Polite Dissent

Tags: comics romance

I got home from working out later than I had planned, so the House review will be up in the morning (first thoughts: good drama, not-so-good medicine).

This medical review of House contains spoilers, so don’t say I didn’t warn you…

Dr. Sebastian Charles is an American doctor who spends his time treating tuberculosis (TB) in the poor regions of Africa. While back in the United States on a fund raising trip, he collapses while talking to some pharmaceutical executives. Dr. House is assigned to the case when Dr. Charles is admitted to the hospital and the two of them butt heads almost immediately.

Charles wants to be involved in the discussion of his case, but House won’t allow it. Charles believes he has TB, but House suspects that there is another diagnosis. All of the initial tests are normal except the EKG which shows a subtle abnormality of the heart rhythm. House suspects that Charles may have Sick Sinus Syndrome (SSS). A follow-up echocardiogram and stress test are normal, but a tilt table test is positive. Charles is scheduled for a pacemaker.

On the way to surgery, Charles complains of a headache and numbness of the hands. He vomits and then passes out. As these symptoms are not consistent with SSS, the team looks for a new diagnosis. Foreman suspects an acoustic neuroma, but the MRI is normal. However, the PPD skin test that Cameron placed is positive, suggesting that Charles does indeed have TB.

House admits that Charles has TB but continues to insist that there must be a second diagnosis as well. Meanwhile, Charles refuses to take his antibiotics and seems determined to make a martyr of himself. House will have none of it and confronts Charles on several occasions, the last at a press conference that Charles has called. During the press conference, Charles suffers a cardiac arrest and is successfully resuscitated. Now he is the one who must admit that something more than TB is going on. Reluctantly he agrees to take his medication so that the team can determine which symptoms are due to the TB and which are caused by something else. Ultimately the team diagnoses Charles with a nesidioblastoma — a small insulin-secreting tumor. The insulin from this tumor led to dangerously low blood sugars which are the explanation for Dr. Charles’s symptoms.

A short surgery later, Dr. Charles is ready to head back to Africa, TB drugs in hand. After he holds a press conference, of course.

I’ve noticed that when House does a “character show,” the medicine suffers. This week was no exception. The drama came from Dr. House versus Dr. Charles and the medicine seemed like an afterthought.

Medical Concerns:

• As Julia points out, if the patient is suspected of having TB, why is no one treating him wearing a mask? Why he wandering around the hospital and not in isolation? Why is he not in a negative-pressure room?
• PPDs are not read by sight, but by feel. It doesn’t matter how red it looks, but instead how indurated it is.
• TB is slow growing. How did the team know almost immediately that it was resistant TB? How did the antibiotics kick in so fast?
• A nesidioblastoma would explain most of Dr. Charles’s symptoms, but *wow* that’s a convenient tumor. Small enough that it can’t be seen on x-rays or MRIs. Intermittent, so it only releases insulin periodically. And yet strong enough to lower the sugar level in his CSF. It’s more of a deus ex machina than a diagnosis.
• When Dr. Charles coded, why did no one in a room full of doctors start CPR while waiting for the paddles to charge?
• I’m certainly no surgeon, interventional radiologist or endocrinologist, but the scene where the team is trying to induce the tumor to release insulin seemed wrong. Injecting calcium directly into the pancreatic blood supply may be a legitimate procedure, but I doubt those four are qualified to perform it. Also, since they expected the blood sugar to drop to dangerous levels, they should have had the D50 ready to inject and not scramble for an IV setup.

This episode gets a C for the mystery and a lowly D for the medicine. The soap opera aspects earn an A-, mostly for the sparring between House and Charles.

• Previous House reviews

While I understand that certain Marvel writers like to ignore continuity if it allows them to “tell a better story,” I didn’t think that applied to the promotional copy writers as well.

From the recent Previews:

FIRST ISSUE! Busting out from the pages of THE INCREDIBLE HULK, Doc Samson gets his first mini-series! Join the green-haired adventurer as he solves problems with psychoanalytical tactics and good ol’ fashioned whuppins!

I’ll admit that it probably should be forgotten, but Doc Samson already had his first mini-series back in 1996. It wasn’t good; it wasn’t bad; it was pure mediocrity in mini-series format. As the jock in Sixteen Candles says: “There’s no there there. ”

I sure hope this new one is better…

The 1996 Doc Samson mini-series:

Now Lois, Where could you possibly get that crazy idea that
I love you for your body and not your mind?

From Superman’s Girlfriend Lois Lane #82, words by Leo Dorfman with pencils by Irv Novick.

Tags: comics lois lane superman

While reading through some issues of Superman’s Girlfriend Lois Lane, I was astounded by how fickle Lois was. Allegedly in love with Superman, she seemed to be getting engaged to someone else almost every other issue. I decided to count how many time Lois had been engaged or married, and these are the results I came up with. You’ll notice that I’m not counting imaginary or future stories; only canon stories are listed (though admittedly most were pre-Crisis and pre-reboot). Also, I only have slightly more than half the issues of Lois Lane and a few scattered Superman titles so I’m sure there are many more engagements/marriages that I’m missing.

Engagements:

• Engaged to Dino Del Monaco in Superman’s Girlfriend Lois Lane #10 (July 1959). Lois met Dino while on an assignment in Italy. She broke the engagement when she discovered he was a con man. Reprinted in 80-pg Giant #3
• Engaged to the super-powered Native American Strong Bear in Superman’s Girlfriend Lois Lane #49 (May 1964). It turns out he was really an ugly little blue alien. Reprinted in Superman’s Girlfriend Lois Lane #113.
• Engaged to Epimetheus in Superman’s Girlfriend Lois Lane #56 (April 1965). Sent back in time, Lois becomes the Pandora of legend.
• Engaged to Titanman in Superman’s Girlfriend Lois Lane #79 (November 1967). Lois found herself in a bizarre alternate dimension where she was thrown in jail. She was rescued from prison by the super-hero Titanman and agreed to marry him only to discover that she would be his seventh wife. Luckily Superman was able to return her to her correct dimension before the wedding could take place.
• Engaged to astronaut Rand Kirby in Superman’s Girlfriend Lois Lane #80-81 (January, February 1968). After Superman misses her birthday party, Lois starts a new life in Coral City where she fallis in love with Kirby. (My reviews of these issues.)
• Engaged to Kryptonian scientist Dahr-Nel in Superman’s Girlfriend Lois Lane #90 (February 1969). After Superman’s upsets her with a fake wedding, Lois agrees to marry Dahr-Nel and escape to the future. (My review)
• Engaged to the demonic Satdev in Superman’s Girlfriend Lois Lane #103 (August 1970). I really can’t explain this one except to say that Lois’s curiosity manages to get her engaged to a satyr-like man from another planet.
• Engaged to Clark Kent in Superman (Second Series) #50 (December 1990) — engagement broken in Action Comics #720 (April 1996)
• Engaged to the criminal Naga in Superman: The Wedding Album (December 1996).
• Re-engaged to Clark Kent in Superman: The Wedding Album (December 1996).

Marriages:

• Marries Superman in Superman’s Girlfriend Lois Lane #82 (April 1968). The marriage was part of a plan to capture some criminals from the future. Superman offered to stay married, but Lois declined, wanting Superman to marry her for the right reasons.
• Marries death-row convict Johnny Adonis in Superman’s Girlfriend Lois Lane #105 (October 1970). Lois owes him a favor for saving her life, so she marries him shortly before he is to be exectured.
• Marries Clark Kent in Superman: The Wedding Album (December 1996).

Near-Misses:

• Lois is nearly engaged to Mark Benton in Superman’s Girlfriend Lois Lane #3 (July/August 1958). Mark Benton is suave and rich and looks exactly like Clark Kent. Lois is in love with him and Mark is going to propose, but her snooping makes him change his mind. Reprinted in Lois Lane Annual #1 and Superman’s Girlfriend Lois Lane #99.
• Lois may or may not be engaged to Roger Warner in Superman’s Girlfriend Lois Lane #24 (April 1961). Lois is dating the rich and very accomplished Roger Warner. They may even be engaged (the script seems to hint at it). They call it quits after a gust of wind blows off Roger’s toupee revelaing him to be completely bald. To be fair to Lois, Roger is the one who is ashamed and calls it off. Reprinted in Superman’s Girlfriend Lois Lane #88.
• Almost Engaged to Petronius in Superman’s Girlfriend Lois Lane #33 (May 1962). Sent back to the ancient days by a “time bomb,” Lois becomes involved in a slave revolt. The leader of the revolt Petronius has asked her to marry him and she is in the middle of saying “yes” when she is whisked back to her own time. Reprinted in Superman’s Girlfriend Lois Lane #95.
• Atlantean scientist Ron-Thul wants to marry her in Superman’s Girlfriend Lois Lane #42 (July 1963). She refuses to marry him when she discovers that he is evil — though the fact that he looked exactly like Luthor and his name was a near-anagram of Luthor should have given it away. Reprinted in Superman’s Girlfriend Lois Lane #104.
• Lois is forced to marry Clark Kent by a tribe of lost vikings in Superman’s Girlfriend Lois Lane #53 (Novemeber 1964). Luckily Superman rescues them before the ceremony can take place. Reprinted in Superman Family #177.
• Engaged to Herko in Superman’s Girlfriend Lois Lane #57 (May 1965). Lois travels to the dimension where her monster friend Herko lives. Herko wants to get married and tells everyone that they’re engaged, but Lois doesn’t share his sentiment. She escapes, dignity intact, when it turns out that Herko is allergic to her make up. Reprinted in Superman’s Girlfriend Lois Lane #113)
• Marries Superman in Superman’s Girlfriend Lois Lane #90 (February 1969). Superman stages a fake wedding with Lois to draw out some criminals. Unfortunately, he forgets to tell Lois that it’s fake and she flounces off in a huff to marry Dahr-Nel (see above).
• Biron wants to marry Lois in Superman’s Girlfriend Lois Lane #92 (May 1969). Lois and Biron are in love, but there’s a problem. You see, Biron is the human identity of Comet the Super-Horse. He asks the goddess Circe to make him permanently human so he can marry Lois, but an evil magician intervenes and turns Lois into a super-horse. This issue is more than a little creepy (and not in the good “Halloween creepy” way, more in the “I-need-a-shower-right-now creepy”).

It’s Guy Fawkes Day!

Remember remember the fifth of November
Gunpowder, treason and plot.
I see no reason why gunpowder treason
Should ever be forgot…

The latest issue of Wizard (#170, December 2005) has a two-page spread designed to help readers determine which comic book doctors are “real doctors.”

The art by Ty Templeton is funny. The actual article by Chris Ward is less so. The humor is juvenile and mostly of the “gee-I’m-so-clever” variety, but Ward does poke fun at both Dr. Phil and Tom Cruise, so I’ll give him points for that.

First off, he stole my Dr. Doom joke. OK, I admit it’s a rather blatant joke, so I’m sure he came up with it on his own, but still…mine’s funnier.

The only woman mentioned is Night Nurse, go figure…

Ward gets full credit for knowing that a psychiatrist is a medical doctor; however, he then loses points for confusing the two Dr. Mid-Nites (thankfully, he doesn’t mention Dr. Midnght). I also suspect he’s mistaken in his belief that Dr. Octopus is not a doctor, stating that Octavius is “an ex-atomic research consultant.” You wouldn’t get that position without a Ph.D., so I’m sure Doc Ock has a doctorate in physics lying around somewhere.

Overall, it’s a mixed bag. It’s too slight of an article to pick up Wizard for, but clever enough to read through if you already have the magazine (particularly for the art).

(For the record, the following “doctors” are mentioned: Dr. Doom, Doc Samson, Dr. Mid-Nite, Night Nurse, Dr. Polaris, Dr. Light, Dr. Psycho, Dr. Phil, Dr. Druid, Dr. Octopus, Dr. Strange and Dr. Fate.)

Hello.

On the pages inside you’ll find important information — pretty important information — about…well, about sex, mostly.

It’s perfectly possible that you may not be interested in this. It’s every bit as possible that you suspect you’ll be offended by any mention that human beings have things under their clothes, let alone that they do anything interesting with them.

These are the opening words in Death Talks About Life, an eight-page PSA comic published by Vertigo comics in 1994.

Death Talks About Life is different from most PSA comics. First of all, it is written for adults. There are no innocent children in danger and brightly costumed heroes to save them, nor are there anthropomorphized diseases to be battled. Instead, the comic deals in a very straightforward manner with HIV and AIDS.

Second, unlike other PSA books, this comic was fashioned by creators at the top of their game. Neil Gaiman, in the middle of writing Sandman, supplies the words. Dave McKean, the Sandman cover artist and creator of Cages, draws the pictures. Todd Klein does his usual incredible job on the lettering.

Third, this is the only PSA comic that I ‘m aware of that has been collected in a trade paperback. Originally published as a center insert in Sandman #46, Hellblazer #62 and Shade: The Changing Man #32, it was later put out as an 8-page give-away. It was collected in the Death: The High Cost of Living trade paperback.

This plot is simple: seven pages of Death (the kohl-eyed Goth girl) talking to reader about AIDS, and a final page listing HIV and AIDS resources.

Medically, the advice is sound and virtually identical to what I told high schoolers when I taught AIDS education classes. I wish I had this comic then (though I doubt I would have been allowed to use it). Gaiman deftly explains what HIV and AIDS are, how a person acquires AIDS, and what can be done to prevent it. He touches on prejudice and teaches how to use a condom correctly (with help from John Constantine and a banana). Gaiman doesn’t shy away from using the necessary and anatomically explicit language to get his point across. (In my opinion, he throws an unnecessary bone to the HIV-deniers, but it doesn’t lessen the message in any way — and bear in mind that this was 1994).

The comic may be a little talky at times but Death Talks About Life is easily the best adult PSA comic book out there, and probably the best overall.

I’ll leave you with more words of wisdom from Death:

Now this comic contains words, concepts and maybe a few images that some people might find offensive.

If you suspect you’re going to be one of these people, there’s a really easy solution to this.

Don’t read it. It’s as simple as that.

Just don’t read it.

After all, the most it could do for you is to save your life.

Doctor Octopus’s first appearance from Amazing Spider-Man #3
(Click on the image for the full scene)

So is he a doctor or not?

As usual, there are House spoilers below, so I’d suggest you watch the episode before you read (unless you’re one of those people who read the last page of a mystery first).

An interesting and enjoyable episode of House with a good medical mystery.

Cornell, a young black man, is at a party celebrating his graduation from Princeton when he begins to convulse from intermittent and excruciating shock-like pains. Initial work ups are negative except for a low white blood count, and an MRI rules out multiple sclerosis. House thinks the patient might have Type II Neurofibromatosis, but the genetic tests are normal.

Cornell looses control of his bowels. This is a worrisome symptom because it indicates that the central portion of the spinal cord has been compromised. The gang decides that he has transverse myelitis, but they don’t know what caused it. House suspects that it is pesticide exposure, so he starts pralidoxime, an antidote for pesticide poisoning . The medication seems to work at first, but then Cornell starts running a fever of 106°F and his symptoms recur. He develops a perforated bowel from the raging infection and requires immediate surgery.

One of Cornell’s friends from college, who we already knew had a weird rash, starts vomiting blood and is brought to the hospital. House is finally able to put the full story together and realizes that the patients have been exposed to radiation. Cornell’s father runs a scrap yard and gave his son a scrap metal weight as a key chain to remember “where he came from.” Unfortunately, this keychain was radioactive. The father and friend have mild cases of radiation poisoning but Cornell has a much more serious case. The radiation has killed off his white blood cells, leaving him open for infections. It also caused a spinal cord tumor (a cavernous angioma) which explains his neurological symptoms. The surgeons are able to remove the tumor, but as the episode ends it seems unlikely that Cornell will survive his infection.

The medicine was fairly sound in this episode. I have a few nit-picks, but no major complaints. Time course is a concern. It is unlikely that an exposure to a pesticide over spring break would have caused symptoms to appear months later at graduation. Radiation poisoning, especially exposure to long-term low-dose radiation, can take months for symptoms to surface — so the time course there was reasonable. It does seem that the tumor developed awfully fast though. Finally, if Cornell had a white count as low as the story suggests, he should have been in isolation shortly after admission, and his father should have been wearing a mask and gloves (and probably a gown) when he went in to see him at the end.

On the non-medical, soap opera side, the action picks up. House has borrowed $5000 from Wilson to buy a new motorcycle. Of course, it turns out that House didn’t need to borrow that much money — he was just testing Wilson to see how much he’d lend him by asking for increasing amounts over the course of a year. Surprising no one (except maybe House), this annoyed Wilson. Also, House’s parents are in town for a brief layover at the airport and want to go to dinner with him. He is trying to avoid them, but doesn’t want to lie to them. He concocts various schemes to get out of dinner, but ultimately sits down to share a meal with them at the hospital cafeteria. The interactions between House and his father (a bushier-eyebrowed than usual R. Lee Emery) drive home the underlying theme of this episode: fathers and sons, when do they lie to each other, and when do they tell the truth?

I give this episode an A for the mystery with a B+ for the final solution. The medicine overall earns a B and the soap opera also deserves a solid B.

• Previous House reviews

Birds of Prey #87 “Perfect Pitch, part one”
Gail Simone, writer
Joe Bennett and Eddy Barrows, pencilers

Calculator: …Somehow, Lex suspects. Unless it’s just coincidence that three of the doctors supplying me with my Selective Serotonin Reuptake Inhibitors committed suicide on the same night…That this genius of mine — and it is genius, make no mistake — stems from more than a touch of Obsessive-Compulsive Personality Disorder. I don’t wash my hands fifty times a day. I don’t count sidewalk cracks. My weakness is ignorance. When I have a riddle, I can’t rest, can’t eat, can’t even think straight, until I solve it.

Calculator makes a common mistake here: he confuses Obsessive-Compulsive Disorder and Obsessive-Compulsive Personality Disorder — two different conditions.

Obsessive-Compulsive Disorder (also known as OCD) is what most people think of when they hear the words “obsessive-compulsive.” These are the people with behavioral “quirks” such as repetitively washing their hands, locking the door, or flipping light switches. It’s not an easy diagnosis to understand. Most people with OCD have an intrusive thought or impulse that distresses them. They develop these bizarre behaviors in order to alleviate the unwanted thought or impulse. In other cases, people with OCD perform repetitive actions and behaviors in an illogical manner to ward off some dreaded event. In both cases, individuals with OCD know that their behavior is not normal but they are powerless to stop it. (The diagnostic criteria for OCD).

Traditionally, OCD has been treated with varying success with therapy. In the last decade, the SSRI (Serotonin Specific Reuptake Inhibitor) class of drugs has been used as well. This is the class that contains fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), fluvoxamine (Luvox), citalopram (Celexa) and escitalopram (Lexapro). Normally used for depression and anxiety disorder, high doses of these medications can help people who suffer from OCD. Complete remission is rare, but therapy combined with medication can often give an 80-85% relief of symptoms.

Obsessive-Compulsive Personality Disorder describes people who are overly preoccupied with details, lists and schedules, or are such perfectionists that it actually interferes with their life. They are the people who are anal retentive* to the n^th degree. For instance, they spend all day organizing their desk — lining up their pens, making sure each pencil is identical in length — but it takes so much time that they don’t actually accomplish any work. Unlike OCD, people with Obsessive-Compulsive Personality Disorder generally do not realize that there is anything wrong with their behavior or actions. (The diagnostic criteria for Obsessive-Compulsive Personality Disorder).

Obsessive-Compulsive Personality Disorder, like all personality disorders, is extremely difficult to treat. Personality disorders are so deeply ingrained in a person’s very psyche that they do not recognize they have it, or are unwilling to admit that that there is any problem. Therapy is the best treatment for personality disorders, and even that rarely works well.

So what diagnosis does the Calculator have? As I see it, there are 3 possibilities:

1. He has OCD. His high doses of SSRIs support this, though his symptoms don’t seem to match. Of course, he could be taking the SSRIs because of another diagnosis (anxiety or depression) or because of a misdiagnosis.
2. He has Obsessive-Compulsive Personality Disorder. This one is close, but I don’t think that he quite meets the full criteria. I’ll admit that he certainly has some strong Obsessive-Compulsive Personality traits though.
3. He has been misdiagnosed. I suspect that this is the case. There are a too many self-help books, psycho-babble web sites and quacks that diagnose people with personality disorders incorrectly and there are simply too many people who are willing to believe it. Many of these “resources” confuse OCD with Obsessive-Compulsive Personality Disorder, just like Calculator. Given his touch of ego, I suspect he (mis-) diagnosed himself** and arranged medication without every seeing a specialist. Of course, I wouldn’t be surprised if Dr. Psycho had a hand in it as well — that guy is nuts!

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I want to touch briefly again on Personality Disorders. If you look at the list of traits associated with the various personality disorders, you’ll recognize many of the behaviors in yourself, your family, your co-workers, and your friends. Everyone has some of these personality traits and quirks — it’s human nature. It becomes a personality disorder when these traits become so pronounced that they interfere with daily life. Remember that these personality traits are deeply ingrained in the very being of the person so they are nearly impossible to treat. Be wary of being diagnosed with a personality disorder by anyone other than a trained psychiatrist or psychologist, especially if they offer a “cure.”

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Gail Simone does get bonus points for including Dr. Mid-Nite and having him act as a doctor. A real doctor who’s actually following up with patients.

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*The modern understanding of the phrase; not in the original Fruedian meaning.
**My diagnosis? I think the Calculator has many traits of Obsessive-Compulsive Personality Disorder and Narcissistic Pewrsonality Disorder (that ego of his!). There’s some Anti-Social Personality traits mixed in as well, but I’m not sure you could diagnose him with any one particular disorder.

After my previous post, I’ve gotten a great deal of grief about why the the Calculator didn’t just order his SSRI medications from those spam e-mails everyone gets. Look, the Calculator may have mis-diagnosed his condition, but that doesn’t make him stupid. He knows better than to order drugs from spam e-mails:

1. It’s spam. You never, ever answer spam — it only makes the problem worse. (Anyway, I figure that Calculator is enough of a computer genius to have rigged up a super spam filter. If any junk mail manages to get through, he just sends Deathstroke or Talia after the spammer — or if he really wants to embarrass them, he sends Big Sir or the Mighty Bruce.)
2. It’s illegal to prescribe medication without a medical license. Now the spammer (or website) may have someone with a medical license on payroll signing the prescriptions, but that’s not really any better (and would you really trust a doctor who took such a job?). It may be slightly more legal (though the FDA disagrees), but it’s just as dangerous. A physician should never give a prescription without examining the patient first. Yes, I know a number of physicians practice “telephone medicine” — but it’s a risky choice, both medically and legally.
3. The spammers aren’t really going to send you medicine, they just want your credit card numbers.
4. If they do send some medication, you better hope that it’s a placebo. The odds are it’s going to some random drug, say Estrogen instead of Viagra, or canine heartworm pills instead of Prozac.

Happy Veterans’ Day and a hearty thank you to all veterans, past and present. A special thanks to all my friends and former co-workers in the 99 ABW, 99 MDG and 820 RED HORSE.

Each unit in the American armed forces has its own coin. Usually made of brass and 1½ to 2 inches in diameter, these coins are generally struck with the unit’s seal, motto and other identifying information. Special coins are sometimes made to celebrate missions and other accomplishments. In addition, Unit Commanders have special coins that they hand out as a reward for a job exceptionally well done.

This link list a brief history of military coins. Here is more abbreviated history, but more importantly: the rules for the Coin Check, sometimes called the Coin Challenge. Here’s a stricter set of challenge rules. (When the docs and nurses from my clinic met after work for Happy Hour, we were frequently challenged because people apparently figured that the medical corps wasn’t military enough to carry coins — they were qucikly proven wrong. We could usually count on at least 2 free rounds each Friday).

I have a small collection of military coins. While some people traded for coins from other units, I stuck with coins from the units I was assigned to or served with, or missions I participated in.

This is the standard 820th RED HORSE coin. The front side shows the 820th seal and location. The back side has the unit motto around the edge. It also lists what the acronym RED HORSE stand for. Given that this was designed by one of the unit’s Chief Master Sergeants, it’s ironic that he screwed up the acronym. The first “E” stands for Engineers not Engineering.

When the 820th was deployed to the United Arab Emirates, it became the 820th Expeditionary RED HORSE Squadron. This second coin was cast to commemorate that mission. The front of the coin shows a stylized horse’s head/American flag combination. The back of the coin states “Operation Enduring Freedom” and lists how our contribution to the mission went. It may sound like bragging, but it’s really not. RED HORSE set an incredible record for the amount of tarmac laid in 6 months, particularly in a desert environment. The back of the coin also shows a map of the Middle East. The RED HORSE symbol is just above UAE where we were stationed. It’s hard to see on the smaller image (so click here for a larger one), but there is a hoofprint on the map for each project we contributed to while deployed.

An interesting week and weekend in NASCAR. It really all started about two months back…

There had been some controversy since Roush Racing signed Jamie MacMurray to drive for the team in the 2007 season — the year after next. Since McMurray was still under contract to Ganassi Racing at the time, this was seen as “poaching” another team’s driver. It’s certainly not against the rules, just against one of the many “gentleman’s agreements” that seem to make up the NASCAR rules. A few weeks later, Penske racing signed Kurt Busch — one of Roush’s drivers — for the 2007 season and most commentators seemed content that some sort of cosmic karma had been satisfied. Busch immediately wanted his Roush contract canceled so he could start racing for Penske in 2006, but Roush would have none of it.

Jamie McMurray is a good driver and seems to be a genuinely pleasant person. The same cannot be said of Kurt Busch. He has been arrogant since starting the sport and only got worse after winning the NASCAR championship last year. He’s a decent enough driver — but not a great driver — and owes most of last year’s win to NASCAR’s ridiculous “Race for the Chase” playoff system. Though he certainly realizes that fact, he has spent much of the season spouting off in a manner that would make Muhammed Ali blush.

In the past few weeks, in what is known as “Silly Season,” teams hired and fired drivers for the 2006 season (now, whether the driver left the team or the team let the driver go often depends on who you ask). Michael Waltrip and Kenny Schrader are changing teams. Bobby Labonte (my favorite driver) left Gibbs Racing and signed on with Petty Racing (my least favorite team) — so I’m caught in a conundrum. On the midst of this, McMurry and Busch were both quietly let out of their contracts so that they could race for their new teams next year. Everybody’s happy…right? Wrong.

This past Friday night, Kurt Busch was caught speeding and running a stop sign in Phoenix. There is a report that there was alcohol on his breath and that he was less-than-nice to the officer involved. Given that Crown Royal is his sponsor, and he has made public service announcements about drunk driving, this was a dangerous irony. Roush suspended Busch for the rest of the season in a tersely worded statement essentially saying that they were washing their hands of him. Bear in mind that Busch is the reigning NASCAR champion and involved in this year’s “Race for the Chase” (though well behind in the points), yet he was suspended without a second thought. Maybe a little bad blood there? His brother Kyle, another driver, rallied to his brother’s defense and I’ve never seen someone put their foot in their mouth so often in a twenty-second sound bite.

Nothing caps off a week better than a healthy serving of schadenfreude.

Spider-Man and Power-Pack was a giveaway comic produced in 1984 by Marvel, the National Committee For Prevention of Child Abuse, and the NEA. Written to educate children about sexual abuse, this comic contains two stories.

The first is a Spider-Man tale written by Jim Salicrup and penciled by Jim Mooney. Peter Parker is in his apartment darkroom developing pictures when he hears something disturbing from the next apartment. Changing into Spider-Man, he swings over and finds that Tony, the son of the couple next door, has been abused by his babysitter Judy. Spider-Man wants Tony to tell his parents what happened but Tony is too scared.

Spider-Man tells Tony the story of a young man about his same age who lived with his aunt and uncle (could it be Peter Parker?). This young bespectacled boy was a bookworm and didn’t have many friends. He was pleased when a slightly older boy named Skip befriended him. Then one day, Skip pulled out some Girlie magazines (no really, that was the name of the magazine) and told Pete that they should “touch each other like the people in that magazine.” The young boy tells his aunt and uncle what happened and in the end everything works out. Spider-Man tells Tony that just like that other young boy, he should let his parents know what happened. Tony’s parents are very supportive and tell Tony that he did the right thing. They thank Spidey, but he tells them that there’s no need for thanks as Tony has already helped him. Web-swinging back to his apartment, Spider-Man realizes that helping Tony face his abuse has allowed Spieder-Man to face a dark chapter of his own past (an incident never mentioned again in any other Spider-Man comic book ever).

The second part of the comic is a Power Pack story by Louise Simonson with pencils by June Brigman and Mary Wilshire. Jane, a young school friend of the Power children, has run away from home because her father sexually abuses her. Jane told her mother what happened, but her mother didn’t believer her. The Power Pack are able to locate the runaway Jane and they bring her back to their house. Jane tells Mrs. Power what happened. After Mrs. Power consoles her, she gives Jane a number to call to get her family some help.

• SpiderFan on the Spider-Man portion of the story.
• Scott Shaw!’s Oddball Comics entry on this comic.
• The Appendix to the Handbook of the Marvel Universe entry on Skip Westcott.

• I finally saw that television commercial for the Kawasaki Ninja agin. The tagline is “It’s hard to stay unnoticed.” That pretty much contradicts the whole idea of “ninja.”
• As an example of Kyle Busch saying stupid things:
  Interviewed after yesterday’s race, Busch smugly stated that he beat Greg Biffle again (Biffle finished second to Busch in both of Busch’s wins) and that maybe someday Biffle would be able to beat him. He seems to have forgotten that Biffle has won 5 races this season, so by definition, Biffle has already beaten him five times.
• Busch first caught my attention last year when he was still a driver in the Busch Series. He was proud that he had his blood type embroidered on his uniform in case there was a crash. Sorry Kyle, but it doesn’t work that way. If there’s an accident, the odds are that your clothes will be cut away long before anyone thinks to look there for your blood type. And why would they look there in the first place? Anyway, why would the hospital trust what your clothes say anyway? In an emergency they’re going to run Type O blood until the Type and Cross comes back.
• Two thumbs up for the Hillary Duff as Anne Frank sketch on Robot Chicken. That was hilarious.
• I’ve been enjoying MonkeyBrain Books recently. I just finished Matt Rossi’s (of Howling Curmudgeons fame) book Things That Never Were (two thumbs up) and Jess Nevin’s The Encyclopedia of Fantastic Victoriana just arrived in the mail today and I look forward to digging into the impressive looking hardback.
• Pet peeve of the day: website that automatically start playing sound files. And it’s never ever good music.
• Was the recent Green Arrow #53 the first mention of an experimental serum being involved in the origin of Solomon Grundy, or had that unfortunate ret-con been mentioned before?

This medical review of House contains spoilers, so don’t say I didn’t warn you…

Jeff Forester, a champion cyclist, collapses from respiratory distress during a charity bike race and is brought to the hospital. He readily admits that he blood dopes. He also admits to using amphetamines, diuretics and sleeping in a hyperbaric oxygen chamber. He denies using any anbolic steroids or Epogen. He mentions that he stopped taking his supplements several days previously because it was “just a charity race and it didn’t matter if he won or not.”

The chest x-ray shows no signs of pneumonia or fluid build up. A spiral CT of the chest shows no pulmonary embolus. The team deduces that Jeff must have accidentally injected himself with an air bubble while blood doping and developed an air embolus (regular readers will remember that I covered this back in July when reviewing Manhunter #11). Chase is able to remove the air embolus using a catheter; however during the procedure the patient begins complaining of leg weakness and then collapses, drooling all over his pillow.

Increasing muscle weakness follows, ultimately landing Jeff once again in respiratory distress. The team considers lupus, ALS (probably better known as Lou Gehrig’s disease) and muscular dystrophy but all the tests are normal. They are suspicious of an infection, but there is no laboratory evidence of it. Noting Jeff’s dropping red blood cell count, the team diagnoses him with pure red cell aplasia (PRCA) — a condition where the body cannot make enough red blood cells. Epogen has been linked to several cases of PRCA so House accuses Jeff of lying about not using the drug. Jeff continues to deny ever using epogen, but he fires his manager because he suspects she might have given him the drug. When Jeff continues to have symptoms, the team diagnoses him with a thymoma (a tumor of the thymus) and myasthenia gravis. His blood doping and hyperbaric treatments had prevented the conditions from becoming evident until he stopped them for the charity race.

The medicine was rather muddy this episode. The doctors were all running around like chickens with their heads cut off. They were more interested in what drugs Jeff had taken and why, rather than taking a good look at his symptoms. The muscle weakness and drooling should have made myasthenia gravis an obvious choice. It’s not that the medicine was bad or incorrect, it was just ill considered and the team could have used their time and resources much better.

A few nit-picks:

• The team went to a muscle biopsy way too early in the diagnosis of weakness
• Foreman is wrong: there are several types of muscular dystrophy that strike adults — though they are very rare. One of my first patients in residency was a gentleman in his 50s who was diagnosed with muscular dystrophy only after he developed congestive heart failure.
• Blood doping can be sometimes caught by testing (just ask Tyler Hamilton); amphetamine use certainly would be caught.
• I’m still not clear how they decided that Jeff might have an infection. Something like: “His red blood cell count should be high but it’s low, so that means the white cell count which is also low must be high as well and he has an infection!” That’s quite a stretch. (And they were wrong anyway.)

It was nice to see House return to his arrogant-bastard ways in this episode. He invites himself to the therapy group attended by Stacy’s husband, he gets the cyclist’s manager fired by accusing her of sliiping Jeff Epogen and in the end he breaks into Stacy’s therapist’s office and reads Stacy’s file. This is the House I remember. We also learn a bit more about Wilson’s and Cameron’s past. Both had been tempted to commit adultery; Wilson did, Cameron didn’t.

I give the medical mystery a fair B, but its solution only deserves a C because it was too obvious. Overall, the medicine earns a B-. The soap opera redeems the show, earning a solid A.

• Previous House reviews

Geoff Johns wins the coveted “Technobabble of the Month Award” with this panel from Flash #225 (pencils by Howard Porter).

“Spontaneous Conception via Time Travel.” Does this make sense to anyone?

It’s actually a contradictory statement: Spontaneous conception means a conception achieved naturally without any assistance (such as fertility drugs or IVF). I’m pretty sure that time travel would count as “assistance”.

(And does this mean that there’s a greater than average number of children in Central City, Keystone City, and Gallifrey?)

Today is the Great American Smokeout. I was going to put up some nasty pictures of cancerous lungs, but I’m just not that evil (the pictures are truly disgusting). Instead, I decided just to quietly point out the nasty chemicals in cigarettes and the incredible variety of cancers that smoking causes.

Finally, here’s my favorite smoking-related picture ever. I just love the irony.

Tags: medicine cigarettes smoking pregnancy

I’ve never liked characters with bird-like wings sprouting from their backs.

First, they’re never used well. “While the rest of the X-Men attack the Brotherhood, Angel. You, um, fly around.” And exactly how many issues of the Legion of Super-Heroes was Dawnstar flying around exploring the universe instead of actually contributing to the team? This leads to aloof characters the readers can’t relate to who are quickly written out of the series.

Second, The anatomy and physics just don’t work:

1. Birds (and bats) have four limbs: two legs and two wings. Winged characters (with the exception of Man-Bat) have six limbs: two legs, two arms and two wings. Having wings in addition to the normal limb count is more insect-like than anything else.
2. Bird chests are more barrel-like than the relative flat human chest. This allows birds a greater reach for a more efficient flapping. It also provides a better structure for their flight muscles to attach to.



3. Bird bones are extremely light. They are generally hollow or have air cells in them. If winged characters were built like this, one strong punch would shatter bones.
4. There are bones in bird wings (as any connoisseur of hot wings knows all too well). Has it ever been shown that flying characters have bones in their wings? On one hand, that would be weird — like having an extra pair of arms growing out of the shoulder blades. It would also make it hard for the wings to tuck tightly in against the back, as Warren Worthington likes to do. However, if these wings don’t have bones, then what are the flight muscles attached to? And how do their wings have the necessary rigidity for flight?
5. Characters are inevitably drawn with what is known as “the high-speed wing” or the “long wing.” In nature, this style of wings is found in swallows, swifts, terns and some birds of prey. It is best for a fast level flight. It is not particularly well suited for tight maneuvering or quick take-offs and landings — which is what most winged heroes use it for.
6. An average human would need a wingspan of 48 feet to fly. If you add in the increased muscle mass needed to use these wings then that number jumps to 60 feet.

My usual music listening software had been MusicMatch Jukebox. It’s an excellent mp3 player, it has a wide variety of good online radio stations, and it has a good selection of downloadable content. Howeve,r I’ve noticed that it’s been eating more and more CPU cycles recently, to the point where I am unable to multi-task (and I live for multi-tasking). It’s not just some quirk with my home computer, I’ve noticed the same problem on my work computer. Because of this, I’ve been looking around for some alternate music software.

I’ve never liked Microsoft’s Media Player (I don’t trust it), so I’ve avoided using that. I tried iTunes, and while I appreciate its mp3 playing, I’m not as impressed by its online music stations. XM Radio seems to have the best online radio. I have an XM radio at home, so I can use its online content for free. In particular I’ve enjoyed station #44 “Fred” — which is described as “classic alternative rock”. Basically, it’s the alterntive rock I listened to during high school and college.

It’s been great listening to all that music again. In addition to the usual suspects (the Cure, Oingo Boingo, Depeche Mode, REM) , there have been the occasional bands that I enjoyed that I had loved but totally forgotten about: the Jesus and Mary Chain, Book of Love, and Bauhaus.

I think I’m scaring the nurses though.

I’ve cleared up the database glitch (I’m pretty sure I have anyway…), so I can resume posting now.

When I picked OHOTMU - Horror 2005 up, I immediately turned to the Brother Voodoo page. He has a nice long description, but I did notice a problem. Under his education it lists: “M.D. in psychology, extensive training in voodoo.”

You cannot have a medical degree in psychology because psychology is not a medical specialty.

For the record, Brother Voodoo is a psychologist, not a psychiatrist (which is a medical specialty). He does not have a medical degree. He probably has a Ph.D. in psychology so he is still a “doctor,” just not a medical doctor.

From the American Heritage Dictionary, a psychologist is “A person trained and educated to perform psychological research, testing, and therapy.” (And it defines psychology as “The science that deals with mental processes and behavior”). Notice that there is not mention of medicine or medical anywhere in these definitions. In contrast, the definition of psychiatry states: “The branch of medicine that deals with the diagnosis, treatment, and prevention of mental and emotional disorders.”

Psychology and psychiatry are two different disciplines. While they deal with many of the same topics, they tend to approach them differently. Neither is superior; I like to think that they are complementary.

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And as a final nit-pick, an M.D. is an M.D. — you don’t earn an M.D. “in” something. Specialization occurs after the degree is awarded, during residency and fellowship.

Tags: comics medicine brother voodoo psychiatrist psychologist

A giveaway comic from the fine folks at K-Mart and the National Committee for Prevention of Child Abuse, Spider-Man and the New Mutants was written by the husband and wife team of Walter and Louise Simonson. OK, they each separately wrote a story that appears in the comic, but it sounds better to say “they wrote it together.”

In the first tale, Spider-Man helps young Billy deal with physical abuse from one of his teachers. This story was written by Walter Simonson and drawn by Alex Saviuk. Sadly, it did not feature a hammer wielding frog.

The second feature stars Skids from the New Mutants. In this story by Louise Simonson and Bret Blevins, Skids helps a mother learn how to deal correctly with her misbehaving child (hint: abuse is not the right answer). Long time X-Factor readers (both of you) will remember that Skids herself was an abused child, so this makes more sense than Peter Parker suddenly remembering he was sexually abused and then never mentioning it again. This story does bring up two important questions:

• First, was Skids ever officially a New Mutant? She and Rusty hooked up with the Xavier students during the lamentable X-Terminators mini-series and hung around for a bit, but I don’t think she was ever really a member. After a couple of issues, she and Rusty ended up joining the Mutant Liberation Front and were on Stryfe’s satellite when it exploded. More recently, she showed up as part of the X-Corps so I guess she survived her orbital explosion (but what about Rusty?).
• Second, whatever happened to Bret Blevins? He one of the two great artists who drew the New Mutants (Sienkiewicz being the other one), and he drew a great Solomon Kane too. Isn’t he working in animation now? (And as a piece of total fanboy trivia, Skids’s last name was eventually revealed to be “Blevins”. Coincidence? I don’t think so.)

UPDATE:
How could I forget Rick Leonardi? He was another excellent artist from New Mutants.

The latest edition of Grand Rounds has been posted over at code blog. A collection of the best medical blogging of the week, Grand Rounds is always a fascinating read. Stop by and check it out.

This medical review of House contains a whole bunch of spoilers, so don’t say I didn’t warn you…

House finds himself accosted outside his home by Kalvin, a young man with AIDS who wants House to figure out why he is having increasing shortness of breath and fever. House tells Kalvin that he simply has one of the common infections that occur in AIDS patients and to leave him alone. When Kalvin refuses to leave, House gives him a gentle shove. The patient falls, hitting his chest against a nearby car and going into anaphylactic shock — a sudden and life-threatening allergic reaction.

Kalvin is admitted to the hospital, but House is still sure that he must have an opportunistic infection such as herpes simplex, pneumocystis, or tuberculosis. Kalvin’s tests are all negative and his T-cell count is over 200. T-cells are the infection-fighting cells that are the targeted by HIV; a high T-cell count makes it unlikely that Kalvin has an opportunistic infection.

Kalvin’s drug screen is positive for methamphetamine and ecstasy, and when Cameron confronts him about this, he develops a sudden hemoptysis — a bloody cough — and some of his blood ends up in Cameron’s eye and mouth. Realizing she has been exposed to HIV, Cameron talks to the hospital infection control officer who starts her on some anti-viral drugs. She must wait six weeks before being tested because the AIDS test looks for antibodies against HIV, not HIV itself, and these antibodies take several weeks to show up.

Cameron wonders if Kalvin’s symptoms may have been caused by contaminated drugs so she and Chase search his apartment. They don’t find any drugs, but they do discover some old photographic equipment and speculate that Kalvin may be suffering from beryllium poisoning, since that was a chemical used in old flash bulbs. A subsequent lung biopsy is negative for beryllium damage.

Kalvin becomes suddenly short of breath and his distended neck veins suggest cardiac tamponade. Tamponade occurs when the pericardium, the sack that surrounds the heart, fills with so much fluid that the heart cannot expand properly. The treatment is to drain the fluid through a long needle inserted through the chest wall into the pericardium. Most tamponades are caused by blood, but when a clear liquid is withdrawn instead of blood the team suspects Kalvin must have a cancer of the heart. A CT scan confirms a tumor mass in the heart and some smaller ones in the lung. Non-Hodgkin’s Lymphoma is the diagnosis and surgery is scheduled.

Meanwhile, Kalvin’s father has come from Montana. He and Kalvin don’t get along because they both blame Kalvin for his mother’s death. When House notices the father profusely sweating, he deduces that Kalvin does not have lymphoma, but instead a parasitic infection known as echinococcus. Kalvin and his father both caught this disease years ago while hunting foxes in Montana, and it had laid dormant until recently. In Kalvin, it masqueraded as heart and lung cancer, while in his father it masqueraded as cirrhosis — a liver disease most commonly caused by heavy drinking. It was the fever that gave it away, because cirrhosis does not cause fever. When these parasitic cysts would break open, such as when Kalvin fell against the car, the body would develop an immediate allergic reaction against the parasites causing anaphylactic shock. Two quick surgeries later and Kalvin and his father are healing, both physically and mentally.

The medicine was reasonable. House’s behaviors, such as purposefully inducing anaphylactic shock in the father, were unethical and quite likely illegal, but the science behind them was sound. I do wonder what sort of radiologist could mistake a hollow cyst for a solid tumor on a CT scan, or confuse cirrhosis with a cyst.

The highlight of the show was the soap opera. Using the notes he stole last week from Stacy’s therapist, House begins to worm his way back into her life. He tries to show her that he can do all the things her incapacitated husband can’t — such as cleaning the dishes and catching the rat terrorizing her apartment. He also continues his subtle and not-so subtle jibes at her husband, like leaving the toilet seat up so that he’d know Stacy had had a male visitor. By the end of the episode Stacy realizes that House had read her file and kicks him out of her office, and possibly her life entirely.

Meanwhile, Cameron is not coping particularly well with her HIV exposure. She puts on a brave front, but is clearly scared. She samples some of Kalvin’s drugs and seduces Chase while she’s high. A very dumb move on her part, but a monumentally stupid one on his. Not only does Chase sleep with an intoxicated co-worker, but one who may be HIV positive as well. Only time (and a few more episodes) will tell.

This episode earns a C+ for the mystery, a B+ for the solution, and another B+ for the medicine overall. The soap opera, especially the Cameron and Chase subplot, earns a solid A.

• Previous House reviews

Tiny Toys Remain Major Cause of Child Deaths screams the Associated Press headline in an article about the annual toy survey from the United States Public Interest Reseach Group (USPIRG) carried by many local papers, national news outlets and local news stations yesterday. From the article:

The U.S. Public Interest Research Group’s 20th survey noted that the Consumer Product Safety Commission reported the deaths of 16 children in toy-related incidents last year, along with another 210,000 emergency room visits. Choking on small parts, balls and balloons remains a leading cause of death and injury in children younger than 15.

This makes no sense. How can 16 deaths lead to the conclusion that choking on toys is a “leading cause of death and injury” or a “major cause of child deaths”?

Let’s take a minute to look at the actual statistics:

• The 210,300 toy-related injuries estimated by the Consumer Product Safety Commission (CPSC) is for all ages. 77% of these injuries (161,100) were to children under 15.
• Riding toys were the leading cause of toy-related injuries (34%), and most of these were due to unpowered scooters.
• The NEISS database estimates that there were 12,206 aspiration injuries to children under 15 in 2004. Note that this number includes all aspiration injuries, not just those related to toys. (In contrast, children had 2.3 million falls, three-hundred-thousand bite and stings, and two-hundred-thirty-thousand motor vehicle accidents requiring emergency room visits in 2004).

The CPSC reports 16 toy-related deaths in 2004.

• Choking made up 44% of these injuries (7)
• Riding toys made up 38% (6)

The main causes of death in children depends greatly on age. For children under 15, the leading causes of death include accidents, congenital malformations, assault, cancer, heart disease, influenza and pneumonia. If you have time to kill, the National Vital Statistics Report can be found here (warning, it is a 90 page pdf file).

Here’s a list I compiled of deaths in children under 15 in the US in 2004 due to various causes. This list contains some — but not all — of the leading causes of death and also lists some less common causes. These numbers are presented to contrast to the 16 toy-related deaths in 2004:
Motor vehicle accidents, 2505; Malignant Cancer, 1548; Assault, 1082; Heart Disease, 920; Drowning, 838; Suicide, 273; Falls, 95; Medical or Surgical Complications, 69; HIV, 37.

The following charts do an excellent job presenting the leading causes of deaths and non-fatal injuries in children. You’ll notice that “toy aspiration” is not listed as one of the leading causes. It probably falls under the heading “Unintentional Foreign Body,” but that category includes all foreign body injuries, not just choking, and not just toys.

Conclusion: The statistics simply do not support the claim that “choking on small parts, balls and balloons remains a leading cause of death and injury in children younger than 15.” Nor do the statistics support the headline that small toys are a leading cause of children’s deaths.

Where did these ridiculous claims come from?

• NOT from the CPSC. Their Toy-Related Deaths and Injuries, Calendar Year 2004 makes no such claims (pdf file).
• NOT from the USPIRG. Both their press release and annual Toy-Report are generally level headed and full of good advice. The press release does state “choking on small parts, small balls and balloons remains a leading cause of toy-related deaths and injuries,” which is a much more reasonable claim (the death part anyway, I see no statistics to support choking being a leading cause of toy-related injury).
• Since these are the only sources the Associated Press names, the only reasonable conclusion is that the AP themselves must have come up the misleading statements. Their reporters either misunderstood and misreported the data, or went for the eye-catching headline and sound bite without bothering to accurately report the actual evidence.

Toy-related deaths are tragic and preventable, but they are not the epidemic the Associated Press article claims. The USPIRG Toy Report has good information and I recommend it to parents, grandparents and physicians.

UPDATE:
Apparently the headline I quoted above is just CNN only, other media sources have less salacious headlines. The rest of the article remains the same however.

Happy Thanksgiving!

Son of Vulcan #2 “Burned”
Scott Beatty, writer
Keron Grant, penciller

The Scene: The beautiful android Pandora arrives on Earth to investigate the site where Son of Vulcan was slain, and is confronted by some agents from the DEO. When one of the agents tries to stop her from proceeding, she grabs his arm and efficiently breaks it, commenting: “That is the sound of a compound fracture, agent. You’ll need surgery to set the splintered bone and prevent infection from consuming any exposed marrow. Are you ambidextrous?”

The terminology is a little archaic, but Pandora’s knowledge of how to injure someone — and the subsequent medical concerns — is quite good.

“Compound Fracture” is an older term for an open fracture, an injury that occurs when there is a broken bone AND damage to the skin overlying the bone. In the most severe cases, the broken bone itself juts out through the skin, but any situation where there is both a broken bone and a break in the skin is considered an open fracture. Open fractures are dangerous because the opening in the skin allows bacteria and other contaminants to get into the wound and cause infection.

The most common cause of open fractures is a motorcycle accident, followed by other motor vehicle accidents and falls. I’m pretty certain that getting your arm broken by an annoyed android falls into the “miscellaneous” category.

Causes of Open Fractures
Motorcycle Accident	28%
Motor Vehicle Accident	24%
Fall	13%
Pedestrian Struck by Car	12%
Crush Injury	8%
Firearms	2%
Miscellaneous	13%

Osteomyelitis is the medical term for a bone infection, and it is a common complication of open fractures. In traumatic injuries, it is usually the outside of the bone (not the bone marrow) that becomes infected, though the infection can spread inward and eventually involve the bone marrow. Osteomyelitis can also occur out of the blue, particularly in children, and in that situation the infection usually starts in the bone marrow and works its way out.

Up until World War I, amputation was the treatment of choice for open fractures. Since then, with the advent of antibiotics and better surgical techniques, amputation has thankfully become a treatment of last resort. Open fractures still have an uncomfortably high risk of infection and aggressive surgery and strong antibiotics are almost always required.

Recovery from an open fracture can be a frustratingly slow process, depending on how severe the injury was and whether infection or any other complications occurred.

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Links:

• A list of types of fractures (from the review of Teen Titans #26)
• A site focusing on the surgical treatment of open fractures (includes graphic images)
• A good outline review of open fractures.

The Polite-Wife and I just returned from seeing Harry Potter and the Goblet of Fire. I thoroughly enjoyed it; it’s may favorite of the movies to date, but I’m not certain why exactly it was rated PG-13 and not PG. Still, there was something bothering me about the movie, and the books as well. It took me a while to understand what it was that bothered me, but then I realized the answer: harry Potter is suffering from G-Force Syndrome.

Growing up, one of my favorite TV shows was Battle of the Planets (or “G-Force,” as we called it). It has action, heroes, robots, the Phoenix, and plots that only a child could love. We would run around the elementary school playground pretending to be different members of the team (for the record, I was always Mark and never Jason). One part of the show annoyed me, even as a child. Every day, every episode, it was the same villain. Some episodes, it may seem at first that there’s a different villain, but it always ends up being Zoltar pulling the strings and manipulating everything. It was fun at first, but always having the team face the same villain quickly got tiresome.

This is the same problem I have with the Harry Potter books and movies. I enjoy them; they’re entertaining and do a wonderful job of capturing the imagination. Still, at the back of my mind is the knowledge that the plot will all tie into Voldemort somehow once again. The Tri-Wizard Tournament was a great plot in and of iteself — no need for more. Tying it in to Voldemort just cheapened Harry, and looking back a similar thing happened in most of the other books. It’s Battle of the Planets all over again.

While at the theater yesterday, we saw the trailer for Superman Returns. I had seen it on the internet, but it’s much better in the theater. I can understand why people dislike thecostume or the messianic aspects of the trailer. Personally, I like the trailer, but pretty much for just one reason: the music.

You really have to see the trailer in the theater to appreciate it — computer speakers simply won’t work. As the Warner Brothers emblem appears on the screen, the familiar low roll of the music starts. As the DC sigil appears and the trailer itself begins, horns come in. More horns join in and then the tympani. You are immersed in the full majesty of one of the most perfect pieces of cinematic music — the Planet of Krytpon Theme. Hearing it reverberate from the the vast theater speakers made the trailerworthwhile. I understand there may have been some movie footage in the trailer too, but I missed it; I was listening to the music.

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The main theme from Superman is another excellent piece of music, up there in my top five movie themes of all time (with Star Wars, Raiders of the Lost Ark, Last of the Mohicans, and The Princess Bride). The Planet of Krytpon Theme remains my favorite piece of movie music ever.

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Should it be worrisome that they’re trying to sell the new film by using the music and Marlon Brando voice over from the first Christopher Reeve film?

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If you haven’t guessed by now, I’m more than a little partial to the Planet of Krypton Theme.
It was part of the music in our wedding. In addition to designing the cake topper, my wife also let me choose the music for the ceremony. For the most part, I kept to the traditional music and some common baroque favorites, but I threw in a few fun extras here and there just to see if anyone was paying attention. For instance, my wife and her bridesmaids kept the traditional processional music and bridal march — but the groomsmen and I, we entered with the Planet of Krypton Theme.

I was going define the science terms used by Grant Morrison in All-Star Superman #1, but Silver Bullet Comics beat me to it (scroll down to the bottom of the page. Personally, I would have been a lot more wordy). Instead, I’ll just take a close look at some of the biology used by Morrison in the comic:

1. Apoptosis

Cells of the body can die in one of two ways. The first, known as necrosis, is due to injury, damage, or exposure to toxins. With necrosis, the dying cells swell and their contents leak into surrounding tissues. This causes an inflammatory response that can damage other nearby cells.

The second method of cell death is known as apoptosis. In this situation, the cell essentially commits suicide. The cell receives signals that cause it to shut itself down. The cell shrinks and is broken down into smaller membrane-encased bubbles which are absorbed by the immune system. There is no inflammatory response. Apoptosis allows the body to eliminate particular cells without disturbing neighboring cells.

Apoptosis is an important part of development. There are times when an animal needs a certain anatomical structure for just a brief period of time. After this time is up, the structure is no longer needed and the cells that compose it will be broken down. A tadpole’s tail is a good example. As the tadpole becomes a frog, the tail is resorbed by the animal and its cells broken down by apoptosis. As for humans, apoptosis is known to play a role in fetal development and the female menstrual cycle.

That’s the traditional role of apoptosis. It is used by the body to recycle cells that have served their purpose, and that’s why it is sometimes referred to as “programmed cell death.”

More recently, scientists have begun to understand that apoptosis has other functions as well. The body uses apoptosis to kill off virus-infected cells and to attack certain tumors. It stops the immune system from going into overdrive. Low dose exposure to heat, radiation and certain drugs will induce apoptosis (while high dose exposures will cause necrosis). On the other hand, overly aggressive apoptosis — or a lack of it — is thought to play a role in certain diseases. For example, apoptosis seems to be important in the destruction of CD4 cells by the HIV virus, but the exact mechanism is unclear.

In All-Star Superman #1, Dr. Quintum informs Superman that his cells have entered apoptosis due to an overload of solar radiation. As mentioned above, high dose heat and radiation usually cause necrosis, not apoptosis — but maybe all the radiation that Superman absorbed is considered low dose for a Kryptonian. It also appears that he absorbed enough to kick all his cells into apoptosis at once. It’s certainly unlikely, but as Dr. Quintum himself says, “Only nothing is impossible.”

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• All-Star Superman is by Grant Morrison and Frank Quitely.
• An excellent overview of Apoptosis (in-depth, but not incomprehensible).
• Barbelith’s annotations to All-Star Superman #1 (a well-done wiki page).

The latest edition of Grand Rounds has been posted over at Over My Med Body!. A collection of the best medical blogging of the week, Grand Rounds is always a fascinating read. There’s some particularly interesting articles this week, so make sure to stop by and check it out.

This is the second of three posts on the biology in Grant Morrison and Frank Quitely’s All-Star Superman #1.

2. The Square-Cube Law

Dr. Quintum: Normal restrictions on human size and anatomy just don’t apply in weightless conditions.

What Dr. Quintum is referring to here is the Square-Cube Law. This is a fairly straightforward mathematical law which states that when you increase the size of an object by a factor of x, then its surface area will increase in proportion to x² and the volume will increase in proportion to x³.

This law applies not only to abstract objects, but to living organisms as well. When an organism increases in size, its surface area and volume increase by much larger amounts. This is vital in living creatures as both volume and surface area are important biological factors.

Let’s use Giant Man as an example. Hank Pym, normally 6 foot tall and 200 pounds, decides to grow to 30 feet (for the metricly inclined, normally 1.8 m tall with a weight of 90.7 kg, Pym grows to 9.1 m). Thus he is increasing his size by a factor of 5. His surface area increases by roughly 5² ( or 25). This is key because muscular strength is dependent on area. His volume increases by 5³ (i.e. 125). Weight corresponds with volume, so Giant Man now weighs 200 x 125 = 25,000 pounds (11,339.8 kg). The human body, even at 30 feet tall, is not designed to handle that kind of weight. His leg bones would snap like twigs and Giant Man would collapse on the ground in tremendous pain. He probably doesn’t even have enough strength to expand his rib cage to inhale, so he’d suffocate while he lay bleeding on the ground. He doesn’t even have the strength to scream for help (or even to whisper “Avengers Assemble” or “Avengers Disassemble”). Not a pretty picture, eh?

The human body seems to max out at around 8 feet, and even then, most people that tall have significant health problems.

Now I know that everyone is thinking about elephants and other large animals. Remember that these creatures have evolved over hundreds of thousands of years to be able to handle this extra weight. They are quadrapedal and fairly stocky with much stronger and heavier bones. However, even elephants have a maximum size dictated by the Square-Cube Law.

Dr. Quintum suggests that a weightless environment would allow an organism to escape these restrictions. That’s true…to a point. I suspect a weightless environment would allow for creatures to overcome the strength versus weight consequence of the Square-Cube Law. However, while that is the most graphic consequence of the law and the most common example, it is not the only limitation the Square-Cube Law imposes.

Surface area is a vital part of biology. For example, air exchange in the lungs and the absorption of nutrients from the gastrointestinal tract are both dependant on surface area. Increasing the size of an organism would increase its volume and mass to a much greater degree than the surface area of these organs. A creature that much larger than normal would have a difficult time getting enough air and other nutrients to function. Blood flow would be still another concern.

These restrictions could probably be overcome with the judicious use of technology and/or genetic manipulation, and Dr. Quintum seems to have both. Maybe Giant Man should give him a call.

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• A very readable paper on Comparative Anatomy and the Square-Cube Law.
• The Science of Super-Heroes has much more to say about the Square-Cube Law as well.

A complicated episode of House, but an interesting one. This medical review contains a bunch of spoilers, so don’t say I didn’t warn you…

As the story begins, we discover that House and Chase are facing a hospital disciplinary hearing over the care of one of their patients. This episode takes place mostly in overlapping (and sometimes contradictory) flashbacks. While this is a good storytelling device, it makes for an awkward discussion of the medicine so I’m going to approach the case chronologically.

Kayla, a young mother, is experiencing severe abdominal pain as well as joint pain in her legs. A clinical exam reveals uveitis, a type of eye inflammation. The team considers a variety of diagnoses including gonoccocal arthritis, rheumatoid arthritis, and Takayasu Arteritis. They finally settle on a diagnosis of Behçet’s Disease after finding some genital ulcers on a pelvic exam. Behçet’s Disease is very rare chronic inflammatory disease. Symptoms include mouth and genital sores, uveitis, arthritis and skin rashes. Abdominal pain can also be a symptom. Chase starts Kayla on some medication to calm down the Behçet’s, some antacids for the stomach pain, and performs a skin test to confirm the Behçet’s known as a pathergy test.

When Kayla comes back to the clinic two days later to have her pathergy test read, she complains to Chase that she is still having abdominal pain. Her test is positive, so he refers her to a rheumatologist. He also prescribes some stronger antacids and sends her on her way. He does not perform an exam or ask any more questions about her abdominal pain.

Two hours later Kayla is brought to the Emergency Room after vomiting a tremendous amount of blood. Chase performs an endoscopic exam and notices a stomach ulcer. He cauterizes it to stop the bleeding, but a second stomach ulcer has perforated, spilling the stomach contents into the abdominal cavity. This is very dangerous and Kayla develops peritonitis and then a severe bacterial infection known as sepsis. This leads to kidney damage and liver damage. A blood clot forms in the liver, leading to even more liver damage. Kayla’s best hope of survival is a liver transplant. Despite the fact that she’s too sick for a transplant, House browbeats Cuddy into placing her at the top of the transplant list.

Unfortunately, Kayla has type AB- blood, the rarest blood type, so it will be unlikely that a liver will be found in time. Her brother offers to give Kayla part of his liver, a type of “live organ donation.” He has lab tests to prove that his liver is in good condition and will match her genetically. House blackmails one of the transplant surgeons into performing the operation, and both brother and sister do well.

At a follow-up visit 2 months later, Chase notes that Kayla has a low-grade fever, unusual for someone on immune suppressant medication. He orders some blood cultures and other lab tests, as well as a chest x-ray. One of the blood cultures grows Strep. This usually means that it was a skin contaminant (If it had been a real infection, Strep would have grown in more than one sample. Strep commonly grows on the skin, and a single positive culture suggests that her skin was not cleaned off well enough before the sample was drawn). Her liver enzymes are elevated, signifying liver damage. Chase chooses to believe that Kayla has a Strep infection, but Foreman believes Kayla’s body is rejecting the liver. Her brother comes in and demands to know what is going on with his sister. House looks him over and deduces that he has Hepatitis C and that he faked his liver tests to so that his sister could have the transplant. He transmitted Hepatitis C to his sister and because of her immune suppressant medication, she deveoped a severe infection. In addition, his liver was cancerous (from the chronic Hepatitis C) and he gave this cancer to his sister hidden inside the liver transplant. At this point, there’s not much that can be done for Kayla. She has Hepatitis C rampaging through her body, and because of the liver cancer, she isn’t eligible for a second transplant. Her brother wants her to get a “black market liver transplant” in Mexico, but Chase advises against it. Kayla returns home to her children and dies a week later.

There is no doubt that Chase should have performed a better exam. Abdominal pain is never something to be taken lightly and people can die from gastrointestinal bleeding in a remarkably short amount of time. Both he and House know he screwed up. The question of the episode is why did he screw up. At one point, Chase confides to Kayla’s brother that he killed her by missing her ulcer and blamed it on being hung over. Unsurprisingly, her brother files a malpractice suit against Chase. In reality, Chase was not hung over, but instead had just been informed that his father had died. This threw him for a loop, and he wasn’t really paying attention to what Kayla said. He tried to call her back a few hours later, but by then it was too late and her ulcer had burst.

Chase is reprimanded by the committee and suspended for a week. In addition, the committee is distressed by House’s actions and places him under another physician’s direct supervision for the next month. Cuddy chooses Foreman to be that supervisor.

The medicine was fairly straightforward this episode and almost error free. Chase should have been more concerned about the abdominal pain, and taken a better history to find out what medication Kayla was taken, but his mistakes were the basis of the episode. I’m surprised that the team would accept her brother’s lab values without confirming them, and that goes double for the surgeon (blackmailed or not). I will make my usual complaint that the team is performing tests themselves that are best left to specialists (such as endoscopy). I also wonder why Foreman, a neurologist, was consulted for someone having abdominal pain and arthritis.

The soap opera was more restrained this week, focusing mainly on House and Stacy trying to salvage their professional relationship. I expect more fireworks in the next episode when Foreman is in charge.

This episode earns a B for the mystery, another B+ for the solution, and a B+ for the medicine overall (it was competent, just not as exciting medically as usual). The soap opera earns yet another B.

UPDATE:
My boss just reminded me of a scene I forgot to mention, when Chase performs a pelvic exam on Kayla. First, he performs an unchaperoned exam — that’s a lawsuit waiting to happen. Then, while his hands are still gloved and contaminated from the exam, he flips through her medical records. You use gloves for a reason…

• Previous House reviews

Day Three of a three-day look at the use of biology in Grant Morrison and Frank Quitely’s All-Star Superman #1. (The previous parts can be found here and here). Today, we’re going to start where we left off yesterday: talking about the giant blue Voyager Titans.

Dr. Quintum: The blue skin is typical of these anaerobic meganthropes. His blood is 80% liquid nitrogen.

3. Anaerobic
Anaerobic literally means “without air”, though it is understood to mean “without oxygen.” It can be used in several contexts, but I’m just going to mention the two most common here.

First, there are some organisms, generally bacteria, that thrive in low oxygen environments. These are known as anaerobic bacteria. Clostridium tetani is a perfect example of one of these anaerobic bacteria. This is the germ that causes tetanus and can only survive in environments without oxygen, such as at the bottom of a deep puncture wounds. That’s why we give tetanus immunizations for dirty puncture wounds.

A second common use of the term anaerobic is in reference to exercise. Humans can produce energy both aerobically (with oxygen) and anaerobically (without oxygen). Aerobic exercise is good for long steady exercise such as walking, jogging, cycling, and – duh – aerobics. It is more efficient that anaerobic exercise, but not as powerful. On the other hand, anaerobic exercise is good for quick bursts of maximum speed or strength such as sprinting or weight lifting. The downside is that anaerobic exercise is not as efficient as aerobic exercise and produces lactic acid, a by-product which builds up and causes muscle fatigue.

In this instance, I suspect that Morrison is suggesting that these are anaerobic organisms. These giant men (mega + anthropes) are designed for space exploration and need to live in a low- or no-oxygen environment. The blue color suggests that they do not have oxygenated hemoglobin in their blood, which has a definite red color to it. This makes sense as they are anaerobic and would need no molecules specially designed to carry oxygen (like hemoglobin).

(Actually, both uses of “anaerobic” tie-in together, because an anaerobic organism needs to use an anaerobic metabolism to produce energy).

4. Liquid Nitrogen
Liquid nitrogen is nitrogen that has been converted to liquid form by high pressures and low temperatures. It has a boiling point of –320.5° F (-195.8° C). Above this temperature, nitrogen is a gas. At –320.5° F or below, nitrogen is a liquid. We have a medical term for that: damn cold.

Medically, we use liquid nitrogen to treat certain skin conditions such as warts, seborrheic keratoses and actinic kertoses. It is also used for storage and cryo-preservation of tissue samples.

I suppose that with the right technologic and genetic modifications, liquid nitrogen could be used in the bloodstream, replacing the water that is in ours. But just remember this: at a temperature above –320.5° F, their blood will turn to gas and a small puncture wound would become an explosive blow out.

5. Yoctosphere
Yocto- is a metric prefix that means 10^-24, or 0.000000000000000000000001. It is used to describe the size of atoms and sub-atomic particles. Thus “yoctosphere” would refer to the atomic and subatomic realm.

The Science of Super-Heroes has an interesting section on sub-atomic heroes.