Polite Dissent

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

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 in 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)

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).”

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.

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:

Surgeons and apothecaries, who have served an apprenticeship to those trades, shall be allowed,
For every visit, and prescription, in town, or within 5 miles	5 shillings
For every mile, above five, and under ten	1 shilling
For a visit, of ten miles	10 shillings
And for every mile, above ten	sixpence
To Surgeons,
For a simple fracture, and the cure thereof	2 pounds
For a compound fracture, and the cure thereof	4 pounds
But those persons who have studies phisic in any university, and taken any degree therein, shall be allowed,
For every visit,and prescription, in town, or within 5 miles	10 shillings
For every mile, above five, and under ten	1 shilling
For a visit, of ten miles	1 pound
And for every mile, above ten	1 shilling

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.

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.

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.

This week’s Fringe cipher was: REVEAL.
A list of all previous Fringe reviews is available here.
Karl has much more to say.

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.

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.

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 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.

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.

This week’s Fringe cipher was: FATHER.
A list of all previous Fringe reviews is available here.
Karl has much more to say. And he’s still talking about it a week later.

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.

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 cardiac artery testing to make sure her kidney could handle the dye.
Similar arguments for no one noticing her chronic liver disease bad enough to cause bleeding varices.

Wilson’s disease should have shown up on the MRI. You know, the one they used to dismiss the diagnosis of amyloidosis.

She sure improved from her fifteen years of Wilson’s disease improbably fast, especially her psychiatric symptoms.

A paraphrase:
Thirteen: If she has Wilson’s, why doesn’t she have Kayser-Fleischer rings?
House: Notice how I avoid answering — or even acknowledging — your question by distracting you with another symptom. Aren’t I (and by extension, the writers) clever?
(House could have just said that KF rings only occur in 2/3 of the patients with Wilson’s. Blue nails [azure lunula] are certainly seen in Wilson’s, but less commonly than KF rings).

Technically, Broca’s area is only on one side of the brain, it is not bilateral.

I suspect the fingernail polish under the pulse-ox (oxygen monitor) had already been wiped off – the monitors work a lot better that way.

The team never “ruled out” Wilson’s, they just focused on the tertiary syphilis instead.

The medical mystery was modestly interesting, but quickly forgotten and ear-pain was never again mentioned after the seven minute mark. It deserves a B. The final solution was a bit of a stretch, but actually fit fairly well (especially if you ignore the whole “chronic” aspect of the disease). It also earns a B. Overall, the medicine was spotty, with the team missing things an intern would have noticed. I give it a B-. The soap opera was light, but generally well done. I thought Olivia Wilde held up her end better than expected, but I’m surprised House never ran any sort of background check on his classmate. I give the soap opera a B.

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

Higher scores this episode, thanks to some old friends including syphilis, paraneoplastic syndrome, and amyloidosis. Theta Sigma and The Erskine led the week with 18 points each.

Overall, TRad continues to lead with 59 points. Noether remains in second, but moved in closer with 58 points. Theta Sigma moved into third with 45 points, and Corien drops to fourth with 42 points. The Erskine and atg round up the top five (err, six) with 39 points.

Click here to see the full scoreboard.

The plot of this episode of Fringe was, at best, so-so. They could have at least played up the “trapped in a building with a possible killer” angle. The science — and it’s generous calling it that — was painfully bad.

The Plot: In a large office building in Boston, a man walks into the office of a petroleum corporation, then drops dead, with his last breath spraying a fine mist of blood on all around him. Given the strange nature of the man’s death, the Fringe team is called in. Peter and Olivia arrive first and are interviewing bystanders. Walter, Broyles, and Astrid are on their way into the building, when one of the people exposed to the dead man’s blood comes walking toward the door, as fast as he can. Walter quickly shuts the door before the man can escape, and the man dies, spraying blood against the closed door. Fearful of an unknown contagious disease, the CDC is called in and the building quarantined — with Peter and Dunham still inside.

Some blood samples are obtained, and Walter takes them back to his lab. In the office building, the receptionist falls ill. Doing a little detective work, the team determines that the first dead man was a corporate spy from Dubai who was selling information on the peteroleum company’s competitors. The ill receptionist becomes frantic and violent. She scuffles with Peter, then jumps through a window, plummeting to the street below, dead. Unfortunately, Peter has been exposed to infected blood and now may be infected himself.

Inspecting the car of the corporate spy, the FBI and Center for Disease Control (CDC) find a core sample from 10 miles down that he was trying to sell. They also find the mysterious virus behind the outbreak contained within the core sample. Walter speculates it is 75,000 years old and was responsible for killing most of the mammals on Earth during the Ice Age (as opposed to the ice and cold). From this virus, Walter is able to concoct a test to determine who is infected and who isn’t. Walter believes that the virus has human-level intelligence and is purposefully acting to infect as many people as possible. He and Astrid enter the office building and test the staff. Most are not infected. Peter is showing signs of infection, but through sleight of hand, makes sure he has a negative test. The people who tested clean are escorted out of the building — except Peter. The guard at the door (a competent FBI agent at Fringe?) notices he has a nosebleed and keeps him in quarantine. In the end, eleven infected individuals remain in the building. Walter and Astrid also elect to stay.

Walter deduces that sulfur is a cure for the virus and relays the information to Dunham. Meanwhile, the CDC has called in the US Army to “take care of” the people remaining in the building. Dunham and Broyles ask for more time to synthesize Walter’s cure. Broyles suggests pumping the building full of Fentanyl gas (a strong narcotic) to knock everyone out and buy time. Dunham volunteers to enter the building and turn the HVAC back on. She scuffles with an infected Peter but succeeds in her mission. All the infected people are knocked out, Walter’s cure is made, and everyone (well, except for those already dead) survives.

1. I Give Him Credit For Trying
I applaud the bike messenger for attempting CPR (even if it was the 5 compression/1 breath technique that is not recommended anymore), but give it some time before you declare the guy dead. Ten compressions doesn’t cut it. At least continue the CPR until the EMTs arrive.

2. You Know What They Say About “Assume”
Walter believes the virus is transmitted by bodily fluids. How does he arrive at this conclusion? Certainly blood transmission seems probable, but how does he know about other bodily fluids? Is he surreptitiously testing saliva and semen?
He claims the virus is not airborne, or more people would be sick. How is he so sure about the incubation time? Maybe more people could be sick than he knows, they’re just not showing it yet. Sure, the bike messenger fell ill fast, but how do you know he was not exposed before (maybe the Dutch guy wasn’t patient zero), or maybe the messenger had a weakened immune system and succumbed faster than normal. Walter is making way too many assumptions.

3. Do You Even Know What You’re Testing For
There are way too many problems with Walter’s test.
Why the cheek swab? That’s used for DNA samples. Is he saying the virus can be found in the DNA of cheek cells?
Most viral tests look for antibodies against the virus — they’re a lot easier to develop. Of course, it usually takes several weeks for these antibodies to appear. There are some tests that look for the actual virus, but I don’t care how much of a genius Walter is, he couldn’t have cobbled one together so fast, or made enough of it to test the entire office building.
Most importantly, there was no prior testing to determine the false negative/false positive rate of Walter’s test. No test is 100% right all the time. They are risking everybody’s life on an unknown test.
Then Peter’s test was negative but he clearly was infected. We the viewers know he faked the test swab, but the characters don’t know that. Their first thought would have been: “Peter’s test was negative, but he has the disease. How many of these other people we let outside also had false negative tests?” And then they would have hustled them all back inside and left them there.

4. If Only My Labs In College Were This Easy
The scene in Walter’s lab was laughable.
No protective gear.
Isolating a virus in a test-tube using a centrifuge (and using it poorly) would never work. It’s not even close to being right.

5. Down In The Hole
Admittedly, I’m not a geologist, but how does 10 miles down equal 75,000 years. I would think it would be a lot more (years) than that.
The virus lived 75,000 years without a host — that’s impressive. Plus this virus can apparently be visualized without an electron microscope.

6. It’s A Gas
Fentanyl gas has been used at least once before to subdue a building full of people. In this case, it was a hostage situation in Russia with Chechnyan separatists. The Fentanyl didn’t work as well as expected and actually killed 117 hostages. In situations like that, it’s hard to control the inhaled dose — and Fentanyl can kill at the wrong dose. Plus, a fair number of people are allergic — fatally allergic — to narcotics.

7. Dire-Swine Flu?
Neuraminidase inhibitors are used to treat influenza viruses and … that’s about it. So this is a flu virus now

8. Eli Lilly Is Spinning In His Grave
In vivo does not equal in vitro. In other words, what works great in a test tube often doesn’t turn out to work so well in an actual living organism. If creating a new drug were as easy as Walter makes it out to be, we’d be neck deep in fancy new medications and the pharmaceutical companies wouldn’t be laying off people left and right.

9. Not So Smart, Is It?
If the virus really wanted to infect as many people as possible, why not infect the airplane instead of an office building? Those people would be in an airport and then other planes, not trapped in a building.

8. Nice Try, But…
The US Army is not authorized to act on US soil. National Guard, maybe.

9. Georgia On My Mind
I’m not sure of the actual powers of the CDC in a situation like this, but this seemed unrealistic to me. Their response was incredibly fast and a lot like a sledgehammer. I’m not saying the CDC isn’t fast — they are easily the best in the world at what they do — but they’re not that fast. And they actually do research, rather than just shoot people. Wait, was that a knock at the door?

I thought last week’s science was bad, but this was even worse. I have no choice but to move the Fringe Doomsday Clock forward two minutes to 11:58.

This week’s Fringe cipher was: WINDOW.
A list of all previous Fringe reviews is available here.
Karl has much more to say.

Apothecarius Argentum is a manga series written by a trained pharmacist, so while the setting is a fairly generic medieval kingdom, the medical aspect is well done and based on both Eastern and Western medical traditions. Volume Three covers chapters 9 through 12 of the overall story. Volume One (part 1 and part 2) and Volume 2 annotations are also available.

Beazol is a small prosperous kingdom ruled over by a wise but very stern king. His only child, the princess Primula, is slowly coming into her own as a leader. Her closest companion is Argent, the royal apothecary (healer). He is a basilisk, a member of a secret society who has been purposefully exposed to various poisons since an infant. This renders him immune to toxins, but his skin also excretes a deadly poison, so he cannot touch anyone else.

In this volume, Lorca, the youngest son of Navara, the next kingdom over, comes to Beazol to woo Primula. He is sickly, but very devious -– quite the contrast to the straightforward Primula and Argent. Just as Argent is an expert on medicinal plants and herbs, Lorca is an expert on insects, especially beetles. The volume starts in Beazol, but then the action moves to the famine-ridden country of Navara.

Read more…

Not the best episode of Fringe. The storyline was pretty cliche (the sheriff involved, really?) and the science was wrong, wrong, wrong.

The Plot: A state trooper picks up a young boy running away from home. A few minutes later, he looks over at his passenger and discovers that the boy has suddenly become horribly deformed. The trooper arrives at the station and he and two coworkers photograph the child and enter him into their database. They all mention that they’ve heard rumors of deformities such as this, but never actually seen one. Suddenly, a car pulls up and three adults, all as deformed as the child, enter the station and kill all the troopers, reclaiming the boy.

The Fringe team is called in because of the picture of the deformed boy. Looking through other files at the station, the team finds thirty years worth of similar reports, though no actual evidence, all centered on the nearby town of Edina. Deciding that it’s their next logical stop, the team heads over to Edina where they meet the local sheriff. He tells them he’s also heard stories of deformed people nearby, but never seen one. He also identified the sound the team has heard since entering the town as the “Edina Hum” – which he blames on turbines at a nearby military base. Strangely, the hum causes Walter to start singing nonsense words to Bizet’s Carmen.

As the team heads out of town back to their hotel, they are run off the road by a pick up truck. Dunham was knocked out by the crash but Peter stayed conscious. Walter is blissfully asleep in the back seat. The pickup that ran them off the road comes back and a deformed men gets out and starts shooting at the wrecked car. Peter gets off a couple of shots, and actually thinks he hits the shooter, before he gets back in his truck and drives away. Other federal agents arrive and inform the team that they’ve found an abandoned truck that matches their description. Peter spots a blood trail leading into the woods, and they find a dead man –- but he’s not deformed at all. The corpse is sent to Walter’s lab for autopsy.

Agent Broyles tells the team that the nearby Army base was once home to classified experiments known as “Project Elephant” back in the ‘70s. Meanwhile, in Walter’s lab, when the body bag is opened, the corpse has become deformed once again. Walter continues to sing Carmen and Astrid realizes that the song is really a mnemonic for “Harkness,” which Walter recognizes as the name of the campus’s law library. Furthermore, he remembers that he did work on “Project Elephant” –- which dealt with camouflage — and hid some papers in the library, which he and Astrid successfully recover.

Peter and Dunham are going through the county and federal records on the town of Edina and realize that several key files are missing. The census date shows the town population has only changed by deaths and a few births — no one has moved in or out of town in the past thirty years. The town sheriff calls to tell Dunham that he has located the owner of the truck and wants Peter and Dunham to join him at the subject’s house. They agree, unaware that the sheriff is setting a trap for them.

Walter tells Astrid that the people of Edina are all hopelessly deformed because they lived too close to the military experiment. However, in order to help the people of Edina, one of the scientists built a giant transmitter that sends out powerful EM waves which fool the eyes into thinking what they see looks normal. Thus, as long as the residents stay within Edina and range of the transmitters, their deformities are hidden. When they leave town, their deformities can be seen again. Walter and Astrid find the transmitter and shut it off, proving his theory, as all the deformities are suddenly clear. Across town, the sheriff is not particularly good at his ambush and loses a few men, but he ultimately gets the drop on Peter and Dunham. Luckily, one of the town’s residents – sick of all the death of innocents – steps up and shoots the sheriff, saving the team. In the end, the transmitter is left on for the residents and it is decided that no one outside of the Fringe team and the residents will learn the truth about Edina.

2. Are You Still Rose or Am I Hitting on Susan?
For the sake of argument, let’s say that the EM camouflage does work. How would it remain constant from person, to person, time to time? I see Rose as beautiful brunette instead of a Troma look alike. Does the person next to me see the same Rose as I do? If I leave town and then come back, does she still look the same to me?

3. A Window To the Soul (Kinda)
A Johari window is a cognitive tool that compares how we see ourselves with how others see us. It looks into four areas of personality: Arena (known to others and known to self), Façade (known to self but unknown to others), Blind Spot (known to others but not known to self), and “Unknown.”

4. God, that hand! The window! The window!
This is another episode this season (the third, I think) that had some definite Lovecraftian overtones, in this case “The Shadow Over Innsmouth”, about an isolated town with a deformed populace and a hidden secret.

5. Not What I Expect To See In a Corpse
Frankly, I’d expect histolysis (tissue decay) to be present in any corpse, not just shapechangers.

6. A Generation Unexplained
A germline mutation would be inheritable, but it wouldn’t have a tremendous (really any visible) effect on those originally exposed to the mutagen. So Teddy would be visibly deformed, but if Walter is right, Rose shouldn’t be.

Painfully bad science this week, the Fringe Doomsday Clock advance to 11: 56 (ironically, the real Doomsday Clock was moved back a minute this week)

This week’s Fringe cipher was: MUTATE.
A list of all previous Fringe reviews is available here.
Karl has much more to say.

A recurrent controversy on this blog has been whether Dr. Jericho Drumm (better known as Brother Voodoo) is a psychiatrist or psychologist. In various stories over the years, he’s been referred to as both (sometimes within the same comic). Calling him a psychologist occurs the most frequently, and that seems to be generally accepted. But is it true?

With the recent release of Doctor Voodoo: The Origin of Jericho Drumm, which reprints Brother Voodoo’s first appearance, the question can finally be answered.

So which is Brother Voodoo?

Here is his first appearance (as Dr. Jericho Drumm) and he is clearly identified as a “noted psychologist.” So that answers the question, right?

Not so fast. Here is Dr. Drumm a page later whipping out his stethoscope and tending to his dying brother. He even pulls out a syringe and medication to administer to him.

It seems that Brother Voodoo’s first appearance only complicates the debate. He is clearly identified as a psychologist, yet he is practicing medicine just a page later. I think it can be chalked up to yet another writer confusing psychiatrist and psychologist, an all too common occurrence. However, given that Drumm’s use of Western medicine is key to his character at this point in the story, I suspect the writer fully intended for him to have medical training, and therefore be a psychiatrist.

This was a Fringe episode left over from Season One that had never been aired — and it wasn’t a particularly good episode, but better than some that were aired. There was at least one good plot twist.

The Plot: Lisa, a seventeen year old high school junior has been declared brain dead after a cerebral aneurysm. Her life support is shut off and she is declared officially dead before being wheeled into the operating room to harvest her organs for transplant. Once the operation has started, she suddenly sits up, alive, and screams out a series of code numbers. It turns out the code refers to a naval officer by the name of Andrew Rusk — and he has been reported missing. The Fringe team is called in to investigate.

Lisa denies ever having met Rusk, but when his name is mentioned, she speaks a phrase in Russian which translates to “my (or ‘little’) star.” Lisa has developed a fever and the doctors are watching her closely. Her mother tells Agent Dunham that she doesn’t want the team questioning Lisa anymore when Lisa suddenly screams from the bathroom — when looking in the mirror she has seen the image of Rusk standing behind her. Walter hypothesizes that Lisa’s aneurysm affected Broca’s area, a part of the brain which controls language — and according to Walter — also controls psychic ability.

A little while later, Lisa calls Agent Dunham, telling her that she still is still seeing Rusk. She is at a junkyard, because she saw the image of it in her mind. When the Fringe team finds her, she tells them that Rusk was shot there. Sure enough, a 9mm casing is found and a short time later, Rusk’s body is found. Lisa has a sudden seizure and is readmitted to the hospital.

Walter deduces that Rusk’s death and Lisa’s rebirth occurred simultaneously, and somehow this allowed her to pick up his memories. Lisa’s mother allows Lisa to be taken to Walter’s lab to purge the memories.

Meanwhile, Dunham finds out that Rusk used to call his wife the Russian phrase “my star.” She also finds out that he was exposed to high radiation doses in a shipboard accident and was given an experimental radiation inhibitor.

Back at the lab, Walter hooks Lisa up to an EEG, pumps her full of drugs, and the team discovers that she doesn’t just have some of Rusk’s memories — his entire consciousness is sharing her brain. Rusk’s personality emerges when the drugs put Lisa to sleep. He is able to give the team enough of a lead to track down his killer — a former Navy SEAL. When the suspect is questioned by the FBI he admits that he killed Rusk, but he did it because Rusk was a wife beater — Rusk’s wife hired him to kill her husband. He tells the team that he mentioned this fact to Rusk before shooting him.

Rusk is still in control of Lisa’s body, but by pretending to be Lisa, manages to sneak out of the lab. He goes to his house and grabs his gun. He confronts his wife, but she denies having anything to do with his murder. He ties her up and is getting ready to start a house fire when Peter arrives, with the rest of the team following a short time later. Peter talks to Lisa/Rusk enough to distract him so that Charlie can shoot him with a tranquilizer dart. Further testing in the lab reveals that only Lisa’s consciousness remains within her mind.

2. Infection Control, What’s That?
Lisa has enough of a fever to worry her doctor, but is discharged the next day — and immediately returns to school and church? Where lots of sick people are? (Assuming she goes to church on Sunday, it seems impossible for her to have made it back to school. By my calculation she would have been discharged late Friday at the earliest.).

3. Total Nit-Pick About Balloons
Hospitals are picky about which balloons are allowed. The ones is Lisa’s room are not allowed due to concerns about latex allergy.

4. I Wish All Surgeries Were That Easy
Abdominal surgeries, even on dead people, are not that easy. The renal artery is way in the back and all the intestines have to be moved out of the way before it can be reached.

5. Seize Her
That was one of the more unconvincing seizures I’ve ever seen.
Speaking of seizures, while I agree with the hospital doctor that in most cases the cause of seizures are never identified, I would not so cavalierly dismiss the idea that it was related to her aneurysm. She had a recent bleed in her brain, and blood is a very irritating substance — not to mention the swelling from the injury — which is enough to set off a seizure.

6. Too Many To Choose From
It was nice of Walter to put her on 100 mikes (micrograms) of a benzodiazepine, but it would help if he told Astrid which one to use. He typically has used Valium, but the doses he is giving fits Versed better.

7. Too Late To Matter
With a dose of 600-1000 REM, Rusk would have had the initial symptoms of radiation poisoning starting shortly after exposure (mostly nasty gastrointestinal ones). His bone marrow would be dead and he would require a bone marrow transplant to have any chance of survival (and for the record, only one person has ever survived that dose of radiation).
Once Rusk was removed from the reactor, he was no longer exposed to the radiation — and since he is not radioactive himself (radiation doesn’t work that way) — giving a radiation inhibitor at this point is useless, like closing the barn door after the horse has left. There is no radiation left to inhibit. The damage has already been done.

8. Quickdraw McGraw
Intramuscular medications (like the tranquilizer dart) do not take immediate effect. The medicine must be absorbed into the blood stream and spread throughout the body — or at least reach the brain) before it knocks the victim out.

9. Enough Already, George Michael
Scientifically-based faith (e.g. I have faith the sun will rise tomorrow) is a completely different concept than religious-based faith and the terms are not really interchangeable.

Since this is not a current episode, it’s not going to affect the Doomsday clock — which is a good thing for the show.

A list of all previous Fringe reviews is available here.
As always, Karl has more to say.

This episode seemed like it was trying to be a cross between House and Brotherhood. A novel approach, but the medicine suffered for it.

In a dark garage, a drug deal is going down between two groups of mobsters. When one of them gets antsy and starts flashing a gun around, another of the mobsters jumps him. In the struggle, the gun goes off and one of the combatants slumps to the ground. It turns out he wasn’t shot by the gun — he just collapsed.

A little while later, House is sewing up the Mickey the mobster’s forehead laceration. Being quick on the uptake, House realizes what line of work his patient is in. He suggests Mickey stay in the hospital for a work-up, but he declines. As Mickey and his partner leave the room, House slams his cane into the table and the sudden loud noise causes Mickey to collapse. He gets admitted to the hospital after all.

House presents the patient to the team as a “32 year-old man who recently developed loud-noise induced vertigo.” There is no medical history as Mickey does not want to share anything. Foreman suggests the cause must be in the ear or brain, and since a brain CT scan was negative, it must be in the ear. He suggests an acoustic neuroma (a tumor of the eighth cranial nerve, the nerve involved with hearing). An ABR is ordered to test for the neuroma (An ABR — or Auditory Brainstem Response — is a hearing test that looks specifically at the nerve component of hearing. If you’ve seen a hearing test done on a newborn in the hospital, you’ve seen one of these) . House announces that the diagnosis might be lidocaine or benzocaine toxicity, as both chemicals are commonly used to cut cocaine.

While the team runs the ABR, House talks to Mickey’s partner Eddie who swears that Mickey never touches the cocaine. The ABR is normal, but Mickey has a seizure during the test, which Foreman announces must be due to his elevated blood pressure. Mickey is started on a vasodilator (a blood pressure medication that works by dilating — opening wider — his blood vessels) and his blood pressure improves. The differential now consists of sick sinus syndrome (the heart’s “pacemaker” isn’t working right), carotid stenosis (narrowing of the carotid arteries), or toxin exposure. A carotid ultrasound (to look for the narrowing) is normal. Figuring the cause must be toxin exposure, the team discharges Mickey with the plan of trailing him back to his hideout, but he manages to ditch them.

Mickey is brought back to the hospital several hours later delirious with a high temperature. He is given antipyretics (fever reducing medicine, usually acetaminophen [Tylenol]) and “soft steroids” (basically, a specially engineered steroid with less side effects. Sounds nice, but doesn’t really apply in this case. Technobabble) The differential diagnosis now consists of an environmental exposure (but House figures Mickey wasn’t out of the hospital long enough to be re-exposed) or an infection. A lumbar puncture is performed and shows no sign of infection. Chase notices that despite it being a poorly performed lumbar puncture (and therefore qutie painful) , Mickey’s heart rate never budged when it should have shot up with the pain. Chase suspects Mickey has autonomic dysfunction, but House doesn’t think the symptoms match. He confronts Mickey who admits that he’s been taking a beta-blocker (a blood pressure medication that slows the heart rate) for his nerves.

Given the symptoms of vertigo and fever, and Mickey’s high stress occupation, the team decides he must have “excess adrenalin” and probably has a pheochromocytoma (a tumor that pumps out high levels of adrenalin and similar compounds). An MRI of the adrenal glands is negative, ruling this out. Once again, the team decides the cause must be environmental. Meanwhile, House had bugged Mickey’s room so he could learn more information about his background, but the bug never worked well. Eventually, he realizes that something is interfering with it and suspects that it’s another bug in the room. Sure enough, he finds a second bug and deduces that Mickey is an undercover cop. He reluctantly admits that House is right. Suddenly, Mickey experiences severe abdominal pain. Later, Chase reveals that he suffered a GI infarction (the blood supply to the bowel was cut off, causing some of the bowel to die. Like a heart attack, only of the bowel) of the superior mesenteric artery, and a foot of his bowel had to be removed.

Reviewing Mickey’s symptoms of vertigo, fever, and clotting (the high blood pressure is discounted because it is felt to be a rebound high pressure from skipping his medications), the team decides yet again that it must be an environmental exposure. Thirteen leans on Eddie who agrees to take her to the hideout. It turns out to be a dry cleaners, and she takes multiple samples — but they all turn out to be negative. Just as the team is stumped, Mickey starts coughing up blood. A VQ scan (ventilation-perfusion scan) of the lungs shows a pulmonary aneurysm (a bulge in the blood vessels in the lung), which Chase surgically repairs, but the next morning, three more have appeared. House and team decide this must be a fungal infection and start Mickey on antifungal medication, but it doesn’t seem to be working. Totally out of the blue, House deduces that Mickey has Hughes-Stovin Syndrome, an autoimmune disease. Unfortunately, by the time it’s reached this stage it is fatal and according to House, Mickey has but a few days — or hours — to live. House’s prediction is true, and Mickey dies in the arms of his wife a little while later.

Lots of errors this week, and several big ones, too. As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

Hughes-Stovin Syndrome is not a good fit. True, once the aneurysms start rupturing the patients often die (but even then there are treatments that have been tried — sometimes successfully — and since when has House’s team just given up like that?)
The aneurysms do not appear overnight, but appear over time.
Hughes-Stovin Syndrome is associated with venous thrombosis — but the patient had an arterial thrombosis — a different animal all together.
There is a good chance the steroids given earlier would have helped the Hughes-Stovin Syndrome.

10-20% of pheochromocytomas occur occur outside the adrenal glands, so a negative adrenal MRI would not rule them out (especially in House’s world, where the uncommon is common).

The superior mesenteric artery is a major blood vessel and supplies much of the bowel with blood. A blockage in it would cause the patient to lose more than just a foot of bowel.

Despite having a diagnosis of “vertigo”, the patient didn’t really show much in the way of vertigo. Sure, vertigo can cause drop attacks (from extreme dizziness and loss of balance), but the patient never complained of any of those symptoms. The drop attacks looked more like those cataleptic goats.

It’s quite a jump in logic to decide that the high blood pressure caused the seizure. There’s so many other possible causes. For instance, Lidocaine toxicity — House’s suggested diagnosis — is well known for causing seizures.

Did I really see Foreman jam something in the mouth of seizing patient? In 2010? He’s a neurologist, he should know better.

Expect to see results from antifungal medication in a few hours? Nonsense. That would be fast for regular antibiotics, let alone antifungals which are slower (as I tell patients in the office, fungus grows slowly, so it dies slowly).

If Mickey took enough beta-blockers to not respond to pain, then he would have an extremely low heart rate, definitely below sixty and probably even lower.

Beta-blockers do not cause a noticeable rebound high blood pressure. Certainly not one high enough to cause a seizure.

A VQ scan is a logical approach to diagnosing coughing up blood (looking for a pulmonary embolus), but isn’t good at showing aneurysms. The image Chase showed was way too clear for a VQ scan (here’s what one really looks like; very fuzzy) — it was probably a CT.

Is Foreman really expecting inhaled Albuterol to fix what is clearly a systemic problem?

It was strange the way the writers were being very coy with medications this episode: “vasodilator,” “antipyretic,” and “soft steroid” rather than actually naming the drugs, like they always (or almost always) have before.

It was hard, but you’ll notice I made it through the entire review without resorting to a “Can’t Hardly Wait” pun.

The scene in the clinic (at least I assume it was the clinic) where House deduces the source of Mickey’s injury was well done, and very Holmesian.

The medical mystery was okay, but I question if the patient really had what they said he had — I give it a C. The final solution was a big stretch, and in shooting for pathos, they shortchanged the team. It gets a D. Overall, the medicine was more often than not, painful to watch: another D. The soap opera was quite good though (with this week’s theme seeming to be “deception”) and earns a solid A.

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

Another low scoring episode. Austin Иосефович and Joe led the week with 5 points.

Overall, TRad continues his lead with 48 points. Noether remains second with 42 points. Corien is third with 34 points, atg is fourth with 33 points and Heidi is fifth with her 31 points.

Click here to see the full scoreboard.

It’s a lot harder to weasel your way out of bad blind dates now.

From the “Jerry Jitterbug” story in Adventure Comics #171 (December, 1951). Click here for the rest of the strip.

It’s that time again: time to look back on the past year and find the best — and worst — that comic book medicine has to offer.

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

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

scenes from New Avengers #60 (Bendis/Immonen)

I’m sure Neilalien will be all over this, but let me just quickly point out that — despite what the New Avengers seem to think — over forty years of continuity has firmly established that Dr. Strange is a neurosurgeon, not a heart surgeon.

For example, here’s how his biography on Marvel’s own site reads: “His talent was unaffected, though, and he became a wealthy, celebrated neurosurgeon before he turned thirty.”

Batman #5

see also: “Anesthesia? Batman don’t need no anesthesia!”

Betsy Crane’s friend and fellow nurse Diane has met and fallen in love with a Jeff, a widower with a young daughter. He saved her from drowning a few weeks before and she has fallen head over heels in love with him.

One day though, Jeff is uncharacteristically brusque to her and Betsy when encountering them on the street. The two nurses head over to Jeff’s house to figure out what is wrong. Jeff is angry that Diane has appeared on his doorstep, but it doesn’t stop him from complaining of a severe headache and eyes that are very sensitive to light. He also suffers a seizure while Diane is pleading with him. Meanwhile, Betsy is talking to Jeff’s young daughter, who mentions that her dog Shag has been hiding from her lately and doesn’t want to play. She also mentions that her father won’t take her swimming anymore because he is afraid of the water. Betsy puts two and two together and realizes that Jeff has rabies, and that he must have gotten from the dog Shag.

Betsy calls her boss Dr. Kiel and he rushes an ambulance out to collect Jeff and admit him to the hospital. He is given daily rabies injections and suffers “sleepless nights and momentary spasms” but “Dr. Kiel and Betsy were always there giving their medical skill and tireless sympathy.” Three weeks later, Jeff is released from the hospital, completely cured, and he and Diane (and Jeff’s daughter and her new dog, Little Shaggy) live happily ever after.

Even by the low standards of a fifty-year old romance comic, this is a horrible and misleading story medically:

Although this is clearly a story about rabies, the word “rabies” is never used.
Jeff has “hydrophobia” (an older, and now seldom used term), but never “rabies.”
A wild fox was “rabid” and bit Shag, who became “sick.”

Rabies is not that easily cured.
In the entire history of mankind, only a handful of people have survived rabies without receiving injection therapy, and even then they all suffered from some brain damage, usually quite severe. At this point in time (forty-eight years after the comic was written), the best case scenario utilizes the recently developed “Milwaukee protocol” — but it’s only been used successfully twice.
Yes, Jeff did receive rabies injections, but at that point his rabies was so far along — he’d already developed neurological signs including seizures — it wouldn’t have done much good.
Plus, Dr Kiel gave the injection wrong. Most of it should be injected near the bite, not in another limb entirely.
Bottom Line: Even if Jeff had somehow managed to survive the rabies (very very unlikely, say about 10,000:1 odds), he would be left with months if not years of intense physical therapy afterward. There is no way he would walk out of the hospital completely cured in three short weeks.

Hulk #15, #16
Jeph Loeb, writer
Ian Churchill, penciler

At the end of Hulk #16, The (Red) She-Hulk stabs the (Red) Hulk in the neck with a sai. As the next issue starts, Samson gloats over the Hulk’s injury:

Samson: She severed your carotid artery. The more you move, the closer the sai will get to cutting into you aortic arch. Apparently, all those years in medical school weren’t for nothing. My father would be so proud.

I wouldn’t go counting on your father’s praise just yet, Samson, considering how little understanding of anatomy you have. It seems that medical school was a waste for you — at least anatomy class.

Let’s take another look at the scene when the She-Hulk stabbed the Red Hulk in the neck. This time, I’ve annotated the panel to make my point. The path of the sai is outlined in green (but bear in mind this is a two dimensional representation and the sai’s path is angled much deeper in the neck than I can show here). I’ll agree that she probably injured the carotid artery, so that part is true. Now, the blue arc is the aortic arch — which as you can see is not even close to the sai. Plus, with the prongs buried into the Hulk’s neck, despite what Samson says, that sai is not going anywhere.

Then a page later Samson is called “Leonard Samson, PhD”; is he a medical doctor or non-medical doctor? Make up your mind. Remember, psychiatrists and psychologists are two different professions — they may both deal with the mind, but they deal with it in very different ways. (For the record, Samson has always been identified as a psychiatrist: Leonard Samson, MD.)
Admittedly, a severed carotid is still fatal, at least to most (non-Hulk) people.
Samson’s speech contains some of the most bizzare emphasis I’ve ever seen in a comic. Who would speak like that, with the emphasis on “she” rather than — I don’t know — maybe the “severed” and “carotid.” And “the sai” — who emphasizes an article like that?

In this scene from the Monkeyman & O’Brien Special #1, two thugs are psychically dominated by the mind of an evil white space gorilla.

As an added bonus(?), have some fan service, courtesy of artist/writer Art Adams.

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed monkeyman o’brien art adams fan service

I liked the plot of this week’s episode of Fringe — at least for the first two thirds (until Walter was captured, when it started going downhill) — but the “science” and “medicine” was ridiculous.

The Plot: Mysterious men break into a mental health facility and perform some sort of brain operation on one of the patients. They remove some sort of foreign tissue from his brain, but are disturbed before they can finish the operation, so the patient is left with part of his brain exposed. Strangely, the patient has also been completely cured of his schizophrenia.

The Fringe team is called in and it is clear that Walter is uncomfortable with being back in a mental health institution. The security tapes manage to capture the face of the intruders’ leader, and Olivia recognizes him instantly. It was one of the frozen heads that was stolen earlier in the season and belongs to a man named “Newton.”

Looking through the patient’s medical records, Walter finds reference to a mysterious psychiatrist by the name of “Paris.” Astrid can find no records of the mysterious doctor, but with Walter’s help, is able to track down some prescriptions he wrote. They find two other institutionalized patients with prescriptions from Dr. Paris. Visiting these patients, they find that they have also been recently miraculously cured of various psychiatric diseases and show evidence of recent brain surgery. Walter recognizes that one of the drugs they’ve been given is used to prevent tissue rejection in organ transplant patients. He then realizes that the patient’s brains had been used to store the tissue from someone else’s brain.

The team is informed that Walter’s old mental health records show that Dr. Paris visited him six times while he was in the asylum — visits which Walter does not remember. Peter check’s Walter’s scalp and, sure enough, there’s an old surgical scar. An MRI of Walter’s brain is obtained and it shows three missing sections of brain — missing sections that perfectly match the pieces implanted in the other patients. Someone has removed part of Walter’s hippocampus (important in memory storage) and placed it in other people’s brains. And now someone has taken these pieces back.

Meanwhile, Walter has been captured by the Newton and his cohorts. They hook him up through some sort of contraption to the missing pieces of his brain. Once the connection is made, Walter seems suddenly awake for the first time since the show began. Newton is able to get Walter to tell him how to make a door to the other universe. He then injects Walter with some sort of drug before high-tailing it just before Dunham and the rest of the team arrive. While Peter helps Walter, Olivia chases after the bad guys. She manages to shoot the driver of their van (who bleeds silver — one of the shapeshifters), and then the second man (regular blood). Newton is captured — but only for a moment — because he tells Dunham that Walter has been given a neurotoxin, and he’ll only tell her how to administer the antidote after he is allowed to escape. Dunham acquiesces and Walter survives, but she is chided by Newton for her “weakness.”

In a final flashback, we see that the mysterious Dr Paris was actually William Bell and Walter’s brain surgery was done — apparently with Walter’s consent — to remove the knowledge of how to open the cross-dimensional door from his brain and store it someplace “safe.”

2. “Iä! Iä! Cthulhu Fhtagn!”
There were a couple of H.P. Lovecraft references this week (purposefully?)
Dr. West (as in Herbert West, Reanimator)
Dunwich Mental Health Facility (as in The Dunwich Horror)

3. Department of Redundancy Department
“Global destruction of biblical proportions.” That’s ridiculously redundant — global destruction, by definition, is of biblical proportions.

4. The AMA Does Not Do What You Seem To Think It Does
A common mistake, but an irritating one. The American Medical Association is really nothing more than a professional organization for doctors, like a union or lobbying group. It has no official sanction. It is not in charge of medical licensing, and keeps no “official list of doctors.” Depending on which source you use, only 15-30% of the physicians in this country are members of the AMA, so someone not being on their roster is no proof that they’re not a doctor or don’t exist. [I've blogged about this several times before, most recently here, in relation to the Beast and Dr. Mid-Nite.]

5. But I Asked For Infinite Refills
You cannot write an “indefinite prescription.” One-year, maximum.

6. I Reject Your Rejection
The four drugs listed on the patient records (Sirolimus, Muromonab CD3, Basiliximab, Azathioprine) are used to prevent rejection in organ transplant patients.
You would think that in their years in the asylum, at least one doctor or nurse would realize the drugs make no sense.

7. Bad Radiology
Those spots on the patients’ brain MRIs were way too big to be thought of as artifacts. The brain tissue was large enough that it would show up on multiple MRI slices (images).
No radiologist ever noticed the three holes in Walter’s brain before?

8. Respiratory Depression and Death
Tolerance or no, 50MG of Valium is one helluva dose. That’s two-and-one-half times the maximum daily dose of Valium.
Dr. West is either extremely trusting or extremely naïve to give that much Valium to Walter just on his say so, especially when it’s clear that Walter is not all there.

9. It’s Not a Two-Dimensional Jigsaw Puzzle
The brain is three-dimensional. The tissue cut out was three-dimension. It was inserted into people’s brains (crammed in, basically, because there was no “slot” to put it in), but somehow manages to show up on a two-dimensional MRI as a perfect fit, like a jigsaw puzzle piece. There was no way they could fit the extra piece in the brain so precisely at just the right point and at just the right angle for this to be true. [A similar problem occurred in the infamous autopsy scene in Identity Crisis #6, where Dr. Mid-Nite managed to find just the right slice to find perfect footprints in the brain.]

Good plot but goofy science cancel each other out. The Doomsday Clock stays at 11:55

This week’s Fringe cipher was: PORTAL.
A list of all previous Fringe reviews is available here.
Karl has much more to say.

At exactly what point is a joke considered overdone and beaten into the ground? (Is there a committee that votes on stuff like that? Can I get on this committee?)

In this scene with the recuperating Luke Cage, there are a couple of things I’d like to draw your attention to:
1. An example of the too-many tubes problem, as Luke Cage has six separate tubes/wires going into his mouth.
2. Another example of a patient who is intubated (hooked up to a breathing machine), yet still has a nasal cannula (which delivers oxygen to the nose — which is unneeded in this situation because Cage has no choice but to breathe through the tube in his mouth). [Annotated panel]

Other thoughts:
It’s interesting how there is always a bag of blood hanging next to Cage — even when he’s in the Avengers HQ — though he’s never shown with an IV, so there’s no way to give him the blood if he needs it.
Plus, now that there’s no power drainer around, there isn’t any way to place an IV at all through his invulnerable skin.

This week’s episode of Fringe was fairly creepy, and the science wasn’t all that bad

The Plot: A boat from Hong Kong has run aground in the harbor and dozens of illegal Chinese immigrants have washed up on the shore, dead. It turns out it wasn’t the water or cold that killed them, but giant tentacled parasite worms lodged in their gastrointestinal tracts. The Fringe team is called in. One of the immigrants, Mai Lin, managed to survive. She tells the team that all her fellow immigrants were given a strange capsule to treat sea-sickness, but since she was raised in a fishing village and never got sea sick, she didn’t take it. The team suspects these capsules contained the larvae for the giant worms. She tearfully tells the team that her husband and daughter are on the next boat arriving in few days.

The immigrant smugglers are tied to a local Triad gang best known for smuggling and selling illegal drugs. The team initially surmises that the worms secrete some form of opiate, and this is why they’re being smuggled. After being bitten himself, Walter realizes that the worms produce a powerful immune boosting agent. Walter does some research and discovers that the worms are genetically modified Ancylostoma duodenale (hookworm), an intestinal parasite used in traditional Chinese medicine. The genetically modified versions make an immune boosting agent that is stored in their lymph glands.

Some financial documents tie a local woman to the one of the Triad’s front. She tells Agent Dunham that she has no knowledge of any illegal activity and only invested the money where her financial adviser suggested. Peter notices that her house has a surprising number of air filters and hermetically-sealed windows. Once the team learns about the immune-boosting aspect of the worm, they realize this woman knows more than she is telling. This time, Peter approaches her son who tells him that he has a rare immune deficiency. He receives a special monthly treatment of worm-powder delivered surgically, directly into his spleen.

Walter, with some reluctant help from Astrid, heads off to Chinatown to find a herbalist that sells Ancylostoma that is genetically similar to the giant worm. He finds several shops that sell the worms, and inadvertently discloses to one of the shop owners — the wrong one, of course — that he has a giant worm back at the lab. The Triad follow Astrid back to the lab, beat her up, and steal the parasite.

The ship carrying Mai Lin’s family is found and boarded, but it is too late — all the immigrants have already been carted off. Luckily, Peter is spying on the shop in Chinatown where they have been taken. He calls Agent Dunham then decides to do some investigating of his own. He breaks in to the shop and is in the process of freeing one of the immigrants when he is captured. The Triad and their crooked doctor are force feeding Peter one of the larva when the FBI team arrives, just in the nick of time. The villains are shot or captured, Peter is saved, the immigrants are taken to the hospital where they are treated, and everything ends happily.

(Oh, and Walter implanted a tracking chip in his neck.)

1. As the Worm Turns
Nematodes such as Ancylostoma are too primitive an organism to have a lymphatic system. They don’t even have a circulatory system.
Admittedly, these are “genetically engineered” hookworms, and for a worm to grow as large as those shown, thanks to the square-cube law and other similar concepts, they would have to have some sort of circulatory system.
In the actual worms, the many-tentacled end is the tail, not the head.

2. Glad I Don’t Have to Take Them Out
Matt’s staples should have been removed long ago. He was 3 ½ weeks out from his surgery. By this far out, the incision is healed with 80-90% strength. Leaving in staples or stitches that long serves no purpose, is going to lead to train-track scarring, possible stitch abscesses, and skin-growth around the staples.
Open abdominal surgery is to be avoided whenever possible, especially in immune compromised individuals. Why not just inject the powder into the spleen?
Credit-Where-Credit-Is-Due Dept: That is where an incision for splenic surgery would be made.

3. High is Not Always Better
A high white blood count is a sign of infection (or leukemia, not the sign of a healthy immune system).

4. Ahhh, Just Right
I was starting to have concerns with Walter’s mention of “boosting the immune system” — a common alternative medicine/quackery claim. In reality, the human immune system is finely tuned: too little leaves you open for infection; too much and you get allergy problems and autoimmune disease. If all the alternative “medicine” boosted the immune system like it was claimed, we’d have an epidemic of autoimmune problems in this country. I’ll give the episode credit for having the medication be used by immune-compromised patients — a proper use.

5. What Does the FBI Teach These People?
Walter’s about as good an investigator as Olivia — that is, very bad. The logic of his whole “find a matching worm” plan had more holes than Swiss cheese (though this is Walter we’re talking about). For instance, who’s to say the various different herbalist shops didn’t all use the same importer of worms — which they probably did — so the worms from the various shops would be identical.
And Peter’s not any better. Why would he think breaking into a shop owned by the Triad — known for their brutality — would be a good idea at all?

5. Lions and Tigers and Bears, Oh My!
The song Walter was singing was “The Menagerie“, which was also mentioned in the first season (episode 16, Unleashed).

While there was some errors of scientific-concerned, most of them were minor and could be hand-waved area. Thus, for the second week in a row, there is a one-minute improvement on the Doomsday Clock.

This week’s Fringe cipher was: HIDDEN.
A list of all previous Fringe reviews is available here.
Karl has much more to say.

A quick reminder: Jimmy Olsen is the third most common cause of heart attacks.

Those of you with good memories may recall that I have warned about this before, but it’s been over three years, and the new evidence keeps piling up — evidence which cannot be denied. If you have a personal or family history of heart disease, for God’s sake, stay away from Jimmy Olsen.

Almost entirely a Wilson character episode, so the medicine was fairly straightforward, if surprisingly sloppy

Wilson is out hunting turkeys with Tucker, a friend who he helped defeat leukemia five years earlier. Tucker nearly shoots Wilson when his left arm becomes suddenly numb and paralyzed. Wilson has Tucker brought to the Princeton Plainsboro Hospital emergency room for evaluation. A head CT is negative, and the blood count is normal, which tells Wilson that Tucker has not had a recurrence of his cancer. Noticing a fever blister on the lip of Tucker’s girlfriend, Wilson diagnoses him with tranverse myelitis (inflammation of the spinal cord, it can have many causes, in this case the Herpes simplex virus passed from the fever blister). He admits him to the hospital for treatment with acyclovir (an antiviral drug). House chides Wilson for his diagnosis, telling him that Tucker has cancer. Wilson disagrees and they end up betting $100 on the final diagnosis.

Paying a visit to Tucker a little later, Wilson discovers that he now complains of tingling in his left foot in addition to the continuing numbness and paralysis of his left arm. Wilson sticks with his diagnosis of transverse myelitis, but adds a second antiviral — Ribavirin — to the therapy. There is no improvement, and in the meantime Tucker has developed a nasty cough that eventually devolves into a respiratory arrest (which he survives, or it would have been a very short episode).

Perplexed, Wilson enlists House’s team in reviewing the case. Cancer is suggested, as is a subdural hematoma (bleeding around the brain), bacterial infection, or fungal infection. Wilson agrees with the fungal infection, and suspects that Tucker has aspergillosis (infection by the Aspergillus fungus) including fungal balls (exactly what they sound like) in the lungs and spine. He declares that Tucker is too sick for tests and rushes him into surgery. Chase sees no Aspergillus, but instead finds “global lung damage” suggesting PCP (Pneumocystis carinii pneumonia, a fungal infection of the lungs).

House is watching the surgery beside Wilson, and points out that a PCP infection means that Tucker must have a weakened immune system (since healthy immune systems can easily defeat the Pneumocystis carinii). He states that Tucker must have HIV (the virus that causes AIDS), acquired SCID (Severe Combine Immune Deficiency), or cancer. He suggests that Wilson test for all three.

Sure enough, this round of testing shows cancer — more specifically ALL (Acute Lymphocytic Leukemia, also known as Acute Lymphoblastic Leukemia). This is not a recurrence of Tucker’s original leukemia, but a different one, possibly caused by the chemotherapy required to treat the initial cancer. ALL is fairly treatable, so Wilson starts Tucker on chemotherapy. Twenty-four hours later, there is no change in his condition, and Tucker is concerned he may be in the 10% of ALL cases that Wilson says do not respond to therapy. Wilson decides to double the dose of chemotherapy. It works, more or less. The high dose chemotherapy knocks out the ALL, but it also severely damages Tucker’s liver (the yellow eyes were a sign of jaundice). In fact, the liver damage is so bad that Tucker will die in twenty-four hours if not given a transplant. When it becomes apparent that no transplant is available, Tucker asks Wilson to donate part of his liver to him (he know that they have the same blood type). Wilson thinks on it, and drinks on it, but eventually acquiesces and Tucker receives part of his liver. After the operation, both are doing well and expected to recover fully.

No deal-breaker errors this week, but worse than the last couple of episodes. Some real sloppiness in writing/editing/continuity as well. As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

Wilson is being generous with his ALL prognosis of 90%. The remission rate of ALL in children is 95%. In adults, it is 60-80%, with patient have CNS disease (which Tucker does) having a worse prognosis.
Chemotherapy cures leukemia completely in twenty-four hours? Nonsense. That’s too soon to tell if it’s working at all. Best case scenario is usually remission in 4-6 weeks.

There is no surgeon — even Chase — who would operate on Tucker without at least getting a CT first to show where the suspected fungal ball is. You don’t just slice up the lung indiscriminately. If there were a fungal ball, it would have shown up on the CT, as would PCP severe enough to cause a respiratory arrest.

By my understanding, SCID is currently defined to be a genetic disease, not one acquired later in life. There are acquired immune deficiencies, some severe (most notably HIV), but they are not “SCID.”

I’m surprised none of Wilson’s original blood work showed the cells associated with ALL.

Not my area of expertise or interest, but would a patient with a history of two cancers (though admittedly, no liver cancer or liver metastases) be placed that high on the transplant list?

Left arm or right arm? The episode description and House referred to right arm paralysis, yet the patient was clearly paralyzed in the left arm. Wilson later mention left arm. This is just sloppy.

“PCP Pneumonia” is redundant. The second P stands for “Pneumonia.”

A real nit-pick here, but by the time a patient has PCP, it is considered AIDS, no longer just an HIV infection.

I enjoyed the scenes with Wilson and his other patients.

Last week’s House review
A list of all prior House reviews

Not a lot of high scoring this episode. A handful of 5s, 4s, 3s, and 2s.

Overall, TRad remains in the lead with 44 points. Noether is close behind in second with 42 points. Corien remains in third but closes the gap with 33 points, atg moves to fourth with 29 points and Heidi drops to fifth with her 28 points.

Click here to see the full scoreboard.

How head mirrors are really used…

Nellie the Nurse #5

House Challenge scores are up to date through Episode 8.
I also corrected the scores from Episode 5 where I forgot to count “paraneoplastic syndrome”

Overall, TRad remains in the lead with 44 points. Noether is close behind in second with 42 points. Corien is third with 29 points, Heidi is fourth with 28 points, and Theta Sigma rounds out the top five with 27 points.

Click here to see the full scoreboard.

I’m not going to explain what’s wrong with this caption from The Last Days of Animal Man #6 — I’ll leave it to you.

The Last Days of Animal Man
Gerry Conway, writer
Chris Batista, penciller

I just finished reading The Last Days of Animal Man, and I’ve got a couple of problems with it, particularly the last issue.

1.
Animal Man defeats the villains by using his powers to infect them with Yersinia pestis, the Bubonic Plague. At first read, this is extremely clever — in a Merlin versus Madame Mim sort of way. But the more you think about it, the less sense it actually makes.

Animal Man’s powers allow him to gain the abilities of any animals he is near. He can gain the strength of a gorilla, the flight of a bird, the swimming ability of a fish, and so on. In this case, it appears he used his powers to gain the virulence of the bacteria.

Animal Man doesn’t become the animal in question; he just gains some of their abilities. So if he had won by incapacitating his opponents with a nasty bacterial toxin, that would make a certain amount of sense. But instead he actually infected them with the bacteria. How did he manage this? His powers don’t work this way. You need the actual bacteria to cause an infection, let alone one which is “overwhelming their immune systems.” Animal Man wasn’t infected himself, and he didn’t come into contact with the bacteria, so how did he infect the villains? He seems to have achieved abiogenesis – creating life (in this case the bacteria) from nothing.

2.
The biggest problem is basic biology. It goes back to something I first learned in seventh-grade science. Everyone read what Superman says, and then repeat after me: bacteria are not animals.

They belong to a separate kingdom entirely.

The mystery was fairly bland in this week’s episode of House, but the medicine was much better overall. Good bye Cameron. Don’t let the door hit you on the way out.

Hank, a successful porn star is admitted to Princeton Plainsboro Teaching Hospital after developing a severe headache and photophobia (sensitivity to light) while on set. House starts off by ordering a series of tests: an STD panel (to look for sexually transmitted diseases), a toxin screen (to look for common toxins), C-Reactive Protein (”CRP”, a measure of inflammation), ANA (antinuclear antibodies, to look for autoimmune diseases) and a lumbar puncture (to look for viral encephalitis). While the patient is having his spinal tap performed, he develops severe muscle spam and pain (tetany) in his arms. Foreman orders meperidine (Demerol, a strong pain medication).

About this time, House starts hitting up Taub and Thirteen for ideas, trying to lure them back on the team. Taub suggests that Hank must have a brain problem, such as a tumor or seizure. Foreman believes that Hank suffers from cerebral vasculitis (inflammation of the blood vessels in the brain). House agrees with Foreman’s assessment and starts the patient on steroids. He also orders a brain angiogram (an x-ray of the arteries in the brain), as well as an EEG and a nerve biopsy, just to be sure. Foreman convinces Chase to perform the angiogram, but he and Cameron suspect that the patient is suffering from Vitamin D deficiency, so instead of checking the angiogram, they decide to start Hank on light therapy and intravenous vitamin replacement. Unfortunately, while undergoing the light therapy, Hank develops a nosebleed and is found to have petechiae on his legs.

Hank is now diagnosed with disseminated intravascular coagulation (DIC, a weird, but very serious, condition, where the patient is both bleeding too much and clotting too much). Sepsis is suggested as a possible cause, but since he is showing none of the shock associated with sepsis, the idea is discarded. Bacteremia (bacteria in the blood) is suggested, but Cameron shoots it down suggesting instead Meningococcemia (meningococcal bacteria in the blood — really a subset of what Chase suggested). House concurs with Cameron’s diagnosis and Hank is started on heparin (a blood thinner, for the clots) and a broad spectrum antibiotic that covers meningococcus (but if you know which bacteria you’re treating, then you don’t need a broad spectrum antibiotic).

Hank does not improve and he starts to run a fever. Taub suggests that he might have an infection hidden away in his sinuses, where the antibiotics have difficulty reaching, so Chase performs sinus surgery to clear out the sinuses. Now Hank begins to complain of severe abdominal pain and Cameron discovers something on the exam (apparent ascites — fluid in the abdomen) that makes her diagnose liver failure. She suggests a Klatskin tumor (cancer of the bile duct), but it doesn’t quite fit the symptoms. Foreman suggests that Hank has sclerosing cholangitis (a disease that damages the bile ducts). House agrees and an ERCP (an endoscopic exam of the bile duct and pancreas) is ordered — surprisingly it shows a mass in the common bile duct that ends up being a large clump of worms. Hank apparently has strongyloides (”whipworm threadworm”), and is given mebendazole to kill the worms.

Once again, Hank’s condition dramatically worsens. He develops severe pulmonary edema (fluid build up in the lungs). Chase thinks it might be a combination of a hematological (blood) problem and cardiomyopathy (a heart problem). Foremen suspects Hank has lymphoma, with peritoneal carcinomatosis (malignant spread of cancer across the abdomen) and paraneoplastic syndrome explaining his symptoms. House sides with Foreman, and Hank is started on chemotherapy. A short time later, Hank’s condition takes another turn for the worse when he starts urinating blood. Next, his blood pressure and heart rate skyrocket, and he starts to bleed from his mouth. He then suffers a cardiac arrest, but the team is able to stabilize him.

The latest labs are back and show that Hank barely has any red blood cells, white blood cells, or platelets. The differential diagnosis now includes hypopituitarism (an underfunctioning pituitary gland), renal cell carcinoma (a type of kidney cancer), or aleukemic leukemia (a leukemia that is associated with low white blood counts instead of the normally high counts found in leukemia). House tells the team that the latter is the most likely and orders them to ablate (destroy) Hank’s bone marrow in anticipation of a bone marrow transplant. There is a lot of hemming and hawing about whether this is the right thing to do, since it could make Hank sicker or kill him, but at the last moment, Thirteen and Taub call in with the correct diagnosis: extraintestinal Crohn’s disease. According to them, Hank’s exceptionally clean childhood made him more likely to develop diseases such as Crohn’s, and the worms were actually helping him keep the disease in check. Once the worms were killed off, the Crohn’s flared up with a vengeance. With some methylprednisolone (steroids), Hank should get better — but the team wants to give him some worms again, just to make sure.

I found no massive errors in tonight’s episode. There was the usual: jumping randomly between unrelated diagnoses, bizarre test interpretation, and Chase being a specialist surgeon, but nothing horrible. Of course, that’s not to say I have no complaints (as if!). As usual, minor complaints are in blue, nit-picking ones in green:

Where exactly was the extraintestinal focus of the Crohn’s?

Why did he develop a headache and photophobia in the beginning? Was that the Crohn’s? Why did everything suddenly worsen when he got in the hospital? The steroids he was given for the vasculitis should have calmed down the Crohn’s.

The strongyloides worms may not have been the cause of his disease, but their blockage of the bile duct would still cause serious problems for the patient.

Again, no oncologist is going to start chemotherapy for cancer without a tissue diagnosis.

Special precautions are taken for patients who are neutropenic (dangerously low in white blood cells, and thus more susceptible to infection) including gowning and gloving everybody in contact with the patient. You do not roll them down the hospital’s common hallway without a mask and with the wife holding his hand.

The CRP should have been significantly elevated with the Crohn’s disease (and the cerebral vasculitis too).

While the ANA is generally strongly positive for certain types of autoimmune diseases, it is not found in every autoimmune condition (or even most autoimmune conditions), so a negative ANA does not mean there is no autoimmune disease (and positive ANAs in the absence of autoimmune pathology are also possible).

How about checking the vitamin D level — an easy thing to do — before treating the patient.

I noticed how they avoided actually saying the word “ascites” and instead chose a wordier explanation. Probably because of their problem pronouncing it last time.

Cameron shoots down Chase’s idea of bacteremia, but then suggests meningococcemia, a type of bacteremia. The same argument she used against Chase would go against her as well.

Why would you ablate the bone marrow without finding a donor first? (OK, maybe House was never planning on really following through with it, but why would the others go along?)

And now credit where credit is due:
The hygiene hypothesis is a legitimate and controversial scientific theory concerning the rise in asthma and allergy rates in industrialized nations. Some researchers link it to autoimmune diseases as well.
Helminthic therapy — treatment of disease using intentional infestation of parasitic worms — is being tested in a variety of diseases, including Crohn’s/
Shocking ventricular tachycardia, like Foreman did this episode, is the right treatment.

The mystery was okay, but seemed to get lost in the shuffle as the show progressed. I give it a B. The final solution was a stretch, especially when you look back at the original symptoms. It earns a C. Overall, the medicine was better that it has been the past few weeks and earns another B. The soap opera was decent as well. I enjoy Tab and Thirteen, so I’m fine with having them back, though I know many will disagree. The soap opera earns still another B.

Last week’s House review
A list of all prior House reviews

Another thing I have to tell patients and their families at least a couple of time per week.

An incredibly mediocre show that didn’t meet a cliche it didn’t like (except, unfortunately, the psychic nosebleed). Sorry if the write up seems brief, but I’m really having a hard time caring about this show recently.

The Plot:The police are called for a kidnapping/hostage situation at the top of a parking garage where two guys are holding a teen hostage in a car. When the police arrive, they order the men out of the car. The duo get out of the car and then strange things begin to happen: one cop backs up and throws himself off the garage, while his partner shoots the other cops and then herself. The two guys get back in the car and drive off with the kid.

The Fringe team is called in to evaluate the case. Walter suspects that there is hypnotism of subliminal messages involved. The team heads to Massive Dynamic because the kidnapped boy is the son of one of their top aerospace researchers. By now, the two guys in the car have been identified as two local used car salesmen who had been upstanding citizens until now. The kidnappers and teen stop by a convenience store and ob it. A burly customer tries to intervene, but suddenly he is pouring scalding coffee over his head and the breaking the carafe over it. The cashier tries to shoot the men, but finds himself picking up a key and inserting it into an outlet and shocking himself unconscious.

Walter has been performing an autopsy on the cop who shot the other cops and deduces that it was not hypnosis, but instead mind control. He makes his deduction based on the fact that there are hematomas (pockets of leaked blood) on the surface of the brain, suggesting some mind/body conflict. He then infers — for no good or logical reason — that this mind control must be done via the cochlear (hearing) nerve.

A call comes in from the kidnappers demanding two million dollars. Meanwhile, Walter has concocted white noise headphones for the FBI troops to wear in the field which should block out any mind control. At an abandoned factory, the teen’s father hands over a briefcase of money to the kidnapper, who then runs into a nearby building. Agent Dunham follows. Meanwhile, Peter sees someone else running with the briefcase and follows, only to find the teen, Tyler, holding the briefcase. It turns out Tyler’s the one with mind control and the others were nothing but patsies. Unfortunately, Peter’s white noise headphones don’t protect him and Tyler orders him to drive the two of them out of town in the Bishop family roadster.

Peter tries to rebel, but Tyler forces him to drive the car as fast as it can go and plays chicken with a truck before Peter agrees to behave. A little while later, they are pulled over by a policeman. Tyler wants Peter to shoot the cop, but in the end, he lets Peter just knock him unconscious. Finally, Tyler and Peter arrive at his mother’s house (by way of a strip club), where Tyler finally gets to meet the goal of his quest — his mother. He believes that his father had driven her away and lied to him about her, but that turns out not to be the case, and when he learns she is married he has Peter pull out a gun and point it at her husband. Luckily, Agent Broyles arrives and shoots Tyler with a taser — but it’s a bad shot. Tyler has Peter shoot Broyles, and then he and Peter hop back in the family roadster and take off. Agent Dunham, Astrid and Walter are following close behind, and when they get near off, Walter activates the EMP device he has been working on. It knocks Tyler out for a split second, and that’s enough for Peter to realize what is going on and drive into a telephone pole. He survives with a mild concussion, but Tyler is knocked unconscious and captured.

2. La La La! I Can’t Hear You!
Why go through all the elaborate set up of the white noise headphones instead of just using ear plugs?

3. Bleeding On The Brain
Hematomas don’t form with brain/body conflict. There are certainly medical conditions with conflict between mind and body — somatization comes to mind — but none of them cause hematomas. You could argue that the straining led to an increased blood pressure which popped the vessels, but high blood pressure related bleeds occur within the brain, not on the outside.
That was a surprisingly intact brain for someone who received a bullet at point black range.

4. On the AM Radio
Why amplify the brain waves — that should have been the team’s first realization that something wasn’t kosher — why not just make better sensors?
Amplifying the brain waves means that you are increasing the voltage within the brain itself, which is wonderful way of setting off a seizure.

5. It’s Better Than The 10% Cliche, But Just Barely
Brains are not computers. Whenever someone uses this analogy, it’s a safe bet that they don’t understand brains or computers
Having Tyler’s mother actually be a surrogate was a fairly clever twist — really the only one in an episode thick with clichés — but how does the doctor raise all five Tylers? Are they frozen until needed? Does he spend one day of the week with each one?

6. The Blind Leading the Blind
Geez, Olivia is a bad detective. She already knows Tyler’s mother died when he was young, and then can’t figure out why he’s looking at records of women who died in car crashes fourteen years before.

7. Crime And (Lack of) Punishment
Why would Tyler get off with just seeing some psychiatrists? That makes no sense at all, especially the way they explain it. He was directly involved in the murder of five people, the maiming of three others, and at least three attempted murders. He’s fifteen — old enough to be tried as an adult.

Why exactly am I still watching this show? I’m sure I have much better things to do.

This week’s Fringe cipher was: ARRIVE.
A list of all previous Fringe reviews is available here.
Karl has much more to say.

I swear, I have this same conversation with at least two or three patients a day. When will the horror of water allergy end?

This episode of House started well but collapsed under the weight of its ridiculous medicine in a surprisingly short period of time. The soap opera was well done and enjoyable, though

Jordan, a sixteen year-old girl, and her best friend bluff their way into a band’s post-concert party. The next morning when they are regaling their other friends with the details of the night (including alcohol, marijuana, and skinny dipping), her friends notice that Jordan’s ankles are very swollen. Seconds later, her fingers become swollen too, and then she collapses on the floor.

Admitted to Princeton-Plainsboro, House is convinced that Jordan has rhabdomyolysis (muscle damage, often caused by a crush injury. He thinks she injured herself climbing the fence to the pool to go skinny dipping). The rest of the team suggests that she may have a deep vein thrombosis (a blood clot), anaphylaxis (a life-threatening allergic reaction), or even a heart condition, but House maintains that Jordan must have rhabdomyolysis. Tests reveal that Jordan’s muscle enzymes are elevated (a sign of rhabdomyolysis), but the scans show no sign of the muscle injury House was suspecting.

House now looks over the labs and notices that Jordan has a low potassium. He has her air drum (like air guitar, only drumming), but she can only drum for a minute or two before her arms are too tired to lift. House states that this muscle weakness is a sign of low potassium, and since she would have had a low potassium the previous night as well, there was no way she had the muscle strength to climb the pool fence. In other words, he accused her of lying about what happened. Later, Jordan and her friend admit to Cameron and Chase that in reality, they only wanted to go to the party because their favorite comic book/movie writer Jeffrey Keener would be there. They then proceeded to stalk him for the next few hours (going where he went, eating what he ate, etc), before finally going to bed.

The differential now consists of an unknown food allergy, plus Cameron thinks that Jordan may be bulimic. They run a scan to look for a Mallory-Weiss tear (a rip in the esophagus seen in people who vomit frequently, like bulimics), and when they don’t find one, decide that she isn’t bulimic. As they finish the test, Jordan’s blood pressure drops suddenly and then she flatlines. Foreman starts CPR (good for him). Chase announces that Jordan has cardiac tamponade (the pericardial sac — the membrane around the heart — has become filled with so much fluid the heart can no longer beat correctly) and he plunges a needle into her chest to draw off the blood around the heart and relieve the problem. Somehow, this brief moment of tamponade has severely damaged (“constricted”) her heart, necessitating use of antiarrhythmic medications (drugs to prevent abnormal heart rhythms). Since Jordan’s blood pressure drop was sudden, House decides that this means she has an acute problem, not a chronic one. Therefore, the most likely diagnoses are toxin exposure or infection, but the team still needs to figure out which toxin or which infection.

Things continue to worsen for Jordan. She tells the team about stopping by Bruce Springsteen’s house and playing guitar with him . She is lying and does not even realize that she is doing it. Additionally, Foreman notices blood dripping from her ear and announces to her friend that bleeding in her brain is affecting her thalamus and this is causing her to lie. (When did he get an MRI to determine this? And why would bleeding in the thalamus — in the center of the brain — leak out the ear? Did she somehow rupture her eardrum too?)

The team reviews the videotapes from the hotel that night and discover that Jordan sneaked out of her room briefly in the middle of the night. They see her a few minutes later carrying Keener’s journal. He apparently left it in the restaurant and she went back to get it. They figure that she must have stopped by his room to return the journal and maybe something happened to her there. Chase and Cameron confront Keener in his hotel room — he shuts the door in their face. Cameron now suspects that Jordan was slipped some roofies (a slang term for Rohypnol, an alleged common date rape drug) and wants to start her on Flumazenil (a medication which reverses the effects of Rohypnol and similar drugs). When they return to the hospital, they find Foreman frantically working on Jordan. He tells them that she has been bleeding behind her kidneys and has required multiple units of blood. Cameron thinks it looks like a “toxic reaction.”

Cameron realizes that they must figure out what really happened to Jordan that night. Her plan is to give Jordan Amobarbital — i.e.truth serum — so they can discover the truth. Jordan is given the drug, and under questioning, admits that she went to Keener’s room where he invited her in and gave her Ecstasy — only it didn’t have the same effect on her that Ecstasy usually does — this pill made her sleepy. She then begins telling the team how Keener started to touch her. As her father gets more and more upset, Foreman points out that the scans indicate “increased periorbital blood flow” meaning that everything she just said is a lie.

Most of the action now shifts upstate, where Cuddy, House, and Wilson are at a medical conference. At one point, the team talks to Wilson and tells him that since Keener travels with his dog, Jordan may have come down with Rickettsia (not the name of an infection per se, but a genus of tick-borne bacteria that cause such diseases as typhus and rocky mountain spotted fever). A short time later, in the middle of an argument with Wilson, House has his Eureka! moment and calls the team. He announces that Jordan has Vibrio vulnificus, a not uncommon bacterial contaminant of the raw oysters Jordan ate. For most people, the bacteria present no problem (or mild nausea and vomiting), but Jordan also has hemochromatosis. According to House, this made her more susceptible to the contaminated oysters. The Vibrio infection explains her initial symptoms. Then the team, thinking she had bulimia, started her on iron-containing vitamins, which worsened the symptoms of the hemochromatosis (by causing iron overload), resulting in liver damage and bleeding. They gave her transfusions, which again worsened her symptoms (more iron overload). However, with the right diagnosis and some Cetazidime (an antibiotic for the Vibrio) and chelation (for the excess iron), she should be as good as new.

Tonight’s episode was rife with errors, far worse than usual. I did my best, but I’m sure some obvious one slipped by. As usual, major complaints are in red, minor in blue, nit-picking in green:

The truth serum idea was simply ridiculous. Amobarbital does not work like Cameron explained, and it is far from foolproof — for example, it’s easy to create false memories (and the questioner Cameron clearly had a preconceived belief of what happened to Jordan).
Telling truth from lies is not nearly as black and white and Foreman makes it seem. You can’t look at an fMRI report and definitively state “she was lying the entire time” like he did. But it sure would make police interrogations and court a lot easier if it worked as easily as Foreman implies.
Anyway, where is the fMRI? Jordan was in a bed in the center of the room. There was no MRI equipment in sight. Nothing to read the “increased blood flow” he mentions.

Cardiac tamponade or not, you don’t just plunge a needle and syringe blindly into the chest — you’re likely to do more harm than good. Yes, you can perform a needle pericardiocentesis, but it’s more involved than “plunge and pray.”
Why would 20 seconds of tamponade cause a permanent conduction problem in the heart?

A day or two of iron supplementation is not enough to cause that severe liver damage in a patient with hemochromatosis. And apparently it kicked in really fast, because it bled into her pericardial sac mere minutes after suggesting the diagnosis of bulimia, let alone giving her vitamins with iron.

Jordan’s symptoms do not match Vibrio at all. For starters, she has no gastrointestinal symptoms from what is essentially food poisoning.

When did Foreman get an MRI to determine that Jordan had “bleeding into her thalamus?” And why would bleeding in the thalamus — in the center of the brain — leak out the ear? Did she suffer head trauma which disrupted her ear canal and also ruptured her eardrum?)

Rhabdomyolysis can have other causes other that a direct muscle injury, so not seeing a specific injury on the scan means little (for example, many marathon runners end up with some rhabdomyolysis by the end of their race, but it’s not a single muscle, but most of them, so a scan would show nothing)

Not everyone with bulimia develops Mallory-Weiss tears, in fact, most don’t. So not seeing a tear does not mean she is not bulimic.

Edema is swelling of soft tissue. Effusion is the swelling of a joint. They are not the same thing and the terms should not be used interchangeably. A halfway decent physical exam, especially on someone as skinny as Jordan, should easily tell them apart.

Assuming Jordan did receive Rohypnol, the flumazenil, a benzodiazepine antidote, is a reasonable choice. But by the time Cameron would have given the drug to her, the rohypnol would have been long gone from her system.

Rickettsia is a genus of bacteria, not a specific disease.

Rhabdomyolysis is very hard on the kidney. I would think twice, and then a third time, before giving such a person IV contrast (also very hard on the kidneys).

I thought the medical mystery itself, and the confusion of the always changing history, was intriguing this week and deserves a B+. It goes downhill from there. The final solution did not fit the mystery at all — either solution — and earns a D-. The medicine overall was a complete mess, with scattershot diagnoses, ideas abandoned for sloppy reasons, and missing equipment. It earns a solid dismal F. The soap opera was a bright spot — especially all the scenes at the conference — and earns an A.

Last week’s House review
A list of all prior House reviews

The criminal who discovered Jor-El’s super-power pills has escaped from prison and rumor has it that he has hidden one last pill somewhere. Superman, Batman, and Robin rush off to capture him before he can reach the pill, but the criminal slips by them. Batwoman (the mini-skirted all-but-incompetent Silver Age Batwoman, not the current one) decides she wants in on the act. She manages to find the villain and grabs his pill before he can swallow it. She then swallows the pill herself — and with her new super-powers — returns the criminal to prison.

Now that Batwoman has super-powers for the next twenty-four hours, how do you think she decides to use them? Stop crime, right? Wrong. She decides she is going to use her super-powers to discover the identities of Batman, Robin, and Superman.

So, not only does Batwoman — an alleged super-hero — not use her new powers to fight crime, but instead she uses them to betray the confidence of other heroes. Nice going.

Batwoman follows Batman and Robin as they drive around Gotham City in the Batmobile. They give her the slip — or at least they think they do — but as soon as they drive into the Batcave, there she is waiting for them. She tells the duo she used her x-ray vision to find the Batcave, and now, based on the mansion above the cave, she knows their identity. Next she sets out to discover Superman’s.

Batwoman catches up with Superman when he is saving a small town from an avalanche. She follows him, hoping he’ll lead her to his secret identity. He tries to scare her away by flying through a lightning storm, walking through an artillery proving ground, and floating over Niagara Falls, but none of it works. Finally, he decides what his only option is to expose her to the thing every woman is scared of: mice.

Superman’s plan works and he sneaks out through the basement, drilling through the ground, making sure to stay below veins of lead-bearing ores, but Batwoman is able to track him by sound. When he emerges from the ground, she tells him that he has fallen into her trap. She’s lured him away from his job for the whole afternoon, and since she saw what block of Metropolis he came from, all she has to do now is find the office in that block where a worker has been missing all afternoon. When she shows up at the Daily Planet, Lois tells her everyone has been there the whole day (but she only mentions Clark, Jimmy, and Perry — so in the Silver Age the Daily Planet apparently only employed four people). At this point, Batwoman’s twenty-four hours of powers are up and she admits defeat in figuring out Superman’s identity — but at least she knows the true identities of Batman and Robin. Not so fast, says Superman:

And just in case you were wondering:

Story from World’s Finest #90 (September/October 1957), by Edmond Hamilton and Dick Sprang

Tags: comics medicine kryptonite superman batman robin batwoman jor-el pills

Could have been a contender, but was KO’d by bad science and too many clichés

The Plot: A married man in Boston mysteriously turns to ash while waiting to spring an anniversary surprise on his wife. The Fringe team is called in to investigate. Broyles tells Dunham that he’s seen this before — there were five similar deaths several years ago at a hospital in Washington DC. He tells her he was contacted by an “Eastern European” man who provided a strange formula to him and indicated it was the solution to the deaths. Unfortunately, none of the FBI’s scientists could decipher the formula several more deaths occurred before they suddenly stopped — until now.

Dunham digs a little deeper and finds that the victim had recently been visiting his sick mother at a hospital. The Fringe team stakes out the hospital, trying to find a link between this hospital and the one four years ago in DC. They find a critical care nurse named Tomas Koslov who has worked at both institutions. Meanwhile, another ash-death has occurred on the in the hospital. A review of the hospital’s surveillance tapes show a strange being made entirely of shadow moving down the hall right before the death was discovered.

The team locates and searches Koslov’s apartment but discover he has abandoned it. They are able to find a fingerprint. When they run the fingerprint they find that their suspect is man by the name of Timur Vasaleiv who is wanted by both the CIA and the Russians because he stole something important from Russia. Broyles is told that the CIA will be taking over the case, but he decides to keep his team on it anyway. A contact at the Senate sends him Timur’s file. It turns out that his brother Aleks was a cosmonaut who returned comatose from a space mission, and it is his brother that Timur has stolen from a special Russian quarantine facility. He has been keeping him in various American hospitals while posing as an ICU nurse.

Walter has been working on the formula and realizes that it represents an organism that seems to feed on radiation. The hospital patients died because they all had been undergoing radiation treatment, and the husband died because he had been on a recent cross country flight (where he had been exposed to higher than normal levels of background radiation).

Timur returns to the hospital and takes his comatose brother out of the ICU and to a hotel. The shadow tries to emerge, but using a series of car batteries, Timur shocks his brother enough that the shadow retreats. He also knocks his brother into asystole (flatline), but after a few moments, a normal heartbeat returns.

Confident that Walter can crack the formula, Agent Broyles reaches out to Timur and offers his help. Timur is trying to decide whether to take Broyles assistance when he slowly turns to ash — the shadow is loose. The FBI arrives to find the comatose cosmonaut and the dead Timur. Peter thinks Walter can shock Aleks to make the shadow return, but Walter cannot read the equipment as it is all in Russian. When they hear a young girl scream from another motel room, Broyles takes unhesitating action and shoots Aleks in the head, killing him. The girl tells her mother that there was a shadow man in the room, but he disappeared. Later, when the CIA approaches Broyles to warn him off their case, they tell him that despite being shot in the head, Aleks returned to life, and they apparently sent him back into space.

2. Feed Me, Seymour
What had the shadow been feeding off of for the past four years, after DC but before the husband died?

3. I See You
There is no way a patient is going to sit for four years in a hospital ICU like Aleks apparently did.
ICU beds are incredibly expensive. The hospital billing department would have been on the phone to his insurance company as soon as he was admitted. No insurance? While they wouldn’t have kicked him out (unless he was medically stable and had a place to go), they would have been looking at the records very closely.
If someone is in a permanent coma, they would be transferred to a rehabilitation hospital or a nursing home as soon as they were medically stable. They wouldn’t keep them in a regular hospital ICU indefinitely.
How did he get him admitted to each new ICU? ICU transfers are very irregular unless one is going from a less-equipped hospital to a better-equipped one, and that doesn’t seem to be the case here.

4. Eleven Herbs and Spices
In my brief look at the formula, there seemed to be a number of carbon atoms with more than 4 bonds. I admit that Ionly had two years of Organic Chemistry, but that seems quite unlikely to me.

5. Blackjack
Your Osama Tezuka link for the day: the little girl was watching Kimba, the White Lion.

The plot line had potential, but was dragged down by too much bad science, reliance of clichés, and deep piles of nonsense they didn’t even try to explain away. The clock moves closer to midnight.

This week’s Fringe cipher was: DEJAVU.
A list of all previous Fringe reviews is available here.

UPDATE: And I should mention that I’m already dreading next week’s show, just based on the preview, where they mention the completely debunked “most people only use 10% of their brain” myth as if it were fact.

I’m not entirely sure what to make of this scene, so I’m just going to engage is some speculation and throw out some ideas. There’s not quite enough information provided to know for sure what is going on. This may be due to cleverness on the writer’s part, or laziness. Regardless, Bendis’s glacial pacing is making this scenario last months.

We know that Luke Cage has had a “cardiac episode” — probably a heart attack — so he needs someone to restore the circulation to the arteries that supply his heart. Non-surgically, this can be done with thrombolytics (“clot-busting” drugs), or by angioplasty. Since he’s undergoing surgery, it seems he’s receiving a CABG (coronary artery bypass graft), the surgical method of restoring the heart’s circulation.

But then the surgeon mentions the pulmonary artery and also mentions a pump in the next panel (not shown here). Why is the surgeon messing with the pulmonary artery? It’s not part of coronary bypass surgery.
Is Cage’s heart so badly damaged that he requires a ventricular assist device to keep him alive (basically, a pump that helps the heart pump)? The doctor is focusing on the pulmonary artery which would mean Cage is getting a right ventricular assist device (VAD) instead of the much more common, and useful, left VAD. Frankly, neither VAD really fit Cage’s situation all that well.
Maybe he meant an intra-aortic balloon pump — which fits the circumstances better — and he just messed up the anatomy.
Or is Osborn up to something nefarious and implanting something nasty (which is my suspicion)? Time will tell, though at this rate my great-great-grandchildren will be reading the conclusion long after I’m gone.

Other thoughts:
♥ If you’re using a scalpel and the skin is “tearing”, then you’re doing something wrong. Surgical scalpels cut through skin like a hot knife through butter — if anything, it’s easy to cut too much.
♥ No mention of “cracking the chest” — opening the rib cage (because it’s hard to reach the heart, otherwise) — though the previous panel does show some rib spreaders at the ready.

The basic concept of defibrillation is to provide enough current to knock the heart back into a normal rhythm, but not enough to do any damage.

I think Norman Osborn missed that memo.

A new masked and super-powered bank robber appears in Metropolis and Superman tracks him to his lair only to find that the robber had been waiting for him with a chunk of kryptonite.

A few months before, our robber realized that if he wanted to be a successful criminal in Metropolis, he needed to find some kryptonite. He spent months tracking down every meteor¹ that landed nearby, looking for elusive chemical. He lucked out: not only did he find kryptonite, but he also found a box with some pills in the meteor. There is a note with the pills that reads “These radioactive capsules to be used only if needed to renew our super-powers on Earth. [Signed] Jor-El”

The robber took the kryptonite-embedded box back to his lair. He swallowed one of the pills, gained super-powers, and went on a crime spree. Then he lured Superman to his hideout and exposed him to the kryptonite. Leaving the Man of Steel for dead², the criminal flies off to commit more robberies.

Of course, Superman’s not quite dead yet — he takes his last bit of energy and uses his heat vision to break the water pipe in the ceiling, sending water cascading down on the box of pills, washing all the kryptonite away³. Able to stand up again, Superman grabs the box of pills and swallows one, figuring he needs the super-powers they’ll provide since his have been stolen by the kryptonite. Too late, he discovers that some kryptonite dust had gotten in the pills when Krypton exploded — the same explosion which sent the box to Earth. Now he’ll be completely powerless until the chemical leaves his system⁴.

Thinking quickly, Superman calls Batman and Robin. When the duo shows up, he gives them each one of the super-power pills, and they fly off to capture the robber. Since they’re not used to their new powers, not only do they let the villain escape, but they cause some serious property damage. Undeterred, Superman trains them in the use of their powers and they fly off again to capture the robber.

Meanwhile, Superman — using his crafty reporter skills — has discovered the robber’s new lair. Unfortunately, the robber catches Superman in his hideout and pulls out a gun, shooting him in the chest. About this time, Batman and Robin arrive and capture the villain, who is still gloating over Superman’s body. Could the Man of Steel be dead? Of course not. It turns out that while Superman may have been powerless, his suit was still invulnerable and it blocked the bullet, saving Superman’s life. It’s all a moot point now anyway, as the kryptonite has worn off and Superman has regained his powers. He gives the super-power pills to Batman who promises to keep them safely hidden away in the Bat-cave⁵.

Notes:
1. Yes, technically he was searching for a meteorite, not a meteor, but I’m sticking with what’s written in the comic for this review.
2. If I were a criminal who gained his super-powers through a pill, I would take the pills with me instead of leaving them behind. Sure, leave the kryptonite-encrusted box — just take the pills.
3. Apparently kryptonite is water soluble.
4. Kryptonite or not, shouldn’t the pills have given Superman super-powers? They were developed to give Kryptonians who lost their powers (like Superman) temporary powers. He took one after losing his powers temporarily from kryptonite exposure, so why should more kyrptonite dust in the pills stop them from working? It’s not like they’re affected by kryptonite — Batman and Robin got powers despite the kryptonite in the pills.
5. As far as we know, the pills are still there. Or at least, all but one of the pills…

The synthesis of heme (an important part of hemoglobin and red blood cells) is a complicated process requiring eight different enzymes. If any one of these enzymes is not working correctly, then a chemical known as porphyrin builds up and the person is said to have porphyria. There are several different types of porphyria depending on which enzyme isn’t working correctly. Generally, the porphyrias can be grouped into two classes: the acute (or hepatic) porphyrias, and the cutaneous (or erythropoetic) porphyrias.

The acute porphyrias cause severe abdominal pain as well as neurological and psychological symptoms. Some of them have cutaneous (skin) symptoms as well.

The cutaneous porphyrias, as the name suggests, have primarily skin symptoms. Photosensitivity — a painful rash when exposed to light — is a common problem.

In the late seventies and early eighties, several papers and a book or two were published suggesting that porphyria was the basis for vampire and werewolf legends. There is a certain undeniable logic behind the idea. People with porphyria do not venture out in the daylight, which explains the sunlight aversion of vampires (and werewolves, to a lesser extent). The disease can cause a thinning of the lips and gums, exposing more of the teeth, giving the individual a more bestial appearance. Historically, porphyria was treated by having the patient drink animal blood. Additionally, increased hair growth can be seen in some cases of porphyria and the psychiatric symptoms can lead to strange behaviors and increased violence.

It’s an interesting hypothesis, but I’m skeptical. I’m certain that people unfortunate enough to have porphyria were accused of being vampires or werewolves, but I don’t buy the idea that the entire legend is based on the disease. The theory seems to pick and choose the symptoms of different porphyrias to support the idea, creating a hodge-podge disease that doesn’t actually exist in nature (or if it does, would be extremely, extremely rare). Drinking animal blood does not equate to a blood lust — people with porphyria may understand that blood helps their symptoms, but they don’t actually crave it. The theory also describes the modern depiction of vampires — which is quite different from the how our ancestors understood them. For example, the vampire’s violent aversion to sunlight — a main part of the porphyria link — is a twentieth century embellishment to the vampire.

I’m not alone in my views as the majority of the scientific and medical community has dropped the theory (and I’m sure most have even better reasons than the ones I mentioned.) This hasn’t stopped the “porphyria = vampirism” link from appearing in pop culture over the past several decades. I’m pretty sure I remember it showing up as a side plot in an episode of St Elsewhere in the ’80s. More recently, the idea has shown up in the Batman and Detective Comics annuals as well as this week’s episode of Castle.

In the back-up story in the Batman and Detective annuals, the Gotham City Blood Bank is vandalized and robbed, and there is also an attempted murder or two. The villain — or is it villains? — is revealed to be someone with porphyria who believes that they are a vampire.

In one scene, some blood found at the crime scene is sent off to the lab and is returned with a diagnosis of porphyria.
Here’s my annotated version of that scene:

1. DNA testing — DNA and genetic testing is one of the best ways to diagnose porphyria. However, it’s a specialized test that is only run by certain labs and it takes more than just a day or two to get results.

2. There’s been DNA testing, but they still refer to it by the general term “acute hepatic porphyria” rather than which specific porphyria it is. That’s the point of the DNA testing: to pinpoint the exact enzyme deficiency.

3. I don’t think there’s any doubt where the information from this first paragraph came from, and it’s a nice accurate paragraph. [link fixed]

4. The second paragraph is a mess though, referring to a largely abandoned theory as if it were fact. The inaccurate “blood craving” is mentioned. And what is “pale pallor?” By definition, someone with pallor is pale.

I will point out that for the most part the writer makes it clear that it is the villain who believes in the porphyria/vampirism link — and other than the lab report shown above — does not seem to endorse the connection herself.

In Castle, an insane individual who believes himself to be a vampire screams out in flames and starts to smoke when exposed to sunlight. This is later explained away as porphyria.

Now, sunlight can be painful to people with severe cutaneous porphyria, but the skin rash (blisters, usually) take several minutes of exposure to develop — and that’s in the most severe case. The skin never smokes though, that’s simply ridiculous, even for Castle.

It’s time for three more case studies to determine if you’d be a good doctor in a super-hero world. So put on your thinking caps and your diagnostic head mirrors and see if you can make the correct diagnosis.

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

In the closing panels of Red Robin #4, Tim Drake is stabbed in the abdomen with a sword by the villainous Widower. In the next issue, it is revealed that his injury required the removal of his spleen.

Found in the upper left aspect of the abdominal cavity, the spleen is roughly the size of a grapefruit and serves several important functions: It removes old and damaged blood cells from the circulation, as well as removing harmful bacteria. It assists the immune system by acting as a large lymph node. It stores extra blood to act as an emergency reserve in case of severe blood loss.

Both blunt and penetrating abdominal trauma can injure the spleen. Penetrating trauma can lead to splenic lacerations. Blunt trauma can rupture it. Unfortunately, the spleen is very difficult to repair — it was once described to me as having the consistency of a sopping, water-logged sponge. Imagine trying to sew that back together. Often the only treatment for a severely damage spleen is splenectomy (removal of the spleen), leaving the patient asplenic (without a spleen).

The main concern in people lacking a spleen is an increased risk of infection. This is not just a slight increase in risk, but a significant increase in the risk of serious infections. In the worst case scenario, there is a condition known as OPSI (overwhelming post splenectomy infection) that can be fatal within just a few hours.

Asplenic individuals are susceptible to a wide variety of germs, but the three most concerning are:

1. Bacteria that have a thick protective capsule. These bacteria include pneumoccocus (a cause of pneumonia and other infections), meningococcus (a cause of meningitis), and Haemophilus influenzae (another cause of meningitis, among other nasty infections).

2. Capnocytophaga canimorsus, a bacteria found in dog bites.

3. Parasites that like to hide within red blood cells (malaria is the main one, but also babesiosis and ehrlichiosis, rare tick-borne infections).

Asplenic individuals need to be aggressively immunized against the riskiest bacteria. They will require the pneumococcus, meningococcus, and Haemophilus influenza vaccines. The pneumoccocal vaccine may need to be repeated every 5 years. Additionally, pediatric patients who lose their spleen need to be started on daily broad spectrum antibiotics for the next 2-5 years. Those who are considered particularly high risk for infection may need daily antibiotics for the rest of their life.

The medical mystery was intriguing on this week’s House, but the medicine was shaky from the beginning, resulting in a rather pedestrian solution. Plenty of so-so soap opera, if you like that sort of thing.

The patient this week is Donny, a police officer with a deathwish. His father, grandfather, and great-grandfather all died at age 40 due to a sudden heart problem. He is convinced that he is going to die at forty as well, so he has started to take crazy chances at work, certain that he will be dead soon enough anyway. In his latest escapade, he fell 30 feet trying to jump from roof to roof after a parkour-ing thief and ended up with a concussion, a couple of broken bones, and a punctured lung. When Cameron hears about his family heart history she admits him for evaluation, to the dismay of House who thinks Donny’s family history nothing more than a coincidence.

The initial differential diagnosis for Donny, focusing on a suspected genetic heart condition, includes Marfan syndrome (an inherited disease of the connective tissue that can affect the aorta and heart valves), Brugada syndrome (an inherited abnormal heart rhythm), and familial hypercholesterolemia (an inherited condition that results in very high cholesterol and early heart attacks). Foreman orders some vague “genetic testing” in addition to an EKG, cardiac catheterization, and echocardiogram. All of the initial tests are normal, so Foreman and team proceed to run further genetic testing on the conveniently available remains of the patient’s father, grandfather, and great-grandfather. It is also discovered that Donny has a son he didn’t know about, so DNA is collected from him as well. Once again, all the tests are negative.

House decides it is time to send Donny home as there is no evidence of any disease. He and Chase tell the patient that he has the very rare (and completely fictional) condition known as Ortoli Syndrome, and that it can be successfully treated with the (fictional) drug Nabasynth. They give him a few breath mints as a placebo and send him on his way. Only it doesn’t work out so well. Donny collapses, dead, four hours later in the laundry room at his apartment complex.

Foreman has Donny’s body moved to Princeton Plainsboro so they can perform the postmortem. As he and House begin the autopsy, starting the Y incision, they notice the body is bleeding, which shouldn’t be happening in a corpse that old. Suddenly, Donny sits up and screams. It turns out he wasn’t dead after all — and no one noticed. He is readmitted to the hospital, and after a brief period of lucidity, becomes essentially unresponsive with a dangerously low blood pressure (though this is forgotten soon enough and he is awake for the rest of episode). The new differential diagnosis is tetrodotoxin exposure (the toxin from the fugu, of pufferfish), sick sinus syndrome (a condition where the heart’s natural pacemaker isn’t working right), or a sinoatrial block (another abnormal heart rhythm). House suggests the underlying problem may not be in the heart at all and recommends the team look elsewhere. Chase proposes some sort of metabolic disturbance and Foreman suggests an autoimmune disease (actually he suggests that the family suffers a “pre-disposition to an autoimmune disease”, but clearly they all had more than a mere disposition). He suggests anti-Ro antibodies (a marker for autoimmune disease) which can lead to heartblock. House concurs and Donny is started on steroids.

There is no improvement, in fact, Donny begins to complain of a severe headache that later becomes jaw pain and then a severe tooth pain. He finds a heavy surgical clamp, conveniently left in the room, and pulls his own tooth out. The team has the tooth evaluated by a dentist (using a specialist, for once) and it is normal. They now decide that Donny must have bone cancer with paraneoplastic syndrome. The inheritance is explained by Li Fraumeni syndrome (an inherited condition where patients have a high chance of developing cancer at an early age), which makes people more likely to develop bone cancer. A gamma scan (a bone scan to look for cancer) is performed but is normal — there is no bone cancer.

House now decides that the condition is a nerve problem and diagnoses Donny with hereditary sensory autonomic neuropathy, type I (an inherited degenerative nerve disorder). He is started on carbamazepine (an anti-seizure drug that can provide partial relief of pain in HSAN1). Almost immediately after starting the drug, Donny loses bowel control, so the team decides they once again have the wrong diagnosis. Autoimmune is suggested once more, but shot down. Wilson’s disease (an inherited disease of copper metabolism) is also suggested, but House notes Donny’s liver functions are normal. The counter suggestion is that his liver is so bad, the labs look normal, so they decide to go ahead and start him on the treatment for Wilson’s disease, penicillamine (rather than, you know, actually testing the liver). Later, while bantering with Cuddy, House has his Eureka! moment and deduces that Donny has a berry aneurysm slowly growing in the brain in just the right place to press against the part of the brain responsible for the heart. Some quick brain surgery and both Donny and his son survive to live a full life.

The medicine had some problems this week. As usual, major complaints are in red, minor in blue, nit-picking in green:

Berry aneurysms can be inherited, but 5 generations of patients with an aneurysm at the identical location in the brain — out of all the arteries in the brain — growing at an identical rate. If you buy that, I have some oceanfront property to sell you in Arizona.
Are the cardiac centers and tooth pain centers even near each other in the brain?

Cardiac catheterizations can have serious complications and they’re not undertaken lightly. I doubt any self respecting cardiologist — at least one who wants to keep her malpractice insurance rates somewhat affordable — would perform a cath on a healthy forty year old with no cardiac symptoms. EKG and Echocardiogram are probably overkill too, but at least they’re not invasive.

Bone Marrow DNA is “more pure?” DNA is DNA — it’s the same whatever cell you take it from. If the blood isn’t “pure enough” surely there are easier — and less painful — ways to get a sample than a bone marrow biopsy.

So this week, in addition to being the team leader and a neurologist (who missed an intracranial aneurysm — the bread and butter of his profession), Foreman is:
A pathologist
A cardiologist
A radiologist
A geneticist.

Sequencing the cardiac sodium channel, in a hospital lab, in a day. Right. See me about that property in Arizona. Even with modern equipment, gene sequencing is tricky, time consuming, and a specialized skill.

HSAN1 doesn’t fit the case at all.

For once, they don’t get a brain scan, and where is the solution? The brain.

At least run some simple tests before declaring it to be Wilson’s Disease.

Verbatim from my wife: “If I were House, I would just walk around the hospital having random conversations with people until I have my Eureka! moment and solve the case.”

I thought the medical mystery was very good this week, but the initial presentation and the Lazarus-like return; I give it an A-. The final solution was pedestrian, an incredible stretch of coincidence, and didn’t really fit all that well. I give it a D. The medicine overall was barely okay — not good, but not horribly bad — like a car accident where the car isn’t a total loss — and earns a C-. The soap opera was plentiful, but nothing spectacular. For the second week in a row, it earns a C.

Last week’s House review
A list of all prior House reviews

A low scoring week, with the high score of 5 point for the episode. Bubbarum, Dana, Jamie II, jwsellers, Robb, and Theta Sigma all scored 5 points.

Overall, TRad remains in the lead with 23 points. Alex Davis stays in second with 19 points, but is now joined by Theta Sigma. Kevin Lighton drops to fourth with his 18 points and Elizabeth drops to fifth with 15.

Click here to see the full scoreboard.

Elasti-Girl is taken over by Mento, grown as tall as her powers allow, and then used as conduit for Mento’s psychic powers. The results aren’t pretty for the locals, or for Elasti-Girl.

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed elasti-girl mento doom patrol

The science, while a little sketchy, wasn’t half-bad in this episode of Fringe. Despite this, I found the story itself rather lackluster.

The Plot:In Seattle, Greg, a businessman, walks through his office, late for a meeting with his boss. As he moves through the office, he notices that everyone he sees has the heads of demons rather than their proper heads. When he enters the conference room, he sees that his boss is also a demon, so he bludgeons him to death with his briefcase. The co-workers who wrestle Greg to the ground notice that his eyes are cloudy and twitching.

The Fringe team is called to Seattle to evaluate the case. They interview Greg at the hospital and he tells them what he saw in the office. Suddenly, he begins thrashing wildly in bed, his hair turns completely white, and he collapses, dead. Walter assists that local medical examiner with the autopsy and determines that Greg died of “acute exhaustion.” He arranges for the body to be sent to his lab at Harvard for a more complete, Walter style, autopsy.

Talking with Greg’s wife, Dunham and Peter learn that he had a history of sleep walking, but it hadn’t been a problem for several months since visiting some specialists.

A second incident has occurred: a woman driving a mini-van told her husband she saw a monster and drove her car into an innocent cyclist. She died at the scene and was found to have the same white hair Greg did.

Back in his lab, Walter finds a microchip implanted in Greg’s midbrain. A quick look at the body of the second victim shows an incision on the neck suggesting she had the same operation. Broyles takes the microchip to Nina Sharp at Massive Dynamics who identifies it as a chip designed to work on the thalamus to promote sleep. She identifies its creator as a Dr. Nayak, also in Seattle.

Dunham and Peter pay Dr. Nayak a visit. He identifies both victims as patients of his who are taking part in a clinical study on the brain chip. He takes Dunham and Peter to his office only to finf there has been a break-in. Nayak’s office has been trashed and the computers containing all the patient data are missing.

Walter and Peter hypothesize that someone is using the chips as a rudimentary form of mind control. Meanwhile, in a dark room, we see shadowy someone access the clinic’s computers and select a patient — a waitress at a local Greek restaurant. Soon she begins hallucinating before attacking the chef and then collapsing, dead. Nayak identifies her as one of his patients as well.

Back on the east coast, Walter has been experimenting with the chip and discovers that it siphons the patient’s dreams away so that they never dream. The chips can also be used to place the patient in a dreaming state while awake. Finally, he discovers that whoever is on the receiving end of the chip gets an incredible high from the stolen dreams. Olivia realizes that they are looking for someone addicted to the dreams. A brief amount of detective works reveal that Dr. Nayak himself is the perpetrator. He has a dream-addicted dark side that is causing all the problems. They track him to his home just as he is using his machine to activate the chip in an airline pilot’s head. Dunham destroys the computer, saving the pilot (and his crew and passengers), but killing Dr. Nayak in the process.

1. Wherein I Make Some Concessions
I agree that exhaustion/stress can cause high cortisone levels and dehydration. For the sake of the story, I will also accept that it can cause sudden loss of hair pigment (a la Jean Valjean) and thyroid disorders. However, I am at a loss to explain how it can cause the sudden appearance of large patches of thickened flaking skin. Sure, dehydration and low thyroid can cause skin problems, but it is the entire skin, not just large discrete patches.

2. We Solve the Problem by Breaking the Space-Time Continuum
Let me get this straight: the brain chip is used to correct non-REM sleep disorders. It does this by siphoning off dreams. Now, dreams generally occur in REM sleep, which comes after non-REM sleep. So the chips fix the sleep by removing something that hasn’t even occurred yet.

3. Department of Redundancy Department
“Blood CBC” is hopelessly redundant. CBC stands for complete blood count, so a blood CBC is a blood complete blood count.
A CBC looks at the blood cells (white, red, platelets). It doesn’t look at hormones like thyroxine and cortisol, that’s a different test entirely.

4. OMG, n00b
Yes hackers steal passwords. They also mount DDOS attacks, but these are two separate things. Claiming the lack of DDOS attack means that a hacker couldn’t be involved means the FBI (or the Fringe writers) need much better forensic computer experts. (And what would a DDOS attack against a single clinic server accomplish, anyway?)

5. It’s Not Brain Surgery — Wait, Maybe It Is
The thalamus is located deep in the center of the brain. Any surgery to reach it, let alone implant a chip in it, is going to be a major undertaking — a hole in the skull needs to made after all — and wouldn’t be performed as an outpatient clinic procedure.
The thalamus is part of the diencephalon, making it forebrain, not midbrain.
And good luck getting the clinical trial approved by the IRB.

6. Your Suspicions Are Suspicious
Hearing that one of his employees was suspected, one would think that Dr. Nayak would have volunteered the information about his assistant being missing earlier in the day, rather than waiting until the end of it (or was that the effect of Hyde-Nayak?).

7. A Shot In The Dark
Peter, Dunham and the other FBI agent can’t find an on/off switch or a plug or a circuit breaker between the three of them? So the next logical step is shooting the server?

It’s the reverse of last week. This time, I found the science acceptable, but the story tepid — so they cancel out and the clock stays at 11:55

A list of all previous Fringe reviews is available here.

Tags: television medicine fringe sleep rem hacker adrenalin

When and why did placing the hands on either side of the forehead become the official pose of telepaths and other comic book psychics?

I figure there are several possibilities why:
1. The brains of psychics are heavier than normal — especially when using their powers — and they need the extra support.
2. It’s an aiming device.
3. Psychic powers cause migraines and they’re massaging the sensitive spots.
4. It increases downforce, in case one of those pesky psychic winds comes along. It also helps them in cornering on banked tracks.
5. They close their eyes when concentrating and it prevents them from bumping into anything if they start walking around.
6. It prevents a psychic nosebleed.

As for when , as far as I can find (in my admittedly brief search), it goes back to X-Men #3 (January 1964):

A common theme of DC Comic’s public service ads in the 1950s and ’60s was support for the United Nations. This was from an era when the relationship between the US and the UN was much less contentious than it is now. I thought this was an appropriate ad because it features both Iran and the UN, which have been in the news frequently lately, albeit for vastly different reasons.

The four planes representing Iran’s “United Nations Friends” are labeled US, USSR, India, and Pakistan.

Based on when this PSA was written, I suspect the planes are spraying DDT, which — depending on your view of Rachel Carson and Silent Spring — may very well have caused more problems than it solved.

This PSA scores a hat trick and is found in DC comics from December 1950, March 1955, and November 1963. This particular ad was scanned in from Adventure Comics #202 (March 1955) This PSA was written by Jack Schiff with Win Mortimer on art.

More PSAs

Tags: comics psa united nations iran jack schiff bob brown

High score for the week goes to Alex Davis and Linda Pollock both with 7 points.

Overall, TRad retains the lead with 23 points. Alex Davis moves to second with 19 points. Kevin Lighton drops to third with 18 points. Elizabeth remains in fourth with 15, and atg and Theta Sigma are tied for fifth with 14 points.

Click here to see the full scoreboard.

Amazing Spider-Man #600

When evaluating the pupillary response in a patient, have them take off their sunglasses first.

Invincible Iron Man #14

We already know that Norman Osborn is no good at anatomy, but it turns out he is clueless at computer science as well. Here, when he is trying to convince the Russians to allow him in their county to look for fugitives Tony Stark and Pepper Potts, he refers to “picobytes of…data.”

There is no such thing as picobyte — it is impossible. A byte is made up of 8 bits*, and a bit is as small as you can subdivide a byte. A “picobyte” then, would refer to one trillionth (10^-12) of a byte, which is orders of magnitude smaller than a byte can be divided.

I assume Osborn meant to say “petabyte” (a quadrillion bytes) — or maybe he meant Pikabyte, the loneliest of the Pokemon.

*There have been computer systems in which a byte is more or less than 8 bits, but 8 bits is standard now, and it was never more than 36 bits-per-byte.

An exciting episode of Fringe that did a nice job advancing the overall plot. The action and suspense were well done, but the medicine was rather abysmal.

The Plot: A cryogenic storage facility is robbed and a truckload of frozen human heads is stolen. Four security officers are killed in the robbery — well, actually it’s three officers killed and one shape shifter. The Fringe team is called after the last corpse is found bleeding a silver colored liquid. While Walter inspects the corpse, Peter mentions that this is the third cryogenic facility robbed in the last week, and every time, only human heads are stolen.

Back at the lab, Walter has Agent Dunham drink a concoction of ground up flatworms to help restore her memory of her time on the parallel Earth. It seems to work as she begins to have brief flashbacks as the episode progresses.

Walter finishes the autopsy and discovers that the shape shifters’ blood is 47% mercury. He realizes that there was only trace mercury in the previous body they thought had been a shape shifter (the Nurse from the first episode), so that means the shape shifter who tried to kill Olivia is still out there.

Walter and Peter to hunt down Rebecca, the girl from the ESP video (first episode again), to see if she can still detect the shape shifters with her psychic powers. She tells them her powers faded a few years ago, but she agrees to repeat the experiment to see if her powers will return. She returns to the lab and is dosed with a variety of hallucinogens.

Meanwhile, Agent Dunham takes the device found on the dead shape shifter to the lab at Massive Dynamics. They tell her they can use the new device to repair the damaged device from the first shape shifter and will be able to generate an image of who he is disguised as now. They’ll have the results sent to Walter’s lab and Olivia’s phone.

Back at the lab, Dunam collapses and has an extended flashback to her time in the other universe. She remembers William Bell telling here that there is a war coming and he needs her to guard the gate between the two worlds. He tells her the shape shifters are looking for a certain person — a leader who can open the gate — and that’s why they’re after the frozen heads; one of them is the leader. Later, when Dunham is telling Nina Sharp of her recovered memories, Charlie calls to inform her that Nina is the shape shifter. She all but runs out of the building and encounters Charlie outside. Just then, her phone rings and sends her the results from the device that reveal that it is Charlie who is the shape shifter. There is a brutal fight, and at the end, Dunham shoots him, repeatedly. And then she learns that the other shape shifters have found their leader. This is what we call a downer ending.

1. The Worm Turns
Ah, the famed planarian experiments from the 1950s. A “scientist” trained some of the flatworms to run a maze. He then killed them and fed their remains to a second group of flatworms. This second batch of flatworms was found to be able to run the maze faster, suggested that they had gained the memories of the worms they ate. This experiment was actually featured in one of the greatest comic books of all time (Saga of the Swamp Thing #21 — “The Anatomy Lesson”). Trouble is, it’s not true. While the story of the experiment persists as a myth/urban legend, few actual scientists believe the results are valid. Over the intervening fifty years, no one has been able to duplicate the results despite repeated attempts. The current suspicion is that the positive results of the initial experiment were due to either observer bias (the tests weren’t double blinded), or the fact that the worms were following the slime trails left by the initial batch of worms.
Even if the experimental results were valid, why would that apply here? By drinking all the flatworms, shouldn’t Olivia have gained flatworm memories, not her own?

2. The Medicine Cabient
Salvia – a native Mexican plant with hallucinatory and dissociative properties. Currently legal in the U.S., but maybe not for long.
Phenothiazine - medically, it refers to a class of antipsychotic drugs derived from the chemical phenothiazine. The chemical itself isn’t really used in medicine, but is used as a dye, insecticide, and livestock dewormer.
Valium – a benzodiazepine. A relaxant and sedative. Addictive.

3. A Bad Resuscitation
How is turning Olivia’s head to the side going to open her airway?
Nitroglycerin relaxes blood vessels and drops the blood pressure. How’s that going to help Olivia?
30cc is a large amount of medication to give. If oral, that’s a shot-glass full of liquid to get down an unconscious person. If intravenous or intramuscular, that’s a hell of a lot to get in. Most IV or IM medications are 1cc or less.
I know I’ve mentioned this before several times (including a previous episode of Fringe), but despite what you’ve seen on Pulp Fiction, shooting adrenalin into the heart is a bad idea. It’s a blind stick and you could easily miss the heart, or worse, rupture one of the coronary arteries and cause a heart attack. There are other options for giving adrenalin: inject it into a blood vessel, or squirt it down the throat.

The story was good, but the medicine was bad, so it’s a wash and the Doomsday Clock stays at five ’til midnight

UPDATE: Oh look, I’ve made a Fringe landing page. It’s plain now, but I’ll fancy it up soon.

from the cover of Angel #23 (by Lynch and Urru)

What’s the error in this picture taken from the cover of Angel #23. It may be a little subtle, but once you catch it you’ll kick yourself. (And for the record, the interior art does not share the same mistake.)

Previous picture quizzes

A good episode of House, with a nice turn by Thulsa Doom, full of many layers of moral dilemmas. Plus, if you ignore the scenes dealing with the heart, the medicine was pretty good.

Dibala, a brutal African dictator suspected of genocide, is in the United States to address the UN when he suddenly starts coughing up blood (or vomiting blood — it’s not entirely clear). He is admitted to House’s Foreman’s team at Princeton-Plainsboro for evaluation. The team’s initial differential diagnosis includes hemorrhagic ulcers of the lung, an assassination attempt using polonium (suggested by the dictator), and acid reflux. Foreman notices a bug bite on the patient’s hand and thinks he had has malaria. House, on the other hand, thinks the bump is not a bug bite but instead chloracne indicating dioxin poisoning (probably from an assassination attempt). Foreman goes with House’s idea and starts Dibala on Olestra (the same “fake fat” once used in no-fat potato chips. It is thought to increase fecal excretion of dioxin — i.e. it makes you poop more).

Dibala suffers a heart attack. He is started on oxygen, heparin (a blood thinner), and streptokinase (a “clot buster”). He survives, but since the heart is now involved and he has also developed a low grade fever, the team revisits their differential diagnosis. They now focus mostly on infectious causes including Lassa fever, Ebola, Marburg, and trypanosomiasis (African Sleeping Sickness). Once again, Foreman goes with House’s suggestion and starts the patient on ribavirin to treat Lassa fever. Dibala’s staff bring in an expatriate who has survived Lassa fever. They want to use her blood to help treat Dibala (they will presumably inject her antibodies — which would include antibodies against Lassa — into Dibala, providing him with passive immunity). Cuddy agrees over Cameron’s dissent.

Meanwhile, an opponent of Dibala has sneaked into the hospital and attempted to assassinate the dictator. The shots miss, but while evaluating Dibala, Chase notices a right eye hemorrhage. Further evaluation shows that an enlarged lymph node has blocked the retinal vein, leading to the bleeding into the eye. With lymph node involvement, the differential changes again and now consists of sarcoidosis, a Staph infection, and lymphoma. The lymphoma seems the most likely, so a biopsy is checked, but turns out to be completely normal. When Chase and Cameron tell Dibala the results of the test, it becomes clear that he is having problems with his short term memory. House suspects scleroderma is the cause, but Foreman suggests blastomycosis, a fungal infection (the argument here seems confusing to me: Chase says he agrees with Foreman, but then says he doesn’t think it is fungal). This time, Foreman sticks with his choice and starts Dibala on Amphotericin B, an antifungal medication. Cameron begins to have second thoughts that maybe it was scleroderma after all. Some blood tests are run which show that Dibala is positive for anticentromere antibodies (a test for scleroderma). As Foreman points out, it’s not a perfect test, but it does strongly suggest that scleroderma is the cause. Taking this into account, Foreman stops the Amphotericin and starts steroids to treat the scleroderma.

The next time we see Dibala, he is bleeding copiously from his mouth and nose. Chase is using a bronchoscope to look down into his lungs to find the source of the bleeding. He is able to cauterize one bleeding area, but another appears, and then another and another. It is too much for Dibala and his heart stops and he flatlines. Foreman calls for the paddles and the patient is shocked and shocked and shocked and shocked — all the while blood is pouring from his mouth and nose. It’s no use though, Dibala is dead.

After it’s all over, Foreman is mulling over the case and can’t decide what mistake he made. Was he too stubborn, or not stubborn enough? He wants to recheck some tests, but Dibala’s body is locked in the morgue. He discovers Chase visited the morgue earlier in the day and realizes that the blood tests for scleroderma did not come from Dibala at all, but from an elderly patient who died of the condition. Chase had purposefully misled Foreman so that Dibala would get the wrong treatment and die.

The medicine, for the most part (i.e. ignoring the cardiac scenes) was fairly sound. But, oh, those heart scenes dragged it down.As usual, major complaints are in red, minor in blue, nit-picking in green:

I’ve discussed shocking flat lines many times before — and I’m going to do it again — but with a twist: Dibali’s problem isn’t that his heart has stopped, it’s that’s he’s losing massive amounts of blood — which in turn is leading to the heart stopping. No amount of shocking (or anything) is going to restart the heart until the bleeding is stopped and blood replaced. It probably would not have been a bad idea to try some other maneuvers before declaring him dead (epinephrine or atropine, or CPR), but as I mentioned above, it wouldn’t have made a difference unless they stopped the hemorrhage first.

A recent bleeding problem (i.e. in the last six weeks) is a relative contraindication to the use of thrombolytic (clot busting) therapy. In another words, while not an absolute no-no, think twice before doing it. Dibala had some significant bleeding in his lungs just a day or two before — is using streptokinase really a good idea?
Regardless, you don’t give heparin with streptokinase (other thrombolytics, yes, just not streptokinase).
You’d think they’d use a newer thrombolytic at a cutting edge hospital like Princeton-Plainsboro.

You don’t give Amphotericin IV push — it’s too dangerous. Quoting the FDA: “rapid intravenous infusion has been associated with hypotension, hypokalemia, arrhythmias, and shock.”

The incubation period of malaria is at least seven days, usually longer. The mosquito bite mark should have gone away by then.
To be fair to Foreman, it’s quite a stretch for House to consider a single bump on the hand chloracne.

Anticentromere antibodies tend to occur in the more limited, milder forms of scleroderma. This should have given Foreman more reason for pause.

The mirror box is a relatively new technique for phantom limb pain, and while it does show promise, it doesn’t work that fast (it takes multiple treatments) or that completely.

The medical mystery was good this week — lots of unexplained bleeding usually is — though not terribly original. It earns a B+. The final solution generally fit the symptoms, and had a nice twist, so earns another B+. I have mixed feelings about the medicine overall. Most of it was quite good, but two scenes were particularly bad. I wish I could split the score, but I can’t (well, it is my site, so I guess I could — but I won’t), so I give the medicine a weak C. The soap opera was very good. There was House/Wilson, House/Neighbor, House/Foreman, Foreman/Thirteen, Chase/Cameron, Chase/Dibali, Cameron/Dibali, and of course, Foreman/Chase. It deserves an A.

Last week’s House review
A list of all prior House reviews

High score for the week goes to TRad with 13 points with Elizabeth second with 12 points.

Overall, TRad is in the lead with 20 points. Kevin Lighton is second with 17 points, and Theta Sigma is third with 4 points. Tied for fourth with 13 points are atg and Elizabeth.

Click here to see the full scoreboard.

Power Girl #5 “Space Girls Gone Wild”
Jimmy Palmiotti, Justin Gray, writers
Amanda Conner, penciler

Power Girl is caught in the middle of the explosion of a spaceship that crashed in a city park. The local police, firefighters, and EMTs rush in survey the damage, provide first aid, and move her out of the crater.

They’ve got her on oxygen and they’re using a backboard, so everything’s good right?

Not quite. They forgot to secure Power Girl’s head/neck and if there’s any damage to the cervical spine or cervical spinal cord, this could be a big problem (what sort of problem? Quadriplegia). The image above shows the danger perfectly. Look at the angle her head is at compared to the rest of her body.

Here’s an annotated version to make it even clearer:

I suspect the rescue personnel were a little distracted.

I found this the best episode of the season, so far, and one of the better ones overall. There were certainly scientific mistakes, but it was nice to see some of the “police procedural” scenes well done, fo once

The Plot:Officer Gillespie, a policeman in Philadelphia receives a mysterious phone call from the “Colonel” and is told to head to a nearby subway station and stop a man in a black trenchcoat with a black briefcase. When the officer spots the suspect and tries to grab the suitcase, he suddenly begins to crystalize. Gillespie screams in pain, then explodes, killing all around him

The Fringe Team is called in to evaluate the Philadelphia explosion because no evidence of any explosive material can be found. Poking around, Walter finds some crystallized parts of Office Gillespie, and realizes that it was the officer that exploded. He takes the bodies back to the lab for autopsy. As he pieces the crystallized officer back together, he finds needle marks between the toes — Gillespie had been injecting himself with some unknown medication.

Meanwhile, Peter takes the subway station surveillance tapes to one of his contacts, because the tapes all were strangely full of static. Peter’s friend is able to remove a little of the static but not much, so what led up to the explosion of Gillespie remains unclear. His friend speculates radio wave interference caused the static. Later, Peter and Dunham are talking to the officer’s widow when Dunham stumbles across a hidden case consisting of a syringe and a strange injectable medicine.

Across the country, Captain Burgess, once a military officer, now a suburban housewife, is seen injecting herself with the same medication. Later that day, the Colonel appears and tells her she is needed on a mission to Washington D.C. He provides her with airline tickets and hotel reservations.

Dunham and Peter discover that the Gillespie was part of an experimental medical program while he was stationed in Iraq. They travel to Iraq and track down one of the doctors who worked on the program, which was developed to produce an antidote to the chemical agent cyanogen chloride. The experiments weren’t very successful — only four out of 200 patients survived. Plus there was another unfortunate side effect: the serum turned the users into human bombs if they were exposed to a certain radio frequency.

Back in the United States, Broyles in charge of taskforce put together to capture Captain Burgess and the Colonel. They track her to a Metro station in Washington. Peter spots the Colonel and a brawl begins. Dunham is able to shut down the radio signal the Colonel had been sending just in time to stop Burgess before she exploded.

Back in FBI custody, the Colonel tells Broyles that he was trying to stop the “others” — who were planning a war and passing intelligence by a network of couriers. In the end, we see a courier hand a briefcase to the Observer, who opens it to reveal surveillance photos of Walter.

1. A Quick Summation
The idea of a person being turned into an explosive device is clever, but I just don’t see how it would work. Where would the energy of an explosion that powerful come from — even if the person were injecting a strange medication and turning to crystal? I just don’t think there are that many high-energy bonds to break in a human (particularly since the explosion left behind identifiable pieces). Admittedly, this is all “back of the envelope” math so I could be wrong, but color me suspicious.

2. Deus Ex EMP
Does an “EMP disabling device disable” EMPs, or is does it utilize EMPs to disable devices?
If the former, wouldn’t the EMP disabling device itself be disabled by an EMP?
If the latter, how did it know which device to disable or when to activate? It can’t be “always on”.
Regardless, if the device scrambles all radio waves, you wouldn’t be able to listen to the radio or talk on your cell phone inside the station.

3. Moses Supposed his Toeses are Roses
The webspace between the toes is used by addicts to inject drugs because the track marks are harder to find. It is commonly used by medical personnel who are addicted.
Captain Burgess’s injection was horrible as she has apparently never heard of sterile technique. There are nasty germs on the soles of the feet, why invite them into the body?

4. Just Like Detective Comics
Cyanogen chloride is a nasty chemical weapon. It acts as both an irritant (to the skin, mucous membranes, and respiratory tract) and a cyanide agent. Like most cyanide agents, it is quick acting (less than 10 minutes, usually). Treatment involves skin decontamination and use of cyanide antidotes.
With treatment, the chemical is cleared from the body quickly, there would be no need for continuing injections. And even if the soldier