Polite Dissent

Mild Spoilers Below

I’m going to spend the next few posts looking into the medicine behind the recent storyline in Batman: Gotham Knights. Before I get into that, I wanted to spend a moment to give my general opinion of the story:

I didn’t like it. It’s not because of the medicine, though there was quite a bit of bad medicine in it. It’s just an uninteresting and uninspired story with bland, overused characters and no resolution of the problem.

Though this appears in Batman: Gotham Knights, it is not a Batman story. He appears as a supporting character, but he isn’t the focus. This is a story about villains. That is not in and of itself a bad thing. With the right characters and the correct writer, villains can certainly carry a story on their own — just look at the recent Injustice League storyline in JSA Classified. Hush and Joker can’t pull it off though.

In a nutshell, here’s what’s wrong with the story:

1. The Villains
• The Joker – It’s time to put the Joker out to pasture. Sure, he’s the most recognizable Bat-villain — but he’s also the most overused. He’s been so diluted that he lacks any hint of a threat anymore, so writers keep trying to up the ante and make him seem formidable by having him kill more and more innocents.
  As an example of how overused the Joker is, the same time he is appearing in this story trying to kill Hush, he is also appearing in Batman where he is kidnapped by the Red Hood and blown up.
• Hush — I’ve made my low opinion of Hush known on many occasions, and this storyline does nothing to change my mind. I’m reading about this guy running frantically through the rain, looking like a combination of Mumm-ra and a flasher, and I’m wondering if he’s still going to be around in 10 years*? How about 5 years? How about next year? To quote Sixteen Candles: “There’s no there there.”
2. The Threat

At the beginning of the storyline, the threat is laid out: the Joker has a device that can kill people who have a Waynetech pacemaker. At the end of the storyline, the Joker has a device that can kill people who have a Waynetech pacemaker. The threat is never resolved.

3. The Ending

A clever ending that leaves you guessing? Or a lame attempt to make a poor story seem more interesting than it actually is? You decide.

*I predict that in a few years there will be a big Bat-storyline that will be advertised as having the death of a “major villain.” This villain will be Hush. This way DC can get rid of this ridiculously lame villain, but still pretend that he was something special.

Tags: comics joker hush batman

Batman: Gotham Knights #73 “Payback”
A.J. Lieberman, writer
Diego Olmas, penciler

The Set-Up: Three people in Gotham City suffer sudden cardiac death: a traffic copter pilot, a business woman, and a train engineer. Autopsies showed that not only did all three of these people die of a heart attack, but that they all had a particular model of pacemaker made by WayneTech. Batman deduces that somehow someone is overriding the pacemaker’s frequency leading to a rapid heart rate which causes a heart attack. He accuses Hush, but he knows nothing about the pacemakers.
It turns out that the Joker has taken up bird training and has been using a clicker to train his birds. Coincidentally, he has discovered that this clicker causes WayneTech pacemakers to speed up so much that they cause heart attacks. He decides to use this information to get back at Hush and Batman.

Topic One: A big typo. This is one of those typos that strikes me as funny because it actually changes the meaning of the sentence significantly.

Medical examiner: “…Each one of these people died of amyocardial infarction.”

It should be a myocardial infarction, not amyocardial infarction. Myocardial infarction is the medical term for a heart attack. There is a blockage in one of the arteries that supplies the heart with blood and consequently part of the heart dies from lack of oxygen. If a big enough portion of the heart dies, the patient will too.

Amyocardial is not a word. But bear in mind that the prefix “a-” when added to medical terms means “without” or “absence of” — for example asplenia refers to someone who is lacking a spleen. Therefore amyocardial infarction would be an infarction not involving the heart.

Topic Two: The autopsies. Sloppy, sloppy work. Autopsies use a Y incision, not the chainsaw-style down the middle incision shown here. The medical examiner is also mixing specimens up. The three pacemakers should be kept separate and labeled, not all kept in one bin.

Topic Three: The pacemakers. Well drawn. Good job.

Topic Four: Could the Joker’s plan really work? Could you increase a pacemaker’s rate enought that it would be fast enough to kill someone? Theoretically yes, but death would probably be from a fatal rhythm, not a heart attack.

There is a rare phenomenon known as runaway pacemaker. In these instances, the pacemaker’s rate increases to an incredibly rapid level. In the early days of pacemakers (the 1970s), this led to a few deaths from a lethal arrhythmia known as ventricular fibrillation. In today’s modern pacemakers, runaway pacing can happen, but only very rarely, and there have been no deaths associated with it for many years. There are two main reasons for this: 1) pacemakers have a programmed upper limit to their rate, and 2) the faster the pacemaker fires, the lower the voltage, so at high rates it doesn’t give off enough electricity to start a contraction. The most common symptoms of runaway pacing are dizziness, light-headedness, and the sensation of an irregular heart beat.

Theoretically, I could imagine that a rapid heart rate from a malfunctioning pacemaker might cause a heart attack in a susceptible individual, but there have never been any recorded cases of this happening. If a malfunctioning pacemaker were to cause a rapid heart rate leading to death (a very big if), it would be more likely from a fatal heart rhythm than from a heart attack.

Tags: comics medicine joker hush batman autopsy pacemaker heart attack ventricular fibrillation

Batman: Gotham Knights #74 “Payback, part 2“
A.J. Lieberman, writer
Diego Olmos, writer

Spoiler Warning
The Joker knocks Hush out with a dive bombing pigeon. When he wakes up, Hush confronts the Joker, only to discover that he’s been sedated for three weeks, not just a few minutes, and the Joker had a physician implant one of the WayneTech pacemakers into him while he was sedated. The Joker is more than happy to demonstrate to override Hush’s heart.

Hush at first decides to cut out the pacemaker himself, but then decides it would too risky (but not before anesthetizing himself with heroin). He comes to Bruce Wayne for help. Bruce agrees to help, but only if Hush checks himself into Arkham. Reluctantly Hush agrees and the pacemaker is removed. He then escapes the asylum and goes looking for the Joker. Batman confronts him and suggests that maybe the pacemaker was never removed; maybe Batman has changed the rules henormally follows. As the story ends the reader is left to wonder whether or not the pacemaker was removed or not.

Sadly, there are quite a few glaring medical errors in this issue of Batman: Gotham Knights.

1. Hush grabs his right side when he’s having heart pain. [pages 6, 11]

2. A pacemaker surgery is not the major heart surgery the writer makes it out to be. It is a fairly minor same-day surgery that takes about 3 hours. An overnight stay in the hospital is rarely required. [pages 6, 20]
From the Healthy Hearts site:

The procedure is performed with mild sedation and a local anesthetic. Patients are not put to sleep. A 2 inch incision is made parallel to and just below a collar bone. Pacer wires are then inserted into a vein that lies just under the collarbone and advanced through that vein under fluoroscopic guidance into the heart. The other end of the pacer wires are connected to a “generator” that is implanted under the skin beneath the collar bone. This generator is about half an inch deep and one and a half inches wide. The skin is then sutured closed and the patient leaves the hospital later than same day or the following day. Incisional pain is mild and transient and usually responds to Tylenol. It is possible to feel the pacer generator under the skin and a slight deformity of the skin can be visually noticed.

3. Why did Thomas Elliot, a neurosurgeon, study under David Gilmour, a cardiac surgeon? (And did David Gilmour become a surgeon before or after Pink Floyd?) [page 5]

4. According to the story, the Joker had the pacemaker implanted via the femoral artery so Hush wouldn’t discover it. It’s theoretically possible I guess, but then the pacemaker unit would be in the thigh with long wires leading up to the heart (and Hush would definitely be able to tell a deck-of-card-sized piece of metal was in his leg). In the x-rays shown in the comic, the setup is completely backwards of what is described, with the pacemaker unit in the chest and wires running down the leg. [page 10]

• And since when does the femoral artery go all the way to the foot? [page 10]
• I know I complimented the artist on his well-drawn pacemakers last issue. No so this issue. Did he lose the reference? [page 10]
• The x-ray is taken wrong as well. Hush is leaning against the machine, but there is no film cartridge behind him. He’s radiating himself for nothing. [still on page 10]

5. Hush, a brilliant neurosurgeon, is not smart enough to realize that 3 weeks have passed instead of mere minutes, and that now he has a chunk of metal in his body and a 2-inch scar on his leg? [pages 5, 6]

6. Why would Hush even consider using heroin as an anesthetic? I’ll grant you that it is a morphine derivative and would kill most of the pain, but he would be far too impaired from the drug to perform surgery. [pages 10, 11]

• In an earlier issue, Hush used the fancy anesthetic narcopropaline to kidnap Alfred. Why not use it now?
• Hush is injecting the medication into an arm bent at more than a 90-degree angle. That’s going to make the vein nearly impossible to find. Think about it, whenever you have blood drawn, give blood, have an IV placed, or inject medication the arm is always held straight. Any doctor, nurse (or junkie, for that matter) knows better than to try it with the arm bent. [page 11]

Tags: comics medicine joker hush batman autopsy pacemaker x-rays heroin

Regular readers of this blog will know that I don’t think much of “alternative” medicine because the vast majority of it is composed of wishful thinking and/or snake oil. A favorite target of mine has been Berkley Premium Nutraceuticals, producers of the alleged “male enhancement” drug Enzyte; they are the ones responsible for those horrid Smiling Bob commercials.

Well guess what — Berkley Nutraceuticals must pay a 2.5 million dollar fine and provide customer restitution because:
1) Their products don’t work as advertised — or at all (Duh!)
2) They misled consumers and billed for “free” supplements.

Read all about it here.

Chuckle.

Tags: medicine alternative medicine enzite schadenfreude

One final post about Batman: Gotham Knights #73, then I’ll never talk about it again. Promise. This last one deals with statistics, logic, and the media.

In one scene in Gotham Knights #73, we see Bruce Wayne watching TV (well, TVs) in his mansion. There are six different news stations going on at length about WayneTech’s “faulty” pacemakers.

This uproar over the pacemakers is ridiculous:

1. As covered in earlier posts, it is medically unlikely that a malfunctioning pacemaker would cause a heart attack. Plus, those autopsies were sloppy and you’d be hard pressed to prove anything by them. 2. Even assuming the pacemakers were responsible, there were 3 failures out of how many? Batman mentions “hundreds”, but it would have to be thousands if WayneTech expected to make any profit, especially since one reporter mentions that “85% of all pacemakers in the tri-state are from WayneTech”. Assuming 1,000 patients, that’s a 0.3% failure rate. True, that’s unacceptably high for a medical device, but nowhere near the catastrophe it is suggested to be. 3. Correlation does not equal causation. Just because two events appear to be related does not mean that one causes the other. A quick example: I have a handful of patients with cataracts. All of them happen to be taking the drug metformin. Does this mean that metformin causes cataracts? Absolutely not. Metformin is used to treat diabetes, and diabetes is the primary risk factor for cataracts. The metformin doesn’t cause the cataracts, the diabetes does. This comic presents a similar situation. Three patients died of a heart attack and they all had a WayneTech pacemaker. Is this proof that the pacemaker caused their heart problems? No. These patients already have some kind of heart condition or they wouldn’t have needed the pacemaker in the first place. Heart attacks are much more common in individuals with pre-existing heart disease. There is a correlation, but no evidence of any cause-and-affect relationship.

I don’t consider this an error on the part of the writer; instead it is an all too accurate picture of how medical news tends to reported. Let’s be honest: medical news is rarely exciting. Reporters and news outlets want an eye-catching story, so they tend to pick and choose excerpts with little understanding of the underlying science. Most of the actual results get lost in the shuffle and inaccurate information rapidly spreads. Just like in Gotham Knights.

Tags: comics medicine pacemaker heart attack

It’s time for my bimonthly look at what search terms brought people to Polite Dissent over the past two months. Sure, it’s a lzay post — but a fun one.

Common search terms:

• Weird n Wild creatures, Scottie from Mythbusters, and D&D module X2 (Castle Amber)

Trivia (Some people are clearly entering trivia questions verbatim as search terms. This is particularly evident in the last question as it starts out with the category. Click and drag the mouse to reveal the answer.)

• What cable hit is introduced by the voice over what happens when people stop being polite and start being real? Answer: The Real World
• Drs Kildare and Gillespie could be found in which hospital? Answer: Blair General
• gen x tv before coming to WKRP johnny fever got fired for saying what word on the air? Answer:Booger

Medical Concerns:

• Humorous spiral fracture Spiral fractures are rarely funny, at least to the people who have them. I suspect you want information on a spiral fracture of the humerus.
• Strep throat involving blisters on plate of mouth Blisters on the roof of the mouth are more suggestive of a viral sore throat than a strep throat.
• How many vials of csf are take during lumbar puncture? Usually four.
• What can I do to lower my blood pressure besides medicine? The big three: Healthy diet (low sodium), weight loss, and aerobic exercise — lots of it.

Alternative Medicine:

• Blood type O personality traits I hope I don’t have to tell you that any connection between blood types and personality is nonsense. Still, it is a common concept in many Eastern cultures and shows up in manga from time to time.
• Homeopathic remedy scaphoid fractures First, homeopathy is a ridiculous concept and doesn’t work. Second, no medicine can fix a scaphoid fracture. Third, scaphoid fractures can have long-term consequences if not repaired, so I’d suggest going to see an actual medical doctor.
• Incurable autoimmune disease natural cures Anyone else see the logical error here?

• Mistletoe side effects homeopathy Homeopathic remedies are nothing more than water, so there should be no side effects.

You People Are Sick (presented without comment):

• Wonder girl chloroform
• Sarah sutton dr who nyssa bondage
• How many seasons of Full House are there on DVD
• Self-circumcision clamp

I’d be Interested to Know What They Were Thinking:

• nuns & comics
• comic books with sodium involved
• sputum fantastic 4

Miscellaneous:

• Hostess cupcakes. For some reason, it pleases me to know that my site turns up in a search for “Hostess Cupcakes.”
• Playlists for depressing songs. I suspect it depends a great deal on your taste in music. I consider Billy Joel’s Captain Jack to be one of the most depressing songs ever. And one of my friends in college felt that if you could listen to the Pink Floyd album The Final Cut all the way through and not contemplate suicide, then you were uncommonly stable (or in denial)
• Bode Miller fanfiction. You can tell it’s fiction because Bode actually wins.
• Digital Fortress is the worst book ever. I agree it’s not a good book, but there are worse books out there. I mean, I actually finished this book and there are many books so bad I couldn’t finish them (one that springs to mind as an overly praised work I could never finish is A Confederacy a Dunces.) Digital Fortress does follow the same plot Dan Brown uses in every book.
• inttel inside idiot outside What’s funny is that they spelled Intel wrong

I’ve been trying to play Dungeons & Dragons Online all weekend. I haven’t been able to log in to the server once. Looking at various message boards around the web, this has been a significant problem and seems to be generating a good amount of ill will and an upset customer base.

Consider Dungeons & Dragons Online strongly NOT RECOMMENDED until this problem can be fixed.

From Haunt of Fear #26 (August 1954):

Click for the full image

The Grand Comics Database lists the artist as Jack Davis and Albert B. Feldstein as the scripter. It refers to this as a “tongue in cheek attempt to link efforts to destroy comics to Communists.”

Personally, I don’t think it is tongue in cheek. By the time this comic was on the shelves, Dr. Wertham’s infamous book Seduction of the Innocent had already been released (and excerpts published in the Ladies Home Journal) and the House Subcommittee on Juvenile Deliquency had already turned its eyes toward comics. Within just a few months, the Comics Code Authority would begin, and within a year EC was no longer publsihing comics.

Tags: comics psa seduction of the innocent frederic wertham communists ec Comics

[This post marks the beginning of an occasional series on various medical diagnoses that are -- if not unique to comic books (particularly super hero books) -- generally restricted to comics and related genres and media. While most of these diagnoses are entirely imaginary, some are genuine conditions -- only re-imagined in a way only comic book writers can.]

I’ll start off with an oldie but goodie: Frozen Solid.

Classically, villains (and sometimes heroes) encased their victims and opponents in ice. They were trapped for a time, and undoubtedly very cold, but otherwise unharmed.

Medically, the largest risks involved were frostbite on exposed skin and hypothermia. Also, looking at some of these images, I think suffocation would have been a significant concern because it is damn hard to breathe through ice (Go ahead — try it. Get an ice cube from the freezer and just try to breathe through it).

Even in today’s comics, this remains the preferred use of ice:

In recent years, things have gotten more dangerous. Some villains are no longer content to just immobilize their opponents, but instead freeze them through. This can prove fatal as shown in one of the early Gotham Central storylines and the sadly overlooked one-shot Firebirds.

Medically speaking, the rapid freezing of body tissue is extremely damaging because it disrupts cell membranes and kills the cells. That’s the main reason we use liquid nitrogen to treat warts. Frankly, even if the frozen victim wasn’t shattered, they would never survive being frozen solid.

In the real world, I’m not aware of any cases of anyone every being rapidly frozen (fatally or otherwise) similar to comic book scenarios. Forozen bodies are common though; it seems that not a year goes by without a dead frozen body being found somewhere in the world, here a two recent examples:

• The Iceman of the Alps
• Frozen WWII Flier

You’ll notice that in all these cases the person ended up frozen after death.

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FINAL NOTE: Don’t ask me to explain Captain America other than the fact that it was a fairly slow freeze and he had the benefit of the Super Soldier Serum

Tags: comics medicine ice frozen mr. freeze iceman icicle

Sex and marriage and sex after marriage, and maybe some extra-marital sex. Yes, it’s another episode of House. But be warned, there are spoilers below!!

Before I began I just want to make sure that everyone realizes that the part of the patient Henry was played by none other than Dr. Johnny Fever (Howard Hesseman) of WKRP in Cincinnati fame.

Anyway, it was an interesting episode that dealt more with ethics than medicine.

While talking to his daughter during a game of bridge, Henry suffers an absence seizure (basically a prolonged non-responsive staring spell). While at the hospital to evaluate this seizure, Henry tells Dr. Foreman that he also has a swollen right testicle. An MRI of the brain shows a tiny smudge — it might be a micro-abscess, or it might be nothing. The team’s initial differential diagnosis is testicular cancer, lymphoma, or a sexually treated transmitted disease (STD) such as syphilis. A needle biopsy of the testicle reveals no cancer and House decides to start the patient on antibiotics for a suspected STD.

As House is injecting him with medication, Henry starts to cough up frothy bloody sputum. This is consistent with Flash pulmonary edema, othe sudden build up of fluid in the lungs An echocardiogram reveals infected growths along his mitral valve. These growths are known as vegetations and are caused by some kind of infection in the bloodstream. The team considers psittacosis and Strep viridans as possibilities, but neither completely fits the situation. House remembers Henry mentioning attending a wine and cheese party and deduces that Henry has caught brucellosis from unpasteurized sheep cheese. This infection led to the growths on his mitral valve which caused a small embolic stroke, causing the seizure. Unfortunately, Henry suffers a massive heart attack when one of these growths breaks off and plugs an artery supplying blood to the heart. His heart suffers so much damage that he is only days to live.

House goes to the transplant committee, but they turn him down because Henry is too old. So House decides to procure a heart for Henry himself. A female school teacher has been killed in a car accident and House decides that she would make a perfect candidate. She is turned down as an official donor because of concerns about possible Hepatitis C because she had a recent fever and elevated liver enzymes. After convincing her husband to donate her heart to Henry (a painful and extremely ethically questionable situation), House elects to treat the cause of the woman’s liver problems so that her heart can be given to Henry. An MRI of her gallbladder and liver shows no gallstones, but does show a cyst in the liver. A presumptive diagnosis of amebiasis (infection by amebas) is made and she is started on high dose antiparasitic medications. Unfortunately, these medicines have a nasty effect on her heart so they have to be stopped. House considers other causes of liver disease, particularly toxins or infections. No toxins are found in her house or school room, but he becomes suspicious that she might have had an affair. She tests positive for gonorrhea and House begins treating her with ceftriaxone.

Not a moment too soon! Henry’s heart gives out completely and both patients are rushed into surgery. The transplant goes well, and Henry soon regains consciousness, daughter and ex-wife at his bedside.

Not as much medical mystery in this one as usual — basically two mini-mysteries — but as I mentioned earlier this episode was mostly about ethics and marriages (and, apparently, cows).

Just a few significant medical concerns:

• Henry is well outside the normal age range for testicular cancer (it’s primarily a disease of younger men), so that wouldn’t be as high on my list of possible diagnoses. If it were on my list, I certainly wouldn’t do a needle biopsy. There are certain cancers where needle biopsies are not performed for fear that the cancer will track — spread up the needle’s path. Testicular cancer is one of these cancers. If it is suspected and confirmed by scrotal ultrasound, then the testes is removed. No biopsy except in rare cases, and then a special surgical biopsy is performed. Never a needle biopsy.
• I realize that heart transplants do not require as careful a match between donor and recipient as other transplants, but tissue compatibility is still important. Was this even mentioned? How about blood type compatibility?
• An ultrasound or CT is a better choice in looking for gallstones than an MRI.
• I’m not a transplant surgeon, but the cavalier way the heart was transported between patients seemed a little sloppy to me.

The soap opera dealt with marriages and sex: Henry and his ex-wife, the organ donor and her husband, and Dr. Wilson and his wife…and maybe an affair.

This episode earns a B for the mystery, another B for the solution, and a B+ for the medicine overall (extra points for including Johnny Fever). The soap opera also earns a B+.

• The previous House review
• A list of all prior House reviews

Tags: television medicine house brucellosis gonorrhea transplant.

Scene from Green Arrow #58.
Words by Calafiore, Pencils by Lee

The set up: Connor Hawke has just been rescued from a collapsed building and transferred into an ambulance. How many mistakes can you find in this scene? As usual, several are nit-picks but a couple are pretty significant.

I’ve got five items on my list, how many can you find? (Extra credit for finding things I missed.)

• Previous Picture Quizzes

Tags: comics medicine green arrow ambulance trauma calfiore lee

It starts out promising, with an extremely well drawn hospital room scene. Towards the end of the issue, however, there’s a slip. While the art remains very good, the last several years of medical privacy laws no longer permit the patient’s name to posted outside the room anymore (or anywhere a non-hospital employee might see it).

From Detective Comics #816, “Victims, part Two.” Art by Cliff Chiang, words by Shane McCarthy.

Tags: comics medicine batman autopsy

Once again, another excellent job. I think everything on my list was mentioned — plus a few extras.

1. SUPPORT — Any trauma victim absolutely needs to be strapped on a backboard with neck support. (And as redrabbit points out, it’s a poorly drawn ambulance bay). 2. VITALS — The EMT to the right looks like she’s taking his blood pressure, but there’s no bloodpressure cuff. And how does the EMT at Connor’s head know the vitals? I think the vitals themselves are reasonable: the blood pressure and pulse are both higher than Conner should normally run, but then he was just blown up. (But I would like to know an oxygen saturation since he’s being bagged). 3. IV LINES — Where is that saline line the EMT allegedly put in? 4. AIRWAY – There was never any sign that Connor had a compromised airway or trouble breathing, so why is he bagged? In fact, he’s speaking in the next panel, which makes airway compromise unlikely. If there were airway compromise, an ambu-bag is a good way to go. It can be used with either a face mask (as shown), or with endotracheal tube on an intubated patient (though the EMT should be holding the mask tight against Connor’s face to ensure a good seal). 5. INSTRUCTIONS FROM BASE — Ridiculous. First, he’s telling them things they should be doing already (immobilize the neck), and then orders a shot of Demerol. Why? Other than a slightly elevated BP, there’s no evidence that Connor’s in pain. I’m all for treating patients who are in pain, but not just randomly slamming patients who have a “possible head injury” with strong narcotics. And speaking of Demerol — what’s the dose? Is the EMT just supposed to pick a dose? (“Ummm, three?”) And why put a fresh dressing on the leg laceration that will just be ripped off when he arrives in the ER for evaluation (and as TayJK points out, why cover it up like that?) David: As for nipples, has it ever been firmly established that Connor even has them? Maybe lack of nipples is his mutant power? I personally don’t know for certain. (I suspect if anyone would know offhand, it would be Kalinara or Ragnell).

Tags: comics medicine green arrow ambulance trauma calfiore lee

As a pleasant surprise, Dorothy #5 came in the mail this week. It’s another intriguing issue of this fumetti-style modern retelling of The Wizard of Oz. In this issue, Dorothy finds herself in Munchkinland, where the Scarecrow brought her after her bout with infection in the previous issue. Dorothy meets with the Munchkins and their allies to learn what exactly is expected of her — and she doesn’t like what she hears. All she wants is to get back to Kansas. Meanwhile, the Wicked Witch explains some of her plans and what she has in store for Oz and the Emerald City.

This is an enjoyable book for comic book fans as well as those who don’t regularly read comic books. The art is approachable and everyone is familiar with the basic story of The Wizard of Oz. Dorothy is one of the few comics the Polite-Wife, a non-comics person, will actually sit down and read. (For the record, the others are Courtney Crumrin, the recent Mouse Guard, and the occasional light romantic comedy manga such as Love Hina.)

If your local store does not carry Dorothy, check out the Dorothy website. All five issues are available there as well as a trade collection of the first four issues (and I can vouch for the store having bought the first several issues there myself.)

Tags: comics dorothy wizard of oz

Contrary to popular belief, Las Vegas does experience four seasons. There is summer, which lasts from late-March through early-September, and is dry and extremely hot. There is winter, which lasts from late-September through early-March. It is dry and not-nearly as hot (and sometimes even cool).

Fall lasts for a week in September. Hard rains, usually with some flooding. Similarly, spring lasts for a single week – the second week of March. Light drizzly rains and cool temperatures every year, like clockwork.

So why does NASCAR choose this week to run the race in Las Vegas? One of the two weeks it’s virtually guaranteed to rain (or snow, as was the case this year)?

nascar las vegas

It doesn’t always take a strong body or superhuman physical abilities to make it as a superhero — or supervillain. Sometimes all it takes is brains. Or a brain. All alone. Usually in a jar or glass case.

Who can forget the eponymous Brain, once a French surgeon and then the leader of the Brotherhood of Evil? (And are there any heroic teams that use the name “brotherhood” or is only villainous ones?) Or Martha, from Grant Morrison’s run on the X-Men.

A step up are those characters whose exist primarily as a brain that can be transplanted between bodies, human or otherwise. A classic example would be the Ultra-Humanite. Robotman would be a good example of a hero in the same situation. Gorilla-Man from the Headman is close enough to count.

Then there are those who have no body at all. They exist as only a soul or free-floating personality. They have to possess an unwilling victim to take on physical form. The Shadow King and Malice are a good example of entirely bodiless characters. (I’m not counting Deadman or any purely supernatural characters here. I’m just focusing on those that are considered alive but without bodies or form).

Finally, this being the computer age, there are characters that were originally human but wound up existing only as a computer program. The best examples are the villains Thinker and from the Jihad (opponentes of the Suicide Squad), Djinn (and later Ifrit).

Other Media:
Evil brains are prevalent in science fiction movies and television? Who could forget such wonderful films as Donovan’s Brain, The Brain that Wouldn’t Die (particulalry the MST3K version) and Steve Martin’s The Man with Two Brains. And brains don’t come any eviler than the giant flying brains from Futurama.

Real Life:
Sorry, medical science has not reached the level where brains can be kept alive in a jar or transplanted from one person to another.

Having trouble getting girls to dance with you? It could be that you’re too Brainy, Emotional, or Muscular. Girls don’t want any of that! What they want is a BEM (which surprisingly does not stand for Bug-Eyed Monster).

Click here or on the panel to the right to see the full PSA

This helpful 1967 PSA is from Superman’s Girl Friend Lois Lane #74 (as well as Superboy #138 and The Inferior Five #2). The art is by Sheldon Moldoff working from a script by Jack Schiff.

This PSA was provided by the National Social Welfare Assembly, the same group that not only brought us the Mysterious Unnamed Doctor™ PSA, but also seemed to sponsor most of the Silver Age single page PSAs.

Tags: comics psa national social welfare assembly jack schiff sheldon moldoff

UPDATE: Error found and fixed. The pop-up image should now work in both IE and Firefox.

Several people have had problems getting the full-size BEM PSA ad to pop-up like it should. I have little idea why this would be since it’s the same script I always use and it’s working for me. Maybe it’s due to a pop-up blocker?

Anway, since I don’t want anybody to miss this fine ad, I’ll post the full image here below the cut.

Read more…

Missing your weekly dose of medical education because House isn’t on tonight?

Don’t worry! All the medical intrigue you could ever want is just around the corner at Grand Rounds, held this week at Geek Nurse. Grand Rounds is the weekly collection of the best medical blogging on the ‘net. There’s always fascinating posts to read, and this week is no exception. Go check it out and be back for more House in three weeks.

Tags: medicine grand rounds

I’m going to take a little time tonight and point out a couple of well done medical scenes from recent comic books. (OK, there are some problems with the scene from Green Arrow, but it’s still a clever scene).

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In the opening scene from Marvel Knights 4 #26 (by Aguirre-Sacasa and DeLandro), we get a look at a kid undergoing an old time doctor’s exam. Congratulations to Delandro for drawing a doctor using a head mirror correctly. Head mirrors are used to focus a beam of light from an external light source onto the doctor’s area of interest. They’re tough to use correctly and for the most part have been supplanted by improved lighting technology such as head lamps. I only used one during my ENT rotation back in medical school and frankly I’m glad other options are available.

The eye chart is also correct.

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In Green Arrow #57 (by Winick and Garney), Connor, Black Lightning, and Mia have been attacked by Dr. Light. Mia has been severely wounded and suffers a cardiac arrest. Black Lightning rushes to her side and uses his powers as a defibrillator in an attempt to restart her heart. It’s a neat idea and the art depicting the shock is well done (not to mention the sound effect: TZACK!). Black Lightning’s powers use direct current; defibrillators use direct current. If he can control his powers well enough, there’s no reason it shouldn’t work* (other than the basic fact that you don’t treat a flatline with defibrillation).

*OK, to be nit-picky, let me give you two reasons it wouldn’t work:
First, while it’s a good idea to restart the heart, it would also be a good idea to correct what caused the cardiac arrest in the first place. If not, Mia will just suffer another arrest. In this situation, Mia is bleeding profusely and it is likely this hemorrhaging that led to her cardiac problem. Stopping the bleeding is just as important as restarting the heart.

Second, remember that electricity needs to make a circuit. That’s why defibrillators have two paddles so that current is passed from paddle to the other through the heart. There’s dosen’t seem to be any circuit here.

**I should also point out that Black Lightning skipped straight to C (Circulation) and missed A and B entirely. I’ll agree that Airway is not an issue here, but Breathing is as Connor noted that Mia had stopped breathing.

Tags: comics medicine fantastic four green arrow defibrillation

Julius Caesar, Act I, Scene ii SOOTHSAYER: Beware the ides of March. CAESAR: What man is that? BRUTUS: A soothsayer bids you beware the ides of March. CAESAR: Set him before me; let me see his face. CASSIUS: Fellow, come from the throng; look upon Caesar. CAESAR: What say’st thou to me now? speak once again. SOOTHSAYER: Beware the ides of March. CAESAR: He is a dreamer; let us leave him: pass.

Tags: comics ides march julius caesar

Other comic book connection to Caesar…

Tags: comics ides march caesar

Medics: Code 3 Special was a one shot put out last month by Shanda Fantasy Arts (though you’ll find no mention of it on their website). It concerns the ambulance crew of “Shift A from Southside.” It’s your standard “wild and crazy” crew: there is the handsome heroic leader (with a spit curl, of course), who’s good at anything he does. The second in command is a beautiful and intelligent woman (and cat). The rest of the crew is comprised of the dumb blonde, the Elvis-loving assistant, the wide-eyed newcomer, and the surprisingly wise cook.

In the first story, the team attends their annual training. There are simulated rescues, obstacle courses, and classroom work. They screw up a little bit at first, but come through when it counts. In the end, the trainer passes them and sends them home early because another teacher warns him “that whole bunch is crazy.” (Though it’s never made clear why that warrants them getting sent home early. There’s no property damage and the only people injured are on the Southside A team.)

The city (Cedar Rabbits) is planning on switching to a private firm to run their ambulance service in the second story. The paramedics mount a full offensive to save their jobs: they talk to council members, lecture school children, and steal drugs from their competition (to prove the drugs are illegal, of course). With the help of a friendly city council member and some conveniently delivered memos, Southside A is able to prevail.

The final story has the most medicine in it, and honestly, all the medicine is well done. The plot is straightforward: the main hospital used by the ambulance is on diversion and they have to take their patients to another hospital. In this hospital, the nurses (all female, by the way) ignore the EMTs and provide horrible patient care. By the end of the story, the ambulance team gets their revenge (more by luck than skill though).

The stories are strictly by the book. Within the first page or two, you know how the story is going to end and there are no surprises. There’s certainly potential, but not much more.

The art is very loose and cartoony. Inking and shadow show up now and again, but not often. The background, when drawn at all, resembles what you would expect from a second-grader. The color art on the front and back cover are very well done; it’s a shame the same art wasn’t produced internally.

I grew up on Captain Carrot. I read Kevin and Kell daily. I enjoy a good anthropomorphic comic. Sadly, this isn’t one. Don’t get me wrong — it’s not a bad comic, just very mediocre. The only interesting aspect is the anthropomorphism, and if you remove that, the comics’s not even mediocre. For $4.95, I expect a great deal more.

Tags: comics medicine furries ambulance

On the inside front cover of Medics Code 3 Special, there is a brief editorial from the Shanda Fantasy Arts publishers decrying the recent change in Diamond policy setting a higher minimum order that comics need to reach before they will be distributed.

This is going to change the face of comics for everyone. To be sure, part of this is due to higher gas prices being paid by shippers, printers and distributors. But the publishers are feeling it first. Several independent comics have announced that they are preparing to shut down, such as STRANGERS IN PARADISE and FINDER.

While I sympathize with the small comic book publisher and wish there were a way to allow them to publish everything that they desired, this paragraph is disingenuous. Neither of the comics mentioned as examples decided to stop publishing because of Diamond’s change in policy.

First, according to ICv2.com, Strangers in Paradise has been routinely seling 8500-9000 copies per issue, well above the cut off for the new Diamond policy. It’s ending because its creator Terry Moore has decided that he has no more Francine and Katchoo stories to tell.

Second, Carla Speed McNeil, the creator of Finder, denies any connection between the policy and her decision to stop publishing the comic. As reported in Heidi MacDonald’s The Beat from September 26, 2005:

She [McNeil] stressed that the decision had nothing to do with the recent announcement that Diamond would be tightening up order minimums on books it carries. (Finder had been held up numerous times as an example of a quality book which hovered at the edges of Diamond’s benchmark.) Diamond has always been very supportive, she said, and the very week the announcement was made, she received a large Diamond order for the trades.

Both Strangers in Paradise and Finder make a large portion of their earnings from their trade collections. The same cannot be said for Shanda, which offers few — if any — trades.

Again, I sympathize with small publishers like Shanda and wish they had a better option for getting their books distributed, but there’s no need to distort the facts when it’s already such an unfortunate situation.

Tags: comics shanda diamond

Tags: comics porky pig leprechaun st patricks day

I’ve update the CBDR (the Comic Book Drug Reference). Added were:

• Draxx, from Vertigo’s The Exterminators
• Flat, from Seven Soldiers: Mr. Miracle #3
• Key 17, from The Invisibles
• added a picture for Sky, also from The Invisibles
• added a picture for Kick, from The X-Men
• minorly reworked a couple of other entries

Tags: comics medicine drugs cbdr

I thought I’d talk about medicine for a post or two. Not “television medicine” or “comic book medicine”, but real honest to God medicine.

Abdominal pain is the topic of choice today. This is one of those complaints that every doctor loathes. Mostly because it can include everything from a mild stomach upset to a surgical emergency and you have little idea what you’re in for until you peruse the chart and actually take a look at the patient. In addition, the physical exam is rarely as clear cut as you’d like. Plus if it’s a female patient, you’ve just doubled the number of possible diagnoses.

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The patient was a female in her late 50s complaining of right lower quadrant abdominal pain. Her past medical history was generally unremarkable except for some mild depression that was well controlled on a low dose of Lexapro. Her surgical history consisted of a tonsillectomy as a child, and the removal of a right-sided tubo-ovarian abscess about 10 years ago.

She presented with three days of slowly increasing abdominal pain. She described it as a crampy pain, 6 out of 10 on the pain scale. While the pain was always present, it waxed and waned in intensity. It was at its worst in her right lower quadrant, but she could feel some pain everywhere in her abdomen. She denied any radiation of the pain to the back, flank, or chest. There were no aggravating or alleviating factors. She denied any nausea or vomiting. She denied any diarrhea — in fact she mentioned that she had not had any bowel movements for three days, and no flatus either.

On exam, she was in moderate distress from the abdominal pain. Vital signs were normal; there was no fever. Abdominal exam revealed a non-distended abdomen with generalized tenderness. The pain was worst in the right lower quadrant, just under her old surgical scar. There was no rebound or guarding. There were no bowel sounds on auscultation.

My main concern at this time was a small bowel obstruction. Patients with bowel obstructions generally have more nausea and vomiting associated with them, but the rest of the symptoms fit, as did her history of prior abdominal surgery.

An acute abdominal x-ray series was obtained. The x-rays showed a couple of small air fluid levels in the small bowel and dilated bowel in the right lower quadrant. TWhile the x-ray was consistent with a small bowel obstruction, it was certainly not a smoking gun. An ileus would have a similar appearance on x-ray. (An ileus occurs when the bowel stops its normal peristaltic movements because of irriation, such as from an infection or a recent surgery)

I remained suspicious of a small bowel obstruction, likely related to adhesions from her previous surgery. I was also concerned about the possibility of an appendicitis with an overlying ileus, but appendicitis usually involves fever and nausea. The rest of the differential diagnosis included diverticular disease, cholecystitis, gastroenteritis, pancreatitis, mesenteric adenitis, or severe constipation. The patient was sent for stat labs and a stat CT scan.

The labs showed an elevated white cell count of 21,000 (normal would be 4,000 – 10,000) with a definite left shift. The other labs (including a BMP, LFT, amylase, lipase, and urinalysis) were all normal. The lab tech did inform me that the patient had an episode of vomiting while waiting for her labs to be drawn. These results were more suggestive of an infectious cause, but an elevated white count with a left shift can be seen in small bowel obstructions as well.

The CT scan showed no evidence of bowel obstruction. What it did show was a nasty appendicitis with a resultant ileus. The patient was taken to surgery and has done very well post-operatively. This patient was the perfect example of why doctors create a differential diagnosis. Nobody is correct all the time; my initial suspicion was shown to be wrong — but the next one on my list was the correct diagnosis. Sometimes the actual diagnosis is way down the list (this seems particularly true in cases of abdominal pain).

Note: This anecdote is very closely based on an actual patient. Some details have been changed to protect anonymity.

Tags: medicine abdominal pain bowel obstruction appendicitis

A different kindof PSA tonight. A one-page, one-image PSA featuring James Gordon in the hospital.

Was it the Joker? Did Bane take out the commissioner? Or Poison Ivy? Riddler? Two Face?

Nope. It was the Marlboros. (And a bum ticker. And probably lots of donuts. And stress — did I mention stress?)

Click here or on the panel to the right to see the full PSA

This anti-smoking message was brought to you by the American Heart Association, DC Comics, and the GCPD.

This PSA (found in Flash #58, January 1992) is an interesting one for several reasons:

• It is one of the few to actually address events that occurred in continuity.
• It focuses not on a teen hero or a schoolkid that children are supposed to relate to, but instead on a late-middle age chain smoking cop. So for all you 40-or-older cigarette-smoking comic book readers, this one’s for you.

And now to revert to form and be a total nit-picker: What’s with those electrodes on his chest? And why is his heart rhythm sinusoidal? That can’t be good. Why would the monitor be tilted down? Who’s his doctor, Ray Palmer? At least they drew his IV correctly.

Tags: comics medicine psa heart attack james gordon

Are you disappointed because American Idol is on instead of House tonight and you still need your medical fix?

No worries: all the medical fascination you could ever want is just around the corner at Grand Rounds, held this week at HealthyConcerns.com. Grand Rounds is the weekly collection of the best medical blogging on the ‘net. As always, there are plenty of intriguing posts you shouldn’t miss. Go check it out and be back for more House in two weeks.

Tags: medicine grand rounds

Hypertrichosis is the medical term for an overgrowth of body hair. There are several good comic book examples of this including the Shaggy Man, the Beast, Dartalon, and Furball.

In real life, hypertrichosis is a genuine, but rare, condition. It can affect just parts of the body or the entire body. Generally hypertrichosis is an inherited condition, but it can also be caused by metabolic disorders, certain drugs, cancer, and anorexia nervosa. Some experts consider congenital hypertrichosis to be the basis of the werewolf legend; through the 19th century, people with this condition were frequently found in circus side shows as wolf men, ape men, and “dog faced boys.”

One of Moon Knight’s first villains, Lupinar, identified himself as having been born with hypertrichosis (and apparently blamed it for his life of crime). While it looks like he did indeed have the condition, hypertrichosis does not explain the wolf-like teeth.

Click for a larger image

I’m leaving those characters off the list whose excess body hair is more related to their animal nature (such as Wolfsbane and Cheetah, for example) than just being extremely hairy. Several on my list did become more beastlike later, but it was their earlier form I’m referring to here.

This post was inspired by Lupinar fromMoon Knight Essentials, Volume 1. I didn’t read much Moon Knight when it was originally out — I vaguely recall picking up issue #7 — but this book is the most fun I’ve had reading reprints in quite a while.

Other Comic Book Diagnoses:

• Frozen Solid
• Brains! Brains!

Tags: comics medicine hair hypertrichosis beast furball moon knight

The Exterminators #1 “Bug Brothers, chapter one”
Simon Oliver, writer
Tony Moore, penciler

The main character Henry is providing narration, and letting the reader know how a common household pest humbled the great Roman Empire. Unfortunately Henry has most of his facts wrong.

Henry’s Narration: Cultural imperialism right up till 164 A.D. when the Empire slipped up on a banana skin. Nature’s banana skin. The army had returned from conquering Iraq and unwittingly carried home black rats. Innocent enough, but those rats carried fleas and the fleas carried the most f****d-up bacteria, Yerainia pestis…the “Black Death”…and over the next 16 years 100 million people died.

There was a plague in Rome in the years 165-180 A.D. It is known as the Antonine Plague, the Plague of Marcus Aurelius, or Galen’s Plague. As Henry suggests, it was brought back from the Middle East by the Roman armies. However modern research as well as Galen’s contemporary account suggests that the disease was smallpox or possibly measles. It was not the bubonic plague that Henry implies and thus the rats and fleas had nothing to do with it.

Speaking of the bubonic plague –the most commonly accepted source of the Black Death — it is caused by Yersinia pestis, not Yerainia. Yerainia is not even a real word.

Finally, the 100 million deaths due to the Antonine Plague is way too high. Most researchers pin the number at around 5 million, though some go as high as 25 million. It was a devastating disease, killing up to 25% of the population in some areas, but not as severe as Henry believes. (Recall that the infamous Black Death of 1347-1350 “only”” killed about 34 million).

I’m willing to lay the blame for most of these errors on Henry and his incomplete understanding of the history and medicine involved. But not the “Yerainia” — that comes down to sloppy fact checking and editing.

Tags: comics medicine plague yersinia smallpox black death

Look, Carol: I know that you’re a multi-decorated Air Force officer, but I’d hope that you’d realize that USAF Captain’s insignia are silver and not gold (or that at least colorists Ponsor and Mounts, or editor Macchio would). I’m not going to say anything about that weating the gunbelt with the blues you’re wearing because I figure that maybe that’s what the Ultimate USAF wears…

From Ultimate Extinction #1. Words by Ellis, Pencils by Peterson.

Seriously though, is it too much to ask that the colorist put a little effort into some simple research?

Tags: comics air force captain military carol danvers

A patient and her husband are in the clinic for a rash the wife has, an angry red splotch in the center of the abdomen. It was nothing out of the ordinary: a nickel dermatitis. Basically, she’s allergic to the nickel on the button fly of her jeans. It’s easily treated with avoidance and a topical steroid cream.

Her husband wasn’t so easily convinced. “Are you sure she’s not allergic to her IUD?” he asked.

I told him that he watched too much House.

(And then his wife sweetly informed him that she’s never had an IUD.)

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A young professional in her mid-twenties was in complaining of insomnia. She stated that she had begun having trouble sleeping about two years ago, just after her daughter was born.

“Nobody ever told me that babies cry at night” was her explanation.

I really had nothing to say to that. I just smiled and nodded politely.

Tags: medicine house dermatitis insomnia

On the advice of David Welsh, I picked up Monster, a “Viz Signature” manga. Flipping through the comic, there looks to be something for everyone: murder, suspense, politics, and cute girls (and guys). There’s also quite a bit of medicine involved as the lead character, Dr. Kenzo Tenma, is an upwardly mobile neurosurgeon.

Starting next week, I’m going to take a close look at the manga — a chapter or two at a time — and provide medical annotations (and corrections, if necessary). If you enjoy manga, murder, medicine, or just a good story, pick up a copy of this book and follow along.

Tags: comics medicine manga monster

My wife and I went to see V for Vendetta this afternoon. It’s not a bad movie, but I prefer the original comic version much more. There are several reasons for this, but the main one is that the movie makers had the need to “cross every t and dot every i”. They apparently felt that every little detail had to be explained and that all the pieces had to fit perfectly.

It’s not just V for Vendetta. I see this a great deal in the more mainstream media. Every idea is spoonfed to the audience and reinforced again and again so that no mysteries remain. I suspect this is why shows that eschew this concept, like Lost, seem so fresh and innovative.

Good stories don’t need every little thing explained and it can be a good thing when the occasional mysteries persist. In the V for Vendetta movie, the writers felt the need to explain in detail about Larkhill, the precise experiments that were done there, and V’s resulting super-powers. The rise of the totalitarian state was also explained in lengthy detail. Subtlety was never an option. For example, the film hits you over the head with the idea that V’s emergence from the flaming prison corresponds to Evey’s exultation in the rain. How many times did they juxtapose the images in that scene? Two? Three? More?

Not every mystery is revealed…entirely. Like the comic, V’s identity is never revealed…though unlike the comic, the mystery is narrowed down. Let’s just say that Dorian was right all along.

I like my stories more complex and the answers slowly given out. I suspect this has a great deal to do with the science fiction and comic books I grew up reading. The stories that remain my favorite were the ones where the reader had to work to put the pieces together on their own, so that when the reveal came — if it did — you felt as if you had earned it.

Again, it’s not a bad movie. It just ended up being the watered-down, for-mass-consumption version I always suspected it would.

Tangent: The biggest puzzle to me is why the rose in question was identified in the movie as a “Scarlet Carson” instead of the “Violet Carson” it was in the book. The producers loved all their V allusions, so why discard this one?

Tags: comics v for vendetta

I seem to have been reading more trade paperback collections and graphic novels recently. Almost all were enjoyable, but several stood out at the head of the pack:

Finder, Volumes 1 and 2.
I’d heard good things about Finder for years, but never had the chance to read it until recently.
Every few years I’ll finish a comic series and be blown away, thinking to myself that “this is what comics should be.” Finder is one such series. It’s a fascinating, intelligent read and Carla Speed McNeil has clearly put a tremendous amount of effort into the book. Not just the art and story, but in the creation of the underlying setting. This series is definitely worth your time and effort to read. I purchased Finder from McNeil’s website.

As an aside, I like collections that include annotations in the back, letting the reader gain insight into the whats and whys of the story. McNeil includes a nicely thorough lists of annotations in both volumes mentioned here. Tow great graphic novels with annotations include Leah Hernandez’s Texas Steampunk series: Cathedral Child and Clockwork Angels.

Bone Sharps, Cowboys, and Thunder Lizards
What is there not to like? Dinosaurs, conniving scientists, and history, all combined in a near impossible to put down package. The era depicted in this book has always been one of the most fascinating in the history of paleontology, but it’s one we hear little about. This book corrects that oversight. Johanna has covered this book recently (and better) as well.

The Essential Moon Knight
The most fun I’ve had reading a super-hero book in quite some time.

Seven Soldiers, volume 1 and 2
It reads much better in collected format.

Marvel Romance
What can I say? I have varied tastes.

Tags: comics trade paperbacks

Taking a break from saving the world, stopping bank robberies, and stopping a variety of other felonies, Flash stops by the local schoolyeard to shoot some hoops and educate the kids about AIDS.

This public service announcement is from Flash #73 (February 1973 1993) and it looks like Travis Charest supplies the art (Update: And according to the Official Unofficial Travis Charest Art Gallery bibliography page, it indeed is his art). This is part of the same campaign that gave the suddenly stupid Robin the Boy Wonder ad — but then again, maybe he was playing basketball with these kids. There are several other ads in this campaign and I’ll post as many as I can find in the near future (next up: the JLA).

The advice is good, but I wonder if the audience may be a little young (though they’ve clearly got misconceptions, so it’s probably high time they got the facts) — look at their height compared to the basketball hoop, or compared to Flash’s thigh — they’re the size of three year-olds (I figure he must be standing on his knees in the panel where they come up to his chest).

Click on the image to the right for the full size ad.

Tags: comics medicine psa robin

The Emerald City Comicon is a go. Hotel room, convention tickets, airline tickets and a rental car have all been purchased (or, umm, rented). We should be arriving late afternoon Friday and departing mid-morning Monday.

Tags: comicon

Another episode of House that starts with sex and ends with a near-death condition. Sure…you want to hear more, but be warned, there are spoilers below!

While involved in some rough sex play, Bob suddenly has difficulty breathing. His tongue swells so much that it cuts off his airway. He’s gasping for air and his lips are beginning to turn blue. His wife calls 911.

When he is examined several days later by Cameron, Bob mentions that he has already seen a variety of doctors who were unable to find the source of his problem; they was referred him to House. The team’s initial differential diagnosis includes food allergy and ALS (amyotrophic lateral sclerosis, better known as “Lou Gehrig’s Disease”). House suspects that there may be something wrong with the lungs and not just the throat. He is right: plethysmography shows decreased lung function and a CT scan of the lungs shows significant scarring.

Foreman diagnosis Bob with interstitial pulmonary fibrosis, but he isn’t sure what the underlying cause of the lung fibrosis is; Bob does not have arthritis or sarcoidosis, and he has not been exposed to any toxins such as asbestos, silica, or coal dust. About this time, Bob develops an intensely itchy red rash on his chest. Foreman suspects lupus while Chase continues to believe that it is a food allergy. House declares that Bob has heavy metal poisoning.

Treatment for lead poisoning — the most common toxic heavy metal — is started but does no good; to appease Chase, allergy testing is started as well. At this point, Bob complains of peripheral neuropathy — a very painful burning sensation in the feet. A short time later he begins having difficulty breathing again. Bob needs intubation, but he is vomiting so much that the team is worried about aspiration. A tracheostomy is performed instead. Additionally, he is now starting to show signs of kidney failure.

House is convinced that Bob’s wife is poisoning him, but he can find no evidence, even when she submits to a search. Meanwhile, things are going from bad to worse for Bob. He suffers a cardiac arrest that requires defibrillation to correct.

Foreman continues to believe that lupus is the cause, but House now suspects that Bob has a post-viral autoimmune reaction (basically, Bob’s body over-reacted to a viral infection and is now producing antibodies that are damaging his own body). He is started on interferon, an immune-system modulator, but it has no effect even at high doses. In a flash of sudden inspiration, House realizes that Bob is indeed being poisoned by his wife with small amounts of gold (actually, gold sodium thiomalate, an older arthritis treatment rarely used in the U.S.) He catches the wife red-handed (or purple handed, as it were) and starts Bob on dimercaprol, the treatment for gold toxicity.

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I’ve really got no big medical complaints with this episode. The gold was actually quite clever. There are some nitpicks, of course (such as starting the defibrillator at 360 joules), but nothing major. I would also have run some tests differently (for example, I’d probably have performed a biopsy of the rash fairly early on), but that’s mostly personal preference.

The soap opera dealt with House and Wilson, who are now sharing an apartment since Wilson’s wife kicked him out. It also involves food and house cleaning.

This episode earns an A for the mystery, and another A for the solution, and yet another A for the medicine overall. The soap opera was minor and average and deserves no more than a C. I’ll give the herpes side plot an A of its own, because that’s an all too common situation that doctors find themselves in (and by that I mean diagnosing someone in an allegedly monogamous relationship with an STD, not getting herpes).

• The previous House review
• A list of all prior House reviews

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Still want more top of the line medical information? Check out this week’s Grand Rounds over at NHS Blog Doctor. Grand Rounds is the weekly collection of the best medical blogging on the ‘net and is well worth your time to check out.

Tags: television medicine house gold heavy metal lupus grand rounds.

Metadocs Type A #1 is the sequel to Metadocs #0. It continues the storyline from the first comic.

While the initial issue dealt with the emergency evaluation, transport, and stabilizatio nof the injured heroes and villains, this second book concerns their subsequent treatment in the hospital. Gravity Girl’s immune system has gone haywire and the doctors are trying to calm it down. Stalagmite is still bleeding heavily. The doctors are trying to improvise some sort of synthetic skin for him to bandage the wound. The villain, Lord Drehd, is in the hospital as well, suffering a nuclear overload from his injuries.

As in Metadocs #0, the medicine is excellent. I note no medical errors of any significance, and the typos that bothered me last issue are absent as well. This is not your standard “ABC” emergency medicine I’ve described before — it goes way beyond that. If anything, the medicine may be too advanced,covering topics such as phagocytosis, histocomptibility, and complement. The science is done well and entirely correct, but I suspect it will be over the heads of most readers. A full understanding of the science isn’t necessary to enjoy the story, but it may just as well be technobabble.

The art is better this time. It may just be that I am getting used to Espinosa’s manga-influenced style, but I think the art is significantly improved, particulalry the characters and the coloring.

My only complaint is the incompleteness of the storyline. This is the second part of what appears to be a two-part Metadocs story. There is no indication in this book, or from Antarctic Press, that the story will ever continue. It is a shame then that so much of the basic storyline is left unfinished. Characters are left injured and there’s no indication of their recovery. In the most egregious example, Dr. Orchid is performing CPR on the injured Commander Patriot…and that’s where it ends. That particular storyline is never addressed again before the comic, and presumably the series, finishes.

Even with that complaint, both Metadocs show the tremendous potential for a comic that deals with medicine in a super-hero world.

Tags: comics medicine metadocs

Get your copies of Naoki Urasawa’s Monster out because this is the first of a series of medical annotations of the manga. This first post addresses chapter one of volume one — well, chapter one actually has a great deal of medicine in it, so I’m splitting it into two posts. The second part will be posted later tonight.

I’ll start with a brief synopsis of the plot, and then provide the medical footnotes. As always, questions are welcome

Chapter Synopsis:
Dr. Kenzo Tenma is the star neurosurgeon at the Eisler Memorial Hospital in Germany. He is a brilliant young doctor, who emigrated to Germany from Japan to benefit from working in a larger hospital with better equipment and staff.

As the chapter opens, Tenma is congratulated by his team upon a successful surgery. As he walks into the hospital corridor, he sees the wife and children of a Turkish man who was brought in at the same time as his patient. Unfortunately, the Turkish patient was operated on by the less skilled Dr. Becker and died.

Tenma is catching up on sleep at his apartment when his girlfriend — the daughter of the hospital’s director — stops by. While there, they watch a press conference by the director explaining the surgery that Tenma just performed on a famous singer¹. Of course, the director takes full credit for the operation and doesn’t even mention Tenma. Later on, it comes out that the director is even publishing Tenma’s papers under his own name.

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Footnotes:
^1. A cerebral aneurysm occurs when there is a weak spot in one of the arteries that supplies the brain with blood. Arterial pressure causes this weak spot to bulge out like a balloon, forming an aneurysm. Some aneurysms are so small that nobody knows that they even exist. Sometimes they can become large enough that they press against a nerve or a vital part of the brain and cause symptoms such as pain, numbness, or weakness. Aneurysms can also leak or burst, sending blood into the area surrounding the brain (the subarachnoid space, hence this is known as a subarachnoid hemorrhage).

This is precisely what has happened in the case presented: the patient’s aneurysm burst causing a subarachnoid hemorrhage.

This is where a neurosurgeon like Dr. Tenma comes in. He and his team remove part of the skull and retract the tissue layers surrounding the brain. The hematoma is drained and a small metal clip is placed on the base of the aneurysm to stop it from bleeding.

Even with quick surgical treatment, complications can follow a subarachnoid hemorrhage. Vasospasm (“cerebrovascular spasm”) is a common complication. In this situation, one or more of the large arteries at the base of the brain narrow and reduce the blood flow to the brain. This restricts the supply of oxygen (“cerebral ischemia”) to the brain and — despite maximum therapy — leads to stroke or death in about 15-20% of patients. The exact cause of the vasospasm is unknown. It generally starts 3 days out, peaks around day 10, and resolves in 2-4 weeks.

The ventricles of the brain produce and recycle the cerebrospinal fluid. When the ventricles become blocked (or otherwise stop working), they swell leading to a condition known as hydrocephalus. When this follows an injury (such as a subarachnoid hemorrhage) it is known as secondary hydrocephalus.

Compare the sizes of the ventricles

Tags: comics medicine aneurysm subarachnoid hemorrhage hydrocephalus naoki urasawa monster

Chapter Synopsis (continued)
After another brain surgery², Kenma bumps into Dr. Becker who warns him not to get involved in hospital politics. He talks briefly to a nurse³, and then has an unsettling encounter with the Turkish wife who accuses him of letting her husband die. Apparently, Tenma was originally supposed to operate on her husband, but was shifted at the last minute to the celebrity patient. She blames Tenma for the subsequent death of her husband.

Later, while eating dinner at a fancy restaurant with his girlfriend, Tenma is mulling over what the Turkish woman said. He has read the chart and thinks that he could have saved the man’s life had he been the surgeon⁴. He suspects he was pulled away from the original case because the singer was more famous and would bring more prestige to the hospital. His girlfriend gets upset that he is obsessing about this during their dinner, and pointedly tells him that “not all people are created equal.”

As the chapter ends, there has been a brutal murder of an East German expatriate family. The mother and father are dead. The daughter survives but the son has sustained a bullet to the brain and is in critical condition. Dr. Tenma is paged…

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Footnotes:
^2. Dr. Tenma is performing more brain surgery here, but the exact nature of the surgery is hard to determine. It is safe to assume that it involves the area of the brain known as the cerebellum because that is where the pyramis is.

^3. Dr. Tenma tells the nurse to increase the patient’s Inovan 3 gammas. Inovan is one of the brand names for the drug Dopamine. Dopamine is a class of drugs known as a pressor and it is used in critically ill patients to keep their blood pressure high. It is given by an intravenous drip in tiny amounts. A “gamma” is a term some doctors use for a microgram. In the United States, Tenma would have told the nurse to increase the Dopamine drip by 3 “mikes.”

^4. The Turkish construction worker suffered a blow to the head during a construction accident. This tore open one of the blood vessels in the head leading to a large subdural hemorrhage (a subdural hemorrhage occurs outside the membranes surrounding the brain, while a subarachnoid hemorrhage occurs between these membranes and the brain). The pressure from this large hemorrhage herniates the brain, pushing it down toward the spinal column. This injures the brainstem, which is unfortunate as the brainstem controls many of the basic functions of life including breathing and heart beats. A severe injury to this area of the brain is fatal.

Tenma feels that if he had been the surgeon, he would have been faster at drilling a hole in the skull (craniotomy) to relieve the pressure and would have been able stop the brain from herniating.

Tags: comics medicine herniation dopamine naoki urasawa monster

The wife and I are off on the long flight to Seattle for the Emerald City Comicon. In the meantime, here are two beautiful pieces I commissioned for my exam room from the multi-talented Lea Hernandez. Her website can be found here.