I Have A Secret

By Shawn Vuong


There are times when practitioners and patients get caught up in the world of pharmaceuticals.  It's human nature to want the 'pill' that solves it all.  Truth is that sometimes pills aren't always the right answer.


A good primary care doctor knows this.  The good family practice doctor knows when to just suggest that chicken noodle soup for the flu, the relaxation methods for insomnia, or the many many others.  In this post Dr. Holm talks about such a technique.  


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By Richard P. Holm MD

I have a secret way to prevent loss of control of bowel and bladder, which costs nothing, is under-used, and works.  Let me explain.

The muscles between the pubic bone, in the front of the pelvis, and the tailbone, in the back, are called the pelvic floor muscles.  They act like a hammock to keep all the organs of the abdomen from falling out.  These muscles also control the release of urine and feces, which most people prefer to do in a private place and in a sanitary way.  To accomplish such control, however requires the pelvic floor muscles to work well. 

Although this topic is almost verboten in proper public forums, if you think about it, anyone who eats and drinks also has to discharge waste products.  There is nothing secret about that.

In 1948 an OB-GYN doctor Arnold Kegel developed exercises to strengthen the pelvic floor muscles in order to help fix urinary incontinence in women after childbirth.  Since then his ideas have spread.  The exercises have also been recommended for helping with bowel and bladder control for men as well as women; for conditioning muscles to make birthing easier; for rehab following prostate surgery; even for improving sexual enjoyment in women and men.

All that considered, what has been repeatedly proven by scientific study is that men or women with urinary incontinence who actually do the exercises over more than a month experience significant improvement in their symptoms.  It works.  I believe Kegel exercises must be considered as a solution for incontinence before contemplating drug or surgical solutions.

Kegel exercises are simple to do.  Find these pelvic muscles by starting and stopping the flow of urine without using your stomach, leg, or buttock muscles.   Simply tighten and relax the pelvic muscles about 200 times a day.  There are many variations and even devices to encourage the strengthening of the pelvic floor muscles, but the key to success is to simply do it.  To say it again, the benefits come with tightening the muscles 200 times a day, and making that a habit.

Kegels are something you can do quietly, while just sitting there, without anyone else knowing.  It’s a secret habit worth having.

Stress

By Shawn Vuong


The human stress response is a balance of two delicate systems, the sympathetic and the parasympathetic nervous systems.  The sympathetic system gives us that boost of energy and anxiousness we get before something big is about to happen or if we are surprised.  Our hearts beat quicker, we breathe faster, our pupils dilate, and our muscles prime for action.  This is the acute stress response that has helped us through our hunting and gathering years.  After that stress our parasympathetic response takes over.  It is known as the rest and digest system.  Usually after a big meal you'll feel pretty tired, that's your parasympathetic response at work.  


The problem becomes when stresses become a long-term issue.  Money, work, kids, relationships, and time all can add up and continuously stress us out.  This is bad, because this stimulates our sympathetic nervous system for a long period of time.  This system was not meant to be chronically simulated, and because of this we see the harmful effects of stress on the body. 


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By Richard P. Holm MD


Whose life is not stressful? The one who says she or he is not stressed has blindfolds on, or hasn’t lived long enough. A definition for stress is needed. What is stress? The dictionary says that it is a state of mental, emotional, or physical strain resulting from adverse or demanding situations.


The other evening I turned and asked my wife what she thought was the most stressful thing. We both agreed that it is to watch our children (and parents, for that matter) individually struggle with their own challenges in life… as we stand helplessly on the sideline, without the ability, or the right, to intervene or fix what’s happening. I know that at some point children should be left to learn from their own mistakes.


Knowing when to or NOT to step in is addressed in the Serenity Prayer: God grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference. The prayer makes it seems so clear but the difficult part of the serenity prayer is the wisdom comment. When do you take the challenge to change something versus when do you leave it alone?


In the same vein, a recent study showed that men who bottle up their anger over unfair treatment at work and who are unable or not allowed to express their resentment over conflicts, are more than twice as likely to have a heart attack and/or die than those who can vent or manage such work-stress. I would never suggest people should let anger and temper rage, but unhappy-at-work people should either try to make appropriate changes there or switch jobs. No job is worth holding emotions in and dying young.


Whether it is children or a job that is making life stressful, may we all discover serenity and find the wisdom to change what we can, and let go when we must.

Corrosive Stomach Acid

By Shawn Vuong


A wise pharmacology professor once told me, "All substances are poisons; there is none which is not a poison.  The right dose differentiates a poison and a remedy."  


This week Dr. Holm talks about drugs, particularly in the context of heart burn.  In our pharmacology class, we are learning about how all types of drugs interact with the body.  Prescription drugs, over-the-counter drugs, herbals, and even supplements all effect the body in different ways.  The key to prescribing drugs correctly is weighing the risk of toxicity of a drug versus the benefit gained. 


Each substance has it's own toxic effect when given at too high of doses.  But we must make the dose high enough to see a benefit.  In effect, we get a titer-totter like scenario where we are trying to balance the correct dose to see benefit while trying to limit toxic effects (also known as side effects).  Some drugs are easy to give, since they have a high benefit but low toxic effects such as statins.  Other drugs have medical health professions constantly walking that fine line between lethal effects and benefit to the patient such as chemotherapy agents or anesthetics.  


So remember, every substance has toxic effects when given at incorrect doses.  Even water can cause lethal effects if you drink too much.  So, please work with your doctor to correctly dose your medications, because they can sometimes give you nasty side-effects.  




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By Richard P. Holm MD


It has always amazed me that the stomach can produce large amounts of a very corrosive hydrochloric acid. Of course, we do that in order to breakdown food so our bodies can absorb nutrients.


In response to food stretching the stomach and esophagus, tiny proton-pumps in special cells that line the stomach make acidic stomach juice. The resultant strength of gastric acid during digestions can be not as corrosive as battery acid, but almost.


Fortunately, a special layer of mucus protects the stomach from the acid, and as food moves on into the small intestine, the corrosive juice is neutralized by sodium bicarbonate produced by the pancreas.


When something goes wrong: the stomach-mucus layer fails; the acid rolls up into the unprotected esophagus; or there is not enough sodium bicarbonate to neutralize the acid… then symptoms occur. People can be pretty miserable as digestive juices are eating away at their own tissue, rather than the food they just ate.


Fortunately we have very effective medications to reduce acid production when something goes awry. One group of antacids, which reduce acid quickly are the H2 blockers with ranitidine (Zantac) as an example. Another group, which reduce acid slower but more effectively, are the proton-pump inhibitors, with omeprazole (Prilosec) as an example.


These two types of powerful antacids have been a blessing for many people who truly suffer from excess acid stomach. A major drawback with both types of medicines, however, comes when trying to stop them, which can result in rebound acidity.


A recent study provided two months of omeprazole to people who at start had never been troubled with heartburn. When the medicine was stopped, however, the volunteers had rebound acid symptoms.


People need to be warned when using these stomach acid medicines that short-term use is safe and can be very helpful. However, getting off of them after prolonged use can be a challenge and may require a gradual reduction over two to three months. Certainly some people should never be off of them, but that should be discussed with your doctor.


Take home message: we have good medicines to counter the corrosive battery-like acid made in our stomachs, but they need to be used with caution.

Asthma

By Shawn Vuong


This post from Dr. Holm really hits home with me.  In my late elementary school/early middle school years I was plagued with exercise-induced asthma.  When I would play in PE class or recess, my chest would just feel like it was tightening up.  The wheezing, the tightness, and the shortness of breath is very scary. 


My parents took me to a pediatric pulmonologist and I was tested for asthma.  Right then, the doctor prescribed me an albuterol inhaler, which became my life line.  After that, any physical activity that I did was preceded by a couple puffs from my inhaler.  I was too scared to have another asthma episode.  


Asthma is not just something that is brought on by exercise, but can be induced by allergies, pollutants, smoking, chronic disease, infections, or even stress.  Asthma can be deadly.  If you think you have some of the signs or symptoms of asthma I encourage you to see your doctor.  


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By Richard P. Holm MD


A few years ago, a 40-something woman was walking across the farm yard when something in the air brought on wheezing, like gangbusters. She turned back to the house for her inhaler, but just couldn't make it, and collapsed in the yard.


While her husband was hurriedly driving her to town, she stopped breathing entirely. Her husband gave her mouth-to-mouth until the ambulance met them.


In the ER, we were able to place the breathing tube down, but her brain had been too long without oxygen. And a few days later, I will never forget how she gently escaped from this earth surrounded by her loving family.


This tragic death taught me how asthma kills. So what can we do to prevent a similar calamity?


First, recognize when you are at risk. Have you experienced an asthma attack that comes on fast and out of the blue?


Next: are you using your rescue-immediate-acting inhaler more often lately? I should add here that albuterol or any of the fast acting adrenaline-like asthma inhalers might cover-up or even cause worsening inflammation in the lungs. They only work for the short run-and increased use of these fast acting rescue meds is a big time danger signal.


Finally: know that when your asthma is accelerating you need to turn off the inflammation and our best tool to do that is a steroid. Not a body building type, but and anti-inflammatory which slowly turns off asthma for the long run.


That's the take home message: although fast acting rescue inhalers are good to have-they forecast danger. The real hero in this disease is the anti-inflammatory steroid inhalers.


So if you or your family member with asthma is using the rescue inhalers more than usual do not dally. You need to be talking to your doctor about anti-inflammatory steroids.

Earwax and Elbows

By Shawn Vuong


In this post, Dr. Holm talks about one topic that doctors have been losing ground on for a long time, the Q Tip.  Every physician from the ENT to the family practitioner has seen the damage Q Tips have caused eardrums and ear canals.  They warn their patients to not stick anything into their ears, and to let ear wax come out naturally. I remember when I was in grade school, some health professional came in and told us only to use a wash cloth to clean out our ears and to never use a Q Tip.  Almost 20 years later, I still use them like a bad habit.  


Using Q Tips and Bobby Pins to clean out your ears is a bad habit, although it may seem like you are doing it to keep your ears clean.  In this case, the gross wax that a person is trying to clean out of the ear canal is actually the stuff you want in there for protection.  Dr. Holm explains more about the Q Tip problem, and gives some better solutions to cleaning out one's ears.  




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By Richard P. Holm MD

It was 1973, and the Professor advised our Sophomore Med School class that the smallest thing that should ever go into the ear canal is your elbow.  Through 31 years of practice I have seen many injuries to ears resulting mostly from Q Tips and Bobby Pins.  People use these weapons sometimes to scratch an ear itch, but mostly to remove earwax. 

Earwax is an oft-maligned material that has an interesting story.

Recently scientists have discovered genetic differences by the character of earwax.  East Asians and American Indians are more likely to have a dry grey and flaky type of wax, while Africans and Caucasians are more likely to have the moist honey-brown type.  Anthropologists have even used earwax type to track human migratory patterns, and claim the dry type indicates a genetic change, which came as a beneficial reduction in sweating for those living in cold climates.

Also called cerumen, the stuff that comes out of ears is a mixture of oil, sweat, and old sloughed off ear canal skin. As we chew, the jaw movement moves the gooey stuff outward down the canal, dragging with it dirt, dust, and debris.  We know it also provides for lubrication and protection against bacteria and fungus.

With aging, dehydration, or metabolic problems, the earwax can sometimes thicken, stop moving, fill the ear canals, and cause trouble.  In this case one should apply a couple drops of warm olive oil or baby oil to each ear two or three times a week. 

Q-Tips or Bobby Pins should be avoided since they will only pack the wax and potentially perforate the eardrum.  If oil fails to drain the wax plug, a few weeks of drops will at least prepare the wax for removal.  Then a solution of warm (not hot or cold) vinegar-water irrigated by an inexpensive ear syringe purchased at any drugstore should clear the plug.  Failing that, see your doctor.

There’s lots to do besides putting your elbow up there.

Q. and A. about Health Care Reform

By Shawn Vuong


This week Dr. Holm writes a short Q & A about the current health care reform and debate.  It's a nice concise summary of the basic problems of the reform, and I have nothing to add.  Hopefully, we find a workable and solid solution to our healthcare system problems.  So without further ado, the Health Care Reform Q & A.  
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By Richard P. Holm MD


Q. Do we really need health care reform?


A. The answer is a clear yes, because of ACCESS and COST issues:
1. Without reform, insurance companies will remain free to increase profits by cherry-picking only the well people, leaving too many Americans without access to health insurance. What’s more, many people will continue to be unable to change jobs for fear of losing insurance. These are problems of ACCESS;
2. Without reform, health costs will continue to rise, and health insurance will become more unaffordable for many businesses, let alone many individuals. Unchecked, by 2017 Medicare will bankrupt social security. This is a problem of COST.




Q. Why is US health care twice as expensive as any country in the world?


A. There are many reasons, which is why this is so hard to fix. Here are the most significant.


1. Payment for health care rewards hospitals for making available and encouraging the most expensive technology which does not necessarily improve care;
2. Physicians, especially in the emergency rooms have every reason to order the most complete and often most expensive tests or treatment because the patient wants it; the hospital wants it; and there is a risk of law suit if every test or treatment is not done and something bad happens. This again, does not necessarily improve care;
3. Patients expect the most expensive care for their family and for themselves, someone else is paying for it. Studies show the most expensive does not necessarily mean the best care;
4. Too often we do not have our personal doctor directing care, but have turned to that which is specialist driven. This kind of care can become very disjointed and very expensive.




Q. Will the solutions working their way through Congress right now solve the access and cost problems?


A. Both problems are being addressed. Ethically, I believe the access problem must be solved first. Although the more complex challenge of reducing health care costs will require a great deal of political will, it is a problem that also must be solved.


Both parties, of course, are playing their political hands with this issue, but I believe that without health care reform the consequences will be too dire for the any of us to tolerate. Our Washington leaders will have to find a way to make it happen.

Boys to Men

By Shawn Vuong


In the current society, men and boys are having a hard time defining themselves and fitting into their gender role.  What does it mean to be a man?  


It is said that nearly one fourth of all American children live in mother-only families.  At school they are more than likely taught by a female teacher.  Boys are growing up without a solid male role model.  This is a problem, as research shows that fathers tend to be more tend to be more challenging, prodding, loud, playful, encourage risk taking, and physical when compared to mothers.  This is important for children, and especially boys who are looking to their father for what it means to be a man.



In a world where being a woman is celebrated, it may be difficult for boys to figure out their gender role.  Women these days do a great job banding together, groups such as Women At Work, Women In Medicine, Women's Health Group, YWCA, and the many many organizations are devoted to celebrating what it means to be a woman.  Yet, you do not see similar things for men.  This could be that men only groups seem sexist and are discouraged, or that men just do a poorer job defining their gender role.  Either way, this lack of men groups in conjunction with a lack of male-role models may be making it hard for boys to understand what it means to be a man.  


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By Richard P. Holm MD

For men, there is always something about our Fathers.  I heard it today in my office coming from a very hurt, yet extremely successful businessman how his father had always told him that he was too soft and would never amount to anything.  His Dad always expected way too much.  He could never do enough… never do it right.  His Father was never satisfied with anything he did…  Never!

On the other end of it, some would suggest that much of what is wrong in our society comes as a result of inner-city boys growing up without Fathers, or Grandfathers, or male role-models.  Without mentoring, these angry boys make the world a very dangerous place.

Robert Bly, a Minnesota poet, is one of the leaders of what has been called "the expressive men's movement," and he tells us that a “man’s work” is to not deny his inner suppressed “wild man”, and at the same time learn from older men principles such as the work ethic, honesty, justice, and especially respect.


They say that a boy growing up needs to experience, from older men, a ritualistic initiation, a robust challenging physical experience with nature.  This could be at basic training, at a work setting, or during a football or sports experience.  There should be a separating time from Mama when a boy becomes a mature man and learns about his responsibility to protect, not harm.  He needs to learn that virtue and justice is the goal, never violence, betrayal, or abandonment.


My own Dad had been a Sergeant in the Army during WWII, and if I dropped the ball on something, I learned to say, “No excuse, Sir.”  He challenged me to work hard, and demanded the truth from me always, calling me on it big time when I deceived him. 


Certainly he had his failings, and every son sees these things in his Father, but my Dad taught me the “golden rule” and proved it by the way he treated others.  And somehow I always sensed that I was safer from whatever bad there was, when he was around. 


He has been gone for seventeen years this month, but I still feel him protecting me.

An Old Dog’s Computer Quest

By Shawn Vuong


Technology.  I love it.  


I am a proud member of the millennial generation (aka Generation Y).  While we aren't known for our humility or strong work ethic, we are known for our extreme integration with technology.  As time goes on and more of the Generation Y hits the workforce, we will be expecting businesses to be updating to fully integrated all digital business schemes.  In medicine this means the adoption of the electronic medical record.  


While this seems like a huge step for older physicians still in practice (the baby boomer generation), this is hardly what we (as the Generation Y) envision as our ideal digital medical record.  As time goes on, and our generation starts becoming the majority of the medical work force I for see the trend digital medical record becoming much more than some doctors could ever imagine.  Fully integrated, international, digitally accessible and protected medical records.   If I go to vacation in California and get hurt, I expect the ER doctor to be able to read my full history since my birth on his EMR at his/her hospital.  If my child gets a test done at Mayo, I want to see the results online as soon as my physician gets them.  We may have a long way to go before we get to this kind of integration.  But I believe this is the future of medicine.  


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By Richard P. Holm MD

They say you can’t teach an old dog new tricks.  Yet today I found myself in front of a Brookings Health System computer with a personal nurse tutor trudging through our new test version of an electronic medical record. 

Indeed, for about a year we have been gradually getting used to seeing parts of the hospital record on computer screen.   Finally this month we are about to take the leap of dropping our paper orders and progress notes, and going entirely paperless in the hospital. 

We have to be prepared so that no patient is harmed by this transformation.  That is why the physicians and PA/NPs have spent many meetings this spring developing orders sets, which are pre-defined orders for specific illnesses.  That is why we have been having two hours a week of educational meetings all summer long on the topic.

It will be difficult for many of us to make this change, especially since we have been doing things on paper for so many years.  At first it will take us all a lot more time.  But the whole process is not only taking time, it means our hospital has to make  a significant commitment both in personnel and money.

So why would we spend this kind of time and effort?  Along with many who are so capably helping us through this, are two RN experts.  Today I asked them both just what will result from all this effort, and their answers were straightforward.  “It’s all about patient safety and accessing information.”  Safety, for example means avoiding dangerous medication allergies and interactions.  Access, for example means seeing the patient’s Problem List, prior test results, and medication list whenever needed.

Still, the electronic medical record cannot look into the eyes of a frightened person in pain, listen for a clue to solve a problem, provide for relief of suffering, and then find a way to healing and better health.  That’s something this old dog better not forget.

Impossible To Fix

By Shawn Vuong

Medicine demands perfection. Nobody wants their loved one to die of something that could have been caught earlier on a blood test or CT scan.

So, a lady with a headache comes into the ER. The ER doctor knows that this headache is probably a tension headache or a migraine headache. The ER doctor also knows that the odds of this lady having a brain tumor are low, very low. Although every other ER doctor in the state would order a CT scan for every headache case that comes to the ER (due to the fact that they are scared of litigation brought against them, not because they think every headache warrants a CT), this ER doctor decides it is close to the end of his shift and he doesn't want to waste time ordering the CT scan this lady probably doesn't even need. So, he sends her home with some migraine medication.

Well, thanks to Murphy's Law this lady ends up permanently injured due to a malignant brain tumor. So because of this devastating turn of events, the family files a malpractice claim against the ER doctor.

Thanks to the teachings of a very wise law professor with significant expertise in tort law, I know what's coming next.

The doctor will be asked if it is the 'Standard of Care' to order a CT scan for a headache patient. Although medical literature may say that it is not the best practice to order a CT for every headache patient, and although every other ER doctor in the nation is ordering CT scans for fear of medical malpractice litigation, it IS considered the 'Standard of Care' just because every other ER physician is doing it. Right or wrong. Thus, this ER doctor will likely lose this malpractice case.

How do we as a profession change this? Obviously, a group of ER doctors cannot just follow the medical literature and stop ordering CT scans for every headache. This will just increase the chance that they will be successfully sued in a malpractice case. So, in reality, no ER doctor will stop ordering unnecessary scans. The more the 'Standard of Care' deviates from what the medical literature considers the best medical practices, the more of a disservice physicians are providing to patients. Yet, the legal climate prevents the doctors from changing the way they practice from the 'Standard of Care' due to fear of litigation.

This sounds impossible to fix.

-- Please note that this article is not trying to say ER doctors should not order CT scans for headaches. I have no idea if you should or not, I am not a licensed physician. This hypothetical scenario was merely thought up to help illustrate the problem with defensive medicine.

Very-Close-Veins

By Shawn Vuong


Failing leg veins are also known as varicose veins.  In this post, Dr. Holm describes how people develop varicose veins, why they are a health risk, and how best to treat them.  


Some times conservative treatment can fail, but one should not worry.  Many other treatment options exists for varicose veins, although they are usually more invasive and expensive.  Some of these options include sclerotherapy, laser surgery, vein stripping, ambulatory phlebectomy, and endoscope vein surgery.  If you are having problems with varicose veins, it is best to see your physician to discuss the best treatment option for you.


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By Richard P. Holm MD

I’ve heard failing leg veins called everything from “spider veins”, or “a bag of worms,” to “very-close-veins.”  Affecting more than fifty percent of people over fifty, these gnarled, distended, varicose veins represent a problem that, generally, only gets worse.

Arteries take blood out away from the heart, like a steel pipeline from a powerful pump station.  On the other hand, veins bring blood back like a lazy river that works because of locks or valves located to prevent back flow.  But there is nothing lazy about the job of returning all that blood up hill, against gravity, all the way back to the heart.

The trouble with leg veins usually starts during pregnancy, or with a job which requires lots of standing in one spot without walking, or with the increased venous pressure associated with obesity.  Of course, some people inherit better veins than others.

When a few valves begin to fail, then veins gradually become distended and dilated, which makes more valves fail, and the problem swells.  Common signs of failing veins include edema, redness, rash, fever, pain, and even hard to heal sores.  What’s worse, when blood movement slows down, clotting can happen, and when clots spread the result can be life-threatening clots to the lung.

What can we do to prevent varicose veins?  Muscles surround most veins within the leg, so when we walk or use our legs, the muscles contract and squeeze, acting like pumps.  If the one-way valves are still working, walking and leg movement makes blood flow upward and in this way regular walking or rocking back and forth while we stand helps prevent varicose veins.  And don’t forget to put the feet up whenever possible.

The next best solution is to wear compression stockings.  Although they can be hard to put on and many people are hesitant to use them, the lower, knee-high stockings are easier to use, do the lion’s share of the job, are relatively cheap, and the results are well worth the effort.  Some people absolutely swear by them since they prevent so many problems and feel so good.

There is a lot you can do if you stand to inherit those very-close-veins.  Left alone, they only get worse.

Surprise Death

By Shawn Vuong


In the light of the current healthcare reform debates and all of the craziness that has come with it (the infamous 'death panel'), let us not forget what this debate is truly about, the patients.  


As Dr. Holm reminds us, eventually we will all come to our death.  The important thing is that we must let our loved ones pass away with a little dignity and pride.  To do this we must talk to our family members about their death wishes, as well as our own.  This is an important and often ignored piece of medicine that never gets the attention it deserves until it is too late.  
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By Richard P. Holm MD

The late physician poet John Stone wrote of Death… I have seen come on/ slowly as rust/ sand/ or suddenly as when/ someone leaving/ a room/ finds the doorknob/ come loose in his hand.

This is not a topic about which anyone likes to talk.  The poignant truth, however, is that all of us will die one day, so we should go there every once in a while.  Many say they would like to die quickly and unexpectedly.  Let me go at ninety, shot by a jealous lover.  Or more realistically, let it happen in the night during sleep, after a joyful day, as a very old person, still with all my faculties.

As a physician, I have seen death occur in many ways.  Certainly, no one wants to die slowly while suffering, or after a long period without the capacity to know what is going on.  In these cases I have grown to appreciate the hospice attitude of comfort care, instead of medically trying to prolong an un-enjoyable life.  Perhaps our ability to keep someone alive has gone past our ethical understanding about how to know when to allow a natural death.

But here we are talking sudden death.  The kind of end that is unexpected.  When we lose someone and we have to say “Why?”

I have often wondered what the ghosts of those who die so abruptly must think.  Is it, “That wasn’t so bad!” or “Wow, that caught me off guard!” or “I wish I could have told my family one more time that I love them.” Or “That was a better way to go than that long and drawn out suffering way!”

I have had too much opportunity watching people hear and react to words like, “We have found cancer, and your condition is terminal.”  We are simply not built as human beings to handle the hopeless sound of a phrase like that.

It is better to live our lives with hope for a reasonable future, but still knowing that at any moment this could be our last.  One friend told me that when it’s his time to go, “Surprise me.”

Take home message:
   1. Talk to your family about your own death wishes;
   2. Finish your business and say what you should say everyday.

Hip Pain

By Shawn Vuong

According to MayoClinic.com, osteoporosis is a condition where bones become weak and brittle due to low calcium levels. Osteomalacia on the other hand is a condition where the bones soften do to low Vitamin D. In children this condition is called rickets.

This week Dr. Holm give a very common medical story about the nice elderly lady who fell and broke a hip, due to these hiding conditions. But what does this have to do with us young people you may ask? Dr. Holm's story is more than just a description of a common clinical picture of osteoporosis or osteomalacia, it's about bone health. These days more and more people are sitting in front of the computer all day at the office, or maybe in the dorm room skipping class and playing WOW (World of Warcraft). We are not getting enough Vitamin D and we are not leading lives conducive to good bone health.

So some suggestions for those of us who do not want to break a hip include:

- 30 minutes a day of weight bearing exercise

- Drink more milk and get a little sun

- Take a multivitamin

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By Richard P. Holm MD

Osteoporosis is a condition of thinning and porous bone, while osteomalacia is about soft protein-poor bone. To understand the difference, listen to this common and real story.

The eighty year-old woman arrives in the emergency room by ambulance with a new hip fracture. She would be writhing in pain, but if she moves it hurts even more, so she is lying perfectly still in pain.

After injecting pain reliever, the doctor notes the right leg is shortened, turned outward, and the X-Ray indicates a fracture of the hip. More specifically the break is in the neck between the ball and the body of the thighbone, also called the femur.

The doctor listens carefully to her story and discovers that she is a widow still living in her own home, still doing some gardening, still driving her friends around town to club meetings, still cooking and cleaning for herself. But all of that changed when she lost her balance on the back stoop, couldn’t find a rail to catch herself, and down she came striking hard on the cement sidewalk.

Her daughter-in-law says that it is a miracle she hadn’t tripped before what with the loose rugs scattered through the rooms, the electrical cords running everywhere, and the hand-knitted slippery foot warmers she wears after supper while shuffling around the darkened house.

The diagnosis of osteomalacia is suspected, as she describes generalized fatigue and aching over the last five years, and on exam she has a remarkable arching back and now this fractured hip. Later a very low Vitamin D level confirms the diagnosis, and the doctor suspects it’s been low the last half of her life, resulting from working inside the house most of the day, with little exposure to the sun. Vitamin D supplement becomes part of the patient’s treatment.

It is interesting to point out that there is no real clinical difference between osteoporosis and osteomalacia.

This was a story about home safety and prevention of falls, about bone building and bone maintenance, and how much more important vitamin D is than we used to think.

The Big Cover-Up

By Shawn Vuong

Erectile disfunction, as well as sexual problems in general are difficult for any man to talk about. Whether that be friends, family, or the physician sexual performance is still a secretive area of a person's life. Even in this day and age with all kinds of sexual and personal information and entertainment a click away, many people shy away from the subject of sex.

If you or someone you know is having sexual problems such as erectile disfunction, the "blue pill" may not be the right answer. It's important to go in and speak with a primary care professional about these subjects. Although you may be tempted to keep these problems under wraps and consult Dr. Google, these problems could signify significant medical problems. While google can be a good starting source for information, it shouldn't be your only one.

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By Richard P. Holm MD

Just last week a ninety-two year old man asked me to renew his prescription for Viagra. I gleefully responded, but it made me think how complex and difficult this issue can be.

There is probably nothing so personal, and maybe so important to a guy growing up than his ability to perform sexually. I mean we’re talking that part of the sexual ego of every young man that wishes to be superb, something that women crave to have, and every other guy would envy.

It is all covered up, however. Knowing what a man is supposed to do in the bedroom, and what constitutes normal male sexual function is something that is all too clouded in secrecy. When I was 14, the major source of information about male performance came to me at the roller-skating rink, when camping out, or late in the night from reading questionable literature with a flashlight, and I don’t think this kind of education has improved much since.

And with all the overblown expectation, and not knowing what is normal, comes the self-consciousness and hesitation to ask when there might be a problem.

A recent study indicated loss of erectile function or so-called impotence occurs in more than 50% of 40-70 year old men, and increases with age. The problem is twice as bad for smokers than for non-smokers, three times as bad for diabetics, and four times as bad for people with heart disease. It also increases significantly with psychosocial problems associated with hostility, suppressed anger, and depression.

But that’s not all. Men in poor physical condition, or with thyroid disease, B12 deficiency, sleep apnea, and other medical conditions may also present with a loss of desire for sex, or an inability to have an erection.

Bottom line: the loss of erectile function might indicate something is medically wrong, and men should expect more from their doctor than a prescription for Viagra. This is a problem that shouldn’t be kept under the covers.

Good Medicine

By Shawn Vuong

This week Dr. Holm talks about the over-use of medications. Sometimes, patients are on too many medications and there are many factors (or maybe the combination of these factors) that could be the culprit. As medicine continues onward so does drug and pharmaceutical research. This will only aggravate the over dependence on drugs we see today. Every day researchers and scientists discover more genes, cell markers, and biochemical pathways to target with new drugs.

As medicine becomes more and more advanced, we may see a decrease in pharmaceuticals. But I predict patients may actually be on more as research shows that therapies which include a combination of old and new drugs work best. What can we do about this over abundance of drugs? The patients can question their physician on why they need certain medications. Doctors can also help battle this by practicing good medicine.

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By Richard P. Holm MD

The other day an 80 plus year old woman came into my office visiting from another state and asked if she could get off some of her pills. “I take too many,” she said, and I agreed with her. We stopped ten of the fourteen she was taking.

We live in a pill-taking society. Some of this probably comes from the human tendency to find an easier way to do things. If we have a choice whether to walk or ride to work, we will likely ride. If we have a choice whether to exercise or take a pill to lower blood pressure for example, we will likely take the pill. A pill is easier than a lifestyle change. And there are other forces also encouraging too many pills.

Some significant medical conditions just call for it. Sometimes it takes two to five drugs to get blood pressure down, or control a diabetic’s blood sugar or help a weak heart pump better. If you happen to struggle with a combination of these or other conditions, you can end up taking a smorgasbord of pills.

Clearly drug companies work very hard to convince doctors and patients that drugs work for almost every ailment. And think about how providers are asked by patients to solve a new problem each time, and how simple and pleasing to give a pill to satisfy their needs.

We have a culture with an inclination to over-rely on drugs and over-play their benefits, but what is worse, we under-play their risks. This is a fact: the more drugs, the higher the likelihood for a significant side effect or a dangerous interaction between medicines.

I am not saying that all medicines are bad, and I’m not encouraging you to stop taking your medicines without careful direction by your doctor. The next time you see your provider, however, ask her or him to review the pills you take and try to get the number down. That would be good medicine.

The Power of the Sun

By Shawn Vuong

The sun provides the body a vitamin. It is weird to think about right? We are not plants, yet we need sunlight. The sun is a great source of vitamin D, and also provides cues for your body to keep hormones in balance which is important for a person's sleep cycle and his/her psyche. In the same token, the sun is not something to be enjoyed too much, a person could have a so called "sun over-dose." UV rays from the sun are known to cause many skin conditions that Dr. Holm touches on in this following article. So, enjoy the sun in moderation. If you aren't getting enough sun, consider drinking more milk, eating more fish, or maybe even a short time in a tanning bed. While we don't need the sun for photosynthesis, humans health is affected by the great power of the sun.

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By Richard P. Holm MD

There is something about the power of the sun. I was a sixteen-year-old Boy Scout on a canoe trip in Northern Minnesota one summer and we had been soaked with rain and chilled to the bone for two days straight. And then the sun came out, and I stretched out on a rock to gather some of its warmth.

At that moment I could feel the force of ol’ sol beaming into me, and 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 gravitate to the beach, and how sad some get in the days of the winter solstice when they don’t get enough of it. But can you get too much?

The answer is yes. We know that excessive sun exposure causes premature aging with wrinkles, sagging, brown spots, rough skin, not to mention skin cancers, some of which are terrifically malignant. You hear and read everywhere the following words of advice: stay out of the sun; use sunscreen; wear protective clothing; and avoid tanning.

Recently, however, we have become more aware of the importance of enough vitamin D, which comes to us from the rays of the sun. We know that just about 50 percent don’t have enough of it when measured by blood. It is also interesting to note that the other natural source of that vitamin comes from the oil of deep-sea fish.

Scientists have linked low levels of vitamin D with not only increased bone fractures and pain but also heart disease, diabetes, and cancer of the breast, prostate, and colon. Therefore I encourage people to daily take 2000 units of vitamin D. We don’t, however, know yet if giving vitamin D supplements will help.

Maybe we all need to get outside and gather in more of that sun… just not too much of it.

The On Going Project

By Shawn Vuong

Dr. Holm and I continue in our pursuit to make this blog more informative, more educational for patients, and reach a broader range of people. We are currently working on a project to post whole segments of On Call, the famous South Dakota PBS medical broadcast. We hope to be able to post short segments on to YouTube and use them to augment this current text-based blog. After all, streaming video is the wave of the future.

Keep on the look-out for updates!

Forbidden Abdominal Surgery

By Shawn Vuong

In this editorial Dr. Holm brings up a little history of a group of operations so common now, we actually take it for granted. Back in a time before anesthesia and sterile technique, abdominal surgery led to almost certain death. Today, great advances in anesthesia and surgical technique make this type of surgery routine. As we look into the future of surgery with advances in robotic and minimally invasive techniques surgeons and patients are seeing better outcomes and shorter hospital stays than any other point in history. By looking at the history of surgery we can really appreciate the modern miracle of abdominal surgery.

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By Richard P. Holm MD

Abdominal surgery was absolutely fatal until the time of Ephraim McDowell.

In the early 1800s medical school professors from every country in the world taught that cutting into the abdominal cavity would always result in infection and death. It was forbidden territory for surgeons.

People settling this new American country were less bound by rules and regulations however, and there was rumor of a West Virginia surgeon who had, a few years earlier, saved his wife and baby with what we now call a cesarean section. But, it could have been just rumor.

Ephraim McDowell was a young doctor from Danville, Kentucky, who had been educated mostly by following and assisting another doctor. Although he had one year of med-school training in the late 1700s, McDowell had never received a formal degree. Despite this, he earned a superb reputation as a neat and meticulous surgeon.

It was in 1809 that Jane Crawford’s lower abdomen began to swell. Her local doctors had made the mistaken diagnosis that she was over-due with twin babies, and called McDowell for guidance. After examining her he knew this was not a pregnancy. He explained to the desperate patient that it was an ovarian tumor, and the only possible cure could be surgery – which had never been done before.


Anesthesia was not to be discovered until the 1840s, and aseptic or sterile technique not to be popularized until the1870s. Despite all convention against doing abdominal surgery in 1809, McDowell knew the woman was doomed without it.

Mrs. Crawford pleaded for him to try, and so he had her come to his office some 60 miles away. While she sang hymns, Ephraim McDowell surgically removed the twenty-two pound tumor. Twenty-five days later Mrs. Crawford returned home in good health and lived for thirty-two more years.

It was quite a while later before the medical profession would admit that a small-town physician from Kentucky had opened the door to the life-saving possibilities of abdominal surgery.

Breast Cancer

By Richard P. Holm MD

I've heard it said that we should all have a close brush with death about once a year, in order to keep our priorities straight. 

I spoke to a good friend the other day about her breast cancer experience, and the following story unfolded. During her routine monthly self-breast exam she found a nodule; an abnormal mammogram followed; and then she had a biopsy, which showed cancer cells.

Treatment began with a lumpectomy and then followed six weeks of radiation to the site. Finally gene testing showed how she had a very favorable prognosis and wouldn't require chemotherapy. The expression favorable prognosis is a sweet duet of words, which means that the future looks optimistic, with a very good chance that the cancer won't be back. 

Now it's been three years of disease free survival and she tells me the whole experience changed her life dramatically. Considering the possibility of dying and realizing that her life will not go on forever made her live more in the present. She re-thought what was important in her life, and refocused on giving time to her family.

During this difficult time my friend sensed a rising spiritual presence accompanying her, and grew to feel that she was not alone. She told me that this experience would have been ten times harder without a faith in God.

I have observed many people walk this kind of journey through the valley of death. I am a physician, not a religious leader, but I know that people who get through this experience change how they value their family and friends. They seem to listen more, treasure the little things, and savor the tastes and flavors of each day.

Sometimes we don't know what we have until we almost lose it.

Three Cheers for Government Research

By Richard P. Holm MD

It was 1948, in Framingham, Massachusetts, when more than 5,000 people were first questioned about lifestyle, physically examined and blood tested. It was the beginning of the Framingham Heart Study, a government funded project, which has continued to this day. Every two years these same individuals are very carefully re-studied. In 1971 their children were added to the study, and in 2002 their grandchildren were entered.

Prior to this time little was known about the general causes for heart disease and stroke. In 1948, the rates of these conditions had been increasing steadily since the beginning of the century. How much is related to environmental factors and how much is inherited were the questions? Is it nurture or nature, and what can we do to make things better?

Over the years we have learned a lot from the Framingham data and we continue to discover from this large investigation why people develop heart disease and related conditions.

Now a similar survey called the National Childrens Study (NCS) is about to begin. The scope and diversity of the people in this research program is so much broader than from Framingham, however. It will involve 100,000 children, from representative counties all across the US, including right here in Brookings county. The NCS will follow these children from even before they are conceived until age 21.

It is important to note that, like in Framingham, no special interest group, such as the Pharmaceutical Industry or Medical Testing Industry, financially sponsors the NCS. Our government, specifically the U.S. Department of Health and Human Services along with the U.S. Environmental Protection Agency, is the fiscal supporter for this splendid and colossal effort.

I believe that our government should be much more involved in sponsoring research like the NCS and the Framingham Study; since industry sponsored studies, although important, have an inherent bias.

It is with the gathering of such information that we may finally learn what causes conditions like obesity, asthma, autism; or what influences intellect or mental health. Is it nurture or nature, and what can we do to make things better?

SDSU television show honored

A television show produced by South Dakota State University has won a national excellence award.

The weekly health-focused show "On Call" won the annual Award for Excellence from the National Association of Medical Communicators.

--STAFF REPORTS • ARGUS LEADER • APRIL 11, 2009

Are Two Heads Better?

By Richard P. Holm MD

Collaboration is a fancy word, which means two heads are better than one. It's the buzzword that always pops up when physicians are talking about Physician Assistants (PAs) and Nurse Practitioners (NPs). I believe that the art of collaboration, or knowing when and who to call for help, is about the most important and difficult challenge any PA, NP, or MD faces everyday. 

Take for example the isolated over-busy practitioner who knows a lot about everything, but not enough about the specific problem troubling that individual patient. Hopefully that care provider has enough experience and depth of knowledge to recognize when to ask for help and collaborate with someone who knows more. Two heads can be better than one.

There is another side to that story. Last month Mr. X had a complicated problem and I sent him to the specialist in another community. Before he returned, three other specialists were consulted by the first, each adding another test, and medicine, and expense. I was faxed copies of all these consults, but basically kept out of the loop until the patient returned to my office. Here's a time when the big picture had been lost while focusing on all the tiny parts. Sometimes one head is better than four.

Many experts say that the cost and access problems we have with our health care in the US are because care is so fragmented. All the parts are not speaking to the whole. 

In this time where it is likely major health care reform will occur, we must be very careful to construct a system that would encourage care that starts with a medical home. This would be when one very well trained primary care MD, PA, or NP would know when to refer, when not to refer, and expect a return of responsibility for the patient.
Collaboration is the name of the game.

Rick's editorial for vaccines & disease prevention

Curiosity and rabies
(on Louis Pasteur)

The sum of all the world's knowledge in medical Science comes from people with open minds who Look with curious eyes at the messy world about Them. Louis Pasteur, born in rural France late in 1822, grew up to become one of those scientists whose curiosity made all the difference.

Starting with a knowledge of chemistry and a new tool called the microscope, Pasteur showed how different kinds of microorganisms were present when beer and wine ferment, when milk turns sour, and when meat decays. 

He helped the French beer and wine industry understand why their beverages sometimes turned bad, how to prevent contamination, and how to culture the right organisms for the best beer and wine. He showed how to heat milk in order to extend time before souring, which is still called pasteurization. 

Not long after that, Pasteur rescued the French silkworm industry from a bacterial worm disease that had been decimating the silk producing worm crop.

Pasteur came to understand a method for vaccination almost by accident. Overworked while studying how chicken cholera can be given from one chicken to another, he took a week off, leaving his vials of infected juice in the window. When he returned he used the old and weakened material to infect more chickens. When this didn't make the chickens very sick, he had to start over with newly infected material, and discovered that the chickens already exposed to weakened material were resistant to infection.

This and another experiment with anthrax in cattle brought Pasteur to refine the process of vaccination, which protects by stimulating the individual immune system.

He is most known for his vaccination rescue from rabies and certain death when in 1886 he first saved a young man and then countless people from the bites of rabid animals.

Louis Pasteur, a great and curious man, indeed.

Expensive High-Tech Medicine

By Richard P. Holm MD

In this country the health care system is sick. There are 47 million uninsured people and the number is rising; med students as well as PA and Nurse Practitioner students are choosing fields other than primary care; and the massive numbers of baby-boomers are getting old. Worst of all, we cannot seem to get a handle on the spiraling cost of health care.

Why is it that in this country health care costs are twice as high as the rest of the developed world? Experts explain that it comes from the excessive use of high-tech medicine, which yields only minimal benefit at a very high price.

It seems that much of the spiraling expense comes from excessive and unnecessary use of imaging such as CT scans and MRI; from very high-priced and borderline-helpful types of radiation and chemotherapy for cancer; and from costly techno-heavy procedures that are not proven to significantly improve the patient's condition.

Others have explained that the out-of-control cost of care is due to over-ordering these items since the patient and family expect and demand the latest and greatest, and threaten a lawsuit if the doctor is reluctant, or anything goes wrong.

But alas, insurance companies and the government have tried desperately to get a handle on these costs and have not been able to control the ever-escalating expensive technology. All efforts with preauthorization and oversight have simply not worked.

The solution must begin with patients being financially encouraged to seek proven methods for diagnosis and treatment. Also, everyone must have access to a primary care provider, which means we must find a way to encourage students into this field. Finally the provider must not be pushed by patient, lawsuit, or financial incentive for unproven technology. Value and quality should be the watchwords, and high-tech methods should be used only when it is part of that equation.

The health care system in our country is sick, and the cure should start with a primary care doctor, not with a CT scan.

The Warm Light

By Richard P. Holm MD

A man more than 90 years of age came into my office one day following a spell in the hospital for severe pneumonia. While I was examining him, he stopped me, looked into my eyes, and said, "I need to tell you that I think I died one night when I was so sick. Then I came back." 

He spoke about a scroll unrolling rapidly before his eyes, re-running all the experiences of his life. Then he found himself walking through a meadow beside a large lake, towards a warm light, along with others coming from somewhere else, all walking in the same direction. The comforting warm light then told him was not ready, and shortly after that he woke up in the hospital as his fever broke.

I have heard similar stories several times in the thirty-five years since I started interacting with patients. It's been interesting and reassuring that the people who have had these "life after death" experiences often have talked about losing their fear of dying after the experience.

What happens to the soul after death is the great mystery about which all religions seem to turn. In this way they give important support to people as we struggle and suffer in this often tough world. 

I should add that, in my opinion, differences in religion or belief systems, about what happens after death, should not be used to separate people. Rather, I believe such questions should help draw us together as human beings. 

I see it as an honor that my job as a physician often brings me to be there at the bedside of a dying person, when the spirit lifts up from the body, and passes to another place. So it happened with my ancestors before me, and so it shall be when my turn comes to walk toward a warm light.

Blizzard On the Journey Home

By Richard P. Holm MD

This last month while driving home from a distant city after holiday feasting with family, we ran into a blizzard. Intermittently the powerful wind and new snow would explode between passing shelterbelts, other vehicles, and especially big trucks. Suddenly all vision of what was before us would be gone. 

The idea of coming to a stop during such blinding snow was not an option, as moving vehicles were coming upon us from behind. So we pressed on as carefully as we could, white knuckled, leaning forward, staring hard out onto a here-and-gone-and-here-again prairie highway, until we finally arrived home safe.

Being able to see what is in front of us is one thing most take for granted. But this will change for many as aging occurs. It's one of those unhappy surprises about growing old that many will have to face.

If we don't lose our vision from a bottle-rocket, cataracts, glaucoma, diabetic retinopathy, or other condition, many will develop age-related macular degeneration. Although this type of vision loss only affects two percent of those over 50, it climbs to 30 percent in those over 75. It's like winter snow that turns into a blizzard as we get older.

The macula is the central element of the retina. It provides for that concentrated part of our eyesight necessary for threading a needle, painting the lips of the Mona Lisa, finding a lost button, or seeing excitement on the face of your grandchild as she discovers a new thing.

The prevention of this age related blindness comes with all the same things that would prevent premature aging, heart attacks, and stroke; namely regular exercise and the avoidance of smoking and sleep apnea. 

Other possible preventatives include eating oily fish and ground golden flax seed, taking regular vitamin D, and maybe special zinc and oil supplements. I hold mostly with the staying physically active and eating a balanced and perhaps fishy diet. 

Growing old has it's challenges, like coming home from a long wonderful trip, and finding oneself in the middle of a South Dakota blizzard.