By Jill Kruse, D.O.
 
My daughter recently brought home a monarch caterpillar. We cared for it in a container making sure it had a supply of fresh milkweed leaves and kept its cage clean. It seemed perfectly content to munch on leaves all day. After a few days it hung upside-down from the lid of the cage and we waited for it to form a chrysalis, and eventually convert to a butterfly.

We used the time lapse video capability of our cell phone to capture the transformation. Watching the video, the change seems easy, quick, and effortless. There does not appear to be any major effort or pain involved for the caterpillar. However, after researching the subject, we came to appreciate the significant process the caterpillar undergoes which is not apparent to the naked eye of the observer.

Unless we take time to learn about the butterfly’s makeover, we may tend to minimize it as an uncomplicated process. Literally everything about the caterpillar changes. Its old body is completely broken down for the new one to form. Enzymes are released to break down the caterpillar skin and hormones allow new body parts to be formed. To the spectator, it looks easy, to the caterpillar, it is a monumental task.   

This got me thinking about how change is difficult for people, and how important it is for us to support each other as we attempt it. Many changes in life are painful and complicated, especially those we make to improve our health, or our physical, emotional, or spiritual wellbeing.

Breaking old habits and creating new, healthier behaviors involves a transformation. It requires that we learn new ways of thinking and practice positive self-talk which is sometimes uncomfortable and challenging work. Quitting smoking, walking every day, choosing different healthier foods, and avoiding junk food are changes that offer long-term benefits. The work may not seem worth it in the short-term. You may want to give up, especially when others do not seem to notice your struggles or understand how you are feeling inside. You may miss the way things were before you embarked upon your journey.

Look to the butterfly for encouragement to continue your transformation. Change may feel like a struggle, but when your wings emerge and you take flight thanks to your healthier habits, the change will be its own reward.
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Jill Kruse, D.O. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.  

By Andrew Ellsworth, M.D.

When the Declaration of Independence was signed on July 4, 1776, the American colonies still needed to win the Revolutionary War to truly gain their independence from the British Empire. The war continued another seven years until September 3, 1783. One of the deadliest threats to the Continental Army, however, was not the British Army, it was disease, especially smallpox. 

Boston had an outbreak of smallpox in 1775 from British Redcoats arriving to fight the rebellion. George Washington knew very well the dangers of smallpox after having had it himself as a young man, which left scars on his face. To keep his soldiers safe, Washington did not allow anyone from Boston near his troops. Washington wrote to John Hancock, the president of the Continental Congress, that he would “continue the utmost vigilance against this most dangerous enemy.” Later, when the British withdrew from Boston, Washington allowed only soldiers with immunity into the city. 

Most of the Continental Army had never had smallpox while most of the Redcoats had. This put the Americans at a big disadvantage. An attempt by the Continental Army to take Quebec failed in part because of heavy losses due to smallpox. In fact, General John Thomas died of smallpox in July 1776. 

This was before the advancement of vaccinations. However, there was a procedure known as variolation, an early form of vaccination which involved exposing a cut on the recipient’s arm to a small dose of the virus, hopefully just enough to trigger immunity without causing severe illness or death. The procedure was illegal in many places including Washington’s home state of Virginia.  

Washington knew they could not afford to lose more soldiers to smallpox. Thus, despite push back from the Continental Congress, Washington ordered this primitive form of vaccination for the entire army, and by the end of 1777 more than 40,000 soldiers had received it. Infection of the army dropped from 20 percent to one percent and lawmakers repealed bans of variolation for smallpox across the colonies.  

George Washington’s efforts at quarantine and primitive vaccination helped protect the Continental Army from disease which helped them eventually defeat the British Army and earn independence for the United States of America. 

The war on Covid-19 may take several years as well. History shows how vaccination can be a great weapon against disease. Unfortunately, many remain unvaccinated, and hundreds in the U.S. continue to die each day. We need to rally both nationally and locally, to unite our efforts so we can gain our independence from Covid-19.

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 Philip Meyer, D.O.
 
For most of us, seeing the doctor means making a trip to the local clinic to see our primary care physician in person, but an increasing number of patients are seeing their doctor remotely by telehealth, using two-way video telecommunication technology.

The popularity of telehealth services soared during the COVID pandemic much like Zoom and similar technologies. Historically, patients and health care providers alike have been reluctant to adopt it, but federal health policy changes have removed many of the barriers to telehealth access and have promoted its use in both primary and specialty care.

According to the National Institutes of Health, twenty percent of us live in rural America where less than ten percent of physicians practice. I personally have known patients who live more than one hour from their primary physician and more than three hours from a medical specialist. Taking time off work and the travel expense required cause many patients to delay seeking care until their acute illness becomes complicated or their chronic condition deteriorates.

Thankfully, as telehealth services have grown, time and expense of travel to a specialist have decreased and access to care has increased for many. Rural emergency physicians and hospitalists utilize telehealth services for additional support and expert opinions for issues ranging from acute trauma and cardiac arrests to coordination with critical care specialists regarding the optimal management of a patient’s ventilator. Although not every specialty is available, the advent of telehealth has afforded many outpatients the opportunity to stay in their hometown and see a specialist.

While my patients and I have had many positive experiences with telehealth, none exemplifies the power of a remote video connection better than one of my first encounters with a critically ill COVID patient in my local ICU last Fall. Moments after placing a call to my telehealth affiliate, I was video chatting with a critical care specialist in Seattle – America’s first COVID epicenter. I was in my central South Dakota rural ICU wearing my PPE standing beside my patient who was now on a ventilator struggling with a disease I had never seen or treated and in the room with us virtually, but 1300 miles away, was a specialist with six months of experience treating dozens of patients like the one before me.

There will never be a replacement for in-person health care and a physical examination is required for proper diagnosis in most cases, but I urge you to keep an open mind to seeing a physician remotely by telehealth when necessary and consider the power it can add to your overall health care.
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Philip Meyer, D.O., a hospitalist in Pierre, South Dakota, is a contributing Prairie Doc® columnist. He appears as a guest during On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB Thursday, July 1 at 7 p.m. Central. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook. 

By Kenneth A. Bartholomew, M.D.
 
The liver is one of the most amazing but underrated organs in our bodies. We cannot live without it, and, unlike the kidney, we cannot bypass it with a dialysis machine. Lose your liver and you lose your life.
 
The liver is essential for digestion, but also detoxifies our blood, filtering, breaking down, and disposing of chemicals we cannot use. While there are many toxins that can harm the liver cells, it has an amazing ability to regenerate itself. It can suffer immense damage, nearly die out, then recover and allow many more years of life.
 
To help us discuss liver damage, we look at ‘hepato’ from the Greek ‘hepar’ or liver. Thus, the words ‘hepatocellular’ meaning cells of the liver, and ‘hepatitis’ referring to inflammation of those cells. Hepatitis can cause cirrhosis (liver scarring), liver failure, liver cancer and death.
 
The classic forms of hepatitis (yellow jaundice) are caused by the hepatitis viruses, A, B, and C.  Hepatitis C is particularly aggressive but thankfully there is now a drug that can kill this virus.
 
Toxins and chemicals can also cause hepatitis, the most common being drinking alcohol and acetaminophen (Tylenol). The combination of both is especially toxic. Other commonly used medications that can damage the liver include aspirin, cholesterol drugs called statins, anti-seizure meds like phenytoin (Dilantin), ketoconazole, some antiviral drugs, and anabolic steroids. If you take these prescription meds, do not stop. Instead talk to your doctor if you have questions.
 
Unknown to many people is the fact that even some herbs and supplements, used excessively, can cause liver damage. Comfrey, black cohosh, aloe vera, cascara, kava, and chaparral are just a few; even vitamins taken in quantity have poisoned the livers of children who mistook them for candy.
Regrettably, in our obese society, fatty liver is fast becoming one of the most common forms of liver damage. Fatty infiltration of the liver cells causes inflammation. NASH (nonalcoholic steatohepatitis) is the worst form of this. There is no medication; the only known cure is significant weight loss.
A simple blood test can reveal if your liver enzymes are in the normal range or if they are showing inflammation. The liver may be underrated, but please do not ignore it. Schedule your annual exam and talk to your doctor about your liver. Catch problems early and you might prevent long-term complications.
 
Kenneth A. 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 Debra Johnston, M.D.
 
I’ve been spending a lot of time talking with patients about the COVID-19 vaccine. Sometimes we celebrate being fully vaccinated. Some patients are skeptical about how serious COVID-19 infections actually were. And others are not convinced they can trust the vaccine.
 
When I talk to the first group, we chat about our plans to reunite with people and activities we love. With the second group, I share stories of my firsthand experiences as a doctor during this crisis. We talk about interpreting death rates, how death certificates are filled out, or how health care is reimbursed.
 
I particularly enjoy the conversations with the third group, many of whom share some of the same questions I had. I did not believe, at the beginning of the pandemic, we could possibly have a vaccine by the end of 2020. How could a vaccine for a brand-new disease be developed so quickly?
 
There are two lessons beautifully illustrated by the lightning-fast development of the COVID-19 vaccines. The first is what can happen when money is no object. The typical process of drug development involves a relatively small investment for initial testing, investing a little more only if those results are encouraging, rinse and repeat. With the COVID-19 vaccines, all needed funding was available almost immediately.
 
The second lesson is the importance of past research. Other coronaviruses caused outbreaks of SARS (severe acute respiratory syndrome) in 2003, and MERS (Middle East respiratory syndrome) in 2012. Researching these deadly infections taught us how coronaviruses invaded human cells, so we knew that the spike protein was a good target for a vaccine. Developing a vaccine for Ebola taught us how to safely edit the genes of a less harmful virus and use it to teach our immune systems to fight a more serious infection. Thirty years of mRNA research led to clinical trials of mRNA-based cancer therapies, and investigation of mRNA vaccines for influenza, rabies, and Zika. All this research and technology was used in COVID-19 vaccine development.
 
Chinese scientists published the genetic code for the virus in January 2020. Within days, using all that previous knowledge, researchers began production of vaccines. When the clinical trials began, the pandemic was raging, and many trial participants were exposed to COVID-19 over a short period of time. Trials could proceed faster than usual because when lots of people are getting sick, it doesn’t take as much time to determine if a therapy, including a vaccine, is effective.
 
Were the COVID-19 vaccines developed in record time? Yes. Because money was no object, and because 30 years of scientific research and development left us poised to succeed.
 
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.

I was sitting in my beach chair on vacation soaking up the sun when I overheard the couple next to me sounding concerned. They were throwing out lots of big medical terms but were very confused and said that they did not understand anything that they read on this MRI report. I turned to them, apologized for eavesdropping, and introduced myself as a physician. I offered to “translate” what the radiologist report said, and they gladly accepted. 

Their problem was not a lack of information. They had access to the patient portal and were able to download the MRI report and the physician’s notes. All this information was written in medical terms, acronyms, and shorthand with a few words in Latin and Greek sprinkled in. What they lacked was clarity and understanding.

So, I sat there on the beach and translated the report into layman’s terms. The family was grateful, and I was happy to help ease their minds. This was not what I had planned to do on this beautiful day at the beach, but it was rewarding to be able to use my knowledge and skills to help them get some clarity. However, it was disheartening that they had to rely on help from a stranger who happened to overhear their discussion about arteriovenous fistula.   

The medical record is written by doctors to communicate to other doctors and is full of terms and jargon that are not used by most people. Having access to this information is good, but when taken out of context or the relationship of a visit with a physician, information can cause more confusion and unnecessary anxiety.

To quote Takeda Shingen, “Knowledge is not power, it is only potential. Applying that knowledge is power. Understanding why and when to apply that knowledge is wisdom!” Years of medical school, residency, and continuing medical education help doctors gain knowledge, understanding, and hopefully, the wisdom to communicate effectively with our patients.

A worthy health care team welcomes and encourages questions, eager to give you the best information possible. We want you to know what is going on with your health, and to fully understand what all the labs and tests mean.
If you ever feel like this family on the beach, my recommendation is to contact your physician or health care provider and ask for more time to discuss your health status. Doctors on the beach everywhere will thank you, as we relax and enjoy our time with our family knowing that your family is well taken care of.
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Jill Kruse, D.O. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.  

By Andrew Ellsworth, M.D.
 
My last conversation with Grandpa was over the phone. He was sick and dying. I was 1,200 miles away in residency, learning how to be a family physician. I was not going to make it home in time to see him one last time.
 
We did not know exactly what was wrong. Sure, he could have had more tests and been admitted into the hospital, but that was not what he wanted. Thankfully, a family friend and physician had talked to my grandparents about their end-of-life goals. This discussion helped Grandpa realize what was important to him, like his faith and being with Grandma, and what was not, like spending time in doctor’s offices and hospitals. 
 
Even though I was a physician in training, I supported his choice. He was in a peaceful place, listening to music, talking with Grandma and other friends and family. 
 
Most people want to die at home. However, only 20 percent do. When it comes to dying, some advance planning may make a world of difference. 
 
It does not require an official document or appointment with a lawyer to make plans for how you would like to spend your final days. It does not even necessitate a visit with your doctor, although all the above may help. The most important thing is talking to your loved ones about your wishes and goals of care.  
 
How do you know when to have this talk, how to bring up the topic, and what to say during the conversation? How and when do you say “enough is enough” when it comes to searching for a cure, a surgery, a treatment, or spending a few more nights in the hospital? Discussing these questions may not be easy, but it is more productive and less stressful to have the conversation now rather than during a crisis.
 
Start with scheduling an appointment with your doctor for the sole purpose of talking about your end-of-life goals, expectations, and values. Then, together, adjust your care plan accordingly. Revisit these discussions periodically with your family and your healthcare providers. 
 
It was tough not being there with Grandpa, but he was at peace, so I was at peace. This past year, many others have had to say goodbye remotely or did not even have the chance. This is a reminder for us all to have meaningful conversations, to tell our loved ones how much they mean to us, and to cherish the time we do have together. 
 
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.
 
We all know the feeling. You ate too much, and now your stomach is letting you know about it. Or maybe you ate some junk food, and now you don’t feel well. How is it that another slice of pizza one moment seems like exactly what we want, but later we realize it was not what we needed?
 
In the simplest of terms, it comes down to hunger and cravings. The message for hunger is initiated by the body. When our stomach is empty, and our blood sugar and insulin levels begin to drop, our bodies release the hormone ghrelin and send it to the hypothalamus in our brains resulting in a desire to eat. Cravings, however, are entirely controlled by our brain. Fatty and sugary foods help release feel-good opioids and dopamine in our brains. The message in this case is a misapplied sense of reward.  
 
Our bodies, especially the gastrointestinal system, respond directly to what we put into them. Many common problems like abdominal pain, heartburn or reflux, constipation, and diarrhea are often directly caused by our diet. Other conditions like irritable bowel syndrome and Celiac disease can also be treated by a change in diet. Cutting down on processed meats and processed carbohydrates may help decrease your risk of colon cancer. 
 
Thus, when it comes to filling our hungry stomachs with healthy options, there are ways to overpower the feel-good cravings from our brains. First, turn off the TV. Plenty of studies have shown we eat more than we ought to with the TV on. That goes for your phone, too. Second, slow down. Savor your food. Give your body time to send the signals from your digestive tract to your brain that you’ve had enough. Third, drink water while you eat. Room temperature water is best for digestion. Also, we often misinterpret being thirsty for being hungry. Having a glass of water before you eat can help satisfy your thirst and help you eat less. Fourth, eat with someone in person, via Zoom or phone call. When you eat with someone you are more likely to make healthier choices and eat slower.
 
Our bodies know what is good for us. We just need to understand the messages. Next time you have a craving, or think you feel hungry, rather than automatically eating more, take time to assess your situation. If you discover you are tired, stressed, sad, angry, or lonely, appreciate your new self-awareness and explore behaviors other than eating that could better satisfy your needs. If what you are feeling truly is hunger, give your body what it really wants: a healthy diet.
 
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 Tyler A. Ptacek, M.D.
 
Back pain can be disabling, not only in terms of employment but also in terms of social connections. This point was never more clear to me than when I saw Maria, a 56-year-old experiencing severe low back pain for nearly five years. The pain prevented her from standing or walking for more than five minutes at a time and had cost her the job she loved. Maria shared with me her one heart-wrenching goal; she wanted to hold her first grandchild, a six-month-old baby boy. Doing so had caused pain so intense it put her in bed for a full day afterwards.
 
At our first visit, we discussed the treatments she had exhausted with no relief. Pain pills had severe side effects. She tried numerous steroid injections which seemed to help for several weeks, but the pain returned as did her disability. These "quick fixes" were not only failing to relieve her pain but were causing other health issues. She was diagnosed with osteopenia and pre-diabetes; both are known risks of prolonged steroid use. She had been told there were no other options for her. I reviewed her medical history and immediately noticed a glaring treatment deficit; she had never been to physical therapy. 
 
After six weeks of physical therapy and a trial of some basic non-opioid medications, she was able to lose weight and developed a home routine to decrease the pain significantly, but one problem remained. She still could not pick up her grandchild without severe pain. 
 
We ordered new imaging and found arthritis in the small, paired joints in the back of the lumbar spine, plus inflammatory disc/bone problems in the front of the low back structure. This is a well-known phenomenon called “Modic endplate changes.” For perhaps the first time, Maria received a full explanation of her imaging and learned what was causing her pain.  
 
We treated her L4 and L5 Modic changes with an outpatient, minimally invasive procedure which targets the basivertebral nerve. This treatment has the potential to provide a permanent cure for pain related to this specific problem. Maria’s recovery process was mostly anesthesia-related, and she had 80 percent relief of the pain within two weeks. At her three-month follow-up appointment, she had tears of joy as she told me how wonderful it was to hold her now one-year-old grandson!  
 
This is why I am a pain doctor, not only to relieve pain, but to restore function and help patients achieve their basic life goals. Life is about the little things that most of us take for granted, whether it is standing, walking or holding our grandkids. 
 
Tyler A. Ptacek, M.D. is a contributing Prairie Doc® columnist and a guest this week on the Prairie Doc® television show. He practices in Rapid City, South Dakota as a board certified and fellowship-trained interventional pain physician. 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.

Artists and medical personnel both know the importance of art. The famous nurse Florence Nightingale once said, “Variety of form and brilliancy of color in the object presented to patients are an actual means to recovery.” Elaine Poggi, Founder of the Foundation for Photo/Art in Hospitals agrees and stated “The mood changes when our beautiful nature photos are placed on the walls, providing color, comfort, and hope to patients, caregivers, and loved ones.”

Before COVID, the walls of my exam rooms featured some of my favorite art. Each room had a different, deliberately chosen theme. One theme was photographs of the Grand Tetons and Canyon De Chelle taken by Ansel Adams. Canyon De Chelle is on the Navajo reservation where I did a rotation as a resident. Another room was filled with an Asian mural and photographs of my time in South Korea when I was a student ambassador for SDSU at their sister school in Taejon, South Korea. My third exam room had circus posters and pictures of Baraboo, Wisconsin, hometown of the Ringling Brothers, and the location where I did my residency training.

The art helped break the ice with patients and allowed me to share a special part of myself and my life with them. It also provided my patients with something to look at while waiting for me to come into the room. It gave us something to talk about other than their illness or why they came to the doctor that day. As part of the discussion, I learned about my patients’ travels, their love of photography, or memories of going to the circus as a child. Each picture was an opportunity to share a common bond. 

COVID forced those pictures off the walls and into storage. The rooms were stripped of anything extraneous that could potentially become contaminated. My exam room walls are now blank and sterile; the rooms seem a little colder and less inviting. There is less color and joy in the rooms. Without art, we tend to jump into the clinic visit topic without first connecting as people. I didn’t realize what a big difference the loss of art on the walls could make until it was gone. 

Dr. Rachel Naomi Remen said “At the deepest level, the creative process and the healing process arise from a single source. When you are an artist, you are a healer: a wordless trust of the same mystery is the foundation of your work and its integrity.” Photographer Prakash Ghai explained it much more succinctly when he stated, “Art heals both the creator and the viewer.” I miss my art and cannot wait until I can once again hang some healing on my exam room walls. 

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.