Polite Dissent

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What was the rash from?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

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

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

Tags: television fringe precognition bomb hypnosis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Interferon is not a treatment for encephalitis or meningitis.

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

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

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

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

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

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

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

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

More Comic Book Truth Serums

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

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

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

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

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

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

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

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

Oops. How could Matt have missed that?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Of bandaging the head over the costume?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

More Little Dot…

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Schizoid and schizophrenia are not the same thing.

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

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

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

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

scene from The Sixth Gun #14

All previous Psychic Nosebleed Zen posts.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

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

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

9. Gratuitous Product Placement
Sprint for the win.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

scene from Amazing Spider-Man #673

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Nitrates don’t cause renal insufficiency.

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

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

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

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

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

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

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

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

Watching the Cardinals/Phillies game. Come back tomorrow.

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

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

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

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

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

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

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

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

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

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

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

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

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

Was Nick’s broken arm/elbow ever treated?

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

A list of all prior House reviews

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

Click here to see the full scoreboard.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

An autopsy of the translucent men back at Walter’s lab reveals some tech similar to that used by the shapeshifters from the previous two seasons. To Walter, this is proof that they are part of a scheme by Walternate. Olivia takes the suspicious tech to the Liberty Island dimensional bridge and hands it over to Fauxlivia, who says she’ll “look into it.” Agent Lee tags along as well, learning more of Fringe Division’s secrets.

The episode ends with a few more brief vignettes: a third translucent “man” is seen, only this one looks just like the female second victim. An Observer shows up outside Walter’s lab with his machine, the one designed to erase someone from history. He turns it on, but appears to think better of it, and switches it off. Finally, Walter sees Peter’s reflection in his television set, and it is clear that he is spooked by the fact that he keeps seeing this person who he does not recognize.

1. Lesson One: Never Partner with Olivia
Which partner is Olivia referring to when she told Lee about her dead partner? Agent Scott? Charlie?

2. Is She Reading Ahead in the Script?
Why evidence did Olivia have that the translucent men were shapeshifters, other than the suspicious tech? I bring this up because she referred to them that way when talking to Fauxlivia but had she seen one change, or appear in someone else’s shape? The only shapeshfiting I recall was the female translucent “man”, and we saw that after the Liberty Island hand off.

3. Is this FRINGE or HOUSE?
Walter is making quite a reach with his statement blaming heavy metal poisoning. First, bear in mind that there are dozens of heavy metals (from a medical point of view, pretty much every metal with toxicity is considered a “heavy metal”) and they each can cause different symptoms. Sure, everything he mentions can be associated with heavy metal poisoning, but only in very very rare cases. Yes, some heavy metal poisonings can cause hair loss. But it is an extremely unusual cause of hair loss and there would be many other more telling symptoms of heavy metal poisoning. Genetics, sadly, is by far the most common cause of hair loss (trust me on this one: personal experience). Similarly, some heavy metal toxicities can cause kidney disease, but there are many more common causes — high blood pressure or diabetes, for instance. High lead levels can cause gout (saturnine gout), but this once again is a very rare cause. I’ve probably seen several hundred gout cases, and never yet seen one associated with lead toxicity. Most gout is caused by bad genes, and poor diet is the second most common cause. Crohn’s is not associated with heavy metal poisoning either (but in this case, I assume it was the iron Agent Danzig was taking that Walter was referring to, not the Crohn’s itself).

4. One Way Street
If the translucent man was injecting into a vein, the chemical was flowing the wrong direction, but maybe it was an artery…

5. Be Careful Around the Thirteenth One
I’m pretty sure the secret to being a good FBI Fringe Agent is just to keep an eye on every warehouse in town. Damn villains are always using those warehouses.

6. Put On a Jacket
I suspect Walter’s prominent mention of John le Carre’s novel The Spy Who Came in from the Cold is a hint at things to come, but its exact significance escapes me, unless he is similar suggesting intricate plots within plots within plots in the Fringe world (which, like the era of le Carre’s book, is in a Cold War — this time between the two dimensions).

7. Flashpoint
I’m sure the timing is just coincidental, but this Fringe reboot is reminding me an awful lot of the current Nu52 reboot at DC Comics. If Olivia starts wearing red lingerie or sleeping around, I’ll become extremely concerned (of course, this is Fringe after all — maybe it’s Walter who’ll wear the red lingerie).

A fairly slow episode, but it was clearly designed to introduce the new status quo and stir up some plot elements for later in the season. The Fringe Doomsday Clock remains where it ended last season at five seven minutes to midnight. (Or Doosmday Clock, if you prefer.)

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

I thought we had this one licked: psychiatry ≠ psychology

One does not earn a degree in psychiatry because it is medical specialty, not a field of study per se. Having a “PhD in Psychiatry” would be like having a degree in Family Practice, or Surgery, or Rheumatology. That’s not how medical education works.

A PhD would be in Psychology – a related, though distinctly, different field.

(For the record, Leonard Samson, MD, is a psychiatrist. He may also have a degree in psychology, but if so, it’s never been mentioned)

Panel 1: I have yet to called in by law enforcement to assist on any case. On reflection, this is probably a good thing for all involved.

Panel 2: You cannot diagnose hypertension (i.e. high blood pressure) from across the room. There are generally no symptoms in hypertension until it is too late, and the patient is suffering a heart attack, stroke, or hypertensive crisis — that’s why it’s called “the silent killer.” And let’s not forget that it’s impossible to diagnoses high blood pressure without actually checking the blood pressure!

Panel 3: “Jim, this man is a Klingon!”

Panel 4: A pulseless patient makes the original diagnosis of high blood pressure all the more ludicrous, doesn’t it doctor? You can’t have high blood pressure if you don’t have a pulse. Also, it appears that not having a pulse is a crime in this town.

In this scene from the final issue of the overwhelming treacly mini-series Heroic Age: One Month to Live, reformed banker Dennis Sykes uses his recently acquired powers to stop the villain Hammerhead from crushing his family with a car. The series had a rotating cast of writers and artists, but this issue is courtesy of Rick Remender and Jamie McKelvie.

All previous Psychic Nosebleed Zen posts.

Tags: comics medicine nosebleed heroic age remender mckelvie

I would love for somebody to explain this picture to me.

In Red Robin #26, the final issue of the series, Red Robin distracts the guards at S.T.A.R. Labs by dosing their coffee with Ipecac.

Like Bromide, Ipecac is what I like to call a time capsule drug: it’s familiar to readers of a certain generation, but not as familiar to modern readers because time, and medical therapy, have passed it by.

If you were a parent in the 1960s, ‘70s, or ‘80s, you probably remember the drug Ipecac (and if you were a child of that era with certain bad habits, you may be familiar with it as well). Ipecac was once considered one of the most important drugs for conscientious parents to keep at home. Parents of newborns were sent home with a bottle of it, and at every routine office visit the pediatrician would make sure you still had your Ipecac.

What was so special about Ipecac? Simple: it is an incredible effective emetic. In other words, it makes you vomit. Ipecac works by directly irritating the stomach as well as stimulating the CTZ (the puke center of the brain). About thirty minutes after taking the drug, the vomiting will start.

Why was this thought to be a good idea? Ipecac was felt to be a very effective treatment for poisoning. If Junior swallowed down some of Grandma’s pills, or downed a bottle of Grandad’s Old Grandad, you could feed him some Ipecac and have him throw up the offending substance before it could cause problems.

Over time though, opinions about Ipecac began the change. Though many physicians had an anecdote or two about patients saved by the drug, recent studies demonstrated no real benefit in using the drug over other treatments. Additionally, like many pediatric drugs, overdoses by frantic parents were common. (This is the same reason that many children’s cold medicines have been pulled off the market: there’s no evidence they actually solve the problem, and there’s documented risk of overdosing).

Ipecac also provided a couple of other problems. First, there are many poisons you don’t want to throw up — including a number common household chemicals. For example, caustic cleaners or gasoline burn and scar the esophagus when swallowed and would do the same thing again if vomited back up. Second, Ipecac was often too effective and patients would continue to vomit for hours, including throwing up the treatments given by hospital personnel. Third, because Ipecac was easy to obtain and very effective, it was often abused by bulimics. Meanwhile, over the same period time, advances in emergency response and hospital treatment of poisoning meant that victims can receive definitive treatment for poisoning in the same time it would take for Ipecac to take effect.

Given all these factors, Ipecac is no longer recommended for treatment of poisoning and — though it is technically still available over the counter — it has become harder to find.

Personally, I remember that my mother kept a small brown bottle of Ipecac in the medicine cabinet, but never used it and eventually threw it away, unopened. In medical school, I was taught about the drug during Pharmacology class and briefly during an Emergency Medicine rotation. It was never mentioned during any Pediatric rotation. During residency, we instructed parents to have a bottle of Ipecac at home, but only to use it when directed by the poison control hotline; they were never to use it on their own. Since starting private practice, I have never mentioned the drug or discussed it with parents – though admittedly I live and practice in an area with an abundance of hospitals and an excellent ambulance service.

Season Eight of House starts in three weeks, on October 3rd, so it’s time to begin this year’s House challenge.

It’s free, it’s fun, it’s easy. Here’s how to play:

To play the full season, your list must be posted in the comments section by 7pm (Central time) October 3rd — the night the season starts. Later entries are accepted and will start accruing points the following week.

The spam filter likes to hold on to these lists, so if yours doesn’t appear right away, don’t panic. If it’s been at least six hours and it still hasn’t shown up, drop me a line and I’ll hunt it down.

Make damn sure you take Undead Medicine as one of your fourth year electives during medical school — you never know when it will come in handy.

Two more recent syringe covers. I think this syringes must be the most common modern-era medical cover theme (as opposed to older eras, where the standing x-ray cover gag was the most common).

Streets of Gotham #28

Victorian Undead II #5

Here’s one more to add to the list of common medically-based cover themes (previously I’ve covered x-rays, nurses, and syringes, just to name a few).

Uncle Scrooge #28

Looney Tunes #194

Panic #8

Oh no! Will Flash run again? Will his leg somehow be saved? Don’t ask me — ask the doctor with the strange head mirror since he seems to know what’s going on.

This panel presents a nice view of outdated medicine:

scene from Worlds of Fear #8 (1953)

For the better part of the twentieth century, bromide (potassium bromide) was a common treatment for anxiety and other “nervous afflictions.” Potassium bromide was first used medically in the 1850s as a successful treatment for epilepsy¹. By the turn of the century, its beneficial effects in treating anxiety were also noted — most of which were probably due to its sedative effects. Extremely common, bromide was found not just in prescription medications of the time, but in over the counter remedies as well.

In the Merck Manual, 7th Ed., published in 1940, potassium bromide was listed as the preferred medication for treating anxiety and hysterics. Here’s more of what the Merck Manual listed under Potassium Bromide²:

Over time, the use of bromide became less and less common. Newer, more potent medications with fewer side effects were developed. Chronic bromide toxicity (bromism) was also recognized as a very real problem. By the Merck Manual, 11th Ed. (1966), the drug isn’t even mentioned. In 1975, potassium bromide was withdrawn from the medicinal market in the United States³.

Remember last week when I remarked how strange it was that so many people in Superman storylines seemed to come down with incurable tropical diseases? Here’s another good example: actress Lyrica Lloyd. Clark Kent falls in love with Llyrica and reveals his secret identity only to learn she’s dying from a fatal disease she picked up at a film shoot in Africa.

Superman vows to help, promising to scour the universe to find a cure, but instead we see that he’s constructed a “super oxygen tent” that does little to help Lyrica, and she dies…another victim of the Superman writers and their fondness for tropical diseases.

I always like to post non-Big Two comic book public service ads when I run across them, and here is one I stumbled across recently from Comico in 1987.

A simple one-panel anti-smoking PSA from Justice Machine #2, the Comico years. For those of you unfamiliar with the Justice Machine, the character shown is Talisman, who has luck/karma based powers, hence the “Don’t Press Your Luck” tagline.

Mike refers to Mike Gustovich, the artist and creator of the Justice Machine — who apparently is really opposed to smoking — and Tony refers to non other than recent blogging convert Tony Isabella, who was writing the comic.

More PSAs

Tags: comics psa justice machinemike gustovich tony isabella

A hospital x-ray machine has more than enough penetrating power to send x-rays all the way through the skull and brain. (In fact, you could argue that the x-ray machines used in 1961, when this comic was published, were more powerful than modern equipment. Today, we worry about radiation dose so we focus on finesse and minimizing exposure, while in years past the issue was one of raw power, radiation exposure be damned.)

The problem with locating the glass fragment has nothing to do with the range of the x-rays, it’s the fact that glass is radiolucent — invisible to x-rays. It doesn’t matter how strong the x-rays are, glass simply won’t show up on them.

Final Note: Not all glass is radiolucent, but the great majority of it is. For example, it is my understanding that the glass used in automobile windows is purposefully designed to be visible in x-rays (radiopaque). Personally, I’ve had numerous patients come in to the office complaining of a stepping on a splinter of glass, and only once has it ever showed up on x-ray — and that was a piece of lead crystal.

Mr. Malverne, the father of Supergirl’s boyfriend Dick Malverne, has come down with a deadly tropical disease¹. As his condition worsens, the doctors decide they have no choice but to try the experimental “miracle” serum Spracolicin².

Meanwhile, Supergirl is having problems of her own because she has been exposed to six red kryptonite meteors. As every fan of Silver Age wackiness remembers, exposure to red kryptonite causes bizarre, but temporary, changes in Kryptonians. Each meteor has affected Supergirl in a different way, but luckily, like bad ninjas, she only has to deal with one at a time. The first meteor caused her to become morbidly obese³. The next turned into a wolfman (or wolfwoman, rather). When she turned back to normal, she used her x-ray vision to check on Dick and learned about how sick his father was.

The third red kryptonite meteor causes her to shrink down to microscopic size. Seeing the opportunity to help Mr. Malverne, trial-sized Supergirl flies across town to the hospital and enters his bloodstream by flying down a conveniently open transfusion bottle^4,5.

Once in his body, she locates the bacteria⁶ causing the tropical disease and pummels them into submission, then allows the body’s natural defenses to take over.

The doctors, of course, credit Mr. Malverne’s miraculous recovery to the Sparacolicin serum. But unfortunately: “What a shame our supply was the only amount of it in existence and the formula has just been destroyed in a fire!⁷”

Notes: 
1. What is it with the Superman writers and tropical diseases? Remember that in Silver Age continuity, Ma and Pa Kent died of a tropical disease. (Personally, I’m guessing this allowed the writers leeway with the symptoms by claiming it’s a “tropical disease” and nobody can argue otherwise.)
2. Or Sapracolicin. It’s mentioned twice in the story, and spelled differently each time.
3. At which point she disguised herself as a giant parade balloon. Seriously.
4. An infection requiring a transfusion? How unusual. Oh, it’s a tropical disease.
5. An open transfusion bottle? This couldn’t have been a good idea, even before our current era of acronym-laden health and safety regulations.
6. Forget those microscope photographs you saw in biology class — they’re wrong. What you see here is exactly what bacteria really look like.
7. Great planning there, guys. (No great loss though as the serum didn’t actually do anything.)

Story from Action Comics #283, “The Six Red K Perils of Supergirl,” by Jerry Siegel and Jim Mooney. I wasn’t sure where to file this one, was it a Forgotten Medicine of the Silver Age, Transfusion Confusion, or just general Supergirl Silver Age Wackiness?

An prison escapee uses her psychic powers to rob a bank, much to the detriment of the bank manager, resulting not only in the classic psychic nosebleed, but also psychic eyebleeds (oculorrhagia?)

All previous Psychic Nosebleed Zen posts.

Tags: comics medicine nosebleed hercules oculorrhagia

…always coming to Earth with their ultra-medicine and stealing our patients! And making a profit to boot!

(From an imaginary tale in Superman #230-231, where Jor-El is Lex Luthor’s father, and they both come to Earth from the dying Krypton. Meanwhile Clark is the biological child of Jonathan and Martha Kent, criminals in the style of Bonnie and Clyde. )

The really bizarre medicine in this story comes not from Kryptonian ultra-medicine, but from Dr. Markem, a good old Earth mad scientist (go Earth!):

From this we learn that:

1. Criminality is inherited.
2. There are evil genes — and chromosomes.
   • Are the chromosomes evil because they contain evil genes, or are they evil on their own?
3. These genes and chromosomes can be implanted in the brain where they will eventually take root.
   • Do these evil genes make an evil protein or evil enzyme?
   • Are these genes only important in the brain?
4. The scientist apparently didn’t trust that Clark would inherit his parents “evil genes” on his own.
   • Which, by my quick math, would be a 75-100% chance per gene, depending on his parents genotype.

Throughout the Contagion storyline, a number of different terms are used to refer to the proposed cure Batman hopes to make for the Apocalypse Virus.

First, it is called an antibiotic. I’m certain everyone reading this knows that antibiotics are only effective against bacterial infections, so is the wrong term to use on a treatment for a viral infection.

Next, it is repeatedly called an antidote. Antidotes are good for poisonings or toxic exposures, but not so much in infections.

Third, throughout most of the story, Batman calls it a vaccine –- but what he’s proposing isn’t a vaccine.

Finally, an antiviral cure is developed (and the correct term “antiviral” is used) — after Azrael suddenly remembers after a dozen chapters that the people who released the virus might also have a cure. Why couldn’t he figure this out on the fourth or fifth page of the story, right after he told Batman about the virus? It’s a miraculous cure too, as everybody who receives it becomes instantly better, even those on the brink of death. I wished the anti-infectives I gave worked that fast and that well.

Basically, this is a technobabble explanation why Batman and his cohorts cannot use antibodies obtained from survivors of the Apocalypse virus to protect others. You see, inside the body the antibodies are extra strong, but outside the body (and don’t ask me how the antibodies know they’re in a tube of blood outside the body) the antibodies become very weak.

It’s not clear if the pathologist is talking about all the survivor’s antibodies, or just those to the Clench.
Mutations occur at the genetic level, not the cellular one — though the effects may be seen at the cellular level phenotypically, and this may be what she is referring to…
Except that antibodies are not cells, but instead complex proteins produced by cells and released into the bloodstream.

Like much of the storyline, this whole aspect of the plot gets abruptly abandoned later when Batman announces that the survivors of the Clench weren’t actually survivors per se, but instead people who never were infected in the first place. To me, this would seem to be setting up a further line of inquiry: what prevented these people from getting infected, and can it be used to protect others? But then again, I’m not Batman.

For the first part of my look at Batman: Contagion, I want to take a close look at the cause of all the trouble: the Apocalypse Virus.

A viral plague has come to Gotham City: the Apocalypse Virus — unleashed upon the city by the Order of St Dumas. Azrael, once a member of the Order, warns Batman of the impending pandemic.

Azrael describes the Apocalypse virus as a Filovirus.

Batman goes on to state:

Filoviruses are a family of pathogenic viruses which cause a particularly nasty type of infection known as a viral hemorrhagic fever. Not all Filoviruses are infectious to humans, but those that are have extremely high fatality rates. At the time the story was written, there is no known cure for any Filovirus.

Ebolavirus is one of two genera in the Filovirus family, and there are five known species of Ebola (and none of them are Ebola Gulf-A, it’s a fictitious virus). Despite what Batman says, the Filoviruses are all from Africa, and none have been found in Central America. There is no Ebola Honduras, so your flesh is safe.

A short time later, Batman breaks into an Army germ warfare center and learns:

Initial flu-like symptoms are commonly seen in Ebola infections. Airborne spread is likely, but not conclusively proven. Blood has been shown to transmit the infection.

A key part of viral hemorrhagic fevers like Ebola is the bleeding (hence the “hemorrhage” in the name). Under normal conditions, the liver makes the proteins that prevent our blood from hemorrhaging. The Ebola infection attacks the liver, stopping the production of these proteins, which ultimately leads to heavy bleeding from pretty much every orifice in the body, including the eyes.

While I appreciate the visual of the misshapen victims of the Clench, the reasoning makes little sense. If the muscles are shrunken and desiccated (dried out), then how would they have the strength to break bones?

I give the writers credit for creating a truly alarming disease. Ebola is frightening enough in the real world, let alone the enhanced version seen here. Both the “Clench” and the “Apocalypse Virus” are nicely evocative names, even if the latter sounds like something that should be found in an X-book. Their underlying science is a little shaky and their geography suspect, but that does little to undermine what they’ve accomplished in creating the “Clench.”

As a final note, there have been some very promising work on both Ebola vaccines and anti-Ebola drugs recently, but none of these were around when the story was written, so it would be unfair to hold that against the writers.

I’m off to San Diego for the rest of the week for a medical conference and a little family R&R.

As I’ve done several times previously when I’m out of town, I’ve written a close medical look at a “‘90s comic event” to post while I’m gone. In the past, I’ve written about Batman: Knightfall and The Death of Superman. This year’s topic is Batman: Contagion. Unlike previous years, this is going to be a multi-post review.

I’ll start out with a brief Spoiler Warning, but really — this is a fifteen year old storyline — if you haven’t read it by now, you have only yourself to blame:

The Plot: Through the machinations of the Order of St Dumas (the quasi-religious cult that churns out Azraels), a highly contagious Ebola virus is loosed in Gotham. There is no known cure, but there are rumors that three people survived a previous outbreak in Greenland, so Robin, Catwoman, and Azrael head out of Gotham to track them down, hoping that they may yield a clue to a cure. Back in Gotham, Batman scowls and glares. Huntress appears and gets scowled at. Nightwing appears, but only for a few panels, because apparently he’s got better things to do. In the end, Azrael deduces that if the Order of St. Dumas created the virus, then they probably have a cure. He busts a few heads, finds the cure, and Gotham is saved.

It’s not quite a deus ex machina ending, but close. The cure is found with only Azrael breaking a sweat, and just a little one at that. There are twelve chapters in the storyline, but the center ten could easily be cut out without affecting the outcome one bit. Neither Batman’s, nor Robin’s, nor Catwoman’s, nor Huntress’s actions in anyway hasten the finding of the cure. Their actions have no effect on the plague whatsoever. Only Azrael is important in finding the cure, and frankly, he should have figured it out in the first chapter.

It’s a Batman event, but, like I said, he contributes little, if any, to the solution. Sure, it can be argued that he kept the rioters in check — but this is Gotham City, the populace riots at the drop of a hat. The anarchy on the streets of Gotham has been done many times before and since, and while this is a decent interpretation, it’s not the best (which would be No Man’s Land).

It’s not that I don’t like Batman: Contagion — I do — it just has its share of flaws, including an ending that effectively renders most of the previous issues pointless.

For those of you who’ve been around long enough to remember the S.C.R.U.B.S. system, Batman: Contagion has a SCRUBS score of 22.

Avengers #240 is a veritable treasure trove of comic book medical cliches:

From the errant tubing on the cover:
Why is the air conditioner hooked to her cheek?

To the precordial thump:
A poor choice because her collapse wasn’t witnessed; she was just found down

To the doctor-with-a-head-mirror (and in the hospital lobby, no less):

scene from Rom #2 (by Mantlo and Buscema)

Dr. Peters comes all the way out to the Clarks to make a house call — a rare thing, even back in 1980 — and gets all but called a quack by his ungrateful patient. Note that he never calls Brandy a liar or tells her she was imagining things¹, just that she has a case of shock. He may actually believe her: if she actually saw an alien robot shoot and kill townspeople, that in itself would be enough to cause “a mild case of shock.”

1. Admittedly, it is strongly implied.

New Avengers #11
Brian Michael Bendis, writer
Mike Deodato, penciler

Mockingbird has been badly injured and is rushed to the nearest emergency room. When she is found to be pulseless, she is shocked (defibrillated). Is this appropriate?

Shocking a patient without a pulse may be a good choice — it all depends on why they’re pulseless. Remember, the pulse is a finding on physical exam; it is not read from a monitor or display.

There are many reasons a patient could not have a pulse:

1. They could have an abnormal heart rhythm, such as atrial fibrillation or ventricular fibrillation, which causes the heart to beat so fast there is not enough time for it to fill with blood and pump it throughout the body. In this situation, defibrillation is the correct treatment.

2. The patient could be in asystole (flatline) or PEA (pulseless electrical activity– some electrical activity in the heart, but not enough to cause the heart to beat.) These are signs of a dead or dying heart. Defibrillation is not appropriate.

3. The heart could be beating normally — or almost normally — but there is some systemic reason there is no pulse. For example, there could have been so much blood loss that not enough force can be produced to generate a pulse. Other reasons would include vascular damage from trauma, or abnormally hardened arteries that don’t transmit a pulse well. The treatment in this situation is to correct the systemic problem, and hopefully that will be enough.

4. Finally, you could have an incompetent doctor who can’t find the pulse. (Admittedly, trying to find a pulse in a crashing patient, let alone one with significant trauma, can be quite challenging). Treatment? Keep trying.

If Mockingbird falls into the first category, then defibrillating is a good choice. However, every sign points to her being in the second category, where shocking is not appropriate.

Her initial heart rate shows bradycardia (a slow rhythm) with no signs of fibrillation. If anything, it appears to be slowing down. It also make the official flatline sound of “beep beep beep beep beeeeeeee—“

The doctor reports that she has “no readable pulse.” As I mentioned earlier, you don’t read a pulse — you palpate (feel) it. This suggests he is looking at the heart monitor and reading the heart rate, not the pulse. A heart rate of zero is a flatline, and as I’ve discussed many times before, you don’t shock a flatline.

Final thoughts:
Kudos for at least acknowledging the need for an airway.
For a patient with a chest wound, they’re futzing with her abdomen an awful lot.

First of all, “a thousand gigawatts”? Why not just call it “terawatt”? (I know, a thousand gigawatts sounds bigger, but then why not go with “one million megawatts”?)

I’m not surprised that Maul’s brain is short circuited: a terawatt (oops, “one thousand gigawatts”) is a huge amount. In an entire year, mankind uses just under 16 terawatts of power. That means that Maul is being subjected to 1/16th of the world’s total energy consumption. Or to look at it another way, all the wattage produced by every nuclear reactor in the world is now flowing through him. Ouch.

That’s one hell of a taser.

Please Dr. Heath: a brain embolism is a stroke.

(Technically, a brain embolism is a type of stroke. Broadly speaking, there are two types of stroke: ischemic and hemorrhagic. In ischemic strokes, one of the blood vessels supplying the brain has been blocked. This blockage could be due to a clot formed in the brain [thrombus] or a clot or other blockage from elsewhere in the body that has traveled to the brain [embolism]. On the other hand, in hemorrhagic strokes, one of these blood vessels supplying the brain has started to bleed out. )

Ordering an MRI to determine which type of stroke is appropriate, since they’re treated in very different ways.

A rare treat here, a doctor who knows how to wear a head mirror: it’s over an eye instead of in the center of the forehead, and the hinge is drawn correctly off-center.

On one hand, you’d think technologically advanced Thanagar wouldn’t need head mirrors — but then again, it’s clear we are dealing with the Thanagarian underclasses here. It still doesn’t explain why an Ob/Gyn doctor needs a head mirror, though.

What’s the error in this scene from WildC.A.T.S. Annual #1? (On a scale of 1-10, with 1 being the easiest and 10 being the hardest, I rate this quiz a ½.)

Previous picture quizzes

Let’s not even talk about how this doctor is sharing the bad news (not too poorly, actually), or how accurate his information about leukemia is (greatly oversimplified), let’s just look at the horrendous blocking of this scene:

scene from Extreme Justice #0. Click to embiggen.

Panel 1
Outside view of doctor’s office

Panel 2
Doctor: Leaning against counter, reading long printout of labs
Ron Raymond: Sitting on exam table.

Panel 3
Doctor: The shadow obscuring the left half of his face has somehow turned his lab coat gray.

Panel 4
Doctor: Appears suddenly behind Ron. Lab coat is white again.

Panel 5
Doctor: Now he’s behind a desk; on top of which there is apparently a hobbit skull.

For the record, on the next page, the doctor remains behind the desk, though his lab coat flips between white and gray – maybe the room is lit like a bad disco? His top shirt buttons also are now undone — he opened them out of compassion, I suppose.

scene from Fear Itself: Spider-Man #3 by Yost and McKone

Once again, you don’t shock a flatline (”Why?” you ask — I’ll make it simple: defibrillators are used to stop a dangerous heart rhythm; they cannot “jump start” a heart).

And what’s especially frustrating is this comic got it right just a few pages before.

Amazing Spider-Man #661 “The Substitute, Part One”
Christos Gage, writer
Reilly Brown, penciller

Isoflurane is an inhaled anesthetic used for both induction of anesthesia (knocking patients out) and maintenance of anesthesia (keeping them out). It also works as an analgesic (pain killer) and a bronchodilator (opens up constricted airways — useful for people with asthma).

The original inhaled anesthetics used in surgery were flammable and had the unfortunate tendency to cause explosions. Sure, the anesthesia was good, but does that really matter when the entire operating room in on fire? A new generation of non-flammable anesthetic were developed — this included isoflurane and its close relatives enflurane and halothane. Over the past several years, the use of isoflurane has been gradually phased out in favor of an even newer generation of anesthetics that have a faster onset, though it is still commonly used in veterinary medicine and many third-world nations (because the newer anesthetics are ungodly expensive).

Invincible Iron Man #503 “Fix Me, part 3: Fear Itself”
Matt Fraction, writer
Salvador Larroca, penciler

Pepper Potts needs to find a better doctor for her employees:

I’ve heard this statement time and time again, and I’m regularly asked about it, so let me put it simply: wrong, wrong, wrong.

This advice generally comes in one of two forms, either “don’t let someone with concussion fall asleep” or “wake-up a patient who suffered a concussion periodically to check on them.”

The first advice is just plain wrong. To put it bluntly, someone who has suffered a concussion has had a bad day. They’ve been in a car crash, played a losing game of football, been beat up, fallen off something, or had some other sort of accident. They’re going to be cranky and they’re going to be in pain. The last thing they need to be is kept awake because it will only make the pain and the crankiness worse. Study after study has shown that sleep is good for healing, particularly healing from head injuries. Let the poor patient sleep!

The second bit of advice is a bit harder to pin down. There have been a few studies done and they showed no benefit from repeatedly waking the patient up to check on them, but they didn’t show any harm in the practice either. I can’t claim to be innocent in this regard: when I was a resident on my Neuro ICU rotation, I regularly wrote orders for “neuro checks every 4 hours,” though more out of habit and tradition than any particular concern. Today, I don’t recommend regular waking and neurological checks to my patients with concussions because I think they’ll heal faster (and certainly be less cranky) if they can get a good night’s sleep¹.

As a rule of thumb, I’d say that if a patient is examined by their primary care doctor or an ER doctor after a head injury and admitted to the hospital for observation, then waking them up to check on them at regular intervals is reasonable. On the other hand, if a doctor has examined the patient and sent them home, then there is no need for repeatedly waking up the patient — let them sleep!²

2. If I have a patient with overly anxious parents, then I would assent to them waking up the patient for a quick neuro check now and then. There are some fights you just can’t win, and overly anxious parents are behind most of them. Remember, no harm is done by the practice (other than poor sleep), it’s just that no benefit is gained either.

UPDATE/FINAL THOUGHT: I should have made this point clearer: Up until about 10-15 years ago, “wake-them-up-to-check-on-them” was the advice commonly given by doctors in regards to all head injury patients. Your parents weren’t just doing it to be mean. But then doctors started looking at the situation scientifically, and not just as a matter of tradition. At this point, it was determined there were no clear benefits to waking up patients, and it was also realized that sleep is very important for healing. Over the next several years, the advice began to change, pushing for more sleep and less — if any — checking. Of course, as in most things medical, especially where “tradition” is concerned, some doctors are more resistant to change than others. Though well intentioned, the advice is outdated — and the advice given to Pepper Potts is even more outdated (you’d think Stark Industries would use more cutting edge physicians).

Avengers Academy #14 “Disaster Response”
Christos Gage, writer
Sean Chen, penciller

Small electrical currents directed through the heart can cause ventricular fibrillation, a dangerous heart arrhythmia that can quickly degenerate into a fatal rhythm.

As suggested in the scene above, larger electrical currents can damage the heart enough to completely stop it. Throw even more current at the heart and you’ll fry it (which, admittedly, would be a subset of “stopping the heart”).

It’s not just the heart which is susceptible to electrical shocks, but the entire body –- especially the brain and muscles because they are organs that, like the heart, rely on electrical current to function.

This panel also offers a nice reminder of why “you don’t shock a flatline.” In a nutshell, a defibrillator works by — just for a split second — stopping the heart, allowing a healthy rhythm to reassert control. You don’t shock a flatline because there’s no benefit to stopping an already stopped heart.

There is so much wrong in this story that it hurts my head to think about it. FDA approval works nothing like that; everything the researcher did actually made the FDA more likely to turn him down. Even if his plan works perfectly, he has nothing to gain from it, other than prison time. Even an amoral scientist running an illegal drug trial knows it takes more than a single subject. Why would an antihistamine turn someone into a plant? Did they really think Goldenrod was an good name for a villain?

Despite all this bounty to work with, what I want to focus on is the name they gave the antihistamine: Nuevafed.

A brand name like Nuevafed is not selected until after the drug is approved for sale, and even then the final name is in the hands of specially trained medical marketers (who, you’ll notice, seem to be inordinately fond of the letters Z and X). At this point in the story, the drug would be called by its generic name, which, because it’s an antihistamine, should end in -ine (e.g. cetirizine [Zyrtec], loratadine [Claritin], or diphenhydramine [Benadryl].)

I can’t think of any other drug sold in the U.S. that has Spanish prefix in its name. There’s some Latin inspired names (Paxil, for instance), but I can’t name a single one with a Spanish (or French, or Italian, or German, or Swahili, etc) name.

The “fed” suffix is used for drugs that contain decongestants (such as Sudafed and Actifed) because it is short for pseudoephedrine, a common decongestant (admittedly, since the crack down on pseudoephedrine a few years ago, you’ll now find phenylephrine in most of these meds instead, but it’s still a decongestant). A pure antihistamine, even a potent one like Nuevafed, wouldn’t contain any decongestant.

Last thought: If your antihistamine is actually “hyperallergenic” then you’re doing it wrong.

scene from Captain America: Hail Hydra #2

Two observations, and a couple of explanations — and recommendations — for artists drawing IVs:

1. Two IV catheters going into the same site — ouch! If two IVs are needed, either piggy-back them, or use a Y-connector to link their tubing. Only one catheter per site.

2. A third IV with its tubing dragging the floor. The same IV tubing is generally used from bag to bag, so when a bag is empty, the IV tubing is just switched to another bag and not left to hang. If it’s an IV bag that hasn’t been used yet, then there would be no tubing attached. (It’s possible that it’s an old IV bag from a site that was discontinued, so the tubing wasn’t going to be used again — in that case, hanging it like that is just tacky and unclean.)

A few thoughts on this scene from Daken #6:

1. The EMT speaks truer than he intends — if the heart stops, you CAN’T resuscitate someone by defibrillating it. It falls under that whole “don’t shock a flatline.” In other words, it’s a defibrillator — it stops fibrillation (i.e. bad heart rhythms) — it’s not a jump-startinator.

2. That being said, removing all extraneous metal — like a handcuff and metal briefcase — before defibrillating is a good idea.

3. It’s all a moot point though, as it’s not a real resuscitation, it’s a sting.

The Spirit #15
David Hine, writer
Moritat, artist

Honey Steel, the protagonist/villain of The Spirit #15 has decided to commit suicide by starting a fire and then taking a handful of pills.

Which pills did she take? Conveniently, the artist provides us with a panel showing two nearly empty bottles of carbamazepine 100mg tablets.

Carbamazepine (brand name Tegretol) is a drug with three official uses: seizure prevention, treatment of trigeminal neuralgia (chronic pain of nerves of the face), and treatment of bipolar disease. It has a number of unofficial “off label” uses as well including treatment of depression, attention deficit disorder, restless leg syndrome, post-traumatic stress disorder, and neurological pain conditions.

Drowsiness is a common side effect of carbamazepine at normal doses, and can be quite severe — up to and including unconsciousness — in an overdose situation. It is entirely believable that the overdose would cause Honey to pass out. Of course, in real life, it wouldn’t happen quite so quickly and there’d be other nasty effects of the overdose such as nausea, vomiting, slurred speech, ataxia, blurred vision, tremors, and seizures.

Would the carbamazepine overdose alone be enough to kill Honey? Quite possibly. High levels of carbamazepine cause some nasty cardiac effects including AV blocks and arrhythmias.

Looking over the prescription bottles, we can glean a few more facts.

First, since 60 pills were prescribed, this tells us Honey is taking carbamazepine 100MG twice a day for a total of 200MG a day. That’s a tiny dose of carbamazepine – not high enough for seizures or bipolar. Trigeminal neuralgia takes a lower dose than the other two condition, but even it requires more than 200MG/day. I’ll admit I don’t know the doses for the off-label uses of carbamazepine since I don’t prescribe it for them.
The prescription is from Dr. Cobra, one of the Spirits archenemies, and the villain who “killed” Denny Colt, giving birth to the Spirit.
Dr. Cobra fails my Quack Doctor test:

Look at the picture — you know the doctor’s trying to subtly slip his stethoscope on so he can’t hear what’s going on behind him.

In my experience, science fiction comics — particularly those at least partially dystopic in nature — tend to have the best thought out and most entertaining fictional drugs.

Example #1: Transmetropolitan
Example #2: American Flagg
Example #3: Smileezys from the Flesh stories in recent issues of 2000AD

Secret Hearts #133

Sadly, I’ve never been chased down a hospital hallway by a cute blonde.

But I can always hope.

scene from Uncanny X-Men Annual #3 by Asmus and Bradshaw

First off, this is one of the better drawn hospital scenes I’ve seen in quite a while. The bed and medical equipment are drawn well and it is clear that the artist did his research.

That being said, there are few nit-picks worth mentioning, purely as teaching points (a few of them are even classics that I mentioned in my needs-to-be-updated common medical errors posts [1][2]):
1. While I congratulate Bradshaw on the correctly drawn nasal canula, it shouldn’t go under the bandages.
2. There should be no bubbles in IV bags — they are closed systems.
3. Speaking of IVs, the IV in the left arm goes to different places in the two panels.
4. Blood and other IV fluids require gravity and fluid dynamics to work right — they flow down from the IV bag to the IV canula and into the patient. The fluids won’t be able to flow up the length of vertical tubing seen here.
5. I applaud Dr. Rao for counting the ulnar pulse, but most people use the radial pulse (on the thumb-side of the wrist) as it is stronger and easier to find.

Thanks to a succesful polio vaccination program — and let’s hope it stays that way — so ads like these don’t make a come back. [1][2][3][4]

an old comic book ad about polio

Apothecarius Argentum was a manga published by DC imprint CMX. The story takes place primarily in the quasi-medieval kingdom of Beazol and features the Princess Primula and her Royal Apothecary, Argent.

Argent is something of a contradiction, being both a Basilisk and an apothecary. An apothecary is simply another name for a physician. Basilisks are rare individuals who were fed increasing doses of various toxins as children until they became immune to all poisons. Unfortunately, this process turns the Basilisks themselves toxic to anyone who touches them. Thus Argent is both a healer and a killer.

The initial volumes of the story took place in Beazol, but later volumes have had the characters travel to other countries. Recently, Argent has traveled to Castoria, looking for a fabled gem that is said to cure a Basilisk of their toxic nature.

Most of the medical scenes are found in the first third of the book; the last two thirds contain stories focusing on political maneuvering and rescue missions.

1. Anesthetics
The anesthetic used by Lulu for the dental extraction mad is made by “mixing minerals or metal with nitric acid.” She also mentions that some people “deliberately inhaled the fumes to become intoxicated.” What she is describing in Nitrous Oxide (i.e. laughing gas). Traditionally, it was produced by pouring nitric acid over iron filings. It can be used as an intoxicant – in fact it was used in such a way long before its anesthetic properties were discovered.

She mentions another anesthetic gas that is both stronger and more dangerous than nitrous oxide. This could be either chloroform or ether (she’s probably referring to ether, as that was mentioned in the previous volume).

2. Claviceps
Lulu keeps some moldy rye, which she tells Argent she uses to treat migraines. This mold is the fungus Claviceps pupurea, which contains the potent chemical ergotamine. Until about twenty years ago, ergotamine was the primary treatment for severe migraines. While it is still used a little today, most migraine patients now take the safer and more reliable Triptan drugs (Imitrex, Zolmig, Maxalt, etc.). Ergotamine can also cause uterine contractions, and has been used since the Middle Ages to induce abortions. For this reason, it is a Category X drug, and should not be taken during pregnancy.

3. Placental Abruption
An abruption occurs when the placenta pulls away from the wall of the uterus. This can be life threatening to both mother and child. The placenta is literally the lifeline for the baby, so if it is injured in any way, the baby’s life is at risk. An abruption can also cause a severe hemorrhage and lead to the mother bleeding to death. Mild abruptions can be treated with bed rest and observation, but severe cases require an immediate caesarean section.

Previous Apothercarius Argentum annotations
Other manga medical annotations

What’s the error in this scene from Firestorm #3, featuring the origin of of the villainess Killer Frost?

Previous picture quizzes

Once again celebrating the head mirror, an artifact seen more often in comic book depictions of doctors than in real life. Now available in 4-D.

This anonymous — and soon to be a casualty — doctor is not only rocking the head mirror look, but is also sporting the “I shoulda been a chef” white coat.

Here’s a bonus head mirror for certain unnamed other bloggers…

Sadly, nothing this exciting happens in the actual issue.

This is the final chapter in the original Korvac storyline, and by the end of the issue, though Korvac is defeated, all the Avengers save Thor and Moondragon have been laid low. Thor transforms to Dr. Donald Blake so he can save his teammates (although all we see him do is approach Iron Man), and Moondragon sulks off, using her mental powers so none of the Avengers will remember what actually happened. A whole issue of nothing but CPR chest compressions would have been more exciting.

While that is a striking cover by Dave Cockrum (and much better than the interior pencils), let me point out that the medicine is wrong. Blake is using a technique known as the precordial thump where a solid blow is given over the heart. It’s a real technique, but only has very limited use. The precordial thump should only be employed in the event of a witnessed cardiac arrest, and only at the beginning of resuscitation. When you come across someone who is already down, and has been for some time, then the precordial thump is not the right choice (standard CPR would be a better option, or maybe calling 911). [More about the precordial thump and comic books]

With the help of a recently discovered Kryptonite meteorite, Luthor creates a special liquid Kryptonite serum. Anyone who drinks the serum will emit Krytponite radiation.First Luthor tests the serum on a monkey¹, and when that works, he drinks the serum himself.

Giving off green Kryptonite radiation, Luthor confronts Superman, who becomes too weak to stop him. Not willing to admit defeat, Superman dons a lead suit and flies after Luthor, but the villain expected this and has placed a satellite in orbit around Earth that changes all lead to glass2, rendering Superman’s protective suit useless.

Superman has another trick up his sleeve and fools Luthor into believing that Superman has become immune to Kryptonite (he has himself strung with hidden wires, like a marionette). Thinking his serum is now useless, Luthor drinks the antidote to the liquid Kryptonite³. This allows Superman to capture him and haul him off to jail⁴.

NOTES:
1. The Kryptonite monkey eventually escaped Luthor and returned to the zoo, making Clark Kent’s visit there a painful experience for him. Luckily, there was a lead water pipe nearby, and he could lure the monkey into it. I can only assume Kent was there to investigate all the zoo animal deaths related to lead poisoning.

2. Wouldn’t this be a self-defeating satellite, since all the lead in its solder would turn to glass?

3. Once Luthor realized Superman was faking his Kryptonite immunity, why didn’t he just drink the serum again?

4. Which is strange, because Luthor actually commits no significant crime in this story — certainly nothing requiring jail time.