Dr. Boomer & the PDA Kid

Stay regular with “Colon Blow”

2011-08-05T23:23:00.003-05:00

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?

2011-08-05T23:23:00.001-05:00

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.

Respecting kidneys

2011-06-21T11:31:00.002-05:00

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.

To straighten the bones of children

2011-06-08T21:49:00.001-05:00

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.

Tornado Alley

2011-06-01T19:12:00.002-05:00

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.

Dreaming of poison ivy

2011-05-11T09:34:00.001-05:00

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.

When the sugar gets too low

2011-04-23T17:45:00.001-05:00

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.

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

2011-04-18T19:17:00.002-05:00

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.

Brain injury in a football hero

2011-04-03T17:55:00.002-05:00

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 www.cdc.gov/ConcussionInYouthSports.

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

2011-04-03T17:54:00.000-05:00

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.

What do you say?

2011-03-24T14:15:00.000-05:00

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.

A triple-degree burn

2011-02-04T11:08:00.002-06:00

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

Ovarian cancer

2011-01-24T00:16:00.001-06:00

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.

Jumping on the Vitamin D bandwagon

2011-01-13T21:29:00.001-06:00

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.

Guess I’ll eat some worms

2010-12-19T18:36:00.001-06:00

By Richard P. Holm, M.D.

This month, a scientific journal reported the remarkable case of a 35-year-old man who took an unusual treatment for ulcerative colitis. His colon was so inflamed and sore that he had been advised by doctors to have it surgically removed. After researching experimental therapy for ulcerative colitis, he decided to travel to Thailand where a doctor gave him 1,500 roundworm eggs to swallow.

The idea that worms might have something to do with ulcerative colitis and Crohn’s disease came from the observation that colitis is common in developed countries like America, where worm or parasitic infections are rare. In contrast, colitis is rare in countries where virtually the entire population has worms living inside of them.

This is similar to scientist David Strachan’s “hygiene hypothesis,” that was presented in the British Medical Journal in 1989. He showed data that hay fever and eczema were more common in families with one child than in larger families, and he speculated that the difference was because of an earlier and broader exposure to infections in the larger families. He suggested that more exposure to the dirty world results in less allergies.

Strachan’s idea has expanded and the “hygiene hypothesis” proposes that in developed countries, as a result of a “too-clean” environment, there is an increase in the diseases of the immune system such as inflammatory bowel disease, multiple sclerosis, asthma, and even childhood-onset diabetes mellitus type 1. Remember, however, the “hygiene hypothesis” is still just theory.

Let’s get back to our patient with colitis that traveled to Thailand. To everyone’s delight, after eating worm eggs, the gentleman quickly became symptom free. About three years later, after a relapse, he took more eggs and got better again. Over the six years that scientists studied the patient, they found his immune system was changed by worm therapy and noted that his colon had increased mucous production.

We are not talking night crawlers here, and some worm infections can be very harmful in humans, so people should not eat worms without scientific direction. Studies are now underway using pig whipworms, which are a less-aggressive worm, in treating not only inflammatory bowel disease, but also multiple sclerosis.

“Nobody loves me, everybody hates me, guess I’ll eat some worms.” Maybe some day we’ll be eating worms for colitis, too.

On suffering

2010-12-13T17:07:00.001-06:00

By Richard P. Holm, M.D.

Part of the mantra or sacred prayer of every physician is to reduce suffering, but what is it to suffer? The dictionary explains suffering as more than just experiencing something unpleasant or painful. The origin of the word comes from the Latin word “sufferre” or “to bear,” as if carrying a burden.

It is interesting to note that neuro-imaging maps have found that a certain part of the brain fires up when we feel either physical pain or emotional distress. Two radically different kinds of suffering seem to share a single neurological space in our heads. I also read in researching this topic that some individuals feel suffering leads to the construction of meaning in life and that it helps us to know more about our world.

To better understand the concept of suffering, this week I asked a number of patients and friends what it was that had caused them the most suffering. Surprisingly not one described an experience of physical pain. Rather the answers all turned around emotional loss. I heard about emptiness and anxiety following the death of parents and siblings, about the psychological stress of having kids, and a lot about the depression following divorce. People seem to forget about physical pain, but they remember emotional hurting.

Recently a national survey of hospice directors asked how we treat those dying from various illnesses and I was asked to fill out a form with challenging questions. Two questions were especially difficult for me: “Is pain and suffering a means for spiritual growth?” and “Should physicians seek to relieve patients’ spiritual suffering just as much as patients’ physical pain?”

I have no problem with the idea that people grow from suffering, but I struggle with the subtle implication that to relieve people of life’s emotional and spiritual pain could possibly rob their lives of meaning.

Bottom line, emotional pain is probably more significant than most of us realize, and my hat is off to the psychiatrists and psychologists whose jobs concentrate on just that part of the quest to enhance human health.

May we all find meaning in this crazy and sometimes hurtful life, and may we all find some help when it gets too painful.

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.

Send the kids outside to play

2010-11-14T16:49:00.001-06:00

By Richard P. Holm, M.D.

Last night at a lecture about the value of education in Afghanistan, the speaker told us of kids growing up surrounded by war, without being able to play outside safely. He said that kids throughout the rest of the world need to step away from their computers and TVs, and exercise their glorious freedom by going outside to play. The place erupted in applause.

This simple statement is supported by a recent “Move Muscles” or 2M study we did with first- to fifth-grade children. It was a combined effort by staff at the Brookings Boys and Girls Club, researchers from South Dakota State University, South Dakota medical-school students, and the South Dakota Internal Medicine organization, called the American College of Physicians. We found pedometer and activity readings were significantly greater when children were simply allowed to have free-play, as compared to organized activity.

For as long as humans have lived, until now, kids have been encouraged to go outside and play. As a kid growing up in DeSmet, I was outside for all four seasons. I remember jumping into piles of leaves, building snow forts for ferocious snowball fights, floating stick rafts down melting spring snow gutter-rivers, and summer biking everywhere.

But things have changed. Now we drive our kids to school to sit and listen all day to people talking, they watch while a few athletes compete in a game of some kind, and then they come home to play video games of action heroes, while they sit on a couch eating high-caloric snacks. Unless something changes, this generation of kids will grow up to be adults who drive to work while they earn money sitting in an office, and who have labor-saving devices do the work while they continue to sit and watch other people play.

It is easy to understand why there is an epidemic of obesity and diabetes, and why adult joints are so stiff and immobile, and why life expectancy in this country is dropping. Simply put, people will die and are dying young from diseases of inactivity. This problem is only getting worse.

We could do something to change this deadly trend if we would simply send our kids outside to play. And remember, what’s good for kids are good for people of all ages.

Send the kids outside to play

2010-11-04T23:30:00.001-05:00

By Richard P. Holm M.D.

Last night at a lecture about the value of education in Afghanistan, the speaker told us of kids growing up surrounded by war, without being able to play outside safely. He said kids throughout the rest of the world need to step away from their computers and TV sets, and exercise their freedom by going outside to play. The place erupted in applause.

This simple statement is supported by a recent “Move Muscles” or 2M study we did with first to fifth grade children. It was a combined effort by staff at the Brookings Boys and Girls club, researchers from SDSU, South Dakota med students, and the SD Internal Medicine organization, the ACP. We found pedometer and activity readings were greater when children were simply encouraged to have free-play, as compared to organized activity, or screen time.

For as long as humans have lived, until now, kids have been encouraged to go outside and play. As a kid growing up in DeSmet, I was outside for all four seasons. I remember jumping into piles of leaves, building snow forts for ferocious snowball fights, floating stick rafts down melting snow gutter-rivers, and biking everywhere.

But things have changed. Now we drive our kids to school to sit and listen all day to people talking, they watch while a few athletes compete in a game of some kind, and then they come home to play video games of action heroes, while they sit on a couch eating high caloric snacks. Unless something changes, this generation of kids will grow up to be adults who drive to work while they earn money sitting in an office, and who have labor-saving devices do the work while they continue to sit and watch other people play.

It is easy to understand why there is an epidemic of obesity and diabetes; why adult joints are so stiff and immobile; and why life expectancy in this country is dropping. Simply put, people will die and are dying young from diseases of inactivity and this problem is only getting worse.

We could do something to change this deadly trend if we would simply send our kids outside to play.

Mental health and mortality

2010-11-02T22:11:00.002-05:00

By Richard P. Holm, M.D.

Mental and emotional problems are everywhere. More than half of what I do, as a general internist, is to help people deal with emotional problems. It comes with the heartbreak and suffering of loss, pain, or growing old, with debilitating illnesses, and with the burden of mental illness itself. It is truly a challenge to try to help people cope with such trouble.

This September a large, 13-year Canadian study reported a 322-percent higher death rate in people taking minor tranquillizers compared with those not taking such medicines. Use of this type of drug can be taken as an indicator of emotional problems. Looking closer, there were huge socio-demographic and lifestyle differences between groups.

The study implied that if one comes from a tough neighborhood, drops out of school, struggles with addiction, abuses alcohol, smokes, does not exercise, and has mental health problems, then the risk of premature death is more than three times higher than one without such problems. In other words, emotional illness often walks side-by-side with tough social, economic, and health problems. And the combination is associated with premature death.

There was also an inference from the study that the use of minor tranquilizer-type sleeping medicine might alone carry some risk to one’s physical health. My personal interpretation from the data is that sleeping pills and anti-anxiety medicines can cover up or make worse an underlying depression. What’s more, these tranquilizers often put off or prevent appropriate therapy, such as counseling, exercise programs, and very effective antidepressant medicines.

Mental health is truly an important ideal but it comes and goes for each of us as we struggle and meander through our lives. Physicians and care providers have tools to help, including ears to listen, words of advice, and sometimes even good medicine to prescribe. To ignore indicators that there might be a mental health problem could mean the difference between life and death.

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.

The medicine wheel, the Great Spirit, and John Wesley

2010-10-28T10:54:00.001-05:00

By Richard P. Holm M.D.

The American Indian medicine wheel is thought to have existed for more than 5,000 years and has been the basis for not only medicinal but also religious approaches to problems of living.

Although there are significant differences between regions and tribes, the medicine wheel reflects not only certain botanicals but also the circle of life and the Great Spirit surrounding all of us. East is spring, sunrise, childhood, physical, and yellow; south is summer, noon, adolescence, social, and red; west is autumn, sunset, adult, intellectual, and black; north is winter, night, elder, spiritual, and white. Up is sky and Father; down is earth and Mother; and center is fire.

The history of modern medicine in the Americas starts with the spiritual and herbal knowledge of the Indian. As the Europeans made their great western migration into this new land with Mediterranean medical concepts, there was a great mixing of ideas with the American Indian’s spiritual and herbal way. This resulted in the evolution of a uniquely American way of caring for the ill, especially helped by Indian knowledge of the medicinal nature of flora and fauna, and their respect for the spiritual element needed for healing. This in turn, influenced health care throughout the world and reflections of it remain with us today.

In 1735, when young John Wesley the famous English Methodist came to a new American colony at Savannah, Georgia, he was impressed by the rugged health and the medical practices of the American Indian. Later back in England he even composed a book, which described many Indian secrets to the art of healing.

Wesley wrote that Indian illnesses, during this era, were exceedingly few because of their continual exercise and lack of excessive alcohol. The great epidemics brought from Europe followed, however, and the physically rigorous life was no longer required. It resulted in decimation of about 80% of the Indian population with severe injury to their spiritual focus and culture.

We should learn and never forget the lessons from American Indian heritage: the proper use of medicinal ingredients, the value of a physically active life, and the spiritual power of the circle of life and the Great Spirit surrounding us all.

A lousy essay about cooties

2010-10-01T09:59:00.000-05:00

By Richard P. Holm M.D.

Remember a cruel playground game about cooties or “you’re it?” Also called pediculosis capitis, cooties, or a head louse infestation truly is something from which to run. Head lice are small wingless insects that get into the hair and scalp. Except for the common cold, this infestation is the most common communicable condition of childhood, affecting something like 10-20 million people per year.

They do not jump or fly, or live on any other animal but humans, but these little blood-sucking invaders are extremely easy to spread by head-to-head contact. This happens especially in pre-school, kindergarten, grade-school spaces, where kids will be kids, and personal hygiene has nothing to do with it.

The diagnosis is confirmed by finding the louse, which is clear to tan and the size of a sesame seed, crawling around the ears and at the nape of the neck, or discovering tiny white to grey eggs, also called nits, attached to hair shafts.

It is nice to know that head lice generally do not crawl outside the scalp, and other than causing severe itching, the condition does not cause any other important problem or carry any illness.

This is in contrast to their cousin “body lice,” who reside below the scalp, after feeding set up in the creases of clothes, and can carry infectious diseases such as typhus, trench fever, and relapsing fever. Head lice are also different from bed bugs who are brown and larger, can live away from the human body, and can feed off warm-blooded mammals other than humans. It is a relief to know that bed bugs carry no disease, which is similar to head lice but unlike body lice.
The treatment of head lice involves attacking from several directions. Start with over-the-counter Permethrin lotion (Nix), or Pyrethrin (Rid, A200, or Pronto shampoo). These need repeating in one week to get the next egg hatch. (Suffocating with mayonnaise, herbals, olive oil, or butter does not work.) What is most effective and yet underutilized is to thoroughly comb wet hair every two days for two weeks with a special fine-tooth comb. Finally wash all bed linens and clothing that came in contact with those infested, drying in a hot dryer for 40 minutes. Bagging stuffed animals and clothing for two weeks also works.

So when your little one comes home with cooties, don’t panic and don’t run. Get out a fine-tooth comb, special lotion, and get to work.

Sharing of Cultures and The Art of Healing

2010-09-19T18:17:00.002-05:00

By Richard P. Holm MD

The earliest records of medical teaching came from very ancient Egypt, Babylonia, India, and China. Accounts of experimental and scientific thought, however, first began in Greece and expanded into the medical teaching of Hippocrates and his students. Medical learning then spread to ancient Rome where the word medicine was derived from the Latin “ars medicina,” meaning the art of healing, and this knowledge spread throughout the Roman Empire.

Alas, the ancient knowledge of the Mediterranean would have been lost with the burning of the Library of Alexander and the sacking of Rome except for the collections saved in the Arab world.

Probably the first medical school developed one thousand years ago in the southern Italian coastal city of Salerno. It happened because of a monk named Constantine the African, who understood Arabic and other languages of the time. He could translate, back into Latin, the surviving ancient Grecian and Roman medical texts, which were then written in Arabic and had been invigorated by more than a hundred years of medical practice in Arabia. So it was that in a small library in a Salerno monastery, ancient medical knowledge became accessible once again to the Western world.

Reinvigorated with these translations, the medical practitioners of Salerno became the best care providers of the medieval world, and, in turn, drew the sick in hope of discovering a cure and students seeking to learn the art of medicine. Over time, the sharing and learning accelerated. Salerno thus became known as the “Town of Hippocrates,” where Greek and Latin medical traditions merged with Arab and also Jewish wisdom.

The coming-together of different cultures and information led to a wonderful augmentation and synergy of medical knowledge, where men and women of mixed backgrounds reveled in learning how to care for the sick in a medieval world. Of course this golden time ended by forces of political and cultural hatred, but the knowledge that almost had been lost still survived. Some of it is taught in medical schools today.

May we always remember the lessons of the past, the value of recording knowledge, and the wisdom of sharing cultures.

The Hippocratic Promise

2010-07-29T19:06:00.000-05:00

Richard P. Holm MD

Through ancient and modern history, there is a tradition in the medical profession that the graduating medical student publicly and formally takes an oath and promises to uphold high ethical standards. It is a med student rite of passage, which has been handed down from our ancestors.

Historically it has been the Hippocratic oath, which is to swear by Apollo the Physician, and Asclepius and Hygieia and Panaceia and all the gods, and goddesses, to preserve life and to care for all regardless of rank, age or intellect. This apparently represented a shift in attitude in ancient Greece, as earlier many had used the knowledge of medicines and herbs to poison. Also it asked that the life of a slave, the life of the Emperor, the life of a foreign man, and the life of a child with a disability should all be valued as equal in importance.

But this traditional oath is replete with modern controversy. For example if the old oath is followed, the children of physicians would have preferential admission into medical school; we could not cut out kidney or bladder stones, or do any surgery for that matter; physicians could not take payment for providing care to patients (except maybe room and board); and there would be conflict with how we presently give suffering terminal patients enough pain medicine. Indeed, the old oath was meant for another time.

At the Sanford USD School of Medicine as in every medical school graduating medical students still give a contemporary version of the Hippocratic oath. Although there is some variation between schools, every version promises to diminish suffering and enhance health; to do no harm; to search for truth through science; and to respect the freedom and right of self direction for every patient. Modern versions also speak to just distribution of care when resources are limited, avoiding over and under-treatment, asking for help when necessary, and the art of a warm, sympathetic, and caring bedside manner.

Every physician upon entering the medical profession has made an oath and covenant to uphold a worthy ethical standard. This is more than tradition. It is a promise.

Valuing Others

2010-07-13T13:36:00.002-05:00

By Richard P. Holm MD

This week, in our little town in South Dakota, a young man in his twenties came into my office weeping and scratching his arms and legs. I was expecting a rash-type problem, when he blurted out that he was injecting methamphetamine two to four times a day. “It has destroyed my life,” he said. “I used to have a job, insurance, a house, and a life. Now I have nothing. Please help me,” he cried. I did my best for him.

By definition addiction is the state of physical or psychological dependence on a drug, which is liable to have a damaging effect. It’s a habit, a compulsion, or an obsession, which turns around and bites the user and everyone nearby. Alcoholism is the most pervasive and obvious addiction in our society. If it doesn’t directly affect you, most certainly it affects someone dear to you.

The potential for addiction is part of our collective human nature. I dare say that every one of us given just the right situation would be addicted to one drug or another, whether it be cigarettes, pain medicines, sleeping pills, marijuana, methamphetamine or a fine red wine.
What is it that separates the addict from normal happy people who are able to function in society? Some experts define addiction and, specifically, alcoholism with the four features of craving, loss of control, physical dependence, and tolerance. Others add that addiction means losing perspective about what has value in life. Vision of the surrounding world dims, and instead the addict obsesses on self and how to get another shot, pill, snort, drag, or drink. Addiction accelerates like a maelstrom into such selfness until nothing else exists.
It makes sense then that the opportunity for recovery comes with the sacred message of the Golden Rule: treating others with compassion and fairness. Valuing others is the key ingredient in order to sober- up the self-absorbed addicted individual. It is no wonder spiritual based programs for sobriety are the most successful.

No question, we are all at risk for the selfish cycle of addiction, and our best help comes by relearning how to care for others.

Protecting Little Girls

2010-06-18T00:36:00.000-05:00

By Richard P. Holm MD

Lying on the rolling cot in the emergency room, the beautiful six-year-old little girl was unconscious with bruises on her head, face, and scattered over her body. “Please help her,” pleaded the woman with a baby in her arms. She told me the little girl had been trying to learn how to ride the bike her Daddy had just purchased for her, and I believed what the woman told me.

After the bleed into the brain was diagnosed the story unfolded, and I learned that the woman was not the mother of the injured girl, rather the girlfriend of the father and that the overwhelming evidence showed the physical abuse came from the girlfriend. No one had been there to protect that little girl, and she died a day later from severe head trauma.

Child abuse is only one kind of violence, which can occur between members of any group of people living together. The American Psychiatric Association defines domestic violence as control by one family member over another with some kind of physical, sexual, emotional and/or economic abuse. It comes down to an issue of power, where someone with the upper hand takes advantage of another.

The Centers for Disease Control states that we know about only one third of the cases, and estimates that domestic violence affects more than 32 million Americans, or over ten percent of the U.S. population.

Why does this happen? Is it because our human nature wants to put someone else down when feeling inadequate or angry with our self? Is it because children who are raised in a home where it is not safe learn to threaten and bully rather than to protect people close to them, and this kind of activity perpetuates itself?

No one should have to live in a home where someone with an upper hand abuses another person, a spouse, a partner, a child, or even an elderly parent. Our job in this family of humanity is to find ways to protect little girls and everyone else from those who are threatening abuse.

Finally Met

2010-06-18T00:04:00.000-05:00

By Shawn Vuong

Dr. Holm and I finally met in person at an SDSMA dinner!

Slow Food

2010-05-19T23:11:00.001-05:00

By Richard P. Holm
Why does food satisfy the appetite? If we could understand what tells us when to stop eating, then maybe we could understand the cause for obesity.

We know that a hormone called ghrelin delivers feelings of hunger to the brain and that two hormones called cholecystokinin and leptin bring feelings of satiation. So far, however, scientists, and especially those of the pharmaceutical industry, have failed in efforts to safely manipulate these natural signals to stimulate or suppress hunger.

Another direction of research comes with understanding how certain foods like oatmeal, boiled potatoes, or fresh fruit fill you up, and others like donuts, French fries, or even dried fruit do not. It is interesting to note that drinks of any kind seem very poor in providing feelings of fullness or satiety. It makes perfect sense then that if one is struggling with obesity, foods that do not satisfy hunger, especially those that are highly caloric, should be avoided.

And what about eating too fast? We know it takes time for the food we eat to stimulate our satiety hormones. We all know it is not very satisfying when we shove fast food into our mouths and swallow it down with a big gulp. No one can argue that the obesity epidemic could be related to oh-so-convenient fast food, which seems to match the fast-paced, unsatisfying rush of modern life.

In contrast, there is the Slow Food movement founded in Italy in the 1980s. Slow Food asks us to preserve regional cuisine and local flavors, and to promote local gardens and local family farmers. Slow Food asks us to shop the farmer’s markets, raise our own gardens, teach our children to cook, take time around the supper table to eat slowly, savor the food, and enjoy the company of family.

Bottom line, and the pun is intended: all the rush, with our busy frenetic modern lives, and especially with all that fast-fast food, has left us weighing more and satisfied less. It is time to slow down and savor our food and our lives. to slow down.

When Grandma Wants to Pull the Plug

2010-05-19T23:10:00.002-05:00

By Richard P. Holm MD

“We will all be dead one day, we should not pretend that it won’t happen, and we should all prepare for the experience rather than ignore it.” Recently I was asked to give a talk about the value of the Living Will, and I remember that it became very quiet after those words.
I spoke to a room full of mostly retired people, some of them quite elderly, and I explained that, too often, I have watched helplessly while desperate, fruitless, excessive, and painful health care was provided to a person certainly dying. Put it down as one more paradox in medicine. The fear of death and not facing the reality of dying can be responsible for much of the suffering that can occur at the end of life.

A Living Will, also called an Advanced Directive, is simply a tool to communicate about how you would like to die. It is not about a legal document, it is all about talking to your family. We know there is a time to intervene with fancy medical care and there is a time to let go. My final talking point: the Living Will makes it easier for families to allow a natural and comfortable death when the time is right.

After the presentation one guy told me his wife purposefully avoided coming because she didn’t want to think about such gloomy things. He said wryly, “We are all going to die. Why shouldn’t we talk about it?”

Another asked, “I still don’t know the definition of a Living Will. Does it have anything to do with death squads pulling the plug on Grandma?” I responded, “No, just the opposite. It is all about Grandma telling us when not to put tubes in, so no one has to pull a plug.”
I can’t say it was my happiest audience, and I’m afraid I may have offended some of them by being so blunt. But in this age of external chest massage, shocking paddles, breathing machines, feeding tubes, and the potential for years of vegetative bedridden life, there is hardly a more important message.

Blueprint for Repair

2010-04-19T21:22:00.000-05:00

By Richard P. Holm MD

We don’t always appreciate the wonderful healing capacity of our bones.

A few years back I was on call, and the ambulance brought in a young college gentleman who had fallen three stories off a roof onto the cement below. Apparently he landed first on his feet and fell forward. As he landed, he sequentially, like a row of falling dominoes, broke parts of his feet, legs, knees, hands, wrists, elbows, jaw, and nose. The orthopedist who came in to help when I called, counted something like 26 fractures, and my ENT specialist who also came in estimated the patient was going about 35 miles per hour when he hit the concrete.

We ended up sending the young man to the trauma center in Sioux Falls, but what was amazing was how his brain and vital organs had been protected. He had not lost consciousness, remained perfectly awake, and his heart, lungs, gut. and spine were just fine. But the best news came with how eventually, after a lot of rehabilitation, his bones repaired themselves. A year later he walked into my office, without a limp I should add, and shook my hand firmly to thank me for helping him that fateful night.

Most people have the concept that our bones and joints are continuously wearing out and deteriorating over time. It is common thinking that if we simply live long enough, we will end up as a slumped over pile of soft bones and frozen joints. This doesn’t have to be..

Instead, our bodies are constantly remodeling and repairing bones and joints; taking apart, breaking down, and then rebuilding anew. Small injuries are always happening along the way, and maybe it happens more so as we get older, but there is a continuous remodel-and-repair process always going on, throughout your whole life..

The key point to remember is that the blue print for the remodel comes from the daily motion and activity we ask our bodies to perform. Rehab is always going on, especially as we get older.

We shouldn’t have to fall three stories to realize the value of movement.

On Call : Asthma

2010-03-21T12:00:00.001-05:00

[Video]

On Call : Mental Health

2010-03-21T11:58:00.002-05:00

[Video]

The New Orleans Flooding Disaster

2010-03-20T13:41:00.003-05:00

By Richard P. Holm MD

Some say that the measure of a society is how it learns from its mistakes.

What did we learn from the flooding of Hurricane Katrina, which affected New Orleans and a wide swath of southeastern Louisiana in late August of 2005? Eighty percent of New Orleans was flooded in up to 15 feet of very dirty water.

From the 1940s through the ‘60s the city waterways were closed, levees were built, and the land dropped by eight feet with drying and compaction of previous swampland. We knew already by the 1990’s that about 50% of New Orleans was below sea level. After Hurricane Georges (ZHY-ORZH) in September 1998 engineers called the poor condition of levees a catastrophe ready to happen, and yet they were still unprepared when Katrina hit.

After Katrina for many weeks southeast Louisiana lost most forms of communication with downed towers and lines, although text messaging was left, as it requires little signal power.

Most area hospitals were flooded and lost electricity while looters and drug seekers attacked in boats. One hospital indicated that many people died due to lack of supplies and simply the overwhelming need to provide care without enough help.

Civil disobedience also involved extensive looting and even sniper fire, while one third of the New Orleans Police Department had deserted the city in the days before the storm. Major health problems that followed in the hours and days after the flooding mostly involved not having a safe water supply.

Be prepared is the lesson. Structures for flood prevention should be in top shape; a chain of command for rescuers and maintenance of law and order should be ready; a failsafe method of communicating to include text messaging needs to be available; and effective evacuation plans should be available. Each family should store a safe water supply, non-perishable food, and a portable crank radio and flashlight. Finally we should all learn to text message.

Our local, state, and national society can and should learn from past mistakes.

I Have A Secret

2009-12-17T17:34:00.000-06:00

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

2009-12-10T17:11:00.000-06:00

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

2009-11-24T10:45:00.000-06:00

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

2009-11-01T20:10:00.000-06:00

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

2009-11-01T19:58:00.000-06:00

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

2009-10-15T23:17:00.000-05:00

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

2009-09-25T22:46:00.000-05:00

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

2009-09-25T22:03:00.000-05:00

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

2009-09-25T21:25:00.000-05:00

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

2009-09-25T21:24:00.000-05:00

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

2009-09-25T21:06:00.000-05:00

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

2009-08-08T20:45:00.002-05:00

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

2009-08-08T20:30:00.003-05:00

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

2009-07-31T16:35:00.005-05:00

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

2009-07-10T13:45:00.002-05:00

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

2009-07-10T13:40:00.002-05:00

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

2009-07-10T13:31:00.002-05:00

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.

________________________________________________________

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

2009-04-16T22:41:00.001-05:00

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

2009-04-11T15:22:00.000-05:00

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

2009-04-11T15:20:00.001-05:00

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?

2009-04-06T21:23:00.001-05:00

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

2009-04-06T21:22:00.000-05:00

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

2009-03-25T16:55:00.000-05:00

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

2009-01-21T09:29:00.001-06:00

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

2009-01-21T09:27:00.000-06:00

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.

Farmer's Lung

2008-12-30T23:22:00.000-06:00

By Richard P. Holm MD

We call it the "South Dakota syndrome", said the Mayo Clinic kidney specialist to a room full of doctors at a conference on the intensive care patient.

I think I was the only South Dakotan there; it was some 1200 miles away.

"These SD farmers wait until they are next to death from kidney failure and appear at the Mayo Clinic with words like: "I'm feeling a little weak lately but I don't want to complain"" he said.

As I heard this I was both a little proud and yet very dismayed. We don't want to look like whiners around here.

The problem with this denial and cover-up is that not only do we lose the opportunity to diagnose a medical problem early, but often precautions are not taken which could prevent a lot of trouble later.

This goes for all systems of our body: the kidney, the brain, the heart, the colon, the skin and the hearing.

But this is especially true for the farmer's lung. Here's the take home message: Don't cover up symptoms. If your cough lasts longer than 2 weeks, go in and see your doctor.

An ounce of prevention is worth a pound of cure. Don't go into that silo or pit when you shouldn't, avoid unnecessary exposure to toxins and dust, and I can't stress this point enough; wear a mask!

I would rather the South Dakota syndrome mean we are a bunch of hard working but careful people who live long and are able to enjoy a full and easy breathing retirement someday.

Creative Listening

2008-12-30T23:19:00.001-06:00

By Richard P. Holm MD

We all know people who are never happy. Contrast those with individuals who almost always seem interested, satisfied, and enjoying life. What is it that makes the difference?

Numerous studies have shown that people find self-fulfillment when they have strong social support, sense a spiritual meaning to life, and last but not least, are able to find time to be physically and creatively active. I think it's that creative element for many that is so elusive.

Obviously we would all be better and happier if we allowed for our creative parts to come out, but how does one do that in a loud and cacophonous world? All the noise out there makes it difficult to create music of our own. I would submit that true creativity begins not with making more clamor, but with very concentrated listening. For example, the improvisational jazz sax is best when played in sync with piano and base.

As a med student I had a physician teacher, he was a cancer specialist, who taught by example on how to find fulfillment by creatively approaching patients with ears wide open, listening with all concentration. He was known as one who could perceive the nuance, the hidden pain, the color of the mood, sensing the broken heart& He said the creative person is one that is open-minded and listens.

I remember learning about his reputation as a true healer, one who creatively found a way to bring the patient back to health relying not only on the knowledge of medicine but also of human nature. He had the capacity and confidence to know when to cure, and when to move to comfort, to let go, to sing the lullaby&

Whatever job or talents we possess, each of our lives could be so full and balanced if we learned to let go of unneeded and rigid rules and fears, opened our minds, and creatively listened, truly listened with all of our might.

Medical Education

2008-12-15T18:57:00.002-06:00

By Shawn Vuong

The decision to go to medical school is a big one. Dr. Holm brings up a good point, why do people chose to go to medical school? I think there are many reasons why a person would want to pursue medicine, but Dr. Holm hit the big one, "to help people."

If you're interested or have a child who is interested in pursuing medicine that's great. But remember doctors are not the only ones who work in the health care field. Physician assistants do similar work to that of a physician and have a lot of autonomy, schooling is also much shorter. Nursing is a great career choice for those who want to work directly with patients. Nurses are more involved in direct patient care than physicians, and if that's what gets you up in the morning consider nursing school. Also, with nursing school there is a lot of room for growth with nurse anesthetist programs, LPN programs, and many others. And there are much more than nurses and PA's, consider social workers, psychologists, dentistry, physical therapy, occupational therapy, and many others.

If you are interested in helping people, there is a wide variety of options out there not just medical school.

Why Go To Medical School?

2008-12-15T18:54:00.001-06:00

By Richard P. Holm MD

Why do we choose the paths that we take in life? Certainly some of it is just happenstance, a chance occurrence that came about for no particularly reason. I believe, however, that often we are influenced to take on challenges by seeing other people fulfilled by doing good things.

I remember, as a kid, watching on black and white television, a Hallmark-Hall-of-Fame version of Arrowsmith, by Sinclair Lewis. This was a 1920's story about a Midwest boy who goes to the East coast to med school, comes back to practice medicine in a small town, and there develops a special interest in infectious diseases.

The hero goes on a quest to halt an epidemic on a tropical island, has a tragic love with great heartbreak along the way, and then, of course, saves the day in the end. There was something about the compassion this physician had for using science to help people that intrigued me.

Growing up in a small community I experienced the typical cuts and colds, bumps and bruises of a kid. There the good doctor, who was also a respected community leader, cared for me. One day during my high school freshman biology class while dissecting a frog, it came to me, "Maybe I should be a doctor!"

It was at that moment I started pointing in this direction, and here I am 45 years later, still thrilled by the challenge.

What is it that triggers a person to apply to medical school? Is it an idealistic wish to make a difference in the world; the intellectual challenge to use science to discover something new; or the model of someone who provides one-on-one caring and healing to the sick or dying?

I would say almost 34 years after graduating from medical school, that practicing medicine is a little bit of all those things, but mostly it is about trying to do what you can to help people, and the reward in knowing that sometimes you are able to help.

Whatever the experience, or example, or dream that moves a kid down the road toward a health care profession, I would call it a very good thing.

Doctor Shortage Makes Headlines

2008-12-11T22:27:00.002-06:00

Dr. Chen with the New York Times makes the public more aware of the extreme situation known as the doctor shortage. She wants people to know, "its three strikes and game over" and we are already at strike 2. So soon-to-be president Obama please remember to address the physician shortage before mandating/allowing people to have insurance and putting us at strike 3.

The Gift

2008-11-24T16:26:00.001-06:00

By Richard P. Holm MD

Like a lot of men who make their way to my internal medicine office, Mark Ekeland came by the urging of his wife. He even put it this way, She told me to make the appointment because Ive been really dragging lately. This is classic guy.

During the examination I felt the liver and to my dismay it came down quite a bit below the rib cage, indicating that it was enlarged. The blood tests indicated bile duct blockage, liver cell destruction, no Hepatitis A, B, or C, and the ultrasound test did not show gallstones or tumor but only a large liver.

After a phone consultation with a gastroenterologist, a liver biopsy was done, which proved a rare liver scaring disease called Primary Biliary Cirrhosis. This kind of cirrhosis has nothing to do with alcohol but rather an immune system gone awry, and predicts a gradual worsening, eventual liver failure, and a premature death.

Over the ensuing ten years I watched as my patients condition worsened. Although never complaining, his muscles wasted, his color turned grey-green, his belly swelled, and he seemed to age right before my eyes.

One day he came close to death bleeding from varicose veins of the esophagus, and although near the top of the transplant list, he still waited. Since there was such a great demand for organs, it looked like he might not get one in time.

Then, a relative of his wife offered to be a living donor, an incredible gift of half of her liver. The transplant happened rather soon after, and it was a glorious thing to watch Marks general health come back to him over the next three or four months.

Now four years later, Mark enjoys and savors every healthy day because of the courage and compassion of his donor, and the miracle of modern medicine.

Take home message:
The advancement of science has offered remarkable treatments for what used to be terminal conditions;
All of us should do what we can to help those in need of organ transplant. Sign a donor card AND tell your family about your wishes to donate if tragedy should happen;
Living donors, and those willing to donate after brain death provide a gift for a lifetime of marvelous relief from illness and suffering.

Tom Daschle for Health and Human Services Advisor

2008-11-19T22:10:00.005-06:00

By Shawn Vuong

Well its pretty much official, our own Tom Daschle will be the secretary of HHS. What does this mean for doctors and patients in South Dakota? What does this mean for doctors and patients nationwide?

Some don't believe Daschle is the right man for the job. They may be worried about his past voting history, his history of partisan politics, or even his wife's job as a lobbyist that may play in conflicts of interests. Others think he's perfect. Either way you look at it, he's going to be a key component of the healthcare reform that America is about to see.

To get a good idea of what's in store for us, I plan on reading "Critical: What We Can Do About The Health-Care Crisis" by Daschle. The book came out Feb 2008, and I think its going to be the outline of what's to come.

Are South Dakota's Current Abortion Laws Hurting Doctors?

2008-11-19T17:40:00.003-06:00

By Shawn Vuong

While many South Dakotans are glad we are done with "Initiative 11" Zita Lazzarini thinks South Dakota has already taken it too far. Today in the NEJM, Lazzarini says that the current law that was passed in 2005 known as the "abortion script" threatens the physician-patient relationship.

At one level this type of law pushes our state's beliefs onto doctors and patients. Also, the abortion script may actually be keeping doctors from giving scientifically based information to allow for an informed consent. Lastly, Lazzarini says that if we let the states push it this far, what's next? Who knows what other ethical dilemmas the state will try to push onto doctors & patients.

If legislatures can mandate thatphysicians provide women with ideological, vague, intimidating,and false information about abortion, what is to stop them fromintruding further into physician–patient discussions regardingend-of-life decisions, the use of future stem-cell–basedtherapeutics, the efficacy of birth control, or the role ofcondoms in preventing sexually transmitted infections?

How important is the doctor-patient relationship to you? Whether you are pro-choice or pro-life should not make a difference in this issue. Imagine that you are in the hospital with your loved ones, and the doctor was mandated to tell you and make you sign paperwork that the end-of-life decisions you and your loved ones are making are wrong.

Doctors Feeling Gloomy?

2008-11-18T23:52:00.003-06:00

By Shawn Vuong

Yesterday I was talking about my worries of becoming a bitter doctor. But why do doctors loose morale? Today, Sarah Rubenstein of the WSJ gave me some insight on this matter.

Here are some of the bracing findings from 11,950 primary care docs and specialists who responded to the survey:
94% said the time they’ve devote to non-clinical paperwork in the past three years has increased. 63% said the paperwork has meant they spend less time per patient.
82% said their practices would be “unsustainable” if proposed Medicare pay cuts were made.
78% believe there is a shortage of primary care docs in the U.S.
49% said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely.
60% would not recommend medicine as a career to young people.
42% said professional morale is either “poor” or “very low.”
17% rated the financial position of their practices as “healthy and profitable.”
6% described morale of their colleagues as “positive.”

Wow, if that isn't depressing I don't know what is. Paper work, a shortage of doctors, and low morale possibly through low reimbursements, insurance controlling care, and less doctor-patient time. I may be wet behind the ears in the world of medicine, but I can tell you one thing, I am going into medicine to take care of people. If a primary care physician told me that all the paper work they do keeps them from seeing the patient, I'd dodge primary care like the plague. Many other medical students already are dodging away from primary care.

A couple questions come to mind after reading this. First and most obvious question, how do we fix this? Also, since Dr. Holm is a family doctor himself, I would like to know what his general opinion is on this article. Is morale really low here in South Dakota? Are family physicians here feeling the pinch of administrative work, low reimbursements, and insurance control?

Healthcare Costs Part 1

2008-11-18T11:50:00.003-06:00

By Richard P. Holm MD

Maybe it was ten years ago I heard a political reformer pose the question: What if we paid for groceries like we pay for health care in the U.S.& how different would it be? He described buying groceries where there would be no reason to look for a bargain, but rather motivation to buy the most expensive items, and everybodys basket would be filled to the brim.

I think there is still some truth to the comparison, because in this world of third party payers for health care, the consumer is still not driven to look for value. Rather it seems the employer who buys the insurance has to do that. But in 2008 there are some changes we would have to make to the grocery-store/health-care comparison.

Now you find that there are only three grocery stores in the state, and you have to go to the store your employer chose. Upon arrival to the store you find a very elaborately decorated and expensive building, the carts are robotic, the aisles are wide and beautiful, and there are way more managers than checkout people, due to government beaurocracy.

Looking around you realize that every customer in the store seems to have a different way of paying for the food. One person has a plan where all the food is free, once he reaches his deductible, but it pays only for certain food, and he cant figure out what that is, except to know that generic beans are always paid for. And then there are customers who have managed care advisers walking around the store with them pointing out which food is not available to them. What's more, there are many people outside the store that can't get in.

It is not a perfect metaphor but it makes one point very clear the system is a mess. In this age of healthcare reform, please be pro-active and contact your Washington legislators.

Primary Care Shortage Worsened

2008-11-18T11:47:00.001-06:00

Med School to Doctor Transition

2008-11-17T20:10:00.002-06:00

By Shawn Vuong

These last two posts highlighting some of the medical education we would like to give through this blog to the general public, has had me look back on my extremely short medical career (currently in week 17).

Healhcare reform is in the air, and from what I've read and heard about the morale of health care professionals, it is at an "all time low." Many professors and physicians come in to teach us different topics, and many say, "It looks bleak out there, I hope you know what your in for."

What worries me is the transition. What happens to the altruistic medical student who wants to save the world? What beats him/her into submission and makes them into bitter doctors? Is it the troubles we deal with during our residency training?

A recent article by Dr. Edwin Leap makes me think so. He calls out to all residents and interns as medicine's last hope. It is inspiring and really heartwarming, makes me want to go out and save a life. Hopefully I can keep this in the back of my mind for the rest of my hopefully long and fulfilling career.

Be our hope, my friends! Be the hope of medicine, the hope of the wounded parents and febrile children, the gasping elderly and the poisoned teens. And learn to see all you do through the eyes of a higher calling. That perspective, if you can develop it and hold tightly to it, will keep you happier than any political reform or paycheck ever could.

The Hot Toe

2008-11-17T19:55:00.001-06:00

By Richard P. Holm MD

It was 1972 and I was a green sophomore med student spending my summer shadowing a doctor in Watertown. As soon as we walked into the patients room, my hero-teacher told me the patient was suffering from an acute attack of gout.

The crusty old German doctor explained we were seeing the classic signs of inflammation. He said that the great Celsius, a physician living in the first century, described inflammation with four cardinal signs and the definition still applies.

"In Latin it's rubor, calor, tumor, dolor," is what he said. "Commonly inflammation means infection, but in this case there is no infection. Rubor is redness, calor is heat, tumor is swelling, dolor is pain, and add to that loss of function." There it was, a red, hot, swollen, painful toe. And the patient said, "It hurts so bad I can't stand for my wife to look at it."

The patient was a 45 year-old man with a tendency to drink too much, a prior experience of similar bouts of severe single joint inflammation, and he came from a family many of whom also experienced this same condition. He was moderately over-weight, quite sedentary, and was taking a water-pill for high blood pressure.

"This is the classic picture of gout," my teacher told me. "His body suffers from too much uric acid, partly because of dehydration from the water pill, partly because of his weight and lack of exercise, maybe a little from eating too much protein, but mostly because he inherited the tendency. Too much uric acid causes the formation of needle shaped crystals in the joint fluid, and then comes inflammation."

"We need to treat the inflammation first, and then later get at reducing the uric acid level, or he may destroy his joints, develop kidney stones and destroy his kidneys," he instructed.

The complex treatment of gout made our patient better. It was the perfect lesson from a great teacher.

Take home lesson:
1. Inflammation is characterized by redness, heat, swelling, pain, loss of function, and can be due to reasons other than infection.
2. Gout most often presents as recurrent episodes of a severely inflamed single joint, most often involving the big toe but it can effect other joints as well;
3. This condition results from the formation of uric acid crystals in joint fluid;
4. Gout can progress to destruction of joints and kidneys, so it needs proper treatment.

That All Important Shoulder

2008-11-17T10:13:00.000-06:00

By Richard P. Holm MD

One moment I was jetting down the ski slope unbelievably free, on the edge of control. The next moment I saw a bare spot under a bunch of trees right where I was headed, but I thought too late and was going too fast.

When my skis hit the dirt, I went for one of those head-over-heels flips, struck my right shoulder on an icy hard spot and, finally, came to a stop, a heap of body parts just like Beetle Bailey in an old comic strip.

When accidents happen like that, I find myself wishing in vain to go back five seconds and do that one differently. But of course there was no re-doing it. I felt a burning pain coming from somewhere near my right shoulder, and it was not subsiding.

The doctor in the emergency room examined my shoulder for rotator cuff injury by testing, with resistance, three movements: 1) bring bent arm with imaginary mug of coffee to the chest, 2) rotate the arm out again, and 3) with straightened arm to the side, empty the mug away from the body. Luckily my rotator cuff was fine.

He also reviewed the X-Rays with me and pointed out a separated shoulder blade-collarbone, or AC joint, which ties the arm and shoulder to the chest.

Days later, my orthopedic partner reassured me that although I had torn the AC joint, it wasn't unstable. The only real problem was that I should expect it to hurt for maybe six months, which it did.

The whole experience helped me appreciate the sudden and long lasting consequences of a reckless choice, helped me empathize with others in pain from any cause, and helped me learn about the value of the shoulder and all its parts.

And it helped me to avoid those bare dirt spots too.

Take home message:
1. Accidents can happen in a flash, and can result in long lasting suffering. Therefore it is wise to make good choices to avoid accidents when possible;
2. The shoulder has many important parts, and because it is so very mobile, is also more at risk for becoming unstable if injured;
3. The three movements mentioned above test the Subscapularis, the Infraspinatus with the Teres Minor, and the Supraspinatus muscles.

Alcoholism

2008-11-14T21:37:00.000-06:00

By Richard P. Holm MD

There is good science showing a glass or two of wine per night protects against heart disease. But what can be helpful to some, can be poison for others.

One study found 53% of people in the US have a close relative who has a drinking problem. At last count 17.6 million in this country are alcoholic or alcohol abusive. Alcohol excess causing auto crashes, homicide and suicide, liver-heart-brain-kidney illness, and brain damage to the unborn, costs the US about 185 billion dollars per year, not to mention incalculable human suffering.

"Alcoholic" means four things: craving, can't stop, withdrawal symptoms, and needing more and more to get high. This is different from "abuse", which means a pattern of drinking which results in failed work or school responsibilities, driving while drunk, legal problems or social and family problems. Although separate by definition, many alcoholics also experience alcohol abuse.

The CAGE questions help identify when there could be a problem: C stands for "cutting down", A for "annoyed" be criticism about drinking, G for feelings of "guilt", and E for the "eye-opener" in the morning to steady nerves. One yes is worrisome, and two means someone needs help.

There is a myth that alcoholism is a sign of moral weakness, and to seek help is to admit some type of shameful act. In fact, alcoholism is a disease like diabetes or asthma, and not a sign of weakness or ethical deficiency.

Why is it that alcohol will take hold of some people, and not let go until it's destroyed their lives or the lives of those around them? We dont know the answer to that question but we do know is that if there is a problem with alcohol, there is help to be had. You just need to ask for it.

Ethics & Alcohol

2008-11-12T18:26:00.002-06:00

By Shawn Vuong

Today, Dr. Craig Uthe, a Family Practice phsyician in Sioux Falls, came in to talk to the medical students during their Introduction to Clinical Medicine class. The topic for the day was Substance Abuse in General Practice. We learned lots about the addiction process, and the tough road through recovery.

Most interesting to me was the dilemma brought up near the end of the class.

Lets say there is a man named Mr. Jones. Mr. Jones seems like he works non-stop, and today he finally has a day off to catch up on some things around the house. He gets up early, fixes that dripping faucet that needed fixing, enjoys a wonderful lunch with his wife and children, and plays some ball outside with his kids in the afternoon. Later that afternoon, he decides the grass is looking a little long. Mr. Jones gets out the old lawn mower and starts cutting grass. About half way through, he grabs an ice cold beer and drinks the whole thing before continuing to mow. At that moment, he gets a call from work. Its an emergency, and he needs to come in right away.

Now lets say Mr. Jones is a maintenance man at the local hospital, and the power is cutting out in one wing of the little hospital. Does the fact that he had a beer effect his work? Should he be coming into work at all?

Now lets say Mr. Jones is actually Dr. Jones, and he is coming into the local hospital to deliver your baby. Does the fact that he had one beer effect whether or not you want him to deliver your child? Should he have been called in at all?

Tough Questions About Death & Dying

2008-11-11T20:52:00.014-06:00

By Shawn Vuong

In Dr. Holm's latest post, "When Should the Heart Stop Beating," some interesting questions are brought up.

When is a patient too old or too sick to receive expensive procedures?
How can we pay for expensive healthcare for so many people?
If we take away the "easier death" of an abnormal heart rhythm, how will people die?

These are extremely difficult questions, that I do not think many people are ready to discuss. But these are important topics for families, and are a hot topic in medicine.

One factoid that has been cruising around the medical blogosphere for quite sometime now, is that 5% of our population spends approximately 50% of our healthcare dollars. How can this be? Some believe it is all of the expensive treatment we utilize at the end of life. This time is a very difficult for the family, they may want everything done for their loved ones, when its obvious to the clinical team that there is just not much more anyone can do. But more often then not, the clinical picture is in a "gray area." How does a doctor decide that the act of performing surgery or giving the treatment may be worse for the patient than the benefits gained? The Happy Hosptalist sums up the cost effectiveness of this problem quite nicely.

How do you make a decision on how aggressive to be? We all want to sit here and say that age should not be an independent predictor for making medical decisions. I ask why shouldn't it be. Why should we not employ age in the equation of resource allocation. Let me ask you this:

Would you put a $30,000 defibrillator into a 60 year old patient with sudden cardiac arrest due to ventricular tachycardia and concurrent colon cancer with metastatic lung and liver lesions? How about a $5,000 pace maker? If you would, why would you. If not why not? What would be the basis of your decision? These are clinical decisions that are made every day. Judgement calls by medical professionals. You can't write guidelines for this stuff. Some doctors lose site [sic] of the big picture and do things to patients because they can. Because they lose sight of the big picture. And sometimes, when you focus on the nail, it's just easier to ignore the house falling apart around you.

As a patient and a family member, you may be thinking "Why do these costs even matter? We want everything done for me (or my family member) because that's the right thing to do." Researchers at Dartmouth argue that more interventions and aggressive treatment do not necessarily prolong patient's lives, and by doing less you may be "sparing patients the agony of unnecessary tests and reducing the risk of hospital borne infections."

The end-of-life decisions are not decisions for cost-effectiveness, insurance companies, or even doctors to make. The patient and their family ultimately have to decide what is the best route for them. But I hope families realize, they can let their loved ones pass away with peace and dignity without demanding every possible intervention.

The Picture of Health: A View from the Prairie

2008-11-09T16:17:00.003-06:00

Just in time for holiday give giving. A new book of highly informative medical essays by "On Call" Dr. Rick Holm, Avera Brookings Medical Clinic, with accompanying photogaphy by Dr. Judith Peterson, Sodak Rehab, Sioux Falls.

A masterful work that will make a wonderful addition to your library, coffee table or patient Waiting Room...

"Wow, what a book! A mix of wisdom, beauty, practicality, and valuable insights into health and medicine."

-- Neil Shulman, MD, author of "Doc Hollywood," Associate Professor, Emory University School of Medicine

When Should the Heart Stop Beating?

2008-11-09T16:02:00.000-06:00

By Richard P. Holm MD

In the end, we will all die of something. As a guy who has to fill out death certificates, it is interesting that when the cause of death cannot be defined I find myself stating that the person died of heart disease. Think about it, even when the ultimate reason is due to cancer, stroke, pneumonia, or a motor vehicle accident, when a person gets sick enough from anything, ultimately the doctor calls them dead when their heart stops beating.

Recently at a medical meeting I listened to a cardiologist speak about just that issue. He explained about the implantable cardioverter defibrillator (ICD). The device is a small-computerized battery buried under the skin, which is connected to the heart with a wire. It monitors the heart rhythm and automatically triggers the heart when the beat is too slow, or shocks it back to normal rhythm when the heart goes too fast.

He explained we should be providing this for many more people than who are presently receiving it. He didn't tell us that the cost for putting in an ICD is roughly $50,000, and it needs replacement every 3-5 years.

It is pertinent that the very next lecturer spoke about health care costs. We listened in dismay about the ever spiraling out of control cost of health care. The expert explained that our country soon would no longer be able to pay for "everything for everybody right now". In order to provide for reasonable and basic health care for everybody, she explained we would have to limit some of the stuff that is so very expensive, especially when the value and benefit to the individual is minimal or unproven.

The presentation was well received by the room full of doctors, and yet the real and scary future task of determining who gets what care when resources are limited, left us all uneasy.

The back-to-back lectures left me with several questions. When is the patient too old, or too sick to get one of those devices? How can we afford such a thing for so many people? And if we take away the easier death of an abnormal heart rhythm, then how will people die? These are tough questions, and we need to talk about them.

Take home message:
1. We have fabulous life-saving devices that can keep people alive when they shouldn't die.
2. How do we know when it is time to let people die?

The Effect of the Placebo

2008-11-09T15:29:00.006-06:00

By Shawn Vuong

I find it extremely interesting that Dr. Holm would bring up the power of faith and hope in the relief of pain and suffering, so closely to the article the British Medical Journal recently published about placebos.

The study found that nearly half of the physicians that responded claimed that they regularly prescribed "placebos" to their patients. So any reasonable person should be asking themselves, 'Hey what's going on here? These doctors sound like their engaging in some pretty shady behavior that could be effecting my health!'

The New York Times also got wind of this journal article, and they question the ethical findings of the study's results. A solo-family practice doctor thinks this maybe the media's "Gotcha Style" journalism at work. The doctor points out that the survey in the BMJ study didn't use the word placebo even once.

Kevin MD also stated that the effect of placebos can be very powerful, "however ethically incorporating the power of the placebo effect in everyday medical practice remains a challenge."

I believe that the faith that the patient has in his/her provider is just as important as the actual treatment. While placebos have shown that they can have strong effects on many illnesses, this makes me question the real value of some medications. Also, this brings up some questions about treatments. Can some illnesses be cured through a mind over matter technique? If so, do alternative medical therapies take advantage of this idea? How does the traditional practitioner take advantage of this mindset? Hopefully, it is not only through prescribing placebos.

An Autumnal Festival of Faith and Hope

2008-11-09T15:13:00.000-06:00

By Richard P. Holm MD

There is a very old Greek, then Roman, then Christian story of three pre-teen girls: Faith, Hope, and their younger sister Charity. They were tortured and killed with their mother while traveling along an early Roman highway. This apparently became the reason for an ancient yearly autumn festival to celebrate faith and hope in the face of suffering.

The relief of suffering certainly was about the most important job of those first Greek physicians, and it remains so for physicians today. What's more, we are still using some of the same medicines they used back then, with opium-based narcotics to dull the pain of illness and injury.

We now know more about these important morphine-like pain relievers. Scientists have discovered that narcotics work by attaching to special pain relieving receptors in the brain, and we know that our brain makes its own pain relievers, called endorphins, when the occasion calls for it.

We have even discovered an antidote to narcotic overdose called naloxone (Narcan), which works by displacing or pushing narcotics off from opiod receptors in the brain. I remember a big burly fellow, in a city hospital emergency room years ago, who was almost not breathing from what we presumed was heroin overdose. Right after I injected the naloxone, he came up almost off the table to try to choke me. I think he was angry for losing his "high".

One study about pain relievers has always intrigued me. In analyzing medicines for the relief of pain following childbirth, they found codeine gave about 80% relief, aspirin 70%, and placebo (a sugar pill) 60%. The amazing finding came when they gave naloxone to the patients receiving pain relief provided by a sugar pill (placebo) and it brought back the pain.

How about that! Not just morphine, but also faith and hope work by providing pain relief through turning on the endorphin system, which we can measure and even reverse.& So when they say, "it's all in your head" you know that's the truth.

Thus, in understanding narcotics and something more about Faith and Hope, we are better equipped to relieve suffering.

Take home message:
1. An autumnal festival of faith and hope came from an ancient story of suffering;
2. Narcotics have relieved suffering for thousands of years;
3. All kinds of narcotics and even the pain relieving effects of a placebo sugar-pill are reversible with a narcotic antidote or antagonist named naloxone;
4. Having faith and hope that a medicine will work is an important part of providing pain relief.