Polite Dissent

The Polite-Wife and I are safely in Seattle. It was a long plane flight — because we had to go through Dallas, but a comfortable one. I was able to polish off two books (the latest Spencer book by Robert Parker and R is for Ricochet by Sue Grafton) while Robin read one of her “chick lit” books and burned through some Sudoku.

The Emerald City Comicon has been nice. We has to stand out in a light rain for a few minutes before entering, but it wasn’t bad. Once inside, it was a nice setup in one large room containig exhibitors, dealers, and “artist alley.” We meandered for most of the day, talking to a variety of professionals — finally got to meet Gail Simone…

Scrounging through the dealers’ area, I managed to fill some holes in my Kamandi and Superman’s Girl Friend Lois Lane collections. I’m one issue shy of filling out my Flash collection (#92). There were many dealers carrying Silver Age comics, but few carried much more than the super-hero titles, so I only managed to find one issue of Dr. Kildare and no Doctor Tom Brent, Medical Intern.

Thanks to everybody’s suggestions for places to eat. Tonight we head off for Andaluca for some Spanish themed food.

Tomorrow, back to the Con. We also want to fit in a visit to the Science Fiction Museum before we leave Seattle.

Back to the ‘Con this morning. Much shorter line to get today — and better weather as well. Once inside, the first thing we did was stop by the CBLDF booth. I re-upped my membership, and in return got a copy of All-Star Superman signed by Grant Morrison. Nice.

Next, Robin and I swung by the Comics Fairplay booth and met Heidi and Jim Meeley. Had a great talk with them, particularly with Heidi. I did get to connect with Laura as well, but more briefly than I would have liked (check out the sword she gave to Kurt Busiek).

We proceeded up to the “DC Comics Panel” featuring writers Kurt Busiek and Gail Simone and editor Bob Schreck. It was a fun hour, as all three of the speakers involved can easily be described as…umm…having a strong personality. Not much information was gleaned, but it was an entertaining time nonetheless. (To me, this was the biggest shortcoming with the ECC. It had great guests, dealers, and exhibitors — but few panels. Panels have always been one of the best things about a good con. For one thing, they give me a chence to rest my feet. More, they give me a good chance to learn more about the creator — and see their interactions with one another — than a brief chat getting a sketch or a Newsarama interview will. More panels next year!)

Went back to the Dealer’s Area and picked up a few more Kamandi and Superman’s Girl Friend Lois Lane. I also bought several Batman Family and Superman Family comics. I also managed to find several PSA comics in a 25¢ box, so expect some fun over the next few PSA Mondays.

It was a nice weekend for the Hawk & Dove fanatic as well. Saturday, Rob Liefeld was kind enough to sign his five issues of the Hawk & Dove mini-series. Say what you will about Liefeld and his recent art, his Hawk & Dove work was good and he was extremely friendly and easy to talk with. He pointed out a couple of facts about the Hawk & Dove covers that I had never knoen. Sunday, I met Karl Kesel and chatted with him about Hawk & Dove, as well as some more recent work, and geot him to sign the comics as well.

Robin and I left the ‘con about 1:00 and headed over to the Science Fiction Museum. It was interesting and had some great stuff, but I was a little underwhelmed. Robin liked it a great deal better. I suspect it is because the museum is aimed at the general public and not a specific “science fiction fan” audience. I would have liked something more in depth, but if I were a science fiction novice I would have probably found it just right. Note to Sterling: The first issue of Swamp Thing is used as one of the exhibits in the Science Fiction and Society display. Other comics were mostly limited to some of the older EC titles.

Tonight, we’re just going to relax at the hotel, play in the pool, and have a simple dinner. Tomorrow — back to St. Louis!

It seems that while I was enoying myself in Seattle, some wild weather — including at least one tornado — rampaged through my part of Illinois. The house (and cats) survived, though some of the street signs around the corner were bent in two.

Power and cable are sporadic, so posting may be a little intermittent for the next day or two.

Adventures in Reading, starring the Amazing Spider-Man. Spidey Travels Through Time and Space in the battle against Illiteracy!Story by Louise Simonson, Pencils by Jon Bogdanove. Marvel Comics, 1990

Cara, Mike, and Dwane are bored inner-city kids who are lamenting the fact that they have nothing to do. As luck would have it, at just that moment Spider-Man swings by chasing a villain called the Troglodyte who has stolen a prototype weapon known as the Transporter. The Troglodyte shoots the bazooka-sized ray gun at Spider-Man and the kids, and they all find themselves in The Lost World. They help Professor Challenger and his crew fight off some pterodactyls, but then the Troglodyte hits them with the ray gun again and they find themselves in Victorian England during the Martian Invasion from The War of the Worlds. Next they find themselves in The Jungle Book, then That was Then, This is Now, and finally in Ivanhoe before they manage to subdue the Troglodyte and return to our world.

Spider-Man, a brilliant scientist and a college graduate, falls prey to the ONISGS (Oh No, I Suddenly Got Stupid) Syndrome commonly seen in PSA comic books: it took him until That was Then, This is Now to figure out they were being transported into the storylines of famous books. Seriously, if he didn’t recognize Professor Challenger or H.G. Well’s Martians, then a talking bear named Baloo should have given it away.

When it comes down to it, this book really has othing to do with fighting illiteracy. Instead, it’s geared toward encouraging children who already know how to read. Not to mention that there’s something fundamentally wrong about a comic book — with a narrative relying almost entirely on the written word — combating illiteracy.

As usual for a PSA comic, this book features several pages of “fun and games” such as word searches and anagrams in the back. One feature in particular caught my eye. How many of you fanboys (and -girls) can identify the source of this “code”?

Tags: comics psa spider-man illiteracy

The fourth episode of House in a row that features sex as a selling point. Enough already, please!

Melinda Bardach is 16 year-old girl who is deathly allergic to penicillin, bee stings, and peanuts. Thanks to trauma from an automobile accident, she also needed a heart transplant. She lives in a specially prepared clean room, and is not allowed out except to visit the doctor. When friends come to visit, they have to scrub down and wear a mask. Melinda’s boyfriend visits her and she wants a kiss. As he leans down to kiss her, he notices hives on her skin. Within seconds, she is wheezing and having difficulty breathing. angioedema sets in. Her mother rushes in and gives her a shot of epinephrine to stop the anaphylaxis.

By the time Melinda is admitted to House’s service, she has undergone “4 days of work-ups” which were all negative. Looking around Melinda’s room at home, Cameron and Chase notice that one window is unlocked, does not have and alarm, and is conveniently near a tree. They confront her boyfriend who admits he snuck in the night before her attack and that he and Melinda had sex. They test his semen, but Melinda shows no allergies against it. House questions him more closely and discovers that he took a week’s worth of antibiotics — penicillin, he thinks– before visiting her because he didn’t want to get her sick. The team deduces that just enough penicillin molecules were in his semen to set off an allergic reaction the next day. Just as House is ready to discharge Melinda home with a diagnosis of ‘allergic reaction” she goes into pulmonary edema, with sudden onset of wheezing, crackles in the lungs, white frothy sputum, and jugular venous distention.

Tests show that Melinda has developed congestive heart failure (the heart isn’t beating strong enough and fluid is backing up into the lungs). There is question whether this is a separate event from the allergic reaction, or if the two are connected. Cameron suggests a toxin of some kind, but that is ruled out. Other thoughts include an infection, heart disease, or rejection. A CT (apparently of her entire body) was negative, as were blood tests to rule out infection (though they came back way too soon. Negative blood cultures take forty eight hours) and a heart biopsy to rule out rejection. Meanwhile, Melinda has fled from her room. Foreman finds her on a back staircase, wanting to go outside, but too scared to go. As he escorts her back down to her room, he notices a left foot drop, which he refers to as steppage gait, but that’s a neurologist for you. As she is being examined for the foot drop, he also notes muscle fasciculations in her leg and diagnoses her with an ascending paralysis (a paralysis that starts at the extremities and works its way in, rather than the other way around).

Cameron suggests tick paralysis, but this is discarded when House points out that thorough exams showed no bites or ticks. ALS and MS — the usual suspects — are mentioned, as are Guillain-Barre Syndrome, botulism, and the catch-all viral infection. A spinal tap is obtained but is shows no evidence of viral infection. EMG (electomyography) shows increasing weakness in her lower-extremities and Foreman is convinced she has Guillain-Barre (an overactive immune response that causes paralysis). She is started on plasmapheresis, which filters out the offending proteins, but shows no improvement. Clearly depressed, she once again develops trouble breathing. This time her lungs are clear and there is no evidence of any allergic reaction. She is intubated and Foreman informs her parents that the paralysis has spread to her lungs (though presumably he means her breathing muscles, and not the lungs themselves).

Foreman and House agree that the paralysis has spread too fast for Guillain-Barre. Cuddy has taken over the case and ordered a spinal MRI to look for a possible lesion there. The team discusses but quickly dismissed the possibility of a toxin from glue inhalation or pesticides. House now decides the answer must be botulism and figures that the boyfriend smuggled in some food. He pulls his usual extubate-the-patient-so-I-can-question-them-as-they-are-gasping-for-air stunt, but Melinda is adamant that her boyfriend did not bring her any food. She also mentions that he had not been taking penicillin, but instead clindamycin – an antibiotic that she is not allergic to. The team now realizes that all three conditions (the allergy, the heart failure, and the paralysis) must be related – House belatedly decides that Cameron was right all along about the diagnosis: tick paralysis. He deduces that the boyfriend must have accidentally brought the tick in with him and that the team must have missed the tick on exam. As Melinda is sliding into a fatal heart rhythm, House declares that he must find and remove the tick before anything else. As Foreman pumps her full of atropine, House searches her entire (and I mean entire) body and manages to find the tick, lodged in the most unlikely of places (and during the most ridiculous scene in quite a while).

Let’s look at the diagnosis and the three main complaints:

1. Anaphylaxis: There have been cases of anaphylaxis from tick bites, though the time course seems a little off. Anaphylaxis usually kicks in quickly, or at most four hours after an exposure, not a day later — though it is possible that the tick had been wandering around for a while before it decided to settle down and bite. I’d also like to know that if it was an allergy to the tick bite that caused her anaphylaxis, then why didn’t she continue to have the reaction while in the hospital as the tick was still attached.
2. Heart Failure: I’m assuming that the paralysis is what led to the heart failure, though some animal studies have shown that tick venom has a direct affect against heart muscle. While atropine is used as an antidote to some neurotoxins, and it can speed up the heart rate under certain conditions, I think its use as depicted here is quite a stretch. It is not indicated in the treatment of tick paralysis or the routine treatment of heart failure. Speaking of heart failure, I never saw them do anything to treat the failure, and the CT scan is not a good way to evaluate heart failure (echocardiogram with doppler is much better).
3. Ascending paralysis: Right symptoms, but the time course is wrong. The symptoms of tick paralysis are fairly slow, taking several days to progress once they appear, not just a few hours. It usually occurs in people who have ticks that have been attached for 5-7 days, and that seems to fit this case as Melinda underwent “four days” of tests before coming to see House. I will agree that House is absolutely correct in that removing the tick solves the problem.

The soap opera again centered mostly on House and Wilson being roommates. House was cruel, but Wilson got him back in the end. Foreman is becoming the strongest of the junior doctors, standing up to House on several occasions this episode. Finally, for Hawk, who thought that Cameron wasn’t getting her share of the limelight: not only was she correct about the diagnosis, she also got the best zinger of the show in her little crack about Chase’s “staying power.”

The mystery was good, so I give it a B+, but the solution was quite a stretch so earns a C-. The medicine overall gets a C because there were too many holes. The soap opera was slight, but fun, so earns a B+ as well.

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

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Still want more top of the line medical information? This week’s Grand Rounds are being held over at UroStream.

Tags: television medicine house guillain-barre botulism tick paralysis grand rounds.

Ex Machina #18 “March to War, Chapter 2″
Brian K. Vaughan, writer
Tony Harris, penciler

In the end of issue #17, Mayor Hundred’s former aide Journal is attending a peace rally when she and hundreds of other protestors are exposed to some form of chemical toxin. In issue #18, the effects of the poison and the number of casualties becomes known. Journal is one of the victims: in the hospital and not expected to survive.

The Mayor’s security detail suspects sarin, but the Department of Homeland Security suspects that the toxin is ricin.

Sarin is a liquid nerve toxin that was developed in Germany prior to World War II as a pesticide. Poisoning can occur from skin exposure, eye exposure, or breathing sarin vapor. The toxin works on the communication between nerve cells. There are many symptoms of exposure including runny nose, watery eyes, blurred vision, drooling, and nausea. Symptoms usually appear within seconds of exposure, but may take several hours. Large doses can lead to loss of consciousness, paralysis, respiratory failure, and death. There are antidotes, but they work best if given early. Other than that, the best medical treatment is supportive.

Ricin is a toxin made from the castor bean. It is one of the most potent poisons known, and less than a milligram can kill a person. It works by disrupting the protein synthesis within a cell. It is a powder that can be inhaled, swallowed, or injected. If inhaled — as in the story — victims would develop shortness of breath, cough, and nausea within a few hours of exposure. Later, they would develop pulmonary edema (fluid building up in the lungs). A dangerously low blood pressure and respiratory failure may follow, leading to death. There is no antidote to ricin, and the best treatment medically is to provide as much support as possible and hope the patient pulls through.

When the mayor visits Journal in the hospital, the doctor refers to ricin poisoning. However, if you look at the time course (seconds vs. hours) and the symptoms, you’ll see that sarin fits the scenario better.

Journal’s treatment is a little suspect as well. The doctor is right that there’s no known treatment for ricin poisoning, and even survivors face a good chance of organ damage. However, someone as sick as Journal needs more than just an (incorrectly drawn) nasal canula and a single IV. They would need intubation and mechanical ventilation. Special medications such as dopamine would be needed to raise the blood pressure. Intensive care admission would be a must.

One last thought, Police Commissioner Angiotti refers to Ricin as “Schedule I”, but I’m not entirely certain what she means by that. At first I thought she meant it was a DEA schedule I drug — but ricin is not on the DEA list at all. However, it is listed as a Schedule I Controlled Substance according to the international 1997 Chemical Weapons Convention, so I guess this is what she is referring to. A strange thing for NYC cop to know off the top of her head.

• A belated thanks to Aaron for suggesting I take a look at this issue. In addition to my concerns, he notes the excellently drawn ventilator next to Journal in the hospital — which is strange as she’s not being ventilated. He also points out what appears to appear a tire gauge in the doctor’s pocket (image coming later).

Tags: comics medicine ricin sarin ex machina

Personally, when checking vital signs, I always found a blood pressure cuff easier to use than tire pressure gauge .

Scene from Ex Machine #18
Words by Vaughan, Art by Harris

Tags: comics medicine ex machina

Here’s an easy one. All of the following diseases have been mentioned in mainstream comic books. How many of them are real diseases, and how many are fictional? Answers are hidden in the normal way; just highlight with you cursor to reveal.

Necrotizing fasciitis	REAL - the basis of the plague in the Red Rain Avengers storyline
Sakutia	FICTIONAL - the tropical disease caught by Garth Logan after he was bit by a green monkey
Chagas Disease	REAL - the disease that killed Dr. Mid-Nite’s mother
Virus X	FICTIONAL - the germ that causes Kryptonian Leprosy
Vaccinia	REAL - the virus used to vaccinate against smallpox
Grazer	FICTIONAL - one of the futuristic diseases from Transmetropolitan
Camelpox	REAL - a virus that causes diseases in camels
Mugre	FICTIONAL - A tropical disease that Batman and the new Tarantula confront
S.T.O.R.M.S.	FICTIONAL - from Top Ten
Typhus	REAL - An infectious disease contracted from fleas. A diferent disease entirely from typhoid.
Clench	FICTIONAL - The ebola-like virus that caused an epidemic in the Batman: Contagion storyline.
Murray Valley Encephalitis	REAL - A rare mosquito-borne viral disease from Australia.

Tags: comics medicine disease

From The Beat comes some news about a recent health scare involving Chris Claremont (emphasis mine):

On March 5, comic industry legend and current writer of Uncanny X-Men and Excalibur, Chris Claremont, was overcome by exhaustion while attending a conference in Italy.

Thankfully, he is expected to make a full recovery and return to the comic industry he helped build.

Chris Claremont is best known for being the definitive X-Men writer and over thirty years later is still writing Uncanny X-Men along with New Excalibur.

After treatment and tests in Italy, Claremont was diagnosed with cardiac stress and last week returned to New York City where he will continue his rehabilitative therapy.

I read this and I get suspicious that there’s a little more going on than the press release reveals. Let me take a second to read between the lines:

For starters, cardiac stress is not a diagnosis, it’s a cause. Saying someone has been diagnosed with cardiac stress is like saying someone has “pollen” instead of allergies.

Next, we have to wonder what condition was caused by the cardiac stress. Whatever it was, it is something that requires both recovery and rehabilitation.

Let’s face it: minor injuries generally don’t need recovery and rehab.

Now when I see the words rehab and cardiac close together, I think “cardiac rehab”, which is the professionally monitored slow and careful resumption of activity after a myocardial infarction (i.e. a heart attack). This makes me wonder if Claremont may have suffered a small heart attack. Another possibility would be that he sustained some sort of acute coronary syndrome, a similar condition caused by a lack of blood and oxygen getting to the heart.

Finally, note that the incident happened on March 5th — yet he didn’t return from Italy until last week. To me this suggests there was a lengthy hospital stay involved, or at the very least a significant period of time where he was not medically cleared for traveling.

Therefore, based on what’s revealed — and not revealed — in the Marvel press release, I am very suspicious that Chris Claremont has suffered an ischemic heart injury of some variety.

Regardless of the cause, I wish him and his heart a speedy and full recovery.

Tags: comics medicine heart chris claremont

Looks to be a beautiful weekend with gorgeous weather. Plans include:

• Yard work, and lots of it. Mow the lawn and get the gardens ready for planting.
• Bike riding. Hopefully a nice long ride on both Saturday and Sunday.
• Pick up the in-laws at the local airport Sunday night.
• Wasting time with my new toy: an X-Box 360 (thank you, state income tax refund). Elder Scrolls IV: Oblivion here I come!

Tags: home yardwork bicycling xbox360 in-laws

Picking up the medical annotations of Naoki Urasawa’s Monster with Chapter Two (the annotations for chapter one can be found here and here).

Since last we left Dr. Kenzo Tenma, he has been appointed the Head of Neurosurgery at the prestigious Eisler Memorial Hospital. He and Eva, the daughter of the hospital’s director, have become engaged. At tea one night with Eva and her father, Tenma is stunned to learn that the director wants him to give up on his own promising research¹ and instead write a paper for the director to give at an important European medical conference. The director seems to feel that money and prestige come before research and patient care. Tenma disagrees but doesn’t say anything. Thoughts of that conversation flash though Tenma’s mind as he rushes to the hospital to treat an emergency patient.

A young boy and his twin sister are the only survivors of an attack that killed their parents. The girl is physically fine, but in a state of mental shock. The young boy, on the other hand, is in critical condition with a bullet through his forehead. He is brought to the emergency room where the x-rays and CT scan show the bullet deep in his brain next to the vital left middle cerebral artery². Dr. Tenma chooses to perform a frontal craniotomy to remove the bullet and repair the damaged artery³. As the surgical team begins to prep the patient for surgery⁴, Dr. Tenma is called out of the room.

It seems the mayor has suffered a stroke and is being brought to the hospital for emergency surgery to remove a suspected clot⁵. The hospital director orders Tenma to operate on the mayor and let another team handle the dangerous surgery in the child. He reminds Tenma that the mayor has promised an increase in funding to the hospital. Tenma is conflicted but ultimately decides to go against orders and returns to his original operation; he performs surgery on the injured child instead of the mayor

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Footnotes:
¹Dr. Tenma’s research is on vascular spasms after subarachnoid hemorrhages, a subject we beat to death last time, so I’m going to spare you and not repeat it here.

²The x-ray (though it looks more like an angiogram as x-rays don’t show blood vessels this well) shows that the bullet has gone in straight and lodged resting against the middle cerebral artery on the left, one of the key arteries in the brain.

Now, I haven’t read enough of the story to know who shot the boy, but let’s play forensic scientist for a second. First, note the bullet’s path: it’s at a slight angle, almost straight down. He must have been shot by someone above him. In addition, the bullet is still remarkably intact, providing important ballistics information about the power behind the shot.

³Dr. Tenma has chosen to perform a frontal craniotomy. He is going to go through the frontal bone of the skull to access the brain. He has two concerns with the injury the patient has sustained. The first is the bullet itself. It needs to be removed and any damage it might have caused to the middle cerebral artery repaired. Second there’s the danger of contamination. The area around the wound is filled with small chips of bone and other debris from the gunshot shattering the skull. These can lead to delayed healing and infection. Dr. Tenma is cognizant of these facts andfeels that his first priority is to remove the bullet and check the artery for damage.

⁴The patient is intubated and ready for surgery. Dr. Tenma has marked out his incision. He is utilizing the bullet hole because it makes access easier and provides less additional trauma to the patient.
The patient’s vitals are strong and appropriate for someone his age.

⁵The mayor has suffered a “cerebral blood clot” — in other words: an ischemic stroke. A clot has cut off circulation to part of the brain, and that part is dying from lack of oxygen.

Hospital Flunkie: There’s a possibility that his internal carotid may be blocked.

The internal carotid artery provides most of the blood to the brain, so a clot stopping its flow is very serious. Narrowed carotid arteries are an unfortunately common sign of atherosclerosis (cholesterol deposition and hardening of the arteries), and if they get narrow enough a surgery called a carotid endarterectomy can be performed to clean them out. Sounds like it’s too late for this for the mayor.

Tags: comics gunshot wound medicine stroke carotid artery cerebral artery naoki urasawa monster

Power Man is coaching a track team of inner city teens. His star runner Bret has been performing poorer and poorer. He and his girlfriend sneak off after practice one day. Suspicious, Power Man follows them and discovers that they have been smoking and playing pool (Gasp! Professor Harold Hill was right!) at the South Side Social Club. As Power Man is trying to listen in, Spider-Man swings by and eavesdrops as well.

For no discernible reason at all, these two experienced and powerful heroes decide that they need to bring in outside assistance to keep an eye on Bret. So they choose a hero who’s good at tracking like Wolverine, right? Wrong. So they choose a hero who was raised in the inner city and is streetwise like…um…Power Man, right? Wrong. Nope, Spider-Man and Power Man decide that they need the help of none other than Storm. There is no logical reason for including her in the story except that she was Marvel’s only notable black female superhero at the time (and probably still is).

Shortly, the bad guys’ dastardly plot is revealed! A ridiculous looking villain named Smoke Screen has decided he wants to control the local sports betting scene. Apparently the way to do this is by influencing the results of the high school track meet (because every gambler knows that’s where the big money is). His plan? Hook the star athlete on cigarettes so that he no longer has the cardiovascular endurance to compete in top form. No, really, that the plot: silly looking villain hooks star athlete on cigarettes so that he can take over the local mob by making millions from people betting on high school track.

No writing or art credits are given on this comic, and even the Grand Comics Database has no clue. That looks to be a John Romita Spider-Man on the cover, but I suspect it’s a cut and paste job as it doesn’t quite match the rest of the art. After some more thought, I realized I’d seen that Spider-Man pose before — it’s from the cover of Marvel Treasury Edition #28 (Spider-Man and Superman versus Dr. Doom and the Parasite) whose cover was penciled by John Romita. Spider-Man, Storm and Power Man was produced by Marvel Entertainment Group, Inc. and the American Cancer Society. It was first published in 1982 and I have the 1992 reissue — though it’s clear they never updated the math between the two editions:

Tags: comics medicine psa spider-man power man storm cigarettes tobacco

The review of this week’s House will be posted later than usual tonight (or maybe early morning tomorrow). I’ve got hockey tickets and plan to enjoy the spectacle for all it’s worth.

UPDATE: The Blues lost 2-0. You know, in all my years of watching hockey, I’ve never seen the pull-the-goalie-at-the-last-minute ply actually work.

Tags: house hockey st. louis blues nashville predators

No sex this week, just a very sick six year-old and the memories of a sick seventy-three year-old. Be warned, there are spoilers aplenty for this week’s episode of House ahead

Ian, a six-year old with bloody diarrhea and ataxia (loss of coordination) is admitted to the hospital. Cuddy thinks it is a case of gastroenteritis (food poisoning or a “stomach flu”), but House suspects it is something more. Twelve years before, a patient of his was admitted with the same symptoms and ended up dying within twenty four hours. That patient — a 73 year-old woman named Esther — developed kidney failure, pituitary failure, liver failure, and respiratory failure before she died. House believed she had a rare condition known as Erdheim-Chester Disease, but he was never able to prove it. With Ian, he sees a chance to redeem himself.

While House believes it is Erdheim-Chester, the rest of the team is not convinced. They also want to consider Listeria infection, leukemia, asthma, or even diabetes. A colonoscopy is performed but shows no evidence of Erdheim-Chester. Just when the team is starting to think that it may only be a case of gastroenteritis after all, Ian develops kidney failure.

The differential diagnosis now includes infection with the bacteria E. coli 0157:H7 (which Chase incorrectly calls HO157) leading to hemolytic uremic syndrome, Goodpasture’s Syndrome (an autoimmune disease that attacks the kidneys and lungs), heavy metal toxicity, and lymphoma. Blood tests for lymphoma are normal, but an MRI of the brain shows a pituitary mass. House starts Ian on a variety of medications in an attempt to ward off liver failure. They seem to work at first, though soon Ian’s platelet count drops and he has trouble breathing, ultimately requiring intubation and mechanical ventilation.

The team is now concerned with sarcoidosis, juvenile rheumatoid arthritis, an autoimmune disease, or Kawasaki Disease. An echocardiogram shows no evidence of the aneurysms normally seen in Kawasaki, but it does show a mass in the heart. House biopsies the heart mass, but the procedure causes a cardiac arrest. Ian is successfully resuscitated, but it takes eight minutes so he may have suffered some brain damage from the lack of oxygen during that time.

Knowing they only have a small biopsy sample to use to save Ian’s life, the team has to decide which three tests they can run because the sample is only large enough for three tests. They are considering histiocytosis (an abnormal increase in the number of histocytes, one of the cells of the immune system), tuberous scelerosis (a genetic disease), leukemia, sarcoidosis, neurofibromatosis, chondrocytoma (a tumor of cartilage tissue), or sarcoma (a muscle tumor). The tests for histiocytosis and tuberous sclerosis are negative. With only one biopsy sample left, House decides he must have been right all along and runs the test for Erdheim-Chester — which of course is positive. The diagnosis has been made, treatment is started, and the ghosts of old failures are exorcised.

An interesting episode with a good mystery. However, the ultimate solution really is not that good a fit for either Ian or Esther. Erdheim-Chester Disease is a rare form of histiocytosis that affects the long bones of the skeleton. Bone pain is one of the first signs, and it has a very distinct appearance on x-ray — something they should have looked for right away. It is most commonly seen in middle aged individuals, and while it has a high mortality, it takes years to run its course, not hours. It can cause kidney, liver, heart, pituitary and lung problems, but it has not been shown to affect the colon or cause bloody diarrhea.

The writers were unusually sloppy about medical terminology this episode. Erdheim-Chester is a type of histiocytosis, but Chase had already run a test to rule out “histiocytosis” — they were probably referring to Langerhans Cell Histiocytosis (”Histiocytosis X“), the most common kind, but it was still sloppy. Cameron mentions “connective tissue diseases” though the team had already ruled out “autoimmune diseases” and the two phrases are synonyms. Of course, that didn’t stop them from mentioning Goodpasture’s Syndrome and Juvenile Rheumatoid Arthritis — two specific kinds of autoimmune disease.

The rest of the medicine was pretty good, though I have a few quibbles about the lab tests (the results were amazing quick, and I’m astonished that their hospital has all the reagents to run these very rare and very expensive tests and doesn’t have to send them out to a specialty lab like the rest of us have to).

In terms of the non-medical content, the poker tournament was a clever set-up and fun to watch. The interactions between House (in person or on the phone), Wilson, and Cuddy were well done. However, this was at least the third or fourth time this season that a random comment from someone (Wilson this time) suddenly makes House realize what the solution to the mystery du jour is. I realize that’s a common cliché in detective fiction, but I find it distracting in a medical show.

The mystery gets a strong B+, but the solution earns a meager C because it really doesn’t fit. This drags the overall medical score down to a high B-. The non-medical content was enjoyable and earns an A as well.

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

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Still want more great medical reading? This week’s Grand Rounds are being held over at Anxiety, Addiction, and Depression Treatments.

Tags: television medicine house gastroenteritis histiocytosis grand rounds.

As usual after donating blood, I have the urge to write about blood-related comic book stories. Today, I have a sadly overlooked gem of a story for your enjoyment entitled “Clark Gives Blood, Superman Saves Lives” from Superman Family #214 (January 1982):

Lana Lang is in charge of the WGBS blood drive and she is determined to have it succeed, no matter what. If that means that everyone at Galaxy Broadcasting has to donate blood, then so be it.

Clark tries to weasel his way out of it, but Lana will have none of it. She leads him over to the nurse who introduces herself and then takes a drop of his blood to make sure he’s not anemic. When that test is normal, she takes him to the donation area where another nurse gets him all set up to give blood. After about ten minutes of whining and chatting with Jimmy Olsen, Clark has donated a pint of blood. A few minutes later, Clark rejoins Lana at the canteen as he is served some orange juice and cookies (“I’ll let you in on a secret, Clark – I really do this for the cookies!” confides Jimmy).

The question*, of course, is how did Clark manage to donate blood? I assure you, it’s actually Clark Kent; not a double, not a robot, not an imaginary story (any more than every comic book story is imaginary). As we’ve seen in the past, Superman’s skin is impervious to needles. This meant that in previous stories, whenever Superman had to donate blood, he ripped his skin open himself. So what’s his secret this time?

Remember Superman is not entirely invulnerable; he has his weaknesses. Two of them in particular. One of them is Kryptonite and the other is…well, take a look at the nurse and see if she looks familiar.

Need a hint?**

The “Superman Saves Lives” part of the story comes from the fact that Clark overhears an emergency call from a hospital in Washington DC in desperate need of type AB- blood. Metropolis has the four units they need, but no way to get them there in time. Clark quickly changes into Superman and delivers the blood to Washington DC himself.

The story was written by Bob Rozakis and penciled by John Calnan. Subtitled “A Salute to the 100th Anniversary of the American Red Cross,” the story does a good job of encouraging readers to donate blood by showing how quick, easy, and (relatively) painless the procedure is. So what are you waiting for? Go give blood.

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*The other — and in many ways more intriguing — question raised by this story is what happened to the person who ended up receiving a transfusion of Superman’s blood? Remember, his blood can promote miraculous healing and grant temporary super powers.

**(I hope you’ve figured it out by now, but if not, here’s the answer.)

Tags: comics medicine blood superman clark kent lana+lang bob rozakis

Ex Machina #19 “March to War, Chapter 3“
Brian K. Vaughan, writer
Tony Harris, penciler

Ricin was implicated as the poison in Ex Machina #17, #18 and now continuing into #19. As I explained in a previous post, I don’t really think that ricin fits the scenario, and based on the comments, others agree. Still, let’s go with the story and assume the poison gas was ricin.

In Ex Machina #19, Mayor Hundred asks the local Jewish leader for some assistance. He is under the impression that acetone is used in the extraction of ricin from castor beans and he knows that the diamond industry uses this chemical. He asks the rabbi to see if any of his parishoners have sold any acetone.

I have several problems with this:

• First, despite the impression given in the story, acetone is very easy to come by. For small quantities, just pick up some nail polish remover. If larger quantities are needed, there are easy and less suspicious ways of obtaining it than dealing with the diamond inudustry. It is a common industrial agent and used in the manufacture of polymers such as polyurethane. It can be found in large quantities in most high school and college chemistry labs (I remember our chemistry teacher had a huge drum of the stuff). If all else fails, acetone is easy to order on the internet.
• Second, experts cast doubt on the idea that acetone can actually be used in the extraction and purification of ricin. I’ll admit I’m not a chemistry expert, but I’ve talked this over with people who are. There is a recipe floating around the internet on how to make ricin. I’m not going to provide a link to it (because I’ve probably already set off enough red flags with this post as is), but it’s not at all hard to find with some decent Google skills. The recipe involves castor beans, lye, and acetone. Chemistry and security experts say the recipe doesn’t work and the lye and acetone serve no useful purpose in extracting the toxin. Acccording to other sources I’ve read, ricin extraction is a fairly complex procedure and definitely not “kitchen chemistry.”
• I’m suspicious of the recipe as well, given the last paragraph:
  

  The powder you have made is tasteless and odorless. It can be sprinkled into soup or placed in a drink or inhaled. It takes about 3-4 days to act and when it does the guy will be dead within a week. The death is slow and painful as this poison attacks the blood and internal organs starting with the digestive tract. The cure is rare and expensive and the poison is almost impossible to detect.

  Ricin is odorless and colorless, but the time course given is wrong. There is also no antidote, not even an expensive one. These basic errors lead me to believe that the author of this recipe dosen’t really have any idea what they’re talking about.

Somwhere in New York City, I’m certain that there’s a chemisty professor or professional chemist who can provide Mayor Hundred with some actually useful information. I suggest he look them up.

Tags: comics medicine ricin acetone ex machina

Things I’ve learned in clinic this week:

• MONDAY: There’s a higher than normal rate of no-shows for appoinments when it’s spring break and the weather is nice.
• TUESDAY: An average three year-old can fit at least five marbles in their nose
• WEDNESDAY: When advised to cut back on running because of recurrent injuries, this does not mean that it is a good idea to compete in just a half-marathon.
• THURSDAY: It’s never to early for sunburn
  …or poison ivy
• FRIDAY: A tongue piercing done by a friend with a sewing needle is really just an accident waiting to happen.

Tags: medicine tongue piercing sunburn poison ivy

I will be attmpting to upgrade WordPress this weekend. It’s always a little harrowing, but seems to work out well in the end…I hope…

Last year it was Justice League Peeps. This year it’s Marvel’s turn…

Read more…

The upgrade to WordPress 2.02 seems to have gone very smoothly — which scares me a little. With the upgrade, I plan on adding in some much requested features such as comments with previews sometime this week. I’ll also need to clean up the template a little.

There’s one more Peeps-post coming this year, but don’t expect it until sometime tomorrow night.

It’s another in the series of HIV and AIDS public service ads that DC ran in their comics in the early ’90s. This particular ad features Blue Beetle (the late Blue Beetle), Booster Gold (in what must be the ugliest costume ever), and Fire (though now that I look at it, her costume is pretty ugly too). It was found in Flash #87 (February 1994).

Brazil, Fire’s home country, has been hit hard by the AIDS epidemic. It saw its first case of AIDS in 1983 and now has over 600,000 individuals living with AIDS or HIV. Brazil accounts for 57% of the AIDS cases in Latin America and the Caribbean. Despite this, or because of this, Brazil has one of the world’s most aggressive HIV treatment and prevention programs in the world.

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

Tags: comics medicine psa hiv aids

Tags: comics peeps blue beetle infinite crisis

A clever mystery, and some interesting ethical debates made this a good episode of House. There are some major spoilers for this week’s episode of House below, so read at your own risk.

Hannah, a twenty-five year old woman, can’t sleep. She has not been able to sleep for ten days. She tells her girlfriend Max that she’s going to get a glass of wine and will be right back. When her girlfriend wakes up in the morning, Hannah’s not in bed; instead, she finds Hannah banging her head against the wall after taking an entire bottle of sleeping pills and still being unable to sleep. Hannah is brought to the hospital and assigned to House’s team.

The doctors’ first thought is infection, schizophrenia, or drugs – but they are all ruled out rather quickly (and frankly, not rather well. A single blood count doesn’t rule out a hidden or low grade infection, and there is no simple test to rule out a mental disorder). Next they wonder if it might be a visual perception issue, so they take a look at Hannah’s retinas and optic nerves. While performing the test, Foreman and Cameron notice that Hannah is sleeping, just in little 10 to thirty second intervals that she’s not even aware of.

A CT of the head shows no tumor, clots, or seizure disorders (which is impressive, as CTs don’t show seizure disorders) and the eye studies are normal. House’s plan now is to purposefully keep Hannah awake and see if they can provoke more symptoms. It His plan works too well: they quickly notice bright red rectal bleeding. With these symptoms, the concern becomes a clotting disorder or a tumor in the colon. Chase performs a colonoscopy but it is essentially normal. (Given that House wants to keep Hannah awake, I can see why they would not sedate her during the procedure, but there’s still no reason they couldn’t give her some pain medication). During the procedure, Hannah develops a copious nose bleed. She is transfused with 2 units whole blood (most physicians would have used packed red blood cells instead of whole blood, but whole blood is a theoretically better for people with clotting disorders and that might be why they chose to use it). An examination of the rectal blood reveals nasal epithelial cells, suggesting that the blood came from the nose (Generally, upper bleeding that comes through the gastrointestinal tract ends up dark maroon, black, or coffee ground in appearance due to the digestive process. Bright red blood like this patient had suggests a lower gastrointestinal tract bleed).

The differential now includes a toxin or a coagulopathy (another name for a clotting disorder). Some more history comes to light: shortly before she began having sleeping problems, Hannah had a rash diagnosed as poison ivy, and was given a dog by Max as a gift. The rash resolved on a dose of steroids, and the dog was returned because Hannah was allergic. House begins to suspect Wegener’s Granulomatosis. As Cameron is performing an upper airway biopsy to look for Wegener’s, she notices that Hannah appears to be in REM sleep, but with her eyes open while sitting up (these symptoms never seemed to be fully explained). To House, this suggests a movement disorder of some kind. Foreman thinks rabies, though Chase is concerned about allergies. While an allergy test is being administered (ever notice how many of House’s patients only develop problems during testing? My recommendation: never undergo testing by one of House’s team.), large bruising on the abdomen is seen correlating with severe internal bleeding. Foreman reports that blood tests show that Hannah is in acute liver failure, and without a transplant, she’ll be dead within hours. (In terms of the bruising and bleeding, the liver makes blood clotting proteins, so as the liver fails, it stops making these proteins any more and bleeding occurs).

Hannah’s partner Max volunteers donate part of her liver to her since they have the same blood type. House figures that the transplant will give them another thirty-six hours to figure out what’s wrong with Hannah. Thoughts include viral hepatitis, cancer (splenic or ovarian), non-Hodgkin’s Lymphoma, Wilson’s disease, or poisonous mushrooms. Multiple tests are performed to look for these conditions.

The surgeries are successful (though none of the surgical teams are wearing eye protection, a major safety infraction). All the tests come back normal. House decides that Hannah’s immunosuppressant medicine is hiding the underlying condition, so he stops them all (immunosuppressants are used after transplant to prevent rejection of the new organ). Soon Hannah has severe a severe rejection syndrome with a high fever. Her white count is normal, when it was expected to be low, so this tells the team that she has an infection of some sort. The differential includes tularemia, leptospirosis, typhoid, and relapsing fever (typhus). House suspects that the infection is somehow related to the dog, and when he realizes the dog came from the southwest, he examines the patient and quickly finds a buboe (a swollen lymph node infected with the bacteria Yersinia pestis), confirming the diagnosis of bubonic plague. Plague is transmitted by fleas, so House hypothesizes that the plague-carrying fleas which normally affect prairie dogs infested Hannah’s dog, and then jumped to Hannah. With time and strong antibiotics, she’ll be better.

The medicine was fair. No big mistakes — other than the lack of protective eyewear and the bright red blood — but a number of medium-sized errors. No story breakers this week.

The non-medical soap opera content was the highlight of the episode. This week, it all dealt with ethics. First, there was the disagreement between Foreman and Cameron over the ethics of publication. Cameron had prepared a paper on one of their patients and given it to House to review. Foreman also wrote a paper on the same patient well after Cameron did, managed to get House to review it quicker, and got it published first. This incensed Cameron and she accused Foreman of stealing her work, or at least her idea. At the end, she apologizes to Foreman, but he refuses to apologize to her, telling her that he had done nothing he needed to apologize for, and furthermore, they were not friends, only colleagues. Second, there was the ethics of love between Hannah and Max. Hannah is planning on leaving Max, but there was concern that if Max were to find out, she wouldn’t donate part of her liver to Hannah. Cameron wants to tell Max the truth, but House doesn’t want her to. In the end, it turns out that Max knew all along, and is using the guilt of the liver donation to keep Hannah in the relationship. I liked the way that there were no clear winners or right answers in the ethical debates. Nobody was right.

The mystery gets a solid B+, and the solution earns a B+ as well. This overall medical score gets a straightforward B. The non-medical content was the best part of the episode and earns an A.

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

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Still want more great medical reading? This week’s Grand Rounds are being held over at Fat Doctor. It’s an especially good Grand Rounds this week, and not just because I have an article in there. Make sure you take a look around Fat Doctor’s while you’re there, she’s one of the best of the more recent medical bloggers.

Tags: television medicine house plague grand rounds.

Batman Annual #25 “Daedalus and Icarus — the Return of Jason Todd”
Judd Winick, writer
Shane Davis, penciler

The real reason Jason Todd is mad. A play presented in three panels:

Jason in the hospital, soon after emerging from the grave. Note the bleeding head wound.This scene is actually drawn well, I just wish they’d change the dirty bandage.	A segue: One Year Later…(sound familiar?)	They left the stitches in! For a year! No wonder he’s mad (and poorly drawn stiches at that. Stitches are supposed to hold the two sides together — those sutures look more like it would pull them apart.)

Tags: comics medicine jason todd batman batman sutures

Manhunter #21 “Psychobabble, part 2: Mind over Morals”
Marc Andreyko, writer
Javier Pina, penciler

For what must only be the second time since starting this blog, I’m actually reviewing a comic the same week it came out…

The comic in question is Manhunter #21, the second issue of the “One Year Later” storyline. In this book, Kate Spencer finds herself defending the villainous Dr. Psycho in court, much to her disgust. The question before the court is whether or not Dr. Psycho used his mental powers to cause innocent bystanders to become homicidal maniacs. In one particular scene, Dr. Mid-Nite is on the stand.

Dr. Mid-Nite: If you do a side by side comparison of the MRIs, you can see the difference in electrical charges of a normal brain versus the brains of those from the Metropolis event.

Notice that the patterns of synaptic firing in the victims, all twenty-three of them, are exactly the same in the hours following. This is a statistical impossibility — unless one mind is overriding the inherent individuality and causing a “hive mind” effect.

Dr. Mid-Nite is wrong. While Magnetic Resonance Imaging (MRI) is excellent at showing the anatomy of the brain, ittells us absolutely nothing about the activity going on within the brain. A brain MRI of a living person and a recently deceased individual would be identical (unless, of course, the person died from severe head trauma).

If you want to look at the activity going on within the brain, a PET scan (positron emission technology) is your best bet. In this procedure, a faintly radioactive isotope in injected into the patient and tracked by a special machine. Areas of higher blood flow light up more than areas of lower blood flow. It is assumed that these areas of high blood flow are the parts of the brain where the most activity is occurring. In recent years PET scans have been used to determine which areas of the brain are used during certain activities or used to express emotions (studying, sleeping, love, hate, etc.). PET scans have also been used to study the brains of the mentally ill to look for differences from “normal” brains. (The Wikipedia article on PET scans is a little dry, but full of good information).

I also think Dr. Mid-Nite is wrong when he refers to a “statistical impossibility.” I’ll agree that it is extremely unlikely for the brain scans of 23 people to be identical, but I doubt that it is categorically impossible — just like DNA evidence is always stated as an odds ratio (6 million to 1, for instance), and never a 100% certainty.

UPDATE: Several commenters have mentioned Functional MRI (fMRI), and they’re right. It works much the same as a PET scan, measuring blood flow in the brain, so it would give some information about brain activity. It doesn’t do as much as Dr. Mid-Nite claims but it’s closer than a regular MRI.

Tags: comics medicine manhunter dr. mid-nite pet mri

Looking at the location of Jason Todd’s head wound — and assuming it is not just a superficial cut — it appears that Jason has sustained an injury to his frontal lobe.

The frontal lobes, as the name suggests, are at the front of the brain. They are a key part of the brain and play a part in motor function. They also influence with memory, language, and problem solving. Finally, the frontal lobes play a large role in personality, judgement, impulse control, spontaneity, and social and sexual behavior. Because of this, it should come as no surprise then that injuries to the frontal lobes can cause severe personality and behavioral changes.

Traditionally, left frontal lobe injuries have been noted to cause pseudodepression (apathy and indifference without a sense of depression). This doesn’t seem to apply to Jason (but now that I think about it, he was showing these symptoms when he was living as a homeless man in the recent Batman Annual #25). Injury to the right frontal lobe often manifests in psuedopsychopathy (lack of impulse control and restraint without the emotional components of psychopathic behavior). To some extent, this seems to apply to Jason, but I suspect he is more of a true psychopath then pseudopsychopath. (Don’t worry too much about the left/right aspect. As with many brain injury syndromes this can vary from person to person. Frankly, most patients never meet the exact criteria for either specific condition and show a mix of symptoms.)

The post-Crisis Jason Todd was always a bit wild, but not to the extent seen as the Red Hood. His more agressive and sociopathic nature has many possible explanations. Writer Judd Winick suggests it is due to a sense of betrayal and abandonment by Batman. There was also his dip in the Lazarus Pit, known to cause psychosis. Still, one cannot discount the fact that brain injury plays a role in his new behavior. There is evidence of a left frontal lobe injury, but remember he was caught in an explosion and likely suffered more brain injuries that are not visible to the naked eye.

Admittedly, Jason doesn’t seem to manifest any of the non-behavioral aspects of frontal lobe injury such as loss of fine motor skills and difficulty with language, but it seems reasonable that his poor impulse control and increase in risky behaviors may have tipped an underlying pathology over the edge.

Tags: comics medicine jason todd fontal lobe brain

There was some confusion this week with someone who posted some rude comments under my name (well, it could be under their name too — Scott isn’t exactly a rare name). The problem is they pretended to be me.

No more.

I will now be using the “Official Comment Plugin.” This only affects my comments — they will be marked as “Offical Comments” and will be a lovely shade of green. It only affects the comments that I post from here on out, so previous comments by me will still appear the same.

If it’s not marked as “Official,” it’s not by me (see my example in the comment section)

No changes to the comment policy otherwise. I’m doing my best to keep this site an open forum and I welcome all legitimate commentors including those who disagree with me. There is moderation that kicks in occasionally, but it is designed to stop comment spam, not legitimate posters. If your comment doesn’t appear right away, some word in there knocked it into the moderation queue. Be patient, I’ll clear it as soon as I can.

(And I still haven’t found a good comment preview plugin. I’ll keep trying…)

UPDATE: OK, now I’ve found a comment preview plugin that seems to work well.

Continuing the medical annotations of Naoki Urasawa’s Monster with Chapter Three (the annotations for Chapter One can be found here and here, and Chapter Two can be found here). Chapter Three is when the story really begins to pick up speed. The cocktail party scene is so masterfully written it still gives me chills. Pick up your copy of Monster and follow along.

As the chapter begins, Dr. Kenzo Tenma is struggling to remove the bullet from the boy’s brain.

Dr. Tenma: Make use of the gunshot wound when cutting
Dr. Tenma: Make sure the debridement is done thoroughly.

NOTES: Tenma is starting his incision at the wound site to provides less trauma to the patient. It also makes it easier on him. As I mentioned in the previous installment, it is a dirty wound. Tenma and his team are debriding the wound, removing all the dead tissue and foreign matter from the wound so that it has less chance of infection and a better chance of healing.

It is a delicate operation, but Tenma successfully removes the bullet and repairs the damaged blood vessels.

NOTES: Proline is a brand of suture (the “thread” used in surgical stitches). It is a non-absorbable (permanent) monofilament (single-stranded) suture made of polypropylene. The “8-0″ denotes the size of the suture, which in this case is very small, about a hundred times less than the diameter of a single hair. Wikipedia has a good article on sutures, if you would like more information.

The boy survives, but remains in a coma. The mayor is not so lucky, he dies during the operation and the other neurosurgeons blame Dr. Tenma for not helping them. The Director shares the bad news at a press conference.

NOTES: “Emphraxis,” one of the words the Director uses is just an old fashioned word that means “clot.” The Director is saying that part of the Mayor’s brain did not get enough blood flow because of a clot and died off. Enough of the brain died that the Mayor did too. Basically, the Mayor had a stroke. As the Director points out, the Mayor’s Inner Carotid (we Americans would say “Internal Carotid”) Artery was clotted off. Because this artery supplies most of the blood to the brain, this was a very serious condition and it is likely the Mayor would have died even if Dr. Tenma had been there.

At work Dr. Tenma is distracted. The nurse has to ask him multiple times for some simple orders.

NOTES: Halcyon is the European spelling for the drug Halcion, generic name triazolam. This drug is a type of drug known as a benzodiazapine that works as a relaxant and a sedative. Valium is probably the best known drug in this family.
A book very critical of Halcion was published in the early ’90s, and whether the books complaints were justified or not, the sales of Halcion suffered in American and have never fully recovered. It is used more in other countries.
You’ll notice that Dr. Tenma does not give a dose for the Halcyon — not a good idea. It’s likely that he has an algorithim the nurse will follow, but it’s always a good idea to give a dose when ordering any medicine, let alone a powerful sedative.

Tenma attends the Director’s cocktail party in an attempt to redeem himself, but the damage has been done. While the Director seems friendly at first, Tenma quickly discovers he’s been demoted and is no longer head of the neurosurgery department. The Director also makes sure that he understands that he no longer has any chance of advancement at Eisler Memorial Hospital and that the Director does not intend to make it easy for him to leave to practice medicine elsewhere. On the way out of the party, his fiancée returns the ring and all but laughs in his face. The cocktail party scene is chilling, and the best scene of the book so far.

Tags: comics medicine suture stroke carotid artery naoki urasawa monster

I’m sure that like most people contemplating the immigration issue you think to yourself, “What could early-Silver Age DC comics teach me about immigration and getting along with people who are different from me?”

Ponder no longer, for today’s PSA Monday page answers that very question. From the DC Comics published in September 1957*
comes the inspiring tale “Danger: Prejudice at Work” ** by Jack Schiff (words) and Ruben Moreira (art). As with most other Silver Age PSA ads, this was sponsored by the National Social Welfare Assembly.

In the end, this magnum opus reminds us once again that there is no problem in life that cannot be solved with baseball.

Click on the image for the full size PSA ad.

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*This PSA appeared in Action Comics #232, Adventure Comics #240, Batman #110, My Greatest Adventure #17, Showcase #10, Sugar & Spike #10, Superboy #59, Superman’s Pal Jimmy Olsen #23, and World’s Finest #90. Insome comics it was printed in color; in some, black and white. It may have appeared in the other DC comics that month, but I can’t confirm it.

**An ironic name, as the story is about play and not work.

Tags: comics psa silver age prejudice baselball

This episode of House concerns a young faith healer who hears God talk to him, and frankly was better than most people (including me) were expecting. The medicine was interesting and the Wilson/House dynamics intriguing. There was also sex, of course (but not between Wilson and House, get your mind out of the gutter). There are spoilers below, and I probably should have given a spoiler warning before that whole sex thing. Oops.

Boyd, a fifteen year-old faith healer, is in the middle of a church service when he experiences sudden devastating cramping. At the hospital for evaluation, it is unclear at first whether he had abdominal cramping or muscle cramping, so the team works up both. When the x-rays show no intestinal obstruction, they focus on muscle cramping. Cameron notes dilute urine and his blood tests show low sodium. It also comes out in the conversation that Boyd has been hearing God talk to him since he was ten.

The team’s initial thoughts of causes for his cramping include Addison’s Disease (a malfunction of the adrenal glands) and cirrhosis (a liver disease), but his other tests do not support these diagnoses. They talk a little about mental illness and hearing God talk, but leave the issue out of their diagnosing for now. House discovers that Boyd has been drinking several gallons of water per day, and suspects that this water intoxication is what is causing his low sodium, which led to his muscle cramping.

That night Boyd suffers what appears to be a complex partial seizure and stumbles out of his room and down the hospital corridor. (Partial seizures just affect a portion of the brain, as opposed to generalized seizures which affect the entire brain. “Complex” means that Boyd’s consciousness is impaired during the seizure.) Boyd runs into one of Dr. Wilson’s terminally ill cancer patients and lays hands on her and proclaims her cured. Chase manages to drag Boyd back to his room.

The differential diagnosis now includes infection, Wilson’s disease (a disease of copper metabolism), a glycogen storage disease (an inherited metabolic disease), a brain tumor, or tuberous sclerosis. An MRI shows an abnormal area in the frontal lobe that is consistent with tuberous sclerosis. With the help of Dr. Wilson’s “silver tongue,” House talks Boyd into agreeing to surgery for the tuberous sclerosis tumor.

Meanwhile, Dr. Wilson’s cancer patient has gotten better and her tumor has shrunk. When Boyd hears about this, he cancels his surgery. House’s team explores the patient’s history (and apartment) at length to discover if there is any other possible reason for her remission and discover nothing, well, except for the fact that she’s sleeping with Wilson.

Boyd spikes a fever to 103° (that’s 39°C to you metric people) and becomes delirious. Now it seems that not only does Boyd have the tuberous sclerosis, but some kind of infection as well. House wants to perform a lumbar puncture (a spinal tap), but Boyd refuses.

House and Wilson discuss the issue and House suddenly realizes that Boyd must have some kind of viral infection. He passed this on to Wilson’s patient when he touched her, and it is this virus that has shrunken her tumor (but not cured her). House believes it must be herpes, so confronts Boyd who grudgingly undresses revealing a herpetic rash on his buttocks. Thus Boyd has a tumor from the tuberous sclerosis (which is causing his hallucinations of hearing God talk), and herpes encephalitis, which is causing his fever, seizures, and low sodium.

The medicine was fair. There were a few questionable items, but no big errors. First off, when a patient comes in with dilute urine and low sodium, Addison’s and cirrhosis are going to be fairly far down on my list of possibilities. I’d start off looking at his kidneys (which to be fair, Cameron did imply she was going to this), and look at dietary intake of both sodium and water. Fiteen years old is a little late to start exhibiting an inherited metabolic disorder (but not entirely unheard of). The radiation-from-household-appliances-curing-cancer idea was simply ridiculous; radiation therapy uses sepcial wavelengths of specifically focused beams of radiation, not just random entire body radiation. In terms of the lumbar puncture, you could argue either way whether or not they should have done it sooner. Personally I would have, but I could be convinced otherwise (I’ve always lived by the maxim: “If you even think about doing an LP, it means you need to do one.”) The virus-causing-a-tumor-remission makes since theoretically, but there’s never been any proven cases of it actually happening. Finally, I’m a little puzzled as to why Boyd had the rash on his rear end (other than because of the Fox censors). If it were sexually transmitted herpes, as the show implies, then the lesions should have been somewhere more…intimate. As it was, it looked more like shingles, which is a reactivation of the chicken pox virus – which is itself a type of herpes virus, so the tumor-shrinking is still possible. It just wouldn’t have been as salacious (just more logical).

Frankly, I was expecting a great deal of heavy-handed faith versus science diatribes on the non-medical side of the story, and was pleasantly surprised when that didn’t occur. Everyone’s positions on the religion and medicine were consistent with past characterizations. The House/Wilson friendship got most of the play, and this week it was Wilson who was the most unethical, which was a first.

A couple of last thoughts. First, after near misses in the last two episodes, I got this one correct. If you look back at my predictions from the earlier in the season, herpes encephalitis in on there. Second, I hope everyone recognized Boyd’s father was played by William Katt, better known as the Greatest American Hero.

The mystery gets a B, because the hearing God and a brain tumor were pretty much gimmes. The solution earns a B+. This gives an overall medical score of a strong B. For a second week in a row, the non-medical content was the best part of the episode and earns an A.

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

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Still want more great medical reading? This week’s Grand Rounds — the best medical blogging of the past week — are being held over at the Health Business Blog. As usual, there’s an incredible amount of fascinating reading.

• I will be hosting Grand Rounds next Tuesday, so e-mail any submission to me by Monday, 8PM Central time.

Tags: television medicine house tuberous sclerosis encephalitis grand rounds.

I will be hosting Grand Rounds next Tuesday, May 2nd. Please e-mail any submissions to me no later than 8PM central time, Monday May 1st.

Submissions should be sent to: grand@politedissent.com.

When I receive your submission, I’ll fire back an e-mail so you know I’ve gotten it. If you haven’t received a confirmation note in 24 hours, it’s probably best to send you submission again. Thanks.

Robin has it right. Under normal conditions, rigor mortis starts at about 3-4 hours. That makes Robin the only one of the Batcrew currently in Gotham who actually knows how rigor mortis works.

Previous Gotham: CSI episodes:
1. Batman (wrong)
2. Anarky (wrong)
3. Sasha Bordeaux (right)

Tags: comics medicine robin rigor mortis csi

I’m just wondering why the emergency medicine intern at Gotham General Hospital is ordering paracetamol — a British drug — for her patient? Paracetamol is the British name for what we in the States call acetaminophen – probably better known by its brand name Tylenol.

It also seems to me that acetaminophen is a pretty weak pain killer for a patient who has suffered so much facial trauma that he needs a surgeon. If I were the patient, I know I’d want something stronger.

(I suspect we can blame Eddie Campbell, the British co-writer of this issue, for the use of paracetamol.)

• Despite my nit-picking, the emergency medicine in this comic (Batman: Legends of the Dark Knight #200) is very well done. The narrative drags a little bit in the second half when it degrades into a moderately inventive “find the bomb before it explodes” storyline. The medicine in this comic actually deserves a post of its own, which I’ll get to sometime next week (hopefully).
• I notice that Joker’s venom, at least its gaseous form, is called Smilex in this comic. Is this the first time the name Smilex has been used in an in-continuity Bat title? As far as I know, the name orginated in the Tim Burton Batman movie.

Tags: comics medicine batman paracetamol acetaminophen tylenol xmilex

Due to some unexpected delays including power outages, tornado sirens, and a DOS attack against my host, postings have been lighter this weekend than anticipated.

Anyway, the CBDR has been updated. Appendix B now covers the entire run of Transmetropolitan. H will be happy to here that his suggestion of the Atlantean “Serum X” was included in this update.

An easy one here — nobody better miss this!

All nit-picking aside, I’m really enjoung the Annihilation storyline, and I’m not usually much on Marvel’s cosmic-level stories. Looks better than Civil War, that’s for sure.

• Previous Picture Quizzes

Tags: comics annihilation

Chapter Four of Naoki Urasawa’s Monster only has two brief medical scenes in it, but it is a key chapter with a murder (or two, or three).

In the previous chapter, Dr. Tenma found himself demoted from Head of Neurosurgery for choosing to operate on a young boy rather than the mayor. In this chapter, the police try to question Anna, the boy’s twin sister, but with no results. Meanwhile, the Hospital Director, his crony, and the recently promoted Head of Neurosurgery decide to milk the situation for all the PR they can, and decide to stage a photo-op with the two siblings, even though disturbing the boy is contrary to what his physician — Dr. Tenma — has ordered. The boy wakes up, the sister screams and collapses, and Tenma is forced off the case. This combined with seeing his ex-fiancee Eva going out with one of his colleagues drives Tenma to a long night of drinking. That same night, three of his superiors are found dead.

• Medical annotations of the previous chapters of Monster

I disagree with the doctors here: dissociative hysteria is an incorrect diagnosis. First, it is an out-of-date (and somewhat sexist) term. Second,it applies to people with dissociative identity disorder (formerly called multiple personality disorder). Anna simply has none of the symptoms of identity disorder.

I agree that she is suffering from some form of dissociation. In dissociation, a person who has suffered some form of trauma mentally distances themselves from their own body and personality. The Mayo Clinic describes it well: “People with dissociative disorders chronically escape their reality in involuntary, unhealthy ways ranging from suppressing memories to assuming alternate identities. These dissociative patterns usually develop as a reaction to trauma and function to keep difficult memories at bay.”

Anna is suffering from dissociative amnesia and what appears to be a dissociative catatonia (a state of limited — if any — motor activity and no response to external stimuli)

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Anticonvulsives (more commonly called anticonvulsants) are medications used to prevent seizures. They are given to people who have a history of seizures (as in epilepsy), but are also sometimes given to people who do not any prior history of seizures but are at risk of developing them in the near future. Brain trauma, brain tumors, and other brain injuries can cause seizures, so these patients are sometimes placed on medication to prevent them, just in case. Some neurosurgeons place their patients on anticonvulsants after brain surgery for six to twelve months because seizures are more likely while these people are healing from their surgery (though still rare).

Hypotensive is another term for blood pressure medicine (“hypo” = low, “tensive” = pressure). Dr. Tenma wants to keep Ms. Hankel’s blood pressure low. This will put less strain on the blood vessels in her brain. He is most likely concerned about a stroke or aneurysm. I suspect Mrs. Hankel had an aneurysm that bled. He managed to repair it, but wants to keep her blood pressure low so it is unlikely to bleed again, and wants to keep her on seizure medications while her brain heals, just in case.

Tags: comics medicine amnesia catatonia dissociation seizure blood pressure naoki urasawa monster

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