Friday, August 5, 2011

Stay regular with “Colon Blow”

By Richard P. Holm MD

Several years ago a comedy TV show on Saturday night parodied high fiber breakfast cereal calling their fake brand “Colon Blow.” At our house, that’s what we call our fiber breakfast cereal mix topped off with ground flax seed and dried or fresh fruit.

There is good reason I promote high fiber, but the story is a bit complicated. Many of my patients, especially the elderly, struggle with constipation problems. Very often these people have been taking one stimulant laxative or another such as senna or casanthralol, and have been doing so for many years.

Specialists have known for a long time that stimulating the bowels with an irritant only works for a short while, and then a higher dose is required, and then a higher dose… and so on. What’s worse, following the use of bowel stimulants, commonly there is diarrhea and then rebound constipation when these drugs are stopped. Thus, many people have had a roller-coaster bowel problem for a very long time as a result of using stimulant laxatives.

But in a controlled environment like a nursing home, I’ve noted that when you stop the stimulant laxatives, and use instead fiber with as-needed osmotic non-stimulating laxatives, the problem goes away in about two weeks.

Here’s the formula:

1. Start with enough fiber. I generally recommend food fiber, not the packaged type, such as bran-type breakfast cereal or oatmeal. Another good source is ground golden flax seed, which has an additional fish oil-type benefit. Start slow, and increase gradually;

2. If needed add plain stool softener, one to three capsules once or even twice a day if necessary. Adjust dose to daily balance bowels. Avoid softeners when in combination with a stimulant laxative. I repeat: don’t use stimulant laxatives;

3. If still no success by the above, add one of the following: milk of magnesia, polyethylene glycol (Miralax,) or sorbitol “but only when needed.” All three work by drawing fluid into the bowel rather than by irritating it.

Fiber is the most important part of the formula, and new science shows significantly reduced over-all death rates in those who eat enough fiber. So as the TV comedy skit goes: “I stay regular with colon blow. You can too.”

Early to bed?

By Richard P. Holm M.D.

I must admit I am not one for getting enough sleep. Like many others, I have an internal drive and clock, which I presume comes from the combination of disparate genetic threads of many and varied ancient ancestor. Somewhere from back in the recesses of my heredity appears the desire to stay up late, revel, and dance around a campfire. Yet within this same combination of chromosomes appears also a separate and compelling force to get up early and get work done.

The result of the coming together of just such ancestral drives is a guy who cuts short his daily requirement of sleep. I’m always pushing it, and short naps are my only saving grace.

Having watched the scientific literature about sleep through the years, until now I have noted that the data has been relatively inconclusive about the value of getting more sleep. Of course grandmothers have always scolded those who wanted to stay up late, and Ben Franklin joined in with, “Early to bed and early to rise makes you healthy wealthy and wise.” But where is the proof that people would benefit from getting more sleep?

A recent small study seems to clarify that question. It followed 11 male basketball players and monitored their sleep, finding the actual sleep obtained in this group was between six to nine hours. The researchers then required players to get at least 10 hours of sleep per night, including naps, for about seven weeks.

Measurement of player abilities before and after the sleep intervention found that with increased sleep the players ran faster sprints by five percent, free throw percentages increased by nine percent, three-point field goal percentages increased by 9.2 percent, and the players reported feeling and doing better during games.

Of course there is also scientific data to say that individual needs vary, and as a person ages sleep needs lessen. We also know that too much sleep can result from depression, and we don’t exactly know what the ideal hours of sleep would be for what age and what individual.

That said, perhaps it is time to heed what Grandmothers have told us for years, we would do better if we got more sleep.

Tuesday, June 21, 2011

Respecting kidneys

By Richard P. Holm MD

Your two bean-shaped fist-sized filtering organs called the kidneys, as the comedian says, “just don’t get no respect.” We take them for granted until they stop working.

But there is more to these inglorious and obscure organs than you would think. Each day something like 200 quarts of blood are pushed through the kidneys to remove about 2 quarts of urine loaded with toxins and waste products. But these guys aren’t just filtering out waste.

Kidneys know when to remove excess water when over-loaded or to conserve water when dehydrated; they know how to and when to balance electrolytes and body chemicals; they stimulate the bone marrow to make blood when red cells are low; they stimulate bones to grow and to strengthen when needed; and along with several other body systems, they measure, manipulate, and balance the blood pressure in order to get oxygenated blood out to all the cells of the body.

So what can hurt these magnificent unappreciated organs and then what should we do to protect them?

Inherited and genetically caused problems, autoimmune illnesses, birth defects, aging blood vessels, infections, blocking kidney stones, certain medicines, and even environmental toxins all can cause kidney trouble.

Of course if blood pressures are too high then kidneys can be harmed, but the opposite is true, too. That is, sometimes sick kidneys may be the cause of high blood pressure, making it hard to know which one is the egg and which one is the chicken.

By far the most common destroyer of kidneys, however, is a prolonged exposure to high sugar levels. Indeed, diabetes mellitus is responsible for about 40% of all kidney failure, and with the epidemic of obesity and diabetes in this country, we are facing a future where there will be more people suffering with kidney failure than ever before.

The formula for each individual to best avoid such a fate has to do mostly with living a healthy life-style, that is to get regular exercise and eat a balanced smaller portioned diet.

Your kidneys deserve a little respect.

Wednesday, June 8, 2011

To straighten the bones of children

By Richard P. Holm M.D.

The history of medicine is filled with stories of bonesetters, and in the middle ages they even had a guild. These people splinted broken bones with sticks, leather, and clay casts, and were separate from physicians and barber surgeons.

Then in the 1700s, Nicholas Andre’ a professor of medicine at the University of Paris, formally described methods to treat boney deformities in newborn children such as clubbed feet with splinting. He described similar methods used for the straightening of young tree saplings. Andre’ wrote a textbook on the subject titled L’Orthopedie. The ancient Greek word orthos means free from deformity, to straighten, to make right; and the Greek word paideia refers to the art of raising a child. Literally orthopedics means to straighten the bent bones of children. Together they provide for the name of a present day surgical specialty, but other things needed to happen first.

In the mid-1800s ether and then chloroform were discovered. Available and popularized during the Civil War, anesthesia made amputations a way to save lives after limbs were shattered from dirty gunshot wounds. It wasn’t until after the war that we learned of bacteria and discovered how antiseptic methods could prevent the need for amputation, and avoid infection after surgery. Just about at the same time, X-rays were discovered by Wilhelm Roentgen, which allowed for the marvelous and revealing image of our internal boney structure.

This all set the stage for expanding the orthopedic focus from just casting deformities of children. In the 1890s a well-known bonesetter from Liverpool, England, Evan Thomas encouraged his son Hugh to go to Medical School, and afterward taught Hugh bone setting and casting methods, which at the time were not being taught in Medical School. Hugh and his nephew Robert Jones worked together to develop orthopedic surgical methods in treating not just deformed children, but also bone injuries to construction workers, and then war injuries to military men during World War I.

And thus we have come from bonesetters, and straightening the bones of children, to the marvelous field of orthopedic surgery.

Wednesday, June 1, 2011

Tornado Alley

By Richard P. Holm M.D.

Did you know that three out of four tornadoes in the world happen in the U.S. and that many of them occur in this neck of the woods? They call it tornado alley starting early in Texas, and progressively later in the season through the spring and summer up through Oklahoma, Missouri, Kansas, Nebraska, and the Dakotas. That said tornadoes can happen anywhere and at any time of the year.

A tornado typically forms when a cold front with wind going one way bumps up against warm moist air with wind going the other way. The theory goes that updrafts on one side, and falling rain on the other can start these opposing winds spinning. When one end of the twisting wind is sucked into the updraft of a tall thundercloud, the speed of the whirling is enhanced and becomes concentrated as it tightens down into a funnel, much like a skater spins faster as the arms and legs come in.

About two percent of tornadoes reach speeds of up to 300 mph causing 70% of the damage, and 70% are minimally destructive, with winds of less than 110 mph.

The major rule to protect oneself from tornadoes is to avoid flying debris. Experts advise avoiding windows, (and not wasting time opening them.) If you are in a sturdy permanent home, go to a lower central windowless room, maybe under a stairwell, or in a bathtub. Get low and cover with a mattress or sleeping bag if possible. If in a mall or church, avoid large spaces; find a hallway, bathroom, or smaller windowless room and crouch.

If you are in a mobile home or a vehicle of any kind, get out, as these are all extremely dangerous in a tornado. In a vehicle, if you can safely drive away, do so. Otherwise get off the road, get out and away from anything that can roll over or fall on you. If you cannot find a permanent sturdy building, you are safer in a lower spot or ditch away from cars or trees. Lie flat or crouch; face down, with your arms covering your head. Avoid bridges as they offer little protection against flying debris.

It is wise to make a plan and be prepared since we live in tornado alley.

Wednesday, May 11, 2011

Dreaming of poison ivy

By Richard P. Holm M.D.

Every spring through summer I expect a call from a patient of mine after he’s had an exposure to poison ivy. Like 80% of the population, when he touches the plant he breaks out with a miserable blistery and itchy skin reaction. But my friend is so allergic to poison ivy that he gets a rash if he even dreams he’s gone camping.

In this area of the country poison ivy is a very common weed, as it crops up around lakes and streams and on the edge of wooded areas. Normally there are three green or red almond shaped leaves, the side leaflets sometimes have a notch, the middle leaf has a longer stem, stems are hairy without thorns, and there can be small clusters of green or white berries. This might be a freestanding shrub, a trailing ground plant, or come from a rope-like woody and hairy vine, which climbs trees. Remember: leaves of three, let it be; berries white, run in fright; and hairy vine, no friend of mine.

The rash is an allergic reaction humans have from the oil or sap that comes off the fine hairs on the stems, the leaves, and the woody vines, the later of which remain a threat even through the winter.

Once exposed to the oil, there is less than 15 minutes to remove it, and antiseptic rubbing alcohol towelettes are effective, readily available, and cheap. Then rinse this with cold water, followed with a dish detergent cleansing in lukewarm water as hot water too early can spread the toxin. Finally wipe down shoes with rubbing alcohol; wash clothes, and someone not so allergic should wash the dog.

Usually 12 to 48 hours after exposure the allergic skin reaction is a linear, very itchy, blistery rash, which may worsen over days or weeks if not treated. Know that the fluid from blisters is not toxic.

Treatment includes laying on of cool moist washcloths, followed by topical calamine lotion or over-the-counter cortisone cream, and if bad enough, see your doctor for a prednisone prescription.

So if you are dreaming of a camping trip, know what plant to avoid, bring alcohol towelettes, and call the doctor if you get that darn rash.

Saturday, April 23, 2011

When the sugar gets too low

By Richard P. Holm M.D.

“What would it feel like if my blood sugar gets too low?” the patient asked. I had advised her to watch out for hypoglycemia, or low sugar, since it might happen as a side effect of the new diabetic medicine I was prescribing.

I explained to her when sugars are low the body releases two rescue hormones in order to the sugar up. However these life-saving hormones cause symptoms.  Adrenalin brings cold sweats, a light-headed nervousness, butterflies, tremors, and a pounding heart. Glucagon causes a hungry-weak-uneasiness, nausea, and headache. Also the brain doesn’t work right when the sugar is too low and this causes irritability, blurry vision and confusion.  If severely low, loss of consciousness, seizures, and finally permanent brain injury can result.

I remember having a similar feeling as a high school student, when I wasn’t well prepared was standing in front of a crowd trying to play a trumpet solo by memory. My sugar wasn’t low. Rather, I was filled with adrenalin because I was so worried that I would forget the notes. But the feeling was the same: my heart was in my throat, sweat was pouring off my brow, and I was shaking like a leaf.

This same “fight or flight” feeling from an adrenalin surge is the first warning sign that happens when sugar gets too low, and should tell a savvy person to take some action to bring sugar levels up. Probably the fastest absorbed carbohydrate to raise sugar would be crackers, a piece of white bread, a baked potato, or a glass of fruit juice. Of course if the sugar is too low and the patient is having trouble swallowing, then an injection of glucagon or an IV with sugar water would be needed.

There are many and varied causes for low blood sugar, such as tumors of the pancreas, alcohol abuse, complications from gastric bypass surgery, and adrenal insufficiency to name a few. There is even a mild low sugar feeling that commonly occurs when one over-exercises on an empty stomach, but any such symptoms should be discussed with your doctor.

By far the most common cause for hypoglycemia is from certain diabetic medicine, however, and every diabetic should understand the symptoms.

Dr. Rick Holm wrote this editorial for “On Call®,” a weekly program about health on South Dakota Public Broadcasting-Television that is produced by the South Dakota Cooperative Extension Service. “On Call” airs Thursdays on South Dakota Public Broadcasting-Television at 7 p.m. Central, 6 p.m. Mountain.

Monday, April 18, 2011

How do you get rid of the pain of degenerative arthritis?

By Richard P. Holm, M.D.

Many people deal with the chronic pain of degenerative arthritis, and every day people walk or sometimes wheel into my office asking for relief. Whether it is hip, knee, or shoulder arthritis resulting from an injury that happened years ago, or back and neck arthritis coming from an inherited condition or the aging process, these folks suffer. They have pain during movement, when they are still and trying to sleep, or too often continuous pain. Unfortunately, arthritis prevents movement, which only confounds the problem.

Of course we have medical weaponry to fight against such an enemy. I could prescribe exercise, stretching, hands-on physical therapy, topical ointments, pain medicines, muscle-relaxing pills, anti-inflammation solutions, injections, and finally call for a surgeon to repair or replace bad joints. My preference of these is to do whatever it takes to keep people moving and strengthening. Unfortunately, although these options can be very helpful, too often they are inadequate and some people still hurt.

In response to continued pain and dysfunction, individuals will sometimes turn to complimentary and alternative therapies such as massage, spinal manipulation, progressive relaxation, acupuncture, yoga, and tai chi. Also there are herbal remedies such as glucosamine, chondroitin, gamma linolenic acid, and many more. I should say here that there is a growing body of scientific evidence to support some of these options when used appropriately. 

In spite of all these standard or legitimate complimentary therapies, however, there are those who still hurt and can fall prey to scam artists trying to profit from someone’s misfortune and desperation. I would warn people about advertisements that promise too much, yet it is difficult for me to attack such claims, since our standard therapies for arthritis can also be expensive and inadequate.

When all is said and done, people will still hurt. It is simply the human condition and most often the consequence of staying alive a long time. But I believe the best plan to deal with the chronic pain of degenerative arthritis should be to do whatever you can to keep moving.
Dr. Rick Holm wrote this editorial for “On Call®,” a weekly program about health on South Dakota Public Broadcasting-Television that is produced by the South Dakota Cooperative Extension Service. “On Call” airs Thursdays on South Dakota Public Broadcasting-Television at 7 p.m. Central, 6 p.m. Mountain.

Sunday, April 3, 2011

Brain injury in a football hero

By Richard P. Holm M.D

If you ask any of us who were on the DeSmet High School football team of 1966, we will tell you about how hard we played, the joy of our teamwork, our lasting friendships, and, of course, about our winning record. But I have come to realize now how foolish I was to repeatedly lower my head and use it as a battering ram hitting my opponents with everything I had.

Although contact sports are so much an enjoyable part of our modern life, we are finally coming to realize the danger such games can cause to the heads of the players. Nearly one and a half million head injuries occur in the United States each year and 20% or more of these are sports related. Researchers show that in football, soccer, and ice hockey, every season around 50% of the athletes experience some kind of concussion symptoms following a hit to the head.

What is worse news, research has revealed that once a concussion happens, that individual is very susceptible to permanent brain injury after a second-impact. Like playing on a twisted ankle, it’s the second hit that does the real damage.

It is a scientific fact that head trauma can result in subtle neuro-cognitive loss and later even chronic progressive brain disease and mental illness. One well-known example is the boxer Mohammed Ali who struggles with Parkinson’s disease, the likely consequence of repeated head trauma.

So how do we protect the brains of our youth? We should start by teaching players, couches, and parents to recognize the symptoms of concussion. If head trauma results in a headache, dizziness or imbalance, nausea or vomiting, any confusion, double vision, memory loss, sleep disturbance, emotional change, intolerance to loud noise or bright lights, or especially any hint of loss of consciousness, then there has been, by definition, a concussion. More on this at

Any athlete with such an experience should immediately stop playing, especially in order to prevent the second impact syndrome. Medical professionals should direct any athlete, who experiences concussion not to return to contact play until they experience one completely symptom-free week.

It is better to miss one game than be brain injured for a lifetime.

The miracle of the tube

By Richard P. Holm, M.D.

By the 16th day after conception, the human embryo has grown into a hollow ball of cells. Then a fold develops on the underside of the sphere, and it pushes inward until the sides wrap around the bend and become a cylinder that starts at a primitive head and extends down to what looks like a tail.

The resulting pipe is called the primitive gut, and it is evolving into what later will become the mouth, esophagus, stomach, and both the small and large intestines. Eventually this tube will extend about 26 feet from lips to anus. During development, pouches budding out from this food tube will also form the lungs, liver, gallbladder, and pancreas.

Once the embryo fully develops and is born, the gastrointestinal (or GI) tract begins performing the marvelous act of digestion. When food is shoved into the mouth, it is gummed or chewed until the tongue pushes it down. Food is swallowed as a small ball – doctors call it a bolus – and it passes the entrance to the lungs where a fleshy a trapdoor called the epiglottis protects the lungs and helps move the food into the esophagus.

The esophagus is a toothpaste-tube-type apparatus that moves the bolus into the stomach. There, acid not only helps break down the food, but it also kills most of the microorganisms that enter with food. Now liquefied, food then moves into the small intestine where tiny, shag-carpet-like fingers provide a surface area that’s about the same size as a football field. All that space is needed, and those tiny fingers work together to absorb nutrients.

The leftover liquid material finally moves to the large intestine, or colon, and this organ works mainly to reclaim water. The colon also harbors colonies of good bacteria that work on the leftover material and produce an important vitamin. That vitamin subsequently is absorbed and the body uses it to prevent bleeding.

The tube from lips to anus may not receive the respect it deserves, but it is an engineering masterpiece that humbly nourishes our lives.

Thursday, March 24, 2011

What do you say?

By Richard P. Holm M.D.

Before my junior year in high school, I returned from a Boy Scout canoeing trip to discover my sister had been killed in a car crash. I will never forget the sadness of the moment when I walked into the house, which was filled with what seemed like half the caring and wonderful town of DeSmet, to find my Mom and Dad there grieving. It was near the end of that summer, but the beginning of a long period of mourning for my family and me.

There were lessons that came to me after my sister’s death. I realized how important support from a community could be. Consolation came from our friends, neighbors, church community, as well as people who we barely knew. It seemed more about their presence, and not their words. I noticed there were people who had trouble themselves dealing with such loss, and they sort of disappeared.

Also I realized that a funeral is not exactly a time of closure for a family, but really just the beginning of a time to accept reality and forge ahead with the difficult changes that life can and does deal out. It took me years to think about my sister and relish in her memory rather than cringe from the pain of the loss. In that sense, I know I will never have closure and that’s good.

Some 14 years after her death, while I was on the faculty of a medical school in Georgia, I found myself having to advise medical students how to talk to patients or family about sad news. I reviewed the medical literature on the subject at the time, and concluded that there is no right way to do it except to be 100% honest, and to say whatever is needed with compassion. Through the years those guidelines have sustained me while I have had the burden of sharing awful news.

Bottom line, it is being there, more than words, that consoles. Never worry about what to say, just show up, be honest, and care.

Friday, February 4, 2011

A triple-degree burn

By Richard P. Holm, M.D.

She was removing the pan of hot grease from the stove when she spilled the stuff all over her right hand. One area of skin was just red like sunburn, which is defined as a first-degree burn. Another spot blistered making that burn second-degree. But in the center there was a third-degree burn where the grease had injured both the outer and inner layer of skin so severely it caused, eventually, a small open ulcer. Fortunately there was no fourth-degree burn, which is when the muscle and connective tissue below the skin is also injured.

She ran cool water on it for 10 minutes, and then came to see me in the clinic. I removed the dead skin gently where blisters had broken, applied antibiotic ointment with silver and sulfa, and a cotton gauze dressing to the injured skin, and prescribed pain medicine. She was instructed to protect the wound, gently wash and redress it twice daily, cut away dead skin but not break the intact blisters, just let them break by themselves, and watch carefully for infection. I set an appointment for her to see me in a few days.

I have had the experience of treating burns that were so severe that the nerve endings were destroyed and there was little pain. More common however, is the unrelenting pain associated with less-severe burns, and that was the case with our hot grease injury. The wound looked good and healed nicely over time, but she and I were challenged dealing with her pain until thankfully it resolved after a several weeks.

The skin is the largest organ of the body and it weighs six to nine pounds. It spreads a thin-but-important layer over the outside of our body, protecting us from invading bacteria and viruses, managing fluid balance, controlling body temperature, and allowing for sensations that include touch, pressure, heat, cold, and especially pain.

It shouldn’t take a burn to realize the value of our skin.

Dr. Rick Holm wrote this editorial for “On Call®,” a weekly program about health on South Dakota Public Broadcasting-Television that is produced by the South Dakota Cooperative Extension Service. “On Call” airs Thursdays on South Dakota Public Broadcasting-Television at 7 p.m. Central, 6 p.m. Mountain

Monday, January 24, 2011

Ovarian cancer

By Richard P. Holm, M.D.

When this story begins, Mrs. Z. was 70ish and a special patient to me because years earlier, I had discovered her need for heart-valve surgery and later had helped direct her breast cancer care after she had discovered a lump. Now she had pelvic pressure pain and fullness, vaginal bleeding, and some urinary symptoms. She knew something was wrong, and apologized for delaying this visit because she was afraid of what I might find.

It is one of those moments I will never forget. On exam I was surprised to find a grapefruit-sized mass in her pelvis and when I looked up to her worried eyes it must have been written on my face. She knew before anything was said.

The very next day she went to surgery, and I was asked to assist. Indeed the tumor was a malignancy coming from her ovary, and although 85-90 percent of ovarian cancers come from the cells that cover the surface of the ovaries, I think my patient had what is called a germ-cell tumor. This kind of tumor comes from inside the ovary, is usually found in younger women, and starts from egg-producing cells. There is a third kind of ovarian cancer that starts from hormone-producing tissue or stromal cells, but we had to wait for the microscopic exam to tell.

She had several ovarian-cancer risk factors that included a family history of colon cancer, a late menopause, and her previous breast cancer history. Even when we understand risk factors, ovarian cancer is called a silent killer because, like in Mrs. Z’s case, the symptoms usually appear late, often after the tumor has spread. But in her case the cancer hadn’t spread.

Mrs. Z eventually died of heart failure in her late 80s, had many wonderful retirement years with her kind husband, and our friendship grew through those years. It’s the kind of thing that makes my job such a joy.

Thursday, January 13, 2011

Jumping on the Vitamin D bandwagon

By Richard P. Holm M.D.

“Jump on the bandwagon” is a political phrase started in the mid 1800s when a circus clown turned politician and used his musical bandwagon for political rallies. As he passed through different towns it happened that local politicians found seats on the bandwagon, wishing to share in his popularity. As the political use of bandwagons spread, the phrase “jump on the bandwagon” came to refer to opportunists who support popular ideas without proof of value.

What proof do we have of the value of taking calcium and vitamin D, or have we all jumped on a bandwagon? Recently a committee of scientists and experts were gathered by the Institute of Medicine (IOM) to define what is scientifically proven about calcium and vitamin D.

After extensive hearings and study they said that there is solid proof that low levels of vitamin D are associated with poor bone health. We don’t have enough evidence yet to say conclusively vitamin D deficiency effects cardiovascular health, or causes hypertension, diabetes, falls, colon cancer, and psychiatric illness. They didn’t deny it they just said more studies are needed.

With regards to dietary calcium, the IOM concluded that most people in the US and Canada daily get enough Calcium, except for girls aged 9-18. They also discovered that significant numbers of postmenopausal women are taking too much calcium.

Vitamin D is more complicated, because levels are quite unpredictable, although commonly low in the elderly, those with dark skin, the obese, and people living in institutions. Even though multiple experts have advised that levels are too low when under 30 to 50 nanograms per milliliter, the conservative IOM declared that levels below 20 are deficient. The IOM did advise supplementation for all over one year of age, stating that for adults taking up to 4,000 units is safe, and advised not to take more than 10,000 daily.

Take home message: I encourage calcium supplements for 9-18 year old girls but not for adults. I also like to measure vitamin D levels, especially in people with dark pigment, obesity, osteoporosis risk, those institutionalized, or in persons older than 60. And for bone health I strongly recommend, along with an exercise program, all adults should daily take 2 to 4,000 units of vitamin D. That’s not just jumping on a bandwagon.