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.
Showing posts with label primary care. Show all posts
Showing posts with label primary care. Show all posts
Friday, October 1, 2010
Tuesday, July 13, 2010
Valuing Others
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.
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.
Wednesday, May 19, 2010
When Grandma Wants to Pull the Plug
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.
“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.
Thursday, December 10, 2009
Stress
By Shawn Vuong
The human stress response is a balance of two delicate systems, the sympathetic and the parasympathetic nervous systems. The sympathetic system gives us that boost of energy and anxiousness we get before something big is about to happen or if we are surprised. Our hearts beat quicker, we breathe faster, our pupils dilate, and our muscles prime for action. This is the acute stress response that has helped us through our hunting and gathering years. After that stress our parasympathetic response takes over. It is known as the rest and digest system. Usually after a big meal you'll feel pretty tired, that's your parasympathetic response at work.
The problem becomes when stresses become a long-term issue. Money, work, kids, relationships, and time all can add up and continuously stress us out. This is bad, because this stimulates our sympathetic nervous system for a long period of time. This system was not meant to be chronically simulated, and because of this we see the harmful effects of stress on the body.
___________________________________________________________________________
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.
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.
___________________________________________________________________________
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.
Tuesday, November 24, 2009
Corrosive Stomach Acid
By Shawn Vuong
A wise pharmacology professor once told me, "All substances are poisons; there is none which is not a poison. The right dose differentiates a poison and a remedy."
This week Dr. Holm talks about drugs, particularly in the context of heart burn. In our pharmacology class, we are learning about how all types of drugs interact with the body. Prescription drugs, over-the-counter drugs, herbals, and even supplements all effect the body in different ways. The key to prescribing drugs correctly is weighing the risk of toxicity of a drug versus the benefit gained.
Each substance has it's own toxic effect when given at too high of doses. But we must make the dose high enough to see a benefit. In effect, we get a titer-totter like scenario where we are trying to balance the correct dose to see benefit while trying to limit toxic effects (also known as side effects). Some drugs are easy to give, since they have a high benefit but low toxic effects such as statins. Other drugs have medical health professions constantly walking that fine line between lethal effects and benefit to the patient such as chemotherapy agents or anesthetics.
So remember, every substance has toxic effects when given at incorrect doses. Even water can cause lethal effects if you drink too much. So, please work with your doctor to correctly dose your medications, because they can sometimes give you nasty side-effects.
_________________________________________________________________________
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.
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.
_________________________________________________________________________
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.
Friday, September 25, 2009
Very-Close-Veins
By Shawn Vuong
Failing leg veins are also known as varicose veins. In this post, Dr. Holm describes how people develop varicose veins, why they are a health risk, and how best to treat them.
Some times conservative treatment can fail, but one should not worry. Many other treatment options exists for varicose veins, although they are usually more invasive and expensive. Some of these options include sclerotherapy, laser surgery, vein stripping, ambulatory phlebectomy, and endoscope vein surgery. If you are having problems with varicose veins, it is best to see your physician to discuss the best treatment option for you.
________________________________________________________________
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.
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.
________________________________________________________________
By Richard P. Holm MD
I’ve heard failing leg veins called everything from “spider veins”, or “a bag of worms,” to “very-close-veins.” Affecting more than fifty percent of people over fifty, these gnarled, distended, varicose veins represent a problem that, generally, only gets worse.
Arteries take blood out away from the heart, like a steel pipeline from a powerful pump station. On the other hand, veins bring blood back like a lazy river that works because of locks or valves located to prevent back flow. But there is nothing lazy about the job of returning all that blood up hill, against gravity, all the way back to the heart.
The trouble with leg veins usually starts during pregnancy, or with a job which requires lots of standing in one spot without walking, or with the increased venous pressure associated with obesity. Of course, some people inherit better veins than others.
When a few valves begin to fail, then veins gradually become distended and dilated, which makes more valves fail, and the problem swells. Common signs of failing veins include edema, redness, rash, fever, pain, and even hard to heal sores. What’s worse, when blood movement slows down, clotting can happen, and when clots spread the result can be life-threatening clots to the lung.
What can we do to prevent varicose veins? Muscles surround most veins within the leg, so when we walk or use our legs, the muscles contract and squeeze, acting like pumps. If the one-way valves are still working, walking and leg movement makes blood flow upward and in this way regular walking or rocking back and forth while we stand helps prevent varicose veins. And don’t forget to put the feet up whenever possible.
The next best solution is to wear compression stockings. Although they can be hard to put on and many people are hesitant to use them, the lower, knee-high stockings are easier to use, do the lion’s share of the job, are relatively cheap, and the results are well worth the effort. Some people absolutely swear by them since they prevent so many problems and feel so good.
There is a lot you can do if you stand to inherit those very-close-veins. Left alone, they only get worse.
Surprise Death
By Shawn Vuong
In the light of the current healthcare reform debates and all of the craziness that has come with it (the infamous 'death panel'), let us not forget what this debate is truly about, the patients.
As Dr. Holm reminds us, eventually we will all come to our death. The important thing is that we must let our loved ones pass away with a little dignity and pride. To do this we must talk to our family members about their death wishes, as well as our own. This is an important and often ignored piece of medicine that never gets the attention it deserves until it is too late.
__________________________________________________________________
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.
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.
__________________________________________________________________
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.
Saturday, August 8, 2009
The Big Cover-Up
By Shawn Vuong
Erectile disfunction, as well as sexual problems in general are difficult for any man to talk about. Whether that be friends, family, or the physician sexual performance is still a secretive area of a person's life. Even in this day and age with all kinds of sexual and personal information and entertainment a click away, many people shy away from the subject of sex.
If you or someone you know is having sexual problems such as erectile disfunction, the "blue pill" may not be the right answer. It's important to go in and speak with a primary care professional about these subjects. Although you may be tempted to keep these problems under wraps and consult Dr. Google, these problems could signify significant medical problems. While google can be a good starting source for information, it shouldn't be your only one.
_______________________________________________________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.
Friday, July 31, 2009
Good Medicine
By Shawn Vuong
This week Dr. Holm talks about the over-use of medications. Sometimes, patients are on too many medications and there are many factors (or maybe the combination of these factors) that could be the culprit. As medicine continues onward so does drug and pharmaceutical research. This will only aggravate the over dependence on drugs we see today. Every day researchers and scientists discover more genes, cell markers, and biochemical pathways to target with new drugs.
As medicine becomes more and more advanced, we may see a decrease in pharmaceuticals. But I predict patients may actually be on more as research shows that therapies which include a combination of old and new drugs work best. What can we do about this over abundance of drugs? The patients can question their physician on why they need certain medications. Doctors can also help battle this by practicing good medicine.
___________________________________________________
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.
Friday, July 10, 2009
The Power of the Sun
By Shawn Vuong
The sun provides the body a vitamin. It is weird to think about right? We are not plants, yet we need sunlight. The sun is a great source of vitamin D, and also provides cues for your body to keep hormones in balance which is important for a person's sleep cycle and his/her psyche. In the same token, the sun is not something to be enjoyed too much, a person could have a so called "sun over-dose." UV rays from the sun are known to cause many skin conditions that Dr. Holm touches on in this following article. So, enjoy the sun in moderation. If you aren't getting enough sun, consider drinking more milk, eating more fish, or maybe even a short time in a tanning bed. While we don't need the sun for photosynthesis, humans health is affected by the great power of the sun.
__________________________________________________
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.
Monday, April 6, 2009
Are Two Heads Better?
By Richard P. Holm MD
Collaboration is a fancy word, which means two heads are better than one. It's the buzzword that always pops up when physicians are talking about Physician Assistants (PAs) and Nurse Practitioners (NPs). I believe that the art of collaboration, or knowing when and who to call for help, is about the most important and difficult challenge any PA, NP, or MD faces everyday.
Take for example the isolated over-busy practitioner who knows a lot about everything, but not enough about the specific problem troubling that individual patient. Hopefully that care provider has enough experience and depth of knowledge to recognize when to ask for help and collaborate with someone who knows more. Two heads can be better than one.
There is another side to that story. Last month Mr. X had a complicated problem and I sent him to the specialist in another community. Before he returned, three other specialists were consulted by the first, each adding another test, and medicine, and expense. I was faxed copies of all these consults, but basically kept out of the loop until the patient returned to my office. Here's a time when the big picture had been lost while focusing on all the tiny parts. Sometimes one head is better than four.
Many experts say that the cost and access problems we have with our health care in the US are because care is so fragmented. All the parts are not speaking to the whole.
In this time where it is likely major health care reform will occur, we must be very careful to construct a system that would encourage care that starts with a medical home. This would be when one very well trained primary care MD, PA, or NP would know when to refer, when not to refer, and expect a return of responsibility for the patient.
Collaboration is the name of the game.
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.
Thursday, December 11, 2008
Doctor Shortage Makes Headlines
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.
Tuesday, November 18, 2008
Doctors Feeling Gloomy?
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.
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.
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.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.”
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?
Subscribe to:
Posts (Atom)
