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.
Thursday, March 24, 2011
Friday, February 4, 2011
A triple-degree burn
By Richard P. Holm, M.D.
She was removing the pan of hot grease from the stove when she spilled the stuff all over her right hand. One area of skin was just red like sunburn, which is defined as a first-degree burn. Another spot blistered making that burn second-degree. But in the center there was a third-degree burn where the grease had injured both the outer and inner layer of skin so severely it caused, eventually, a small open ulcer. Fortunately there was no fourth-degree burn, which is when the muscle and connective tissue below the skin is also injured.
She ran cool water on it for 10 minutes, and then came to see me in the clinic. I removed the dead skin gently where blisters had broken, applied antibiotic ointment with silver and sulfa, and a cotton gauze dressing to the injured skin, and prescribed pain medicine. She was instructed to protect the wound, gently wash and redress it twice daily, cut away dead skin but not break the intact blisters, just let them break by themselves, and watch carefully for infection. I set an appointment for her to see me in a few days.
I have had the experience of treating burns that were so severe that the nerve endings were destroyed and there was little pain. More common however, is the unrelenting pain associated with less-severe burns, and that was the case with our hot grease injury. The wound looked good and healed nicely over time, but she and I were challenged dealing with her pain until thankfully it resolved after a several weeks.
The skin is the largest organ of the body and it weighs six to nine pounds. It spreads a thin-but-important layer over the outside of our body, protecting us from invading bacteria and viruses, managing fluid balance, controlling body temperature, and allowing for sensations that include touch, pressure, heat, cold, and especially pain.
It shouldn’t take a burn to realize the value of our skin.
Dr. Rick Holm wrote this editorial for “On Call®,” a weekly program about health on South Dakota Public Broadcasting-Television that is produced by the South Dakota Cooperative Extension Service. “On Call” airs Thursdays on South Dakota Public Broadcasting-Television at 7 p.m. Central, 6 p.m. Mountain
She was removing the pan of hot grease from the stove when she spilled the stuff all over her right hand. One area of skin was just red like sunburn, which is defined as a first-degree burn. Another spot blistered making that burn second-degree. But in the center there was a third-degree burn where the grease had injured both the outer and inner layer of skin so severely it caused, eventually, a small open ulcer. Fortunately there was no fourth-degree burn, which is when the muscle and connective tissue below the skin is also injured.
She ran cool water on it for 10 minutes, and then came to see me in the clinic. I removed the dead skin gently where blisters had broken, applied antibiotic ointment with silver and sulfa, and a cotton gauze dressing to the injured skin, and prescribed pain medicine. She was instructed to protect the wound, gently wash and redress it twice daily, cut away dead skin but not break the intact blisters, just let them break by themselves, and watch carefully for infection. I set an appointment for her to see me in a few days.
I have had the experience of treating burns that were so severe that the nerve endings were destroyed and there was little pain. More common however, is the unrelenting pain associated with less-severe burns, and that was the case with our hot grease injury. The wound looked good and healed nicely over time, but she and I were challenged dealing with her pain until thankfully it resolved after a several weeks.
The skin is the largest organ of the body and it weighs six to nine pounds. It spreads a thin-but-important layer over the outside of our body, protecting us from invading bacteria and viruses, managing fluid balance, controlling body temperature, and allowing for sensations that include touch, pressure, heat, cold, and especially pain.
It shouldn’t take a burn to realize the value of our skin.
Dr. Rick Holm wrote this editorial for “On Call®,” a weekly program about health on South Dakota Public Broadcasting-Television that is produced by the South Dakota Cooperative Extension Service. “On Call” airs Thursdays on South Dakota Public Broadcasting-Television at 7 p.m. Central, 6 p.m. Mountain
Monday, January 24, 2011
Ovarian cancer
By Richard P. Holm, M.D.
When this story begins, Mrs. Z. was 70ish and a special patient to me because years earlier, I had discovered her need for heart-valve surgery and later had helped direct her breast cancer care after she had discovered a lump. Now she had pelvic pressure pain and fullness, vaginal bleeding, and some urinary symptoms. She knew something was wrong, and apologized for delaying this visit because she was afraid of what I might find.
It is one of those moments I will never forget. On exam I was surprised to find a grapefruit-sized mass in her pelvis and when I looked up to her worried eyes it must have been written on my face. She knew before anything was said.
The very next day she went to surgery, and I was asked to assist. Indeed the tumor was a malignancy coming from her ovary, and although 85-90 percent of ovarian cancers come from the cells that cover the surface of the ovaries, I think my patient had what is called a germ-cell tumor. This kind of tumor comes from inside the ovary, is usually found in younger women, and starts from egg-producing cells. There is a third kind of ovarian cancer that starts from hormone-producing tissue or stromal cells, but we had to wait for the microscopic exam to tell.
She had several ovarian-cancer risk factors that included a family history of colon cancer, a late menopause, and her previous breast cancer history. Even when we understand risk factors, ovarian cancer is called a silent killer because, like in Mrs. Z’s case, the symptoms usually appear late, often after the tumor has spread. But in her case the cancer hadn’t spread.
Mrs. Z eventually died of heart failure in her late 80s, had many wonderful retirement years with her kind husband, and our friendship grew through those years. It’s the kind of thing that makes my job such a joy.
When this story begins, Mrs. Z. was 70ish and a special patient to me because years earlier, I had discovered her need for heart-valve surgery and later had helped direct her breast cancer care after she had discovered a lump. Now she had pelvic pressure pain and fullness, vaginal bleeding, and some urinary symptoms. She knew something was wrong, and apologized for delaying this visit because she was afraid of what I might find.
It is one of those moments I will never forget. On exam I was surprised to find a grapefruit-sized mass in her pelvis and when I looked up to her worried eyes it must have been written on my face. She knew before anything was said.
The very next day she went to surgery, and I was asked to assist. Indeed the tumor was a malignancy coming from her ovary, and although 85-90 percent of ovarian cancers come from the cells that cover the surface of the ovaries, I think my patient had what is called a germ-cell tumor. This kind of tumor comes from inside the ovary, is usually found in younger women, and starts from egg-producing cells. There is a third kind of ovarian cancer that starts from hormone-producing tissue or stromal cells, but we had to wait for the microscopic exam to tell.
She had several ovarian-cancer risk factors that included a family history of colon cancer, a late menopause, and her previous breast cancer history. Even when we understand risk factors, ovarian cancer is called a silent killer because, like in Mrs. Z’s case, the symptoms usually appear late, often after the tumor has spread. But in her case the cancer hadn’t spread.
Mrs. Z eventually died of heart failure in her late 80s, had many wonderful retirement years with her kind husband, and our friendship grew through those years. It’s the kind of thing that makes my job such a joy.
Thursday, January 13, 2011
Jumping on the Vitamin D bandwagon
By Richard P. Holm M.D.
“Jump on the bandwagon” is a political phrase started in the mid 1800s when a circus clown turned politician and used his musical bandwagon for political rallies. As he passed through different towns it happened that local politicians found seats on the bandwagon, wishing to share in his popularity. As the political use of bandwagons spread, the phrase “jump on the bandwagon” came to refer to opportunists who support popular ideas without proof of value.
What proof do we have of the value of taking calcium and vitamin D, or have we all jumped on a bandwagon? Recently a committee of scientists and experts were gathered by the Institute of Medicine (IOM) to define what is scientifically proven about calcium and vitamin D.
After extensive hearings and study they said that there is solid proof that low levels of vitamin D are associated with poor bone health. We don’t have enough evidence yet to say conclusively vitamin D deficiency effects cardiovascular health, or causes hypertension, diabetes, falls, colon cancer, and psychiatric illness. They didn’t deny it they just said more studies are needed.
With regards to dietary calcium, the IOM concluded that most people in the US and Canada daily get enough Calcium, except for girls aged 9-18. They also discovered that significant numbers of postmenopausal women are taking too much calcium.
Vitamin D is more complicated, because levels are quite unpredictable, although commonly low in the elderly, those with dark skin, the obese, and people living in institutions. Even though multiple experts have advised that levels are too low when under 30 to 50 nanograms per milliliter, the conservative IOM declared that levels below 20 are deficient. The IOM did advise supplementation for all over one year of age, stating that for adults taking up to 4,000 units is safe, and advised not to take more than 10,000 daily.
Take home message: I encourage calcium supplements for 9-18 year old girls but not for adults. I also like to measure vitamin D levels, especially in people with dark pigment, obesity, osteoporosis risk, those institutionalized, or in persons older than 60. And for bone health I strongly recommend, along with an exercise program, all adults should daily take 2 to 4,000 units of vitamin D. That’s not just jumping on a bandwagon.
“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.
Sunday, December 19, 2010
Guess I’ll eat some worms
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.
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.
Monday, December 13, 2010
On suffering
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.
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.
Sunday, November 14, 2010
Send the kids outside to play
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.
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.
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