Polite Dissent

The final episode of House. I liked it and found it fitting, even if the medicine was spotty, but YMMV

House awakens on the second floor of a burning abandoned warehouse next to the body of a dead junkie. Through a serious of flashbacks told as question and answer sessions with House’s subconscious — played by various former characters, both alive and dead — we learn what brought House to his current predicament.

The junkie was a drug-seeking patient who showed up in the clinic, trying to connive House into writing him a prescription for narcotics. House wasn’t fooled, but decided to admit the patient after he noticed Cullen’s sign — bruising around belly button — a sign of pancreatitis (or, if the patient had been female, an ectopic pregnancy). House obtains an ultrasound of the patient’s abdomen which shows no pancreatitis, but does show blood and air within the peritoneum — neither of which should be there. The storytelling gets a little muddled at this point and House ultimately explains that the patient has a perforated ulcer (which would get both air and blood into the abdomen).

Later the patient suffers respiratory arrest and codes. While his team dithers about blaming it on a pulmonary embolus (“a clot in the lungs”), House calmly enters the room, searches through the code blue trolley, and injects the patient with naloxone. This immediately brings the patient, screaming, out of his arrest. It turns out the patient had overdosed on some heroin he had acquired. (Naloxone blocks the effects of narcotics on the opioid receptors. This will dramatically cure narcotic-related respiratory depression, but it also abruptly ends all the pain-killing benefits and euphoric effects of the medication, which explains why the patient woke up screaming.)

After the code, House sits and talks to the patient, who admits he will never give up heroin, because he likes the way it makes all his problems go away. This description of heroin intrigues House, even as he now diagnoses the patient with ALS (amyotrophic lateral sclerosis, i.e. Lou Gherig’s disease), based on nothing more than the twitching of the base of the thumb (the thenar eminence) and thinning of the muscle there (suggesting muscle atrophy). A short conversation later, he notices a bulge in the patient’s right supraclavicular notch and a handy ultrasound reveals a foreign body. It seems the patient had once inhaled some plant matter which caused an autoimmune reaction, which explains all his symptoms (the ALS ones, anyway. Kind of, if you pretend. Maybe the ulcer too, I’m not so sure. Not the drug addiction, though — can’t blame that one on an autoimmune disease.)

After that, House goes missing for two days and ends up in an abandoned warehouse, which just happens to be on fire, with his former patient dead next to him. It’s left to conjecture, but I think it’s fair to assume that House was intrigued by the patient’s description of heroin and decided to score some with the patient. House passed out, the patient OD’d, and…well, I don’t know how the warehouse caught on fire. It just did, OK?

Foreman and Wilson manage to track down House and arrive at the burning warehouse just in time to see him try to escape before being brought down by a collapsing rafter. Then to add insult to injury, the warehouse explodes.

A body is removed and identified as House through dental records. Everybody who is anybody is at the funeral – except Cuddy, but to be fair, he did try to kill her. In the middle of his shockingly appropriate (and classic Kubler-Ross) eulogy, Wilson receives a text on House’s cellphone –conveniently in his pocket — telling him to “shut up you idiot.” A short time later Wilson meets up with a clearly alive House who explains that he escaped out the back door of the warehouse and switched dental records. With him now officially “dead” he is free to spend the next five months with Wilson.

As the episode fades, we see the Chase is now head of the Princeton Plainsboro Diagnostics Department, with Adams and Park still working on the team. Taub is spending time with both of his daughters, and both of their mothers. Cameron heads out the door of her ER in Chicago to meet with her husband and child. Foreman discovers House’s conspicuously hidden hospital ID in his office. And Wilson and House head off into the sunset on their motorcycles.

The medicine was very random and entirely illogical this week. That being said, this episode was never going to be anything other than Greg House himself, and I’m going to respect that by not highlighting any errors or giving any letter grades this time. If you really want, you can probably divine my opinion on the medicine by my comments in the plot summary. Or there’s always the comments.

I thought this was a fitting end for the series. House himself was such a complex character and had such a rich history over eight years that there was no way they were going to be able to keep everybody happy, or even satisfied, with any ending. This ending hit most, if not all, of the key points: friends, family, pain, loneliness, and mystery.

It wasn’t a perfect episode, or probably even a great one – too many coincidences for my taste – but it was at least a very good episode.

Medically, as much as I complained, let me make it clear once last time that the medicine on House was still miles ahead of every other medical show. Even the bad medicine on House was better than what passed for good medicine on other shows.

Thanks for stopping by and reading — and commenting, or at least lurking — for the past eight years. Next year, I’ll continue to review Fringe, and any new medical show that catches my eye. In the meantime, I’ll continue to focus on the depiction of medicine in pop culture, particularly comics. (For those of you playing, the House Challenge scores should be updated and completed by the end of holiday weekend.)

One last thought: a bit of advice for all current and aspiring writers who want to write good medical scenes. It’s simple — Primary Care. Specialists are great, they are the big names and bring in the big bucks, but they only look at one small part of the problem (which is fine, we need them to do that in the real world). But if you want someone who knows how everything fits together, who sees the forest for the trees, then talk to your primary care doctor. Have them take a quick look over the script (or story or novel or comic) to make sure it hold together medically as a whole. Most of my complaints about medical writing could be solved with this one little step.

The review of the previous episode of House
A list of all prior House reviews

While the soap opera aspect of this penultimate episode of House was outstanding, the actual medicine left much to be desired

Derrick is a 19 year-old cheerleader who was admitted after suffering from dizziness and a massive nosebleed (and dropping his partner). A head CT was normal. Taub suggests a “mini-stroke” (though you’d think a doctor would use the correct term TIA, especially when talking to other physicians), but House tells them it is a midline granuloma and has them check a PET scan. The scan is negative for any cancer, but it does show activity in the auditory area, suggesting that Derrick is hearing to something, though no sounds are present. He denies hearing voices, but the team suspects otherwise. They suggest schizophrenia or drug use. His dorm room is searched, and though his roommate is an active participant in the drug culture, he insists Derrick is clean. A thorough exam of the room finds a picture of a young boy hidden in the back of a drawer. Confronted with this evidence, Derrick explains that the picture is of his long dead brother, and reluctantly admits to hearing his voice for the past ten years.

The differential diagnosis now consists of viral encephalitis (though, as pointed out on the show, an infection of the brain wouldn’t persist for ten years) or temporal lobe epilepsy. The team runs tests on Derrick trying to trigger a seizure, but nothing happens — except that he suffers a sudden blindness in his right eye which Adams diagnoses as a “clot in the artery behind the eye” (i.e. a retinal artery occlusion, and massage is one of the treatments supported by anecdotal evidence) and rubs out of existence. The team debates how many of Derrick’s symptoms are physical, and how many are psychological. Park is a firm believer that years of purposefully avoiding grief over the death of his brother has left Derrick with an anxiety disorder that appears as physical symptoms (though this wouldn’t explain the clot). Taub is more prosaic and believes in a physical cause. He suggests polycythemia vera (blood that is thicker than normal), Hodgkin’s lymphoma, or DIC (disseminated intravascular occlusion) due to some trauma suffered in cheerleading (I can believe this: I see more injuries due to cheerleading than any other high school activity. Basketball is second, and football a distant third.). A spinal tap is obtained. It shows no evidence of bleeding (and therefore, no trauma), but an abnormally high opening pressure (reflecting the intracranial pressure) tells them something else is going on. The suspect a “extreme” migraine as the cause. An MRI is obtained, but shows no evidence of migraine – and then the ceiling collapses due to a prank House pulled on Foreman. Before the collapse, Park noticed that he misidentified her as Adams, and that is enough for House to deduce that Derrick has a persistent stapedial artery. This is a small artery in the fetus that should fade away before birth, but sometimes it remains. In Derrick’s case, this artery has been pressing against his temporal lobe causing dizziness and hallucinations. After surgery to remove the artery, his symptoms should resolve.

Neither House nor Wilson is doing well now that they’ve learned that the chemotherapy didn’t work and the tumor remains. Wilson decides to go without any more chemo, figuring he has five months left to live. House refuses to accept this. He wants Wilson to take the chemotherapy and extend his life another couple of years. He tries a number of tricks on Wilson to get him to agree: he doses him with Propofol (a potent IV general anesthetic – what killed Michael Jackson) to mimic death, he fills a room with former patients, he has a quiet nostalgic dinner with him – but nothing he does convinces Wilson to try chemotherapy. Instead, it drives a wedge between them.

Foreman buys House season tickets to the New Jersey Devils, with seats next to his, in a bid to help House get over Wilson, but House decides to stuff the tickets down the hospital bathroom drain. This leads to a massive water overflow, ultimately collapsing the ceiling over the MRI and requiring the city emergency crew to be brought it (apparently, there is no way to shut the water off at Princeton Plainsboro).

In the end, Wilson decides to go through with the chemo for House’s sake, but House tells him not to, and they’ll just enjoy the time left. They are making plans for the next few months, when the Foreman and the hospital lawyer walk in (but why is the hospital lawyer acting as an accusing officer hear? He should be protecting his doctors, not acting like a DA), telling House his plumbing stunt was severe enough to draw police attention and his parole is being revoked and he must server the remainder – six months – of his sentence.

As usual, with a soap opera heavy show (not that I’m necessarily complaining, just noting), the patient and medicine are given short shrift. Major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

The main issue with this week’s diagnosis is what I call the “have your cake and eat it too” problem — commonly seen on House — but not usually this blatantly. In this case, Derrick has a persistent stapedial artery significant enough to cause a rise in intracranial pressure (leading to clots and bloody noses) and large enough to press against the temporal lobe causing hallucinations – yet, this large artery is not seen on CT or MRI, and the patient has none of the common symptoms such as hearing loss or tinnitus (ringing in the ears). The writers want to have it both ways — bad enough to cause extreme symptoms, but yet small enough to be missed by every exam until the last minute.

TA midline granuloma would have been seen on CT.

I see little evidence (really noevidence) in the literature of a migraine, even an extreme migraine, causing an elevated intracranial pressure. Now, an elevated ICP can cause a headache, sometimes even a migraine, but that’s the opposite of what’s suggested here.

I notice they make no effort to actually lower the elevated ICP – other than the initial spinal tap.

How did misidentifying Park as Adams lead House to the final diagnosis?

Here’s one I have no answer to, and so I’m not really calling it an error; I’m just wondering. Would an auditory hallucination light up the same areas of the brain as actually hearing something would, or would it light up different areas?

The medical mystery would be boring for any medical show, but was particularly pedestrian for House. It earns a meager D. The final solution made a little sense, but not much when you consider the so big to cause major symptoms, yet too small to be noticed paradox. I give it another D. The medicine overall was just OK. Not horrible, but not particularly brilliant. I give it a C. Once again, the soap opera was quite good. Both Laurie and Leonard deserve kudos for their scenes. I give it an A.

The review of the previous episode of House
A list of all prior House reviews

The final episode of the penultimate season of Fringe. The universes are safe (again).

The Plot: Peter and Olivia head back to Walter’s lab only to find Walter and Astrid missing. Soon after they arrive, Olivia receives a phone call from one of the victims she saved last week from the nanite attack. She tells Olivia she thinks she is being watched. Olivia agrees to head right over. It turns out that she is being watched, by September the Observer, but he falls prey to a second level cleric spell and is trapped.

Olivia and Peter arrive to find an empty house and a strange hole in the floor. Broyles calls and tells them Astrid is in the hospital, recovering from a gunshot wound. They rush to the hospital and learn about the warehouse where Walter was last seen. Peter and Olivia head to the warehouse and find September, still trapped. The woman Olivia helped last episode steps out of the shadows, holding a pistol. She makes it clear that is working for William Bell and her job is to get Olivia riled up. She shoots September, but due to his “super Observer speed,” he is able to catch the bullets. She then pulls out a special pistol, designed by Bell, which can shoot so fast the Observer can’t catch the bullets. She fires a shot, and sure enough, September is hit in the chest. She fires three more shots but Olivia catches them and throws them back at her, killing her. Of course, in the Fringe universe, no one stays dead forever, especially when they hold the clue to Walter’s location, so she is brought back to the Harvard lab, hooked up to a machine, and dragged back to life, temporarily at least.

The Fringe team learns that William and Walter Bell are on barge, presumably heading for the safe zone where the two universes will collide. They find the boat, but only Peter (and the satellites, apparently) can actually see it, because it is out of sync with our universe. Peter and Olivia (acting on their own, again), jump to the barge and confront William Bell. He tells them that Olivia’s powers are energizing the collision of the universes, and once begun, there is no way to stop it. Walter disagrees, then pulls out a pistol and shoots Olivia right in the brain, killing her. Without the required power, the universes immediately return to normal. Bell disappears (literally).

Walter rushes to Olivia, reminding Peter of what we only learned last episode, that Cortexiphan has healing powers. Using improvised surgical tools, he pushes the bullet out of Olivia’s brain, and miraculously, her wound heals.

As the episode ends, Congress increases Fringe’s funding, allowing them to add their own science department – a department which the now “General” Broyles asks Nina Sharp to head. Olivia is released from the hospital, but not before telling Peter that she’s pregnant. Meanwhile, September appears to Walter, telling him to warn the others about what is coming.

1. I’ve Heard Of Soft Spots, But This Is Ridiculous
Skulls must be softer in the Fringe universe, because there’s no way a syringe, let along a letter opener, would be able to break through the skull that easily – if at all.

2. Just Ask Penn & Teller
The trick to catching a bullet is not just being fast enough to intercept it, but somehow arresting all its momentum without taking any damage. Super speed may solve problem number one, but not number two.

3. In A Case, Just In Case
That was one of the more blatant examples of Chekov’s Gun I’ve seen in recent memory.

4. Khaaaan!
I couldn’t help flashing back to Start Trek II and the Genesis device in the beginning of this episode, when William Bell was talking about how God created the universe in seven days but it took him [Bell] considerably longer. There is a similar quote in Star Trek II (only it takes them seven hours, not seven days).

5. ParadoxodaraP
A nice time paradox. When September told Olivia that in every universe she has to die, where did he learn this? From Olivia.

Another good episode, but I have the feeling it could have been better. This two-part finale would have worked better a three-episode arc, so some of the key points wouldn’t feel quite so shoe-horned. Still, a good season overall, even if Charlie is still AWOL. The Fringe Doomsday Clock creeps back to 11:55.

This week’s Fringe cipher was: PURGE.
A list of all previous Fringe reviews is available here.
Karl, as always, has more to add.

Better late than never. The Fringe team has their final confrontation with David Robert Jones and learns the identity of the real mastermind in an entertaining, albeit fairly cluttered, episode.

The Plot: The Fringe Team is called in to evaluate a cluster of cases of spontaneous combustion at a nearby convention center. Walter initially suspects a viral infection, but when he realizes the infection was caught from the handrail on the escalator and locates the source, he determines the victims have actually been infected with nanites. Video surveillance shows that David Robert Jones planted the nanites in the escalator, but after looking over the nanites, Walter recognizes them as the work of William Bell.

In this universe, William Bell died in a car crash seven years before, but Walter is insistent that Bell must still be alive and tells the rest of the team that William visited him at St. Claire’s Hospital after he was supposed to be dead. A visit to the hospital shows no evidence of Bell visiting, but Walter keeps the sign-in log for good measure.

The viewers quickly realize that Walter is right and William Bell is still alive, and the Jones is working for him. After some clumsy metaphors about chess, Bell tells Jones that it is time to take out the Bishop. Soon, a bright powerful beam of light comes down from the sky, burning everything in its path. Walter and Peter realize that it is caused by satellites reflecting the sun’s rays and Walter is able to track down the source of the transmission controlling the satellite. Peter and Olivia head off to the transmission sight – antennas on two nearby buildings. They each climb to the roof of one building and shut down the transmitters, but Peter is jumped by Jones. Olivia is able to use her Cortexiphan abilities to take control of Peter’s body and beat Jones senseless. Jones then disintegrates into powder, remarking that he was the Bishop being taken off the board.

Back in his lab, Walter, with help from Astrid, cow’s brains, and an EZ Bake oven, determine that Bell did visit the asylum, leaving behind a trace of his favorite snack – almonds – on the sign-in log. Walter and Astrid head off to the almond warehouse in an attempt to track down Bell. They succeed too well – finding both Bell and some armed goons – and Astrid receives a gut shot as the episode ends.

1. Flame On!
Not quite classic spontaneous combustion. In this case, only their cheeks and respiratory system (or maybe GI system) burnt up – they didn’t all spontaneously burst in to flame.

2. Forget Minute Rice, Try Our Minute Cultures!
That’s way too short an amount of time to declare an area free of airborne germs. Well, unless you’re using a tricorder. Mabey Nimoy brought one with him.

3. Must Be Empty, And Very Understaffed
St. Claire’s hasn’t reassigned the room, or at least cleaned the desk, in the four years since Walter left?

4. And Lets Not Forget the Foreshadowing: Almonds = Cyanide
If William didn’t sign the page of the ledger, then why is his almond-residue on it? And why is only his snack on there? Surely someone else had eaten before touching the ledger.

5. My Get Rich Quick Plan Continues
Tonight’s episode is just more proof that the best way to make money in the Fringe universe is to own empty warehouses.

6. Don’t Try This At Home Kids
It’s not that easy to relocate a shoulder — in fact, I doubt Peter would have the strength to do it the way shown — especially with a posterior dislocation like Peter suffered. (Now if Peter has suffered multiple posterior dislocations before, his shoulder could pop in and out of socket easier than normal, though with all the fights he’s been in, you’d think we’d have seen that before.)

7. Have A Bigger Party, There’s More Than Enough XP To Go Around
It never occurs to Peter and Olivia they might need back up? They have access to an entire FBI division, after all.

8. Loaves and Fishes Lemon Cake and Pigs Brains
Cortexiphan now has regenerative properties? Hasn’t seemed to do much for Olivia in the past, though it does completely restore that tissue lemon cake really easily. Forget telekinesis, Walter has solved the world’s hunger problem.

A good episode, but there was enough here to spread it out over another episode. The Fringe Doomsday Clock remains at 11:54.

This week’s Fringe cipher was: POWERS.
A list of all previous Fringe reviews is available here.
Karl, as always, has more to add.

Another episode with the team being mostly on their own while House and Wilson do their own thing. Not a bad episode, overall.

Dr. Treiber is the hospital’s outspoken pathologist. In the middle of an autopsy, he suddenly decides to cut his own scalp open with a scalpel and complains of being cold. He is admitted to House’s service — but House quickly runs off on a buddy trip with Wilson, so the team is left to solve the case on their own. Before he leaves, House suggests Treiber may be suffering from the Cotard delusion (a mental disorder where people believe they are dead — therefore House thinks Treiber was trying to perform an autopsy on himself), but the history doesn’t fit well. Other suggestions include liver failure due to hepatitis C, toxin exposure in the morgue (in particular, dimethyl sulfate), or blood clots. An ultrasound is obtained but shows no clots, and an examination of the lab turns up no toxins, but does reveal that Dr. Treiber is a big fan of energy drinks, the team now suspects he is suffering from stimulant psychosis, due to all the caffeine he consumes.

Treiber soon develops abdominal pain and distention, meaning that something else besides stimulant psychosis is going on. Adams still suspects the caffeine is behind most of his symptoms, except the abdominal ones, which she believes are caused by a bowel obstruction. Other thoughts are diabetes or ulcerative colitis (a type of inflammatory bowel disease). Chase finally suspects an intussusception (a collapsing of the bowel in on itself) due to cancer. They obtain an x-ray which is normal, but Treiber wants Chase to go ahead and check the small bowel surgically for the intussusception. Chase agrees to perform the surgery, but no abnormalities are found.

The team now decides that Treiber must have intermittent porphyria (an inherited metabolic disorder) and starts him on hemin (a treatment for acute intermittent porphyria). Despite the treatment, Treiber continues to decline and develops bilateral pleural effusions (fluid build up around the lungs). At this point, Treiber finally learns that House is nowhere to be found, and Foreman is brought on to the case. He immediately suspects a cardiac cause (not unreasonable, given the pleural effusions) and obtains a cardiac MRI which shows an enlarged left ventricle. Foreman takes this to mean that Treiber has an infiltrative disease of the heart (an accumulation of some substance in the heart muscle that is not supposed to be there), probably sarcoidosis, and wants a heart biopsy. Chase suspects a prion disease (a neurological disease spread by infected proteins) and wants a brain biopsy; he also wants to start him on amphotericin to treat the suspected prion disease. Unfortunately, only one biopsy can be performed and Foreman elects to go with the heart biopsy. Chase heads down to the morgue to find the source of his suspected prion disease The cardiac biopsy shows fibrosis, not infiltration, meaning Foreman was wrong about sarcoid, but Chase was also wrong about a prion cause (because no prion disease causes fibrosis in the heart). Foreman now suspects a viral infection (like a viral cardiomyopathy) and obtains cultures and starts antivirals, but Chase remains in the morgue, convinced the answer is down there. Overnight, Treiber falls into a coma, making Foreman and the rest of the team rethink their diagnosis. They come to the morgue to talk to Chase who has reluctantly decided that Treiber is too fastidious to have caught a disease in the morgue – but then he realizes it is that fastidiousness – or more specifically, the antibacterial soap he repeatedly uses – that is the source of the problem. The repeated exposure to Triclosan (an antibacterial in soap), plus a high dose of caffeine from the energy drinks, caused Treiber’s thyroid to shut down and Treiber ended up in a myxedema coma (a severe form of hypothyroidism).

As always, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

While triclosan has been implicated in thyroid problems in bullfrogs and mice, human studies haven’t shown this effect (admittedly it was a limited study looking at triclosan in toothpaste).
Similarly, there haven’t been any studies linking high caffeine intake and hypothyroidism in humans (there is a study showing caffeine can interfere with absorption of thyroid medication, but that’s a different situation).

No one thought to check thyroid studies for an unexplained coma?

Studies have suggested that amphotericin may play a role in treating certain prion dieases, but it’s never been tested in humans.

They can’t perform both biopsies because of the amphotericin Chase wants to use because it might theoretically limit the possible prion disease the patient might have. Problem easily solved. Hold the ampho (it’s never been tested in humans for this anyway) then you can perform both biopsies.

That was simply a horrible code, but then, I think it was supposed to be one because it was supposed to be a bad doctor. Just for starters: only two people involved (not counting the patient), and one is just idly looking at IV bags. Shocking a flatline. No airway.

A small amount DMSO applied to the knees got converted to a toxic amount of dimethyl sulfate via several brief shocks to the chest?

Did no one think to ask Treiber why he was cutting his own scalp? The answer would likely have been revealing.
Despite the hypothyroidism/myxedema coma worsening, his mental status was fine in his hospital stay, despite it being his presenting complaint.

Here’s what I could get off of Chase’s whiteboard (or whiteboards) — hopefully someone got a better screenshot. In no particular order: Neimann-Pick disease, Japanese encephalitis, Creutzfeldt-Jakob disease, Q fever, impetigo (really?), typhoid, schistosomiasis, leptospirosis, gastroenteritis, neurofibromatosis, fatal familial insomnia, Tay-Sachs disease, cronobacter, syphilis, kuru, lyme, aortic aneurysm, shigelloisis, malaria, HIV, Klinefelter syndrome, yellow fever, cryptosporidiosis, dengue, German-Straussler-Scheinker syndrome, hypoglycemia.

The medical mystery was interesting, if less so once the patient was admitted. I give it a B+. The final solution made a modest amount of sense, if you accept the fact that the condition has never been seen in humans — that’s a few point off, in my book. I give it a C-. The medicine overall was thorough — on Chase’s end, at least — but missed some obvious possibilities, with myxedema coma topping that list, and easily testable. I give it a weak B. I thought the soap opera was good. The House/Wilson last fling was somewhat cliché, but Chase’s dilemma was well done. I give it an A-.

The review of the previous episode of House
A list of all prior House reviews

As usual, in a soap opera heavy House episode, the medicine suffers — though the writers tries to distract us by adding an unlikable character into the mix.

Emily is a six year girl with a variant form of AT (ataxia telangiectasia, an inherited neurodegenerative disease) who is admitted to House’s team after she develops a nosebleed and breathing difficulties while riding on a merry-go-round. Her mother Elizabeth, a geneticist and expert on AT, also joins the team, whether they like it or not. The initial diagnostic possibilities include a worsening of the AT or head trauma, but her mother rules them both out. Park suggests Wegener’s granulomatosis and Elizabeth agrees that is a possibility, so an MRI is arranged (AT patients have a decreased ability to repair broken DNA strands, so ionizing radiation such as x-rays are avoided whenever possible as they run the risk of damaging DNA). The study shows no signs of Wegener’s, but while undergoing the MRI, Emily develops cold and blue hands and feet. Emily’s circulation is restored and the new differential diagnosis includes primary Raynaud’s disease or Raynaud’s secondary to lupus. Emily’s mother doesn’t like any of these and instead blames heavy metal poisoning from her estranged husband’s new apartment. While she goes to search his apartment, Chase and Adams decide to search hers. They find evidence that Elizabeth has been giving Emily Lex-2, an experimental antibiotic thought to help patients with AT. Unfortunately, the antibiotic has also been tied to renal failure, and now there’s concern that may be what is ailing Emily.

Luckily, an ultrasound of the kidneys is fine, but then Emily develops chest pain and starts to cough up blood. Pneumonia is discussed, as is a pulmonary embolus (a blood clot that blocks part of the lungs(. An MRI of the lungs shows no evidence of any clot. However, Chase notices scleral icterus – yellow eyes – a sign of jaundice and deduces that Emily is now in liver failure. Further studies show she has a blocked hepatic vein (large veins in the liver). Diagnostic possibilities include polycythemia vera (the blood is thickened with too many red blood cells), a connective tissue disease (another name for an autoimmune disease), or advanced Lyme disease. The team decides that the Lyme is the most likely cause — it had been held in check by the experimental antibiotic Elizabeth was giving her, but flared up when the antibiotic was stopped. A lumbar puncture is obtained to confirm the diagnosis, but Emily suffers a stroke after the procedure. The differential diagnosis now includes a fungal infection or a hematological malignancy (cancer of the blood forming cells, like leukemia or lyphoma). Then Chase realizes Emily has an atrial myxoma, a tumor of the heart. Little pieces of this tumor are breaking off and have been causing all her symptoms (Raynauds, obstructed hepatic vein, stroke, pulmonary blockage). Surgery removes the tumor, and Emily is back to normal (her normal, that is).

As always, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

The chest MRI may not have shown a clot, but it should still have shown a blockage, or at least evidence of a recent blockage, especially given the severe symptoms Emily was having.

A normal renal ultrasound does not rule out renal failure. Blood tests and urine tests tell you a lot more about what’s going on in the kidneys.

I can see a shedding right atrial tumor causing blockages in the pulmonary circulation, but how is it going to get all its little clotty pieces into the systemic circulation when they have to travel through the lungs capillary beds first, which act as a filter. An ASD or VSD wouldn’t explain it, because that would cause a left-to-right shunt.

Emily doesn’t seem to be showing many signs of AT – which of course they explained away as “Atypical AT” but she wasn’t showing any signs of the condition at all.

I know it was a pathos thing, but I would be leery of an oncologist with as poor a grasp of statistics as Wilson. Trade a 25% chance of death for a 33% chance of death? Sure! Sign me up!

I like how Wilson’s blood counts miraculously improved overnight. (And how House doesn’t seem to believe in isolation or neutropenic precautions).

Foreman should never have allowed Emily’s mother onto the case. Her objectivity was compromised — demonstrably so with the discovery she was dosing her daughter with Lex-2 — and her alleged expertise added nothing; seriously, she said “no” a lot and never contributed anything constructive.

The medical mystery was fairly interesting, though the AT aspect only contributed slightly to the medical aspect of the show (the “no x-ray” part; the AT did contribute majorly to the pathos aspect of the show). I give it a B+. The final solution was modestly succesful; it explained most of her symptoms — though a murmur probably should have been found on a good physical exam. I give it a C+. The medicine overall was average and earns a C (which still makes it better than most soap opera heavy episodes). The soap opera was good and heartbreaking. Both the Wilson/House aspect and the knows-she’s-dying-before-her-time little girl aspect. I give it an A.

The review of the previous episode of House
A list of all prior House reviews

Another episode of Fringe, more Cortexiphan Kids (haven’t they all died by now?) and another change to the universal status quo

The Plot: Just as the Fringe Teams from both universes are meeting to discuss Walter’s thoughts about David Robert Jones’ master plan, a series of twenty-seven earthquakes occur across the world – both worlds, actually – at precisely the same time. Walter determines that Jones has somehow set off these earthquakes to adjust the underlying frequencies of both universes to bring them together in an attempt to recreate the Big Bang. The team suspects that he’s using amphilicite, but they quickly discover he’s actually using some of the children dosed with Cortexiphan by Walter years ago. They capture one of the Cortexiphan Kids (this sounds like a Saturday morning cartoon about crime solving kids sponsored by a pharmaceutical company) and learn that Jones has told them they are fighting a war against the other universe. With only an hour left before the next, and cataclysmic, series of earthquakes, the teams decide their only option is to shut down The Machine and separate the universes. Everyone says their goodbye to their counterpart – Peter stays in our universe and Lincoln stays in theirs – and the machine is stopped and the bridge between the two universes disappears.

1. The Easy Way Out
Early in the episode, Olivia says the only option is to destroy the bridge. Certainly there are plenty of other options. Just off the top of my head: kill Jones, kill or otherwise stop the Cortexiphan Kids, or do something to increase the integrity of the universe. Shutting down The Machine is the easiest option, but hardly the only one.

2. Needs A Band-Aid
Why, once the bridge is destroyed, would the other universe no longer be in danger from the Fringe events they suffered since Walter’s original breach? (Other than the writers trying to soften the blow of all but abandoning them.)

3. Geocentrism For The Win
Apparently Ptolemy was right, and the Earth is the center of the universe(s).

4. Common Sense
With all the issues with the Cortexiphan kids in the past, you’d think they’d be kept under surveillance. Especially since we’ve learned Jones has been playing with the stuff..

5. No Bridge, But Other Fords Remain
It’s not like Jones has ever needed the bridge to cross over (though it may have helped the Cortexiphan Kids in their part).

6. A Surefire Money Maker
If ever end up in the world of Fringe, I’m going to invest in empty warehouses.

7. Alternotes
No rainbows.

The re-separation of the Universes was well done, but the rest of the episode was just OK. The Fringe Doomsday Clock remains at 11:54.

This week’s Fringe cipher was: ALIVE.
A list of all previous Fringe reviews is available here.
Karl, as always, has more to add.

There’s so much wrong in this scene from Blackhawks #7, let’s just hit the highlights:

Problem #1: Electrical shocks don’t cause a heart attack, though they can can cause a cardiac arrest, which is a different thing entirely.

A heart attack is caused when one of the tiny blood vessels that supply the heart muscle with blood gets blocked and some of the heart dies. It’s what I call a “plumbing problem.” On the other hand, a cardiac arrest occurs when the heart stops beating because there is a problem with the heart rhythm. I refer to this as an “electrical problem.” Strong electrical shocks can override or damage the heart’s intrinsic rhythm, leading to a cardiac arrest. So a shock can affect the electrical system. Makes sense. It also makes sense that electrical shocks would not affect the plumbing.

Problem #2: You can’t shock a flatline back into rhythm, which is just what Lincoln is suggesting here. Despite what you see in such cinematic masterpieces as Flatliners, you can’t just turn the heart on and off like flipping a light switch. Once the electrical system is off, it’s completely off — and you need CPR and medication (and a tremendous amount of skill and luck) to get it started again, not another shock.

Just for the sake of argument, let’s say the bullets just shocked people into and out of ventricular fibrillate or another nasty heart rhythm instead of actually stopping the heart, would that work better? Not really. Once again, despite what you see on TV and in the movies, getting people out of v-fib (or other fatal arrythmias) and back into a normal rhythm is a dicey situation at best. It’s not guaranteed to work, and more often than not, it fails. Overall survivability for a cardiac arrest, even with treatment, is less than 7%. Not quite how I’d define “non-lethal.”

A nice hopefully-we’ll-never-see-this-again scene from an old time Little Angel comic.

House continues the decline started last episode.

Lue, an eight year old Hmong boy dreams of being choked and wakes up unable to breathe. He is taken to the ER in acute respiratory distress (but apparently gets better) and ends up admitted to House’s service for evaluation. House tells the team that SUNDS (sudden nocturnal unexpected death syndrome) is more commonly seen in Hmong immigrants, but cautions the team that SUNDS is the easy way out — he wants a real diagnosis. Initial thoughts include ventricular fibrillation due to catecholamine (chemicals like adrenalin) release from a nightmare, obstructive sleep apnea, lung damage from inhaled toxins, or an upper respiratory infection (URI). House starts Lue on antibiotics for pneumonia and has the team search his house for toxins. The search turns up no toxins, but they do find a ritually slaughtered pig in Lue’s bedroom – a Hmong exorcism rite carried out by his grandfather who believes that Lue is possessed by a demon.

About this time, Lue slips into ventricular tachycardia (v-tach, a potentially fatal arrhythmia), but is brought back to a normal heart rhythm by defibrillation and medication. Bearing in mind the new cardiac symptoms — plus the team has learned Lue’s father is in prison for murder — the differential diagnosis now includes PTSD (post traumatic stress disorder), a malignant arrhythmia (a term for a potentially fatal arrhythmia), or acute pericarditis (inflammation of the membranous sac surrounding the heart). House favors the latter and has the team check an echocardiogram, which is normal. Lue starts to complain of abdominal pain, so the team quickly ultrasounds his belly and finds no evidence of obstruction, but does find constipation. Chase now suspects Hashimoto’s thyroiditis so wants a thyroid biopsy. Lue refuses and shouts in Hmong, a language he doesn’t know, before suffering a seizure. These neurological symptoms have the team again changing their differential diagnosis, which now contains scleroderma and Rasmussen’s encephalitis (an inflammatory disease of the brain in children). An MRI is checked, but is normal. Lue again suffers a bad dream of someone choking him, but this time he awakens with bruises on his neck. The team now considers the diagnoses of a coagulopathy (easy bleeding because of problems clotting blood), anemia, vitamin C deficiency, or leukemia. House suggests liver failure, which the team takes to mean hepatic fibrosis. A liver biopsy is checked, but is negative.

Adams and Taub walk in to check on Lue, and find him levitating in bed, briefly, his grandfather beside him. They insist to House and the rest of the team that the levitation was real, but the others suggests muscle spasm, tetanus, or hypocalcemia (low blood calcium) as possibilities. House favors the hypocalcemia suggestion and wants the team to “pump up” Lue’s electrolytes and start him on a beta-blocker. Meanwhile, Lue’s mother is coming around to his grandfather’s way of thinking. She wants to perform another Hmong exorcism. Foreman convinces her to wait twenty-four hours, but when Lue becomes unresponsive, she and the grandfather proceed with the ceremony. While the ceremony proceeds in Lue’s room, the team goes through other possible diagnoses. Brugada and Long QT syndrome (inherited heart rhythm disorder) tests are all negative. Carotid aneurysms are suggested, but dismissed. Kawasaki’s disease is suggested and Adams immediately wants to proceed with cardiopulmonary bypass. House mentions that he thinks Lue has a PDA (patent ductus arteriosis). The ductus is a bypass in the heart important for the fetal circulation, but it should close shortly after birth.) that was infected and is causing the symptoms. After a heated discussion with the team, he allows them only to treat their suspicion – Kawasaki’s – but after Lue starts crashing, Adams slips him ibuprofen, the treatment for PDA. Lue recovers, but his mother and grandfather credit the religious ceremony, not any medical treatment.

This week demonstrated some of the most inept and nonsensical medicine I have seen yet on House. For pretty much every diagnosis, just ask: “Do the symptoms fit, at all?” The likely answer is NO. Rather than waste your bandwidth and mine by repeating that over and over, I’ll just hit the highlights (lowlights). As always, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

A previously normal eight-year child suddenly begins to have PDA symptoms. His mother never noticed difficulty breathing before – it just started now, eight years after developing the PDA? Maybe that was the mysterious “PSA infection” House was referring to which was supposedly treated by the antibiotics – yet the patient’s symptoms worsened after the antibiotics.
A PDA severe enough to cause symptoms at rest and no murmurs on exam, or abnormal echocardiogram? (admittedly, a standard echocardiogram is not the best way to diagnose a PDA, but there should have been signs in one that severe, particularly one that’s “infected”).
I’ll agree that a PDA can cause some shortness of breath or respiratory distress, but that’s different than a sensation of being choked. Furthermore, how does the PDA explain the seizure, speaking in tongues, or bruising.
As a side note, another repeat final diagnosis. Seen previously in episode #513, “Big Baby“

Right after Adams suggests URI, House has her start IV antibiotics for pneumonia – which is a lower respiratory disease.

Exactly what evidence for Kawaski’s is there? Where was the fever, rash, conjunctivitis, induration of the skin on the extremities, mucosal erythema, and cervical lymphadenopathy?

See if you can spot the theme:
How about some actual evidence for liver failure before poking a hole in the liver.
How about some actual evidence for Hashimotos before poking a hole in the thyroid.
How about some actual evidence for Kawasaki’s before poking a hole in the heart. (Stopped before they got this far, but they did suggest it and start the paperwork)

How about checking for low calcium before treating it?

I can find no evidence that beta-blockers are indicated for hypocalcemia.

The medical mystery was interesting, and maintained interest throughout the episode. I give it an A-. The final solution wasn’t great. The final diagnosis didn’t fit well at all from both a time course and a symptom point of view, plus — for the second week in a row — it was a retread. I give it a D-. I realize they were playing a faith versus medicine angle this week, which is a shame, because the medicine was horrible. The team leapt from diagnosis to diagnosis, without logic, and abandoning previous attempts at the drop of a hat. It earns a weak D-. They rushed to risky procedures with no good reasons or proof. The soap opera was fair. The House and Dominika scenes were good, but the House-tells-the-team-what-they’re-secretly-thinking has been overplayed this season. I give it a C+.

The review of the previous episode of House
A list of all prior House reviews

Another low scoring week; that makes two in a row. This week: Markeb, Ryan, SLC, and Taversham all tie for the lead with 5 points.

Overall, James H retains the lead with 77 points, gaining a point over Dr. R who remains in second with 75 points. brism19 remains in third with 69 points. rileyjo, Harvey, and KingKha are tied for fourth with 64 points. If you have 53 points or more, you are in the top 10%.

Click here to see the full scoreboard.

An enjoyably dark episode of Fringe featuring a depressing possible future.

The Plot: 2036 is a dystopic world, controlled by the Observers, who’ve come from their dead-end future to take over our world. There are a number of resistance fighters, but they are hunted by humans who are loyal to the Observers. The Fringe Team is still around, but no longer investigating strange crimes, instead they are in charge of human-on-human crimes.

Etta is a member of Fringe, but also a member of the resistance. One of her contacts has managed to discover Walter Bishop, encased in Amber for the past twenty years, and hands it over to her. She works with Simon, another Fringe agent and resistance member, to free Walter from the Amber. They want him to complete an anti-Observer machine he was working on. Unfortunately, he’s taken some significant brain damage in the process (well, more). Luckily, Nina Sharp is still alive and also a member of the resistance and she hooks them up with the missing pieces of Walter’s brain (seen in episode #210 “Grey Matters“) which they use to cure his brain damage. In fact, his insanity seems to be cured as well and he’s back to being 100% Walter, who’s kind of an ass, really. Simon, Etta, and Simon then free the two remaining original Fringe members, Astrid and Peter, but Simon ends up frozen in Amber himself. William Bell is also trapped in Amber, but Walter intentionally does not free him — though he does cut his hand off (for security devices, one assumes). As the episode ends, Peter learns that Etta is his daughter who he hasn’t seen in twenty years.

1. My Name is Inigo Montoya
I’m a big fan of dystopian future stories, so this earns some bonus points right there, even without the Star Wars allusions. In parts, this reminded me of Days of Future Past (one of the greatest X-Men stories ever).

2. In Your Satin Tights, Fighting For Your Rights
Etta…candy?

3. Glow In The Dark
Just like Simon says (see what I did there?), neurotrophins are growth factors — hormones that increase cellular reproduction, differentiation, and growth — of neurological tissue. Generally they’re not neon slime green, though.

4. Boom
So anti-matter wipes an entire building off the map, just like that?

5. What About The Other Guys?
Did the Observers only pop up in our world, or the other universe too? Have they ever appeared in the alternate universe?

A solid episode, except that it’s just kind of hanging there, like a dangling participle. Hopefully it will tie into the grand storyline better at some point, otherwise it was an interesting experiment. Still, I liked it enough to grant the Fringe Doomsday Clock another minute of reprieve.

This week’s Fringe cipher was: QUAKE.
A list of all previous Fringe reviews is available here.
Karl, as always, has more to add.

from Batman #479

As a side note, Gordon’s heart attack was the theme of a PSA from the American Heart Association

While you may be able to jump start a car battery, you can’t jump start the human heart — it doesn’t work that way.

Defibrillation works by applying a controlled electrical shock to break a bad heart rhythm (such as ventricular fibrillation) and allow the heart’s natural normal rhythm to reassert itself. If anything, defibrillation is the opposite of a jump start because you actually shut down the heart rhythm for a split second. It only works if there is an arrhythmia (bad heart rhythm) present to affect. If there’s no heart rhythm at all (i.e. a flatline), then there’s no way that defibrillation can work.

As a side note, an automotive battery is probably not the best source to use for shocking the heart because the batteries tend to be low voltage and high amperage, whereas defibrillation (with a direct current), requires fairly high voltage (hundreds to a thousand volts) and low amperage.

Other notes:
1. I really don’t want to know where she attached those jumper cables.
2. I thought Batman’s costume was supposed to be insulated.

After last week’s improvement — medically, at least — House takes a turn for the worse this week.

Henry is a 35 year old who is admitted to House’s service after he is discovered crying blood. The team’s initial thoughts are lymphocytosis (a high white blood cell count — which is more of a symptom than a diagnosis) or a cavernous sinus thrombosis. Further blood work up is done and is normal, and a CT shows no evidence of a sinus thrombosis.

Henry is very guarded about his girlfriend Amy, and Adams suspects he has no girlfriend, but is instead secretly a junkie. A search of his apartment reveals no evidence of drug abuse, but they do find a very lifelike sex doll – “Amy.” When Henry starts running a fever, the team rethinks their diagnoses. Adams thinks there are neurological issues (which, if they exist, seem more psychological than neurological to me), but Chase thinks there are no neurological concerns; Henry is just weird. House suspects a bacterial infection caught from using (and reusing) Amy, but she is clean. The team does notice a strange swelling in her side and obtain a CT, which shows an irregular air-filled area. Chase suspects this may be Clostridium (Clostridium perfringens, a bacteria which causes gas gangrene, and food poisoning), but once again, the test is normal. A short time later, Henry collapses, wheezing. From the description, it sounds like he has pulmonary edema (fluid in the lungs). The team now considers heart failure due to anemia, DIC (disseminated intravascular coagulation), or lung disease caused by inhaling silicone particles. House agrees with the last option and has the patient started on plasmapheresis.

That night, Henry starts hallucinating. On exam, the team notices some right upper quadrant abdominal distention and also deduces he has liver failure. The differential diagnosis now consists of vasculitis (blood vessel inflammation) or hepatic fibrosis (with secondary pulmonary A/V shunts). House starts the patient on steroids.

Henry starts to get worse. He has light sensitivity, vomiting, and a stiff neck. Adams tells him she thinks he has meningitis. The team debates the possible cause of the meningitis. Cancer is discussed but discarded. An amebic cause is brought up and almost discarded until Chase mentions finding a Neti pot in the patient’s apartment. Instead of using the recommended distilled water for the pot, the patient had been using tap water — infected tap water — and given himself an amebic meningitis by pouring infected water up his nose (likely Naegleria, since that is the amoeba recently in the news associated with Neti pots — it’s also been used as a diagnosis before, in the two-parter where Foreman ended up in isolation).

I don’t have much commentary this week, as the medicine was more superficial and slapdash than usual. As always, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

How is plasmapheresis going to improved the deposition of inhaled silicone particles in the lungs?

So…why was he crying blood again? Was it from the poor clotting due to the liver failure — which somehow was bad enough to cause bleeding, but not bad enough to be detected until halfway through the episode?

Bleeding from the eyes is not a symptom of cavernous sinus thrombosis. You know what is? A dozen different things Henry didn’t have.

Still, this diagnosis was miles ahead of the diabetes suggestion. Even if the retina are friable, the eye is a sealed system and you’re not going to cry blood. You don’t cry vitreous humor, do you?

No isolation for a patient with meningitis?

So a needle biopsy was out of the question?

The team is so advanced in medicine that they can find any zebra, but don’t recognize a Neti pot? They wouldn’t last one day in a primary care clinic. Neti pots are not some rare only-used-by-alternative-weirdos device. They are sold at Walgreens, for heaven’s sake. I’d say at least a third of my patients use Neti pots or similar nasal rinsing devices.

The medical mystery started out strong, but was all but abandoned by the end. I give it a A- for at least trying something new. The final solution wasn’t great. The symptoms and timecourse didn’t fit. It was also a retread — and the first time was so much better. I give it a D+. The overall medicine lacked any coherent strategy or logic. I give it a C-. The soap opera was unimpressive. House and Dominika had some good scenes, but for everyone else it was “been there, got the t-shirt“. (Seriously, enough with House fixating on everyone’s relationships.) I give it a B-.

The review of the previous episode of House
A list of all prior House reviews

A low scoring week; lots of goose eggs. Hogan wins this week with 12 points. Numerous others tie for second with 4 points.

Overall, there is no change in the top five (six, actually): James H retains the lead with 76 points with Dr. R a single point behind with 5 points. brism19 remains in third with 69 points. rileyjo is fourth with 64 points and Harvey and KingKha are tied for fifth with 63 points. If you have 53 points or more, you are in the top 10%.

Click here to see the full scoreboard.

Apologies for the delay in getting the review up, but I was out of town and then running (and then recovering from) the St Louis Go! Marathon Relay.

An enjoyable episode of Fringe. The problem of the week wasn’t solved, but the über-plot was advanced nicely.

The Plot: Two corporate officers suddenly die from injuries consistent with a plane crash – only they’re in the middle of a boardroom meeting at the time. Interestingly enough, their doubles in the other universe had just died in a plane crash. Walter heads over to the alternate universe, where he meets with Fauxlivia and Agent Lee to investigate. He discovers that the “vibrations” of the victims – on both universes – was the same, when they should be different. A second similar episode happens: a woman in our universe dies when the cab she was riding in goes off a bridge, and her double in the other universe dies of car-crash related injuries and drowning – in the middle of a pet store. This time, the Fringe Team is able to find the device used to sync the universes and discover that it contains amphilicite, implicating David Robert Jones.

Speaking of Jones, he meets with Colonel Broyles and we learn that Broyles has been acting as a traitor to get life saving treatments for his sick son (last seen in episode #317 “The Abducted“). Jones gives Broyles a device to attach to The Machine that links the universes, but in the end Colonel Broyles surrenders himself to the Broyles of our universe.

Walter concludes the episode by telling Olivia and Peter that he has discovered that Jones is trying to collapse both universes.

1. My Name is Inigo Montoya
This was the first time I’ve noticed that the handprint seen in the opening credits has six fingers.

2. Refrigerator Logic
If it weren’t for the boardroom ceiling, was the boss suddenly going to fly up to 30,000 feet before crashing back to earth? As for the pet shop lady, that was a pretty quick drowning.

3. Alternotes
No black boxes on aircraft. There are satellite recordings of the pilot conversations (though that just covers the cockpit voice recorder, not the box with all the flight telemetry).
Domesticated badgers as pets.
No Sherlock Holmes.
The sport of hitball.
The funeral scene really brought out the point that the alternate Fringe is a military unit, with everyone in dress uniforms and the flag draped coffin.

I enjoyed this episode. It felt slight — from the fringe science/mystery point of view, but there were some genuinely good character moments — enough to grant the Fringe Doomsday Clock a one-minute reprieve.

This week’s Fringe cipher was: SIMON.
A list of all previous Fringe reviews is available here.
Karl, as always, has more to add.

One last Dr. Dan Dazzler story (for now) — courtesy of Ben Casey #5 (Dell Comics April 1963) — as the family and I head to C2E2, and then drive back to St. Louis this evening so I can make it to the Go! St. Louis Marathon on Sunday morning (I learned from last year, and will only be running in the marathon relay with some friends this year).

Click on any of the images for the full story

Here’s the third Dr. Dan Dazzler, intrepid intern (or “interne” — the preferred spelling back then, thankfully lost in the mists of time). This story comes courtesy of Ben Casey #4 (Dell Comics, February 1963)

Click on any of the images for the full story

“Rumble…” is the second Dr. Dan Dazzler story; it can be found in Ben Casey #3 (Dell, December 1962).

Click on any of the images for the full story

I’m on vacation for the next several days, heading up to Chicago with the family, sightseeing, hanging with friends, and then settling in for a day or two at C2E2.

In the meantime, I’m going to go back and highlight one of my favorites: Dr. Dan Dazzler, intrepid intern. Dan was the back-up comic that appeared in Dell’s Ben Casey comics, and was — frankly — much better than than the main comic. For the rest of the week, enjoy a Dan Dazzler, MD story every day. Just click on one of the pages to begin.

Click on any of the images for the full story

Medically, this felt like a return to classic House (with classic errors, of course) — but the mystery and solution were better than most. On the other hand, I did not care for the soap opera storylines this week.

Bobby Hatcher is a 22 year old minor league hockey enforcer who starts coughing up blood (hemoptysis) and collapses on the ice in the middle of the game. He is admitted to House’s service for evaluation. Taub suggests trauma initially, but the ER work-up was negative. Chase and Adams suggests sarcoidosis and psittacosis (patient is a duck hunter), and Taub now suggests dental bleeding or an esophageal tear. House elects to test all the theories — he orders a chest CT, sputum culture, serology, and a stool blood test. The CT is negative for sarcoid but shows splenomegaly (an enlarged spleen). The differential now includes a DVT (blood clot) or leukemia. Once again, House decides to test both diagnoses and orders an ultrasound and a blood count. While drawing the blood, Taub notices that Hatcher has gynecomastia (enlarged breasts in men). With this new information, the differential diagnosis now consists of liver failure, alcoholism, hemochromatosis, leptospirosis, or steroid use. House order antibody titers for the leptospirosis and sends Park and Chase to check out Hatcher’s locker and house for signs of steroid use or alcoholism. The search turns up no evidence of steroids or alcohol, but Park does find that one of Hatcher’s teammates is on Ganciclovir, an antiviral drug, which she takes as a sign he had infectious mononucleosis (i.e. “mono”) — could Hatcher have mono as well?

Returning to check on Hatcher, Taub finds him in the corner, crying, curled in a fetal position. Is this a sign of depression — and is it a symptom or not? Taub suspects it is a sign of traumatic encephalopathy, but the rest of the team demurs. Taub wants a brain MRI, but House just orders a psychiatric evaluation, which is normal. Just when it looks like Hatcher is going to be discharged, he suffers a sudden right ophthalmoplegia (inability to move the right eye). The new differential consists of neurosyphilis and microscopic polyangiitis (an inflammation of small blood vessels). Chase suggests testing for the polyarteritis, but House decides to go ahead and treat with plasmapheresis. As the treatment progresses, Hatcher develops a paralysis of both of his arms. The team now suggests he may have Lyme disease, ALS (amyotrophic lateral sclerosis, i.e. Lou Gherig’s disease), or botulism (from the Botox he had injected to treat a muscle spasm). House decides to start the patient on antitoxin for the botulism, even without a positive test. Despite treatment, Hatcher’s condition worsens and he develops a complete paralysis. House now admits he is now looking for longshot diagnoses (as opposed to their normal common diagnoses, I guess) and the team comes up with polio, MLD (metachromatic leukodystrophy), and prion disease. Despite the risks, House elects to perform a brain biopsy to test for the latter. In a conversation a short time later with House, Taub has his own Eureka! moment this week and realizes that Hatcher has mono after all, complicated with Miller-Fisher syndrome (a rare type of paralysis, seen after viral illnesses). The plasmapheresis did actually improve his symptoms, but the results were delayed.

As usual, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

They never tested for mono. As Park explained, it fit almost every symptom, there was a likely history of exposure — but yet was never mentioned again until the very end. They never ran a simple monospot or similar test.

Right after he was found crying in the corner, Adams mentioned that, otherwise, he was responding to treatment. What treatment? All they had done to that point was run tests, no treatment had been rendered.

There were an abundance of tests that were ordered this week, but the results were never given and they were never discussed again (e.g. the ultrasound, serology, sputum culture, stool tests, ultrasound, leptospirosis antibodies). More specifically, the CBC ordered way back in the first 20 minutes should have shown mono.

Ganciclovir is approved for treatment of CMV, not EBV. That being said, there is good evidence it works on EBV and some studies have been run on mono patients. (Still, if I saw someone was on ganciclovir, I wouldn’t immediately conclude it was for mono).

So it’s a bilateral descending paralysis — except that it only affects one eye?

Other than trauma, none of Taub’s initial diagnoses explain hemoptysis. Bleeding from the mouth, yes, but hemoptysis, no.
Stool could be positive for blood with hemoptysis, too, if he had swallowed some of the bloody sputum.

Once again, lack of a good physical exam delayed the patient’s treatment unnecessarily. The gynecomastia should have been found earlier, and dental bleeding could easily have been ruled out.

ANCA is not always positive in microscopic polyangiitis. It’s only 80%.

The team had a much longer differential for splenomegaly last week — yet none of this week’s suggestions were on the list (or any of last week’s causes on this week’s list). A little consistency please (and both were missing one of the most common causes: mono, of course).

The team seems to use plasmapheresis at least a dozen times a season, yet this is the first time they’ve ever mentioned a possible side effect.

It sure is easy to walk right into the OR in Princeton Plainsboro. I’ve never seen ORs so easily accessible — there are usually multiple automatic doors and hallways to maneuver through – partly to prevent people from barging in, just like Taub did.

The medical mystery was was good this week, it seemed like a return to more classic House. I give it an A-. The final solution fit — mostly. I give it a B+. The medicine was way too circuitous, and I can’t believe they never tested for such an obvious answer, and one they themselves admitted was obvious. I give it a C+. The soap opera was painful. The Wilson scenes were either strangely abrupt or a cruel trick, and neither was fun to watch. Chase and Taub’s storylines fared better, but still I can only give the soap opera a C-.

The review of the previous episode of House
A list of all prior House reviews

Some nice scores this week. yigitoo7 wins this week with 21 points. squeaky is second with 12 points and Indyfrick is in third with 19 points.

Overall, James H retains the lead with 75 points with Dr. R a single point behind with 74 points. brism19 remains in third with 68 points. rileyjo is fourth with 63 points and Harvey and KingKha move into a tie for fifth with 62 points. If you have 52 points or more, you are in the top 10%.

Click here to see the full scoreboard.

A solid episode, nothing spectacular, but it’s nice to see the alternate universe again.

The Plot: With nothing happening in our universe, Agent Lee volunteers to debrief the other universe’s Fringe Team on David Robert Jones. He finds himself in the middle of a serial killer investigation over there, and he is the first to recognize that the killer is a shapeshifter, similar to the original “holes in the hard palate” shifters. He then assists the other Fringe Team in capturing the killer.

Agent Lee questions the shapeshifter, hoping to learn more about Jones, but the shifter is unwilling to divulge any secrets, other than that he was the prototype shapeshifter, and felt to be a disappointment by Jones. After a failed sniper attack on the shifter, which unfortunately kills Captain Lee, Agent Lee manages to convince the shifter to help the Fringe Team. Ultimately, they capture Meana (i.e. alterna-Nina) and gain access to many of Jones’ secrets. The shapeshifter is handed over to Walter to see is he can help, and Agent Lee stays to offers Fauxlivia whatever assistance she may need.

1. “I Shall Become An Insect!”
No Batman, just Mantis? (I guess a bug flew in his window over there.) Hopefully not this M.A.N.T.I.S. (or this Mantis).
Actually, we know that Batman comics existed in the other universe because the “Death of Batman” was one of the alternate comic books seen on Peter’s wall (playing off the “Death of Superman” comic in ours).

2. Snipe Hunt
The sniper wasn’t using any sort of bracing or support for his rifle? No wonder he missed.

3. Alterna-notes
Millard Fillmore on currency.
Moving pictures in Newspapers – that still work even eight years later.
The USSR still exists.

A serviceable episode with a little bit of a HR Giger twist. Nothing outstanding, but certainly enjoyable. The Fringe Doomsday Clock regains a minute and drops back to 11:56

This week’s Fringe cipher was: DREAM.
A list of all previous Fringe reviews is available here.
As always, Karl has more to say over at his blog.

First, a hip, young Head Mirror Theater from Falling in Love #120 (February 1971). Here we have a doctor who wears his mirror even while engaged in casual conversation, and his friend, who sees nothing wrong with smoking in the doctor’s office:

Next is a scene from Brit #1 where Brit is being apprasied of a new threat: a new virus nicknamed “Blue Idol.”

The phrase they are looking for is “uniformly fatal,” no “unilaterally.” It makes a little sense they way it was written — it is an engineered virus after all, but still, unilateral doesn’t quite fit (especially when you know how close they came to the actual phrase).

Trying to mirror some current events (relatively current, anyway), House delivers an episode that in underwhelmingly average.

Brant, a young soldier being escorted by the military police, has a seizure and ends up admitted to House’s service. A previous head CT and EEG were normal. The initial diagnosis includes typhus (caused by lice; discarded because the patient is bald), leishmaniasis, or factitious disease (the patient is faking it). Park and Adams try to fool the patient with a placebo — and it seems to work — but then he develops abdominal pain and bruising. The differential diagnosis now includes esophageal rupture with a subsequent compartment syndrome, a ruptured abdominal aortic aneurysm, or pancreatitis caused by a gallstone. The team proceeds with an abdominal ultrasound which shows no gallbladder problems, but does reveal an enlarged spleen. About this time, Brant starts bleeding everywhere and Chase announces the patient is sequestering platelets in his spleen and he’ll need to have his spleen squeezed in the OR to release these platelets. The surgery goes well and the patient begins to improve, but Chase notices the spleen is abnormally lumpy.

Given these new symptoms, the differential consists of extramedullary hematopoesis (the production of blood cells outside the outside of the bone marrow), tuberculosis, brucellosis, lymphoma, or sarcoidosis. The last seems the most likely, so the team starts the patient on steroids. His symptoms don’t improve, and now he complains of foot pain and is found to have a cyanotic (blue from lack of blood flow/oxygen) foot. A cholsterol embolism and methemoglobinemia are suggested, but the team ultimately settles on DIC (disseminated intravascular coagulation) due to Bernard Soulier syndrome. The patient is started on Heparin. Later, House talks to the patient and learns his hair turned gray in three days. This makes House suspicious of an autoimmune disorder, particularly Grave’s disease. He wants to start him on antithyroid medication, but the team ignores his suggestion.

Brant takes another turn for the worse. He is now running a high fever and has a high white count (a sign of infection). Legionnaire’s disease, dengue, and malaria are all discussed, with House suspecting malaria. The patient is started on anti-malarial medication without success. He continues to have a high fever and high white count, only now his kidneys are failing as well. Gonorrhea is suggested, but House realizes the patient has typhus, not from his own hair (which, because he is bald, is why the diagnosis was abandoned initially), but from the animal skin furniture he used to sit on overseas.

In the B plot, the team has decided that House is sick. A tumor, dietary problems, refsum disease, and serotonin syndrome are all mentioned, but in the end, they settle on hepatic encephalopathy (brain damage caused by a malfunctioning liver) from his Vicodin use (in addition to a narcotic, Vicodin contains acetaminophen – i.e. Tylenol – which in high doses can be toxic to the liver). In the end, House was never sick, but just pulling one over on the team.

I found tonight’s differential diagnoses — both of the patient and House — more maddeningly illogical and superficial than usual. For an example, here’s a good list of differential diagnoses to consider when suspecting typhus. How many of them were actively pursued, let alone mentioned?

As usual, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

I realize it’s been quite a while since I’ve done a surgical rotation, but it was my understanding that the treatment for symptomatic splenic sequestration was a splenectomy, not just “squeezing the spleen.” If you leave the spleen in there, the problem is just going to recur.
If Chase noticed the abnormally lumpy spleen while performing surgery, why not take a second and get a biopsy?

A ruptured esophagus is going to cause compartment syndrome in the thigh?

I don’t seen any indication in the literature that DIC is associated with Bernard Soulier syndrome. And it didn’t bother the team that they were diagnosing two different causes for the patient’s low platelets?
Honestly, I was confused by the resolution of the cyanotic foot. They seemed to just brush it under the table. Was it caused by a clot/embolus that resolved, or a vasospasm, or something else? Park seemed to suggest both a vasospam and clot, but then the patient was started on heparin, an anticlotting agent. (And none of it fits Bernard Soulier)

Methemoglobinemia would be systemic, not just one foot.

Extramedullary hematopoesis is going to cause an enlarged spleen? I guess it’s possible if so much blood is being produced that it’s clogging up the spleen, but that would have been easily visible on a standard and routine blood count.

Starting Graves treatment with potentially nasty antithyroid medication without performing the quick and easy confirmatory tests?

The medical mystery was slightly above average this week, but would a new onset seizure really be admitted to House’s service? That’s hardly an unusual symptom. I give it a C+. The final solution kinda fit, if you ignored symptoms that should have been there, and overlooked some ones that shouldn’t. It earns a C. The medicine was painfully illogical — they’re not looking for zebras, they’re looking for non-existant dinosaurs. I give it a D+. The soap opera was just OK. Once again, Chase is the one who comes closest to getting House, even more than Wilson. I give it a C.

The review of the previous episode of House
A list of all prior House reviews

A good week with most players scoring, many at least 5 points. CKW wins this week with 17 points. Williston is second with 13 points. Gola and Lin tie for third with 10 points.

Overall, there is little change in the top scores. James H retains the lead with 9 points with Dr. R a single point behind with 68 points. brism19 remains in third with 61 points. rileyjo moves into fourth with 58 points and nextsundayad returns to the leader board in fifth with 56 points. If you have 48 points or more, you are in the top 10%.

Click here to see the full scoreboard.

An episode that plays off a mid-first season episode, with even worse science than the first time.

The Plot: The episode starts off identically to episode 13 (”The Transformation“), from way back in season one, where a man starts to turn into a monster while on a plane flight. Unlike the original episode, this plane lands safely and the man doesn’t transform into a porcupine monster until he is being questioned by the TSA later.

Unsurprisingly, the Fringe team is called in. Agent Lee leads the team this time as Olivia is benched until the FBI can determine whether memory-rewritten Olivia would be safe in the field. Not that this stops her, she soon joins up with Lincoln and Peter when they investigate the house of Daniel Hicks, a known associate of the dead porcupine man. The house is dark and torn up, and Lincoln is mauled by Hicks – now a porcupine man – before he escapes.

Back at the lab, Walter suspects Lincoln has been infected with the virus, and hunts to find a cure. A strange tattoo is found on the original porcupine man’s arm, and discovering the meaning of it leads the team to a variety of website touting guided evolution and mutation. Walter also realizes that the project originated at Massive Dynamic, and discovers David Robert Jones had been in charge of it.

Monitoring Agent Lee, Walter discovers that it takes energy obtained from lipids to power the man-to-porcupine-man transformation, and makes the leap that the porcupine men must be raiding cosmetic surgeon’s offices for post-liposuction fat. Discovering that the porcupine men can also fly, the Fringe Team focuses on a high rise plastic surgery office and interrupt the porcupine man – and his girlfriend – during their robbery. The porcupine man is shot and the girlfriend captured, but she can give the team no new information.

1. “They Don’t So Much Fly As Plummet”
For a “standard” 70 kg human to fly, they would require a wingspan of 48 feet. That porcupine man sure looked heavier than 70 kg to me and would need a correspondingly larger wingspan (also remember that in higher animals — in this case birds and bats — wings take the place of the forelimbs because anatomically you need the pectoral muscles to be able to flap them.).

2. DNA, RNA…Can’t Be That Different
“Encoding foreign genomes with retroviral DNA” is going to be exceeding difficult, actually impossible, because by definition retroviruses are RNA viruses. They don’t have any DNA.

3. Viruses, Bacteria…Can’t Be That Different
Walter cured Lincoln’s viral infection by giving him penicillin, an antibacterial drug.

4. Seems Like Common Sense, But Then Again, This Is Fringe
Why hasn’t the Fringe team, or at least Nina Sharp, looked through the Massive Dynamic files to see which projects David Robert Jones worked on?

5. Hit Them While They’re Down
Can’t cure the intermediate stage? Wait for the mature virus? Now I can’t speak for virology per se, but in medicine, we often specifically target the immature stages of organisms because they tend to have less defenses and are easier to treat.

6. Must Be The Wheatgrass
Walter’s 80% chance of curing Agent Lee seems highly optimistic. There are thousands of viruses pathogenic to humans, and we can treat (and even then, not necessarily cure) about six of them.

7. Security Is Less Too
Surely there are more readily available sources of lipids than human medical waste? A butcher’s shop, maybe.

I’m not sure this episode was the best to use when Fringe is dwindling in viewers — it’s not exactly new viewer friendly. Chock full of bad science too — bad enough to advance the Fringe Doomsday Clock 1 minute to 11:57.

This week’s Fringe cipher was: FUTURE.
A list of all previous Fringe reviews is available here.
As always, Karl has more to say over at his blog.

Unlike the hospitals found in Gotham City and Metropolis, the list of hospitals seen in Marvel Comics’s version of New York City contains both fictional and real world hospitals. I’ve done my best to mark the real ones as such.

As mentioned on the other hospital lists, this is not a comprehensive list, just what I’ve run across in my last several months of comics reading (in this case, mostly classic and current Amazing Spider-Man, classic and current Daredevil, and the Punisher from Ennis onward)

Bellevue Hospital [Peter Parker the Spectacular Spider-Man #48, #52]¹
at least once referred to as Belleview Hospital [Daredevil #163]
Beth Israel Memorial Hospital [Marvel Knights Spider-Man #12]¹
City Hospital [Daredevil #164]
Columbia Presbyterian Hospital [Peter Parker the Spectacular Spider-Man #54]¹
County Hospital [Peter Parker: Spider-Man #45]
also referred to as just “County“
Forest Hills Hospital [Amazing Spider-Man #10]¹
Lenox Hill Hospital [Punisher; Ultimate Avengers]¹
Memorial Hospital [Daredevil #216]³
Midtown General Hospital [Fantastic Four #292]
Municipal Hospital [Daredevil #1; Peter Parker: Spider-Man #57]
New York General [Fear Itself: Spider-Man]
New York Methodist Hospital [Marvel Knights Spider-Man #3]¹
NYU Medical Center [Amazing Spider-Man vol. 2 #10]¹
St. Jude’s Hospital [Greenwich Village; Spectacular Spider-Man #1]
St. Mark’s Hospital [Queens; Spectacular Spider-Man #1]
St. Vincent’s Hospital [Punisher; Peter Parker, the Spectacular Spider-Man#131]^1,2
Veterans Hospital [57th St; Spectacular Spider-Man#18]

Also:
Night Nurse’s clinic [Brooklyn]

Just for fun, here’s the list I have of fictional New York City hospitals in the DC Universe:

Anderson Memorial Hospital [Spectre #6]
Saint Camillus [Fifty-Two #6]
Siegel-Baily General Hospital [Spectre #1]
also spelled Siegel-Bailey General Hospital. Assuming it’s named after Jerry Siegel and Bernard Baily, the creators of the Spectre, the first spelling is correct.

Notes:
1. Real world hospital
2. Closed in 2010
3. There are multiple “so-and-so” Memorial Hospitals in New York, but no plain “Memorial Hospital”

Despite being a larger city than Gotham, Metropolis doesn’t seem to have as many hospitals — or maybe I haven’t read enough Superman comics. Like yesterday’s list of Gotham City hospitals, this is not meant to be all inclusive, just a list of the hospitals I’ve run across in the last few months while reading Superman comics.

As an aside, I’ve noticed that most comics with hospital scenes tend to not name the hospital — other than calling it “the hospital” (as in “Superman flew him to the hospital.”) There may also be an outside shot of an imposing building (though they usually look more like hotels than hospitals) with some portion of the letters o-s-p-i-t-a-l perched atop.

City Hospital [Superman #175]
Metro Hospital [Superman #270, #384]
Metropolis General Hospital [Superman: Strength #1, Superman Family #187]
Metropolis Hospital [Superman #186]
Swan-Klein Memorial Hospital [Superman #2, nü52]
also referred to as the Swann-Klein Medical Center [Superman #3, nü52]

Here’s a list of the hospitals found in Gotham City. This is by no means a complete list, just the ones I’ve stumbled across in my casual reading over the past couple of months. For most hospitals, I’ve included a comic or two that it’s been mentioned in — though probably not its first appearance — and occasionally an extra note.

Gotham City Hospital [Detective Comics #173]
I’m also assuming this is the hospital meant when plain “City Hospital” is mentioned.
Gotham Community Hospital [Batman #460]
Gotham County [Legends of the Dark Knight #200]
Gotham General [Legends of the Dark Knight #200, Batman #381]
Gotham Hospital [Brave and the Bold #100]
Gotham Medical Center [Batman: Contagion]
Gotham Memorial Hospital [DC Challenge #1]
Mercy General [Batman: Contagion]
Mercy Hospital [abandoned, Detective Comics #3, nü52]
Sacred Hands of Gotham Hospital [Batgirl #1, nü52]
St. Thomas’s [Legends of the Dark Knight #200]
West Mercy Hospital [Batgirl #24; Stephanie Brown’s mother is a nurse there]
Westside General Hospital [Batman Special #1, Detective Comics #571]
Williams Medical Clinic [Detective Comics #785]

Also:
Arkham Asylum
Leslie Tompkins’ clinic

This week’s episode had two barely-connected plots, both of which were rather meh.

The Plot: In the A plot, Olivia and Lincoln track down a serial killer who targets couples in love. He kidnaps the husband, throws him in a kiln, and dehydrates him completely (and fatally), retaining all the extracted fluids, which he distills to separate out the pheromones. He takes these pheromones and creates a special perfume, which he uses when he breaks into the bereaved widow’s house to try to seduce her. When this inevitably fails, he kills her too. Olivia and Lincoln are able to track down the killer fairly quickly (through no great detecting on their own — Walter and Astrid perform all the detective work this week) and capture him. Once captures, he babbles a bit about love.

Meanwhile, in the B plot, Walter realizes that a split second before the Observer September disappeared, he put something in Peter’s eye. Walter calls Peter into the lab and examines him and, sure enough, there’s a small black dot in his eye. Under the microscope, an address can be seen written on the dot. Peter travels to the address and finds September’s apartment. Inside, he finds a beeping tracking device. It leads him to the woods outside of town and it leads him to one of the iridium bullets from back in early season one. He takes this back to his house (wouldn’t it be extremely heavy for him to carry?) and inadvertently activates it while examining it. The activation of this “beacon” allows September to return to our world, which he tells Peter the other Observers had blocked him from entering. In return for Peter’s help, September tells him that this is his world, and it is his Olivia. He then babbles a bit about love.

Peter and Olivia spy each other across the street, and run towards each other only to get hit by a bus to end the episode in a loving embrace.

1. Fringe: CSI
Video cameras do not film continuously, instead they shoot a certain number of discrete frames per second. A standard video camera shoots around 60 frames-per-second; I’d expect Walter’s hidden teddy bear camera to shoot no better than 20 to 30 frames-per-second. If an action was not captured on one of those frames – that’s it – there’s no way you’re going to be able to extract it from the film, no matter how fancy and expensive equipment you have.

2. The X-Ray Glasses Don’t Work Either
Despite what ads in the back of certain magazines would have you believe, pheromones don’t work on humans. Sorry, but we’ve evolved beyond the need for them. We still have the machinery, more or less, for production of them – the Apocrine sweat glands – but simply don’t produce and/or don’t respond to them anymore.

3. 200C Dilution of Pheromones
The killer dehydrates the entire body, liters and liters of fluid – remember the average person has five liters of blood, let alone other fluids – to find one or two microliters of pheromones. That’s almost a homeopathic ratio. Surely there’s a better way to accomplish this.

4. But I Can Count the Ribs
The skin is one of the first parts of the body to respond to dehydration, not that you’d know it by looking at the victims.

5. Can We Bring Back Agent Jessup Too?
Peter’s plotline was really Fringe old home week, wasn’t it? The iridium bullet and the Greek phrase? Can Agent Scott be far behind?

I found both storylines rather lame. This is especially true for the serial killer storyline, where there seems to be quite a bit they left out — motivation, for instance. It wasn’t a horrible episode, just uninspired and rushed. The Fringe Doomsday Clock remains unchanged.

This week’s Fringe cipher was: QUILL.
A list of all previous Fringe reviews is available here.
As always, Karl has more to say over at his blog.

So Superman’s plan was to replace the gold with radioactive gold and then wait until all the crooks collapse from acute radiation poisoning? Surely he can come up with a better — and less potentially lethal plan — than this.

A soap opera and pathos heavy episode of House

Will is young man with diabetes who has been blind since birth. While trying to cross the street one day, he is overcome by the suddenly extremely loud sounds of the city and is admitted to Princeton Plainsboro hospital for evaluation. House initially suggests that Will must be hyperglycemic and hyperosmotic (too much sugar in the blood, and the blood is too concentrated, a severe complication of diabetes), but the lab studies don’t bear that out. The team suggests drug abuse, schizophrenia, or seizures. House favors the latter and orders an EEG. The study is normal and no seizures are seen, except that Will starts choking in the middle of the test — somehow three of his teeth came loose and he aspirated them. The differential diagnosis now includes heavy metal poisoning, radiation exposure, poisoning, or an infection caused by periodontitis. He is started on antibiotics for the likely infection.

Though he has been stared on the medication, Will doesn’t improve and he suffers a seizure. The new differential diagnosis still contains epilepsy and periodontitis as possibilities, but now drug use has been added — primarily because Park accidentally ingested some LSD when she scored a few snacks while searching the patient’s apartment. Will admits that he did try some LSD a few times because he thought it might let him “see.” An MRI of the brain is ordered and a suspicious lesion is seen. Brain damage from the drugs is a possibility, but so are a congenital malformation, a brain tumor, or a clot. House suspects that clot, and diagnoses Will a clot of the cerebral venous sinus thrombosis. Adams thinks that lupus may have caused the clot, but House goes with Behçets disease, and starts Will on heparin (a blood thinner for the blood clot) and interferon and steroids for the Behçets.

Once again, despite medication, Will seems to be worsening. He is coughing up blood again. Park thinks the clot in the brain is breaking up and part of it traveled to the lung. A scan of the lungs is checked and it does show a blockage consistent with Park’s theory. Suddenly, Will starts screaming that his eyes are in pain. When the team takes off the bandage over them, they see the eyes are seriously swollen and infected. Chase suspects a Strep infection while Adams favors a viral cause. House disagrees and points to a fungal cause of the infection: mucormycosis. The treatment of choice is amphotericin B, a potent and nasty antifungal that — on top of the strong antibiotic he was already on – will most likely cause him to become deaf. Will resists the treatment — he doesn’t want to become deaf as well as blind. Adams brings back his ex-girlfriend who convinces him to try the treatment, and the end of the episode suggests he may not be permanently deaf.

For the second time in the last handful of episodes, I find that I have few major criticisms to make. Admittedly, much of the medicine was rather superficial this episode — to allow time for the patient’s girlfriend(s), Park’s trip, and House’s mother storylines — so there wasn’t all that much medicine to evaluate. (Don’t get me wrong: I think most of the differential, and the final diagnosis were extremely unlikely and not a good fit, but I can’t characterize them as blatantly wrong or impossible.)

Here’s a couple quick thoughts:

The ototoxicity of amphotericin was overrated. It can cause hearing loss, but it’s not “guaranteed” even with gentamicin (and was gent the right drug to be treating a dental based infection with?)

They can’t tell the difference between a lung infection going to the brain, and a brain infection going to the lung. Speaking of that, where were all the pulmonary symptoms? He coughed up blood, twice – and once was from aspirating teeth. Where were the other symptoms– the ones that should have predated the neurological symptoms he was admitted with?

For an episode about a diabetic, and with the team frequently blaming the patient’s diabetes for his various ailments, there was little talk of blood sugars, diabetic treatment, and whether or not his diabetes was well controlled.

I found the medical mystery was only average this week with an ill-defined presenting complaint. The blindness was a nice twist, as was the fact that the team overlooked it when looking for symptoms. I give the mystery a C+. The final solution fit, more or less, and it was nice to see some consequences of the diagnosis (albeit unrealistic ones) I give it a B. The medicine was haphazard and superficial, but rarely wrong. It also earns a B. The soap opera was good and was clearly the driving force of this episode. Billy Connolly is always welcome. I give it an A.

The review of the previous episode of House
A list of all prior House reviews

Scoring this week was like wading the Platte River. A lot of people got wet, but no one got very wet. lectio wins this week with 7 points. CKW, Sean McBride, and Tom A were second with 5 points.

Overall, James H retains the lead with 63 points but Dr. R close the gap to a single point as he now has 62 points. brism19 remains in third with 55 points and Roxana is still fourth with 52 points. rileyjo remains fifth with 51 points. If you have 45 points or more, you are in the top 10%.

Click here to see the full scoreboard.

An alien dying of the Red Plague shows up on Earth, asking for Superman’s help. He collapses, but Superman encounters another alien of the same race who explains that the plague was created in a lab accident. Furthermore, their home planet, Sunworld, is infected with the red plague. He has an antidote, but has been injured and so he asks Superman to fly the plague’s antidote back to Sunworld.

Superman agrees, unaware that the second alien was lying, and in fact sent him to Sunworld with not the antidote, but a vial full of the plague itself. When Superman learns the truth upon his arrival back on Earth, he flies full speed back to Sunworld, but he’s too late: everyone on the planet is infected with the disease.

Luckily, Superman has a plan. He grabs a large chunk of conveniently located white kryptonite — which kills all plant matter — and returns to Sunworld where he uses it to kill all the bacteria on the planet, stopping the plague and saving everyone.

Superman’s plan has a few little flaws.
1. First of all — and most important — is the fact that bacteria aren’t plants, so white kryptonite wouldn’t have any effect on them. True, bacteria were once classified as plants, but it was established long ago –- back in the late 1800s, well before this story was written — that they belonged in their own kingdom. (This isn’t the first time white K has been used incorrectly, Superman once used it to destroy Virus X).

2. Superman reasons that Sunworld III is an artificial world and since they “manufacture their own food”, there were “no useful plants to be endangered.” Because that’s all plants are used for, manufacturing food. Hopefully they have no need of wood, paper, cotton, flax, natural dyes, natural medicines, natural dyes, natural flavors, decorative plants, or carbon dioxide — just to name a few things.

3. Let’s say Superman’s plan worked and that the White Kryptonite killed all the bacteria on the planet. Let’s hope the aliens don’t like cheese or yogurt, because bacteria are key to producing those. Let’s also hope they don’t like having normal disgestion or normal bowel movements either because bacteria are required for those (we have more bacteria in our bodies than human cells). Hopefully the aliens don’t make use of bacteria anywhere else in their planetary ecosystem (artificial as it may be) either.

Other than that, good job Superman!

A little known use for the iron lung: keeping the devil/demon trapped inside a possessed person.

This does raise a couple questions:
Do exorcists know about this?
What happens when the power goes out?
What do we use now that iron lungs aren’t around any more? (By the way, thank you polio vaccination for that.)

Now that our internet has been repaired, finally, I can bring you this Supergirl tale which contains the most egregious example of “shocking a flatline” that I have ever seen.

[Source: Superman Family #186] While trying to stop the Voodoo machine (don’t ask) at a hidden laboratory, Supergirl’s adoptive father is shot in the back by one of the villains and dies.

Another villain, who just happens to have electrical powers, offers to use his powers in an attempt to jump-start her father’s heart.

I can’t level too much blame at the alien because he’s honest: “if the Earthman’s anatomy is anything like that of my people, I can jolt his heart into activity.” Clearly human physiology is different from theirs, and the attempt fails.

Supergirl refuses to accept the failure. Rather than realize that the shock failed because the task was impossible — cardiac physiology simply does not work that way (not to mention her father is dead for several minutes by now) — she decides that the problem is that there wasn’t enough power in the shock. Supergirl is the Tim “The Toolman” Taylor of the Bronze Age.

Supergirl flies off and finds the generator that powers the lab. She repairs its damage and gives it a super spin to boost the power it produces.

She then races – and beats – the electricity back to the lab (yes, that means she’s flying faster than the speed of light). Once she arrives in the lab, she shocks her father, repeatedly, with the high powered wires she rips out of the wall.

Rather than frying his thoracic organs, her high voltage technique manages to bring him back to life. Remember, he didn’t die just because his heart stopped, he died because he was shot in the back. Despite this, Supergirl still manages to shock him back to life.

Ironically, this story is titled: Rendezvous with Reality. I think Supergirl not only missed any rendezvous, she was on the wrong bus.

UPDATE: So I was clearly mistaken about the speed of electricity, yet I was — sadly — still correct about Supergirl flying faster than the speed of light. Witness the following scene from the same comic, paying close attention to the caption:

“A degenerative condition of accelerated aging brought on by unprotected temporal transit.”

Symptoms: fatigue, nausea, insomnia, tactile hallucinations, flashbacks, rapid aging, death.

Treatment: none.

Prognosis: poor.

Prevention: If you’re going to travel through time, wear your protection (whatever that may be). Also, it appears alien war armor is protective.

In a Nutshell: You age rapidly and die of old age years before your time.

Other Notes:
1. The flashbacks are more than hallucinations, the victim actually is disappears back into the their past. Each episode lasts a few seconds.
2. A contradictory disease (or more likely, contradictory writing):

Initially called “ acute time fatigue”, then later SHIELD’s resident time-medicine expert calls it “chronic, in the strictest sense of the word.”
Threre’s only been one victim, SHIELD agent Sheva Joseph, though the way the doctor lectures, it’s clear she’s seen it before.
Though tactile hallucinations are mentioned repeatedly, the patient never seems to actually experience them.
With all the time travel in the Marvel Universe, why has no one else suffered from this condition?

In Wolverine and the X-Men #4, the Beast takes some of his students on a microscopic tour of the Toad’s bloodstream.

This scene suggests that the x-gene is on its own chromosome, and this chromosome circulates freely in the bloodstream.

Some observations:

This contradicts recent statements that the x-gene is located on the x-chromosome (not a complaint, just an observation. The “science” of the x-gene changes frequently).

Those are some huge chromosomes. Each chromosome should be at least a hundred times smaller than the red blood cells shown hear, not the same size.

Chromosomes only assume their “x” shape (classically seen on karyotypes) when they are undergoing replication — otherwise they long, thin, and have more of an “l” shape. When condensed into their x shape, the DNA is tightly coiled and nowhere near as visible as seen here.

That is one tiny gene: it seems to only be made up of around 24 base pairs. So that’s eight codons, making it code for a protein of only about 6 or 7 amino acids (in contrast, the ß-hemoglobin gene has 444 base pairs).

It does no good to have the chromosomes circulate in the bloodstream. To actually function and produce proteins, genes need the machinery found within the cell (RNA, ribosomes, endoplasmic reticulum, etc.).

You’d think circulating x-genes/x-chromosomes would make it real easy to run a simple blood test to detect a mutant. Why’d it take so long to come with one?

Toad looks rather anemic — he’s rather low on red blood cells.

(Yes, yes, I know: artistic license. To which I respond: high school biology. That being said, I like the visual of jellyfish as antibodies. I’m not sure what the barnacles are supposed to represent.)

I would have thought it was too dark down in Atlantis to use a head mirror effectively, but apparently I was wrong (now that I think about it, it’s always surprisingly bright down in the depths of Atlantis). You’d also think a civilization advanced enough to invent a “mind-writer helmet” could invent something more advanced than a mirror (and given the location Ronal suffered the trauma, I’m not sure a head mirror would even be necessary).

Linda Lee (Supergirl) has decided to return to college. Once there, she learns that one of the professors has a rapidly progressing, fatal, incurable brain disease. Because this professor is close to a cure for a pernicious disease (sickle cell anemia), she decides that she needs to find some way to save his life. The computer at the Fortress of Solitude tells her that the best chance in finding a cure is the scientist Nor-Kan in the city of Kandor. Unfortunately, that’s a problem. Supergirl has heard of Nor-Kan, but knows that he died several years before. Not one to let a measly thing like death stop her, Supergirl grabs the ailing professor and flies into the micro-wave tunnel that shrinks them so they can enter the bottle city of Kandor.

Once in Kandor, Supergirl meets with her scientist parents who tell her that, yes, Nor-Kan is dead. However, they point out that he was experimenting with a mushroom-based panacea when he died — perhaps this cure-all is still in his hidden tomb? (Yes, a hidden tomb — Kandorian scientists can never be too careful about security.)

Supergirl and the professor head through the Desert of Burning Hands to the Mirage Mountains just beyond (just how big is Kandor?). After a few harrowing adventures, they manage to find the tomb, and Nor-Kan’s cure-all.

Just as the Professor drinks it, Nor-Kan’s last recording comes over the speaker informing them that he abandoned his formula because it caused “uncontrolled growth – giantism” sixty seconds after the medicine has been taken. Sure enough, the professor is already starting to grow.

With no time to lose, Supergirl zips out of Kandor through the micro-wave tunnel. She uses her heat vision to soften the glass of Kandor’s bottle, then uses her super-breath like a glass-blower, enlarging the bottle and its opening large enough to slip the professor out. She then reshapes the bottle to its usual size and uses her freeze breath to harden it back to normal.

Luckily, the professor’s growth stops just as he reaches his regular size and his incurable disease – cured (I wish I could say the same for sickle cell anemia, but in the forty years since this story was written, there’s been nothing close to a cure.)

This week’s episode tried to be a good story, but there were too many chunks of exposition and questionable science. It was like a Chris Claremont comic book — not one of his good ones, like Uncanny from the ’80s, but the comics he’s written in his various attempts at mainstream books in the ’90s and ’00s. This is the X-Treme X-Men of Fringe episodes (OK, it’s not really that bad, but the comparison is valid).

The Plot: After Olivia’s sudden disappearance last week, Peter and Lincoln search her house for clues. They find a hidden surveillance camera from which Peter is able to recover a memory card. He hopes he’ll be able to pull some old images off it with help from the equipment in Walter’s lab.

Meanwhile, Nina Sharp has been detained and is being questioned at Fringe HQ. Broyles and Lincoln are certain she is involved in Olivia’s disappearance, but she claims innocence.

As we saw last week, Olivia and another Nina are tied up in the same small room. David Robert Jones enters and tells Olivia he is going to jump start her abilities by threatening someone she loves. He proceeds to torture Nina. Later, he removes Nina to an adjoining room where she is shackled to a metal frame. Jones brings in a box containing a grid of lights, just like he had in the first season, and tells Olivia that unless she telekinetically turns on the lights he’s going to torture Nina. Olivia tries repeatedly, but fails. True to his word, Jones delivers a series of electrical shocks to Nina.

Back at the lab, Peter is able to pull a facial image of an unidentified man off the memory card. He hands it over to Fringe. Abruptly, the Observer September shows up in the lab, tells Peter that he’s right to suspect David Robert Jones has a hand in this, and then collapses. Scrambling to his aid, the team finds September has been shot and has a collapsed left lung.

Still in captivity, Olivia tells Nina that she is having trouble remembering their relationship. Nina shares an anecdote of when Olivia first came to live with her, but Olivia confesses she doesn’t think she’ll get her powers to work without Peter. Nina suddenly complains of severe abdominal pain and is wheeled out of the room, where she stands up and tells Jones everything Olivia just told her. Clearly this is a fake Nina.

The picture from the memory card is identified as a known criminal – a criminal who died several years before. The team now suspects Jones is bringing over a crew from the other universe. September is getting worse; he is now in septic shock and doesn’t have much time left. Peter decides their only chance to help Olivia is for him to travel into September’s mind. Reluctantly, Walter agrees.

Once inside the Observer’s mind, Peter finds himself – appropriately enough – in an observation lounge, watching the big bang. September appears and Peter learns that the Observers are a possible future for the human race. Peter learns that he is in some unexplained way “special”, as is his son Henry, who he never knew about – and Henry ceased to exist the same time Peter did. Peter is now more determined than ever to get back to his universe. September tells Peter to “go home” shortly before Peter is kicked out of his mind. September’s body suddenly disappears from the lab. Peter decides that the Observer meant “go home” literally, so he heads back to his house. Inside, he is accosted and captured by some of Jones’ men and brought to where Olivia is being held. Now that Peter is present, Olivia is able to turn all the lights in the box on, and then some. The overhead lights in the building turn to full intensity and then start shattering. Olivia tells this Nina that she knows that she’s an imposter because the anecdote she told was wrong. Jones and alternaSharp flee while Olivia and Peter take out Jones’ other men one by one. Jones opens a gate to the other universe, and just as he is about the escape through it, Olivia shoots him. She hits him dead on, but he just shrugs off the bullet and heads into the gate, which collapses behind him. Peter summons an ambulance for Olivia, then disappears into the night after telling her that no matter what she’s feeling now, she’s not his Olivia, and that’s who he needs.

1. Her Favorite Color is Chrome
I’m amazed that the old images on the memory card were showing up as double/triple exposures — actually, I’m amazed they were showing up at all — and there were no digital artifacts. Apparently, “increasing magnetic contrast” and “decreasing chrome” can do a lot for you. I don’t think flash memory cards even use magnetic memory like floppy and hard disks do.

2. I Bet He Used a Red Vine
What did Walter do to fix September’s collapsed lung? I don’t recall seeing any evidence of a chest tube. Supplementary oxygen is enough for small pneumothoraxes, but large ones — like Walter suggests September has — need chest tubes. A hemothorax (blood in the lung cavity) is even more likely given the location of the gun shot and definitely needs a chest tube.

3. The Observers Are Charlie X!
So the Observers are a possible evolutionary future of the human race. Not sure I like that idea — seems a little too cliché.

4. Too Little!
Propafenone is a drug used to treat abnormal heart rhythms. 30mg is a tiny dose, only 20% of what is suggested.

5. Too Much!
Diazepam is a reasonable choice to break a seizure, but there are better medications, even within the same benzodiazepine class. There are many better choices for preventing seizures (especially seizures that only last a few seconds and have few, if any, lasting effects).

The science — medical and computer — was laughable and there was too much dull exposition. Still, it was an episode that helped propel the season forward, so I call it a wash. The Fringe Doomsday Clock remains at 11:56.

This week’s Fringe cipher was: UNITE.
A list of all previous Fringe reviews is available here.
As always, Karl has more to say over at his blog.

This chart has been the bane of many a first-year med student. This is the Coagulation Cascade. It shows all the factors in the blood (in addition to platelets) that cause it to clot when an injury occurs. You’ll notice how each factor, once it becomes activated (goes from VII to VIIa, for example), acts as a catalyst for the next factor; this is why it’s called a cascade. Eventually the two pathways team up to activate factor X which activates thrombin and the “common pathway.”

As you can imagine, anyone who has a problem with one of their clotting factors is going to have a hard time coagulating their blood and forming clots. We say that these people have a bleeding disorder. For instance, a deficiency in factor VII causes Hemophilia, while a problem with factor IX causes Christmas disease (or Hemophilia B, if you prefer).

There is a flip side to this cascade — a bunch of enzymes that slow down clotting so it doesn’t get out of control. This image gives you a good idea how it works as it superimposes these molecules on the coagulation cascade. A deficiency in one of these enzymes leads to a clotting disorder — someone who is more likely than normal to form clots, including dangerous deep venous clots or pulmonary emboli.

Why do I bring all this up? Because of this scene from Deathstroke #4:

You’ll notice that there is no mention of hemoglobin in the coagulation cascade. There is a good reason for this: namely, that hemoglobin does not coagulate and is not involved in the cascade. It is inside red blood cells and while it may get caught up in blood clots, it in no way itself coagulates.

This is an example of what I call “trying to get too fancy.” If the writer had just left it at blood, as in “look at the way the blood has coagulated,” then there would be nothing wrong with the sentence. Trying to get too fancy in an attempt to make it sound more realistic actual doomed the science in this scene.

A slightly above average episode of House, with a medical mystery and medical diagnoses that are (you guessed it) slightly above average.

Joe is a 38 year-old who makes his living running marriage seminars (and selling videos, books, and tapes) across the country. During one seminar, he suddenly spikes a high fever then collapses. He is admitted to House’s service after an initial emergency department work-up was normal. The initial differential diagnosis consists of cerebral AVM (arteriovenous malformation, i.e. bleeding in the brain), cephalic fibromuscular dysplasia (an arterial abnormality that can lead to a stroke), or a pulmonary embolism (a blood clot in the lungs). A d-dimer is obtained to look for the pulmonary embolism, but the test is negative. Diving into the patient’s history, they learn he used to be a motivation business speaker until he got beaten up in a bar three years ago, then he decided to get married, change his diet (gluten free), and switch from motivation speaking to marriage seminars. House asks if he was kicked in the crotch during his bar fight, and he admits he was, so House diagnosis him with low testosterone due to testicular injury. Lab tests show that Joe does indeed have low testosterone, so he is started on testosterone replacement injections.

Just as he is about to be discharge, Joe and the team realize he is unable to control his bladder, so they decide to go for another look. Chase suggests that Joe has a neurological problem, and multiple sclerosis is suggested. A spinal tap and an MRI are checked, but both are normal. Joe now complains of diplopia — double vision. The MRI already showed there was no tumor, so Graves disease and myasthenia gravis are suggested. House favors the later suggestion and starts Joe on IVIG (intravenous immunoglobulins) and plasmapheresis. Joe starts feeling better after treatment has started, but now he has become jaundiced and his liver is failing. Sarcoidosis is suggested, as is celiac disease (an autoimmune disease of the intestines), and Lyme disease. Myasthenia gravis is still on the table as well. House goes with the diagnosis of Lyme disease and starts the patient on antibiotics. There is no improvement, and some of the team want to press ahead with an intestinal biopsy to look for celiac, but Chase points out Joe’s low platelets and is worried about bleeding. House decides to give the antibiotics more time to work, but Adams goes ahead and performs an intestinal biopsy which shows the signs one would expect with celiac disease.

Looking back over old videos of the patient from when he was a motivational speaker, Taub notices that his voice was lower back then. House realizes that Joe’s hoarsness meant that Joe had silent thyroiditis, which is in itself a sign that Joe has Polyglandular Autoimmune Syndrome type III, and his symptoms are related to different glands being attacked and worn away, explaining away his myasthenia gravis and celiac symptoms. It could also explain away the low testosterone, but so could the injury, and the treatment is the same: calm down the autoimmune disease and replace the missing hormones. In the end, though, Joe decides to do without the testosterone replacement because he didn’t like the guy it made him be — the old Joe.

As usual, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

There are three subtypes of PAS3: one associated with diabetes, one associated with pernicious anemia, and one associated with vitilgo and alopecia. Joe fits none of the subtypes.

Silent thyroiditis will frequently resolve spontantously, but the autoimmune thryoiditis associated with PAS3 does not resolve so Joe would have low thyroid levels, which would have showed up on the tests they ran for the Grave’s Disease.

For someone with celiac diasease eating wheat gluten, he sure isn’t complaining of any intestinal symptoms.

What explained the liver failure? Sure, celiac can cause some liver function abnormalities, but it’s a long was from that to jaundice.

What’s causing the lung disease?

What caused the incontinence? Was it supposed to be the myasthenia gravis, because incontinence doesn’t fit that — though the double vision certainly does.

How did House know Joe was hoarse, and not just that he had a higher voice today because of his lack of testosterone. (Hoarseness plus frequent clearing of throat, I would think GERD or chronic allergies).

Plasmapheresis and IVIG are not the first line treatment for myasthenia gravis.

Testosterone injections are given every 2-4 weeks, not ever few days.

I found the medical mystery was rather average this week — a patient collapsed, which only happens 2/3 episodes. The interesting part, the fever, they mentioned then quickly dropped. It earns just an average C. The final solution almost fit, and with just a little more work, it could have. It could also explain the lack of testosterone, though House seems determined for that to be related to the fight (likely so the writes can have Joe make his sacrifice at the end). I give it a B-. The medicine has some bright points and actually followed some (not much, but some) logic this week. That earns it a B. The soap opera was was decent if fairly superficial. Two thoughts do spring to mind: 1) we need more Wilson, and 2) All this for $200 dollars a month? I give the soap opera a B-.

The review of the previous episode of House
A list of all prior House reviews

Lin wins this week with 9 points. Andrea and MC are second with 7 points. Elizabeth Duverger, KingKha, Markeb are fourth with 6 points.

Overall, James H retains the lead with 62 points and Dr. R holds on to second with 60 points. brism19 moves up to third with 54 points while Roxana drops to fourth with 51 points. riley jo remains fifth with 49 points. If you have 44 points or more, you are in the top 10%.

Click here to see the full scoreboard.

Two stories this week. Olivia’s became better as the episode progressed, the other just kinda ended with little logic or reason.

First, this Olivia is having more and more memories of Peter’s Olivia, and they’re causing her own true memories to recede. Peter gets Walter involved and at first he accuses Peter of somehow projecting his memories onto Olivia. But then he runs some labs and finds traces of Cortexiphan in Olivia’s blood. Walter and Agent Lee head off to see Nina Sharp at Massive Dynamic who controls the only remaining supply of the drug. She assures Walter and Agent Lee that the Cortexiphan is safely protected and shows Walter that no vial is missing, but he quickly determines the drug in the vials (or at least one of the vials) is fake and Cortexiphan is missing.

Meanwhile, authorities at a local mental hospital contact the Fringe Team when the voices Sean, one of their young schizophrenics, hears match a brutal murder committed across town. The team learns that Sean was a product of in vitro fertilization and the man who was murdered was a reporter planning a story on IVF. The team tracks down Dr. Frank, the IVF doctor, who admitted to making genetic modifications to the embryos he produced (yes, and the were all products of his own sperm, in a nod to Cecil Jacobson, who I’ve mentioned before) before implantation. Some of his offspring can somehow communicate with each other and kill people to keep their truth secret. Sean is able to hear these voices. The Fringe Team arrests two, but two more kill Dr. Frank and escape. At the end of the episode, Sean reports he can no longer hear the voices and now for the first time feel alone.

As the episode ends, Olivia has been abducted and finds herself tied to a chair in a room across from Nina Sharp, who appears to have been similarly abducted.

1. Damn, I Knew We Forgot Something: To Write An Ending!
That was a rather lame ending. Suddenly Sean can no longer hear the voices. Why? None of the other brood are dead, just two of them have been arrested. The others escaped.

2. They Look Cool But Don’t Do Much
So the Fringe Team runs karyotypes on all blood they encounter? I don’t really see them as being particularly useful in police investigations (this particular Fringe episode excepting, of course), except that they can tell you if the subject is a boy or girl.

3. Wrong Test, Walter
Walter is able to look at these karyotypes and detect that two people are half-siblings? Nonsense. Karotypes don’t carry that kind of information. Genetic inheritance patterns are noted on a different DNA test entirely (such as RFLP), and even then, unless you have information from both parents, it would be hard to tell if someone was a half-sibling.

4. That’s Not The Problem
The trick in IVF is not necessarily to combine the sperm and egg to get an embryo, but to get an embryo to implant and be carried to term (that’s one reason multiple births in IVF are so common, more embryos are implanted in the hope that at least one will survive. Sometime, multiple ones do). Dr. Frank’s genetic manipulation techniques would have little affect on this. Or, if he had figured it out, he would have stood to make millions.

5. The Hands
This is first time I noticed that this Nina had two normal hands, and doesn’t have a bionic one. Correct me if I’m wrong, but didn’t she lose her hand trying to prevent Walter from crossing over to save alt-universe Peter? If that’s the case, the same thing happened here (the timelines didn’t split until Walter returned with Peter), so shouldn’t she still be missing a hand?

A weak “mystery of the weak” episode, but the uber-plot gained some steam. The Fringe Doomsday Clock remains at 11:56.

This week’s Fringe cipher was: HENRY (hmmm, interesting).
A list of all previous Fringe reviews is available here.
As always, Karl has more to say over at his blog.

There sure seem to be a number of strange diseases when you’re caught out in space in the DC Universe. There’s Space Fever. And Space Crazy. We already knew about Space Fatigue (though this seems to be a milder case than Sun Boy had; no need to be drilling holes in Major Burke’s skull). Only this case of Space Fatigue also comes with “Zero-G Delusion Syndrome.”

That’s one of the most condescending doctors I’ve yet encountered. Way to make your patient feel at ease, Doc, by making fun of him.
He comes up with the diagnosis so quickly, he must have seen Zero-G Delusion Syndrome before.
No talk of cure, just telling his fiancee that he’ll need to be relieved of all future assignments. So apparently there’s no easy cure for Zero-G Delusion Syndrome and it’s a chronic condition (or it recurs whenever they’re in Zero-G).
The doctor is wrong: Burke does not have Space Fatigue or Zero-G Delusion Syndrome. Superman, of course, comes to the bottom of this and there is an erratic planetoid out there.
I hope the doctor got fired over his mistreatment of Major Burke, but I’m pretty sure I ran into him (or someone just like him) during one of my USAF Medical Corps assignments…

As the title suggests, this episode deals primarily with Chase, and how he is recovering from his injuries — physical and mental — suffered in the previous episode.

Chase is not dealing particularly well with his near-death experience, not that he’d admit it, and is trying to avoid House. Foreman convinces him to at least work some hours in the clinic, and that is where we meet Moira. She is a postulate nun, very close to permanently joining a convent. She is in the clinic complaining of left shoulder pain. The shoulder exam is normal, but Chase notes some enlarged cervical lymph nodes. He suggests that she may have breast cancer or angina (pain in the heart — or in this case radiating to the shoulder — from blocked or narrowed arteries in the heart). A quick breast exam reveals a small mass, so she is admitted to the hospital for further work-up. The breast radiology is normal, and a cardiac stress test is also normal, so breast cancer and angina are no longer in the diagnosis. House, inserting himself into the case, suggests she has a fungal infection from the unprocessed flour they use at the convent. Just as she is started on antifungal medication (looks like amphotericin), she complains of nausea and begins to vomit. House now suggests Moira has ascending cholangitis (a life-threatening infection of the bile duct), but then she complains of a numb left foot. On examination, Chase cannot find a pulse. Blood clots are suggested, but Adams suggests vasospasm (the tiny smooth muscles around arteries constrict, stopping blood from flowing to the involved tisses). This seems to fit the case best, so Moira is started on calcium channel blockers (drugs which relax smooth muscles) and improves markedly. She is discharged from the hospital and on her way to taking her vows.

Later that night, Chase finds Moira waiting outside his apartment; she has had second thoughts about becoming a nun. They enjoy a night of fun and frolic, but the next morning, she suddenly develops tinnitus (ringing in the ears) and Chase notices a pulsating mass in her neck . She starts coughing up blood (what is this, the third week in a row?). Chase recognizes this as a carotid artery dissection, a medical emergency (because the carotid artery supplies blood to the brain, and any interruption of blood flow can cause a stroke and brain damage), and rushes her to the hospital. He wants to operate immediately, but the rest of the team points out that he is emotionally involved and should not be involved. House points out that Chase is the most qualified surgeon available for the dissection repair and lets Chase proceed with the surgery. The dissection is repaired and the clot removed and Moira is doing well. Chase tells House he found some nodules during surgery and he thinks it may be lupus, but the labs don’t support that diagnosis. House points out what Chase thought were nodules may be plaques and Moira may have tertiary syphilis. While discussing the diagnosis with Chase, Moira mentions a near-death experience she had while on the operating table. He tells to accept it as a sign of solace.

Foreman takes Chase off Moira’s case due to his involvement with her. Unfortunately, things are going poorly for her now. She is complaining of right upper quadrant abdominal pain, which turns out to be liver failure (of course). The differential diagnosis is now hypotension (low blood pressure) during surgery, another clot, Trousseau syndrome (a type of blood clot seen with certain cancers), or disseminated T-Cell lymphoma. Everyone seems to agree the lymphoma — a fatal condition — is the most likely diagnosis, except Chase, who is still grasping at straws and suggests sarcoidosis. Later, while he is sitting at Moira’s bedside, waiting for the latest results, she mentions her jaw muscles feel heavy. He recognizes this as jaw claudication and realizes that she has giant cell arteritis (also known as temporal arteritis, a type of vasculitis), a treatable condition. She is started on steroids and improves. As a result of what she saw during her near-death experience, Moira decides one again to join the convent. Chase wants to talk her out of it, but House ultimately persuades him to let her go.

For the first time in quite a while, I had not major problems with the medicine in tonight’s episodes. That’s not to say it was perfect — far from it — there were the usual plethora of missed opportunities, strange diagnostic choices, and atypical symptoms, but there were no deal-breakers this week (though I’m sure others will disagree in the comments). So, no red complains this week, modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

Uncommon presentations of carotid dissection (hemoptysis, but no headache) and giant cell arteritis. I’m assuming the shoulder pain, carotid dissection, and claudication are all being blamed on the arteritis. Apparently, they’re also blaming it for the nausea, vomiting, liver failure and vasospasm as well?

When a young woman comes in complaining of left shoulder pain, breast cancer and angina are not going to be the first two diagnoses I think of. They’re going to be pretty far down the list. (History of trauma or not, I would still consider a musculoskeletal casue the most likely in that situation).

Let’s say Adams was correct and Moira’s big problem was vasospasm. I can’t believe they’d let it end there and not perform a work-up to determine why she was having ischemia-inducing vasospam. That is very out-of-character for the doctors, and the show itself.

When Chase found the nodules during surgery, why didn’t he biopsy them then?

Surely someone on the team ran a sedimentation rate on Moira, particularly after her dissection. There aren’t that many non-surgical causes of an aortic dissection in that young a patient. AN elevated ESR would have clued them in to the GCA very quickly.

I know his reasoning was good, but performing a breast exam without a chaperone present is definitely not recommended from a medical-legal point of view.

I can (almost) understand Chase or Taub always doing being called on to play surgeon, but surely there are better assistants than non-surgeons Adams and Park.

I found the medical mystery to abnormally low key this week (you’re going to admit someone for shoulder pain — really?) though it become more complicated in leaps and bounds. I can only give it a C. The final solution was certainly possible, unlikely, but possible. It earns a B. The medicine was full of bizarre choices and overlooking the obvious, but still it was better than it’s been in quite a while: B+. The soap opera was strong and it was nice to see a Chase-centric episode again: A.

A list of all prior House reviews

Silvina wins this week with 9 points. James H, Dr. R, and brism19 all tie for second this week with 8 points while riley jo is fifth with 7 points.

Overall, James H remains first with 58 points and Dr. R holds on to second with 56 points.. Roxana drops to third with 51 points. brism19 is fourth with 50 points, and riley jo is fifth with 48 points. If you have 40 points or more, you are in the top 10%.

Click here to see the full scoreboard.

The writers were clearly trying for a Silent Hill vibe in this week’s episode, and might have achieved it, had the blatantly wrong science and medicine not pulled the viewer abruptly out of the story.

The Plot: After a strange electromagnetic effect causes cars to stop working and a plane to crash, the Fringe Team is called in to investigate. They stumble into the small town of Westfield, which they find strangely deserted. Walter stops in at a local diner, and the cook there alternates between friendly and hostile. He ultimately pulls a knife on Walter and is shot by Olivia. Examining the dead man, Walter finds that his eyes have two irises. The team finds a wounded man in back. They load him in the car and try to drive to the nearest hospital, but find they are unable to leave town. Driving out one direction brings them back to town from the other direction.

Walter gives Cliff, the wounded man, a transfusion, and the Fringe Team learns that things have been going crazy in town for the past three days. People are going crazy and telling of memories and experiences they’ve never had. The survivors are holed up at the high school, so they head there. Of the twelve people in the school, one has gone crazy. Walter examines her and finds a second set of teeth. She tells him of sending her husband off the work that morning – her husband who died seven years ago. A blood draw shows that she has 92 chromosomes, double the normal number. Walter hypothesizes that the town is a center of convergence between the two universes. People are going crazy as their two disparate selves are merging. Now the towns themselves are merging, which apparently causes earthquakes and lots of swirling wind of leaves. Peter proposes finding the “eye of the storm” where the forces balance out. He and Walter map out this safe area and the survivors head for the eye of the storm, but not before another one goes crazy and is shot by Peter (with an assist by Walter).

The Fringe Team and survivors ride out the storm/merger successfully and emerge from the only building still standing to discover that the rest of the town is a desolate wasteland. Later, after Broyles and the rest of Fringe arrive, it is mentioned that they discovered amphilocite-powered devices on the edge of town, suggesting that David Robert Jones had a hand in whatever happened.

Still later, Peter swings by Olivia’s house where she pours him a glass of wine and kisses him — it seems that the Olivia from this universe is channeling the memories of the Olivia from Peter’s universe.

Karl goes into great depth about all the magnetic and electromagnetic problems with this episode. Rather than beat a dead horse, I’ll just send you over there. Instead, I’ll focus primarily on the biological and medical issues.

1. Transfusion Confusion.
O-negative is the universal donor only when just blood cells are transfused. When plasma is donated along with blood — like in the whole blood transfusion Walter performed — you are also transfusing antibodies, and O-negative people have a lot of those, including ones against other blood types. Whole blood transfusion pretty much needs to be same blood type only.

2. Schizophrenia ≠ Multiple Personality Disorder.
The victims in the town have not gone schizophrenic. They are only showing one symptoms of schizophrenia (delusions) and none of the other symptoms.
The team seems to be using the term schizophrenia in its very incorrect use as a synonym for multiple personality disorder, now called dissociative identity disorder. The two are not the same; they’re not even close.

3. More Is NOT Merrier
While there are some organisms that can tolerate polyploidy, human beings are not one of them.

4. Bet She Could Chew Really Well
In “accelerated mitosis”, cells would be dividing/reproducing faster than normal. When this happens in an uncontrolled manner, we usually call that a tumor.
Walter’s theory is extremely vague: is it all cells, or just specific cells? How much faster than normal? What about germ cells, are they undergoing mitosis as well — because that would be even stranger?
Notice that Walter made his deduction based on examination of two patients, neither of which had duplicated cells: irises (which are holes), teeth (I guess you could argue the dental pulp is made of cells, but that’s still a stretch).

5. I Can’t Be The Only One
Peter’s plan made no sense to me: find an area where the forces cancel each other out. First, what forces? And these forces, have they been measured at all? And these forces just happen to have occurred in such a way that there is safe spot? Where on Walter’s venn-like diagram would this “eye of the storm” be? And isn’t it convenient they could perfectly note its location based on a crude map, markers, and a partial town history. And then this spot they found happened to be exactly the size of a bike shop. Convenient. Over convenient.

A hilariously bad understanding of science and medicine dooms an otherwise promising episode. The medicine and science was so badly butchered that I have no choice but to advance the Fringe Doomsday Clock two minutes this week.

This week’s Fringe cipher was: OLIVE.
A list of all previous Fringe reviews is available here.
As always, Karl has more to say over at his blog.

An interesting set-up on this week’s episode of House, but, alas, it led to a poorly execute denouement. And the medicine could have been better, too.

The episode begins with House and his team being questioned individually by Dr. Cofield, a doctor from another hospital, as part of a disciplinary hearing.

It all started with a patient named Bill, who is a thirty-two year-old high school chemistry professor who collapsed while jogging and is now in a coma and “paralyzed in all four extremities.” There was no history of trauma, and CT scans of the brain show no evidence of stroke or structural lesions. Reviewing the case, House initially suggests transverse myelitis, but admits it doesn’t really fit the situation. He then presents the patient to his team, who suggest the diagnoses of hepatic encephalopathy or normal pressure hydrocephalus. Chase points out that Bill is hypokalemic (low in potassium), which House takes as a sign that he has thyrotoxic paralysis (a temporary paralysis associated with an overactive thyroid). House starts bill on a regimen of steroids, PTU (an anti-thyroid medication), and beta-blockers (a class of drugs, that among other things, blocks the effects of too much thyroid hormones).

Bill improves and wakes up from his coma. His wife and some of his students visit, and they make a comment about a lab explosion he was in earlier that day. After this key fact is mentioned, Bill starts coughing up some blood. The team learns that during the explosion, conveniently uploaded to the internet, Bill was caught in a burst of hydrofluoric acid and hit his head fairly hard against the wall. The team now suspects that Bill is coughing up blood because of the inhaled chemical, and the rest of his symptoms can be explained by the trauma of hitting his head. House wants to treat Bill with aerosolized (inhaled) Heparin (a blood thinner), a treatment not yet approved, or apparently even tested, in humans.

Everything seems to be going well and Bill is getting ready for discharge. He is being given a bath to remove the remaining chemical on his skin when Adams notices a rash. While she is trying to get a good look at it, the patient freaks out. Adams thinks the rash is invasive Strep, while Park thinks the rash is nothing special but thinks the patient’s freak out was because of the steroids they had put him on. Taub feels the rash, together with the other symptoms like the lung problems, is a sign of Wegener’s granulomatosis. House decides to put Bill on steroids again. If he has Wegener’s, the steroids will cure the condition. In the other two cases, it will worsen the condition enough so the right diagnosis can be made.

Chase agrees with Adams and decides a biopsy of Bill’s rash is the best way to get a diagnosis. Unfortunately, Adams was wrong and Park was right — the patient is having steroid-induced psychosis. Thus, when Bill sees the needle Chase plans on using, he has a psychotic break which requires an injection of Haldol to bring to an end. In the scuffle, Chase was stabbed in the heart with a scalpel. He is rushed off to surgery. The hole in his heart is patched, but Chase later discovers that he can’t feel his legs. The concern is whether Chase has a post-traumatic syringomyelia (a cyst in the spinal canal), or a clot of a radicular artery (vessels which supply the spinal nerves with blood). It ends up being the clot, which is good news because its removal should allow Chase to regain some use of his legs. While all this is going on, House keeps popping in updating the team on Bill, even though they are no longer on the case. First, he suggests that is autonomic dysregulation, then he reports kidney failure which rules out his last diagnosis. Finally, after having w Eureka! moment with a pranked bottle of Vicodin, House diagnoses Bill with tumor lysis syndrome, caused when he he struck the wall after the explosion and ripped open the tumor he didn’t even know he had, spilling its contents into the bloodstream.

The news of Bill’s survival reaches the team just as the results of the disciplinary hearing are to be announced. Learning the patient survived, Cofield lets House of the hook (yet again), a decision that even House is upset with.

As usual, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

The first step in treating thyrotoxic paralysis is supplementing to low potassium, which House failed to do.
Steroids are not indicated for the treatment of thyrotoxic paralysis.

The primary sign of tumor lysis syndromeis is hyperkalemia (high potassium) — the exact opposite of what the patient had.
Bill wasn’t showing any of the myriad other symptoms of tumor lysis syndrome.

Syringomyelias can occur post-traumatically — when there is trauma to the spinal region. A scalpel to the heart is not going to cause a cyst formation in the spinal cord.

Hydroflouric acid is a very nasty chemical. They should have decontaminated the patient much earlier and I’m surprised he didn’t have any acid burns or other damage. Was he even wearing goggles when performing the experiment? (I also find it hard to believe that he’s use HF for a classroom demonstration with a risk of explosion).

Why biopsy a lesion you suspect is bacterially infected? I can understand performing a biopsy on an unknown lesion, but Chase specifically said that he agreed with Adams, and a biopsy is not how you prove a Strep infection.

I’m a bit confused how a clot in a single radicular artery (caused by what exactly?) could cause paralysis in both legs.

Swelling in the brainstem, like Park suggested, would have shown up on the initial head CT.

What was the rash from?

House carefully scrubs into surgery and gets gowned and gloved – and then grabs an unsterile surgical mask and holds it against his face. Masks are put on before scrubbing.

A disciplinary hearing before the patient’s disposition is even known? No bureaucracy moves that fast.

I found the medical mystery to be moderately interesting this week. It earns a B-. The final solution directly contradicted some of the earlier patient history and left several symptoms unexplained. It earns a C-. The medicine was sloppy and perfunctory this week. When the anatomy is wrong, why would we expect better from the medicine? I give it another C-. The soap opera had some good drama, but the ending was rather anticlimactic — and virtually a deus ex machina (or in this case, patient’s wife ex machina). It earns a B.

The review of the previous episode of House
A list of all prior House reviews

For the second week in a row, Roxana wins, this time with 7 points. AndyW, mbrigdan, Sean McBride, and TheJester tied for second with 5 points.

Overall, James H is still ahead with 50 points. Roxana jumps up to second with 49 points, while Dr. R falls to third with his 48 points. Nextsundayad is fourth with 45 point and mbrigdan is fifth with 43 points. If you have 36 or more points, then you are in the top 10%.

Click here to see the full scoreboard.

A very good B-plot, a mind-numbing A-plot. Neil should have visited me before I saw this episode to put me out of my misery.

The Plot: A man recently diagnosed with melanoma, but given a good chance of survival, is found dead, with mysterious bleeding from his eyes. The Fringe Team is called in to investigate. During the autopsy, Walter discovers that the victim was killed with a strange mixture of chemicals that shouldn’t act as a poison, yet they do. He concludes, with logic bizarre even for Walter, that it was impossible for someone to discover this toxin on their own — that they must have learned it from someone else, someone with godlike powers.

A second victim is found. Then a third victim manages to escape the killer. The Fringe Team talks to him at the hospital, but learns little other than the killer seems to have some knowledge of the future, and claims to be killing people now to put them out of their future misery. The Fringe Team can’t find any connection between the victims, but Mentat Astrid, visiting from the other universe, is able to find a connection — they all passed through Logan Airport and had the same TSA screener. The Team looks into the screener and learns he was a former MIT professor and mathematical prodigy who felt that the correct mathematical equation could “flatten out” the universe and let someone see the past, present, and future. This professor claimed that he discovered this equation, then disappeared from the university. Interestingly enough, he was working on the equations at his lake house — at Reiden Lake.

The Fringe Team tracks the killer down, but rather than be taken alive, he commits “suicide by cop” and is shot and killed by Olivia. Later, the Observers look through the killer’s belongings and find what he was using to read the future, a gadget belonging to the Observer September, that he lost years before. The head Observer also learns that September did not wipe Peter from existence.

(The B-plot deals with Mentat Astrid crossing over to our universe to talk with our Astrid because Mentat is having difficulty dealing with the death of her father. Bolivia also crosses over, ostensibly to bring Mentat back, and while here has a reconciliation of sorts with Walter. On second thought, this may be the A-plot, which would explain why the Tears of Ra plot felt so thin.

1. Glowing In The Dark Is Not Necessary
Stage I Melanoma is 90-95% curable. Radiation therapy is not used in its treatment at this state, however.

2. Works Great, Unless the Chase Lasts More Than 73 Miles
More blatant Leaf-vertising.

3. Fear Is The Mind-Killer
This is third variation of alternate Astrid we’ve seen. First, was Mentat Astrid, not seen since the merging of the universes. A few episodes ago we had Sheldon Astrid — more nerdy than savant (and Sheldon Astrid had more social skills – well, slightly). This episode, we’re back to the savant, though with more clearly autistic symptomatology. I dub this variation Rain Man Astrid.

4. Strike That, This Plot Is The Mind-Killer
This had to be one of the stupidest plots I’ve seen in Fringe this season, if not ever. Neil can see the future and wants to put people out of their misery. Fine, that makes sense, more or less. But to do it, he chooses to use an unknown yet highly distinctive poison that draws attention to his crimes? Thus allowing him only to “save” two people?
And that entire “no one would ever think to combine these chemicals to make this unexpected poison” concept is ludicrous as well. Why could Walter tell so fast that these chemicals, that apparently cannot be combined, were combined, and were what was killing the victims. Why did the person using them have to have learned from God or someone godlike. Walter was able to learn the creation of this toxin just be performing the autopsy, and there’s nothing godlike involved in that at all.
As stupid as the plot was, the Astrids and Olivias did pull off some excellent acting.

The Astrid and Olivia storyline was well done, but the “main” story was (almost) entirely unsatisfying (I’ll give a little credit to the Obervers for trying to make it interesting). Despite Anna Torv’s and Jasika Nicole’s best effort, the ludicrous Tears of Ra plot causes the Fringe Doomsday Clock to advance a minute toward midnight.

This week’s Fringe cipher was: EMPATH.
A list of all previous Fringe reviews is available here.
As always, Karl has more to say over at his blog.

House shows some heart in tonight’s episode, unfortunately, he seems to have left his brain at home.

A teenager presents to the Princeton-Plainsboro Hospital clinic complaining of some difficulty breathing. All she wants is an inhaler for her “asthma” but House correctly recognizes that she is homeless and the man with her isn’t really her father. What really piques his interest is when she starts bleeding from her ear. He mentions that this is a sign of a skull fracture, but can find no fracture — or any other cause of the bleeding — so he admits her to his service. The team’s initial diagnoses focus on her homelessness and consist of drug use, malnutrition, or HIV. Chase goes further and suggests she may have a squamous cell cancer of the middle ear with paraneoplastic syndrome, while Taub, backed by Adams, suggests a possible cerebral (brain) infection, probably pneumococcus. House agrees with Taub and Adams and starts “Jane Doe” on ceftriaxone (a potent antibiotic).

Adams and Park check out Doe’s school — where she is doing quite well — and also check out her address on record with the school, which is a foreclosed home she has fixed up. Looking around the house, Adams finds a few beers and some mold. She now suspects Doe has a fungal infection and starts her on fluconazole (an antifungal medication). Upset that the team went behind her back digging into her history, Doe tries to leave, but collapses as soon as she gets out of bed, complaining that she “can’t feel her legs” (her symptoms are later identified as paralysis, which is different from the paresthesia she was complaining of).

Looking over her symptoms of ear bleeding, problems breathing, and lower extremity paralysis, the team’s new differential diagnosis is transverse myelitis, endocarditis with septic emboli, or the fairly vague “vasculitis” (inflammation of the blood vessels). House goes with the vague and starts the patient on steroids to treat the presumed vasculitis. Initially, she is doing better on the steroids, but then things quickly go to hell. Her estranged mother shows up, identifying the patient as Callie, and in the middle of the confrontation, Callie begins coughing up blood. Different diagnoses are considered based on where the blood may be coming from (respiratory or gastrointestinal source). Chase suggests she has a sinusitis and a bleeding disorder, and Adams suggests Zollinger-Ellison syndrome (a condition where the patient has a tumor which secretes gastrin, which causes the stomach to pump out too much acid). House thinks Adams has the better idea and orders an EGD (upper endoscopy), which reveals bleeding ulcers in the esophagus; unfortunately, this doesn’t fit any of the diagnoses discussed. The team now considers the diagnoses of HPV (human papilloma virus), alcohol-induced esophagitis, or a berry aneurysm of the brain. House thinks it is the aneurysm and wants a quick cerebral angiogram followed by surgery before the aneurysm has a chance to rupture, which would rapidly kill her. Adams favors the alcohol theory — Callie does admit drinking an occasional beer — and Callie’s mother agrees with Adams and decides to forgo the angiogram and surgery. Callie seems to be doing well and is actually talking with her mother when she suddenly falls unconscious. Coudl she have had a berry aneurysm which burst? Was House right? She is rushed to the OR suite for the cerebral angiogram, but no aneurysm is detected. Her blood pressure begins to plummet and the team buys time with some pressors (medications that increase blood pressure), but still don’t know what is wrong her. Brainstorming, Adams first suggests cancer, then recalls hearing about a trip Callie took to Florida two years before and wonders is she may have contracted dengue or cholera. House (rightfully) scoffs at those, then after learning Callie went swimming in a freshwater canal while in Florida, correctly diagnoses her with ascariasis (a parasitic worm infection). After Callie is treated, she sneaks out of the hospital to be on her own again, still unwilling to trust her mother. (I’m assuming she snuck off to the Disney Channel, where she was able to find a much happier family).

As usual, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

House dismisses Adams suggestions of dengue and cholera by pointing out the two year gap between exposure and symptoms, but then diagnoses ascariasis, which has precisely the same problem. The worms would not have sat quiescent for two years, not when they had their preferred environment, no matter what the fancy graphics at the end showed.
I’ll grant that ascariasis can cause pulmonary symptoms and gastrointestinal symptoms (because the worms travel intestines to liver to liver blood flow to lungs, then up the trachea, and swallowed back down to the intestines). Ears (and even if they could get to the ears, how were they causing bleeding? Drilling a hole?)? Brain (and yet not be visible on CT scan)?

Ears should not bleed. House looked in Callie’s ear and said it was normal. I would expect him to see a bleeding source (such as a scratch, cyst, infection, etc) in the canal, or a hole in the tympanic membrane which would let blood from deeper in the ear out into the canal. He mentioned neither of these – so how could there be blood?
Other than Chase’s mention of squamous cell cancer of the ear, none of the diagnoses mentioned are going to cause ear bleeding, particularly ear bleeding that looks normal on exam. For example, Zollinger-Ellison? How is a gastrin-secreting tumor going to cause ear bleeding? Callie only has four symptoms, and Adams still skips one in her diagnosis

Taub’s phrasing “cerebral infection” was a odd. He seems to be suggesting meningitis — for which pneumoccocus is a common cause and ceftriaxone a good choice of medication — but that doesn’t fit with Adams comment about lack of fever. You would expect a fever — and meningeal signs — with meningitis. They could possibly be referring to a brain abscess, but that would have shown up on the CT, and pneumococcus (and thus the choice of ceftriaxone) much less common.

No vaccine is 100% protective, and Callie could still get pneumococcus even after being immunized. Plus, the vaccine only covers a handful of different pneumococcus serotypes (admittedly the most common), and she could have been infected with one of the serotypes not covered by the vaccine.
Why would Adams, who doesn’t believe much of what Callie says, believe a shot record to be true? Callie likely forged or lied on her school shot records. It’s not like her parents really signed it.

When Callie stands up and collapses to the floor, she complains she can’t feel her legs (paresthesia). That’s different that an inability to move her legs (paralysis). It’s possible she has both and can’t move or feel her legs, but then the most common complaint would be that she couldn’t move her legs, not that she couldn’t feel them.

PPH is in for some tough times. In the past two weeks, they’ve let two patients escape– two they should have been watching closely. Last week, a patient with Alzheimer’s (known to be elopement risks), and this week, a minor left AMA, a minor with a history of running away.

I found the medical mystery to be more interesting than usual this week, because the symptoms were quite disparate. I give it B. The final solution was a let down, because it couldn’t really explain half the symptoms (and the most interesting half at that); it deserves no more than a D. The medicine was very sloppy this week, with many of the diagnoses not explaining all the symptoms — and there were only three or four symptoms to work with. I give it a C-. The soap opera was adequate and average. There were a couple of nice scenes, and Wilson got a few good lines, but it really wasn’t anything above average: C.

The review of the previous episode of House
A list of all prior House reviews

This week, Roxana wins with 9 points. Harvey, Little apple, rileyjo, Rouge Rogue, Silvina and TheJester were second with 8 points.

Overall, James H retains the lead with 46 points. Dr. R moves back up to second with 44 points. Nextsundayad and Roxana are tied for third with 42 points. wkmaier is fifth with 40 points. If you have 35 or more points, then you are in the top 10%.

Click here to see the full scoreboard.

An average episode of Fringe that had too much bad science (and math) for me to truly enjoy. I guess we need some mediocre weeks to let us enjoy the good ones.

The Plot: Emily is a teenager who occasionally catches glimpses of someone’s pending death. She quickly sketches the scene she sees in her sketchbook, rips out the page, and then hands it to the victim. She’s essentially Cassandra, and her warnings of imminent death do no good to the victim. They do bring her to the attention of the Fringe Team, especially Olivia, who is still coming to terms with the Observer who told her that she had to die.

Emily gives the Fringe Team a sketch she made showing numerous victims amid piles of rubble. The image is centered on one particular man. The team is able to figure out who he is via his bus pass. Walter hypnotizes Emily (using the standard red and green lights) to gain more information and learns that the disaster will take place at a courthouse. Olivia and Lincoln learn that the man in question recently lost custody of his children in a divorce proceedings. They track him down to a local courthouse and the FBI finds a large bomb in the bed of his pickup truck. They are able to block the radio detonator, but he threatens them with a small bomb he is wearing. Olivia is able to talk him into surrendering and no one is killed. For once, Emily’s prediction does not come true.

When Olivia calls Emily to thank for her help, she learns that she is missing. Olivia tracks her down to a pond-side bench at a park she was fond of. Emily has foreseen her own death and has come to her favorite spot to die, which she does, quietly, in the arms of her father.

Later in the evening, Nina Sharp comes over to Olivia’s apartment to check on her. Olivia complains about the migraines she’s been having (the ones caused by Nina’s secret injections), so Nina promises to send over some “new medicine” the next day.

1. Math Must Be Different in Spain
The math Olivia and Broyles use on the Spanish Flu doesn’t add up. If the last case was 1919, then 91 years later is 2010, not 2012 (or even 2011, when the episode was undoubtedly filmed). Unless they are suggesting that 1 and 2 year-old do not make antibodies, which would contradict years of immunization and vaccine research.

2. Billy Squier
An “overload of electrical energy in her brain was just too much” is not the definition of stroke; it’s the definition of a seizure. A stroke is what I like to call a “plumbing problem” – the required blood cannot get to the brain either due to a blockage (embolic stroke) or bleeding out (hemorrhagic stroke). A problem with the brain’s electrical system would be a stroke, at least in the sense Olivia is describing.
Neither of these would account for the bloody nose, so I’m going to count that as a psychic nosebleed.

3. Scan Acquired
I’m amazed Walter could get such an accurate reading from the occipital lobe when he had no sensors anywhere near it.
Theta-1 waves are said to occur during voluntary motion and REM sleep, though the exact definition of a theta-1 wave varies.
Theta-1 waves originate in the hippocampus, a part of the brain which is nowhere near the occipital lobe.
Since blood carries oxygen, it would be hard to get increased oxygen without increased blood. And since when does an EEG measure either?

4. Radio Free Albemuth
Now I’m no radio-specialist or electrician, but is it really that easy to jam a specific frequency? How did they know they weren’t going to set off the bomb by accident?
Was it wise to send Peter and Lincoln, not trained in demolitions, it to help the bomb squad? Particularly in regards to Peter, he’s one of a kind and is it really worth risking him?

5. Must Be Those Ceramic Wires and Electrodes
So the bomb Albert was wearing had not detectable metal in it? Really?

6. Oh By The Way
When are the Fringe Team finally going learn that they need to sit down and have a long debriefing session with Peter. How many times has he recognized something they didn’t or knew more than they did? Just off the top of my head: shapeshifter’s memory banks, David Robert Jones, and the Observers. I’m sure I’m missing a few others.

While there was nothing specifically wrong with this episode (other than the questionable science and math), it just didn’t gel particular well, with the attempt at pathos at the end being a more than a little over-the-top. The Fringe Doomsday Clock heads back towards midnight.

This week’s Fringe cipher was: MARCH.
A list of all previous Fringe reviews is available here.
Karl should soon have more to say over at his blog, providing he’s not partying too hard on his vacation.

Tags: television fringe precognition bomb hypnosis

The Mayor of Metropolis summons Superman because he needs his help. It must be some major problem, right? Like a failing dam, a fire at a hospital, or an orphanage perched atop an EPA super-fund site, right?

Nope. The mayor has the measles, yet still wants to attend the City Council meeting. Truly a problem requiring all the abilities of the Man of Steel (sorry, orphans, try to enjoy the searing pain from the toxic waste).

This is Superman, so he must have a brillaint plan to “beat those measly measles,” right? Wrong again. No shrinking down and battling the evil virus and its zombified cells. No jumping forward a few years in time, grabbing a measles vaccine, then jumping back in time to before the mayor was infected. None of that. Instead, Superman visits a glass factory and makes a giant glass globe.

Then he plunks the mayor in the sphere, along with his desk, some papers, and what looks like a very limited supply of air, and flies him off to the City Council meeting.

Mission accomplished.
This was truly a job for Superman.
Join us tomorrow when he helps City Councilman Adams take an old couch to the curb for trash pickup.

The doctor is working hard to “pull them thru” by…doing what, exactly? Putting a warm washcloth over their eyes? Tucking them in?

Now, I’m no expect on knockout gases, but I think I could do better than that.

I like the way there’s a list of rules on the back wall. I can only imagine what they say: “No roughhousing,” “No running with scissors,” “Wash your hands before returning to work”

An unfortunately average episode of House where the most interesting question is left unanswered.

Andres is a man with early onset Alzheimer’s disease. He is being evaluated for possible inclusion in a drug study when he develops bloody vomiting. He is admitted to Princeton-Plainsboro Hospital and assigned to House’s service. The team’s initial thought is that the patient has a gastrointestinal bleed which is causing the bloody emesis. An EGD (upper endoscopy) is performed and it shows a Mallory-Weiss tear (a rip in the esophagus of those who vomit frequently or forcefully), but that is a consequence of vomiting, not a cause. Andres is also noted to have elevated liver enzymes, and the diagnoses of gallbladder disease and steatohepatitis (fatty liver) are mentioned. House favors the latter and decides to start the patient on statins (a class of cholesterol drug as high cholesterol is almost always seen with steatohepatitis) and double check the liver (initially a biopsy, but overruled by Foreman to an ultrasound examination), but before they can perform the testing, Andres becomes more violent that ever, punching his wife, and requires sedation. At this time, the team also notices bloody urine. The differential diagnosis now consists of rhabdomyolysis (severe sudden muscle damage) and TTP (thrombotic thrombocytopenic purpura). House thinks TTP fits best, and orders Andres started on plasmapheresis.

Overnight, Andres elopes (the medical term for a patient, especially a demented one, who leaves the hospital). In the middle of a snowstorm, the team tracks him down to an old soccer field, but by the time they find him, he is hypothermic and pulseless. CPR is started, because, as Chase reminds Adams, they’re not dead until they’re warm and dead (sudden hypothermia can sometimes be protective of a patient, though this is more common in children than in adults, so it’s medical tradition not to declare someone dead until they’re back to normal temperature). Andres is brought back to the hospital, sent to the ICU, and started on extracorporeal warming of his blood. As he warms up, his brain function returns, then his heart. He’s initially in ventricular fibrillation, but he returns to a normal rhythm after some amiodarone (a medication used to suppress heart arrhythmias) and defibrillation. Unfortunately, he seems to have lost his ability to speak English and now only murmurs in Portuguese, his native language. He also develops a fever, but is this a symptom of his original admitting disease, or a consequence of being hypothermic? Looking over Andres’ symptoms, House sticks with the diagnosis of TTP and wants to resume plasmapherises. Foreman, instead, favors a viral infection that has spread to the brain to cause encephalitis. House relents, and has the patient started on interferon.

Andres is not doing any better. He falls back into ventricular fibrillation and this time requires three shocks to correct (apparently they neglected the amiodarone this time around). Foreman maintains it is a viral infection of the brain, such as encephalitis or meningitis, while House now favors toxin exposure. This week, it is Foreman who has the Eureka! moment while talking with some hospital donors. Seeing a flower bouquet still looking fresh despite being over a week old, he recalls that aspirin in the water can prolong the life of cut flowers, and this leads him to diagnose the patient with Reye’s syndrome. Some corticosteroids and Andres is back to normal (well, as normal as someone with early onset Alzheimer’s can be.)

Meanwhile, Wilson is treating a patient with a bladder infection (which he apparently diagnoses by palpating her neck). In the course of his discussion with her, he learns that she and her husband are self-proclaimed “asexuals”, completely disinterested in sex. House finds this head to believe and wagers $100 that he’ll find a medical cause for the lack of sex. He runs tests on the patient’s blood, but everything is normal. He eventually lures the husband in for an exam and discovers a pituitary tumor (a “macroprolactinoma“) that is suppressing the normal sexual urges. With some treatment, the high levels prolactin can be treated and the patient’s symptoms (in this case his nonexistent sex drive) corrected.

As usual, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

Pet peeve here: Defibrillation does not “shock the heart back into rhythm.” The shock from defibrillation momentarily stops the conduction of the arrhythmia, allowing (hopefully) a normal rhythm to take over. The shock itself does not “jump start” the heart or start the normal rhythm, it just stops the bad rhythm — an important distinction.

TTP (thrombotic thrombocytopenic purpura) -– none of three parts (the T, T, or P) fits. There was no mention of low platelets (though other lab abnormalities were mentioned), no clotting, and no purpura. (In fact, there was no mention of rash at all, and rash is almost always seen in Reye’s).

In regards to his symptoms, Reye’s syndrome is quite a stretch with few of Andres symptoms matching well, but then again, Reye’s in adults is quite a stretch in-and-of-itself.

Symptoms of death in the hypothermic do not resolve that predictably (“Ah, 93 degrees, must be time for the ventricular fibrillation”), and frankly, the patient usually remains dead.

Interferon is not a treatment for encephalitis or meningitis.

Cortciosteroids are used in Reye’s to treat swelling of the brain — something they never bothered to look for, despite the more-than-expected behavioral changes.

Third episode so far this season where there is debate whether societally atypical behaviors are symptoms or not. Charity, paranoia, and now aggression.

Before starting statins in a patient with elevated liver enzymes, I’d want to make sure the cholesterol is indeed high and require treatment, as the statins themselves can elevate liver functions.

While there is debate over the use of “chemical restraints” (sedation in aggressive patients), diazepam is unusual for a first line agent. Haldol seems the more common choice. On the other hand, diazepam can be more easily reversed if something goes wrong.

The medical mystery this week was OK, but not great — but that still makes it better than most episodes this season. The big mystery was why Andres developed Alzheimer’s so young, but answering that was outside the scope of the episode. I give the medical mystery a C+. The final solution kind of more or less fit, if you ignored the usual time course of Reye’s Syndrome. I give it another C+. The medicine was uninspiring this week, with diagnoses thrown around that could be easily tested, but never were. Plus Foreman, a neurologist, was using meningitis and encephalitis interchangeably. I give the overall medicine a C. The soap opera was enjoyable this week from the pathos (Chase), to the humorous (the yellow cards, Park and her “tapping”), to the unethical (House and Wilson). It deserves an A-. (Bonus points for the Spider-Man allusion. And what manga was House reading when first talking to Wilson? Maybe someone should tell him they’re read right-to-left, not left-to-right.)

The review of the previous episode of House
A list of all prior House reviews

This week, Hogan and jwsellers took first with 13 points. Nextsundayad, vivalavida, and wkmaier were close behind with 12 points.

Overall, James H and Nextsundayad share the lead with 39 points. wkmaier moves into second with 38 points while Dr. R drops to fourth with his 37 points. Yerkietand mbrigdan are tied for fifth with 35 points. If you have 31 or more points, then you are in the top 10%.

Click here to see the full scoreboard.

The second cat-and-mouse Fringe episode in a row, and the second good one in a row. Coincidence?

The Plot: Fauxlivia and otherLee arrive at the warehouse they learned about at the end of last episode, and find David Robert Jones waiting for them inside. He makes a not-so-subtle threat by killing one of his own shapeshifters, and then surrenders himself to them and asks to be taken to their leader.

At Fringe HQ, Peter recognizes Jones as the man he thought he killed, and watches alternaBroyles’ interrogation of him. Peter even does a little interrogation of his own, a situation that seems to unnerve Jones, even though he doesn’t recognize Peter. Jones asks for a certain hard drive hidden by the shapeshifter Brandon, and when it does not arrive in time, kills an ER full of people. He then demands to be released or he will kill more innocents. Walternate agrees, and the team has just enough time to slip a tracker into Jones so he will be easy to follow. They track him to a crowed public plaza but it is clear he knows he is being watched. He grabs a package from a nearby trash bin containing a thermos and a stack of money. He starts handing out the money to passersby and drinks from the thermos. All the money has trackers identical to his, and the liquid in the thermos knocks out his tracker, so he is able to escape when dozens of extra subjects show up on Fringe’s trackers, but he no longer does.

Looking over the information contained on the hard drive Jones wanted, the Fringe team finds dozens of satellite geographical pictures. Peter realizes Jones is looking for Amphilicite, a rare but potentially very dangerous mineral. They determine one particular quarry is the most likely spot for the mineral so they race to beat Jones there. At first, they believe they’ve beaten him to the punch, but then they realize the satellite pictures are from our universe, not the alternate one. Jones has crossed over and is harvesting the mineral from our side. Peter and Agent Lee cross back to our universe and join the rest of the Fringe Team in trying to capture Jones. As usual, Jones is one stop ahead of the team and is able to escape back to the alternate universe with nearly a hundred pounds of the Amphilicite.

Meanwhile, Walternate’s wife Elizabeth has arrived in our universe to talk Walter into helping Peter, and ultimately, he agrees.

Walternate helms an emergency meeting between both Fringe teams as they realize they have to work together to stop Jones.

As the episode ends, Jones is communicating a secret partner about phase two of their plans, a phase that has to do with a certain unnamed “her.” The final shot of the episode reveals his partner to be Nina Sharp.

1. Bad Feng Shui
I’ve never known an Emergency Room with only one entrance. There are usually a half dozen or more. Strange and dangerous things can happen in ERs and you need lots of room for people to rush in, or out.

2. Spares, Just In Case
Are there just extra guns laying around in Fringe division vehicles?

3. Continui-what?
How many of the previous adventures have the various Fringe teams not experienced?
Nobody recognized Jones.
Walter’s comments about no sign of forgives makes me think he never received the eponymous white tulip.

4. Big Bang Dune
Mentat Astrid seemed less Mentat-like and more Sheldon like this episode.

5. What is the RDA of Amphilicite?
Has Amphilicite been mentioned in the show before? I can’t find any mention of it in my notes so I’m just wondering.

6. A Little Too Trusting
Once again, everyone is way too trusting knowing there are shapeshifters all around. Walternate is even suggesting that Fringe team is compromised, but doesn’t check if the person he’s telling is the real alternaBroyles (probably not, but I wouldn’t put it past the writers to try and pull a fast one).

Another good episode. As always, David Robert Jones makes an excellent villain. The Fringe Doomsday Clock retreats a minute to 11:52

This week’s Fringe cipher was: DEATH.
A list of all previous Fringe reviews is available here.
As always, Karl has more to say over at his blog.

To the best of my knowledge, Demerol has never been considered a truth serum. That is a term usually reserved for certain barbituates (sodium pentothal, amobarbital) or anticholinergic drugs (scopolamine). Demerol (generic name meperidine or pithidine), on the other hand, is a very potent narcotic pain killer. Admittedly, unlike most narcotics, Demerol does have some anticholinergic effects, but these don’t kick in except in very high doses, and the poor victim would be unconsciousness and probably dead from a Demerol overdose long before the effects became clinically useful.

More Comic Book Truth Serums

I’m sure they weren’t the first villains to use fear inducing drugs, but the Scarecrow and Mr. Fear are undoubtedly the best known villains who make use of them. I thought I’d take a brief opportunity to look back and see when they first started using their concoctions.

Scarecrow’s first two appearances were in the Golden Age and, frankly, were not terribly imaginative or exciting. Jonathan Crane was little more than a thug (albeit an over-educated one) who used a scarecrow motif. The only fear he caused was by threatening and shooting victims with a run of the mill pistol. It wasn’t until the Scarecrow’s first Silver Age appearance in Batman #189 that his fear gas was seen, and even then it was fairly underwhelming and only seen in one panel. The gas was just one of several techniques used by Crane to instill fear in Batman and Robin.

scene from Batman #189 (by Gardner Fox and Sheldon Moldoff. February 1967)

Mr. Fear and his fear gas pellets appeared in Daredevil #6 and predated Scarecrow’s use of fear gas by two years. Zoltan Drago was slightly mad chemist who ran a failing wax museum. His brilliant plan was to devise a serum that would bring his wax figures to life, giving him an unstoppable army. Yet somehow, despite his genius, he was unable to get his experiments to work. Then one night, his cat jumped up on his work bench and spilled some of his chemicals onto a Bunsen burner. The smoke it gave off induced terror, and Drago decided to use his accidental discovery to become Mr. Fear.

scene from Daredevil #6 (by Stan Lee and Wally Wood. February 1965)

Q: You need to x-ray Superman, but a normal x-ray won’t penetrate his Kryptonian skin. What technique should you utilize?

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A: You use a Super XXX-ray, of course!

However, after he’s been acquitted of the charges, Hogman admits to Murdock that he did indeed kill Flapper. How did he get this lie past Daredevil?
I’ll let him explain it:

Oops. How could Matt have missed that?

Actually, I can’t blame Matt for missing it, because it makes no medical sense.

Pacemakers only affect a slow heart rate — they do not affect a rapid heart rate. In other words, pacemakers are used to speed up a heart that is beating too slowly, or one that skips too many beats. They do not stop a heart rate from rising and would not have prevented Hogman’s heart rate from increasing when he lied on the stand. Matt should still have caught him in his lie.

(To be fair, Hogman could have an underlying heart condition such as sick sinus syndrome which causes his heart to be beat too slowly and not respond to stimuli — hence the need for a pacemaker — but that is not what is implied by this scene.)

From his very first appearance, Daredevil has had the ability to tell if someone is lying by listening to their heartbeat. It’s a skill he’s used numerous times over the years, and continues to use to this very day. Other heroes, such as Supergirl, have demonstrated a similar aptitude (I don’t know if Daredevil was the first to show this skill – you’d have to ask Waid, Busiek or Shutt about that — but he’s certainly used it the most.)

But is it true? Does someone’s heartbeat speed up when they’re lying? Daredevil presents as a certainty (“I can hear his pulse rate. It’s speeding up, indicating he’s lying!”), but is it? I have my doubts.

Certainly there’s a grain of truth there. When someone is stressed — and lying is generally stressful — their heart rate will speed up. But the heart rate is a very non-specific sign, and there are many, many things that affect it, causing a faster or slower heart rate on a moment’s notice. For a lowlife thug, just seeing Daredevil and realizing he’s soon going to be receiving the beating of his life would be enough to cause his heart rate to skyrocket, no matter whether his answers to Daredevil’s questions were true or false. Or maybe the person has Wolff-Parkinson-White syndrome, or a similar condition which causes rapid heart rate. Or maybe he just took a decongestant, or used his asthma inhaler, or had too much caffeine at lunch. Or maybe he just saw a pretty girl walk by. The point is, there are too many things that can cause a sudden increase in the heart rate to know for sure if the person is lying.

There’s also the question of whether lying always raises the heart rate. I expect it usually does, at least in big lies — but what about little lies or white lies? When my kids ask about Santa and I assure them he will be coming down the chimney on Christmas Eve, does my heart rate rise? What if I’m an accomplished liar? Would a long time criminal like the Fixer actually care enough about “Battling Jack” Murdock for his pulse rate to rise when talking about his murder? I doubt it. Just like there are conditions and medications that can cause an elevated heart rate, there are similar causes of a slower than normal heart rate. How does Daredevil know the people he questions aren’t on beta-blockers or similar drugs that slow the heart rate and blunt any rise in the pulse?

Finally, remember that the polygraph — the “lie detector” — which is generally considered unreliable at actually determining whether someone is telling the truth or not, uses the heart rate as just one part of its lie detection. If the polygraph as a whole is unreliable, why would just one part of it be any more reliable?

(In other words, to believe that Daredevil could actually detect a lie, I’d need to be convinced of two things. First, that a liar’s pulse rate always increases when he’s lying. Second, that lying is the only thing that could account for the increased heart rate. Similarly, to believe that Daredevil could detect that someone was telling the truth, I’d need to be convinced that a liar’s pulse rate always increases when they lie, and that there’s nothing else that could explain away the normal heart rate. Don’t worry, I accept the rapid pulse = lying for the purposes of the story — just like I accept that people can fly and lift buses — I just don’t like the “science” behind it.)

Birds of Prey #4 “Absolutely Mental”
Duane Swierczynski, writer
Jesus Saiz, penciler

Reading the otherwise excellent Birds of Prey #4, I ran across a common misconception about the AMA (the American Medical Association):

The American Medical Association is a no more than a professional organization of physicians — essentially a large powerful lobbying group. They are not a government agency and have no official sanction. The AMA has nothing to do with drugs, or side effects to drugs. They certainly have no power over patients taking drugs — even for unapproved purposes — so would be no concern to Black Canary. Additionally, the AMA has no authority over any doctor’s medical license — they cannot award them or suspend them (not an issue in this comic, but an even more common misconception about the AMA in general).

So this new “experimental stroke treatment drug” has an annoying mind control side effect? Who should handsome young Dr. Cahill report his concerns to? The FDA. They’re the ones in charge of approving (and in some cases, unapproving) drugs and keeping track of reports of side effects. The pharmaceutical company should also be tracking the side effects of their drugs, though recent reports have shown that they’re not always as enthusiastic about that as they should be.

Or this all could be a really lame pick-up attempt by Dr. Cahill.

Another post dealing with AMA misconceptions, the Beast, and Dr. Mid-Nite.

Of bandaging the head over the costume?

scene from Daredevil #164 (by McKenzie, Miller, and Janson)

As 2011 draws to a close, it’s time to take my annual look at the best — and worst — comic book medicine from the past year.

Best Depiction of Medicine:
Slim pickings this year, I’m afraid — there were no great diagnostic or resuscitation scenes. I’ll give the nod to Avengers Academy #14, for the team’s recognition of the dangers of electrical shocks, and it even ties in — a little, at least — to my common admonition not to shock a flatline. link

Best Doctor:
This year, I’m going with the late Thomas Wayne, M.D., for quickly recognizing the symptoms of an obscure Asian disease in Streets of Gotham #20 (though his treatment left a little to be desired, at least by modern standards). link

Best Single Medical or Scientific Concept:
Veil’s clever use of Isoflurane to knock out an entire group of people in Amazing Spider-Man #661. The second win for writer Christos Gage. link

Best Imaginary Medicine or Treatment:
The use of Pym Particles to reduce the swelling in Hawkeye’s injured brain in Hawkeye: Blindspot #4. link1

Honorable Mentionss:
A (generally) well drawn hospital scene in Uncanny X-Men Annual #3.
Tony Stark’s “ubi-vaccine” in the Indomitable Iron Man.
The (slightly evil) use of Ipecac in Red Robin #26.

Worst Depiction of Medicine:
Hands down, the insulting treatment of paramedics in Green Lantern #59. link

Worst Doctor:
I’m giving this one to the unnamed doctor leading the resuscitation of Mockingbird in New Avengers #11. He scores the hat trick of poor vital technique, incomplete understanding or heart physiology, and shocking a flatline. link

Worst Single Medical or Scientific Concept:
John Constantine’s plan in Hellblazer: City of Demons to feed blood thinners to all the people transfused with his demon-tainted blood, and then to cut them so all their infernal blood will drain out — apparently forgetting that if someone loses all their blood, they will die. link

Worst Imaginary Medicine or Treatment:
The creation of a modified Asian Rat Bite Fever was a brilliant idea, until they actually tried to implement the — and did everything entirely wrong (Streets of Gotham #20) .link

Dishonorable Mentions:
A very flawed understanding of Tetanus in Gotham City Sirens #22.
Shocking a flatline while patient and doctor are covered in water (and normal abnormal vitals) in Ultimate Doom #1.
The use of horse tranquilizers in Voodoo #2.

Previous “Best of the Year”: The Best Comic Book Medicine of 2010 The Best Comic Book Medicine of 2009 The Best Comic Book Medicine of 2008 The Best Comic Book Medicine of 2007 The Best Comic Book Medicine of 2006 The Best Comic Book Medicine of 2005 The Best Comic Book Medicine of 2004

Previous “Worst of the Year”: The Worst Comic Book Medicine of 2010 The Worst Comic Book Medicine of 2009 The Worst Comic Book Medicine of 2008 The Worst Comic Book Medicine of 2007 The Worst Comic Book Medicine of 2006 The Worst Comic Book Medicine of 2005 The Worst Comic Book Medicine of 2004

As an early Christmas present, I’m going to provide everyone with the secret formula for an invisibility serum, thanks to Lex Luthor and Adventure Comics #286:

Did you get all that? The ingredients of Luthor’s invisibility serum are:
1) Mouthwash (brand not specified), 2) Orange Juice, and 3) two aspirin.

Chemicals AND acids! And here I thought acids were a type of chemical.

Now Luthor takes two radio parts he had hidden in his shoes, and heads out to the prison yard…

So: Mouthwash + orange juice + aspirin + “amplified” vibrations from the prison siren = invisibility. Genius!

Superman and his son understand the downside of invisibility* in this scene from Superman #166, a topic generally ignored in comics (as far as I recall, only Warren Ellis in Planetary has addressed the issue, though I wouldn’t be surprised if there’s been some Marvel-style pseudoscience handwaving sometime during the Fantastic Four’s run.)

*The problem being that in order to see, a person requires light hitting their retinas. If they are invisible and “light passes through” them, then it can’t strike the retina, rendering them blind)

…or at least the twist endings of pre-Code horror comics.

• Though by 1952, when this story was published, smallpox was all but wiped out in the industrialized nations. Of course, the story does mention that the ship in question is a “dirty old tramp” and it looks like her sailors weren’t much on healthcare…or personal hygeine.

Somehow, probably thanks to this website, I’ve ended up on quite a number of PR e-mail lists. Most, if not all, is little better than spam. One firm in particular, once or twice a week, sends me e-mails showcasing the skills of various doctors or alternative medicine “practioners” that they represent.

First of all, if you’re a doctor who has a PR group, you’re doing it wrong. At the risk of stating a tautology: medicine is practiced by practicing medicine, not by press releases. If you’re not actually in the trenches, spending the majority of your time actually seeing patients – or doing legitimate research – I have no interest in what you have to say.

For example, yesterday, I received a press release about a homeopath who, among other areas of expertise, was an (self) avowed expert in hangover relief. The press release touted her “500 clinical hours in classical homeopathy.” Good for her, I guess. I had five hundred clinical hours as a first year resident, and I sure wasn’t an expert in anything. Currently, in the 2011 calendar year alone, I have 1880 clinical hours under my belt with a couple weeks left to go.

As for her hangover cure, it starts with the usual homeopathy nonsense, recommending drinking a 200c dilution of nux vomica (strychinine – but diluted so much that it’s unlikely that even a single molecule of the chemical remains in the final solution. So if it works, it’s not because of the nux vomica, but because drinking water helps hangovers). The second step?

Cranberry Juice: 2.3 – 2.5
Orange Juice: 3.6 – 4.3

So clearly cranberry juice is dramatically more acidic than orange juice. If the alleged expert can’t get this simple fact from high school chemistry correct, why should I believe what she has to say about anything else?

But then again, when have homeopaths paid any attention to legitimate science?

More Little Dot…

…and another good example of what I like to call the “x-ray gag” [q.v. Richie Rich, Atomic Bunny, and Hot Stuff]

This Maxwell Lord/psychic nosebleed is way past cliched and is well into the realm of completely ridiculous. I’d say that out of all the recurring comic book contemporary villains, Maxwell Lord is the most one-dimensional. Maxwell Lord equals evil mind controlling nosebleeder, end of story. He was more interesting when he barely appeared in Justice League International.

For a supposedly advanced culture, the Krytponians sure have brutal methods of dealing with mental illness.

Also notice that they call it the “Psycho Observation Ward” — not “Psychiatric Observation Ward”, or even “Psych Observation Ward”. They’re not mincing words and have all but diagnosed you before therapy even starts.

If his “brain had left his body,” he wouldn’t have a pulse — because after all, the brain controls the pulse (not to mention there’d be a big hole in his head and quite a mess on the floor).

I think Batman’s actually referring to the victim’s “higher consciousness*” (however you wish to define that term), though what pupil response had to do with “higher consciousness” is a mystery to me (and how can Batman even judge the pupil’s response when he’s behind the patient?).

*Yes, this becomes one of those mind-downloaded-into-a-computer story. And a giant ape is involved as well.

What started out as an intriguing courtroom thriller ended up a barely mediocre episode of House

Tommy is a forty year-old prosecutor who develops sudden severe chest pain in the middle of a court case. He is admitted to the hospital where a heart attack and anxiety are ruled out — with no clear cause of chest pain remaining, he is admitted to House’s service. The team’s initial differential diagnosis includes shingles, asthma-induced pneumothorax (a collapsed lung) or poisoning (particularly chlorine poisoning). House thinks poisoning seems the most likely, so has the team alkalinize the urine, and then interview his wife and search the house. No poisons turn up in the search, but Park and Adams find a hidden bunker filled with guns. Now Chase and Adams think that this is a sign of paranoia, but Park doesn’t think he’s paranoid. Taub, wisely, sits this one out. The new differential diagnosis consists of cocaine abuse, Fahr’s disease, or atrial fibrillation due to hyperthyroidism or sleep apnea. House has all the suggestions checked, but everything comes back negative.

Park notices a bleeding sore on Tommy’s leg, which he tells he didn’t know about. He starts running a fever as well. The team thinks tuberculosis is possibility, as is systemic sclerosis (better known as scleroderma, an autoimmune disease). House decides to go with Taub’s suggestion of sclerosis; he orders a skin biopsy and starts Tommy on enoxaparin (a blood thinner). The treatment doesn’t help and Tommy starts having hallucinations and suffers a psychotic break. Park thinks he has an infection like tularemia and Adams thinks he has GAD autoimmunity. Chase thinks all of the patient’s symptoms are psychiatric or self induced. House favors Adams, and starts Tommy on immunoglobulin and corticosteroids. Tommy continues to get worse with his fever getting higher. Adams wants to up the steroid dose, but this time House agrees with Park and has Tommy checked for a number of infectious diseases, including sporotrichosis and meningococcemia.

Without warning, Tommy goes into anaphylactic shock. Chase performs a tracheotomy, but it doesn’t help because the airway blockage is below the cricothyroid membrane. There are some tense moments (as least I assume they were tense, all we got was a commercial break), but Chase and Taub manage to open the airway and get him hooked up to a ventilator. The team is at a loss for a cause when Park suggests that Tommy’s symptoms are the result of squamous cell carcinoma (a type of skin cancer) along with paraneoplastic syndrome. The team is getting ready to obtain a skin biopsy when House has one of his Eureka! moments and realizes that Tommy has severe diphtheria. One of the classic symptoms of the disease is a pseudomembrane which blocks the airway, and this explains the respiratory arrest. His other symptoms have also been associated with the disease, albeit very rarely. Some antitoxin, and he should be as good as new (though still paranoid).

As usual, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

A patient with non-cardiac non-anxiety chest pain is not a big mystery; they’re a dime a dozen. Once the patient’s chest pain is determined to be non-cardiac, there’s no reason to admit the patient (unless something life threatening is going on, which is not the case with Tommy – at least at this point). The rest of the work-up can be done as an outpatient.
There are many common causes of chest pain that are non-cardiac and non-anxiety (gastrointestinal and musculoskeletal are common, for starters). An ER of that size would see at least a dozen such patients a day. There is no reason House would be intrigued by such a pedestrian complaint.

Notice how, for once, House held off starting broad spectrum antibiotics (or any antibiotics) and waited for tests to come back first – only because if he had given the antibiotics earlier the case would have been solved too quickly. Acting out of character in order to advance the plot is not the sign of a well written mystery.

Do they intend to biopsy the entire chest looking for this squamous cell cancer, or is there a suspicious lesion on the chest just asking to be biopsied – and if that’s the case, why didn’t someone spot it or mention it sooner?

Severe enough diphtheria to cause fever, pseudomembrane formation, skin lesions, chest pain, and hallucinations, but somehow there are no upper respiratory symptoms or swollen lymph nodes?

Giving someone Xanax and noting no chest pain, even when lying to the patient, does not rule out anxiety. For instance, what if they only have anxiety in high-stress situations like a courtroom? What does giving them Xanax in the artificial surroundings of the hospital accomplish?

It was not anaphylaxis, it was respiratory distress/arrest. They are not synonymous. You’d think the team would notice there were no other symptoms of anaphylaxis.

The main symptoms of Fahr’s syndrome are disorders of movement, none of which the patient had.

Once the airway blockage has been cleared, why is Tommy on a ventilator? There was never any indication or any reason given why he was unable to breath for himself.

Someone with a bad infection may worsen on corticosteroids, but giving someone with GAD autoimmunity antibiotics is not going to kill them.

If the EKG was normal and the cardiac enzymes were normal, why proceed with a cardiac catheterization?

Schizoid and schizophrenia are not the same thing.

As I mentioned above, the medical mystery this week was routine, boring even. Chest pain is exceedingly common and this case would not pique House’s interest. I give it a D. The final solution fit, but really only if you accepted the fact that the doctors on the team are idiots and borderline incompetent. I give it a C. The medicine diagnoses seemed more random than logical with many of them fitting the patient poorly, if at all. And did I mention House acting out of character? I give it a weak D The soap opera was better this week with all three storylines (Foreman, Park, House/Wilson) clicking. I give it a B+.

The review of the previous episode of House
A list of all prior House reviews

This week, Akshay R, James H, and Kevin Lighton won with 8 points. Roxanna was fourth with 7 points.

Overall, James H takes over the lead with 39 points. Dr. R drops to second with his 37 points. Yerkietand mbrigdan are tied for third with and has 35 points. Roxanna moves into fifth with 32 points. If you have 29 or more points, then you are in the top 10%.

Click here to see the full scoreboard.

Dashford Dartwell. With a name like that, you’re destined for soap operas – or super heroics.

One night there is an explosion in the lab of Dr. Moss, chemistry professor and father of Dash’s girlfriend. Dash rushes in and the professor tells him that he has successfully invented a Metabo-Catalyst.

He tells Dash: As yet, I don’t know it will do. It might give extraordinary speed-strength-ANYTHING!
I must make human tests!

To which Dash replies: How about some lab testing, or at least animal studies before human studies. Have you talked to the IRB? How about making them on me?

That’s right, Dash has just witnessed the metabo-catalyst cause a lab explosion, yet volunteers to test the chemical concoction – a mixture even the inventor admits he doesn’t know what it will do – on himself¹.

Of course, this is the Golden Age, so Dr. Moss’ Metabo-Tablets grant him super-strength, super-speed, and super-agility. So Dash uses his newfound powers to stop crime and right wrongs – right? Well, not exactly, first he uses his chemically-enhanced abilities to set four world records and help his college (Dravrah) defeat its rival (Elay)^{2, 3}. Then, only when personally threatened by gangsters, does he decide to use his powers to fight crime.

NOTES:
1. It could be that Dr. Moss can’t stand Dash and this was all an elaborate ploy to kill him.

2. It’s bad enough that Dash uses his chemically-enhanced powers to gain an unfair advantage in the game – after all, the Flash did essentially the same thing in his first appearance – but the coach knows what he is doing and does nothing to stop him or even tell him that it’s unethical.

3. Dravah and Elay. Really. Are they in Yvi Eugael?

4. Admittedly, he does spend two of his next — and final — three appearances fighting crime (the third is a reprint of his origin).

Precognitives have never had it easy have they? Ask Cassandra, or ask poor Asher Cobb here:

scene from The Sixth Gun #14

All previous Psychic Nosebleed Zen posts.

A promising episode derailed by a story decision more suited to Grey’s Anatomy or Chicago Hope than House. The B storyline was better.

Two cases this week: the team tackled the case of a moody teenager, while House looked into the death of a four year old boy.

The team takes on the case of Iris, a fourteen year-old girl who was admitted to the hospital with an idiopathic anaphylactic reaction. The first thoughts are hereditary angiodema (a genetic condition leading to swelling of the face and airways), systemic mastocytosis, pheochromocytoma (a tumor that secretes stress hormones, like adrenalin), or an anaphylactoid reaction to opioids. They start out by checking a catecholamine panel (high in cases of pheochromocytoma) and an expanded opioid screen. Taub learns that Iris’s mother has been secretly slipping diazepam (Valium) to her daughter to calm her down, telling her they were vitamin pills. When Iris suddenly begins throwing up, the team starts to rethink their diagnoses. A quick exam reveals some mild abdominal pain and breast tenderness. They run a pregnancy test, even though she insists that she’s never had sex. About this time, she develops numbness in both arms. The pregnancy test comes back positive, explaining away many of the symptoms. To work up the paresthesia (numbness), the team considers the possibilities of a cerebral tumor, vasculitis (inflammation of the blood vessels), multiple sclerosis, or HIV-related mononeuritis mutiplex. The tumor and HIV seem the most likely, so a blood test and MRI are ordered, but both are negative.

In the meantime, Iris’s paresthesia has resolved, but she now has bruises on her upper arm. The team investigates the possibility of clotting disorders such as thromobocytopenia (low platelet count), vitamin K deficiency, or scurvy (severe vitamin C deficiency). The tests for these conditions are negative, but a search of her room at home turns up a hidden stash of love letters and hardcore pornography. When confronted, Iris admits to having a boyfriend and reports that the porn is his. She also explains that he snuck into the hospital and beat her the night before, explaining the bruises. In the middle of the conversation, she develops a sudden attack of tunnel vision, which resolves spontaneously. Chase suggests a TIA (transient ischemic attack — a “mini-stroke”) and an MRA is ordered. House, stopping by, has a moment of inspiration and tells Iris her boyfriend was hit by a car. She angrily tells House that he’s lying because she is the boyfriend. It turns out that she has dissociative identity disorder (multiple personality disorder, to the layperson), and the boyfriend is just one of her personalities. Hypnosis reveals the trauma that split the personalities was the car accident when she was two that killed her father. Snips of memory from that accident (strawberries, an eight ball) caused her initial allergic symptoms — in one personality at least. It seems each personality was exhibiting different symptoms, and that’s why they would come and go so quickly. When she develops severe vaginal bleeding, the team realizes that she still has an unexplained medical ailment. They find that the symptoms that are consistent across all three personalities are the pregnancy, the high blood pressure, and the vaginal bleeding. Bearing this into account, the differential now consists of preeclampsia or an ectopic pregnancy (a pregnancy outside the uterus), but an ultrasound reveals no embryo. She is ultimately diagnosed with choriocarcinoma, a cancer of the placenta (or rarely, very rarely, a choriocarcinoma can be found in other reproductive tissue).

Meanwhile, House is obsessed with discovering the cause of death of a four year-old who died five years before of an unexplained kidney disease. Berger’s disease is suggested initially but when House learns that the lungs were also involved, he considers lupus and Wegener’s granulomatosis, but those avenues of inquiring prove pointless. Next he focuses on heavy metal poisoning, particularly arsenic, lead, and mercury, but his tests are negative. In the end, after a confrontation with the dead boy’s grandfather, mother, and mother’s new-husband — combined with an earlier comment from the boy’s father said — House realize that the boy had been partially deaf and was suffering from Alport syndrome, a genetic condition affecting kidneys and hearing.

As usual, major complaints are in red, modest complaints are in blue, and nit-picking ones in green:

As far as I was concerned, the episode was going along fairly well, but then lost all momentum and semblance of coherence when the diagnosis of dissociative identity disorder (DID) was introduced. It introduced more questions and generating more handwaving than it solved. For example:
What trauma caused the boyfriend personality?
Nobody noticed Iris’s changes in personality? Not just no one at home (explained away by the Valium), but no one at the hospital noticed a change in personality with a change in symptoms?
Iris’s main personality was aware of the boyfriend much more than she should have been if it were a true case of DID.
DID in young patients is not unheard of, but very rare. But a two year old? You can’t blame the Valium for Mom missing a decade of symptoms unless she started Iris on Valium as a toddler.

Three positive HCG tests and no one ran a quantitive test (tells how much HCG there is. Can be helpful in dating the pregnancy, or discovering if something else, like a choriocarcinoma, is going on), or checked an ultrasound for dating. How far along the pregnancy is is an important topic, especially when considering preeclampsia, ectopic pregnancy, or even morning sickness.

I don’t think pregnancy is a “symptom” of a condition. A positive HCG test may be, but that’s not what they were discussing during the differential. They also forgot to mention all the symptoms they explained away by blaming that same pregnancy (vomiting, abdominal pain, breast tenderness, abnormal periods).

Another House episode this season overcome by real world events, in this case the recent news that the most famous of all multiple personality cases, Sybil, was faked – casting doubt (more doubt, anyway) on many of the more extreme DID cases.

A patient taking diazepam would not have a “clean tox screen,” she would be positive for benzodiazepines.

An expanded opioid screen is not better at telling if a person is on opioids or not, it just shows which opioid they are taking. If the initial tox screen was negative for opioids, then the expanded screen would be too.

It was more of a symmetrical neuritis than a mononeuritis multiplex.

For the second week in a row, Park suggests the most ridiculous diagnosis: scurvy. Really? Easy bleeding, sure, but no other symptoms match.

Like most of this season’s episode, this week’s medical mystery was mildy interesting, but little more. I give it a C+. The final solutions to both medical mysteries fit, at least better than usual. They earn a B+. The A-storyline had sloppy medicine, and that was before they added in the multiple personality aspect. The B-storyline was better, but not enough to save the episode. I give it a D+ (the plus is from the B-storyline). The soap opera wasn’t compelling this week. How many times can we see Foreman stew over where to draw the line with House, and how many times can Wilson ineffectually hem and haw. It was particularly hard to accept the hard ass Foreman this week after we say him sharing a beer with House at an out-of-town boxing match last week. The soap opera earns a C-.

The review of the previous episode of House
A list of all prior House reviews

This week, yarnpiggy leads the way with 13 points. Cyndi, Karatesocks, Nextsundayad, and Synth tie for second with 6 points.

Overall, Dr. R retains the lead with 37 points. Yerkiet is still in second and has 35 points. mbrigdan is third with 32 points. James H is fourth with 31 points, and Alex51 is fifth with 30 points. If you have 26 or more points, then you are in the top 10%.

N.B.: This week’s scores also contain the two corrections from last week’s scoring.

Click here to see the full scoreboard.

A disappointing episode of Fringe. The writing was choppy and the science sloppy; it felt only half finished.

The Plot: Olivia wakes up at night with a bad migraine. She heads to a pharmacy to refill her prescription and on the way home she passes an all-night diner where Agent Lee is sitting; it seems he has bad insomnia since joining the Fringe Team.

Across town, a man is heading home late at night and has the strange sensation he is being followed. Just as he makes it to the front door of his apartment building he is attacked. When the police arrive a few minutes later, they find him dead, and white as a sheet – drained of all pigment. Unsurprisingly, the Fringe Team is called in. Walter suggests the victim may have been scared to deat,h and Agent Lee finds blood on some broken glass, evidence of their mystery suspect. The blood is identified as belonging to an infant who died 22 years ago. Visiting the hospital where the baby was born, the team learns the baby had an unknown genetic condition, and didn’t really die, but instead was kidnapped by a company known as Cyprox, an old subsidiary of Massive Dynamic. Olivia visits Nina Sharp who admits Cyprox performed genetic experimentation on Eugene (what the baby was named), but insists the experimentation saved his life. He disappeared after a lab fire ten years before and they had assumed he died.

Meanwhile, another body has been found at another apartment complex. The building is locked down and the lights shut off. Walter has determined that Eugene can be seen under ultraviolet light and so groups of FBI agents search the building with UV lights and dogs. Olivia falls in a hole and Eugene rescues her, but then runs off. The team continues to search the building, but calls it off after there is no more sign of Eugene. They do find his hidden apartment and lab in the basement. Olivia speculates that Eugene just wants to be seen. A short time later, Eugene, now looking normal, enters the elevator at the apartment complex and has a short conversation with Julie, the object of his infatuation. As she leaves the elevator and the doors close, Eugene collapses to the floor, twitches, and dies.

Later that night, Olivia is getting ready to head out to the all-night diner to meet up with Agent Lee when she is knocked out by a gas pumped into her apartment. Two men enter her apartment, disable the security cameras, and inject her with a red medication. They mention that she’ll be out for a couple of hours, and wake with a massive headache. As they leave the room, we see Nina Sharp standing by, supervising the entire operation.

1. Not Quite Thirty Minutes Or Less
It takes more than 4 days to get genetic testing done, especially if so many “experts” are involved.

2. Let’s Digitize The Tests We Didn’t Perform
I realize this may or may-not or may-sometimes be our universe, but hospitals don’t keep DNA databases. And even if they did, why would it be online when the episode made the point of explicitly mentioning that all the hospital records from that era were on paper?

3. It’s A Hard Knock Life
Did Baby Boy Bryant didn’t have any parents? (The name is what you’d expect in a hospital file; all newborns are “baby-boy-mothers-lastname” or “baby-girl-mothers-lastname”).

4. Sorry Jean Valjean
A person’s hair turning white from a sudden fright is a myth. At most, theoretically, you could change the color of any hair that is newly growing, but the color of hair that’s already emerged from the follicles cannot be changed (excluding Clairol and Just for Men, of course).
What exactly was the pigment drained through? The pores? Capillaries? What?
More importantly, if Eugene is pigmentless, how does he see? The retinas require pigment to function.

5. Unclear On the Concept
I’m unclear how Eugene stealing other people’s pigment was returning himself to his original condition, since he was born without any pigment.

6. Ennui
In this entire episode, the Fringe Team accomplished nothing. Seriously: if they had not become involved, Eugene would have talked to Julie and died, just like he did after they became involved. They saved no lives; they prevented no crimes. There’s nothing quite like watching the characters of a TV show so completely not matter.

7. Mischief Managed
No octopus or chameleon can mimic that complicated an environment. They “blend in”, they don’t disappear. It’s camouflage, not the One Ring.

8. Spotting Scorpions
Why not bring in decent sized UV lights rather than those dinky little flashlight ones? It would be very easy to miss someone with one of those, especially the way they were haphazardly swinging them around. The ones we use in our office are easily four times the size of those, light, and portable.

The plot was too sloppy, let alone the science, for this to be considered a good episode, let alone the advertised mid-season finale. The Fringe Doomsday Clock gains two minutes to midnight.

This week’s Fringe cipher was: DAVID.
A list of all previous Fringe reviews is available here.
As always, Karl has more to say over at his blog.

A disappointing episode, as the ones that try to make a broad point (this time: all parents screw up) usually are. There were a few clever moments — who am I kidding, there was one, maybe two clever moments, and the rest was rushing from one imagined crisis to the next

Ben is a teenager working, quite ineptly, as a clown at a kid’s birthday party. After an altercation with one of the kids and their father, he develops the sudden paralysis of an arm and a leg and is admitted to House’s service with a diagnosis of TIA (Transient Ischemic Attack, i.e. a “mini-stroke.”) The team is puzzled why a healthy teenager would have such a condition. The initial concerns are drug use or endocarditis (an infection of the heart valves). A transesophageal echocardiogram is ordered — it shows no heart valve problems, but it does reveal a thickened pericardium (the membranous sack that surrounds the heart). The differential now includes syphilitic vasculitis, histoplasmosis, or Sjögren’s syndrome. The tests for the first two were negative, so House orders Ben started on immunosuppressants to treat the Sjögren’s.

While Taub sets up the medication, Ben develops a bloody nose, then a bloody cough. Taub reports that Ben’s platelet count is low and suggests DIC (disseminated intravascular coagulation). Park reports a low red blood cell count and suggests a retropeitoneal bleed (bleeding into the tissues behind the abdominal cavity). Adams reports few white blood cells and suggests an infection. House notes that the entire blood count (platelets, red cells, and white cells) is low and reports that Ben has aplastic anemia (a condition where the bone marrow stops production of any kind of blood cell). He has Ben started on platelet transfusions and orders bone marrow testing on Ben and his relatives to prepare for a bone marrow transplant. A short time later, Ben complains of back pain and his blood pressure drops. It turns out that he is having an allergic reaction to the platelet transfusion. House orders a more specific kind of platelet transfusion so there will be less chance of a reaction. Ben suddenly starts gasping for breath and after a perfunctory physical exam, Taub announces that he has a pleural effusion (fluid building up around the lungs). A chest tube is placed, but rather than returning blood, it drains an transudate (which to me looked more like an exudate), which Park takes to mean our old friend liver failure is back. The team now has a prolonged and mostly pointless argument about whether the liver failure is due to a failure of protein synthesis or high ammonia levels. House suggests feeding Ben a high protein diet to purposefully worsen the liver, and his symptoms (heart failure or coma) will let the team know which problem he had (because this is so much quicker and easier than running a ten-minute blood test).

Of course, things quickly go from bad to worse. Ben’s left eye starts bulging out and needs steroid injections to resolve. The team now suggests angioneurotic edema, anasarca, or Burkitt’s lymphoma. House suspects that later is the most likely, so starts Ben on chemotherapy. While receiving his therapy, Ben crashes and develops multiple organ failure. The team initially suggests multiple aneurysms or cholesterol emboli as potential causes. But then Ben’s estranged and in-fact-thought-dead father stops by, and House recognizes the abnormal gait of someone with tabes dorsalis, a sign of syphilis. This causes him to realize that the father sexually abused Ben as a youngster and infected him with syphilis, which is what caused his current symptoms — well, that plus the antibiotics causing a Jarish-Herxheimer reaction (severe symptoms caused by multitudes of bacteria dying off and releasing toxins into the bloodstream).

This week’s episode was particularly weak in differential diagnoses. After the first round, they quite trying, and the newer diagnoses just explained the latest symptom and not the previous ones, so the original admitting symptoms were usually left unexplained. As always, major complaints are in red, modest complaints are in blue, and nit-picking ones in green:

Once again, House is starting chemotherapy on a patient without even confirming the patient has cancer, let alone what type he has. There is no generic chemotherapy; it is specially tailored to the specific cancer.

A few simple blood tests would determine the likely cause of the liver failure, though it is quite possible if not very likely to have poor synthesis and high ammonia livers. Despite what House says, it would be quicker too than feeding the poor patient protein and waiting for it to be processed by the liver and have an effect.

Worst diagnosis of the episode: retroperitoneal bleed. How does that even come close to explaining the TIA symptoms?

A pleural effusion is not “bleeding into the lung.” It is bleeding around the lung, a not unsubtle difference.

I have my doubts that the syphilis tests (likely an RPR or VDRL) would be negative in Ben’s case. Those tests are known for their false positives, not false negatives.

If Ben’s white count is so low as to suggest aplastic anemia, why was he not placed under neutropenic precautions?

The effusion should have been clear, not cloudy (and I’d expect it to be a little bloody as a result of the brutal chest tube placement as well).

This week’s medical mystery was a little interesting, but not terribly compelling. I give it a C. The more I think about the final solution, the less it makes sense. Ben had latent syphilis that suddenly, in the space of a minute, exploded into neuro- or at least cardiosyphilis? Really? And the Jarish-Herxheimer symptoms are a poor match as well. It earns a D. The medicine was poor as well, and was more reactive than actually thought out. I give it a C-. The soap opera, at least among the patient and his family, and among the team was interesting, though Taub surely knows that House cares nothing for his daughters’ well-being. The House/Wilson/Foreman aspect, though at times amusing, just reminded me of what a sad defeated man Wilson really is. I give the soap opera a B.

The review of the previous episode of House
A list of all prior House reviews

A high scoring week as a bunch of people had syphilis as a choice. Dr. R was first with 15 points. Seven different players had 14 points , and more had 13 and 12 points.

Dr. R takes the lead with 33 points. Yerkiet makes a surge into second with 32 points. mbrigdan is third with 31 points and SMEL drops to fourth with 27 points. Alex51, brism19, and 4287 are tied for fifth with 25 points. If you have 21 or more points, then you are in the top 10%.

Click here to see the full scoreboard.

An enjoyable episode of Fringe, but then, episodes featuring time travel usually are. (What would have made it even better would have been if the crew had managed to place a red Swingline stapler in Raymond’s house.)

The Plot: A series of strange time-related events have appeared around Boston. They all seem to relate to events that happened four years before. An apartment complex suddenly shows signs of fire damage, but the fire happened four years ago and the damage was long since repaired. A five year-old girl is reverted back to infancy. A freight train appears on a track abandoned four years before.

The Fringe Team is called in and brings along Peter, suspecting that the time effects are somehow the result of him reappearing in our universe. Mapping the disturbances, the team is able to discover that the effects seem to originate from one particular block. Soon, they are able to identify the specific house, but it is surrounded by a time bubble that will disintegrate anyone who enters it. Walter builds a portable Faraday cage that Peter is able to use to enter the house.

Inside the house are Raymond and his wife Kate. He is an electrical engineer and his wife is a theoretical physicist – or was, as she now suffers from severe Alzheimer’s disease. Raymond has used her notes on time to build a machine responsible for creating the time bubble surrounding the house. He brings the time in the house back four years, before Kate’s Alzheimer’s kicks in. Currently, his machine isn’t quite finished because Kate hasn’t finished her time equations, so it only works for a handful of minutes. That’s enough for him to bring her back to work on finishing the equations so the time bubble can become permanent. When Peter arrives, he confronts Raymond about the side effects of the machine, including the imminent deaths of hundreds of people in an underwater transit tunnel. Raymond agrees to shut off the machine, planning on building it again later. He knows that Kate has finished the equations so his next machine should be work perfectly – only, instead of writing down the finished equations, Kate blotted out all her previous work so Raymond can never build the machine again.

As the episode ends, Peter tells Broyles that his appearance in this universe provided the spark Raymond’s machine needed to work – this makes Peter think that he has appeared in the wrong universe.

1. Better Than Sylvia Brown
Peter is able to recognize that something is “growing geometrically” from just a single event?

2. Sure Natural Radiation is Good, but Organic Radiation is Much Better
Despite what Peter says, neutron radiation does occur naturally. (I’d go into a more thorough debunking of Fringe radiation here, but Karl’s always been better at that than me, so I’ll just link to him earlier than usual.)

3. The Fools-Gold Spiral
Fibonacci’s sequence creates something very close to the Golden Spiral, but it’s not quite the same thing. (A true Golden Spiral has a growth factor of phi. The Fibonacci sequence approaches this, but never quite reaches it.)

4. Time Keeps Flowing Like a River
Apparently, time is an electromagnetic wave and can be blocked by a Faraday cage (but walkie-talkies cannot be blocked by time bubbles or Faraday cages. Seriously, at that point Peter was so close to Olivia, why not just pop his head out of the bubble and talk to her?)

5. Steady Hands
Apparently Walter and Peter can both hand draw perfect Golden Spirals without mechanical aid. Must be genetic.

6. Caged Rat
Faraday cages consist of fine metal mesh which block out certain wavelengths of electromagnetic waves depending on the size of the mesh. Whatever Peter was wearing wasn’t a Faraday cage.

7. Ahead of Its Time
How long has Walter’s house been abandoned, because that look’s like a recent model flat screen TV.

8. Old Friends
This is the third episode Burlap Bear has been mentioned in. (Previous episodes 1-16 “Unleashed”, 3-07 “The Abducted.”)
The airplane in the old house looks like the one Peter bought after arriving from his universe into ours (episode 3-15 “Subject 13.”).

9. Gratuitous Product Placement
Sprint for the win.

A somewhat cliched story, but an enjoyable hour nonetheless (plus it’s always enjoyable to see Stephen Root). The Fringe Doomsday Clock retreats a minute, returning to 11:52

This week’s Fringe cipher was: LIVING.
A list of all previous Fringe reviews is available here.
Karl has more to say over at his blog.

Batwing #2 “We Have Blood On Our Hands”
Judd Winick, writer
Ben Oliver, artist

Batwing rushes to the hospital with a severely wounded victim. The emergency department team begins treatment immediately:

A good start to the resuscitation. Blood pressure of “eighty-palp” means that the patient’s systolic pressure is 80 (the top number in blood pressure, usually at least 100), and the diastolic pressure (the bottom number, usually around 80) can’t be read by the machine, but can be felt (hence “palp” for “palpable”). Placing two large IVs, one in each arm, is standard of care for emergency treatment. The large IVs allow fluid and blood to be given quickly. “Four units of O-neg” means to give the patient four units (roughly 2 liters) of O-negative blood (the universal donor; the patient needs the blood now and they don’t have time to test for the exact blood type match). This comic does follow what I call the “Final Thought Intubation Rule” — do not intubate the patient until they can deliver a final confession or clue.

The patient is in ventricular fibrillation (v-fib), a dangerous and usually fatal heart rhythm. Nice to see them starting CPR. Defibrillation is key in the management of ventricular fibrillation (the name should be a clue), so shock the patient fast and often while they remain in ventricular fibrillation. 200 joules is the usual starting setting, followed, if unsuccessful, by 300 and then 360 joules. If more shocks are required after that, the setting stays at 360 joules.

There are a few slightly different treatment algorithms for ventricular fibrillation — some recommend giving Epi (epinephrine) early, some recommend waiting to give it until after three unsuccessful shocks. (A nitpick: would they really use the term “Epi” here? The name epinephrine is only used in the U.S., everywhere else in the world they call it “Adrenalin”.) Amiodarone is used in treating ventricular fibrillation, but is generally not recommended until later in the algorithm if the patient is not responding to the usual treatments.

Did you notice that the patient apparently slipped into asystole (flatline) or PEA (pulseless electrical activity) after the first shock — notice how they keep saying “no rhythm.” If this is indeed the case (and there’s just text and a generic resuscitation scene in the comic; we don’t get to see the actual monitor), then the patient no longer shows a “shockable rhythm” and they should have stopped treating for v-fib and switched to treatment of asystole. (In other words, don’t shock a flatline — but bear in mind this patient is likely dead no matter what they do, he was just too severely injured to survive.)

Chase and Taub are back on the team this week, which makes the episode much easier to watch (because the medicine sure isn’t helping)

Bob Harris, small town businessman and philanthropist collapses while in flagrante delicto with the local beauty queen. He has her bring him to the hospital where he is diagnosed with ventricular fibrillation, though there is no other sign of heart disease. He initially claims he was at his desk when the attack happened, but later admits to the affair when confronted with the evidence (fresh rug burns on his knees). The team decides to run an exercise test to see if another attack will occur. Initially, they get no results, but when Chase adds an emotional component to the stress, Bob collapses with a seizure. The team’s initial differential diagnosis is viral myocarditis, Brugada syndrome (an inherited abnormal heart rhythm), or pheochromocytoma. House suggests photic epilepsy (more commonly called “photosensitive epilepsy” — seizures brought on by flashing lights), but an EEG is negative, so he goes back to Park’s suggestion of a pheochromocytoma. While Chase and Adams run tests for the tumor, Park and Taub check out the seedy motel where Bob had his tryst. The pheochromocytoma tests are negative, but the patient now has a large mass on the right-side of his neck. Park and Taub find an abundance of pathogenic material at the hotel, including traces of fusobacterium necrophorum, which confirms House’s suspicion that the patient has Lemierre’s syndrome (an infected thrombophlebitis of the neck). The patient is started on Augmentin (amoxicillin + clavanulate) and surgery to remove the infected clot is scheduled. However, the surgery reveals no clot, but an enlarged lymph node. Adams suggests lymphoma. Chase obtains a biopsy and the patient’s vital signs plummet. Adams checks his eyes and notes yellow sclera, indicating liver failure to her.

With the new symptoms, the team formulates a new differential diagnosis. Lymphoma has been ruled out because the biopsy was negative. Alcoholism and withdrawal is suggested, but House is sure Bob still has an infection of some sort. He wants to use high doses of broad spectrum antibiotics to kill whatever infection it is. Adams is concerned that his plan will kill the patient’s already compromised liver. Chase suggests a liver transplant, and then the antibiotics. Since time is short, a partial liver transplant from a living donor is suggested. Most of the population of Bob’s small town come to the hospital to be see if they would be good donors for the liver transplant. Most leave after Bob confesses a number of sins, from cheating on his wife to ripping off customers at his car repair shop to stealing scholarship money. None of the remaining townspeople are good matches for his liver. House wants another CT of the liver, and surprisingly, this one shows that the liver is healing.

The team now suspects Bob is having an allergic reaction of some sort. He reacts strongly against the wheat sample, though he has no history of wheat allergy and blood tests don’t confirm the allergy. A latex allergy is considered but tests were also negative for that. Bob’s allergic reaction worsens, with large strips of his skin now tearing off. The team diagnoses Stevens-Johnson’s Syndrome and report that there’s nothing they can do as, according to the team, most medications exacerbate the confession. Not comfortable with leaving the patient alone, Chase sits besides him during the night. Bob tells Chase he has one last confession to make: he tells Chase he is a murderer, having killed his business partner and several others. This is over the top enough for Chase to realize that a large part of the problem is in the brain, with the patient confessing to crimes he has never committed. A brain scan shows an aneurysm. Taking this along with his other symptoms, House recognizes that Bob has Kawasaki’s syndrome, an autoimmune disease (in this case apparently induced by carpet cleaning chemicals Bob was exposed to through the rug burns). After treatment, Bob is feeling good enough to start lying to his wife.

As usual, major complaints are in red, modest complaints are in blue, and nit-picking ones in green:

A patient with a suspected systemic infection is not going to be a candidate for a liver transplant.

House’s team was bizarrely satisfied with the diagnosis of Stevens-Johnson syndrome (SJS), and never explored the all important question of what set it off?
Looked more like toxic epidermal necrolysis (TEN) than SJS to me, though admittedly most subspecialists consider TEN a very severe type of SJS.
The hallmark of SJS is the involvement of mucous membranes, none of which were involved in this patient (at least the ones we could see).
Corticosteroids haven’t been implicated in SJS, though they have rarely in TEN. In fact, they are one of the main treatments of the condition.
Narcotic pain medications are not known to cause SJS or TEN, so there was no reason to withhold them from the patient.

A lymph node biopsy, especially for something like lymphoma, takes the entire node, not just a little bit of juice from it.

Augmentin/Amoxicillin + clanulate is not the proper antibiotic for Lemierre’s syndrome.
Scanning the neck (CT scan or ultrasound) to evaluate the clot — or at least to make sure it exists – is recommended before surgery.
Patient was missing the pharyngeal/peritonsillar signs and symptoms seen before Lemierre’s.

Park complains about the length of time it takes to get culture results back (a valid point), yet she is the one who supplied the surprisingly fast results from the hotel room.

There was no good reason (other than to advance the plot, so make that no good medical reason) to repeat a CT scan of the liver so soon after the first.

You don’t confirm skin allergy test results with blood results. The skins tests are generally more definitive.

This week’s medical mystery was moderately intriguing, admittedly mostly because of its illicitness. I give it a B+. The final solution fit, but was quite a stretch, about average for the last few seasons of House. It earns a C. The medicine started out decent, but rapidly degraded. The treatment of SJS was nearly medieval. And why did it take the team so long to realize his confessions were a symptom? They were quick to consider altruism a symptom just two episodes ago. I give the medicine a grade of C-. The soap opera was much better this week — and most of that is due to the return of Chase and Taub. It’s good to have them back. A-.

The review of the previous episode of House
A list of all prior House reviews

This week, Fred had the high score with 13 points. Jinksb, SMEL, and wkmaier all tied for second with 12 points. Dr. R was in fifth with 10 points.

There was significant change in the overall standings this week. SMEL moves into first with 25 points. 4287, Harvey, and wkmaier are tied for second with 22 points. FlowerPower is in fifth with 21 points. If you have 18 or more points, then you are in the top 10%.

Click here to see the full scoreboard.

The writers should have taken the extra week they had off from the World Series and used it to tighten up the lousy science in this episode of Fringe.

The Plot: Peter has a meeting with Walter but it doesn’t go well, with NuFringe’s Walter not being as confident or comfortable as the Walter Peter new.

Meanwhile, the single remaining Shapeshifter 2.0 is back, this time tracking down a former Massive Dynamic scientist, who she locates and kidnaps at gunpoint. She needs his expertise in “cellular replication” in order to permanently fix what’s wrong with her body. She spins a sob story about being a melanoma patient in remission and he agrees to help her. At the lab she has set up, he injects her with some of his serum and she loses control of her shapeshifting and takes on the appearance of his wife. Now the scientist realizes something bad is going on and tries to kill her by making a toxic serum. She stops him and forces him to make the correct serum.

Agent Lee pulls Olivia in on the scientist’s case because he realizes it involves a shapeshifter. They aren’t making much progress until Peter volunteers his help. He is able to analyze the data disk the team recovered from the dead shapeshifter in episode 1 and use it to track the remaining shapeshifter and the scientist to her lab.

The Fringe team arrives at the lab just as the scientist finishes the new serum. The shapeshifter grabs it and sprints for the roof. Olivia follows but is told by an injured agent that the shapeshifter jumped off the roof into the harbor. Of course — and everyone saw it coming — the injured agent wasn’t really an agent but instead the shapeshifter who, once again, manages to escape. As the episode ends, she pulls out an old typewriter — like those used in previous seasons to communicate with the alternate dimension – and makes contact with her mysterious boss.

Peter has a second meeting with Walter. This one goes better, at first, until Walter denies Peter, telling him that he is nothing more than temptation that must be avoided.

1. Knitting the Raveled Sleave of Care
Sodium thiopental (i.e sodium pentathol, “truth serum”) is a barbiturate and can be used as an inducer of anesthetic. Using it to induce sleep, however, is a little better than Michael Jackson doing the same with Propofol, but not by much. Adrenalin may counteract some of the effects of the thiopental, but isn’t by any means a sure counteragent.

2. Phantom Itch
“Copied genetic data of healthy cells…and used it to replace the damaged ones.” The DNA of cancer cells is abnormal, so that makes a little sense, but Nina also mentioned using the process for people with amputations, and there’s no abnormal DNA in amputated cells; it’s just missing.

3. This Week, in NüFringe
We learned that Nina was a foster mother to Olivia and her sister after their mother died

4. Pluck the Heartstrings
Stage IV melanoma is melanoma with distant spread. The prognosis is dismal and there are no good treatments.

5. Larry, Darryl, and Darryl
Newhart gas station in Vermont — really?

6. Some Restrictions Apply
Restriction enzymes cut DNA strands into smaller pieces (of course, it’s DNA in the lab, not DNA still bound up in chromosomes and all the associated molecules). It would lead to massive cell death, in which case internal hemorrhaging is the least of your worries.

7. Inherited versus Acquired
Despite what Peter says, copying DNA – and even every molecule — exactly won’t duplicate a person. For a quick example, say I lost an eye in a barfight – that’s not going to be reflected in my DNA or molecules – so an identical copy of my genetic material is still going to leave the shapeshifter easy to spot.

8. Sherlock She’s Not
Olivia is smart enough to spot a smudge of grease under a victim’s fingernails, but not enough of a detective to see through the shapeshifter’s clumsy masquerade as Agent Warrick?

This episode didn’t do much for me, from the clumsy understandings of genetics to the worthlessness of Olivia’s vaunted detective skills. The Fringe Doomsday Clock advances one minute towards midnight.

This week’s Fringe cipher was: STILL.
A list of all previous Fringe reviews is available here.
Karl will has much more to say over at his blog.

scene from Amazing Spider-Man #673

Clint, the appendix is on your right side, not your left.

House acted like a real bastard in tonight’s episode. If you like that, then you’ll probably enjoy it. If you enjoy coherent medicine or decent mysteries, then you’d better just skip it

Local businessman Thad Barton is cleaning up his yard when he suddenly develops micropsia (a condition where everything appears small or far away). He is admitted to House’s service. The initial differential diagnosis includes JBE (Japanese B encephalitis, a vaccine-preventable disease), central serous retinopathy, atropine poisoning, or thyrotoxicosis (high levels of thyroid hormones in the blood causing hyperthyroid symptoms). House decides the latter is the most likely, and is just about to start the patient on PTU (propylthiouracil, a drug used to treat hyperthyroidism) when Barton reports he is no longer seeing things appear small, but now things are appearing larger than they should. To House, this suggests that Barton has Alice in Wonderland Syndrome, which House explains as a type of atypical migraine.

A short time later, Barton develops severe respiratory distress and hemoptysis. Angiography reveals a hemorrhagic site in his left lower lobe. The differential diagnosis now consists of hyperviscosity syndrome (blood that is thicker than normal), Factor V Leiden deficiency (a genetic condition that causes blood to clot more easily), or myelodysplasia. House tells the team to give Barton activated protein C. According to the team, it will cause a life threatening reaction if he has either Leiden or myelodysplasia (but a different life threatening reaction in each case); House realizes this and wants to give it so they can figure out which diagnosis Barton has. However, instead of the expected life threatening complications, he develops a brief episode of itching. Adams now proposes that Barton has cancer caused by HTLV-1 infection, which his late wife also had and it caused her lymphoma. House agrees with her theory and starts the patient on radiation therapy. Unfortunately, during his first radiation treatment, he develops chest tightness and a rising heart rate. Adams thinks he’s having a heart attack, but the troponin (a blood test for heart attacks) and EKG are equivocal (meaning “maybe yes, maybe no”). House wants an echocardiogram on the patient (to look for areas of abnormal heart wall motion, a sign of a past heart attack), but the patient’s heart is beating too rapidly for the test. Adams is able to get a cardiac catheterization which is normal. The team next proceeds to look at an EP study (electrophysiology study, a test of the electrical “wiring” of the heart), but Barton’s blood oxygenation suddenly drops in the middle of the test for no reason.

House consults a neurologist who suggests the patient has normal pressure hydrocephalus. Park disagrees and thinks the symptoms suggest autonomic dysregulation. She wants to do a tilt table test to prove her diagnosis, but the other neurologist tells her that the patient will slip into a coma if he has normal pressure hydrocephalus. Park proceeds with the test anyway, and Barton falls into a coma. House considers this a fluke and never thought the patient had normal pressure hydrocephalus. He now wonders if the patient might have hepatic encephalopathy, but a liver biopsy is normal. His team suggests Eastern equine encephalitis or loa loa disease, but a glance at an orthopedic x-ray gives House his Eureka! moment of the week. He diagnoses the patient with hyperviscosity syndrome caused by the increased number of antibodies in his blood because of his rheumatoid arthritis. A quick plasmapheresis treatment and the patient miraculously wakes up.

As usual, major complaints are in red, modest complaints are in blue, and nit-picking ones in green:

Another episode where the team goes straight to treating cancer with radiation therapy, without ever confirming the patient has cancer, let alone what type of cancer it is. The situation is even worse in this episode as no HTLV-1 related condition is treated with radiotherapy.

Similarly, House plans on treating the patient with PTU, despite having no proof the patient actually is hyperthyroid – an easy test to check. PTU is not a benign drug.

So, the patients tachycardia makes getting an echocardiogram impossible (reasonable, if the heart is beating too fast, then it’s damn near impossible to get a good reading on the echo), but yet they are still able to perform a cardiac catheterization, where the same issue would apply – even more so because it is an invasive test with definitive risks, unlike echocardiography.
Apparently no one thought to give a medicine to correct the tachycardia.

Lots of handwaving* with this episode:
What caused the oxygen desaturization? (frantic handwaving – thick blood!)
What caused the heart attack> (more handwaving – thick blood!)
What caused the coma? What did it have to do with the tilt table. And why did it miraculously correct with plasmapheresis?
*My term for when the writers try to distract you so you never notice the patient’s symptoms don’t match the diagnosis.

A migraine is just one possible cause of Alice in Wonderland syndrome; there are others.

House is right to belittle Andrews suggestion of normal pressure hydrocephalus – it doesn’t fit the case at all. But then again, Park’s suggestion is no better.

Ironically, between the time this episode was filmed and broadcast, Xigris (Activated Protein C) has been withdrawn from the market.

This week’s medical mystery was modestly interesting, at least compared to last episode. I give it a B. The final solution fit, but was blindingly obvious — at least it would have been, had the writers been playing fair. Holding out the fact that the patient had rheumatoid arthritis — much different than your standard degenerative arthritis — was clearly intentional. The fact that they had to hide this fact that should have been provided from the very beginning shows that they knew how weak the mystery was. I give it a B for realism, but knock it down to a D for cheating. The medicine this week bad. Missing repeated clots and bleeds. Dropping inconvenient symptoms. Radiating the patient. I give it a D+. Without more Wilson, the soap opera never rose above average: C.

The review of the previous episode of House
A list of all prior House reviews

This week, 4287, FlowerPower, and SMEL had the high score with 12 points. Yep, that’s about it.

Overall, Yerkiet stays in the lead with 20 points while Harvey and jwsellers remain tied for second with 18 points. Nextsundayad is tied for fourth with 4287 with 17 points. If have 13 or more points, you are in the top 10%.

Click here to see the full scoreboard.

A couple of scenes form Fear Itself: FF where Sue Storm tries to use her forcefield powers to separate Angir (the Thing) from the enchanted hammer that has taken him over. Her results are less than succesful.

Xylazine is a real drug — an animal tranquilizer. If memory serves, Voodoo writer Ron Marz raises horses, so it makes sense that he’d be familiar with the medication, and it would also explain the reference to Clydesdales (as opposed to the more common “elephant” when animal tranquilizers are discussed).

It does raise a question, though. Why would they expect Xylazine (or any other human or veterinary drug) to work on an alien? In the case of Xylazine, it targets a very specific receptor, the α2-adrenergic receptor, so unless the alien has an identical receptor used for the same purpose, the drug isn’t going to work. (This isn’t a problem unique to Voodoo, I’ve seen it in numerous super-hero and sci-fi stories.)

Back to the scene pictured: Since you’re basically just guessing, why choose an animal tranquilizer instead of a human one? Xylazine may work wonders on animals (certain animals, anyway), but it’s not a particularly good human tranquilizer. Since Voodoo looks more human than equine, wouldn’t a drug known to work better in humans be a better guess (or go with ketamine, which works well for both humans and animals).

The more I think about it, for all intents and purposes, Jor-El was a mad scientist. He espoused scientific theories well outside the accepted norm and performed numerous unauthorized scientific experiments of questionable ethics.

Superman #83 starts with Jor-El inventing a longevity serum. To test it, he proceeds straight to animal trials — well, animal trial, really. He only tests it on one animal. Now, he doesn’t start small and test it on a rat, monkey, or even a guinea pig — but instead he heads out to a nearby Kryptonian nature preserve and elects to test his serum on a Snagriff, a large dragon-like creature¹. Almost immediately, he notices side effects — the Snagriff’s hide turns metallic and it starts eating all the metal in sight. The creature escapes Jor-El’s lab and runs rampant through the city. Finally, Jor-El captures it and maroons it on one of Krypton’s moons² — but a metallic one, so at least it has something to eat.

When Krypton explodes, the Snagriff is hurtled into space, where — of course — it eventually lands on Earth^{3, 4}. Immediately, the creature starts eating all the metal it can find. The police and army try to stop it, but they have no success. This is a Kryptonian creature on Earth after all, so it has all the standard Kryptonian powers including invulnerability and heat vision. Superman intervenes, but even he has a tough time battling the Snagriff. Things go from bad to worse when an alarmed scientist informs Superman that the monster has just eaten six nuclear bombs. Superman tries a different tactic now. He stretches his cape until it is large enough to contain the Snagriff⁵. He then ensnares the creature in his cape, and flies it up into outer space, where it explodes harmlessly, the nuclear explosion contained by Superman’s cape.

Notes:
1. It’s not clear what Jor-El’s experimental plan was, or if he even had one. Was he just going to watch the Snagriff until it died – or didn’t die – of old age?
2. The KSPCA has a long file on Jor-El.
3. Why do all things Kryptonian end up on Earth?
4. At least this is proof the longevity serum worked – the Snagriff lived long enough to travel from Krypton to Earth. And the serum apparently protected him from the rigors of travel through space as well.
5. No, I have no idea how he was able to stretch out his cape so large, and then unstretch it later.

It’s United Nations Day! If you’re a long time reader here, you probably recall that the United Nations was one of the favorite topics of DC Comics’ public service ad program. What you may not realize is how many United Nations PSAs they published.

In honor of the day, here’s a sampling of DC Comics’ United Nations PSAs (click on the image for more information about that PSA):

Maxwell Lord is back with a psychic nosebleed, but this time he’s immortalized in plastic as psychic nosebleeds emerge in a new medium: Heroclix.

In this scene from Hondo City Justice (from Judge Dredd Megazine), Inspector Inaba gets taken out by her mind-controlled trainee, Cadet Judge Asahara.

Later, Cadet Asahara suffers her own pyschic nosebleed when taking on the head villain.

In order to be proclaimed “Crimeteer Chief” of the far off planet of Zarria, Zunial travels to Earth to kill Superman. His first few attempts are laughable, and Superman just shrugs them off. Eventually, though, Zunial hooks up kryptonite to a radio tower and somehow broadcasts kryptonite into Superman, killing him.

Zunial returns to his home planet with Superman’s body to prove to the rest of the criminals there that he killed Superman. A quick scan by their life detection rays confirms that Superman is dead.

Luckily, there is a Superman robot on Zarria (the one Zunial used for practice) and he invents a machine that sucks the radio waves out of Superman. No, not the kryptonite itself, just the radio waves — the waves that somehow remained in his body — but the effect is the same, and Superman is brought back to life. Without any more kryptonite, Zunial is caught and Superman returns to Earth in much better shape than when he left it.

An average, at best, episode of House tonight. You’ll notice I throw around that phrase a lot tonight: “Average, at best.”

Benjamin, a once rich man who now gives all of his money away, collapses after leaving a million dollar donation to a job skills clinic. He is admitted to House’s team, mostly, House admits, because he is rich. Park is unimpressed with the case and feels Benjamin was just dehydrated. She is even more unimpressed when Dr. Adams, the doctor House got fired from the prison clinic, joins the team. Adams suggests cardiomyopathy as a possible cause. An echocardiogram is checked and it shows nothing wrong with the heart. Along the way, a head CT is checked to rule out a subdural hemorrhage, though it was never mentioned in the differential (pay attention, this will become important later). Park suspects Benjamin’s extreme altruism is a symptom of neurological disease, but Adams disagrees. An electromyogram is tested (because apparently muscle tone goes along with charitable impulses), but it is also normal. Just as he is ready to be discharged, Benjamin complains of feeling “funny” and develops tachycardia (an unnaturally rapid heart rate) that is corrected with the administration of adenosine.

The differential diagnosis now consists of long QT syndrome (an inherited heart condition that can lead to life-threatening arrhythmias) and Whipple’s disease (an intestinal malabsorption syndrome). While undergoing another cardiac test, Benjamin develops severe hand tremors (ridiculously severe — I thought he was having a tonic-clonic seizure. And, though mentioned repeatedly, these tremors were never seen again.) With symptoms of arrhythmia, fainting, muscle tremors and (possibly) mental status changes, the differential diagnosis now consists of drug abuse, polyarteritis nodosa, or echovirus infection. The latter seems the most likely, so Benjamin is started on pleconaril, an antiviral active against echoviruses.

House thinks Benjamin is cured, but then he hears that his patient has volunteered to donate a kidney to one of Wilson’s patients. To House, this means that Benjamin’s condition has not improved and it must not have been echovirus. Whipple’s disease now seems the most likely cause, but all the tests including EGD and DNA testing are negative.

With no proof of anything seriously wrong, Benjamin is wheeled into surgery, but his heart rate spikes and blood pressure drops so the surgery is called off. The team now considers a spider-bite (no specific spider species is mentioned) or LCDD (light chain deposition disease), and Adams wants him started on blood thinners for the tachycardia. Foreman shows up and accuses House of doping the patient with some drug to cause his symptoms, but House denies it — to Foreman, anyway — he admits it to the rest of the team.

Back to the symptoms of arrhythmia, tremor, and mental changes, the team now suggests Graves disease, or some other form of “thyroid disease,” Coxsackie B virus or porphyria. (Why weren’t these mentioned in the original differential diagnoses for the same symptoms? They should have been.) The patient is started on hematin to treat the presumed porphyria. Meanwhile, House has his Eureka! moment of the week when discussing the case with Wilson. It seems Benjamin has Plummer’s Disease — a single thyroid nodule that has managed to pump out enough thyroid hormone to cause behavioral symptoms and syncope, but yet remain undetectable in thyroid tests. Benjamin’s condition worsened when he received iodine based contrast for the head CT, which caused thyrotoxicosis (high levels of thyroid hormones in the blood causing hyperthyroid symptoms). After surgical removal of the nodule, Benjamin is back to normal, losing most, if not all, of his altruistic feelings along the way.

I already mentioned some of my concerns above: the miraculous untestable thyroid nodule that causes personality changes, the poorly explained need for EMG testing , and the only mentioned after-the-fact need for a head CT though it was useful for nothing on the differential diagnosis. Here are a handful more (as usual, major complaints are in red, modest complaints are in blue, and nit-picking ones in green):

In referring to the diagnosis of Whipple’s disease at one point, Adams states that it should have improved since the patient had already been on antibiotics.
No, the patient was on an antiviral, not an antibiotic (which is antibacterial). Frankly, that’s a mistake a first year medical student wouldn’t make.
Even if she had been right, Whipple’s takes a year of antibiotics to treat. Do you really think a day or two is going to make that much difference?

I know I’ve mentioned it before, but this episode really highlighted how poorly this show actually understands what a differential diagnosis is, despite it being a major part of every episode. When creating a differential diagnosis, you list every possible diagnosis that could explain the patient’s symptoms, then you run tests or elucidate a better history so the long list can be narrowed down to a shorter one and then finally to the correct diagnosis. If you’re introducing entirely new diagnoses for the same symptoms, then you’re doing it wrong.

Tachycardia simply means an elevated heart rate. There are many causes of tachycardia, but it seems that Benjamin has SVT, since it responds to adenosine. This is not a rhythm that requires blood thinners.

Whipple’s disease is one of the main diagnoses? Really? Where’s the abdominal and bowel symptoms you’d expect? In other words, throw out all the half-dozen expected symptoms and shoe horn in several one-in-a-million-cases symptoms. I know this happens every week on House, but this episode was particularly egregious.
Repeat with spider-bite, echovirus, polyarteritis, porphyria, and most of the other diagnoses mentioned this week.

This week’s medical mystery was nothing special. In the 100+ episodes of House, how many times has collapse been the initial mystery? A dozen? Two dozen? I know they lampshaded it, but that still doesn’t change the fact that the mystery was average, at best: C-. The final solution was quite a stretch requiring several unlikely coincidences: a nodule strong enough to cause personality changes, but not be detectable? check! An unneeded test that fits no suggested diagnosis that worsened the symptoms? check! The final diagnosis earns another C-. The medicine this week was poor. Zebras were chased left and right while ignoring more likely more common diagnoses. I give it a D. The soap opera had some good moments this week, but for most of the show was barely above average with a B-.

The review of the previous episode of House
A list of all prior House reviews

This week, Ash88 had the high score with 8 points. Ender2003 was second with 7. Cyndi, Harvey, rileyjo, and Silvina all tied for third with 6 points.

Overall, Yerkiet stays in the lead with 20 points. Harvey and jwsellers are tied for second with 18 points. Nextsundayad drops to fourth with 17 points. mbrigdan and Ash88 are in fifth with 16 points. If you scored 13 points or higher, you are in the top 10%.

Click here to see the full scoreboard.

A fairly light episode that clarifies some parts of NüFringe, particularly the Cortexiphan trials. Plus, the full return of Peter.

The Plot: Olivia is awakened one morning by a strange blue energy apparition. She notices that the apparition draws metal objects nearer, but she misses the strange effect it has on the flow of time. She is burned on the arm when she comes into contact with it.

Olivia reports what happened to Walter at his lab, and he sends her and Astrid back to the apartment to get some more readings. Watching over the video link from back at the lab, Walter witnesses another materialization of the apparition, only he sees the events before they actually occur. Talking with Olivia later, Walter tells her that the phenomenon reminded him of one of her fellow Cortexiphan subjects, a boy who had the ability to astral project, but also had some magnetism-related side effects. Olivia looks over the Cortexiphan trial notes, now held by Nina Sharp over at Maxiumum Dynamics. From these notes, they learn the subject’s name, Cameron James, and where to find him.

Olivia and Walter head to New York City to talk to Cameron, but he isn’t at his apartment when they arrive; they’re told by a nosy neighbor that he’ll be back in the morning. She and Walter get rooms a hotel, but Walter freaks out with an attack of mysophobia and the two of them end up enjoying late night rootbeer floats at a nearby restaurant. While there, the apparition manifests again, bigger than before, and doesn’t fade away until it disrupts traffic and is hit by a car.

The next morning, Olivia manages to track down Cameron, but he insists he has nothing to do with the strange occurrences. While talking with him in his apartment building’s lobby, the phenomenon occurs again, but Cameron is able to drive it away using what little remains of his Cortexiphan powers (side effects, at this point really). Walter devises a plan to use Cameron’s abilities and a large chunk of New York’s power grid to destroy the apparition once and for all. The energy apparition appears again, and Walter’s plan seems to be working – but then Olivia sees the face and body of Peter materialize in the energy. She stops Cameron and the apparition disappears – but then Peter suddenly surfaces at Reiden Lake and is rescued by two fisherman. A short time later, the Fringe Team arrives at the hospital where Peter is taken. Broyles is understandably concerned that this unknown person knows so much about Fringe personnel and history. Olivia walks into Peter’s room and he is clearly delighted to see her, but she still has no memory of him.

1. Fallout, Boy?
A rad is an all but abandoned scientific unit that measures absorbed radiation. There is a lot of math in figuring out equivalent doses, depending among other things on the material involved, but two rads is roughly the same dose of radiation from twenty chest x-rays, a CT of the brain, or a third of a CT scan of the chest.

2. Needed Better Career Counseling
If Cameron becomes magnetic when anxious, then why drive a truck for a living? There’s a great deal of metal in vehicles, and you’d think driving a truck in big city traffic would get quite anxious.

3. Amalgamated
Dental fillings aren’t particularly magnetic. By the time Cameron was generating enough of a magnetic field to affect the fillings, surely there’d be a noticeable effect on the silverware and probaly the pots and pans in the kitchen as well, if not more.

4. NüFringe Revelations
Changes over past Fringe Continuity:
The ethical fallout from the Cortexiphan trials has not occurred in NüFringe. Knows nothing of any of the other Cortexiphan .
Olivia has shown no Cortexiphan related powers as an adult.
Nina and Walter have quite an antagonistic relationship while Nina and Olivia seem to share a more maternal/child bond.
Walter mentions that his wife Elizabeth committed suicide after the death of “our Peter” — suggesting that she died before Walter crossed over to get the alternate Peter.

5. What’s In A Name?
“Cameron James” — really? Why not also have Spielberg Steven, Polanski Roman, or (for an almost believable name) Lucas George?

A fairly shallow episode, plot-wise, but I enjoyed the new Cortexiphan revelations and the return of Peter — in an almost logical manner, at least from a Fringe point of view — so the Fringe Doomsday Clock will move back one minute to 11:52.

This week’s Fringe cipher was: RESET.
A list of all previous Fringe reviews is available here.
I’m certain Karl will have more to say over at his blog once he gets back from shooting zombies.

No sir, psychologists agree that you’re full of bunk.

The brain is an extremely specialized organ — in other words, different parts of it are used for different tasks. One part is used for reading, another for writing, a third for short term memory, yet another for hearing, and so on. So while it is true that only a relatively small portion of the human brain is in use at any one time — or at any one task — over the course of a day, all of the brain is used. There is no dormant 90%.

Also, there already is a term for someone who has all of their brain activated at once: an epileptic.

As a final side note, the brain is full of billions of cells, no millions.

Hopefully not too many of you found yourself watching Terra Nova instead of House because of the ALCS running late tonight.

Tonight’s episode of House featured House’s return to Princeton Plainsboro Hospital to work under Foreman, the new Dean of Medicine. The social aspects of the episode was good, and the mystery intriguing, but the follow through lacked some luster.

Foreman, now Dean of Medicine at Princeton-Plainsboro Hospital, has arranged for House to get a conditional release from prison. The conditions are fairly simple: House is to break no further laws, is under Foreman’s direction, and is only to be at his apartment or at the hospital. (Or at least, those are all the conditions we know about now…)

Foreman has arranged for House’s release because of a difficult medical case. A young college student was killed in a motorcycle crash and his lungs were donated. Just as the transplant surgeons were ready to implant them into the new patient, the lungs went bad, showing signs of increasing airway resistance. The lungs were then placed in a pristine plexiglass box (seriously, no blood? No fluids?) hooked up to a ventilator. House has twelve hours to find out what’s wrong with the lungs and fix them so that they can still be transplanted. To help him out, he’s given the services of Park, a resident who punched her Neurology attending after he copped a feel.

House and Park meet with the transplant team. Their initial diagnosis is ARDS (acute respiratory distress syndrome), which House discounts as there is no exudates. He suggests ehrlichiosis, but that’s already been tested for and treated, and then suggests cocaine. While the patient’s drug screen was negative, House feels the cocaine ingestion was too recent to have made detectable metabolites in the urine. He and Park search the victim’s bedroom at his parent’s house, but find no evidence of drug use. They do find a new pair of glasses and an admission from the victim’s father that his son had headaches, leading House to a new diagnosis of brain tumor. He and Park get the body from the morgue with the plan of getting an MRI. House notices a bulge in the arm, and now thinks that instead of a brain tumor, the victim had rhabdomyosarcoma (A malignant muscle cancer) and paraneoplastic syndrome.

However, reality — such as it is on this show — is unkind to House. The MRI reveals no tumors, and what he thought was a muscle mass was a clot caused by the intravenous plasma the victim had received in the emergency room. House now suspects that something in the unit of plasma the victim received caused whatever is happening in the lungs. The trouble is that each unit of plasma is made up of donations from a number of donors — twenty-five is the number House throws around. He has six hours to find something in the history of those twenty-five donors that will explain the lungs. Possibilities include peanut allergy, dengue fever, FMF (Familial Mediterranean Fever), malaria, acute alcohol intoxication, or lead poisoning. The latter seems the most likely so he starts chelation therapy on the lungs. At first, they seem to be improving, but then things take a turn for the worse. Park and Foreman are able to correct the vasospasm in the lungs, but not before the right middle lobe dies. House is undeterred; he looks at the dead lobe as some tissue he gets to biopsy for the right answer.

Considering what conditions might cause chelation to go poorly, House considers and discards the diagnoses of sarcoidosis, heavy metal poisoning, and asbestosis before settling on the diagnosis of hemosiderosis (a type of iron overload). Park stains the lung tissue for iron, but instead of the expected metal, she finds white blood cells. To House, this suggests an infection hiding in the lung cells, likely brucellosis. He starts the lungs on antibiotics and IVIG (intravenous immunoglobulin). The treatment doesn’t help, and in fact seems to make the lungs worse. Desperate for ideas, House looks to Park and the transplant surgeon for ideas, but all they can suggest are IgA Nephropathy and lupus. House has his eventual Eureka! moment watching one of the wards celebrate a nurses birthday with cake and candles and realizes that the patient had eosinophilic pneumonitis, and the cigar smoke he was exposed to the night of his death caused his lungs to shut down. The lungs are given radiation treatment and this cures the problem, allowing the lungs to be transplanted.

The medicine was extremely disjointed this episode, jumping almost randomly from diagnosis to diagnosis. Some of this was due to the nature of the patient: lungs in a box, but part of it seemed to be a return to the usual poorly thought out differential diagnosis of prior House episodes. As usual, major complaints are in red, modest complaints are in blue, and nit-picking ones in green:

I admit it’s out of my field, but keeping the lungs alive in a pristine clean box — no blood, no fluids, no drainage, no mess — seemed unrealistic.

Not a medical question per se, but how did House, a convicted felon, manage to retain his medical license?

Radiation for eosinophilic pneumonitis, even in this “every minute counts” scenario? Ridiculous. Radiation therapy, even if it would work for this condition, takes time — more than a single treatment — and has its own set of side effects (radiation pneumonitis, for instance). Why not stick with the corticosteroids, since a transplant patient is likely going to need them for some time?

Would a patient with active angina be a candidate for a lung transplant?

Nitrates don’t cause renal insufficiency.

An iron-stain of the lung tissue incidentally reveals high white cells, but no one follows through with a simple H&E stain to show what types of white cells they are.

I would expect the patient to have an elevated WBC, particularly elevated eosinophils.

The patient had severe enough EP to cause a life threatening reaction to cigar smoke, but had never had symptoms before? Surely he’d been around tobacco smoke before…

This week’s medical mystery offered an intriguing premise, but it failed to live to it’s full potential. Just like last week, I give it the mystery a A-. The final solution was unsatisfying, even if it was more or less almost nearly logical. I give it a C+. Unlike last week’s logical progression of medical diagnoses, this week seemed particularly haphazard, and this was a case where a consistent logical approach would have been extremely important. It earns a weak C. I enjoyed the soap opera this week, particularly the scenes with Foreman (but lose the ’stache), Park, and especially Wilson. I give it an A-.

The review of the previous episode of House
A list of all prior House reviews

This week, lectio had the high score with 10 points. Ansa was second with 8. Alex51, Christoph, Indyfrick, and squeaky all tied for third with 7 points.

Overall, Yerkiet retains the lead with 20 points. jwsellers is second with 18 points and Nextsundayad is third with 17 points. mbrigdan is in fourth with 16 points, and numerous players are tied for fifth with 13 points. If you scored 11 points or higher, you are in the top 10%.

Click here to see the full scoreboard.

A decent monster-of-the-week episode of Fringe. There was a little advancement on the Peter end of things, plus a little more history of NüFringe continuity, but still a just slightly better than average episode.

The Plot: An aggressive neurotoxic fungus has been discovered in an old tunnel in Boston. By the time the Fringe Team has been called in, it has killed two twelve year-old boys. The extremely decomposed bodies of the two victims explode in a rain of spores. Walter understands what it happening and contains the explosion just in time. The medical examiners in the morgue aren’t so lucky, though, and die when the second corpse explodes. That brings the total dead to three four. A dead homeless man is found in another tunnel, bringing the total to four five. The fungus is spreading throughout the old tunnels underneath Boston.

The team has discovered a third young boy, Aaron, who was in the first tunnel. Walter learns that Aaron and the fungus have sort of psychic bond. When the FBI tries to kill the fungus it, it affects Aaron. Broyles gives Walter two hours to sever the psychic link, but he is unable to. Luckily, at just the right moment, he learns the fungus is more dependent on the boy that the other way round. He convinces Aaron to let go of the psychic bond, and that allows the Fringe Team to destroy the fungus, yet leaves Aaron unharmed.

After the fungus has been dealt with, Walter and Olivia realize that they’ve both been seeing images of a mysterious man — Peter. Walter sees and hears him through visual and auditory hallucinations, while Olivia sees him in her dreams.

1. More Of A Retcon Than A Reboot
We finally learn the fates of the Peters in the NüFringe continuity, and it’s not all that different from the original continuity. Walter’s Peter died young of an illness, just like what originally happened. Similarly, Walter crossed the barrier between dimensions to rescue a sick alt-Peter. Only, when returning to our world, after falling into the icy lake, Peter died. I guess there was no Observer to rescue them this time.

2. I Was Hoping For A Nosebleed
Interesting “psychic bond” from the fungus:
Tinfoil hats offer no protection (despite numerous independent studies showing otherwise)
It can link to a kid at a lab in Harvard, but not to itself in a Boston morgue, which should be closer.

3. I’m Guessing There’s No OSHA in NüFringe
Whose bright idea was it to send the Fringe Team into the tunnel, any of the three times, without protective gear?The first time, all they knew was that something was in there that could cause rapid decay — but that’s reason enough to be protected. The second and third time it was known what was in there and what it was capable of doing, yet no one thought to wear protective equipment (despite wearing it in the morgue). A little foresight would have prevented Agent Lee from getting trapped.

4. There’s No Percentage In That
What sort of reading is a respiratory rate of 89%. Respiratory rate is a number, not a percentage, and the there is wide variation in what is normal – from person to person, and within the same person from minute to minute. I suspect they meant oxygen saturation (which is a percentage score), not respiratory rate.

5. Leave The Carotid Alone
Just like a shot of adrenalin to the heart is a bad idea – no matter what Pulp Fiction says – a shot of epinephrine (another name for adrenalin) into the carotid artery is just as bad. Just put in the IV, it’ll get there nearly as fast and without the risk.
Walter has some of the worse syringe skills I’ve ever seen – not what you’d expect from a self experimenting junkie. Hideously poor sterile technique as well.

6. I’d Rather A Bottle In Front Of Me
The tools that Walter was using were the proper tools for a frontal lobotomy — at least the “from behind the eye” style that was popular for a brief time (a very brief time, thankfully).

Another episode that was neither good nor bad enough to move the Doomsday Clock. The fungus was suitably creepy, but the lack of common sense shown by the agents time and time again hurt the chances of moving the clock.

This week’s Fringe cipher was: REBORN.
A list of all previous Fringe reviews is available here.
As always, Karl has more to say over at his blog.

Watching the Cardinals/Phillies game. Come back tomorrow.

The first episode of what is likely to be the final season of House is off to a good start. The constraints of practicing medicine in prison focus the usually superficial medicine on the show down to its core elements.

After last season’s finale, House is now in prison for driving his car into Cuddy’s house and then fleeing the country for three months. In a meeting before the parole board, House is informed that due to prison overcrowding, he is due to be released in five days, as long as he can stay out of trouble. What follows is a week in the life of Gregory House, prisoner.

As the week start, we see him in line to receive his daily medication. He’s there not only to receive his Vicodin, but also to make sure his sociopathic roommate takes his medications. He also passes one of his painkillers as a “tax” to the head of the jail’s neo-Nazi gang.

Nick, a fellow prisoner, asks House for some medical advice, but House blows him off. Later in the day, when House is doing his rounds as a janitor, he is in the clinic when the doctors are examining Nick. Noting the joint pain and fever, Dr. Adams is prescribing ceftriaxone for a suspected case of gonorrhea. House jumps in, telling her it isn’t gonorrhea and suggests his thinning eyebrows suggest that Nick has lupus. Dr. Adams points out that he doesn’t have the classic malar rash so it can’t be lupus.

The next day, House checks out Nick himself and finds a rash (which he never describes, so it could be any kind of rash) on his left thigh, but Dr. Adams is unimpressed. Later that day, being jostled into a wall breaks Nick’s arm. Bones that break so easily don’t fit with lupus, so House realizes that cannot be the right diagnosis. During his janitor rounds, he discussed the case with Dr. Adams again. Viral syndrome and MRSA infection (antibiotic resistant Staph infection) are mentioned but quickly discarded. Knowing that Nick is a smoker, House now suspects that he has metastasic lung cancer (lung cancer which has spread to the bones, and bones with cancer break easier than normal bones), but it will take a couple days until an x-ray is available. This doesn’t sit well with House. Through an exceedingly thoroughly lung exam, including auscultation and percussion, he is able to convince Dr Adams that Nick has some sore of lung mass. She doesn’t have access to any stat labs or x-rays, so she decides to run an old fashioned bleeding time test (patients with cancer have blood that clots too easily, so she suspects his wound will clot sooner than expected), but instead of clotting, Nick bleeds profusely from his wound.

By the next day, an x-ray has been obtained but it shows a lipoma (a benign fatty lump) rather than a tumor. Dr. Adams suspects a toxin, but she is caught sharing patient information with House and no longer allowed to discuss cases with him. Later in the day, Nick comes to talk to House again. House tries to blow him off, but in the middle of it, Nick collapses in anaphylactic shock. Luckily, House has a convenient ballpoint pen to perform an emergency tracheotomy and save the patient’s life. House’s suspicions are pointing toward some sort of allergy, probably a food allergy, at this point.

On his final day, House has his Eureka! moment when he sees a prisoner drinking a hot cup of coffee. He realizes that Nick has mastocystosis, which caused an anaphylactic attack when he drank hot coffee. House wants to give some aspirin to Nick in an attempt to induce an anaphylactic attack, which would prove the mastocytosis, but Dr. Adams supervisor won’t allow it. A short while later, House intentionally enrages the neo-Nazis in order to get himself beat up so he would get sent to the clinic (whether the riot that followed was part of his plan or not). Once in the clinic, though he threatened with the loss of his parole, he gets Nick to drink the aspirin. As House is dragged away, despite drinking the aspirin, Nick remains symptom free.

When last we see House, he is locked up in the solitary wing of the prison. A meal tray arrives, along with a note that says, “You were right.”

I don’t have that much negative to say about the medicine this week. I liked the idea of having to make a diagnosis with limited resources, and I think the writers pulled it off better this time than previous attempts (like on the plane). The medicine was relatively logical this time with not many curve balls and zebras thrown in just for sake of it. As usual, major complaints are in red, modest complaints are in blue, and nit-picking ones in green:

There are better blood tests from Mastocytosis than House lets on; for instance, a bone marrow biopsy is a good test. Now that Nick has been stabilized, this is not a situation that needs emergent treatment. He can wait the few days required for definitive testing.
ASA has been known to induce mast cell degranulation – and subsequent anaphylaxis – in patients with mastocytosis, but it’s not reliable enough to use a diagnostic test. A positive test would suggest mastocysotis (or an aspirin allergy), but a negative test wouldn’t rule out the diagnosis.

You can’t differentiate a lipoma on an x-ray. You could see that there were no lung masses, but at best an x-ray would suggest a soft tissue mass. You’d need a CT scan or something similar to identify it as a lipoma.
If it were a lipoma, that would be a tissue mass, not a lung mass, so would not have affected the lung exam. The lung beneath it would still percuss as hollow, not solid.

House specifically asked his friend for his pen, but why? He didn’t use it in his firestarting routine. He seems to only have needed it so he could use it to perform a tracheostomy later.

Bleeding time test is a test primarily for platelet function. I don’t know if it’s ever been tested or is appropriate in cancer patients.

Was Nick’s broken arm/elbow ever treated?

This week’s medical mystery was a little vague and general at first, but picked up as the episode progressed. It would have been a two-minute clinic quickie in previous seasons, but it fit the prison milieu perfectly; I give it an A-. The final solution, though a stretch, fit the scenario and earns a B+. The medicine followed a logical progression for once, and the constraints of being in prison helped rather than hurt. It earns a B. Even though the players were new — except House — the soap opera was well done and earns a B+.

A list of all prior House reviews

As of Week 1, Yerkietleads with 18 points. jwsellers and Nextsundayad are in second with 15 points. Rounding out the top five, mbrigdan is in fourth with 12 points, and Sean McBride is in fifth with 7 points. If you scored 6 points or higher, you are in the top 10%.

Click here to see the full scoreboard.

There were enough twists in this episode to redeem an otherwise straightforward hunt-the-serial-killer storyline. Sure, we all knew what was going to happen by the end (turning on his double, amnesia, etc.), but the concept of using an alternate universe analogue as essentially a human bloodhound for himself was clever.

The Plot: Olivia is called in by Broyles to work on a serial killer case, only it turns out it’s a case in the alternate universe and Fauxlivia has asked for their help.

After five years of chasing the murderer, alternate-Fringe have finally learned
his identity, only now they can’t find him. Their solution is to have Olivia cross over with the killer’s double from our universe, hoping he can point out what they might have missed. As it turns out, the killer’s double is a forensic psychiatrist and he is happy to help the FBI on a profiling case, not realizing the true identity of the killer, and the team keeps the secret of the two universes from him. He’s no dummy though, and quickly spots pictures and belongings in the killer’s house that he knows he owns as well, and the Olivias have no choice but to tell him the truth about the second universe.

Word comes down from alternate-Broyles that the killer had kidnapped another victim. While the team deals with this information, the profiler escapes, believing he can track down and stop his other self. Acting like a competent detective for once, Olivia is able to track their whereabouts to an old family farm.

Meanwhile, the killer’s double interrupts his other self in the middle of a murder and tries to help him see the error of his way, but the killer sucker punches him, and soon the double is strapped to a chair and pumped full of sodium pentathol while the killer uses a machine to drain the happy memories from his brain. The Fringe team arrives in time to rescue the victims, and Fauxlivia saves Olivia’s life by shooting the killer when he drew a gun on her. In the end, the killer is dead and his double returns safely to our world –luckily his memories of his time in the alternate universe were drained by the killer’s machine so the secret is safe.

And Walter covers every reflective surface in his lab so he can’t see Peter – and it works – only he can still hear him.

1. Ch-Ch-Ch-Changes
Post-Peter continuity in the Alternate Universe:
Fauxlivia is still with Frank (which makes sense, as there was no Peter to get pregnant by)
Alternate Broyles is still around (which doesn’t make as much sense, since his helping Olivia escape cost him his life, and not Peter)
Meat is readily available now.

2. Led Astray
Multi lead EEG display in the killer’s lab, but there was only one EEG lead, at best.

3. To Tell the Truth
Sodium pentathol is not that powerful a “truth serum,” at the high doses needed to make people with holes-drilled-in-their-head feel comfortable enough to talk that freely to a strange person, they’d either be dead or completely sedated.

4. High Fidelity
As much as Olivia was shown to be a good detective this episode, the alternate-Fringe team was horrible. Did it never occur to them that the killer’s double would see something in the killer’s house to clue him in to the truth? I figured it was going to be a problem the moment they announced their plan.

5. High Fidelity
I liked Walter’s recreation of the classic Maxell ad.

6. Reading Too Much Into It.
The tractor license plate numbers recalled by Olivia were entirely different in the spoken versus closed caption version.

An average track down the serial killer plot helped along by some clever Fringe twists. Still it was neither good enough to loose time from the Doomsday Clock, nor bad enough to advance it.

This week’s Fringe cipher was: LIMBUS.
A list of all previous Fringe reviews is available here.
As always, Karl has more to say over at his blog.

Even with the incorrectly worn head mirror and his unique take on taking Elmer’s temperature, Bugs is still doing better than most comic book doctors.

A fairly slow moving episode, designed to let us learn the new Fringe Division status quo and introduce a new character or two. Plus maybe some recurring villains

The Plot: The episode, and the season, starts with two brief vignettes: A verbal sparring match between Olivia and Fauxlivia as they trade Fringe Division case files, and a conversation between two Observers where they discuss the fact that Peter Bishop, or at least part of him, is still around. The senior Observer admonishes his junior counterpart that he needs to take care of Peter once and for all.

The episode proper starts with FBI Agent Lincoln Lee swinging by to pick up his partner, perpetually tardy family man Robert Danzig. Later, the pair is pursuing an arms dealer but split up when he disappears in a maze-like basement complex. Lee manages to catch the dealer, but when he goes to look for Robert he finds him dead with a strange translucently skinned man standing over the dead body. Robert face has a similarly translucent appearance. Lee gives chase but the strange man escapes by jumping through the window (windows, really).

Fringe Division is called in to examine Robert’s death. Olivia talks with Lee, telling him her division is taking over the case, but won’t give him any more information. Lee won’t take no for an answer, and manages to track Olivia back to Walter’s lab where he demands more answers. A call from Fringe Division HQ comes in, alerting the team to a new body. Lee invites himself along. This time the victim is a female, but she has the same partially translucent look as Robert had. Lee manages to find a witness who has a photo of the killer, a translucently skinned man. Reluctantly, Olivia informs Lee that there have been other similar killings before Robert. She takes him to a morgue at Fringe HQ where there are dozens of dead bodies – all from the last three days, Broyles informs them. Broyles mentions that they have not been able to find any common link between the victims. Lee tells Broyles that Robert had Crohn’s disease and took iron pills, and wonders if that may be the missing connection. Walter looks into Lee’s idea and finds that neither Crohn’s nor iron is the link, but “heavy metal poisoning” is. He also mentions that the victims’ blood seems to have been cleansed of all the expected excess heavy metals.

Meanwhile, in a dingy lab, the translucent man takes a vial of neon liquid, draws it up in a syringe, and injects it into his arm. We see a flush of mercury under one of his fingernails, which then loosens. He pulls the nail off, and seems quite pleased by whatever just happened.

Back at Walter’s lab, Agent Lee makes another connection: all the killings have been close to one of four commuter rail stations. Teams of FBI agents stake out the stations and sure enough, one team sees the translucent man and gives chase. Olivia and Lee arrive just in time to find both agents down: one dead and one wounded. Lee stays to help the wounded agent while Olivia takes off after the translucent man. She finds him in his lab, burning his notes. There is a scuffle, and in the end she shoots him, repeatedly. This takes care of the bad guys, right? Wrong. The wounded agent informs Lee that there was more than one translucent man – and the other one stole his pistol. Lee goes off looking for the missing perpetrator and finds him hiding around the corner. Lee is able to shoot him before the translucent can get a shot off.

An autopsy of the translucent men back at Walter’s lab reveals some tech similar to that used by the shapeshifters from the previous two seasons. To Walter, this is proof that they are part of a scheme by Walternate. Olivia takes the suspicious tech to the Liberty Island dimensional bridge and hands it over to Fauxlivia, who says she’ll “look into it.” Agent Lee tags along as well, learning more of Fringe Division’s secrets.

The episode ends with a few more brief vignettes: a third translucent “man” is seen, only this one looks just like the female second victim. An Observer shows up outside Walter’s lab with his machine, the one designed to erase someone from history. He turns it on, but appears to think better of it, and switches it off. Finally, Walter sees Peter’s reflection in his television set, and it is clear that he is spooked by the fact that he keeps seeing this person who he does not recognize.

1. Lesson One: Never Partner with Olivia
Which partner is Olivia referring to when she told Lee about her dead partner? Agent Scott? Charlie?

2. Is She Reading Ahead in the Script?
Why evidence did Olivia have that the translucent men were shapeshifters, other than the suspicious tech? I bring this up because she referred to them that way when talking to Fauxlivia but had she seen one change, or appear in someone else’s shape? The only shapeshfiting I recall was the female translucent “man”, and we saw that after the Liberty Island hand off.

3. Is this FRINGE or HOUSE?
Walter is making quite a reach with his statement blaming heavy metal poisoning. First, bear in mind that there are dozens of heavy metals (from a medical point of view, pretty much every metal with toxicity is considered a “heavy metal”) and they each can cause different symptoms. Sure, everything he mentions can be associated with heavy metal poisoning, but only in very very rare cases. Yes, some heavy metal poisonings can cause hair loss. But it is an extremely unusual cause of hair loss and there would be many other more telling symptoms of heavy metal poisoning. Genetics, sadly, is by far the most common cause of hair loss (trust me on this one: personal experience). Similarly, some heavy metal toxicities can cause kidney disease, but there are many more common causes — high blood pressure or diabetes, for instance. High lead levels can cause gout (saturnine gout), but this once again is a very rare cause. I’ve probably seen several hundred gout cases, and never yet seen one associated with lead toxicity. Most gout is caused by bad genes, and poor diet is the second most common cause. Crohn’s is not associated with heavy metal poisoning either (but in this case, I assume it was the iron Agent Danzig was taking that Walter was referring to, not the Crohn’s itself).

4. One Way Street
If the translucent man was injecting into a vein, the chemical was flowing the wrong direction, but maybe it was an artery…

5. Be Careful Around the Thirteenth One
I’m pretty sure the secret to being a good FBI Fringe Agent is just to keep an eye on every warehouse in town. Damn villains are always using those warehouses.

6. Put On a Jacket
I suspect Walter’s prominent mention of John le Carre’s novel The Spy Who Came in from the Cold is a hint at things to come, but its exact significance escapes me, unless he is similar suggesting intricate plots within plots within plots in the Fringe world (which, like the era of le Carre’s book, is in a Cold War — this time between the two dimensions).

7. Flashpoint
I’m sure the timing is just coincidental, but this Fringe reboot is reminding me an awful lot of the current Nu52 reboot at DC Comics. If Olivia starts wearing red lingerie or sleeping around, I’ll become extremely concerned (of course, this is Fringe after all — maybe it’s Walter who’ll wear the red lingerie).

A fairly slow episode, but it was clearly designed to introduce the new status quo and stir up some plot elements for later in the season. The Fringe Doomsday Clock remains where it ended last season at five seven minutes to midnight. (Or Doosmday Clock, if you prefer.)

This week’s Fringe cipher was: APPEAR.
A list of all previous Fringe reviews is available here.
As always, Karl has more to say over at his blog.

I thought we had this one licked: psychiatry ≠ psychology

One does not earn a degree in psychiatry because it is medical specialty, not a field of study per se. Having a “PhD in Psychiatry” would be like having a degree in Family Practice, or Surgery, or Rheumatology. That’s not how medical education works.

A PhD would be in Psychology – a related, though distinctly, different field.

(For the record, Leonard Samson, MD, is a psychiatrist. He may also have a degree in psychology, but if so, it’s never been mentioned)

Panel 1: I have yet to called in by law enforcement to assist on any case. On reflection, this is probably a good thing for all involved.

Panel 2: You cannot diagnose hypertension (i.e. high blood pressure) from across the room. There are generally no symptoms in hypertension until it is too late, and the patient is suffering a heart attack, stroke, or hypertensive crisis — that’s why it’s called “the silent killer.” And let’s not forget that it’s impossible to diagnoses high blood pressure without actually checking the blood pressure!

Panel 3: “Jim, this man is a Klingon!”

Panel 4: A pulseless patient makes the original diagnosis of high blood pressure all the more ludicrous, doesn’t it doctor? You can’t have high blood pressure if you don’t have a pulse. Also, it appears that not having a pulse is a crime in this town.

In this scene from the final issue of the overwhelming treacly mini-series Heroic Age: One Month to Live, reformed banker Dennis Sykes uses his recently acquired powers to stop the villain Hammerhead from crushing his family with a car. The series had a rotating cast of writers and artists, but this issue is courtesy of Rick Remender and Jamie McKelvie.

All previous Psychic Nosebleed Zen posts.

Tags: comics medicine nosebleed heroic age remender mckelvie

I would love for somebody to explain this picture to me.

In Red Robin #26, the final issue of the series, Red Robin distracts the guards at S.T.A.R. Labs by dosing their coffee with Ipecac.

Like Bromide, Ipecac is what I like to call a time capsule drug: it’s familiar to readers of a certain generation, but not as familiar to modern readers because time, and medical therapy, have passed it by.

If you were a parent in the 1960s, ‘70s, or ‘80s, you probably remember the drug Ipecac (and if you were a child of that era with certain bad habits, you may be familiar with it as well). Ipecac was once considered one of the most important drugs for conscientious parents to keep at home. Parents of newborns were sent home with a bottle of it, and at every routine office visit the pediatrician would make sure you still had your Ipecac.

What was so special about Ipecac? Simple: it is an incredible effective emetic. In other words, it makes you vomit. Ipecac works by directly irritating the stomach as well as stimulating the CTZ (the puke center of the brain). About thirty minutes after taking the drug, the vomiting will start.

Why was this thought to be a good idea? Ipecac was felt to be a very effective treatment for poisoning. If Junior swallowed down some of Grandma’s pills, or downed a bottle of Grandad’s Old Grandad, you could feed him some Ipecac and have him throw up the offending substance before it could cause problems.

Over time though, opinions about Ipecac began the change. Though many physicians had an anecdote or two about patients saved by the drug, recent studies demonstrated no real benefit in using the drug over other treatments. Additionally, like many pediatric drugs, overdoses by frantic parents were common. (This is the same reason that many children’s cold medicines have been pulled off the market: there’s no evidence they actually solve the problem, and there’s documented risk of overdosing).

Ipecac also provided a couple of other problems. First, there are many poisons you don’t want to throw up — including a number common household chemicals. For example, caustic cleaners or gasoline burn and scar the esophagus when swallowed and would do the same thing again if vomited back up. Second, Ipecac was often too effective and patients would continue to vomit for hours, including throwing up the treatments given by hospital personnel. Third, because Ipecac was easy to obtain and very effective, it was often abused by bulimics. Meanwhile, over the same period time, advances in emergency response and hospital treatment of poisoning meant that victims can receive definitive treatment for poisoning in the same time it would take for Ipecac to take effect.

Given all these factors, Ipecac is no longer recommended for treatment of poisoning and — though it is technically still available over the counter — it has become harder to find.

Personally, I remember that my mother kept a small brown bottle of Ipecac in the medicine cabinet, but never used it and eventually threw it away, unopened. In medical school, I was taught about the drug during Pharmacology class and briefly during an Emergency Medicine rotation. It was never mentioned during any Pediatric rotation. During residency, we instructed parents to have a bottle of Ipecac at home, but only to use it when directed by the poison control hotline; they were never to use it on their own. Since starting private practice, I have never mentioned the drug or discussed it with parents – though admittedly I live and practice in an area with an abundance of hospitals and an excellent ambulance service.

Season Eight of House starts in three weeks, on October 3rd, so it’s time to begin this year’s House challenge.

It’s free, it’s fun, it’s easy. Here’s how to play:

To play the full season, your list must be posted in the comments section by 7pm (Central time) October 3rd — the night the season starts. Later entries are accepted and will start accruing points the following week.

The spam filter likes to hold on to these lists, so if yours doesn’t appear right away, don’t panic. If it’s been at least six hours and it still hasn’t shown up, drop me a line and I’ll hunt it down.

Make damn sure you take Undead Medicine as one of your fourth year electives during medical school — you never know when it will come in handy.

Two more recent syringe covers. I think this syringes must be the most common modern-era medical cover theme (as opposed to older eras, where the standing x-ray cover gag was the most common).

Streets of Gotham #28

Victorian Undead II #5

Here’s one more to add to the list of common medically-based cover themes (previously I’ve covered x-rays, nurses, and syringes, just to name a few).

Uncle Scrooge #28

Looney Tunes #194

Panic #8

Oh no! Will Flash run again? Will his leg somehow be saved? Don’t ask me — ask the doctor with the strange head mirror since he seems to know what’s going on.

This panel presents a nice view of outdated medicine:

scene from Worlds of Fear #8 (1953)

For the better part of the twentieth century, bromide (potassium bromide) was a common treatment for anxiety and other “nervous afflictions.” Potassium bromide was first used medically in the 1850s as a successful treatment for epilepsy¹. By the turn of the century, its beneficial effects in treating anxiety were also noted — most of which were probably due to its sedative effects. Extremely common, bromide was found not just in prescription medications of the time, but in over the counter remedies as well.

In the Merck Manual, 7th Ed., published in 1940, potassium bromide was listed as the preferred medication for treating anxiety and hysterics. Here’s more of what the Merck Manual listed under Potassium Bromide²:

Over time, the use of bromide became less and less common. Newer, more potent medications with fewer side effects were developed. Chronic bromide toxicity (bromism) was also recognized as a very real problem. By the Merck Manual, 11th Ed. (1966), the drug isn’t even mentioned. In 1975, potassium bromide was withdrawn from the medicinal market in the United States³.

Remember last week when I remarked how strange it was that so many people in Superman storylines seemed to come down with incurable tropical diseases? Here’s another good example: actress Lyrica Lloyd. Clark Kent falls in love with Llyrica and reveals his secret identity only to learn she’s dying from a fatal disease she picked up at a film shoot in Africa.

Superman vows to help, promising to scour the universe to find a cure, but instead we see that he’s constructed a “super oxygen tent” that does little to help Lyrica, and she dies…another victim of the Superman writers and their fondness for tropical diseases.

I always like to post non-Big Two comic book public service ads when I run across them, and here is one I stumbled across recently from Comico in 1987.

A simple one-panel anti-smoking PSA from Justice Machine #2, the Comico years. For those of you unfamiliar with the Justice Machine, the character shown is Talisman, who has luck/karma based powers, hence the “Don’t Press Your Luck” tagline.

Mike refers to Mike Gustovich, the artist and creator of the Justice Machine — who apparently is really opposed to smoking — and Tony refers to non other than recent blogging convert Tony Isabella, who was writing the comic.

More PSAs

Tags: comics psa justice machinemike gustovich tony isabella

A hospital x-ray machine has more than enough penetrating power to send x-rays all the way through the skull and brain. (In fact, you could argue that the x-ray machines used in 1961, when this comic was published, were more powerful than modern equipment. Today, we worry about radiation dose so we focus on finesse and minimizing exposure, while in years past the issue was one of raw power, radiation exposure be damned.)

The problem with locating the glass fragment has nothing to do with the range of the x-rays, it’s the fact that glass is radiolucent — invisible to x-rays. It doesn’t matter how strong the x-rays are, glass simply won’t show up on them.

Final Note: Not all glass is radiolucent, but the great majority of it is. For example, it is my understanding that the glass used in automobile windows is purposefully designed to be visible in x-rays (radiopaque). Personally, I’ve had numerous patients come in to the office complaining of a stepping on a splinter of glass, and only once has it ever showed up on x-ray — and that was a piece of lead crystal.

Mr. Malverne, the father of Supergirl’s boyfriend Dick Malverne, has come down with a deadly tropical disease¹. As his condition worsens, the doctors decide they have no choice but to try the experimental “miracle” serum Spracolicin².

Meanwhile, Supergirl is having problems of her own because she has been exposed to six red kryptonite meteors. As every fan of Silver Age wackiness remembers, exposure to red kryptonite causes bizarre, but temporary, changes in Kryptonians. Each meteor has affected Supergirl in a different way, but luckily, like bad ninjas, she only has to deal with one at a time. The first meteor caused her to become morbidly obese³. The next turned into a wolfman (or wolfwoman, rather). When she turned back to normal, she used her x-ray vision to check on Dick and learned about how sick his father was.

The third red kryptonite meteor causes her to shrink down to microscopic size. Seeing the opportunity to help Mr. Malverne, trial-sized Supergirl flies across town to the hospital and enters his bloodstream by flying down a conveniently open transfusion bottle^4,5.

Once in his body, she locates the bacteria⁶ causing the tropical disease and pummels them into submission, then allows the body’s natural defenses to take over.

The doctors, of course, credit Mr. Malverne’s miraculous recovery to the Sparacolicin serum. But unfortunately: “What a shame our supply was the only amount of it in existence and the formula has just been destroyed in a fire!⁷”

Notes: 
1. What is it with the Superman writers and tropical diseases? Remember that in Silver Age continuity, Ma and Pa Kent died of a tropical disease. (Personally, I’m guessing this allowed the writers leeway with the symptoms by claiming it’s a “tropical disease” and nobody can argue otherwise.)
2. Or Sapracolicin. It’s mentioned twice in the story, and spelled differently each time.
3. At which point she disguised herself as a giant parade balloon. Seriously.
4. An infection requiring a transfusion? How unusual. Oh, it’s a tropical disease.
5. An open transfusion bottle? This couldn’t have been a good idea, even before our current era of acronym-laden health and safety regulations.
6. Forget those microscope photographs you saw in biology class — they’re wrong. What you see here is exactly what bacteria really look like.
7. Great planning there, guys. (No great loss though as the serum didn’t actually do anything.)

Story from Action Comics #283, “The Six Red K Perils of Supergirl,” by Jerry Siegel and Jim Mooney. I wasn’t sure where to file this one, was it a Forgotten Medicine of the Silver Age, Transfusion Confusion, or just general Supergirl Silver Age Wackiness?

An prison escapee uses her psychic powers to rob a bank, much to the detriment of the bank manager, resulting not only in the classic psychic nosebleed, but also psychic eyebleeds (oculorrhagia?)

All previous Psychic Nosebleed Zen posts.

Tags: comics medicine nosebleed hercules oculorrhagia

…always coming to Earth with their ultra-medicine and stealing our patients! And making a profit to boot!

(From an imaginary tale in Superman #230-231, where Jor-El is Lex Luthor’s father, and they both come to Earth from the dying Krypton. Meanwhile Clark is the biological child of Jonathan and Martha Kent, criminals in the style of Bonnie and Clyde. )

The really bizarre medicine in this story comes not from Kryptonian ultra-medicine, but from Dr. Markem, a good old Earth mad scientist (go Earth!):

From this we learn that:

1. Criminality is inherited.
2. There are evil genes — and chromosomes.
   • Are the chromosomes evil because they contain evil genes, or are they evil on their own?
3. These genes and chromosomes can be implanted in the brain where they will eventually take root.
   • Do these evil genes make an evil protein or evil enzyme?
   • Are these genes only important in the brain?
4. The scientist apparently didn’t trust that Clark would inherit his parents “evil genes” on his own.
   • Which, by my quick math, would be a 75-100% chance per gene, depending on his parents genotype.

Throughout the Contagion storyline, a number of different terms are used to refer to the proposed cure Batman hopes to make for the Apocalypse Virus.

First, it is called an antibiotic. I’m certain everyone reading this knows that antibiotics are only effective against bacterial infections, so is the wrong term to use on a treatment for a viral infection.

Next, it is repeatedly called an antidote. Antidotes are good for poisonings or toxic exposures, but not so much in infections.

Third, throughout most of the story, Batman calls it a vaccine –- but what he’s proposing isn’t a vaccine.

Finally, an antiviral cure is developed (and the correct term “antiviral” is used) — after Azrael suddenly remembers after a dozen chapters that the people who released the virus might also have a cure. Why couldn’t he figure this out on the fourth or fifth page of the story, right after he told Batman about the virus? It’s a miraculous cure too, as everybody who receives it becomes instantly better, even those on the brink of death. I wished the anti-infectives I gave worked that fast and that well.

Basically, this is a technobabble explanation why Batman and his cohorts cannot use antibodies obtained from survivors of the Apocalypse virus to protect others. You see, inside the body the antibodies are extra strong, but outside the body (and don’t ask me how the antibodies know they’re in a tube of blood outside the body) the antibodies become very weak.

It’s not clear if the pathologist is talking about all the survivor’s antibodies, or just those to the Clench.
Mutations occur at the genetic level, not the cellular one — though the effects may be seen at the cellular level phenotypically, and this may be what she is referring to…
Except that antibodies are not cells, but instead complex proteins produced by cells and released into the bloodstream.

Like much of the storyline, this whole aspect of the plot gets abruptly abandoned later when Batman announces that the survivors of the Clench weren’t actually survivors per se, but instead people who never were infected in the first place. To me, this would seem to be setting up a further line of inquiry: what prevented these people from getting infected, and can it be used to protect others? But then again, I’m not Batman.

For the first part of my look at Batman: Contagion, I want to take a close look at the cause of all the trouble: the Apocalypse Virus.

A viral plague has come to Gotham City: the Apocalypse Virus — unleashed upon the city by the Order of St Dumas. Azrael, once a member of the Order, warns Batman of the impending pandemic.

Azrael describes the Apocalypse virus as a Filovirus.

Batman goes on to state:

Filoviruses are a family of pathogenic viruses which cause a particularly nasty type of infection known as a viral hemorrhagic fever. Not all Filoviruses are infectious to humans, but those that are have extremely high fatality rates. At the time the story was written, there is no known cure for any Filovirus.

Ebolavirus is one of two genera in the Filovirus family, and there are five known species of Ebola (and none of them are Ebola Gulf-A, it’s a fictitious virus). Despite what Batman says, the Filoviruses are all from Africa, and none have been found in Central America. There is no Ebola Honduras, so your flesh is safe.

A short time later, Batman breaks into an Army germ warfare center and learns:

Initial flu-like symptoms are commonly seen in Ebola infections. Airborne spread is likely, but not conclusively proven. Blood has been shown to transmit the infection.

A key part of viral hemorrhagic fevers like Ebola is the bleeding (hence the “hemorrhage” in the name). Under normal conditions, the liver makes the proteins that prevent our blood from hemorrhaging. The Ebola infection attacks the liver, stopping the production of these proteins, which ultimately leads to heavy bleeding from pretty much every orifice in the body, including the eyes.

While I appreciate the visual of the misshapen victims of the Clench, the reasoning makes little sense. If the muscles are shrunken and desiccated (dried out), then how would they have the strength to break bones?

I give the writers credit for creating a truly alarming disease. Ebola is frightening enough in the real world, let alone the enhanced version seen here. Both the “Clench” and the “Apocalypse Virus” are nicely evocative names, even if the latter sounds like something that should be found in an X-book. Their underlying science is a little shaky and their geography suspect, but that does little to undermine what they’ve accomplished in creating the “Clench.”

As a final note, there have been some very promising work on both Ebola vaccines and anti-Ebola drugs recently, but none of these were around when the story was written, so it would be unfair to hold that against the writers.

I’m off to San Diego for the rest of the week for a medical conference and a little family R&R.

As I’ve done several times previously when I’m out of town, I’ve written a close medical look at a “‘90s comic event” to post while I’m gone. In the past, I’ve written about Batman: Knightfall and The Death of Superman. This year’s topic is Batman: Contagion. Unlike previous years, this is going to be a multi-post review.

I’ll start out with a brief Spoiler Warning, but really — this is a fifteen year old storyline — if you haven’t read it by now, you have only yourself to blame:

The Plot: Through the machinations of the Order of St Dumas (the quasi-religious cult that churns out Azraels), a highly contagious Ebola virus is loosed in Gotham. There is no known cure, but there are rumors that three people survived a previous outbreak in Greenland, so Robin, Catwoman, and Azrael head out of Gotham to track them down, hoping that they may yield a clue to a cure. Back in Gotham, Batman scowls and glares. Huntress appears and gets scowled at. Nightwing appears, but only for a few panels, because apparently he’s got better things to do. In the end, Azrael deduces that if the Order of St. Dumas created the virus, then they probably have a cure. He busts a few heads, finds the cure, and Gotham is saved.

It’s not quite a deus ex machina ending, but close. The cure is found with only Azrael breaking a sweat, and just a little one at that. There are twelve chapters in the storyline, but the center ten could easily be cut out without affecting the outcome one bit. Neither Batman’s, nor Robin’s, nor Catwoman’s, nor Huntress’s actions in anyway hasten the finding of the cure. Their actions have no effect on the plague whatsoever. Only Azrael is important in finding the cure, and frankly, he should have figured it out in the first chapter.

It’s a Batman event, but, like I said, he contributes little, if any, to the solution. Sure, it can be argued that he kept the rioters in check — but this is Gotham City, the populace riots at the drop of a hat. The anarchy on the streets of Gotham has been done many times before and since, and while this is a decent interpretation, it’s not the best (which would be No Man’s Land).

It’s not that I don’t like Batman: Contagion — I do — it just has its share of flaws, including an ending that effectively renders most of the previous issues pointless.

For those of you who’ve been around long enough to remember the S.C.R.U.B.S. system, Batman: Contagion has a SCRUBS score of 22.

Avengers #240 is a veritable treasure trove of comic book medical cliches:

From the errant tubing on the cover:
Why is the air conditioner hooked to her cheek?

To the precordial thump:
A poor choice because her collapse wasn’t witnessed; she was just found down

To the doctor-with-a-head-mirror (and in the hospital lobby, no less):

scene from Rom #2 (by Mantlo and Buscema)

Dr. Peters comes all the way out to the Clarks to make a house call — a rare thing, even back in 1980 — and gets all but called a quack by his ungrateful patient. Note that he never calls Brandy a liar or tells her she was imagining things¹, just that she has a case of shock. He may actually believe her: if she actually saw an alien robot shoot and kill townspeople, that in itself would be enough to cause “a mild case of shock.”

1. Admittedly, it is strongly implied.

New Avengers #11
Brian Michael Bendis, writer
Mike Deodato, penciler

Mockingbird has been badly injured and is rushed to the nearest emergency room. When she is found to be pulseless, she is shocked (defibrillated). Is this appropriate?

Shocking a patient without a pulse may be a good choice — it all depends on why they’re pulseless. Remember, the pulse is a finding on physical exam; it is not read from a monitor or display.

There are many reasons a patient could not have a pulse:

1. They could have an abnormal heart rhythm, such as atrial fibrillation or ventricular fibrillation, which causes the heart to beat so fast there is not enough time for it to fill with blood and pump it throughout the body. In this situation, defibrillation is the correct treatment.

2. The patient could be in asystole (flatline) or PEA (pulseless electrical activity– some electrical activity in the heart, but not enough to cause the heart to beat.) These are signs of a dead or dying heart. Defibrillation is not appropriate.

3. The heart could be beating normally — or almost normally — but there is some systemic reason there is no pulse. For example, there could have been so much blood loss that not enough force can be produced to generate a pulse. Other reasons would include vascular damage from trauma, or abnormally hardened arteries that don’t transmit a pulse well. The treatment in this situation is to correct the systemic problem, and hopefully that will be enough.

4. Finally, you could have an incompetent doctor who can’t find the pulse. (Admittedly, trying to find a pulse in a crashing patient, let alone one with significant trauma, can be quite challenging). Treatment? Keep trying.

If Mockingbird falls into the first category, then defibrillating is a good choice. However, every sign points to her being in the second category, where shocking is not appropriate.

Her initial heart rate shows bradycardia (a slow rhythm) with no signs of fibrillation. If anything, it appears to be slowing down. It also make the official flatline sound of “beep beep beep beep beeeeeeee—“

The doctor reports that she has “no readable pulse.” As I mentioned earlier, you don’t read a pulse — you palpate (feel) it. This suggests he is looking at the heart monitor and reading the heart rate, not the pulse. A heart rate of zero is a flatline, and as I’ve discussed many times before, you don’t shock a flatline.

Final thoughts:
Kudos for at least acknowledging the need for an airway.
For a patient with a chest wound, they’re futzing with her abdomen an awful lot.

First of all, “a thousand gigawatts”? Why not just call it “terawatt”? (I know, a thousand gigawatts sounds bigger, but then why not go with “one million megawatts”?)

I’m not surprised that Maul’s brain is short circuited: a terawatt (oops, “one thousand gigawatts”) is a huge amount. In an entire year, mankind uses just under 16 terawatts of power. That means that Maul is being subjected to 1/16th of the world’s total energy consumption. Or to look at it another way, all the wattage produced by every nuclear reactor in the world is now flowing through him. Ouch.

That’s one hell of a taser.

Please Dr. Heath: a brain embolism is a stroke.

(Technically, a brain embolism is a type of stroke. Broadly speaking, there are two types of stroke: ischemic and hemorrhagic. In ischemic strokes, one of the blood vessels supplying the brain has been blocked. This blockage could be due to a clot formed in the brain [thrombus] or a clot or other blockage from elsewhere in the body that has traveled to the brain [embolism]. On the other hand, in hemorrhagic strokes, one of these blood vessels supplying the brain has started to bleed out. )

Ordering an MRI to determine which type of stroke is appropriate, since they’re treated in very different ways.

A rare treat here, a doctor who knows how to wear a head mirror: it’s over an eye instead of in the center of the forehead, and the hinge is drawn correctly off-center.

On one hand, you’d think technologically advanced Thanagar wouldn’t need head mirrors — but then again, it’s clear we are dealing with the Thanagarian underclasses here. It still doesn’t explain why an Ob/Gyn doctor needs a head mirror, though.

What’s the error in this scene from WildC.A.T.S. Annual #1? (On a scale of 1-10, with 1 being the easiest and 10 being the hardest, I rate this quiz a ½.)

Previous picture quizzes

Let’s not even talk about how this doctor is sharing the bad news (not too poorly, actually), or how accurate his information about leukemia is (greatly oversimplified), let’s just look at the horrendous blocking of this scene:

scene from Extreme Justice #0. Click to embiggen.

Panel 1
Outside view of doctor’s office

Panel 2
Doctor: Leaning against counter, reading long printout of labs
Ron Raymond: Sitting on exam table.

Panel 3
Doctor: The shadow obscuring the left half of his face has somehow turned his lab coat gray.

Panel 4
Doctor: Appears suddenly behind Ron. Lab coat is white again.

Panel 5
Doctor: Now he’s behind a desk; on top of which there is apparently a hobbit skull.

For the record, on the next page, the doctor remains behind the desk, though his lab coat flips between white and gray – maybe the room is lit like a bad disco? His top shirt buttons also are now undone — he opened them out of compassion, I suppose.

scene from Fear Itself: Spider-Man #3 by Yost and McKone

Once again, you don’t shock a flatline (”Why?” you ask — I’ll make it simple: defibrillators are used to stop a dangerous heart rhythm; they cannot “jump start” a heart).

And what’s especially frustrating is this comic got it right just a few pages before.

Amazing Spider-Man #661 “The Substitute, Part One”
Christos Gage, writer
Reilly Brown, penciller

Isoflurane is an inhaled anesthetic used for both induction of anesthesia (knocking patients out) and maintenance of anesthesia (keeping them out). It also works as an analgesic (pain killer) and a bronchodilator (opens up constricted airways — useful for people with asthma).

The original inhaled anesthetics used in surgery were flammable and had the unfortunate tendency to cause explosions. Sure, the anesthesia was good, but does that really matter when the entire operating room in on fire? A new generation of non-flammable anesthetic were developed — this included isoflurane and its close relatives enflurane and halothane. Over the past several years, the use of isoflurane has been gradually phased out in favor of an even newer generation of anesthetics that have a faster onset, though it is still commonly used in veterinary medicine and many third-world nations (because the newer anesthetics are ungodly expensive).

Invincible Iron Man #503 “Fix Me, part 3: Fear Itself”
Matt Fraction, writer
Salvador Larroca, penciler

Pepper Potts needs to find a better doctor for her employees:

I’ve heard this statement time and time again, and I’m regularly asked about it, so let me put it simply: wrong, wrong, wrong.

This advice generally comes in one of two forms, either “don’t let someone with concussion fall asleep” or “wake-up a patient who suffered a concussion periodically to check on them.”

The first advice is just plain wrong. To put it bluntly, someone who has suffered a concussion has had a bad day. They’ve been in a car crash, played a losing game of football, been beat up, fallen off something, or had some other sort of accident. They’re going to be cranky and they’re going to be in pain. The last thing they need to be is kept awake because it will only make the pain and the crankiness worse. Study after study has shown that sleep is good for healing, particularly healing from head injuries. Let the poor patient sleep!

The second bit of advice is a bit harder to pin down. There have been a few studies done and they showed no benefit from repeatedly waking the patient up to check on them, but they didn’t show any harm in the practice either. I can’t claim to be innocent in this regard: when I was a resident on my Neuro ICU rotation, I regularly wrote orders for “neuro checks every 4 hours,” though more out of habit and tradition than any particular concern. Today, I don’t recommend regular waking and neurological checks to my patients with concussions because I think they’ll heal faster (and certainly be less cranky) if they can get a good night’s sleep¹.