I Have A Secret

By Shawn Vuong


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


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


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By Richard P. Holm MD

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

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

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

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

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

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

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

Stress

By Shawn Vuong


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


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


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By Richard P. Holm MD


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


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


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


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


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

Corrosive Stomach Acid

By Shawn Vuong


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


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


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


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




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By Richard P. Holm MD


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


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


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


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


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


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


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


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


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

Asthma

By Shawn Vuong


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


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


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


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By Richard P. Holm MD


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


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


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


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


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


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


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


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


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

Earwax and Elbows

By Shawn Vuong


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


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




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By Richard P. Holm MD

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

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

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

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

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

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

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

Q. and A. about Health Care Reform

By Shawn Vuong


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


Q. Do we really need health care reform?


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




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


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


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




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


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


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

Boys to Men

By Shawn Vuong


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


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



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


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By Richard P. Holm MD

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

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

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


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


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


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


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