Polite Dissent

What exactly goes into Joker Toxin (aka Joker Venom, Smile Venom, Joker Juice, and sometimes, Smilex)? The recipe seems to have changed over the years:

1991
HUNTRESS: “Just tell me if any dimethyl silicate has changed hands lately. You know it Charley -– the poison the Joker makes his Smile Venom from.”
Dimemethyl silicate is most commonly found in cosmetics. For instance, it’s a common ingredient in lip gloss.
Source: Wonder Woman #282 (Admittedly, this story takes place on Earth-2)

1993
BRUCE WAYNE: “Some strange compound of chlorides and hydrocolloids with a protein catalyst.”
This one is little more than medical technobabble as all three terms, while real, are maddeningly vague. (FYI: Wikipedia entries on chlorides and hydrocolloids).
Source: Batman: Legends of the Dark Knight #50

2006
DR KOWALSKI: “I had never seen anything like the neurotoxin before. It blocked the calcium and potassium channels and also placed the victim in anaphylactic shock.”
More technobabble, but, like the best technobabble, there is just enough real science present to give it a whiff of truth: calcium channels are found throughout the body, but are especially common in nerves and muscles, and potassium channels are found in nerves and the heart muscle. Anaphylactic shock is a fatal allergic reaction — for example, people who die from bee stings.
Source: Batman: Legends of the Dark Knight #200

2010
BATMAN: “The most lethal element of authentic Joker Venom, hydrogen cyanide, is absent. strychnodide is present, though. It causes the muscle contractions that produce the hallmark grin.”
Hydrogen cyanide is a very real, very fast, and very deadly toxin (its symptoms don’t really match Joker Venom though). Strychnodide is a fictional derivative of strychnine.
Source: Detective Comics #867.
Though this is the first mention (to my knowledge) of this Joker Venom recipe in an actual comic, this combination of toxins was first mentioned in a DC Heroes Role Playing Game supplement in back in 1993 (DC Technical Manual: S.T.A.R. Labs 1993 Annual Report — I scanned in the relevant section here.).

Click on the image for the full ad

Quack diet aids are nothing new — here’s an ad from Captain America Comics #69 (November 1948) touting “Protam.”

I sure would love to know what, if anything, Protam was. The ad is little help — it tells us what Protam isn’t more than what it is: No drugs. No starvation. No exercise. No massage. Nothing to wear (does this mean they’re naked?). Not a drug. Not a laxative. Not a Thyroid.

The ad throws in a bunch of interesting claims and statements:
It works “even if burdened with Fat for many years (illness excepted).”
Drastically cuts down fat producing calories (But what about calorie producing fat?)
Lose Ugly Fat Economically, Simply, Pleasantly.
Protam Plan Good for Ladies, Too. (But not so good for verbs, apparently).
Sorry, no Canadian orders. (Damn Canada and their truth in advertising laws! OK, that’s just a guess…)

Protam wasn’t just advertised in comics, but in magazines such as Popular Science as well.

Here’s an interesting situation: Green Lantern is captured by his enemies and placed in a special forcefield that causes severe pain any time he uses his ring. In order to escape, he uses his ring’s power to create a pill (a green pill, of course), a “highly concentrated pain-killer – a super aspirin!”

Hal swallows the pill and then waits a few minutes for it to kick in. Once it does, it blocks enough of the pain for him to escape the force field.

In other words, Green Lantern used his ring to:
1. Create a drug.
2. And it’s a drug that persists even after he stops concentrating on it. Shouldn’t the drug molecules (green, of course) and their effects evaporate once he stops focusing on them?
3. Pain killers, particularly strong ones, are difficult medicines to create — especially if you want to avoid side effects like sedation or nausea. Would Hal Jordan, a test pilot, know enough to create a super-aspirin? Or can he just tell his ring: make me a super pain killer and poof! it does?
4. Or maybe Hal just created a super-placebo?

(On the other hand, bonus points to Hal for giving the pill time to take effect rather than assuming it would work instantly, a common misconception. Medications, particularly oral ones, take time to kick in.)

Images from Green Lantern #69 (June 1969) by John Broome and Gil Kane.
More can be read here.

In this scene from the X-Women one shot, Rachel Summers is forcefully impressing her memories upon Kitty Pryde. As the art (especially the rendering of Kitty Pryde) makes abundantly clear, this comic is drawn by none other than Milo Manara.

It actually makes sense, if you think about it: Over the past decade, Claremont’s X-Men stories have degenerated into little more than soft-core bondage fantasies (c.f. any issue of X-Treme X-Men), so Manara is the perfect artist for him.

All previous Psychic Nosebleed Zen posts.

Tags: comics medicine nosebleed x-men kitty pryde rachel summers claremont manara

Let’s take another look at Shadow of the Bat #50, where Batman is facing Narcosis, a villain who has created a special gas — a “patented” combination of Ketamine and Acetylcholine — to cause horrific nightmares.

First, the Ketamine:

Ketamine is a sedative and an anesthetic which I’ve covered extensively before. It is a strong tranquilizer and it has been known to cause nightmares, so its inclusion in Narcosis’ nightmare gas makes a certain amount of sense.

Now the Acetylcholine:

Acetylcholine is a neurotransmitter. In other words, it is a chemical messenger used to pass information between two nerves and it is also used to pass information between nerves and muscles. It has multiple effects within the human body. It causes skeletal muscles to contract. It activates the parasympathetic nervous system which, among other things, increase gland excretions and cause the heart to slow down. Within the brain itself, acetylcholine is associated with REM sleep — a state known for its vivid dreams — but its exact effect is not entirely clear. When the body moves from other stages of sleep into REM sleep, acetylcholine production — which had been suppressed — increases, so there is a rise in the level of acetylcholine. Dreaming also increases in REM sleep, but there is mixed evidence that it is the acetylcholine itself that causes the dreams. Some researchers say acetylcholine causes dreams, some say it causes REM sleep, some say it’s the other way around, and some say it’s all just coincidence. For now, I’ll just point out that while it’s true that all three situations (REM sleep, vivid dreaming, high levels of acetylcholine) exist at the same time, correlation does not equal causation. I’d give Narcosis a mixed grade on this (if the acetylcholine gets to the brain, it may cause increased dreaming which may cause nightmares) except for one thing:

The bigger problem with Narcosis’ use of acetylcholine in his gas is the effects of the neurotransmitter on the other parts of the body. Sure, it might cause nightmares, but who cares when you’re having severe cholinergic symptoms (salivation, urination, lacrimation, defecation, nausea, vomiting), uncontrollable muscle convulsions, and cardiac symptoms. Frankly, nightmares are the least of your worries.

Another Maxwell Lord psychic-nosebleed cover. Enough already — this “Maxwell Lord is evil and psychic and his nose bleeds” theme has played itself out, at least as far as visuals go. Time to move on.

All previous Psychic Nosebleed Zen posts.

Tags: comics medicine nosebleed maxwell lord justice league

Superman #701 “Grounded, Part One”
J. Michael Straczynski, writer
Eddy Barrows, artist

Kevin does a good job discussing the meat of Superman #701. There’s not much that I can add, other than to take a more in depth look at one particular scene — you know which one I’m talking about — from a medical perspective.

Yes, you read that right. Superman just told an elderly man that he has a serious heart condition, and then runs off, leaving the man to fend for himself. Wasn’t this journey across the country supposed to help him reconnect with the little guy?

One of three things is likely going on with the elderly gentleman:

1. The gentleman is suffering from angina (severely decreased blood flow to the heart due to narrowed or blocked arteries) or an early heart attack (a complete blockage of blood flow in one or more of the arteries supplying the heart). The pain and the man’s slumped position in the chair fit this diagnosis, but Superman’s comment doesn’t.

2. The gentleman has a dangerously irregular heart rhythm. Brief episodes of an irregular rhythm are fairly common — everybody has them — and generally nothing to worry about. But when you combine an irregular rhythm with chest pain, then there is something more serious going on (ventricular tachycardia or an advanced heart block would be my guess).

3. A combination of 1. and 2. An irregular rhythm could be cutting blood flow to the heart, leading to angina or a heart attack.

In any case, all of these situations qualify as a medical emergency — as in call 911 or proceed immediately to the nearest emergency room. Do not pass Go. Do not collect $200. This is not the time for you to scrounge for the doctor’s phone number; this is when you need to be calling 911. Or better yet, Superman could spend 2-3 minutes flying you to the emergency room. If he has several hours to spend talking a suicidal girl off a ledge, he can spend a few minutes saving an old man’s life (remember, not saving a man’s life is what led Superman into this predicament in the first place.)

And if it is angina or a heart attack, the last thing Superman needs to due is give the guy an adrenalin rush, increasing the blood requirements of the heart even more. Nice going, Superman.

As I discussed last time, while Superman has the ability to detect medical abnormalities, I am not convinced he has the skill to be able to interpret what he finds. It’s easy to misread heart rhythms, for better or for worse. If you haven’t had appropriate medical training, it’s also easy to miss the potential complications of certain diagnosis. For instance, Superman might diagnose the man with atrial fibrillation — a type of abnormal heart rhythm — but due to his inexperience, he wouldn’t know to look for a blood clot in the heart, a potentially fatal complication of atrial fibrillation.

True story: I had a case a few weeks ago, where a patient of mine was in a minor fender bender. The EMTs at the scene ran a rhythm strip and told him that he had an irregular heart beat and needed to see his doctor right away. First thing the next morning, the patient was in to see me, panicked, rhythm strip clutched tightly in his hand. He was convinced something was seriously wrong with his heart. A brief look at the rhythm strip quickly showed nothing was wrong. He had respiratory sinus arrhythmia, which means that the heart speeds up and slows down as the patient breathes in and out. It’s a completely normal finding and is nothing to worry about at all; the poor patient had been panicked, and undoubtedly lost a night’s sleep, for no reason. Thankfully, this story had a happy ending, but it shows that having the ability to check the heart rhythm is not the same thing as knowing what it means.

Batman: Shadow of the Bat #77 “Arwin’s Theory of Devolution”
Alan Grant, writer
Mark Buckingham, penciler

Streptomycin, a potent antibiotic, will indeed kill off the bacteria E. coli — and it’s particularly effective in a Petri dish, where you don’t have to worry about nasty side effects such as kidney damage and deafness commonly seen with such antibiotics.

However, the description of how the bacteria evolve resistance to the antibiotic is a little off:

The mutation in question (resistance to Streptomycin) occurred before the antibiotic was ever added. It may be a recent mutation, or it may be an old one, but when it occurred isn’t important — all that matters is that some bacteria in the dish have the mutated gene and are resistant to the antibiotic.

Once the Streptomycin is added to the dish, the non-mutated bacteria — those susceptible to the antibiotic — die off, leaving only the mutated bacteria to reproduce.

The surviving bacteria don’t “mutate rapidly” to pass along the gene because simply being one of the few bacteria that survived guarantees that their genes will be passed to the next generation. In other words, the mutation has already occurred, no more is required for survival¹.

In all fairness to the writer, these words are spoken by a college professor who is clearly more than a little nuts. So it is likely the character who misstates the science, and not Grant.

Notes:
1. There will of course be the usual random assortment of new mutations that may occur within any generation of bacteria.

I wrote this post a little over five years ago, but I think it is just as important now as it was then. It gives non-physicians a few quick guidelines on how to tell legitimate studies from nonsense studies when they are reported in the press. I originally wrote in about newspapers, but it replies equally well to television news programs and internet news sites.

Almost every day it seems that a new groundbreaking medical reports is mentioned in a front page newspaper article or on the cover of a weekly magazine. The claims are bold: eating red meat leads to colon cancer, drinking soda leads to diabetes, green tea extract cures strokes and so on. But are any of these claims legitimate?

Medicine can be a confusing field, and statistics even more so. T-scores? Z-scores? Power? P value? How is a non-physician (or non-statistician) supposed to find out which reports are reasonable and which are unfounded?

It’s not that difficult if you remember to be skeptical and follow these two simple rules.

Skepticism is Your Friend
Approach all medical articles with a great deal of skepticism. These articles and reports are trying to convince you to do something different, such as eat less of this or that or take this vitamin or medicine. Don’t just take their word at it. Make them prove it to you.

Rule #1
Where was the study published? To be believable, it should have been published in a well-known, well-respected medical or scientific journal*. These journals include the Journal of the American Medical Association (JAMA), the New England Journal of Medicine and Lancet.

Be very wary if the report is from a presentation at a conference and has not been published. Published articles are closely examined and reviewed by experts. The same doesn’t necessarily hold true for a presentation.

Don’t trust a news release or report put out that is not published in a legitimate journal, or at least presented at a legitimate conference. Most suspicious advice, sloppy science and bad medicine comes from these “reports” (and the most eye catching headlines too).

(I would also add that readers should beware medicine by press report. A legitimate finding should be available in a journal that is currently available or one that will be shortly available. If no publication or pending publication is mentioned, then it is likely medicine by PR and less likely to be legitimate)

Rule #2
Look at the number of participants in the study. If it is for a well-known condition (such as heart disease, stroke or cancer) or addresses a common situation (diet, exercise) then there should be several hundred, if not thousands, of participants. A study that addresses a common condition or makes sweeping statements yet only has a hundred — or fewer — participants should be viewed extremely skeptically.

Following these two rules will allow you to efficiently separate the wheat from the chaff and discover which newspaper medical reports you really need to pay attention to, and which can be dropped at the bottom of the birdcage.

---

* That is not to say that smaller medical journals don’t produce quality groundbreaking articles; they do, but it is rare. Big name journals also publish poor papers from time to time. Still, if it is published in a journal even a non-physician has heard of, then it’s more likely to be believable and legitimate.

In X-Men Unlimited #41, a young mutant has unknowingly developed the power to release emotion-controlling pheromones. In this scene, his viewing of a horror movie has unanticipated affects upon his fellow moviegoers.

All previous Psychic Nosebleed Zen posts.

Tags: comics medicine nosebleed x-men unlimited pheromeone

Even space aliens are no match for the power of…Psychology!

from Tales of Suspense #15 (March 1961)

How to tell if you’re not cut out for a career in Super-villainy in five easy steps, courtesy of the Human Flying Fish:

1A. Your partner is named after plankton.
1B. He claims to be an “Aquamanologist.”

2A. He’s a surgeon and an expert in marine biology, but thinks crime is the best way to make money.
2B. You cheerfully agree to be a guinea-pig

3. Your lungs are converted to gills, yet the oxygen and anesthesia during the operation are still being fed to your lungs. Oops.

4. Same theme: the operation replaced your lungs with gills, so why are still breathing air?

5A. Your costume consists of yellow hood and leggings and a purple and white tunic.
5B. You think “The Human Flying Fish” is a good name.

Images from the original appearance of the Human Flying Fish in Adventure Comics #272

A comic book public service ad that start’s out with a pun in the title? Can that be a good sign?

No, not really. It’s not a bad PSA, just uninspired, and the morose penciling of Bernard Baily doesn’t help either.

Click on the image for the full ad

For your edification, here are the take home points from this PSA. Print them out and carry them with you at all times:

This PSA appeared in DC comics published in May 1961. The script was by Jack Schiff with art by Bernard Baily.

More PSAs

Tags: comics psa eye fireworks rocket jack schiff bernard baily

Sam Guthrie, a.k.a. Cannonball, takes on Tsung, who has the “mutant gene for murder” and a handy supply of virtual bullets. Sam’s own mutant blast field protects him from the virtual bullets, but the feedback causes its own share of problems.

Why yes, this is from the Warren Ellis era of X-Force, why do you ask?

All previous Psychic Nosebleed Zen posts.

Tags: comics medicine nosebleed x-force cannonball sam guthrie warren ellis

Just as much of Marvel continuity is based on characters trying to rediscover the Super Soldier Serum, a large chunk of DC history is based on people trying to reinvent or otherwise improve upon the wonder drug Miraclo. This, frankly, is a mistake. It’s not that Miraclo is a bad drug — it’s not — it’s just that there’s a much better option — the original deus ex machina drug: Solution Z.

Solution Z was the secret drug the villain known as Mr. Who used to bedevil Dr. Fate back in the Golden Age.

Mr. Who was a 98-pound weakling who was constantly bullied by the other kids. Once he got to college, he spent his time learning biology and chemistry so that he could develop a drug which would allow him to turn the tables and bully those who used to pick on him*. Thus was born Solution Z.

So what can Solution Z do? Pretty much anything:
In Mr. Who’s first appearance, drinking Solution Z gave him increased stamina, strength, and invulnerability. It also improved his looks and shaved a good twenty years off his age. Later in the same issue, the drug allows Mr. Who to turn invisible and then grow to 15 feet tall.

In the next issue, Mr. Who uses Solution Z to grow gills and replace his hands with fins so that he can swim faster. Later, the solution allows him to become paper-thin and two-dimensional so that he can fit through a thin crack. After that, he uses the drug to change his face and appearance to look just like the city’s mayor.

In his third appearance, Mr. Who uses Solution Z to escape from custody by growing again, this time to 120 feet tall. He also uses the drug to shrink down to a mere 1 inch tall so he can escape a police manhunt. Solution Z also allows him to become intangible and pass through solid walls.

So once again, why waste time with Miraclo, which only does a fraction of what Solution Z does, and only for an hour at a time?

*but you’ll notice he didn’t spend enough time to actually earn an advanced degree, so he stays poor “Mr.” Who.

Source: More Fun Comics #73 (Nov ‘41), #74 (Dec ‘41) and #79 (May ‘42)

In Superman #700, Superman is devastated when a woman accuses him of letting her husband die because Superman didn’t use his powers to cure his fatal brain tumor. She believes that Superman could have used his x-ray vision and heat vision to identify and safely eradicate the tumor.

Now, assuming Superman’s heat vision could cure the tumor without any significant side effects* and he wants to make sure no one else dies of a brain tumor:

There are expected to be 62,930 new primary brain tumors diagnosed in the United States in 2010.
If Superman were to work a 24 hour day, 7 days a week, he would have a little over 8 minutes to spend on each brain tumor patient.
If he were to work a slightly more humane 18 hour day (6 hours for sleeping, eating, bathroom breaks, and saving the world), then he would have 6 minutes to spend on each patient.

But why just stop at brain tumors? Why shouldn’t Superman use his abilities to treat all cancers? In that case, there are expected to be 1,539,560 new cancers diagnosed in the United States this year alone (and that’s not counting non-invasive tumors and certain skin cancers that account for another 2+ million cases).
Now Superman has just 20 seconds to see each patient (or 15 seconds if he wants to sleep).
And why not go worldwide? Then Superman would have just 2 seconds per patient.

(And these numbers all assume the patients with cancer have already been identified before Superman even sees them. If you add some sort of screening program into the mix, then the time-per-patient drops even lower.)

I think it’s also important to remember that for all his skills and smarts, Superman is not trained in medicine — particularly radiology and surgery. How many false positives (he thinks it’s a cancer but it’s not) or false negatives (he misses a cancer) will there be? Is a single treatment of heat vision enough? Is 8 minutes, let alone 15 seconds, enough time to correctly diagnose a patient and treat them?

The Bottom Line: The plotline you thought was ridiculous gets even worse when you take a minute to look at the numbers.

*Which I seriously doubt, but that’s another post.

This ad certainly didn’t age well, unless Luden’s still endorses:
1. The shooting of an endangered species (in the back, no less).
2. Bringing drugs to school.
3. Sending young kids on picnics with strange men who carry guns and provide them with drugs.

Ad found in Action Comics #166 (May 1952)

The inhabitants of the Lost Valley of the Bird-Men have learned how to surgically attach giant wings to humans, allowing them to fly. All it takes it a few stitches and a large supply of the miracle drug Serum Alpha. Unfortunately, the evil Gravio family has cornered the market on Serum Alpha so they are the only ones in the Valley who can fly, a fact they use to their advantage by raiding and robbing from the remaining ground-bound populace.

All hope is not lost! A dissident member of the Gravio family has smuggled out enough Serum Alpha for one person. The villagers decide that Batman is their best chance, so they kidnap him and bring him to the Lost Valley.

He agrees to the surgery and a large pair of bat wings is grafted onto him.

He proceeds to take on the Gravios and defeats them all by executing an undeniably awesome plan which consists of: 1) divebombing with giant bat wings, and 2) gas capsules from his utility belt. In the end, it really wasn’t much of a fight — but then, this is Batman we’re talking about. In the end, the villagers thank Batman, surgically remove his wings, and return him to Gotham City.

“The Flying Batman” by David Vern and Sheldon Moldoff, from Batman #82

Flying through space, Krypto is exposed to the radiation from two strange meteors. One is Kryptonite, but the second is emitting some weird rainbow rays. Together, these two exposures cause him to develop Super-Rabies.

Super-Rabies is fatal, and progresses through three stages:
Stage 1: Uncontrolled super-growth.

Stage 2: Uncharacteristic anger and aggression.

Stage 3: Permanent muscle rigidity.

Once Krypto reaches stage two of the disease, Superboy realizes he’ll have to put him down. He works with the Army to develop special Kryptonite artillery shells. They knock Krypto down, but he’s not out. He tunnels out of range of the missiles, and then uses his super-heat vision to destroy the Army base. It’s at this point that the third stage of the disease strikes and Krypto is paralyzed. Realizing the end has arrived, Superboy then sets up a shrine to Krypto — using the permanently rigid giant dog as his own shrine’s statue (which is wrong in so many ways).

Heartbroken, Superboy flies into space to grieve. He stumbles across the strange meteors Krypto was exposed to and realizes what has happened. Exposing himself to the emanations of the meteors, he gains the same super-growth and increased super-powers Krypto developed. Before the disease can progress, he turns his now more-powerful x-ray vision on Krypto, and it miraculously cures him. Using a pair of mirrors, he then uses his own x-ray vision to cure himself. Both boy and dog live happily ever after, at least until Ma Kent rented Old Yeller.

“The Colossal Superdog” appears in Adventure Comics #262 (7/59). Script by Otto Binder, art by George Papp.

Previous posts on Rabies.

In this story, Namor’s kingdom is ravaged by a plague that can only be cured with radium. Unfortunately, according to Namor, there is no radium available under the sea, so he swims up to the surface world to find some. At the same time, a group of Nazi spies has stolen all the radium from the (one and apparently only) New York hospital. Namor captures the thieves and hands them over to the authorities, but keeps the radium for himself.

This story was written back in the days when radium was believed to a wonderful drug and a cure for just about anything. It was added to creams, lotions, ointments, toothpastes, and other medicines to make them “healthier” and “better for you.” As marketing, that may have been genius, but medically, it was disastrous. Radium could certainly certainly cure some medical conditions (and it has limited uses in medicine today), but back in the day it was just as likely — if not more likely — to cause cancer or a painful death of one sort or another. By the 1940s, when this story was written, the truth about radium was finally starting to become known, but it was still felt by many to be a wonder drug.

As for the doctor, he is wearing his head mirror more or less correctly. It’s just pushed up out of place a little, but one can easily assume he nudged it up when the telegram arrived so he could read it better.

Scene from Sub-Mariner Comics #1 (1941). Story and art by Bill Everett.

Tags: comics medicine head mirror namor radium namor

In this scene from Cable #105, Cable is fighting in an underground mutant fight club when he gets a little overzealous with his psychic blast. He not only K.O.s his opponent –and the referee — but he also manages to take out most of the audience that was sitting behind them. Oops.

All previous Psychic Nosebleed Zen posts.

Tags: comics medicine nosebleed cable psychic blast

Good call Batman.

Exelon (rivastigmine) is a drug that is used to treat dementia when it is associated with Alzheimer’s disease or Parkinson’s disease. It is not a miracle drug by any stretch of the imagination, but it has shown some modest success at delaying the progression of dementia, and some patients experience significant improvement of their symptoms.

Note that Exelon is only approved for Alzheimer’s dementia and Parkinson’s dementia, not for other causes of dementia. This is not to say that it isn’t being prescribed for other kinds of dementia, it is, but these uses are strictly off label and not approved by the FDA.

So not only is the head mirror worn wrong (as usual), but:

1. The doctor is a psychiatrist, so why does he need a head mirror anyway? (Other than peering into the deep recesses of the human soul, that is).

2. The head mirror is unexpectedly giving off light (Remember a head mirror only reflects light, it does not generate light itself. Anyway, the mirror focuses light, so any light reflected would be narrowed, not spread out. And even if the head mirror was flipped over so the convex side was showing, while that would almost explain the spreading light, that side’s not reflective).

And yes, that is Batman in a straitjacket — but that’s a story for another day (basically, one of Batman’s villains rigged the bat-radio to give Batman bad enough nightmares to make him think he was going insane. Insane in that goofy 1950’s way, that is: laughing maniacally. It only took two days in the asylum for the “world’s greatest detective” to figure it out. Read it yourself if you can track down a copy of Batman #84. On the other hand, don’t — it’s not a very good story. In fact, the Batman of the late ’40s/early ’50s had very few good stories).

A mysterious Sleeping Sickness strikes Gotham City, yet strangely it is affecting only the contestants in the “Queen for a Day” beauty pageant. The doctors who examine the patients confidently declare that the women have contracted a “rare but harmless” disease that will cause them to sleep for three or four weeks before recovering. They place each victim in a glass case so that the “medical profession can observe this rare malady.”

Batman is instantly suspicious as the first victim was none other than Selina Kyle, better known as Catwoman. He believes she is faking the illness, but the guard watching over her case swears she has been asleep the whole time.

With all the contestants asleep, it looks like no one will win the Queen for a Day contest, but luckily, Selena Kyle manages to recover from the sleeping sickness in time to win. Batman stops her just before she is about to claim the prize – a bottle of perfume that just happens to be full of smuggled diamonds

It turns out that Catwoman was behind the Sleeping Sickness (I know, quelle suprise!). She had discovered a chemical that caused the Sleeping Sickness; she gave herself a small dose, and then in a display of pure Scooby Doo science, she rigged a couple of movie projectors in her case to make it look like she was still inside when she sneaked out to give the other contestants larger doses of the chemical. Her convoluted plan was to win the Queen for a Day contest so she could claim the perfume bottle where her overseas associated associates had hidden stolen diamonds.

Batman, of course, was too clever for her.

Me, I wonder what kind of quacks they have in Gotham City: they can’t identify a disease (but are quick to claim it is “harmless”), never realize their prime patient is faking (or even absent!), and yet voyeuristic enough to place their patients in glass cases. My advice: never, ever seek medical care in Gotham.

“The Sleeping Beauties of Gotham City” from Batman #84 (June 1954)

Tags: comics medicine head mirror batman catwoman sleeping sickness

A comic-book cover psychic nosebleed this week. As far as I know, this is only the second time a psychic nosebleed has been considered cover worthy (and the first time was Maxwell Lord too, go figure)

I finally got around to listing all the psychic nosebleed posts I’ve done — and the numbers were more than I expected: so far, I’ve cataloged 140 different instances. You can find the list here (it’s a little sloppy because it’s such a long list. I’ll clean up the CSS in the next day or so when I get a chance)

All previous Psychic Nosebleed Zen posts.

Tags: comics medicine nosebleed maxwell lord justice league

Hawkeye & Mockingbird #1 “Ghosts, Part 1″
Jim McCann, writer
David Lopez, Penciler

Hawkeye’s not the only one who’s confused. I’m not entirely certain what Bobbi (Mockingbird) is up to in this scene and why she punctured the wounded man’s chest with an arrow shaft. As I see it, there are three possibilities, with the last being the most likely:

1. Bobbi actually meant to say “Cricothyrotomy.” The victim could have had his upper trachea or mouth injured and be unable to breathe through it, so she performed an emergency cricothyrotomy (an excision through the cricothyroid membrane to establish an emergency airway). Of course, the only injury we saw the victim sustain was to the chest, the tube is in the wrong place for a cricothyrotomy, and that arrow shaft is way to long and narrow to be effective for air exchange (as I’ve discussed before).

2. The victim could have developed a tension pneumothorax — this is a type of collapsed lung (pneumothorax) where the air trapped in the chest cavity is under pressure and starts pushing against the other organs in the chest — including the heart, the other lung, trachea, etc. It is considered a life-threatening condition.
In the field, one way to treat a tension pneumothorax is with a needle thoracostomy. A small needle is inserted into the affected side of the chest, just below the mid-section of the collarbone. This will relieve the pressure, but bear in mind that it actually doesn’t fix the pneumothorax, it just converts it from the life-threatening tension pneumothorax to the less dangerous open pneumothorax. Some kind of seal needs to be placed on the end of the tube because all it’s doing now is letting more air into the chest cavity.

3. The most likely scenario is that the victim developed a hemothorax (or a hemopneumothorax) from the bullet wound — the chest cavity is filling with blood on the injured side causing the lung to collapse. Bobbi has inserted a make-shift chest tube (a “tube thoracostomy”) to drain the blood. I give her full credit for improvising in the field and using the hollow shaft of an arrow for a chest tube is clever. However, there are some flaws in her technique:
The tube needs to be positioned so that the blood can easily drain out. With the tube straight up in the air, there’s no way the blood can drain, even with whatever meager positive pressure the patient can provide.
Placing a chest tube is a risky procedure at the best of times. Placing it at the top front of the chest is just asking for problems as there quite a number of important structures in that area (trachea, aorta, multiple large arteries and veins, etc.) that could be easily injured during the procedure — especially one using an improvised rigid chest tube. The best place for a chest tube is on the flank, about 1/3 of the way down.
Even if she has managed to drain the blood, she hasn’t sealed thetube so the chest cavity remains open to the air, leading to a pneumothorax. Water seals are the most common as they allow trapped air to escape, but nothing to enter.

On one hand, this doctor is wearing his head mirror correctly…but on the other hand what he’s recommending is simply atrocious (admittedly, this ad was from before the Surgeon General warning was placed on cigarette packs — but not before there was strong evidence that cigarettes were dangerous). I’m just going to assume that he’s an ethically-challenged oncologist trying to drum up future business.

Ivy’s daughter Lulu has been very sick. She ultimately received an antibiotic that managed to knock out the infection, but also knocked out her hearing as well.

Unfortunately, hearing damage is a common side effect of one particular class of strong antibiotics: the aminoglycosides. These drugs are infamous for causing ototoxicity (ear damage) and nephrotoxicity (kidney damage). Generally, very careful monitoring of the dosing can avoid these side effects, but not always. It turns out that there is a genetic mutation in about 1-2% of the population that makes them more susceptible to these side effects. The damage from aminoglycosides usually affects the higher frequencies of hearing, but can cause a total hearing loss. The damage is frequently permanent though sometimes — after many years — partial hearing can be regained.

Many of the early aminoglycosides are not used anymore except in a very limited capacity because they had an extremely high rate of these side effects. These included Neomycin (now seen primarily in topical ointments that aren’t absorbed by the body, such as Neosporin) and Streptomycin (used only for treatment of tuberculosis).
Gentamicin is the most commonly used aminoglycoside (in the hospital, anyway). It causes vestibular problems (inner ear damage resulting in dizziness and balance issues) more commonly than hearing loss, though there are some reports that children tend to be resistant to the vestibular problems.
Other similar drugs include Amikacin and Tobramycin.
There are other non-aminoglycoside antibiotics that can cause ototoxicity (however these just cause a temporary hearing loss), but for a hospitalized child as sick as Lulu, an aminoglycoside antibiotic seems the most likely culprit.

Ever wonder what happens to all the sick and injured fish in the ocean? It turns out that Aquaman has a medical clinic where he treats them all¹. A whale with bruised ribs? A swordfish with a broken nose? Come see Dr. Aquaman!

Aquaman is called when a sick sea-lion is spotted. He immediately diagnosis it with “Fish Scurvy” because of its glassy eyes². He mentions that this is a highly contagious disease³ and then brings the sea lion down to his clinic⁴ and places him in a glass isolation cage. He posts a sign⁶ on the cage which says “Warning! If opened will infect area of 100 yards!”

Meanwhile the coast guard informs him that a gold smuggler has been seen nearby. The smugglers try to outsmart Aquaman: they find his clinic and break open the cage, releasing the sick sea lion. The entire area, for 100 yards in every direction⁷, is under quarantine. They quickly speed away, knowing that Aquaman would never break quarantine and risk infecting more fish. But this is Aquaman we’re talking about, and he never lets the bad guys escape. With the help of his finny friends, he hides the signal lantern the smugglers are following (with squid ink and blow fish) and has them follow a fake one (a lantern fish), leading them right back into the quarantine area where he captures them⁸.

NOTES:
1. There are at least ten doctors in my town of 30,000 and we’re nearly always booked solid. How can one man, even if he is Aquaman, treat every fish in the sea? Maybe he franchises.
2. Aquaman of all people should realize that a sea lion is not a fish.
3. Nor is scurvy contagious, it’s a vitamin deficiency.
4. The sea lion is pretty isolated already, why not treat him there, rather then bring a contagious animal down to the clinic in the middle of the ocean?
5. As mammals, sea lions need to breathe air regularly. Keeping him in an underwater glass case would not be conducive to his survival.
6. Who is the sign for? The fish can’t read – the sign is only there to hand the smugglers an escape plan on a silver platter.
7. Apparently the ocean currents flow 100 yards in every direction, and then suddenly stop.
8. I never had any doubt that Aquaman would catch the smugglers, but what about the sea lion? Did he survive? Did Aquaman cure him? Were other “fish” infected as well? This would have made a better end to the story then a few tied-up smugglers.

Last Thoughts: Scurvy
I’m sure the writer was just trying to come up with a clever sounding name when he chose “Fish Scurvy,” but it turns out to be an actual disease. And a cleverly named one at that, being scurvy that occurs in fish.
Scurvy is caused by a severe deficiency is Vitamin C. Symptoms start with appetite loss, poor weight gain, diarrhea, and tenderness and discomfort in the legs. Bleeding, especially of the gingiva (guma) and eyes, is common. Bone and cartilage deformity occur. Scurvy is fatal is not treated — and the treatment is simple: lots of Vitamin C.
Most animals make their own Vitamin C so are not susceptible to scurvy. Only a relatively few do not produce Vitamin C and need to eat some regularly in their diet. These animals include bats, guinea pigs, and certain primates (including humans). Some fish and birds also need Vitamin C to survive.
On the other hand, sea lions make their own Vitamin C, so can’t catch scurvy. In fact, they have plenty of Vitamin C and seal and sea lion meat was eaten by Arctic explorers to treat scurvy.

Calling Dr. Aquaman is from Adventure Comics #188. The writer isn’t listed, but the art is by Ramona Fradon.

scene from All-Star Comics #8

Despite having superior medical skills and technology, it seems the Amazons suffer the same inability to wear head mirrors correctly as the rest of the comic book world.

This week’s episode was a bit of a letdown after last week’s Over There, Part 1 (and the several great episodes leading up to it). It wasn’t bad, but it wasn’t terribly good — or very Fringe-y at all. It seemed like it was an episode designed to get everyone in place for next season, rather than a fitting ending for this one.

The Plot: Olivia and Bell are searching hospitals, trying to find Walter. Olivia sees the alterna-Fringe team arriving and realizes that they must be in the right hospital. Bell stalls them while Olivia finds Walter and escorts him out of the hospital.

Peter meets with his father, who tells him that he wants to repair the rift and save both universes, but that he’ll need Peter’s help. He asks him to take a look at the power source for his “fix-the-rift” device ( power source that looks amazingly like an original XBox).

Walter, Olivia, and Bell stop just long enough to shill for Kentucky Fried Chicken, and then they head out again. Walter and Bell are off to Walternate’s old Harvard lab to build a device to let them cross back over into our universe while Olivia heads back to the city to look for Peter.

Alterna-Olivia has questions for the Secretary of Defense and he admits that yes, the people who crossed over are our doubles, only evil (or, more correctly, eeeviiilll). Sensing a connection between her and Peter, he asks her to escort him to his new apartment. Alterna-Oliva arrives back at her house, only to find Olivia waiting for her. They exchange some family history (Mom dead? No? Sister dead? No? Niece?) before getting to the inevitable fight. Alterna-Olivia is the stronger fighter, but Olivia decks her with a convenient piece of wrought iron. She then cuts and dies her hair so that she looks just like alterna-Olivia. Just about this moment, alterna-Charlie shows up at her doorstep and tells her that there’s been a power surge in Walternate’s lab and they’re supposed to check it out. Olivia tells him they’ve got a new mission, and that’s to move Peter to safety. They arrive at Peter’s apartment and Olivia warns him what Walternate is up to. Alterna-Charlie realizes something’s wrong with Olivia, but not in time to stop himself from being clobbered. After hearing his father’s plans, Peter tells Olivia he doesn’t belong in either universe — but then she kisses him and poof! — problem solved.

Olivia, Peter, Walter, and Bell arrive in front of the theater where they crossed over in the previous episode. A minute later, the alterna-Fringe team arrives. Peter and Walter move his machine inside and set it up while Olivia and Bell hold off the alterna-Fringe. The battle is chaotic, and at one point Bell finds himself confronted by two Olivias — and then clobbered by one of them. When he comes to, he finds the battlefield in flames and Olivia tells him she had to use one of his experimental grenades to save their life. The two of them hustle inside the theater to meet up with Walter and Peter. Walter is still complaining that they won’t have enough power to cross over, but Bell tells him not to worry. Bell explains that he has crossed the dimensional gap so many times his structure is unstable, like trillions of atom bombs, and he will provide the power for crossing over, even though it will cost him his life. The machine is activated and Peter, Olivia, and Walter cross back into our dimension.

A little while later, as Astrid is fattening him up with pie, Peter tells Walter that he’ll stay around for at least a little while. Meanwhile, it becomes apparent that the Olivia who crossed over was actually the Alterna-Olivia, and the real Olivia is locked up in the alternate universe.

1. And Flash Gordon Was There in Silver Underwear
I have to give alterna-Olivia props for her great choice of ring tone on her home phone.

2. Watch It Wiggle
The Quarantine Zones looked like the Jell-O bus from Fringe’s third episode “Ghost Network”

3. Answer Me That, Mr. Green Lantern
The show continued to hint at the subtle differences between the two worlds. I wish I had been able to see more of the comics that were framed in Peter’s apartment, but here’s the one I did catch:

That’s the original cover to Green Lantern #76 (April 1970, cover by Neal Adams) on the left, and the alterna-version on the right.

4. Full Stop
I’m sure it will be hand-waved away with mentions of “door stops” and William Bell’s atom power, but Walter seemed quite insistent that they needed Olivia’s abilities to cross back over. Does alterna-Olvia have the same abilities, or was that just papered over? In other words, was alterna-Olivia exposed to Cortexiphan too?

5. I Thought They Were Twins
Is there anyone who didn’t realize that was alterna-Olivia who helped Bell up? There was nothing even remotely subtle about it. And it never crossed Bell’s mind — who had just seen two Olivias — that this may be the wrong one? (Yes, I’m sure it will be handwaved away because she “knew about the grenade” — but maybe alterna-Olivia, unlike real Olivia, actually has some investigative skills).

6. Frankly My Dear
They never did explain Olivia and Frank’s “last night” comments from last week’s episode.

Not a bad episode, but rather anti-climactic compared to the last several. The Fringe Doomsday Clock stays in place and ends the season at 11:56

Tags: television fringe alternate universe peter olivia

UPDATE: Here’s the other alternate world comic book covers:


The originals are Crisis on Infinite Earths #7 (with Superman holding a dead Supergirl), Superman #75 (”The Death of Superman” — the “Collector’s Cover” shows a bleeding Superman symbol), Justice League #1 (with Guy Gardner instead of Jonah Hex), and Batman: The Dark Knight #1 (”The Dark Knight Returns”).

From DC’s “The Source” blog.

Diagnosing a patient is hard enough in the real world (that headache, is it a tension headache? migraine? meningitis? Strep? brain tumor?). Just imagine how much more difficult it would be in the world of comics, where psychics, aliens, strange drugs, and mutations all come into play.

Still want to be a comic book doctor? Here’s your chance, with four more comic book medicine case studies:

The previous case studies and a bit more an explanation can be found at Dr. Scott’s Case Studies of Comic Book Medicine

The Season Finale of House, Season Six, and it summed up the season in a microcosm: moderately interesting case and uninspired medicine all sacrificed in the name of soap opera.

There has been a crane collapse in Trenton and Cuddy rushes over to lend a hand. House heads over too for reasons of his own, most of which have to do with Cuddy. They spend most of their time triaging victims (deciding who needs treatment first, and who can wait). House diagnoses one person with a skull fracture noting that she has a Glasgow Coma Score (GCS) of 11 (a “moderate” brain injury). He tells Cuddy that her patient is unlikely to survive, so not to waste resources on him. Cuddy agrees, telling the paramedics that the patient is expectant (expected to die — and he does die a short time later).

Foreman is treating the crane operator, who apparently fell asleep on the job. House finds a stash of caffeine pills in the operator’s pocket; he says he was taking them plus drinking coffee – something he doesn’t normally do — all in an attempt to stay awake. Given the fact that the operator fell asleep despite all the caffeine he was consuming, House suspects there is an underlying neurological problem. He has Foreman take the operator back to the hospital to evaluate.

Later, sitting by himself, House hears a clanging sound from deep in the rubble. He alerts the other rescuers, but they can’t find anything. Undaunted, he crawls into the rubble himself and finds Hanna, a woman whose leg is pinned by a heavy beam.

Back at the hospital, the team’s initial diagnosis of the crane operator includes vasovagal episode (a fainting spell), sick sinus syndrome (the heart’s natural pacemaker is not working correctly), or a meningioma (a tumor of the membrane that surrounds the brain). Taub believes the operator simply fell asleep on the job. House suspects a space-occupying lesion (like a hematoma, abscess, or tumor), so orders an MRI.

The paramedics cannot get an intravenous line in Hanna, so House places an intraosseous line (where IV fluids are directed into the bone marrow instead of a vein). It becomes clear that Hanna is trapped by a support beam, so Cuddy and the paramedics recommend amputating her leg or risk crush syndrome (basically, when muscle is crushed it releases a bunch of toxic substances. As long as the muscle remains trapped, these toxins are sealed off from the body, but once the crush is relieved, all the toxins come pouring into the rest of the blood stream causing kidney failure and other serious problems). Hanna will have none of it and House convinces them to give it a few more hours to remove the rubble over the beam. He promises that they will not need to cut her leg off. House wants to head back to the hospital, but Hanna has a panic attack being left alone, so he stays.

The MRI is normal, but the crane operator starts bleeding from both the nose and eye, suggesting something is wrong. Chase thinks that he has a brain infection — but he’s not showing any fever, so House favors a venous sinus thrombosis (a clot in the large veins that drain the brain) and wants the team to perform a venogram.

An attempt is made to lift the beam off Hanna’s leg. It seems to work at first, but a secondary collapse occurs and her leg is still trapped. Furthermore, she suffers a tension pneumothorax (a dangerous type of collapsed lung), which House relieves with a needle thoracostomy.

The venogram is normal, but now the operator is running a fever. The new differential includes a subarachnoid bleed or meningitis. House orders a lumbar puncture.

Cuddy tells House that it’s time to face reality: they need to amputate Hanna’s leg. House insists he can buy her more time by treating her elevated potassium with glucose and insulin. However, in the end, he agrees with Cuddy, and climbs into the rubble to tell Hanna that her leg must be amputated to free her. He tells her about his leg injury and how he wishes his leg had been cut off. She agrees to the procedure, and House performs the amputation himself, getting her free of the rubble. He climbs into the ambulance alongside Hanna and her husband for the ride back to the hospital, leaving his cane behind.

The spinal tap was normal, but now the patient is in a coma. House realizes that his symptoms (passing out, bleeding, coma) always occur at times of elevated blood pressure. From this, he deduces that the patient has an arachnoid cyst on his lower spine. He is about to order a CT scan to confirm when

Hanna starts to have trouble breathing and her blood pressure is dropping rapidly. A quick exam shows no evidence of pneumothorax (collapsed lung) or tamponade (bleeding into the sac around the heart), so he deduces that she has a pulmonary embolism (blood clot in the lung) from being trapped in the rubble for too long. He gives her Streptokinase, a thrombolytic (drug which dissolved blood clots), but when he sees no response, he realizes that she must have a large fat embolism (a clot made up of fat), which can be a complication of orthopedic surgeries such as an amputations (or caused by the trauma itself). Unfortunately, there is little that can be done for a fat embolism and Hanna dies before she can get to the hospital.

Dispirited, House returns to his apartment and grabs the Vicodin bottles he has stashed there. He is sitting on the floor, contemplating taking the medication, when Cuddy walks in and tells him that she has called it off with Lucas…

Most of tonight’s medicine was trauma medicine, and area I (thankfully) don’t practice much in. I’d like to hear what any emergency physicians, paramedics, or EMTs thought. As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

Streptokinase is not routinely carried on ambulances. ( I say “routinely” only because I know there have been a few studies run on pre-hospital thrombolysis in myocardial infarctions, but they use more modern thrombolytics.)
Recent surgery is a relative contraindication to thrombolytic use (as opposed to an “absolute contraindication”, so it can be used if it is felt that the benefits outweigh the risks – but remember, we have no idea if Hanna suffered other injury from the collapse. She very well may be bleeding internally.
Thrombolytics time to work; they’re not immediate.

House didn’t cure her tension pneumothorax, he merely converted it to an open pneumothorax. A less dangerous situation to be sure, but still a collapsed lung.

High potassium is not the only toxin in crush injuries — though it is probably the main one, or at least the one of immediate concern.

Spinal arachnoid cysts present with spinal cord compression symptoms (if they have symptoms at all). Blaming one for unconsciousness, coma, and bleeding from the nose and eyes is quite a stretch. A cyst large enough to cause problems like that would have demonstrated spinal cord symptoms long before.

ABCs. They should have intubated her as soon as she had trouble in the ambulance. It may not have saved her life, but it could have bought her time. You can deliver a lot more oxygen by endotracheal tube than by face mask.

Glucose + insulin is a valid way of dropping an elevated potassium in emergency situations (though at this point, she was still trapped, so worrying about treating the hyperkalemia is premature)

I know of no hard and fast rules about how long you wait in a crush injury before amputation, other than that amputation is considered the treatment of last resort, used in immediately life threatening situations (building on the verge of collapse, for instance).

I’m not sure I buy his statement that he can’t put her out because it will depress her respirations too much. True, she has a pneumothorax, and she’s in a difficult location to keep a close eye on, but surely they can give something stronger than what they gave her.

The medical mystery of the crane operator was interesting, but only made up a small part of the episode. Still, I give it a B+. The solution was quite a stretch and only deserves a measly D+. The medicine in the hospital was pretty good, even if the solution was poor. I have some serious concerns about the medicine in the field, especially the need for an amputation at that point (and even earlier, when Cuddy originally suggested it), and the use of Streptokinase. Overall, I give it a C. The soap opera was good, though it needed more Wilson (and more Foreman — he really got ripped off this season); I give it a B+.

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

House Challenge scores have been updated as of last week’s episode. Final scores should be up tomorrow night.

Another scene with psychic nosebleed king Maxwell Lord, this time from Justice League: Generation Lost #1 (Winick, Giffen, Lopresti).

All previous Psychic and Superpowered Nosebleed Zen posts.

Tags: comics medicine nosebleed maxwell lord justice league

House Challenge is up to date as of last week, just leaving the final week of competition.

Overall, TRad and Noether continue their dominance, with 95 and 87 points respectively. Corien is in third with 74 points, followed by Theta Sigma with 65 and The Erskine with 60 points.

Click here to see the full scoreboard.

A solid outing on Fringe this week. I’m looking forward to next week’s season finale.

The Plot: The episode starts at Fringe headquarters in the alternate universe. A major breach is detected and a team – consisting of Olivia, Charlie, and team leader Lincoln Lee — is sent to an old theater to evaluate. The breach is substantial enough that the Fringe team plans to quarantine it, an act that will somehow cause hundreds of thousands of casualties. At the last minute, the quarantine is called off after the breach seals itself. Scouting the theater, the Fringe team finds a dead body with “multiple carcinomas” (sound familiar?) A search of the body reveals a drivers license and a twenty dollar bill, which they take to be a forgery because they’ve never heard of Andrew Jackson. Meanwhile, watching hidden from a few rows away are the Olivia and Walter from our universe, plus two others.

Thirty six hours before, Olivia is drowning her sorrows in a bar when an Observer drops off a note for her. Walter watches a video of Peter agreeing to cross back to other universe with alternate Walter and is disconsolate because he knows there’s something important about Peter that he’s supposed to remember, but can’t. When Olivia shows him the note, he realizes this is what he was trying to remember: Peter is somehow going to destroy the universes. He recalls one of the Observers warning him once never to let Peter cross back to other side, and this is why.

Walter and Olivia decide they need to cross over to the other universe and retrieve Peter. They head over to Massive Dynamic, because a sketch on the page the Observer gave Olivia looks like one of William Bell’s machines, but the team there knows of no way to cross over without suffering severe molecular damage. Walter theorizes that the Cortexiphan children could cross over safely, but Olivia is the only one who is mentally stable. Agent Broyles reveals that there are more stable Cortexiphan children: James, Sally, and Nick. They agree to help Walter and Olivia cross over to the other universe.

Meanwhile Peter wakes up in a hospital bed. He walks downstairs to find his mother — his actual mother — cooking him breakfast. They have a nice chat.

At the theater in our universe, the four Cortexiphan children form a circle with Walter in the middle. He leads them through a concentration exercise when suddenly James collapses, tumors forming on his skin. He points to a blimp that can be seen through the skylight as proof that they’ve crossed over. They hide as the alternate Fringe team arrives in force, just as in the beginning of the episode. Because of what they’ve found, the alternate Fringe team is brought before the Secretary, other Walter, who tells them his version of what happened. He explains to them that a group from the other universe has crossed over and needs to be found before they can start a war.

Over breakfast, Peter’s mother gives him some notes that alternate Walter left for him. They are for a project he would like Peter’s help with. As he looks through them, the plans are recognizable for the strange machine on the note left by the Observer.

Meanwhile, what’s left of our Fringe team is heading to Central Park to meet up with William Bell. When they arrive at the meeting place, there’s no Bell to be seen. A few seconds later, the alternate Fringe team, with several busloads of additional agents, show up. Nick is shot and killed and his girlfriend Sally uses her pyrokinetic powers to cause a fireball, consuming herself and Nick and severely burning the leader of the alternate Fringe team. Walter runs off, but is shot. He stumbles on and eventually collapses in front of a hospital. Olivia escapes, and uses a convenient street side white pages terminal to track down where alternate Olivia lives. As she is covertly spying on her double, William Bell appears and asks her to trust him, warning her that Walter is in trouble.

1. Bullfinch
There were a number of allusions to the two-years of Fringe mythology we’ve been building up.
The return of the Cortexiphan children
Alternate Charlie clearly never fully recovered from his first-season encounter in Unleashed.
A mention of the ZFT Manifesto (its first mention this season — they still need to explain the missing chapter, though).
And of course, the return of William Bell.

2. Vive La Différence
I liked how the blimps (as I’ve said before, you can never go wrong with blimps — well, except the Hindenburg), the Nixon silver dollar, the Martin Luther King Jr. twenty dollar bill, and the West Wing poster all clearly set the alternate universe apart from ours — in addition to its more militaristic stylings. I’m somewhat creeped out that Cabbage Patch Kids are still a big thing over there.
And how could I forget mentat Astrid?

3. Cellular Biology vs Molecular Biology vs Chemistry vs Physics
My only complaint about the science is a nitpick, when Brandon, the Massive Dynamic scientist, explains that the cells are separating on an atomic level. Once you’re dealing with individual atoms, you’re well past the cellular level.

4. Susan?
I know that Nick is from Bad Dreams and James is from Olivia, In the Lab, With the Revolver. I’m not sure where Sally is from, unless she’s somehow tied into the pyrokinetics from The Road Not Taken.

5. Let’s Be Frank
Clearly something is up with alternate Olivia’s significant other, the way they keep referring to his “last night.”

A nice solid episode that advanced the story greatly, but also tied into many old plot points. The Fringe Doomsday Clock regains a minute this week.

Tags: television fringe alternate universe peter war cortexiphan

Black Canary is on a mission to rescue Katy, a five year old girl who has been kidnapped. It turns out there’s a slight medical complication:

Katy suffers from a ventricular arrhythmia. In other words, her ventricles — the lower chambers of the heart — are beating abnormally. This can be a real problem because the ventricles are the workhorses of the heart: they do most of its work by pumping blood through the lungs (right ventricle) or throughout the body (left ventricle). If something is going wrong with the ventricles, it’s not good.

In particular, Katy has ventricular tachycardia (i.e. “V-Tach”), a condition where the ventricles are beating independently of the atria (the top of the heart) and beating way too fast. This is unfortunate for a couple of reasons: first, the ventricles are pumping so fast that they don’t have enough time to fill up before contracting, so blood is not getting moved around the body efficiently which can lead to heart failure (which probably explains why Katy is having shortness of breath. Well, that and being out in the freezing cold in her pajamas). Second, and more important, is that ventricular tachycardia is an unstable rhythm and can quickly degenerate into ventricular fibrillation or asystole (flatline). These rhythms, as my old cardiology instructor used to say, are “not compatible with life.”

So how do you treat ventricular tachycardia? If it comes on suddenly, like in a code blue situation, then you bring out the defibrillator paddles and shock the heart back into a normal rhythm (hopefully). For long term control, antiarrhythmic drugs are often used. As the name suggests, the medications keep the heart in a normal rhythm and out of arrhythmia. They can be nasty drugs with many side effects (including, ironically, causing arrhythmias) so they aren’t used unless absolutely necessary. In this case, Katie is on Flecainide to prevent her tachycardia from recurring.

Tags: comics medicine black canary birds of prey arrhythmia ventricular tachycardia flecainide gail simone

We’re in the middle of National Nursing Week and I’ve been saving this Careers in Nursing public service ad for just such an occasion.

I’ve always made it a point to get along well with nurses. They’re fellow medical professionals, and as a physician, they can make your life easy, or they can make it a living hell. Personally, I always preferred easy — and it always just seemed common sense to never antagonize the nursing staff.

Here’s a quick true story from residency to prove my point: As a first-year resident, we spent a month working in the NICU (neonatal intensive care unit). When we were the NICU resident on call, one of our responsibilities was to manage the ventilators many of the newborns were hooked up to. (It was a big hospital, with probably 30 to 40 babies at any given time, with at least half of them intubated and on the ventilator.) To do this, a lab known as a blood gas would be drawn, and based on the results, you’d adjust the ventilator settings. This probably occurred forty times during a night of call. Generally, the nurses were very helpful and would wait until they had about a dozen blood gas results before giving you a call. This was to allow you time to catch some sleep in the call room.

However, one of my fellow residents did something that annoyed the nursing staff, and then when called on it, acted very arrogantly. This was not a good idea. In retaliation, when it was his night to be on call, they would page him every single time a blood gas came back instead of holding on to the resultsand calling every few hours. In eight hours of call, he would receive forty pages (or about one every twelve minutes) from the nursing staff alone. The poor idiot never got any sleep on call. Sadly, I don’t think he learned his lesson, and continued to have problems with the nursing staff all the way through residency.

Click on the image for the full ad

This PSA appeared in DC comics from April 1957. The script is by Jack Schiff and the art is by Ruben Moreira.

More PSAs

Tags: comics psa buzzy nurse jack schiff ruben moreira

Though the medicine was sloppy and at time contradictory, I liked this episode of House. The way it was staged was clever, and it was nice to see Alvie again — though a little goes a long way as far as he is concerned.

This episode starts with House arriving at the office of his psychiatrist Dr. Nolan for his weekly session. Nolan can clearly tell that something is bothering House, but that he is reluctant to share it. Instead, Nolan has House tell him about his week, and House relates the tale of the amnesic patient. Alvie, House’s manic room mate from his stay in the mental hospital, also makes a return in this episode.

A young woman is brought to the ER with a complete loss of memory. She was found jogging down the middle of the street with no idea who she was. An MRI was obtained but was normal. The patient had no ID, just her heart rate monitor and clothes — expensive clothes, House mentions. He also deduces that she is an ultramarathoner from her general physique and metabolism.

House takes a closer look at the MRI and notes a region of that shows some “loss of differentiation between the grey and white matter” (grey and white matter are the two types of brain tissue). Chase points out that the area of the brain affected is the part that controls memory, so he doesn’t think it’s a coincidence. The differential diagnosis consists of bacterial infection, multiple sclerosis, a history of head trauma, or toxin exposure. House thinks that he can track down where she bought her heart rate monitor by its serial number. It’s possible someone will recognize her at the running store, or he figures that the store is likely to be close to where she lives, and the view might spark some memory. While no one at the running store recognizes her, it turns out that she’s a regular customer at the donut store across the street. Through them, House is able to track down the patient’s house and husband — none of which is recognizable to her. It turns out that her name is Sidney and she’s a high powered civil rights lawyer who spends almost all her spare time running. Her husband mentions that she recently won a settlement for some individuals who had been exposed to high levels of methane, and House thinks methane exposure might account for her symptoms. He takes her back to the hospital, but she trips in the yard, reporting that her foot has gone numb. She also loses bladder control. House suspects that she has developed partial complex seizures.

Back at the hospital, Sidney’s been under observation for twelve hours with no sign of any seizures. House tells the team to stress her more in an attempt to bring out any seizures, but his team tells him that she’s already under a great deal of stress from fighting with her husband. She suddenly becomes acutely short of breath and starts struggling for air. She is found to have pulmonary edema (fluid in her lungs) that appears to be related to diabetes insipidus (A condition where the kidneys cannot retain fluid correctly. This is a different from diabetes mellitus, or “sugar diabetes,” what most people think of when they hear “diabetes”). The diabetes insipidus is felt to be related to damage to her hypothalamus, making three separate areas of her brain affected. Taking in all the symptoms, House diagnoses the patient with spongiform encephalitis (more commonly called “spongiform encephalopathy.” It’s a rare type of infectious brain disease — the best known are Creutzfeldt-Jakob disease (CJD) and bovine spongiform encephalopathy (BSE), i.e “mad cow disease”).

House wants to perform brain surgery to remove the damaged tissue. Sidney is for it, but her husband is against it. The husband threatens a lawsuit to block the surgery. As the argument rages, House looks at the vitals sign monitor and tells them that it’s too late. The extreme variation in heart rate means that the spongiform encephalopathy has invaded her brainstem and now it’s too late for surgery. All that remains is to implant a pacemaker to control her heart rate, and then give her radiation and chemotherapy in an attempt to buy her a few more weeks of life. A short time later, Taub arrives to tell House that when they implanted the pacemaker, they saw signs of a rapidly progressive cardiomyopathy — which doesn’t fit with the spongiform encephalopathy diagnosis. The team continues to have trouble stabilizing her heart and she experiences fast heart rates and low blood pressure. Endocarditis (a type of infection of the heart) is suggested as a diagnosis, though House favors tuberculosis. Both of these possible diagnoses hinge on the fact that her immune system has been suppressed by her extreme exercise habits. He orders her started on a tuberculosis drug regimen.

Sidney continues to deteriorate. Her oxygen saturation is dropping and her pulmonary edema has returned. The team rushes her…somewhere…wherever it’s convenient to have a crashing patient, I guess. In the dim blue lighting of the hall, House notices a faded tattoo on her ankle. She had clearly tried to have it removed, but only the top layers were taken off – the rest remained. It suddenly all clicks for House. The extreme running has affected her immune system, causing her to become allergic to the tattoo ink, and that’s what is causing all her symptoms. Some surgery to remove the tattoo in its entirety and she’ll be fine — physically, at least. Her memory remains absent.

I have few specific medical complaints about tonight’s show. I thought the medicine was sloppy, with none of the suggested diagnoses fitting well – but then the actual medicine was clearly secondary in this episode. As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

Surgery for prion disease? Chemotherapy and radiation for prion disease? It’s not cancer; it’s a poorly understood infectious disease and none of these are appropriate treatments.

House first tries to convince us that her immune system has been suppressed from all her exercise – which is certainly a possibility. Then they turn around and state that her extreme exercise caused her to be allergic to something she has never been allergic before. In other words, it somehow gave her a heightened immune system. This is the opposite of what he had said a few minutes before, and farther from reality (remember that severe allergies are treated with immune suppression).

I notice the writers were being coy with which specific spongiform encephalopathy House thought the patient had. That way, they could borrow symptoms from several. Variant CJD seems the most likely, yet she has some symptoms that are closer to traditional CJD than vCJD.

Other than one episode of incontinence, she didn’t have any signs of diabetes insipidus.

There are frequently findings on the MRI with people with spongiform encephalopathy.

Amnesia almost always makes a good mystery, and this was no exception. I give the medical mystery an A-. The solution was clever, but didn’t make much sense as it contradicted earlier information. I give it a C. The medicine was sloppy and superficial. The superficiality I can forgive in an episode like this, but not the sloppiness: C-. The soap opera was the major part of this episode, particularly focusing on House and Nolan, House and Alvie, and the patient and her husband. It earns a solid A.

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

Maxwell Lord is back, and he’s here with one of the biggest psychic nosebleeds ever. Really, what more can I say (except that I’m glad I’m not cleaning up the mess)?

All previous Psychic and Superpowered Nosebleed Zen posts

Tags: comics medicine nosebleed maxwell lord blood

This episode of Fringe started out great, but crashed and burned in the last twenty minutes. Stupid adrenalin trick.

The Plot: Peter Bishop is heading west and stops by a diner in a small town in (nonexistent) Noyo County, Washington. He flirts with one of the waitresses who promises to make him a music mix CD and drop it by his hotel. He waits in the lobby, but she never shows. The next morning he discovers the waitress has disappeared and the police want to question him as a suspect. Luckily, he has a good alibi and a glib tongue. The waitress’ dead body is found a short time later, missing part of her skull and a piece of her brain. This makes Peter suspicious that Newton is involved, especially since he thought he spotted him in the crowd around the diner.

Peter explains to the local police that he a consultant for the FBI and offers to help them on the case. He tells them about Newton, and explains his suspicion that Newton is hunting him. Peter decides to turn the tables and use this as a chance to finally capture Newton. An autopsy of the waitress shows a high level of adrenaline, but nothing else of interest, so Peter retires to his hotel. The phone rings, but only static and muffled voices can be heard. The phone rings a second time and it’s the Sheriff telling him that her deputy Ferguson has disappeared. Peter joins her in the search, but they find nothing of importance. Peter hears a strange sound from the nearby woods and rushes in to find Newton and another man. A gunfight follows, but Peter loses track of them in the forest. When the Sheriff catches up with Peter, she tells him that she saw no other people and all but accuses him of hallucinating.

About this time, another body with part of the skull missing is found. Fearing it might be Deputy Ferguson, the Sheriff and Peter arrive to discover that it is another local girl, again with part of her skull missing. No connection can be found between this victim and Peter, making him wonder how much of this might be his imagination. With a jump of Walter-like logic, Peter deduces that he can use the adrenalin levels in the corpses to help him locate the hunter. The levels will help him pinpoint how far away from their abduction sites were the victims killed. He is able to identify several square miles of interest. The Sheriff points at an old dairy farm in the zone as the most likely location for the killers. She and Peter drive up there and meet the caretaker, who tells them nobody’s been at the farm for years. He shows them a map of the dairy farm, and it’s quite extensive. While the Sheriff goes to call for more help in the search, Peter stumbles across the mix CD the waitress made him, proving that the caretaker was involved in the murders. The caretaker lunges at Peter, but Peter is easily able to batter him senseless. In the end, it turns out that the caretaker was the lone murderer who had become fixated on the girls. The missing pieces of brain? A killer’s quirk (and a convenient red herring). He also tells them where to find Deputy Ferguson, who is wounded but still alive.

The killer caught, Peter lies down in his hotel room, ready to get his first good night’s sleep in days when Newton suddenly shows up in his room. He introduces his companion, “Mr. Secretary,” who, as we suspected, is the Walter from the alternate universe and Peter’s real father.

1. Sypathetic
Let’s look at Peter’s adrenalin idea, and look at the many reasons it wouldn’t work:
The idea: There is a bunch of extra adrenalin in the muscles of the victim, and Peter believes that there are two spikes of adrenalin, one from when they were abducted, and a second from when they were actually killed. By knowing the speed at which adrenalin is “absorbed” he figures he can deduce the time between the two spikes and thus the distance between the two events.
Let’s look at just a few of the major problems with Peter’s plan:
1. Adrenalin is adrenalin, how is he going to differentiate the adrenalin produced during the first spike from the adrenalin produced during the second spike.
2. It’s a moot point anyway, adrenalin has a very short half-life and the adrenalin from the abduction would be long gone by the time they were killed (and the adrenalin from the murder itself is probably long gone too).
3. You can’t base a control level on a single person, especially when that person is trained sufficiently to have a better fight-or-flight response than the average person, and, more importantly, the control person is alive while the others are dead (i.e. active metabolism versus no metabolism)
4. Peter’s making a helluvalot of unwarranted assumptions:
There were only two adrenalin spikes.
The killer drove exactly 45mph — and drove in a straight line.
The victims were murdered the minute the killer arrived at his hideout
The bodies were found exactly the same length of time after death
Everyone, regardless of weight, muscle mass, and metabolism, “absorbs” adrenalin at the same — and constant — rate

2. They Always Said Wonder Bread Is No Good For You
Potassium Bromide is a known (or at least strongly suspected) carcinogen. It was used to improve flour, and is still used by some US bakeries. It has been linked to peritoneal mesothelioma.

3. Glimmer, Glimmer, Glumpkin
Walter may not want to use his glimmer detector to find Peter, but certainly it would work to find Newton…

I was liking the Peter-centric aspect of the episode and the mystery was intriguing, but then the even-CSI-wouldn’t-touch-it-with-a-10-foot-pole adrenalin scene occurred, followed by the let down of a solution with too many convenient red herrings. The blatant product placement just added insult to injury. I dock the clock a minute for what started out as a winning episode.

Tags: television fringe murder adrenalin glimmer

Back in her third appearance ever, Wonder Woman fought Dr. Poison, the Chief of the Poison Division for Nazi Germany. The doctor’s plan? To pour the drug Reverso into the water supply at the local Army base. As the name suggests, the drug causes all who are under its influence to act the exact opposite of how they were commanded. This would turn Army training into chaos, rendering the U.S. military powerless, and eroding the nation’s morale.

Of course, it’s the Bizarro style of “opposite” we’ve come to expect from comic books (though this story predates Bizarro by a good 16 years).

In the end, Wonder Woman triumphs (no surprise there) and manages to reverse the Reverso. Dr. Poison is captured, but managed to make a few more appearances during the ’40s before being forgotten. An interesting change of pace is the Dr. Poison was actually a woman disguised as a man, making her one of the first female super-villains who wasn’t just a femme fatale. A new Dr. Poison, the granddaughter of the original, showed up about ten years ago in the Wonder Woman comic and has been seen sporadically since.

According to the new Dr. Poison, the original Dr. Poison’s death can be blamed on Reverso. In creating the drug, the good doctor somehow reversed her aging process and grew too young to remember to take the antidote.

Tags: comics medicine wonder woman reverso drug dr poison

This episode of House started off strong, with an interesting mystery, and kept the moment — for the first half, anyway. Then it settled into its all-too-common mishmash of acronyms and quasi-medical reasoning.

Ted is a twenty-seven year old about to get married. As he stands at the altar, he suddenly finds that he is unable to speak, and then he collapses. He is admitted to the Emergency Department, where House’s team evaluates him for his “aphasia” and “syncope.” He is told that the initial work-up has excluded infection, vocal cord damage, stroke, low blood pressure, low blood sugar (hypoglycemia), and dehydration. House clearly suspects Ted got a case of cold feet about the wedding and is faking his symptoms. Surreptitiously, he stabs Ted with a needle causing him to scream out loud. Ted seems amazed that he is now able to talk. This sudden resolution of his symptoms lends credence to House’s suspicions and Ted is discharged from the hospital.

Of course, this is House, and being discharged is a sure sign that worse things are about to happen, and — sure enough — once outside the ER, Ted suddenly starts coughing and then gasping for air. Once again, he collapses. A chest x-ray reveals a substantial pleural effusion (extra fluid building up around the lung). House is reminded that the ER found no evidence of infection and Chase insists that there are no parasites (the eosinophils, a type of white blood cells which are usually elevated in parasitic infections, are normal), but House wants to make sure. He orders the pleural fluid cultured, and run through cytology (looking for infection and cancer). He has half the team search the house Ted shares with his fiancée, and the other half check the apartment he used to live in. Apparently, the search of his current home showed nothing because it was never mentioned again. The search of the old apartment turned up some interesting things: possible lead poisoning, possible asbestos exposure, and an old ex-boyfriend.

The lab tests on the pleural effusion show that it is the result of a mono (mononucleosis) infection. This is an unusual presentation for mono, so the team wonders if Ted may be immunosuppressed — in particularly, if he has HIV (the virus which causes AIDS). The subsequent test is negative. When questioned, Ted tells Thirteen that he was gay once, but was “cured” by attending intensive conversion therapy which included aversion therapy (looking at gay porn while receiving emetics, i.e. drugs that cause vomiting), male hormone injections, and ultimately, electroconvulsive therapy (ECT, i.e. “shock therapy”). The team wonders if the ECT may have caused some brain damage, so an EEG is ordered. It is normal, but then Ted suddenly suffers a cardiac arrest; luckily he is resuscitated with the help of a handy defibrillator. The team now evaluates why Ted suffered the cardiac arrest (which they keep calling, incorrectly, a heart attack). His EKG is normal, as is an electrophysiology study (a look at the electrical pathways within the heart). They decide to proceed with a cardiac catheterization (evaluating the arteries which supply the heart with blood). While they are describing the procedure to him, he suddenly faints. They sit him up, and he faints again. This leads House to diagnose him with POTS (postural orthopedic tachycardia syndrome). According to the team, this diagnosis explains virtually all of his symptoms. It can be caused by infections such as mono, which is probably how he developed it. He is started on fludrocortisone for treatment (fludrocortisone increases sodium retention leading to improved blood pressure and blood volume).

A short time later, Ted starts complaining of a severe headache. Infection is considered a likely cause, so a spinal tap is ordered. This offers no answers and only seems to make the headache worse. House now suspects that Ted has a CSF (cerebrospinal fluid) leak where the spinal tap was performed, leading to low CSF and a spinal headache. He has the team apply a blood patch to stop the leak. About this time, Ted develops left-sided facial drooping. The rest of his neurological exam is normal (except for the headache). An MRI is obtained, but is normal. Various diagnoses are considered including sarcoidosis, scleroderma, histoplasmosis, and MELAS (Mitochondrial myopathy, Encephalopathy, Lactic Acidosis, and Stroke syndrome — a genetic neurologically degenerative disease), but none seem to fit. House decides to have the team get a good history from Ted, but this time with both his fiancée and ex-boyfriend present. With prompting, it turns out that Ted had a fainting spell at least once before, and he has had some erectile dysfunction (trouble getting an erection) with his fiancée. The team wonders if there may be an underlying vascular problem causing his symptoms, including his erectile difficulties. A penile plethsmyograph is ordered, but is normal. However, Thirteen notices that Ted is now suffering from galactorrhea — in other words, he’s lactating. Thyroid diseases, including Graves and Hashimotos, are considered but then discarded. Taub suggests a pituitary tumor. It makes a certain amount of sense, so a pituitary MRI is ordered and a prolactin level is checked. Once again, everything is normal (were there any abnormal tests or radiology in this episode at all?) Meanwhile, House is having a conversation with Wilson that leads to his Aha! moment of the week: Ted has a Chiari malformation. This is a narrowing of the skull which puts pressure on the cerebellum, cutting off normal CSF flow. Ted had not previously had any symptoms, but the slight swelling of the brain caused by the electroconvulsive therapy was enough for the malformation to cause his symptoms. Some surgery and Ted’s symptoms resolve.

For the first half of the show, I was thinking that the mystery was really engaging and the medicine was better than usual. Then he had his “heart attack” and things went downhill from there. As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

A cardiac arrest and a heart attack are not the same thing. A cardiac arrest occurs when the heart stops beating (arrests) — this can be due to heart attack, or to a number of other cardiac condition such as arrhythmias. A heart attack occurs when the heart is unable to get the oxygen it requires and part of it infarcts (dies).
Why did Ted suffer the cardiac arrest? Was it supposedly the pressure on the brain from the Chiari malformation? Really?

How did the Chiari malformation cause Ted’s aphasia? Was it the vague “increased pressure?” Amazing how his condition only caused each severe symptoms (aphasia, cardiac arrest) once.

I have no idea if ECT can cause a generalized brain swelling, but one that persists after three months? That is definitely wrong and worrisome.

The time frame seemed a little suspicious to me. Not impossible, just unlikely. Ted received his hormones/ECT and moved out of his old apartment just three months before the wedding. So was that an incredibly quick engagement, or was he dating Nicole while he was still “gay.”
And the most unlikely part: reserving a church for a wedding three months away.

Nice HIPAA violation Thirteen, telling a (for all you know) complete stranger that Ted has been hospitalized.

House’s treating Ted’s headache with a blood patch did nothing to correct Ted original headache, it only cured the secondary headache that the team caused.

Penile plethsmyograph? Not standard of care. And giving him a medication to cause an erection defeats the purpose of the test, since the medications usually work on even vascularly compromised individuals.

It was a good medical mystery tonight: what caused the aphasia and collapse. I give it a B+. The final solution was a stretch. It covered some symptoms well, but for the others you had to squint your eyes just right and hope the stars were in alignment: C. The medicine started off good and for the most part, proceeded logically. They were to quick to grab onto POTS and too slow to let it go, and the cardiac arrest/heart attack confusion was a major mistake: C-. The soap opera was very good, House played well off of everyone tonight: solid A (and for the record, I grade the soap opera because it is an important part of the show; I don’t go into detail about it because these posts are already long enough).

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

Sue Storm (well, Ultimate Sue Storm) is using her forcefield powers to protect her and her friends from harm — with mixed success — while fighting one of the nameless antagonists from Ultimate Enemy #3.

All previous Psychic and Superpowered Nosebleed Zen posts

Tags: comics medicine nosebleed sue storm ultimate

A failed attempt to make a musical/hardboiled detective episode of Fringe

The Plot: The majority of the episode was taken up by Walter telling Olivia’s niece Ella a story: a story that just happened to be a wannabe noirish, anachronistic, musical version of the Fringe mythology including everyone from Massive Sharp to the Observers (here called “The Watchers” — somebody call Stan Lee). And I have to say that it didn’t really work for me — mostly due to the fact that it was too campy (and not in the good way they were probably intending) and the quick realization that Anna Torv doesn’t have the acting chops (or at least the accent) to play a tough noir detective. It pulled me out of the story every time she talked.

Since nothing new was really added to the plot, I’m not going to go into much depth about the episode, other than to note that Lance Reddick and Jasika Nicole have surpisingly good voices (assuming those were their actual voices)

1. Cue the Bubbles
Musical cues included Yes (Roundabout), Tears for Fears (Head over Heels), Traffic (The Low Spark of High Heeled Boys), Willy Wonka and the Chocolate Factory (The Candy Man), A Chorus Line (I Hope I Get It), and Stevie Wonder (For Once in My Life). Personally, I can’t believe they left out Heart from Damn Yankees.

2. She Must Have Bought the Extended Warranty
Olivia’s phone is knocked to the ground and smashed in her first encounter with the Observers Watchers, but is unblemished and working perfectly when she is locked in the pine box by them later.

3. I Must Be Crazy To Be In A Loony Bin Like This
I did like the One Flew Over the Cuckoo’s Nest allusion, and whoever they had playing the nurse was a near perfect copy of Louise Fletcher’s Nurse Ratched.

4. I Don’t Mind If You Don’t Like My Manners, I Don’t Like Them Myself
For good noir and hardboiled crime fiction, I recommend anything by Raymond Chandler (personal favorites are The Big Sleep and The Long Goodbye) and most everything by Dashiell Hammett (start with The Maltese Falcon and The Thin Man). Ross MacDonald shouldn’t be overlooked either (try The Galton Case or The Drowning Pool).

While I applaud the writers and cast for trying something different, it was an experiment that didn’t work. A noble failure (or Noble failure, if you want the pun), but still a failure. The Fringe Doomsday Clock moves one minute closer to midnight.

Tags: television fringe noir musical heart

The SHIELD #8
Eric Trautman, writer
Cliff Richards, artist.

The SHIELD is surprised to find that one of his enemies, the mind controlling Brain Emperor, has been assigned to his team. He is understandably upset and wondering if mind control is involved. His computerized suit reassures him: “Confirmed: No hostile action detected. Baseline EKG readings normal.”

I’m not sure who the SHIELD’s suit is referring to — are the “baseline EKGs” normal in the Brain Emperor or in the rest of the military staff?

It does strike me as unusual that an EKG — a heart test — is being used to detect mental influence; wouldn’t an EEG — a brain test — make more sense? (On the other hand, it does open up some interesting plot possibilities. For instance, if using mind control causes heart damage, then how far are you willing to push it?)

A nitpick: The term “baseline EKG” has a specific meaning, and it doesn’t fit here. When a patient is diagnosed with conditions that have an increased chance of heart disease (high blood pressure or diabetes, for instance), we will often obtain an initial EKG. This is their “baseline EKG” that we keep on file to compare against any EKGs obtained later to see if anything has changed. So someone having a normal baseline EKG just tells us that when the EKG was originally obtained, everything was fine. It tells us nothing about the current situation.

After a big fight, the SHIELD suit’s healing mechanisms kick in: “Nanotech regrowth engaged. Priority reconstruction: bronchial puncture and tearing, shattered third and fifth vertebrosternal ribs.

This is correct, it’s just too wordy. The vertobrosternal ribs are the first seven pairs of ribs, also known as “true ribs”, that start at the spinal column and wrap around to the breastbone (sternum). The remaining five pairs of ribs are known as the false ribs because they don’t attach to the breastbone.

If you haven’t figured this out by now, in medicine we like to convey as much useful information as possible in as few words as possible. This is especially true in emergency and trauma situations. That’s why we like abbreviations and acronyms so much.
There is nothing in the phrase “shattered third and fifth veterbrosternal ribs” that can’t be conveyed simpler by just saying “shattered third and fifth ribs.” (Though which ribs was fractured –the left or right — would be useful to know.)

I’d say this one can probably be blamed on whatever computer techie programmed the suit. In terms of medical programs, I’ve noticed you can tell which ones were written by doctors (good medicine, sloppy code) and by programmers (sloppy medicine, good code). I’m still looking for a program that does both well.

All bad doctors and purveyors of pseudoscience and woo will be taken care of appropriately (though probably not this severely).

Though I enjoyed the fairly understated soap opera on tonight’s episode of House, I found the medicine to be frighteningly bad.

Julia is 35 year-old woman in an open marriage. She is just about to start a fling with her boyfriend when she develops sudden excruciating abdominal pain. She is taken to the ER where all the “usual suspects” are ruled out and she is eventually diagnosed with intestinal blockage (by which I suspect they mean a small bowel obstruction). She is admitted to House’s service not because her condition is particularly interesting, but because Thirteen knows he’ll be intrigued by her open marriage.

The team’s initial diagnosis of herpes colitis (a widespread herpes infection of the intestine) seems to be unduly focused on Julia’s suspected sexual escapades, rather than any real evidence — or the fact that there are many far more likely causes of bowel obstruction. A barium enema is ordered: it shows no evidence of herpes colitis, though Julia’s pain does resolve during the procedure.

Thirteen wants to discharge Julia from the hospital now that the blockage has cleared, but House wants to runs some tests to find out why she developed the intestinal blockage in the first place. He orders an upper GI with a small bowel follow through (have the patient swallow barium, then take a repeated series of x-rays as it slowly makes its way through the intestine). The x-rays are negative, but Julia develops a racing heart rate during the test which is later explained as an “arrhythmia.” Taub attempts carotid sinus massage to slow the heart rate (the massage should activate the parasympathetic system, which slows the heart rate), but it doesn’t work (though clearly something did as her heart rate and rhythm is normal for the rest of the show). With intestinal and cardiac symptoms, the team now suspects a parasitic cause. Neither Julia’s husband nor her boyfriends have been out of the country, so something exotic seems unlikely. A search of Julia’s house turns up evidence her husband was telling the truth about his limited travels, but also a loofah sponge, which the team now suspects she got amebiasis from (an infection by amebas).

Unfortunately, Julia’s symptoms worsen and she loses all movement in her legs. “Tests show no spinal cord injury, no cerebral lesion, and no hemorrhage.” The stool studies also come back and are negative for amebas or any other parasite. House suggests that Julia may have an electrolyte imbalance. Chase suggests that with the husband and boyfriends, she may have an abnormally high libido (i.e. her sex drive is too strong), which can be a sign of adrenocortical carcinoma (cancer of the adrenal glands). An MRI is ordered and it shows no cancer in the adrenals, but it does show a blood clot in the lungs which is confirmed by a VQ scan. The team now believes she has a clotting disorder and starts her on heparin (a blood thinner). The differential diagnosis consists of DIC (disseminated intravascular coagulation), Factor V Leiden, antiphospholipid syndrome, and Vitamin K deficiency. House has Thirteen run tests for all of them — which are, of course, normal. Thirteen now suggests pulmonary artery hypertension, but before any discussion can occur, the team is summoned to Julia’s room where she has once again developed severe abdominal pain. An abdominal ultrasound is quickly obtained and is normal. Chase thinks she may have a problem with her parasympathetic system, but Taub believes she has an intussusception (a condition where the intestine collapses down on itself like closing a telescope). In adults, this is usually caused by cancer. She is rushed to surgery where an intussusception is found. A subsequent biopsy reveals no cancer, just some non-specific inflammation. Chases reports this could be a sign of inflammatory bowel disease, but states that it wouldn’t explain the heart symptoms or the newly-developed kidney failure (oh, House season six, where would we be without our weekly kidney failure?) House disagrees, pointing out that inflammatory bowel disease can be associated with ankylosing spondylitis (an inflammatory disease of the spine), which can have heart and kidney symptoms. He wants Julia started on sulfasalazine and TNF (tumor necrosis factor α) inhibitors (both these medications work on autoimmune diseases, such as ankylosing spondylitis and inflammatory bowel disease).

Julia does not improve on the new regimen and her kidneys are actually getting worse. A kidney biopsy showed IgA nephropathy, for which Chase has kindly written the differential on the whiteboard — a list far too long to reproduce here. The team quickly decides it can’t be sickle cell anemia, celiac disease, hepatitis, cirrhosis, Alport syndrome, anti-GBM antibodies, or Henoch-Schönlein purpura (HSP). They ultimately determine the three most likely causes are hemochromatosis, Weil’s disease, and sarcoidosis and start treatment for all of them (which would include frequent blood draws and possibly deferoxamine, antibiotics, and high dose steroids). Once again, there is no improvement in Julia’s condition. The team starts to list other possible causes of her symptoms including polyarteritis nodosa and mercury poisoning. House looks at the lilacs her husband brought in for her from their garden and remembers that his father didn’t like them because they drew too many bees. The leads House to remember that Henoch-Schönlein purpura can sometimes follow a bee sting — and, sure enough, Julia suffered a sting a few weeks before. The classic rash (the purpura) is still missing, but a quick look in her mouth reveals the lesions at the back of her throat. She is started on IVIG (intravenous immunoglobulin — not a common treatment of HSP) and cyclophosphamide (a common treatment of severe HSP) to treat her condition and a full recovery is expected.

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

Once again, a halfway decent physical exam would have cleared this up right away (and it didn’t even have to be a good exam; a half-assed one would have worked.) Looking in the mouth? That’s really basic. This isn’t a third-year medical student mistake; it’s a first-year medical student mistake.

Herpes colitis is exceedingly rare, especially in patients who are not immune deficient. There are dozens, if not hundreds, of more likely causes. Regardless, a barium enema is not the recommended diagnostic test (though, of course, it does conveniently temporarily fix the patient’s problem without actually diagnosing it)
Technically, it is the DCBE (double contrast barium enema) which corrects intussusception, not the regular barium enema Julia seems to have received.

The ER ruled out all the “usual suspects” for abdominal pain and obstruction, but never ran a CT scan? Of course, this would have shown the offending intussusception right away and it would have been case-closed before it even got to House. (It is possible to diagnose bowel obstruction without a CT scan — it has a classic look on an abdominal x-ray for instance — but one of the first orders of business after diagnosis is to look for a cause, and that requires a CT scan).

Though we no longer follow the maxim “never let the sun go down on a bowel obstruction” (i.e. operate right away, time is of the essence!), Julia was receiving substandard care. The poor choice of tests I’ve already mentioned (and will probably mention again), but she should have had a nasogastric tube to help relieve her symptoms.

Very sloppy differentials tonight, right from the start. The team was jumping around each time a new symptoms was discovered without following any logic at all.

Why didn’t the abdominal ultrasound catch the intussusception? Or at least show a suspicious mass where it was?

If a barium enema corrected the intussusception the first time, why not try that again before rushing off to open abdominal surgery, which has much higher risks associated with it?

Thirteen wasn’t actually ruling conditions out, she was stating which ones weren’t treatable. That’s not medical care, that’s wishful thinking.

It is possible to have HSP without the rash. Depending on the study and the diagnostic criteria, as many as 5% of patients may not have the pupura.

Your standard STD panel does not generally include herpes testing because the answer is not as black and white as the other STDs. Unless you directly test a herpes lesion (which will give you a definitive yes-or-no answer, the test looks at antibodies — which are good at telling if the patient has ever had herpes, but not as good at identifying current infections. And as was pointed out, it does no good to test if the body hasn’t had time to make enough antibodies to detect.

Some clotting tests can’t be run once the patient is on heparin, though most of the important ones can (and boy those genetic tests came back fast).

The medical mystery started off slow, but picked up steam, I give it a B. The final solution seemed to fit, for the most part at least: B+. The medicine was very haphazard and illogical, but significant oversights and poor care in general. It gets a D-. The soap opera was pretty strong though, and I enjoyed it: A-.

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

An average episode of Fringe. Nothing remarkable, but nothing particularly bad, either.

The Plot: Two teenagers are sitting in a car by an abandoned warehouse when they hear a disturbance from within. The boyfriend goes to check it out and is surprised and killed by one of the shapeshifters from the other universe. The shapeshifter take his form, and then his girlfriend meets the same grisly fate a short time later. When the girl’s body is discovered the next morning, the Fringe Team is called in after the medical examiner notices three puncture marks on the roof of her mouth. A quick search of the warehouse reveals the boyfriend’s body in the same condition. A three foot diameter protoplasmic blob is also discovered. When Walter cuts into it with a scalpel, it bleeds mercury, which leads him to hypothesize that it is a shapeshifter embryo and must be how they travel between universes. He has the embryo taken to his lab.

Television signal interference was reported at the same time the shapeshifters appeared. When the interference is analyzed by the science geek at Massive Dynamic, he discovers that it is interference caused by sunspot patterns – only the interference is slightly out of phase with the sunspot interference from our own universe. However, both patterns will be perfectly in sync at 3:31PM the following day, leading Agent Dunham to believe that something big is planned for that inter-universe conjunction.

Across town, the two remaining shapeshifters report to Newton, the leader of the otherworld forces in our universe. They decide to proceed with their plan even though they are down an agent.

With a bunch of car batteries, Walter attempts to “jump start” the embryo. It seems to work at first, but is ultimately unsuccessful and the shapeshifter dies — but not before he croaks the name “Daniel Voss Verona.” The FBI captures Verona, a medical examiner at Boston General, but when they discover he is human and they are unsure of his part in the plan.

Meanwhile, one of the shapeshifters has taken on the shape of a bank president and he and Newton plant a device in the floor of the bank vault.

Walter decides that Newton is going to use the convergence to bring something, or someone, across the universes. He suspects that Newton will accomplish this using “harmonics.” Newton has three devices generating harmonic waves set up equidistant from the transfer point. Using Verona’s location as one point, and the bank as a second (the bank president’s dead body has just been found), the team decides that an abandoned bridge over the Charles River is the likely crossover point. Walter has also worked out a method to stop the conjunction by setting up his own set of waves that will cancel out Newton’s waves.

The team arrives at the bridge just as the convergence begins. Two cops try to stop them, but Dunham realizes they are shapeshifters and a gunfight starts. Walter , and then Peter, set up Walter’s apparatus on the bridge. When a problem develops, Peter stays behind to fix it while Walter and Dunham head to safety. After a loose cable is plugged on, Walter’s device works and cancels the convergence, but not before somebody crosses over. Peter is also knocked unconscious by the force of the waves. Waking up in the hospital, he realizes the truth: that he is the Peter from the other universe. He has words with Walter and then kicks him out. He checks himself out from the hospital and disappears. Meanwhile, Newton is helping “Mr. Secretary” – the person who crossed over – recover from the effects of the transfer.

1. No Stiffies
Apparently Rigor Mortis doesn’t exist in Fringe. Ten or so hours after death, the girl and her boyfriend should been very rigid and not as floppy as they were.

2. A New Record
For the second week in a row, Agent Dunham shows herself to be a gifted investigator.

3. Fancy Equipment, Part 1
Amino acids are way to small to be seen and identified with a microscope.

4. Fancy Equipment, Part 2
I’m impressed the scientist’s computer could predict with exact precision two days’ worth of sunspot patterns for not one, but two universes.

5. Crossed Wires
If Walter was using car batteries to jump start the embryo, why did the fuse in the lab’s power supply blow?

6. Exacting Precision, More or Less
Using a Triple-A map, a thick pen, a crude protactor, and very inexact measurements (4 or five blocks is “close enough”), Peter is able to find the exact spot the convergence will occur. He must be quite the genius.

7. An All-too Common Cliche in Movies and TV
Pills take time before they start working. A capsule like the one Newton took would need to travel to stomach and be broken down, releasing the medicine, which would then need to be absorbed into the bloodstream and spread throughout the body. For most pills, this takes at least thirty minutes; not the three seconds Newton’s pill took.

8. Thanks to Mythbusters, We Know the Bridge Won’t Fall
Newton’s wave must be propagating in a predictable pattern for Walter’s machine to have any chance of success.

9. My Prediction
Mr. Secretary is otherWalter.

There was nothing specifically wrong with this episode, per se, but it just didn’t resonate with me. It may just be that the last couple of episodes have been excellent, and this one, while quite good, was not as good, and paled by comparison. It did advance the uber-plot nicely.

No change in the Fringe Doomsday Clock this week.

Tags: television fringe shapeshifter embryo newton

A solidly enjoyable episode, even with Walter’s Mary Baker Eddy-ish crisis of conscience. But then, I’ve always been a sucker for time travel stories

The Plot: The lights start flickering aboard a car on a commuter train and then a thin man in a trench coat suddenly blinks into existence. He exits the train at the next station, barely avoiding bumping into a beggar. When the beggar climbs aboard the train, he discovers that everyone aboard that car is dead. The Fringe Team is called in to investigate. Meanwhile, Walter is writing a letter to Peter that finally tells him everything. He puts the letter in his pocket and joins the rest of the team.

At the scene, Walter’s first thought is that everyone died of heart failure. Agent Dunham, an astute investigator for once, realizes the lights are out only in that one car. Digging deeper, Peter finds that every battery on that car — cell phone, laptop, MP3 player — all are dead as well. Walter has the bodies moved to his lab where he discovers that the victims are low in ATP, one of the main energy molecules used by the human body. He hypothesizes that whoever this strange man was, he somehow drained all the energy out of everything in that train car.

The FBI is able to track the man’s movements with surveillance cameras and they eventually identify him as Alistair Peck. A raid of his house reveals that he is an MIT astrophysicist. Peck enters the house while it is being searched and is detained by the agents on site. When Dunham questions him, he spouts out some confusing answers and then suddenly fades from view.

Now we’re back on the commuter train that started the episode, this time seeing it from Peck’s point of view. As he exits the train, this time he tells the beggar that he is sorry for putting him through this again. He also leaves a fingerprint behind which allows the Fringe Team to identify him sooner this time. The search of his house reveals walls of mathematical formulas, but this time, Peck doesn’t come home during the search. Checking at MIT reveals that Peck was a brilliant scientist who studied time travel. His research was over almost everyone’s heads and he quit a year ago. The MIT professor they talk to is able to provide Dunham with some of Peck’s recent research, which she then hands over to Walter. Reading through the research, Walter realizes that Peck has discovered how to travel through time, but it takes a tremendous amount of energy. Meanwhile, Dunham has learned that Peck’s fiancée died in a car crash just about a year ago and the team suspects Peck’s ultimate goal is to go back in time to rescue her.

The Fringe Team tracks Peck to his old lab at MIT. Walter goes in to see him alone, hoping a fellow scientist who has also lost family will be able to talk him out of his plan. He explains all the regrets he has about bringing Peter from the other universe and how he feels that God in now punishing him. As the conversation ends, the SWAT team enters, and Peck once again fades from view. This time, he reappears at the lab at his house, where he works feverishly to complete his formulas so he can jump back to save his fiancée. A SWAT sniper just misses, and Peck fades from view, appearing in the empty field he described to Walter in their conversation. His time jump worked! He rushes to find his fiancée and climbs in her car just before she drives off. He holds her hand and tells her that he loves her – and then a truck barrels into the car, killing them both.

Now we’re back to the scene where Walter is writing the letter to Peter. This time, instead of carrying it around, he throws it in the fireplace to burn. The mail comes, and within it is a letter from Peck – he had carried it to the past with him and left orders for it to be mailed on this specific day. In it is a simple drawing of a white rose tulip — the sign Walter was looking for that God has forgiven him.

1. I remember you! You’re dead. We killed you!
Heart failure and heart attacks are two different things. A heart attack occurs when the heart is not getting the blood and oxygen it needs and part of it dies. Heart failure occurs when the heart is not pumping as strong as it should. While a heart attack can lead to heart failure, but they are not the same thing.

2. I’d buy that for a dollar!
A Faraday cage is a box of fine mesh made of some conducting material (gold is common). It blocks EM waves of a wavelength larger than the holes in the mesh. I don’t know what Peck was wearing, but it wasn’t a Faraday cage. (Plus if he was in a Faraday Cage, he wouldn’t be able to use his fiancée’s cell phone).

3. Dead or alive, you’re coming with me
Loss of ATP is the main cause of rigor mortis (ATP is required for muscles to relax, so when it is no longer available, the muscles stiffen up). All those corpses should have had severe rigidity.

4 . You better pray that that unholy monster of yours doesn’t screw up.
I love all the science fiction shows, books, and comics where people have wires and implants of all sorts in their bodies, yet never get infections. Metal or plastic implants within the human are so easily infected it’s not funny. People with them have to take extra antibiotics whenever they undergo certain procedures (dental work, colonoscopy). And those are the deep surgically implanted ones like artificial joint, heart valves, or pacemakers. More superficially places implants, like the wires and all on Murphy Peck, become infected at the drop of hat. I’ve never seen one go for over a week or two without getting infected, and that was in the clean hospital environment, not a dirty old house or train station. Peck would be a walking mess of MRSA.

5. Murphy… I’m a mess…
So God is punishing Walter by killing a bunch of other people?

6. I want a recount! And no matter how it turns out, I want my old job back!
The time travel aspect of the story seemed to leave questions unanswered (which I’m actually fine with; I like time travel stories that are though provoking and raise questions).
For instance, what happened to the 9-months-previous-Peck who was standing in the field when now-Peck appeared? Did he wink out of existence? Was he drained of energy and killed?
It seems to me that Peck killed his fiancée, or at least caused her death. He delayed her a few seconds when he entered the car and grabbed her hand. If he hadn’t been there, she would have had time to drive off and avoid being hit by that truck (though, apparently, she would die in another accident). I can see how Peck would love his fiancée enough to want to die with her, but it seems to me he loved her so much his instinct would be to first save her life.
Also, did he stop to mail the letter in the past, or was the nice-clean letter somehow found on his mangled and crushed corpse?
I’m a big fan of time travel stories. Some of my favorites: By His Bootstraps and All You Zombies, both by Robert A. Heinlein; The Anubis Gates by Tim Powers; the various Time Patrol stories by Poul Anderson; the Paratime stories by H. Beam Piper; and the best of all, The Men Who Murdered Mohammed by Alfred Bester.

7. Massive and immediate retaliation is the best policy
Finally, a question unrelated to this episode that just occurred to me: how do we know the Bell Olivia met with was the Bell from our dimension, and not the other one?

A good episode that left more questions opened than it started with, but in a good way. For the third episode in a row, the Fringe Doomsday Clock gains a minute.

Tags: television fringe time travel energy mad science

Tonight’s episode of House wanted to be clever, but just ended up being muddled. It was a “let’s throw everything against the wall and see what sticks” episode.

William is a knight at a Rennaissance Faire, and he’s actually been living there full time for the better part of a month. After fighting Horace the Black in a tournament, he staggers then suffers a seizure; the whites of his eyes are also bloody. As luck would have it, he is admitted to House’s service.

The initial diagnoses include concussion, subdural hematoma, or an allergic reaction to something at the Faire. House orders a head MRI, which is negative, but William starts vomiting during the test. This is a possible indication of food poisoning, but the idea is discounted as William is the only one with any symptoms. Meanwhile, Foreman and Thirteen check out the Faire. They find evidence that William had been sick prior to his battle — and also discover that the Faire’s king had a wicked sense of humor, forcing his knights to eat all kinds of disgusting foods. House suspects William may be allergic to one of these, so has the team perform scratch tests (an allergy test) for them. At the same time, he also wants to treat William with epinephrine to minimize his symptoms. Shortly after receiving the epinephrine and starting the scratch test, William suffers chest pain and develops an irregular heart beat (a tachycardia, according to Foreman). When William’s shirt is opened in preparation for defibrillation, a vesicular (blister) rash is seen.

The differential diagnosis now consists of an allergy to the preservative in epinephrine injections, Wolff-Parkinson White syndrome (a condition with a rapid heart rate), or MRSA (methicillin resistant Staph aureus — a nasty infection that spreads easily and can be difficult to treat). House suspects the latter — skin cultures are ordered and William is placed in isolation. Meanwhile his chest pain is getting worse and now he’s developing back pain.

House shows up and announces that the rash, and possibly the rest of the symptoms, is due to poison ivy. House found this out when he got a poison ivy from handling William’s sword, and now he wonders if they’ve been burning it in campfires, and William breathed in the smoke and got some in his eyes.

William develops heart problems again, only this time his heart rate is too slow. Chase injects him with a large amount of epinephrine despite the fact that he might be allergic. The heart stops for a second, but ultimately the treatment works. As bradycardia (slow heart rate) would not be symptom of poison ivy, this causes the team to once again re-evaluate their differential diagnosis. The new differential consists of leukemia, environmental toxins, or trichinosis (a parasitic contracted from undercooked pork). House has the team treat the suspected trichinosis and check a muscle biopsy. The tests for trichinosis come back negative and Foreman is starting to wonder if it may be a fungal infection. William now complains of leg pain, reporting that his legs feel like they are “on fire.” When the sheet is yanked back, it reveals grossly edematous (swollen) legs. Thirteen reports that William now has rhabdomyolysis complete with kidney failure. Taub suspects William has cancer. Foreman and Taub ultrasound the liver looking for the tumors while Thirteen and Chase investigate William’s apartment. The ultrasound reveals a number of lesions which at first are thought to represent tumors, but they appear more vascular than tumors would be. The investigation of William’s apartment reveals the chivalrous knight to have also been practicing the occult.

The team suspects William may have been poisoned by some of his occult rituals/concoctions while House suspects lead poisoning (until the past few years, most metal miniatures had a high lead content). Tests for lead poisoning are negative. Meanwhile, William’s heart rate and blood pressure are getting worse.

House visits the Renaissance Faire himself and heads to the Apothecary shop (basically, a medieval drug store). He finds a number of mislabeled herbs, the most concerning of which is water hemlock mistaken for a wild carrot. The Apothecary admitted selling a small amount to the Faire’s king. When questioned, the king replies that he thought it was a wild carrot and admits to using a small amount in one his knights’ challenges, but denies any poisoning attempt. None of the other knights became sick. Lab tests show a small amount of hemlock in William’s system, but the standard treatments aren’t working, and Taub insists that something else must be going on. A talk with Wilson’s ex-wife/current girlfriend gives House the inspiration he needs to realize that William has been abusing anabolic steroids. These made the hemlock more potent, explaining why only William suffered the ill effects. (So you got that? Rash was poison ivy. Heart, liver, muscle was the steroids. Hemlock was apparently everything else).

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

North American hemlock (water hemlock) has cicutoxin, which is not a piperadine (as opposed to European poison hemlock which has coniine, which is a piperadine). Thus tests that show piperadine in William’s blood would NOT be an indication of water hemlock poisoning.

Gastric lavage and activated charcoal wouldn’t do anything for hemlock poisoning 2+ days out.

What is the point of running allergy testing when you’re giving medicine to treat the allergies at the same time?

The patient is dying of hemlock poisoning and only suffers a single mild seizure? One of the classic signs of the condition?

There are two types of MRSA: community acquired and hospital acquired. Both are nasty, but the latter is much, much worse than the former (which is what William would have contracted)

Water Hemlock is extremely poisonous, even in small amounts. The other knights would have had some symptoms as well, even if not as severe as William’s.

Again, fungal tests take weeks to get results, not “spore tests” overnight.

What was up with that whole occult/witchcraft angle? That came out of nowhere and added nothing to the episode, other than proving once again that TV writers can’t separate the wiccans, pagans, and occultists.

Why would a king who thinks that making people eat cow brains, eyeballs, etc. is the height of fun, even conceive of making his men eat a small sliver of wild carrot as a “challenge?”

The medical mystery was a little better than average: C+. The final solution was a mess. Anything that takes three answers isn’t clever: D. The medicine was haphazard, but better than average: B-. The soap opera was pretty good: B.

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

Thor #602 “Uncertain Destinies”
J. Michael Straczynski, writer
Marko Djurdjevic, penciler

What’s good for the goose is good for the gander; or in this case, what’s good for the gander is good for the goose. I’ve picked on Donald Blake enough for now, so I think it’s time to pick on Dr. Jane Foster.

Myocardial arrhythmia, while technically true, is horribly redundant. Saying someone has an “arrhythmia” implies the heart (i.e. “myocardium”) — there really is no other part of the body that has arrhythmias. This would be the same as Foster driving her car to the dealer and telling them she needs her “automobile transmission” repaired. What she says is accurate, but nobody talks that way.

EKGs don’t “fall.” An electrocardiogram (called an “EKG” after the original German, though some do say “ECG”) measures electrical flow in the heart towards and away from the skin electrode. Movement towards the heart gives an upward bump; movement away gives a downward bump. In either case, the EKG tracing always eventually returns to baseline; there is no way for it to fall. Remember, a bad EKG is known as a flatline, not a slope.

While I appreciate the writers’ desires to try something different, three low-medicine episodes of House in the first sixteen episodes of the season is too much. Generally, the episode was good, though the clichés were pretty thick.

Since this was really five mini-storylines in one, I’ll deal with each one separately.

1. Chase/Cameron
I thought it was well done and almost painful to watch (as in the “I’ve had relationships end badly, too” way), though the ending cliché sex cheapened the arc for me.

2. Taub/Foreman
While I ‘m not surprised that Taub, and even Foreman, would be snooping around personnel records, I found the whole “let’s take drugs so we can be like House” scene was hard to believe. That’s far out of character for them, especially uptight

3. Thirteen/Wilson
Enjoyable, but did we really learn anything? We already knew Thirteen was a good liar and Wilson is a pushover. Nice flash at the end.

4. Cuddy, P.I.
Is there nothing Cuddy can’t do? Doctor, administrator, mother, and now detective. She must have one hell of a resume.

If the baby was located just outside the maternity ward, then the staff clearly didn’t do a very thorough job of looking for the baby.

Based on all the hospitals I’ve practiced at (and had children delivered at), the proximity alarms should have gone off. They go off anytime anyone leaves the ward with a baby, and that includes stairwells and back hallways. In fact, the alarms are often so sensitive you are warned to avoid going near the doors at all when holding the baby

5. House
The concept of House having to watch a patient he turned down die was clever and the for the most part, well done. There was a little too much of the “wise dying man” cliché for my tastes.

So was House telling the truth when he said he was still mooning over Lydia, or did he obliquely mean Cuddy?

No medicine or mystery scores for this week as their wasn’t enough to evaluate. I’d give the soap opera a strong B+.

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

While not as good as last week, I thought this was still a better-than-average episode of Fringe, even if did return to the Walter-caused-the-monster-of-the-week formula

The Plot: A young lawyer has lunch with a man who is clearly ill and claims to be an old classmate of hers. Shortly after lunch, a blistering rash develops where he touched her and soon spreads over her entire body. She dies before help can arrive. The Fringe team is called in to investigate the case and attend the autopsy. Walter concludes that she has been killed by a fast growing sarcoma (a cancer of the connective tissue). He is able to identify where the cancer started — at a handprint on her wrist.

The team visits the law office where the victim worked and discover she was working on a case against a pharmaceutical company. The Red Herring pharmaceutical company, I believe.

The team is called in on a similar case — a man who died almost immediately from a rapidly spreading tumor. They realize that someone is somehow giving the victims cancer. Based on an eyewitness who saw the killer in the café at the beginning of the episode, the team theorizes that the killer has some kind of cancer himself and is able to gain beneficial energy from his victims while infecting them with his cancer.

The team (finally) decides to do some investigatings and finds three other similar cases scattered across the United States. Olivia recognizes one of the names, but she is not sure from where. A little while later, in the middle of a game of Clue (hence the episode’s title) with Sam, the bowling alley owner, she realizes that all the victims were part of Walter’s Cortexiphan trials in Jacksonville. Walter theorizes that the Cortexiphan must made the victims more susceptible to this kind of energy transfer. Later, looking over the list of her Jacksonville classmates, she is able to deduce the identity of the killer. As luck would have it, when she walks outside, there he is waiting in her hallway. She recognizes him, but he quickly realizes that she is a cop (well, FBI agent, technically). They wrestle around her apartment, and she finally subdues him with a candlestick (another Clue reference) to the temple. He tells her that a mysterious man visited him while he was sick in the hospital and told him that, thanks to the Cortexiphan trials, he could cure his own cancer. Technically, it was true, but more of Midas-touch than anything else. Could this have been the same mysterious man who “activated” Nick, another Cortexiphan patient, back in the first season?

1. She Must Have Kept Rolling a “1″
Once again, Agent Dunham – and the rest of the Fringe team – are horrible detectives. Look for more cases? Who would have thought of that? Cross-reference the victims’ pasts to see if there were any connections – like a childhood in Jacksonville, perhaps?. Never!

2. Atypical Atypia
It’s often true that the more advanced a cancer is, the more irregular it is (we like the term “atypia”). Most of these changes occur within the cell itself, usually within the nucleus. That, of course, would make it particularly hard for them to fluoresce under black light since they are not surface changes.
I’m impressed that Walter was able to diagnose sarcoma just by a superficial glance at the lesion. Every other expert would need an actual tissue biopsy.

3. So “Miranda” Became a Lawyer…
Unless my eyes deceived me, Miranda Green was played by Diane Kruger, probably best known in the US for her role in the National Treasure movies. She also happens to be Joshua Jackson’s girlfriend in real life.

4. Turn Your Head When You Cough
While there are no contagious human cancers, there are some in the animal kingdom that are. We do know that there are contagious causes of human cancer. For example, the vast majority of cervical cancers are caused by a certain type of human papilloma virus (HPV), which is infectious – it is essentially a sexually transmitted disease. Now, not all HPV infections go on to cause cancer – most resolve on their own – but it is a contagious cause of cancer.

5. He’s Still Dying, He Just Doesn’t Realize It
Medically induced comas have no use in treating cancer.

6. I Have Got To Get Me One of These
A scanner — like a computer scanner — that can identify genetic codes from what is scans? What – are they on bar codes on the outside of the cells?

A return to the villain-somehow-tied-to-Walter formula, but for all it’s myriad (though minor) flaws, I still found it an enjoyable episode. The Fringe Doomsday Clock gains another minute.

Tags: television fringe cancer energy cortexiphan

I never realized that bowling alleys were such a hotbed of weight loss — good thing I signed up for the spring league. Click on the image for the full ad.

Among the heroes and villains resurrected at the end of Blackest Night #8 is Maxwell Lord — and apparently the evil scheming Maxwell Lord, not the less-evil-but-still-scheming Lord from his earlier appearances. I don’t know what his reappearance portends story-wise, but I bet dollars to donuts this means there will be more psychic nosebleeds in the DC Universe.

All previous Psychic and Superpowered Nosebleed Zen posts

Tags: comics medicine nosebleed maxwell lord guy gardner

I thought this was a well done, poignant episode of Fringe. Mostly, the story was just a confirmation of things we already suspected, but it did throw in some new wrinkes (like whatever happened to Dr Warren?)

The Plot: Most of this episode takes place back in 1985, where Walter Bishop has invented a “window” that lets him see into the other universe. At that point, he has no idea of how to cross between universes other than, scientifically, it is probably a “very bad idea.”

Meanwhile, young Peter is dying of an unnamed genetic wasting disease. Walter is unable to develop a cure, but other universe Walter is hard at work one on. Our Walter is using his window to watch him, hoping he’ll develop a cure in time to save Peter. Sadly, no cure is found in time and Peter dies in his father’s arms.

Other Peter is still alive, though still very sick, and other Walter remains hard at work on a cure. Miraculously, he discovers one, but a poorly timed visit by one of the Observers causes him to miss it. Our Walter notices, however, and is able to use what he saw to produce the cure. It is too late for his Peter, but he resolves to find a way into the other universe to save that Peter.

Walter heads to the lake and sets up the apparatus he has developed to open a gate to the other universe. His co-worker Dr. Warren and Nina Sharp arrive to talk him out of it, but he can’t be dissuaded. He opens the gate and walks through, the gate snapping shut behind him. Unfortunately, Nina was still trying to hold him back, and her arm was injured by the dimensional gate.

In the other universe, Walter arrives at the lake house and convinces his other wife (who believes that he is her Walter) that he has found a cure, but has to get Peter back to his lab immediately. Peter is bundled up, and he and Walter head out. Walter takes Peter across the lake to the gate, which Walter reopens and they enter our universe. As they arrive, the ice over the lake cracks beneath their feet, and they fall into the freezing water. As fate would have it, the Observer is there and rescues them. He tells Walter that Peter is very important and must live. He then gets out of the car and walks away. Walter takes Peter to his lab and gives him the cure, which seems to help. Unexpectedly, his wife arrives looking for him, and is overcome with emotion when she spots other Peter. She makes it clear to Walter that, despite his original intention, he will not be returning Peter back to the other universe.

1. Oh The Humanity!
The other universe has zeppelins, which are cool. Need I say more?

2. I Knew I Should Have Paid More Attention in Class
The Casimir Effect is an actual consideration in quantum physics. Near as I can tell, it deals with metallic plates in a vacuum. Walter certainly had the metallic plates, but he seemed to be missing the vacuum. But — hey! — zeppelins!

3. Wonder What Green Would Have Meant
So a pink solution is bad, and a blue solution is good. Was the writer of this episode, perchance, male?

4. 1.21 Gigawatts!
According to Dr. Warren, the wormhole will require a tremendous amount of power that will devastate both universes — yet Walter manages it with a small generator. Either Dr. Warren is bad at math, or those generators put out way more power than I thought.

5. One Prozac a Day, Husband’s a CPA
The faux-1985 opening sequence was well done, as were the location titles (nice 80s computer font).
Back to the Future was a nice touch. Especially the Eric Stoltz part as he was the only other actor seriously considered to play Marty McFly.
By the time Nina whipped out her giant cell I thought they were pushing “the 80s” a little too much (and apparently it takes only three or four digits to reach William at his hotel in France)

A solid story, and the science, though Fringe, wasn’t over explained, it just was. The clock regains a minute and moves back to 11:57

Tags: television fringe peter universe wormhole

My favorite parts of Blackest Night #8?

Read more…

In addition to having his right arm amputated by Prometheus, Arsenal also seems to be suffering from Too Many Tubes and Wires Syndrome. Let’s count:

4 chest leads , 2 each on the right and left. Which is unusual because the heart is situated on the left, and those right heart leads aren’t doing much good.
2 nasal canulas, one for each nostril. How are they supposed to stay up there unless someone jammed them in really hard. Ouch!
1 IV going to the tourniquet around his arm, which is unusual. Air bladders are common in medical equipment (like a blood pressure cuff for instance), but water bladders? (Or maybe the tourniquet is an air bladder and hooked up the machine next to it, but then the IV must be one of those mysterious stealth IVs that start but never end).
1 blood transfusion going into the stump of his right arm. I’m no expert on the treatment of amputations (thankfully), but that seems like a strange set up. Maybe they’re trying to keep the brachial vein open by forcing blood into it. Personally, I’ll just accept that Dr. Mid-Nite knows what he’s doing here.

Other observations:
I think that’s supposed to be the cephalic vein (or maybe the lateral thoracic vein), but either way, the anatomy is screwy. More importantly, how does Arsenal ever raise his arm without ripping that vein in half?
Apparently Prometheus not only cut off Arsenal’s arm, but he cut off his nipples as well.

Script is by Eddie Berganza with pencils by Scott Clark and Ardian Syaf. I don’t think we can really blame them for these images though as I’ve seen scenes of Arsenal in the hospital, with a set-up just like this, in a number of comics well before this one came out. We’ll give them a point for continuity, but dock them a point for medical errors, so it’s a wash.

Tags: comics medicine arsenal amputation titans

For your Friday reading, allow me to suggest Awesome Hospital, by (non-doctors, but still all around good guys) Chris Sims, Chad Bowers, Matt Digges, and Josh Krach.

It is the most over-the-top, yet medically accurate, webcomic that features doctors, dirtbikes, and guitar solos.

Do I really need to say any more?

This image from a recent issue of Green Arrow has a mistake or two — at least one that is painfully, humorously bad (to me, at least). Can you find it?

If you can’t read the text, it says:
“Why this man is alive is as big a mystery as I have seen in my twenty years of treating brain injuries. The blade perforated the orbital cavity, embedding itself deep within the parietal lobe. He’s not in any pain, as near as we can tell — the brain has no pain-sensory nerves. Most people with this level of traumatic penetration die instantly of central dysregulation.”

Previous picture quizzes

This image was sent to me by another physician/comic book fan since I am about six months behind on my Green Arrow +/- Black Canary issues.

Posts may be a little sporadic for the rest of the week as I am at a medical conference/on a mini-vacation with the family in Scottsdale, Arizona.

No new episode of House tonight, but I would like to talk briefly about what makes up a “good” history and physical exam, since I’ve criticized House and his team so much for failing to do one.

Take a look at this; it’s the card we were given during third year medical school when we started our hospital rotations. It will give you a good idea of what makes up a complete history and physical. This is what we were expected to accomplish on every patient initially.

As the year went on and we became more skilled, we would forgo most of the history and exam and focus on just the key portions that applied to our patients. Sometimes, that was most of the card (e.g. every internal medicine patient); other times, it was just one or two sections (e.g. every surgery or acute care patient). It’s the same policy I follow today. For example, if a patient comes in complaining of a cold, I won’t do the entire card’s worth of history and physical exam. I’ll focus primarily on the history and exam pertaining to the head, neck, and chest. If something unusual appears, I’ll expand the history and physical, but that’s pretty rare. However, when you encounter a difficult case or our stumped, it’s always a good idea to start fresh and get a complete history and physical — it’s amazing what will show up.

This is exactly what House’s team should be doing every week. By the time the patient is admitted to House’s service, they are by definition a difficult case or a “stumper.” Every single one of them requires a good solid history and physical (and no, I never ransacked a patient’s apartment).

I’m sure the card is © Saint Louis University School of Medicine. Posted without permission, but I hope four years of prompt tuition payments buy me some leeway.

scene from Hulk #21 (Loeb/McGuinness)

I had hoped we were done with the whole pyschiatrist/pyschologist thing, but apparently not.

Leonard Samson has long been established as a psychiatrist with an MD, not a PhD. There have been numerous mentions of his attending medical school, including multiple references in Loeb’s own Hulk series.

Heh, heh. Nice one, Foster. Use his “mallet” indeed.
Oh wait, you were being serious? Damn.

In all her appearances, did Jane Foster perform any actual nursing?

Tonight’s episode of House tried to hard to be edgy and ended up losing a coherent plot and any semblance of logical medical care along the way.

Abby is a seventeen year old high school senior who becomes unresponsive while on a school outing to the planetarium. Foamy red sputum drips from her mouth and her boyfriend reports that she’s not breathing; she is rushed to the hospital and admitted to House’s service.

Abby is found to have pulmonary edema (fluid build-up the lungs). The team understands this to mean that she has either a heart problem or a lung problem. Her drug screen was negative and her blood alcohol level was barely positive. Foreman suggests she may have developed heart disease from binge drinking. A C-13 pyruvate MRI is ordered (a test that looks at blood flow within the heart muscle itself). It doesn’t show the heart disease Foreman was looking for, but there appears to be something wrong with the mitral valve. Fungus is considered as a possibility, but the team decides a fastidious enteric bacteria infection is more likely (enteric bacteria are found in the human intestine, and fastidious means they are difficult to culture). A TEE (transesophageal echo — an echocardiogram performed from the inside of the throat which offers good views of the heart valves) is ordered to get a better look at the mitral valve. Under echocardiography, the valve appears normal, but during the test Abby develops an aortic dissection (a tear in the wall of the aorta), a life threatening emergency. She is rushed to emergency surgery where Taub and Thirteen manage to successfully resuscitate her.

The question now is how did Abby develop the aortic weakness which led to the dissection? A genetic defect is mentioned, but quickly dismissed with the aside that she is not Marfanoid (Marfan’s syndrome is known to cause aortic dissections — of course, there are other genetic defects besides Marfan’s). An allergic reaction is also suggested as a likely cause. Thirteen believes that a severe immune reaction could have led to the aortic weakness. She goes on to suggest that Abby may be allergic to her boyfriend’s semen. A quick test is performed but shows no reaction. However, during the test, Abby develops excruciating abdominal pain and is found to have blood in her urine. “Kidney failure,” screams Chase.

The differential diagnosis now consists of neuropathy (by which they mean syphilis, which can lead to a weakened aorta), a blood clot, insterstitial cystitis, or cancer. A full body scan is suggested, but, for the second week in a row, House mentions how much he hates them (a point on which we agree — of course, House’s opinion would carry more weight if they hadn’t already ordered five or six this season — and he wasn’t a fictional character). Out of other options, House agrees to the full body scan, which is negative. This being House, no test can go smoothly, and Abby starts to hallucinate during the study. This causes the team to reevaluate their differential, which now consists of a vascular disease (probably vasculitis from the way Foreman is talking) or an aneurysm. An MRA (an MRI that looks specifically at blood vessels) is ordered to find the aneurysm, but it also is negative. Foreman suggests a parasite found in the Middle East, but House shoots him down abruptly, saying it was too ridiculous to even consider.

Abby continues to hallucinate, but now has also started to have seizures. House convinces the team to try an experimental technology (conveniently available at that very hospital): cognitive pattern recognition. In a scene more at home on Fringe than House, the team see the image of her boyfriend playing baseball, then the universe, then an older man (“her late father” they surmise) from Abby’s brain. Unfortunately, this isn’t enough to build any sort of diagnosis. Grasping at straws, Thirteen suggests something may be wrong with the liver. Chase suggests she may have polycystic kidney disease (which really would have been seen on that full body scan he wanted). Foreman notices the MRI shows that her pineal gland is calcified (which is normal), but wonders if it may be hiding a tumor. A high powered MRI is ordered to check but is completely normal. House is at a loss until a conversation with Taub triggers his Eureka! moment. It turns out that Abby boyfriend’s father travels extensively, to the Middle East even, where he picked up the parasite that Foreman mentioned earlier, which he passed on to Abby in a drunken sexual encounter. The parasite itself died, but it left enough behind to cause a severe allergic reaction which is causing all of Abby’s problems (Cerebellar schistosomiasis hypersensitivity allergy). A quick brain surgery (to the remove the parasite, presumably) and she is fine physically. Emotionally…is a different story.

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

Schistosomiasis is infection by the liver fluke. It is endemic in much of the world, including the Middle East. So far so good, however:
1. It is the eggs of the fluke that illicit elicit a potent immune response. The fluke can cause an immune response itself, but not the level the eggs do (the level Abby demonstrated)
2. The body walls the offending agent off in a granuloma which absolutely should show up on a scan.
3. Schistosomiasis is not transmitted from person to person; it has a complex life-cycle and needs an intermediate host.

Coincidentally, just this past Thursday, NPR ran a segment on using a computer and pattern recognition to read human minds. Suffice it to say that the scene on House bore little in common with reality.

5cc of Adrenalin is a high dose. Even in emergencies, it is generally given in 1cc doses (though it will likely take more than a single dose). Plus, in the medical profession in the United States we call it “epinephrine,” half the OR staff wouldn’t know what you wanted if you asked for “adrenalin.”

Taub is suddenly a cardiac surgeon now? There’s a great deal of difference between a plastic surgeon and a cardiac surgeon. They only share one year of residency — the rest is completely different.

We’ve discussed this before, many times, and in great detail last week, but once more: blood in the urine is not a sign of kidney failure.

If the offending parasite’s body was so small it didn’t show up on a scan, how did they know where to operate to remove it?

Only in the hospital for a few minutes, Taub breaks HIPAA (Health Information Portablilty and Accountability Act, a Federal law which deals with, among other things, patient privacy) by telling Abby’s boyfriend about her medical condition. That’s a big fine for the hospital. $$$$ Nice going, Taub.

I know I often complain about the unrealistic time course of tests on the show, but this week’s deserves a special mention: fungal cultures are very slow growing — weeks, not days — so there’s no way they’d be negative so soon.
To my knowledge, there are no blood cultures for parasites. They are generally detected by O&P (ova and parasite) studies of the stool and blood smears.

She seized for just about a minute, yet in that time they managed to hook up a multi-lead EEG and record the waveforms. That’s damn impressive.
And can we stop the “OMG! If she has another seizure she’ll stroke out!” That’s unrealistic and insulting to people who actually have a seizure disorder.

The medical mystery was average — nothing we haven’t seen before: C. The final solution really didn’t make much sense. If they wanted her to have schistosomiasis, they should have given it to her in a way which could actually happen. If they wanted the edginess of sex with her boyfriend’s father, they should have just made her allergic to his semen, as was discussed earlier. Combining the two was a bad decision: D. The medicine had holes this week, though no more than usual, other than House giving up so fast. I give it a B. The soap opera was good, though not as strong as the last couple of weeks: B+.

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

Sorry Doc, but you don’t treat a black eye by putting some sort of cream on it. Think of it this way: a black eye is essentially a bruise around the eye — and when do you put anything on a bruise? The real treatment of a black eye is easy: ice, and time. That’s it. Nothing fancy needed.

(Now in his defense, I guess the skin around the eye could have been broken open by the punch, and Blake might be putting some sort of antibacterial ointment on it, but that’s still a stretch).

The set-up was clever, but the medicine and final solution were sloppy and average, at best. The speed dating scene was worth it, though

Frankie is a 28 year old vegetarian (well, mostly vegetarian) who presents with a sudden case of severe coagulopathy (blood that won’t clot correctly — in Frankie’s case, her symptoms included facial bruising and bleeding gums). The initial thoughts include a congential thrombocytopenia (an inherited condition of low platelets), a toxic exposure, or a deficiency in clotting factors. House thinks the toxin exposure is the best option, and has the team search her apartment. Nothing is found in the search, but a conversation with a neighbor indicates that she has been exposed to rat poison (this is important because a common kind of rat poison is an anticoagulant and would explain her bleeding problem). Soon, Frankie complains of “muddy” urine, which the team takes to be a sign of kidney failure, meaning that rat poison was not the cause.

Looking at conditions which cause both a coagulopathy and kidney disease, the differential now includes hemolytic-uremic syndrome, Gaucher’s disease, Sjogrens syndrome (an autoimmune disease), and Haff disease (sudden development of rhabdomyolysis shortly after eating fish, thought to be related to some form of toxin). The latter seems the most likely and she is started on saline and mannitol (the suggested treatment for Haff disease is fluid and diuretics so these are reasonable choices). Chase still believes his suggestion of Sjogrens was the best, and reads over Frankie’s blog looking for clues. He sees one post mentioning decreased sexual arousal and he suspects this is due to vaginal dryness, a sign of Sjogrens. He wheels her into the x-ray suite to perform a sialogram (an x-ray of the salivary glands, because decreased saliva production is another sign of Sjogrens). He is unable to get the x-ray because she complains that it is uncomfortable to lie down. Chase recognizes this as a sign of valvular heart disease, and sure enough, an echocardiogram reveals severe problems with an unspecified mitral valve disorder (probably mitral valve regurgitation, as this has been associated with Sjogrens). Her condition is so bad that she will need an artificial mitral valve.

As she is being readied for surgery, Frankie develops severe right lower abdominal pain and vomiting. Emergency abdominal surgery reveals a burst appendix. Even worse, studies suggest that the appendix burst because it was full of cancerous cells — lymphoma — that has now spread throughout the body. The team tells her that it is too late for regular chemotherapy, but that she is a candidate for an experimental anti-lymphoma vaccine. Without it, she has maybe a year to live. She agrees and is started on the vaccinations. Everything goes well at first, but after the third dose she suffers a high fever. The suspicion is that the vaccine has triggered a severe immune response of some sort.

During a discussion of the case with Cuddy, the fact that Frankie is a night owl comes up in conversation because this is new for her. Until six months ago, she was up during the day instead of at night. According to the team, day-night reversal can be a sign of liver disease (true, to a point). A liver biopsy confirms that she has liver failure. What was initially thought to be lymphoma is now recognized as a granulomatous build up (inflammatory cells) related to the liver failure. Instead of a year to live, she is now given a few days.

Looking over her symptoms of fever, cell atypia, coagulopathy, liver disease, kidney disease, and heart disease, the team suspects some form of infection but can’t narrow it down any more than that (I don’t buy it: something inflammatory like an autoimmune disease could explain all the symptoms just as well). House orders her started on broad spectrum antibiotics. A later conversation with Wilson leads to his Eureka! moment. He realizes that in all her blogging, even the intensely personal stuff, she never mentioned her bowel movements. Direct questioning reveals that she had a change in bowel habits consistent with a malabsorption syndrome — in this case Whipple’s disease. A course of antibiotics and she’ll be fine (though she’ll still need the new mitral valve).

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

The writers don’t seem to understand kidney failure. It is – just as the name suggests – a failure of kidneys – that is: they don’t work any more. Instead of normal urine production there is a decreased or absent urine production. Dark urine is not a sign of kidney failure.
Dark urine is a common sign of a bleeding disorder, just like Frankie has. It would be more proof of rat poison exposure, not less.
Her kidney labs are normal, at least the creatinine is (arguably the most significant one), so she has no actual signs of kidney failure.

How did they miss severe liver failure on this patient? Liver labs should be drawn for every patient with an undiagnosed clotting problem,and it should have shown up on her other tests as well.

I don’t buy the whole “the lymphoma is too advanced for chemotherapy” argument. What tests have they done to show how widespread the cancer is? What treatments have they tried and failed?
The vaccine only works for follicular lymphoma, a rare type, and it doesn’t cure it, it just extends the time until the inevitable relapse this type of lymphoma always has.

Frankie has severe enough mitral valve disease to require a new valve sooner rather than later, yet no one heard a murmur on exam?

Other than a possible Vitamin K deficiency, what other signs of severe malabsorption does she show? None. Where’s the long history of weight loss (no way she wouldn’t have mentioned that on her blog), joint pain, fatigue, and fever?

Day night reversal is a sign of severe hepatic encephalopathy, which is seen is severe liver failure.

Her bleeding and bruising came on incredibly fast. I wouldn’t call it impossible, just very very very unlikely.

I find it sloppy work that no one asked about her bowel movements until House finally did. (It’s one of my “big four” questions I ask every patient). Especially in a patient they were considered hemolytic-uremic syndrome in.

If the team ever did a thorough admission exam and history, these shows would be lucky to last a half hour. How many diagnoses have they missed because of sloppy exam or poor history?

Another interesting medical mystery — better than most this season. It earns a B+. The final solution was a stretch. If her Whipple’s (and liver and kidney) had really been that bad, there would have been many signs along the way. I give it a C. The medicine had lots of holes this week, and the parts didn’t add up. It deserves no more than a C-. The soap opera was good. It was nice to a non-melancholy Chase again, and the House/Wilson scenes were well down. The speed dating was terrifically over the top. The soap opera earns a swofting A.

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

This week’s House Challenge scores have been posted

Elizabeth and raininthehills both had the week’s high score with 12 points.

Overall, TRad and Noether continue their dominance, with 82 and 80 points, respectively. Theta Sigma is third with 57 points, Corien retains fourth with 54 points, and The Erskine holds on to fifth with 52 points.

Click here to see the full scoreboard.

A bigoted World War II soldier is gravely wounded, and only a transfusion from an African-American can save him. Sound familiar? It should: it’s the defining scene of the justly classic “What’s the Color of Your Blood?” from Our Army at War #160, by Robert Kanigher and Joe Kubert (Nov 1965).

Only it turns out, this isn’t the first comic with this scene. Sgt. Fury #6 (March 1964) features a similar scene.

Of course, the stories couldn’t be more different:
Sgt. Fury #6, by Stan Lee and Jack Kirby, features Lee’s typical bombastic storytelling. Fury and his squad take on Rommel’s entire North African Division, and were actually winning when they were stopped by the British Army — because the British had found out Rommel had to a part to play in a plot to assassinate Hitler and wanted him to follow through with it.

“What’s the Color of Your Blood” is more down to earth, featuring two former boxing champions meeting on the battlefield to decide once and for all who is the champ. (If you’ve never read it, the entire story can be found here, and is well worth your time).

The Brave and the Bold #31 “Small Problems”
J. Michael Straczynski, writer
Chad Hardin and Justiniano, pencilers

The Atom is called to Arkham Asylum to treat a neurological problem the Joker is having. He has to shrink down to microscopic size, enter the brain, and release an “experimental chemical” at a specific location to cure the Joker.

There are many, many problems with this comic. I’m all for Fantastic Voyage homages, but it is obvious that Straczynski has no understanding of how the brain or nervous system actually functions. A twelve year old with access to Wikipedia and five minutes to spare could write a more accurate — and no less engaging — story.

The main stumbling block is Straczynski’s misunderstanding of synapses — the junctions between nerve cells*, where one cell passes a signal to the second cell. These synapses can be either chemical (a message molecule known as a neurotransmitter carries the impulse from the first cell to the second cell), or electrical (the two cells are connected by channels which allow an electrical signal — ions, really — to be passed from the first cell to the second cell).

I’ll just touch on a few of the bigger errors here:

What the doctor here is describing is not particularly rare at all. When too many synapses fire off, you have a seizure. If it involves part of the brain, it’s a partial seizure; if it involves most of the brain, it’s a generalized seizure. If the seizures happen repeatedly, then it’s considered epilepsy. If it is a seizure that cannot be stopped, then it is called status epilepticus, and yes, it can lead to brain damage and death (but it’s not rare: 42,000 deaths a year). • If the Joker really were in status, he’s be dead long before the Atom ever got there.

This is some horrible, horrible technobabble. I know everyone uses “the brain = a computer” metaphor, but it’s just that: a metaphor; a figure of speech. The brain is not really a computer — it is orders of magnitude more complex and you can’t “reboot” it. For one thing, I’d want my brainstem to keep working no matter what, since it controls such things as the heartbeat and breathing. • “Synaptic array at the microscopic level” is redundant. All human synapses are microscopic.

Straczynski seems to think that all synapses are electrical in nature, but that is not true — in fact, chemical synapses are much more numerous; electrical synapses only show up in certain pathways where speed is important — reflexes, for instance. He spends most of the issue confusing the two types of synapses. “Synaptic gaps” occur in chemical synapses; electrical synapses are tied together by ion channels. Chemical synapses are involved in the higher processes, like memory. Electrical synapses transmit ions from one nerve cell to another through channels in the cell membrane — there is no “electrical pulse” or lightning bolts (as drawn in the comic) between the nerves. The rest is just more technobabble.

For a better “The Atom in somebody’s brain” story, I recommend The Brave and the Bold (original series) #115, where the Atom controls a brain-dead Batman to solve his murder.

*There are also synapses between nerve cells and other cells, such as between a nerve cell and a muscle cell.

As I do every now and then, I’m going to take a throwaway line from a recent comic and use it for some idle speculation. This time, the comic in question is The Indomitable Iron Man, more specifically, “Brainchild,” the story by Duane Swierczynski and Manuel Garcia.

In the story, Pepper Potts granddaughter mentions:

“Five years ago I was one of the millions who caught G7N1. A Stark ubi-vaccine – something you were playing around with years ago – well, it saved my life.”

To me, G7N1 sounds like an influenza virus, so let’s run with that.

A little background:
Influenza A is the most pathogenic flu virus in humans. All known flu epidemics have been caused by it. Influenza A mutates rapidly, so new strains are developing all the time. The subtypes of Influenza A are named for two proteins coded by the virus: hemagglutinin and neuraminidase. Different strains of Influenza A have different versions of these proteins. So the H1N1 virus codes for hemagglutinin #1 and neuraminidase #1, H3N2 virus has hemagglutinin #3 and neuraminidase #2, and so on. So far, nine different Hs and 16 different Ns have been identified. Luckily, most strains are not pathogenic in humans — the main ones that are now are the H1N1 (swine flu), H3N2 (Hong Kong flu), and H5N1 (bird flu).

Influenza B is not as common as Influenza A. It does not mutate as quickly either, so it is not divided into subtypes. Because of the slower mutation rate, and the fact that it is can only infect a few distinct species of animals (humans, ferrets, and seals), Influenza B has never caused large epidemics.

Influenza C is even less common than Influenza B. Like Influenza B, it does not occur in more than one subtype. Generally, it causes mild disease in children, but occasionally Influenza C can cause a local outbreak, but never large epidemics.

Back to the speculation:
G7N1 — the name doesn’t fit an Influenza A virus (no “H”), but it is similar. Given the fact that the virus causes epidemics, it’s unlikely to be Influenza B or C. So it is most likely a new genus of influenza. As I mentioned, the naming pattern sounds similar to Influenza A, so maybe it started as a major mutation of A, or is suspected to have been derived from A at some point.

Also note that it is “G7” so there have been at least 7 subtypes of this heretofore unknown virus identified in about sixty years — a high mutation rate.

Here’s Magneto working hard, oblivious to the rest of the world, trying to save the life of a certain X-Men. I suspect his nose is bleeding from the effort of breaking the laws of physics –more than usual, that is. Magneto is using his power to affect an object so distant in space that his power his is traveling faster than the speed of light — which considering that his power involves generating electromagnetic waves is pretty damn impressive.

All previous Psychic and Superpowered Nosebleed Zen posts

Tags: comics medicine nosebleed magneto x-men

scene from The Web #6 (Sturges/Robinson)

I’m pretty sure the pictures and words are supposed to agree. For someone who has no heart rate or respiration, the monitors show surprisingly normal readings in both.

Smallville is having a hobby contest with the winner receiving a trip around the world. The contest looks for the person in town who has the largest coin, rarest stamp, most valuable mineral, and most unusual autograph. Spoiled rich kid Orville Orville plans on winning by using his money to buy the best specimens. Superboy decides to help the other kids beat Orville by using his power to find specimens that will beat out Orville’s.

For the most valuable mineral contest, Orville enters an uncut diamond worth a million dollars. To help Teddy beat him, Superboy returns with a large boulder of pitchblende for him to enter.

Pitchblende, or uraninite, is a uranium ore that is also a source of radium.

Uranium and radium? Doesn’t that mean Ted’s boulder is radioactive and potentially dangerous?

Yes.

Exactly how dangerous is the rock Superboy has brought to class?

Small samples of uranium ore are not particularly dangerous if handled with care, but Superboy has a very large sample, and he’s not being careful at all.

Now for some quick and dirty math: assuming the chunk of rock he is holding is about 4 feet (1.2m) in diameter, then it weighs around 21600 pounds (9800 kg — uranium ore is very dense and heavy). Since Superboy is holding it in his hands, he is being exposed to about 19.5 million millirem (mrem) per hour. For Teddy and the teacher, in the few minutes they’re standing a few inches from the ore, they’ve probably received on the order of 406,000 mrem of radiation — the equivalent of 400 abdominal CT scans (or 40,500 chest x-rays) all at the same time. This puts them in the range of “acute radiation poisoning” which has at least a 60% fatality rate. [here's the math, if you're so inclined]

The rest of the class is about four times farther back from the boulder than Teddy is, so they’ve only received 1/16th of the same dose, or about 25,400 mrem (which is equal to 25 CT scans at the same time). A dose of this magnitude usually causes a temporary decrease in white blood cells, but is not fatal — well, except for recent studies which suggest that it increases the person’s lifetime risk of cancer by a several percentage points.

Nice going Superboy. You won the contest, but gave Teddy and the teacher acute radiation poisoning and increased the risk of cancer in the rest of the class. I think I’ll hang out with Lex Luthor instead: it’s safer.

(Seriously, even in 1947 they had to know a boulder of radioactive material was a bad idea)

Scenes from the Superboy story “The Great Hobby Contest” in Adventure Comics #121

Thanks to his super-powers, Clark could fake being sick better than anyone else in high school. And I mean anyone else.
Read more…

Yet again, I am here to take on the question of Brother Voodoo: psychologist or psychiatrist?

This time, I’m turning to a new source, MU1 – Gamer’s Handbook to the Marvel Universe (Volume 1 – Abomination through Dreadnought). This was the eight volume encyclopedia of Marvel characters published for the Marvel Super Heroes Game, published by TSR in the mid- to late-80s. In the guide, Brother Voodoo gets a page and a half (and for the record, that’s a little less than American Eagle — who at this point had only appeared in one comic).

On his entry, his profession is listed as “Ex-Psychologist (M.D.), now Houngan (voodoo priest).”

So once again, Marvel (with some help from TSR in this case) reveals that they are unclear on the pyschologist/psychiatrist divide.

Click here to see the entire Brother Voodoo entry

Tags: comics medicine brother voodoo psychiatrist psychologist

In this scene from the Gen 13 (current series) #33, Void uses her teleportation powers to dispose of a bomb — only it’s such a powerful bomb, she has to send it high in the atmosphere, resulting in a classic pushing-powers-to-the-max nosebleed.

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed gen 13 void bomb

You know you’re reading an old comic when the doctors are all sitting around smoking:

scene from Doctor Tom Brent, Young Intern #1 (Charlton, 1963)

To be fair, the comic was published a year before the Surgeon General’s report first condemning cigarettes came out, and three years before warning labels were added to cigarette packs.

Of course, it wasn’t just comic books that depicted doctors smoking, cigarette ads did too:

click on the image for the full-sized ad

For those of you wondering how many doctors smoked in the past compared to how many smoke now, I don’t have a good answer for you. The best I have is a short paper that takes a look at smoking rates among Rhode Island physicians from 1963-1983. It is over twenty years out of date, so I suspect the numbers have fallen even more, but I think it gives a good idea of the trend. Here’s one of the charts from that paper.

Back when I was in residency, I had the opportunity on several occasions to serve as the in-house doctor for the local symphony orchestra. There was no pay per se, but I got two tickets to the show (cheap date!) and the chance to hear some great performances. It was easy: I just showed up on my assigned night and introduced myself to the head usher. I was given a pair of seats in the back of the theater and the staff would come and get me if there were any sort of medical emergency. I attended a little over a dozen symphony performances during my residency and never had any real medical emergency — however, every show without fail, at some point I would be called to examine a little old lady who had tripped on the theater steps. It was never a serious injury, just some bruising or maybe a sprain (and for the record: it was a different lady each time; those were some tricky steps).

All of the residents took turns attending the symphony, and no one else was ever called away for any sort of medical problem — except for Gerry. He was summoned once, only it wasn’t for a little old lady, but for the visiting marquee-name soloist. He later told me it was for a very minor issue and he got to hang out after the show with the star.

As I become bitter in my old age, I like to pretend his experience was more like Dr Landon’s in this back-up story from Nurse Betsy Crane #20:

Click on any of the images for the full story

Dr. Landon went on to co-star in his own brief comic book series, The Young Doctors. In past years, I have looked at issues The Young Doctors #4 and The Young Doctors #5.

Tags: comics medicine landon charltonbetsy crane young doctors

Back in 1736, concerned that certain medical practitioners were overcharging patients, the legislature of the Colony of Virginia passed a law setting mandatory prices for services. The prices, and the philosophy behind them, make for an entertaining and enlightening read:

A couple of things should be obvious looking at this table. First, housecalls were common in the colonial era, and the practitioners charged accordingly. Second, there were two classes of medical practitioners: those who learned the trade by serving an apprenticeship (the surgeons and the apothecaries), and those who learned the trade through years of schooling (the phisic, or physician). Which was better? It varied, and probably depended a lot on both the practitioner and the patient. (Today’s system of medical training combines both methods: multiple years of college and medical school followed by a residency — which is really nothing more than an apprenticeship.) Back in the colonial times, you’ll also notice the surgeons seem to be the only ones who really got their hands dirty.

An atypical episode of House as it focused on a day in Dr. Cuddy’s life, moving every other character to the background. A change of pace, but a solid and enjoyable show nonetheless.

Cuddy gets up at five AM and starts the day with some yoga. Her daughter Rachel wakes up a little while later, sick, and Cuddy comforts her while getting ready for work. The nanny arrives, and then Lucas, who’d been up all night on a stakeout. He talks her into a quickie before work, but unfortunately he was a little premature in his efforts and she heads off to work unsatisfied.

Cuddy arrives at the hospital at eight and things are already going crazy.

House strolls up to discuss his patient he thought had resistant Staph, and who he wanted to treat by infecting him with malaria.

Cuddy walks off, telling House that she has to finish a proposal before an important 8:30 meeting and there’s a crisis in the pharmacy where some paperwork, and some ephedrine, is missing. Next, there’s a problem in surgery, where one of the surgeons is complaining because House has turned on the air conditioning. She gets the heat turned back on and heads to her meeting.

Meeting Cuddy in the hallway, House informs her that his patient now has boils and a large abscess.

Cuddy hears from the nanny that Rachel is still sick, only now she’s running a fever and vomiting. She finally makes it to her 8:30 appointment with the contract negotiator from AtlanticNet Insurance, the largest insurance company in the area. He and Cuddy have been arguing about a contract for eight months, and today Cuddy lays it all on the line. She agrees to capitated care, but wants a 12% increase in rates. He refuses. She tells him that this is the hospital’s final offer and he has until 3PM to agree, or she will make a public announcement that they are no longer accepting AtlanticNet, and why.

Thirteen and Taub report to House that their patient is now hallucinating and has a falling blood pressure and rising heart rate. They suspect congestive heart failure, but House disagrees, telling them that the patient has [elevator door shuts before we hear the answer].

On the way to the hospital board meeting, Cuddy has a run in with Dr. Thomas, the hospital’s Chief of Surgery. He is seething about House — upset primarily about the fact that he stole Chase back from the surgery department. She heads into the board meeting where the board makes it clear that Cuddy’s job is on the line if she can’t pull off the contract with AtlanticNet.

House skipped clinic again, so Cuddy fills in for him. The patient is an older man with metastatic cancer who wants a prescription for breast milk. He has heard that breast milk can help with his cancer, and wants a prescription so the insurance company will pay for it. She refuses, pointing out that even with a prescription the insurance company won’t pay for it. He accuses her of being in the pocket of the insurance company before insulting her and storming out.

Back at her office, Cuddy finds a lawyer waiting for her. He is representing Martin Acevedo, a man who had his thumb reattached after cutting it off with a saw. He is suing because he didn’t want the thumb reattached — he is poor and that was too expensive — but Chase went ahead and did the surgery anyway. When confronted Chase admits that he did sew the thumb back on even though that was not what the patient wanted because he felt that the reattachment was the best option for the patient medically.

A little while later, Cuddy meets with Gail, the pharmacy tech who stole the ephedrine. She tells Cuddy that it was to help her lose weight and asks Cuddy not to fire her. Cuddy takes a little pity on her and tells Gail that she has to fire her, but she won’t report her to the DEA. She grabs a quick unhealthy lunch from the cafeteria.

House is sitting in Cuddy’s office – in her chair – waiting for her. He tells her that his patient has renal cell cancer (kidney cancer) and he wants to treat with malaria in addition to chemotherapy.

Lucas swings by the office, bringing Cuddy a real lunch. He tells her that Rachel seems to be doing better — she is no longer running a fever — but she has developed a rash. Unfortunately, Lucas accidentally grabbed the nanny’s phone, and turned the ringer off on Cuddy’s phone at home, so there is no way to reach the nanny.

With Lucas’s help, Cuddy tracks down the CEO of AtlanticNet at lunch and confronts him about the contract. He blows her off, telling her he doesn’t care if her PR campaign makes him out to be a rich bastard, as long as he stays rich.

Back at the hospital she meets with the head of the pharmacy and discovers that a lot more ephedrine is missing from the hospital than previously suspected — $50,000 dollars worth — and the thefts have been going on for at least three years. She realizes that Gail has been lying to her and has been stealing the ephedrine to sell to a meth dealer (ephedrine can be used to make methamphetamine)

The negotiator from AtlanticNet returns and offers an 8% increase as their final offer. Cuddy declines, wanting the full 12%.

Now House’s patient has liver failure and needs a transplant.

Three o’clock arrives, and as there have been no new offers from AtlanticNet, Cuddy calls a staff meeting and informs the physicians that the hospital has terminated the contract with the insurer. This causes widespread disbelief and dismay among the staff, as many of them made much of their money from AtlanticNet patients.

Foreman arrives, telling Cuddy that they’ve found a liver, but now there’s another conflict. House wants Chase to do the surgery, but Thomas refuses to put him on the schedule. Foreman needs someone who outranks both House and Thomas to schedule the surgery.

Cuddy meets with Acevedo and his lawyer. She tells them that not only will the hospital fight the lawsuit tooth and nail, but that she wants Acevedo to pay the remaining bill for his care.

Next, Cuddy arrives at the surgical suite and breaks up a brawl between Drs. Chase and Thomas. She then returns to her office and confronts Gail, the recently fired pharmacy tech, about lying to her. Gail freely admits the theft and tells Cuddy she can’t do anything about it because she’ll lie to the DEA, telling them that she did it on House’s orders, and that House and Cuddy were having an affair. Frustrated, Cuddy walks out of her office, telling the staff that she quits. She sits quietly in her car for a few minutes until House arrives. He cheers her up, as only House can, by insulting her, but this is enough to get her to head back into the hospital.

Cuddy confronts Gail again, who once again brags of her theft and her plan to lie to the DEA. Luckily, Cuddy captured it all on one of Lucas’s hidden recording devices. The nanny calls and tells her that Rachel is doing fine. To complete the hat trick, the negotiator from Atlantic Net arrives and tells Cuddy that the insurer has agreed to her 12% proposal. Ecstatic, she informs the board and staff, who share her enthusiasm. Finally, she heads home to Lucas and Rachel after a long, exhausting day at work.

No significant medical complaints, and no grading this week either, as the episode didn’t give me much to work with in that regard. Just a few thoughts and comments:

Though I know nothing of its use in Staph infections or cancer patients, before the advent of penicillin, malaria was used a treatment for syphilis. The malaria gave the patients a high fever — high enough to kill off the syphilis germs — and malaria was curable with quinine.

On one hand, you could argue that Cuddy should have acceded to the patient’s wishes and given him a prescription for breast milk, since, as House said, “it might work.” However, I have to side with Cuddy on this one. First, she’s right: the insurance company will not pay for it, even with a prescription — they’ll consider it an experimental treatment. Second, it’s her signature on the prescription, and she should not write any prescription she is not comfortable signing. Finally, and she should have pushed this part harder, the breast milk is at best a shot in the dark — it’s wishful thinking — and by writing the prescription she would be confirming the patient’s false hope. She handled it well: she was upfront and truthful and told the patient she would not write the prescription. He didn’t like what she said, but he’s free to find a new physician.

Though it was mentioned briefly at the beginning, both Cuddy and the lawyer are glossing over the key fact that the treatment Mr. Acevedo received was not covered by the informed consent he signed. Chase may have done what he thought was best for the patient, but he did it through lying and dishonesty. Sure, Mr. Acevedo kept his thumb, and this will probably restrain the jury’s and judge’s enthusiasm for a large payout, but there is clear written evidence that Chase was deceitful in his treatment of the patient. The hospital’s insurance company will pay this off long before it sees a courtroom. And as for Chase, skipping informed consent or lying on it is a good way to lose a medical license.

Every place I’ve ever worked has a two people count the controlled substances in the pharmacy, just so situations like Gail’s can’t happen. And why does the hospital have so much ephedrine? It’s not that common a drug.

Anyone know what the rules in New Jersey are for surreptitiously recording a conversation? I know in Illinois it needs the consent of both parties involved, but I believe this is the exception, rather than the rule.

Consider this a non-scoring week for the House Challenge. Last week’s scores can be found here.

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

Big questions were answered, the science wasn’t that bad, but it still struck me as a surprisingly lifeless outing for the “Winter Finale” of Fringe.

The Plot: At an office building in Manhattan, the workers grouse about a series of small earthquakes the city has been experiencing. Suddenly, there is a larger tremor and one of the workers finds himself caught in the quake. He blacks out for a second and when he comes to, he is pinned by the rubble — and has four arms and four legs.

The Fringe team is called in to examine the office building. So far, no survivors have been found, but many dead bodies. The bodies aren’t normal, however, but each seems to be two separate people fused together. Walter hypothesizes that a “Quantum Tectonic Event” has caused a rip in space that caused the quake and fusion. A survivor is found upstairs: the worker from the opening scene. Walter converses with him while he is slowly dying and learns that the worker is from the alternate universe. Walter has a new theory: an office building from that universe has suddenly merged with the same office building from ours, killing all the inhabitants. Agent Dunham suspects this to be a deliberate act on the part of Newton (the leader of the team from the alternate universe that is trying to destroy ours).

Back at the lab, Walter realizes what has happened — and what will happen. Twenty-five years ago, he and William Bell sent a car to the alternate universe and a short time later, a car of equivalent mass from that universe appeared in ours, merged into a statue. Walter tells the team that a building from our universe will disappear within 35 hours. His only idea how to stop it is to use some of the abilities Dunham gained from Cortexiphan. He drags her and Peter to Jacksonville, where the original Cortexiphan experiments were carried out. He repeats the experiment on Dunham, but it has no effect this time. Belatedly he realizes that her abilities depends on fear, and Dunham no longer experiences fear, but channels it all into anger. Defeated, the three of them return to New York.

While they’ve been in Florida, small earthquakes have started in New York City, signaling that the calamity is impending. The scientists at Massive Dynamic are trying to find a pattern to the quakes, but Walter tells them there is no pattern to find. Instead, he suggests locating the building in New York City of identical mass to the one that appeared from the other universe. They are able to narrow the list down to 147 building, but the thirty-five hours is up. Concern over her failure and the likely loss of life scares Dunham, kick starting her spot-the-things-from-the-other-universe power. She is able to spot a building that weirdly glimmers, a sign that it is the one that is going to disappear. The team is able to identify the building and the authorities evacuate it just in time — with a massive inrush of air the entire building — basement, foundation, and all — disappears.

As the episode ends, Olivia and Peter are heading out for drinks, but when she looks at him, she realizes that he is glimmering too. Walter begs her not to tell Peter the truth.

1. Spellchecker
Manhattan was spelled wrong in the opening scene.

2. Island of Misfit Toys
If the building in Florida has been sealed for 25 years, why did it have toys from the Ice Age movies (’02, ‘06, and ‘09)?

3. Where’s Johnny? He Was Here Just a Minute Ago!
So did a child of identical mass to Peter get transported to the alternate universe when Walter brought Alterna-Peter here?

4. Glimmer Glimmer Glumpkin
If Olivia’s powers detect items from the other universe (that’s what Walter was testing in the classroom after all), why did the building from this universe glimmer?

5. Tick Tock
Why 35 hours? I’m guessing that’s how long it took for the car to appear.

6. Mass Effect
How are they going to be able to find the mass of the alternate universe building when it is merged with ours. Are they assuming it was identical to the one in our universe, just like their Nixon coins and double-decker cars are identical to ours?

7. There’s No Babble Like Good Babble
Quantum tectonic event. That is some grad-A prime of technobabble. It sounds impressive, but notice how none of the words really work together (or at least the two most important: tectonic and quantum. They’re pretty much contradictory — “quantum” suggest atomic or sub-atomic, while “tectonic” is very macro in its implications.)

I so wanted to like this episode with the Peter reveal (that we all knew anyway), but I couldn’t — it was dull. It wasn’t horrible, but an episode this big should be more fulfilling. The Fringe Doomsday Clock stays put.

Tags: television fringe quantum tectonic cortexiphan

Supergirl #49 “Death & The Family”
Sterling Gates, writer
Matt Camp, artist

Lana Lang has been found down and bleeding profusely. She is rushed to the emergency room for resuscitation.

There’s a few things wrong with this scene:

First, they’re shocking a flatline. I’m sure I’ve mentioned at least once before that this is not how to treat a flatline.

How should they proceed? Asystole (the fancy, medical word for a flatline) is tough to treat, and the odds are against you from the start, no matter what television tells you. The key to treating asystole is to correct the underlying cause. One concern: Lana’s lost a lot of blood — there’s at least two panels of her laying supine in large puddles of blood and the staff is splattered with blood. As far as the ER staff is aware, this blood loss is a possible cause of her condition, yet they’ve done nothing to treat it. There’s no blood being transfused — in fact, there’s not even a single IV line, which are important in any resuscitation. (As an aside, the defribrillation paddles are also reversed: the upper paddle should be on Lana’s right, and the lower on the left)

Second, as fancy as that face mask is, it’s not going to be any good at getting the air she needs down into her lungs. I appreciate the fact that Cage at least added a breathing tube entering her mouth, but it’s too narrow to be any use (it needs to be about the width of a thumb to work). Plus, if she’s got a breathing tube in place, why does she need a mask?

Third, Lana is bleeding from her mouth, nose, and eyes. If you were the ER staff, what’s one of the first things that would cross your mind? Hemorrhagic fever (Ebola, Marburg, and for the comic-inclined, the Clench). Sure, none of them are endemic to the US, but in this day and age, who’s to say Lana hasn’t been traveling, or exposed to someone who has? The ER staff would be wearing a lot more protective gear.

On the positive side, fzzCHOOMPH is the best sound effect I’ve seen in quite a while.

Tags: comics medicine lana lang supergirl resuscitation sterling gates matt camp

The team in this week’s episode of House followed a more logical approach to the patient, but they were still hampered by bad medicine. But hey, an opossum!

Daryl is a 22 year-old college football player hoping to be spotted by pro scouts. In the middle of practice, he suddenly becomes uncontrollably violent. He grabs his opponent and drags him around by his helmet until it finally comes loose, and then he bashes himself in the face repeatedly with the helmet until he starts bleeding.

He is admitted to the hospital for evaluation, but has no memory of the incident. A head CT scan and a psychiatric evaluation — both obtained in the Emergency Room — were negative. House suspects Daryl’s symptoms are due to steroids, even though he tested clean in the Emergency Room. He believes he is on the “good stuff,” i.e. steroids that don’t show up on tests. The rest of the team suspects a pituitary adenoma (a tumor in the pituitary gland) caused by repeated head trauma. Tests for GnRH (gonadotropin releasing hormone, which controls the gonadotropins, which control the production of testosterone in men) are high, but a pituitary MRI is negative, which lends credence to House’s theory of steroid abuse. He tells the team to start Daryl on a somatostatin-analog (a medication which inhibits the pituitary gland) to block the effects of the elevated GnRH.

Daryl denies any use of steroids and begins to suffer a racing heart rate and chest pain. He has an episode of paroxysmal tachycardia (sudden onset of an abnormally fast heart rate) that requires cardioversion to return it to a normal rhythm (by definition “cardioversion” means returning the patient to a normal heart rhythm. This can be done chemically, such as with adenosine, or electrically). Taub reports that the cardiac symptoms do not fit the diagnosis of steroid abuse, so the team gives Daryl’s heart a further work-up including EKG and sestamibi scan (a test that looks at perfusion of the heart itself), but they are completely normal. The differential diagnosis now consists of a PFO (patent foramen ovale, a hole between the two sides of the heart) or hypertrophic cardiomyopathy (muscular thickening of the heart). House favors the latter and has the team put Daryl on a treadmill to stress him until he develops cardiac symptoms. Unfortunately (or fortunately, really), Daryl is in good enough shape that his heart rate never rises high enough to cause a problem. Going for “plan B”, House decides to chemically induce heart stress by injecting Daryl with a vasodilator (such as adenosine or dipyridamole — they mimic the effects of exercise on the heart). Before he injects the medication, however, he notices that the palms of Daryl’s hands are unusually white.

This new symptom causes the team to reassess their diagnosis. Taub thinks Daryl’s pale hands are due to Raynaud’s phenomenom (spasm of the smooth muscles around the small arteries of the fingers), which he thinks is caused by rheumatoid arthritis. Thirteen suspects that Daryl has plaques in his arteries, and these are breaking off and sending tiny clots blocking the arteries in his hands. Chase believes Daryl has Takayasu arteritis (inflammation of the aorta and other large arteries), and Foreman, ever the optimist, blames lymphoma. House likes the last two ideas the best, and tells Foreman to put Daryl on an ethanol drip. If he develops itchiness, it’s a sign of lymphoma, and if he loses his radial pulses, it’s a sign of Takayasu. Daryl develops itchiness while on the drip, so Foreman’s suspicion of lymphoma appears to be correct. Daryl is taken to surgery for a splenectomy, but during surgery Chase notices that his spleen is fine but his liver is inflamed.

Biopsies reveal no lymphoma and a non-specific liver inflammation. The new differential diagnosis includes polymyositis (a chronic inflammation of the muscles), Felty syndrome (rheumatoid arthritis + splenomegaly, which doesn’t fit at all), and viral hepatitis. Blood is drawn for further testing, but Foreman reports that the blood clotted almost immediately after being drawn. This suggests that Daryl has cryoglobulinemia (abnormal proteins in the blood that thicken with cold temperatures), brought on by football practice on cold days, and needs to be started on anticoagulants (blood thinners). This isn’t good enough for Daryl; he doesn’t want to miss his shot at the pros, so he leaves the hospital, promising to come back the next day. At the exhortation of Daryl’s mother, Foreman tags along to look after him — it was a good thing he did, too, as Daryl starts to experience shortness of breath and blurry vision. He is admitted back to the hospital. As the team begins to evaluate the new symptoms, Foreman admits that their really aren’t any new symptoms. He had dosed Daryl with nitrates (a class of blood pressure medication) to drop his blood pressure so he’d feel bad enough to want to come back to the hospital.

Looking over the chart, House notices that Daryl has only lost one pound during his stay in the hospital and he should have lost more. This lack-of-weight-loss could be due to steroid abuse, or paraneoplastic syndrome — only there’s been no evidence of cancer. The team performs blood test after blood test, and scan after scan, but can find no cancer. House then realizes that the cancer they are looking for is not inside the body, but outside. It turns out that Daryl has melanoma, a skin cancer hard to spot on African-Americans, and this cancer (or course) is causing paraneoplastic syndrome, which explains his symptoms.

(Here’s my take on what’s going on: you may have noticed during the episode that the team gave two different definitions of paraneoplastic syndrome. First, they described a situation where a cancer produces a hormone which can cause systemic effects: in this case, the melanoma is apparently producing GnRH which increased Daryl’s testosterone and gave the appearance and symptoms of steroid abuse including “roid rage,” weight gain, and probably the heart symptoms. Second, House describes paraneoplastic syndrome as a situation where the body is making antibodies against the cancer, and this produces the systemic effects. This would explain the kidney failure and liver inflammation. The apparent cryoglobulinemia may be an effect of the extra paraneoplastic antibodies, or cryoglobulinemia can occur with certain cancers. Both definitions of paraneoplastic syndrome are correct, but I’m not certain if a patient would ever experience both situations.)

I admit that I’m somewhat confused by House’s take on steroids. If Daryl was taking steroids, his GnRH should be suppressed — lower — not higher. Or is House suggesting that Daryl was receiving GnRH itself, or a synthetic substitute — and if that’s the case, the body generally downregulates GnRH receptors when GnRH levels are unusually high, actually leading to hypogonadism and less testosterone.

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

The clotting in cryoglobulinemia resolves at normal temperatures, so why would Daryl be clotting in the presumably warm hospital room. Did Princeton-Plainsboro not pay the electric bill?
Why didn’t he show abnormal clotting during surgery as most operating rooms are kept PDC (pretty damn cold).
Surely they drew blood before surgery, at least a blood type/transfusion panel, and should have notoiced the clotting then.
Blood thinners are not the recommended treatment for cryoglobulinemia.

Giving a patient enough of a nitrate to intentionally cause hypotension (low blood pressure) is dangerous. How did Foreman know he didn’t give too much? I’d also expect Daryl to develop a severe headache — the most common nitrate side effect – before any other symptoms.
I guess he learned it from House, who was trying to induce a cardiac event in a patient without even having him hooked up to any cardiac monitors.

Stress tests aren’t used to test for hypertophic cardiomyopathy, at least not as a first-, second-, or even third-line test. An EKG has already been obtained. A structural test, such as an echocardiogram or MRI is the next logical step. If needed, cardiac catheterization may also be performed.

Sorry Taub, steroid abuse can cause heart problems, including tachycardia.

Is there really a link between repeated trauma and pituitary adenoma, a type of cancer? I haven’t been able to find one, but then again, I’m not a neurologist or sports medicine specialist.
GnRH is released into the pituitary, not from it, so why would a pituitary cancer lead to “leaking” GnRH?

There is a condition known as the “lymphoma itch” that is a severe itching, primarily of the lower extremities. It is most commonly seen in Hodgkin’s lymphoma, but even then it only occurs in 10-25% of patients.
It is not associated with alcohol. A separate condition (severe aches and pains) can be worsened by alcohol intake in certain patients with lymphoma.

I don’t know it alcohol will really shut off blood flow in the radial arteries in patients with Takayasu’s arteritis, but who in the hell would thank that is a good idea. Personally, I like my hands to have full blood flow, thank you.

Return to full contact football a day after abdominal surgery, even a laparoscopic one? Nonsense.

Blood in the urine is really not a sign of kidney failure. It suggests that there is a problem with something farther along in the urinary system. This is especially true in patients on blood thinners, were urinary bleeding is more common – maybe from inserting the catheter in the first place.

Why would a melanoma secrete GnRH?

It is certainly possible to have rheumatoid disease with a negative rheumatoid factor.
Wasn’t Chase the one who shot down Taub’s suggestion of rheumatoid arthritis? So why would he later suggest Felty’s, which requires rheumatoid arthritis?

Paraneoplastic syndrome has become the lupus of this season.

I found the medical mystery interesting this week. Not great, but better than recent episodes. I give it a B+. The final solution clever (hidden melanoma in a black male), but too much of “Been there, got the T-Shirt” feeling (paraneoplastic, again, and a nearly impossible one at that). I give the solution a C-. Overall, the medicine was more driven this week, and followed a logical progression, but too much of it was questionable or downright wrong. Another C-. The soap opera was decent. I liked the Foreman and Foreman scenes, and the Wilson/House scenes were good, but I figures Lucas was the culprit fairly early on as Mark Michael Weston was listed as a guest star, but nowhere to be seen. I give the soap opera a B.

The House Challenge scores have been posted here.

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

Bunches of high scores this episode, thanks to this year’s ubiquitous diagnoses: paraneoplastic syndrome and “lymphoma.” TRad led this week with 18 points.

Overall, TRad and Noether increase their dominance, with 77 and 75 points, respectively. Theta Sigma stays in third with 57 points, and Corien retains fourth with 54 points. The Erskine holds on to fifth with 52 points.

Click here to see the full scoreboard.

Volume Four of Apothecarius Argentum moves the action from Beazol to the neighboring kingdom of Navara, a poor and starving country with a widespread wasting disease brought on by overuse of a toxic pesticide. Princess Primula and her companions, including friend/love-interest/Royal apothecary Argent and his rival, Lorca, third Prince of Navara.

The storyline revolves primarily around royal intrigue, including a sequestered king, a kidnapped heir, and stirrings of rebellion.

There is not as much medicine in this volume as previous ones, which makes sense as Argent does not play as large a role in this storyline. Several medical errors crop up in this volume, which is unusual, because author Tomomi Yamashita, a pharmacist by training, is usually very careful about his medical references.

There’s probably a spoiler or two in the annotations, so consider yourself warned.

Belladonna
The young prince has been suffering from seizures and was given belladonna to treat them.

Belladonna is a plant that has a long history of use in traditional medicine and continues to be used, to some extent, in modern medicine as well. The plant is very potent and must be used sparingly because of the high potential of adverse events, especially death. This is especially true for children (especially sickly malnourished ones like the prince). Let me put it this way: the more common name for belladonna is Deadly Nightshade.

Historically, while belladonna has been used to treat a variety of different ailments, it has not been used to treat seizures. The only mention I’ve even seen of the use of belladonna for seizures comes from homeopathy, which is not traditional medicine — or really any sort of medicine at all (despite what its practitioners would like you to think); homeopathy can best be described as a delusion combining sympathetic magic, wishful thinking, and an early-19th century understanding of science.

Belladonna contains several potent chemicals, most notably atropine, scopolamine, and hyoscyamine — all drugs that are used today. Belladonna extract itself is still used in a few modern medicines, Donnatal (a stomach medication) is probably the best known.

Dandelion
The prince has been given an overdose of belladonna, and Argent gives him dandelion extract to correct it.

Argent is correct that belladonna is excreted almost entirely through the kidney, so increasing kidney function should get rid of the medicine faster. Diuretics (drugs that increase urine output) are one way of doing this. Dandelion has long been used as a diuretic. While I have seen no recent studies or reports that confirm its benefits in this regard, I’m willing to give the plant the benefit of the doubt because the effects of a diuretic are hard to miss (if you pee a lot, it’s a diuretic).

Activated Charcoal
Activated charcoal is used again to treat the chronic wasting disease that is common in Navara. I covered this in depth in the Volume 3 annotations.

Cochineal
The cochineal is a tiny insect (Dactylopius coccus) that grows on cacti in Central and South America. When the females of the species are collected, dried, and crushed they produce the brilliant red dye carmine which is used for coloring fabrics, cosmetics, and food.

It takes 70,000 insects, all collected by hand, to make a pound of dye, which is worth about $36 in today’s market.

Prince Lorca mentions several times that the insects grow on citrus, but they don’t — they can only live on certain species of cactus. I wonder if this might be a translation error, either in the translation of the manga, or from the author’s original sources. (There is a similar insect known as “Polish Cochineal,” and while it doesn’t grow on cacti, it doesn’t grow on citrus either.)

Marijuana
The story mentions a link between marijuana use and psychiatric disease. There haves been several studies that have looked at this very subject, but the results have been unclear. Can marijuana use lead to psychiatric illness, or do people with pre-existing psychiatric disease tend to use marijuana more? Studies have suggested both results, so just leave this one as “undecided.”

Is it possible to die from a marijuana overdose? Again, sources vary, but almost all seem to agree that it would take an incredibly high level of exposure to be fatal, and many experts suggest that it would be physically impossible to achieve this high a dose. (On the other hand, with incense burning in a sealed room with heavy curtains, I suspect the king suffocated to death when the incense used up all the oxygen).

Does Godwin’s Law apply to television shows? Actually, though the science was questionable, I thought the storyline was sufficiently creepy to be a good episode overall.

The Plot: At a wedding, the groom’s grandmother notices someone standing in the back who alarms her. As she moves to confront him, she starts gasping for breath, turns an ashen gray, and then collapses, dead. Soon, other members of her family start dying as well – fourteen total – and the Fringe team is called in. After examining the corpses, Walter and Peter declare that everyone has died of asphyxia (suffocation). Agent Dunham notices a tattoo on the grandmother’s arm that indicates she was a concentration camp survivor. Poking around the church, they find the groom, still alive, but gasping for air. He dies at their feet, bringing the death toll to fifteen.

At the lab, Walter starts his autopsy of one of the victims and notices that the blood is a deep blue (Prussian blue, perhaps?), indicating some form of toxin exposure. The team also realizes that everyone who died was a blood relative and a direct descendant of the grandmother. Re-examining the church, Peter finds a candle that is different from the others and brings it to Walter. A quick run through the lab equipment shows that the candle contains some sort of cyanide compound. Walter suspects the deaths at the wedding were an experiment by the murderer to see if his toxin would work, and predicts that he will strike again soon. Sure enough, in a similar episode, nine people die in a coffee shop. The connection this time is that they all have brown eyes.

Back at the lab, Walter has isolated the toxin and shows how it can be set up to target different proteins, depending on who the murderer wants to kill. He points out a carbon chain on the toxin that he claims in the creator’s “signature.” When Peter remarks that it looks like a seahorse, Walter realizes that the poison was created by his own father who had been a scientist in Berlin until fleeing in 1943 (his nickname was “seahorse”). He has kept his father’s formulas in some old German books, Peter sold them ten years ago when Walter was in the asylum. It all turns out to be a red herring though, as they are not connected to the mysterious murderer.

Meanwhile, Walter has managed to get a partial DNA profile of the killer from skin cells left on a fingerprint. He claims that it’s a bad sample though, because the telomeres are severely damaged, suggesting that the person must be at least one hundred years old. The FBI is able to track down the chemicals used in the making of the toxin, and get the killer’s address. They search the house (poorly), but find nothing, as their target is at that very moment escaping from his lab in the basement. Eventually, Agent Dunham finds the basement lab, but the killer has set a trap for them, with some of the toxin specifically targeted to Walter. Luckily, Dunham and Peter get Walter to medical care in time, and he survives. A clue (found by Dunham even) tells the team that the killer has his sights set on a World Tolerance conference going on in Boston. Peter, Dunham, and the FBI head over to the conference to look for the killer. Walter stays behind, mixing up something in the lab, and then he heads over to the conference himself. Peters spots the poison and he and Dunham are able to confiscate it before it can be activated – but they are interrupted by a horrible coughing sound and rush over to find the killer, disguised as a waiter, gasping for breath and dying. Walter has turned the tables on him and made a version of the poison specifically tuned to his DNA. As the episode ends, Peter and Walter are still puzzled how the murderer got his hands on Walter’s father’s research, not realizing that the killer was a Nazi scientist himself, somehow still alive sixty years later.

1. Stay on Target
According to Walter, the toxin binds to a particular protein, and this protein can be altered depending on who the target. Unfortunately, the Nazi scientist’s poor understanding of molecular biology has doomed more people than he realizes. For instance, there is no protein specific to brown eyes. Brown eyes simply have more melanin than other eye colors — but the other eye colors still contain melanin. Everyone in that coffee shop, including the Nazi, should have died. Similarly, there is no special protein in dark skin that sets them apart — people with darker skin simply have more melanin than lighter skinned people. Trying to kill off the darker skinned people would have killed everyone — well, except the albinos. Good job, Nazi scientist. Now the albinos rule the world.
Suddenly, in a virtual deus ex machina, the toxin can be programmed with a specific DNA — even though Walter made it point, repeatedly, to mention that it was created before DNA was understood.
Even if the poison could target DNA, how are you going to get that big of a molecule into the nucleus of the cell, let alone through the cell membrane?

2. Those Who Do Not Know History…
Walter is off on his history: the discovery of DNA predated the Nazis, not the other way around. DNA was discovered in the middle of the 19th century, well before the Third Reich. By the 1920s, there was strong evidence that DNA was involved in inheritance, with the first definitive experiment performed in 1943. Walter is probably thinking of Watson and Crick’s famous work on the structure of DNA, which was published in 1953.

3. Sure Hope He Never Testifies in Court
The signs Walter mentions — petechiae, bulging eyes — are seen in asphyxia caused by strangulation (they are related to increased venous pressure in the head from the compression of the blood vessels in the neck), not by asphyxia due to toxin inhalation.
Can the vitreous humor, a gel-like liquid, really swell?

4. How Dare You Kill People With My Dad’s Poison!
Walter was upset that the murderer was “perverting” his father’s work, but let’s not forget that his father’s work was a nasty chemical warfare agent.

5. It Is Impolite To Inquire As To A Telomere’s Age
Telomeres are special DNA sequences on the ends of chromosomes that keep it from breaking down or fraying. There has been some good research suggesting a link between aging and the break down of telomeres. Still, it’s a dubious stretch to tell someone’s age from looking at their telomeres.

6. Nasty Poison
Hydrogen cyanide can kill remarkably fast, depending on its concentration.

6. Comes With A Certificate of Authenticity
That seahorse “signature” is so incredibly bulky and large that it would interfere with the biological activity of the toxin. Plus, it’s bad planning because it provides an easy target to identify and develop an antibody against.

7. Two Puffs Four Times A Day
A nit-pick here, but the groom sure has poor inhaler technique (but then, so do many of my patients — and a quick Google search reveals that much of the internet has a similarly poor understanding.) The inhaler should be held an inch or two in front of the mouth, not actually in the mouth.

The science was quite questionable this week, but I thought the story did a good job keeping the suspense going — and the Nazi scientist was truly creepy — so it’s a wash and the Doomsday Clock stays at 11:58.

Tags: television fringe toxin nazi cyanide

Another DC Comics Public Service Ad teaching about science — this time the topic is “The Atom” — more specifically radiolabeling (using radioactive isotopes to mark certain chemicals, which can then be traced), since that is what most of the vignettes depict.

As usual when dealing with these science PSAs, I have some questions and concerns:
Did the Brazilian doctor use radiolabeling to find the tumor (such as a bone scan or PET scan), or did he use radiation to treat it?
By 1959, there was already a Yellow Fever vaccine available, which would probably do more to eradicate the disease than making radioactive mosquitoes (wasn’t that a SciFi SyFy movie?)
The fourth panel is what really worries me. I think they’re using radioactive fertilizer in Canada to grow mutant tobacco plants.

Click on the image for the full ad

This PSA was found in Batman #128 as well as the other DC comics from December 1959. This ad was written by Jack Schiff. There is some debate about the identity of the artist, but most sources list Lou Cameron.

More PSAs

Tags: comics psa atom isotope mosquito jack schiff lou cameron

This episode was better than last week’s pathos-fest, but it was still lacking in the medicine department.

Valerie is a 27 year-old ruthless business woman who experiences the sudden onset of severe bilateral ear pain. She is admitted to House’s team, even though he finds her case uninteresting, because she is “hot” and yet has an ugly husband. Chase suggests that due to a recent dietary change, Valerie may have a vitamin deficiency which is causing her symptoms. House thinks that her change in diet may have boosted her already elevated cholesterol, leading to blocked arteries, heart damage, and an arrhythmia (abnormal heart rhythm) which she experiences as ear pain. Testing shows no evidence of blocked arteries, but it does confirm an arrhythmia. The team plans to start her on unspecified “cardiac medications.”

An ex-coworker of Valerie’s appears in her room, drunk, and accuses her of having an affair with him and later poisoning him to cause him to lose his job. She denies these accusations and security escorts the man out. The male members of the team jump to her defense, but Thirteen thinks that Valerie is up to something. When the team discussed the situation with House, he suggests that she may have been poisoned with thyroid medication, which would rev-up her heart and cause the arrhythmia. House and Foreman want her started on beta-blockers (to block the effects of the thyroid medication), but Thirteen sneaks her off to the MRI suite. Her testing reveals that Valerie has no emotions and is by definition a psychopath. Confronted later, Valerie admits to everything Thirteen suspects. All that her co-worker said is true — she slept with him and then poisoned him. She also admits she only married her husband for his trust fund.

Taking both the heart and brain symptoms into account, the new differential diagnosis consists tertiary syphilis (late stage syphilis where mental symptoms are common), Wilson’s disease (a disease of copper metabolism), and Hashimoto’s thyroiditis (autoimmune inflammation of the thyroid gland). The first seems the most likely, so they start Valerie on penicillin. There is a heated discussion between Valerie and Thirteen, and when Thirteen reaches to turn over Valerie’s arm, she breaks it. Further testing reveals elevated BUN (blood urea nitrogen) and creatinine levels which suggest kidney failure, which would explain the brittle and easily-broken bones.

House now feels that the Valerie’s psychopathy is something she was born with, and not a symptom of her condition. Focusing on the heart and kidney symptoms, Foreman suggests that she has paraneoplastic syndrome, likely from a lymphoma. House orders full body radiation therapy. Thirteen wants to run some tests first, but Foreman shoots her down.

There are more confrontations between Valerie and Thirteen, with Thirteen’s “innocent” questions lead Valerie’s husband to realize she’s was having an affair, and Valerie reporting her to the medical board. Eventually, Thirteen is removed from direct patient contact with Valerie, but Cuddy explains is it because Thirteen does not deserve to have Valerie inflicted upon her.

Valerie starts bleeding heavily from her mouth due to esophageal varices (enlarged, bleeding esophageal veins related to liver disease). She is taken to the operating room for a TIPS procedure (transjugular intrahepatic portosystemic shunt) — placement of a stent which bypasses the liver, relieving the elevated blood pressure in the liver which lead to the varices. This new symptom causes the team to reevaluate their diagnosis, and this time they consider and discard amyloidosis and alpha-1 antitrypsin deficiency before settling on primary hepatic fibrosis (fibrosis of the liver not due to another disease). She is started on steroids and a search begins for a liver donor for transplant. Thirteen talks to Valerie’s sister and learns that she wasn’t always a psychopath — that started during her teen years. This suggests that the psychopathy is a symptom of her condition, and not something that can be overlooked. Thirteen and House realize that she must have Wilson’s disease, which is confirmed by looking at her fingernails which are blue. She is started on chelation therapy to remove the excess copper. By the end of the episode it seems to be working

Those of you who read comic books will know what I mean when I say that the medicine of this episode was the television equivalent of a Mark Millar comic: a bunch of dramatic set pieces connected by sketchy plotting and poor logic. Sudden ear pain (hand waving) It’s her heart! (hand waving) Oh no, kidney failure! (hand waving) It’s cancer! (hand waving) Now it’s liver failure (hand waving) Wilson’s disease and presto! Iit’s cured, and now the world is safe for democracy.

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

You do not treat a patient for cancer — be it radiation therapy or chemotherapy — without knowing what sort of cancer it is first. Different cancers have different treatments. Even if it is a B-Cell Lymphoma, there are over a dozen different cancers of that type, and only some are treated with radiation therapy. This seems to be a recurrent mistake this year.

Her kidney failure is so bad that her bones break that easily and she’s stopped producing urine and nobody noticed?
There’s no way it took that long before they checked her BUN/Creatinine. They would have been checked before running any card