another question, yet I persist. This is how I honor her memory.                                   
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.
 
Weakness on one side of the body, slurred speech, facial drooping, inability to find or understand words; these are symptoms of a stroke which are typically sudden in onset. The symptoms can be subtle, or they can be severe. Regardless, rapid diagnosis and treatment is the key to recovery. 
 
Not long ago, not much could have been done for someone as they were having a stroke. Often, we could only wait and see how the patient recovered with rehabilitation. For years, prevention was the only tool we had to combat initial and recurring strokes. Preventative measures such as blood pressure control, aspirin or other blood thinners, cholesterol control, and of course, a healthy diet and exercise remain especially important today. Thankfully, we now have a few more options. 
 
Clot-busting medications have been a great advancement in the treatment of strokes since the mid-1990s. If administered soon enough, sometimes these clot-busting medications can work to break up a clot that is blocking blood flow in an area of the brain thus restoring circulation. This can help to preserve or at least minimize the area of the brain that would be permanently damaged.
 
There are risks to these meds, such as bleeding, but the chance of improving the outcome usually justifies their use. To minimize risks, the clot-busting medication must be initiated within three to four- and one-half hours following the onset of symptoms. Physicians also consider other criteria before treating with clot-busting meds, including the patient’s medical history, blood test results, and they must rule out a hemorrhagic stroke using CT imaging of the brain. A hemorrhagic stroke is when damage is done by a ruptured blood vessel rather than from blockage.  
 
More recently, technological developments have changed the emergent care offered for very severe strokes. It is now possible to manually restore blood flow to the brain using minimally invasive surgery. A surgeon inserts a system of catheters and wires into an artery in the arm or groin, advances this system up through the neck and into the brain. Then, at the location of the blood vessel blockage, the blood clot is removed and the circulation to the affected area is restored.
 
Highly specialized, this new procedure seems almost miraculous. It has been referred to as the “Lazarus” procedure as it literally brings people back to life and sometimes immediate improvement is noted as soon as during the procedure.
 
The keys are recognition and time. Know the signs and get help quickly. Think of the acronym FAST:  Face drooping? Arm weakness? Speech difficulty? Time to call 9-1-1. 

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 is a classic presentation: The middle-aged man who develops a painful, swollen, great toe the morning after indulging in a steak dinner with a few beers. The savvy clinician will immediately identify this diagnosis, and I imagine much of the general public might recognize it as well. It’s “The Gout.”
Gout is a unique type of inflammatory arthritis in which a substance called uric acid, accumulating in too-high amounts in the bloodstream, forms crystals within a joint. The presence of those microscopic crystals causes the immune system to attack the “foreign” substance, and the result is excruciating pain. I have seen many a patient limp or be wheelchaired into the exam room when this process occurs in their toe, ankle, or knee. In the most severe cases, patients might be admitted to the hospital.
Gout has been recognized as a disease for many centuries, being described in ancient Egyptian texts in 2600 B.C. and later by the famed Greek physician Hippocrates around 400 B.C. It was once known as the “arthritis of the rich,” and the “disease of kings,” given its propensity to occur after consuming rich food and alcohol. Uric acid crystals were first visualized under a microscope in 1679, during the microscope’s early years, by another famous historical scientist, Antoni van Leeuwenhoek. The chemical composition of what he saw, however, was not known until more than a century later.
If you have had the agony of experiencing a gout attack, know that you are in excellent company. Both Benjamin Franklin and Thomas Jefferson were known to suffer from gout, and historians have speculated that their shared experience led to their strong connection at the time of the American Revolution. In fact, reports have stated that Franklin, unable to walk due to a gouty attack, was carried on a chair into the Constitutional Convention by convicts. Western history and literature are full of references to “The Gout.”
Today, gouty arthritis is a fairly common disease. It tends to affect men more than women, and generally occurs in middle-aged and older adults. Treatment of the acute episode is fairly simple; often we just use anti-inflammatory medication. In patients who have recurrent problems with gout we consider daily medication that lowers the level of uric acid in the bloodstream altogether, which is typically highly effective.
“The Gout” of ancient times was a life-altering condition and as such found its way into many historical texts and literature. Today, well, it’s just gout. And usually, we can treat it very effectively.
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.
 
Early in the pandemic, I had occasion to page through photo albums my mother assembled during my childhood. Some of those happy images chilled my physician heart. There I was, two months old, sleeping peacefully on my stomach, in the middle of a sheepskin rug.
 
There I am, seven years later, seated with my siblings on lawn chairs in the bed of the pickup truck as my parents drove us home. We navigated that 15-mile trip multiple times a week for months.
 
There I am, age 12, grinning from my perch atop a wagon load of corn. On the way home from the co-op, I would ride standing on the wagon hitch while my siblings sat on the fenders.
 
Bear in mind, my parents seemed especially safety conscious for the time as evidenced by snapshots of us buckled into our primitive car seats. And, when sunscreen was introduced, I remember my classmates basking in baby-oil while I was slathering on the SPF4.
 
As the saying goes, when we know better, we can do better. That philosophy should apply to us all, throughout our lives.
 
During my years in medical school, we taught parents to lay their babies down for sleep on their backs or their sides. Now we know better…back sleeping on a firm mattress with a taut fitted sheet and no blankets or teddy bears, presents the lowest risk of SIDS. And, research continues. 
 
Early in my career, we recommended children not be allowed to eat peanut products until at least age two to reduce allergy risk. Now we know better…early introduction to small amounts of peanut butter and other highly allergenic foods is the preferred strategy for most children. Still, research continues.
 
The history of medicine, and of science, is one of constant research and evolution. Some things we once thought we knew, did not hold up under further objective study. It is critically important that we challenge and examine our options and re-evaluate the way we have always done things. We must expect adjustments and be willing to change when healthier alternatives are revealed.
Obviously, I survived the dangerous situations of my childhood. However, too many children do not. We can never eliminate all risk, but we can, and must, continue to invest in the scientific process, using the best available data to determine the most effective solutions, even to old questions. 
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.