Polite Dissent

the early ’90s, Marvel Comics published a series of four loosely connected public service comic books in Canada. Rarely one to turn down a chance to make a buck, these books were republished in the US a short time later with a $1.50 price tag. Today I’m going to take a look at the first of these titles: The Amazing Spider-Man: Skating on Thin Ice. The Script is by Dwayne McDuffie with interior art by Alex Saviuk and Christopher Ivy.

First, look at the cover. That is vintage McFarlane: An uncomfortably posed Spider-Man and webs hanging everywhere! The cover also makes it clear that this book is about a variety of evils: cigarettes, drugs, beer, and apparently test tubes. Todd’s also nice enough to let us know that the comic takes place in Canada by having one of the kids wear an Oiler’s jersey (nevermind that the story takes place in Winnipeg, not Edmonton).

As the story begins, Spidey busts in on Electro. Because he’s a villain, Electro fights unfairly and manages to defeat the “Arach-Knight.” Using those clever detective skills that he has, Spider-Man finds one of Electro’s shipping invoices that just happens to mention the destination of Winnipeg. Peter Parker than convinces Daily Bugle publisher J. Jonah Jameson to send him as a reporter/photographer to Winnipeg to cover a science fair (because apparently there are no science fairs in America, and Daily Bugle readers demand to know the results of Canadian science fairs).

Peter arrives in Winnipeg and travels to the hockey rink to interview one of the science fair competitors who also plays on the local junior hockey team. There, he encounters one of the oldest cliches in comics, the WBM (Wise Black Man) [UPDATE: see note below], who explains that Alan, the team’s star player, has been slacking off lately (sound familiar?)

Spider-Man follows the team members after practice is over and discovers Alan accepting beer, drugs, and cigarettes (but no test tubes) from a gang of local toughs. Spidey swings by and grabs Alan; he shows him the seamy and dangerous side of drugs. Naturally, Spider-Man runs afoul of Electro again, but with Alan’s help (a well-aimed slap shot, of course), Spidey triumphs. Electro’s mysterious lackey escapes though, and Spider-Man decides to stay a bit longer in Canada to track him down.

NOTE: Dwayne McDuffie points out that the character is not a cliche at all, but instead is Herb Carnegie, a famous black hockey player (see his Wikipedia entry here).
He is correct and the character is clearly identified as Carnegie in the story…and I missed it entirely (that’s him smiling from the back in the panel at the end). Mea Culpa

It’s been a little over a year since I first hosted Grand Rounds, and I am amazed by the amount it’s grown in that time. Not only in the sheer number of submissions (nearly three times as many as last time), but in the range of subjects — not to mention the variety of the writers themselves, from physicians to nurses to EMTs to professors to research scientists to patients to economists and on and on. Grand Rounds: it’s always a pleasure! Enjoy!

School Years and Career Choices

• A Word to the Wise about Career Choices, from the MSSP Nexus Blog
• Milliner’s Dream shares her experiences of a rough day on the floors in nursing school.
• On Floundering — the title says it all, from My Life, My Pace

The Patient’s Perspective

• Pixel RN shares her experience of being a patient at an In Vitro Fertilization clinic. Not only can the staff be difficult to communicate with, but she leanrs more than she expected.
• Difficult Patient talks about “Patient Advocates” — who really aren’t advocating for the patient, but instead the hospital.
• A look at the time-honored (but not necessarily correct) use of bedrest in pregnancy, by Doulicia
• Laurie shares her experiences about finding the delicate balance between a chronic medical condition, a social life, and guilt.
• Amy from Diabetes Mine discusses her Top Five List of What Sucks About Diabetes At The Moment

The Practice of Medicine

• Kim from EmergiBlog explains the truth behind ambulance diversion
• A look at nursing morale issues from The Nurse Parctitioner’s Place
• Kevin MD mentions an “old timer” who “bemoans demise of the physical exam.”
• A remarkable experience with a local pharmacy, as related by Dr. Charles
• Dr. Bob from The Doctor is In takes a hard look at Medical Coding and Compliance Programs
• Drug seeking patients and pain, a thoughtful look by Dr. Hébert.
• A chance encounter in a fast food drive-thru leads Dr. Peg to consider a face of courage
• GruntDoc shares some hard earned advice on extubation and paralytics.
• Dr. Flea looks at the (alleged) communication between primary care physician and specialist.
• Zosyn on the Sopranos. Accurate medicine, product placement, or both? From Kidney Notes
• When a post begins “Do you have any idea how many babies are born in a toilet each year?” you know you’re in for a fascinating ride. From Tales from the Womb.
• The Babados Butterfly has thoughts on impaired physicians
• A lovely poem, courtesy of Cricoid Pressure
• Over at Unintelligent Design, Dr. Clark considers screening a newborn’s stool for drugs
• Good news for a patient at Digital Doorway
• Political Calculations provides the unintentional comedy of medical notes

Drugs and Drug Companies

• A consideration of the economics of generic proton pump inhibitors, from InsureBlog
• Barely MD takes a different look at the profits of the pharaceutical companies
• “Yet Another Lilly Study” from Health Policy & Research, looks closely at a study of Zyprexa that is supposed to show that the medication can prevent the conversion of pre-psychosis to psychosis.

Diseases and Conditions

• A new swine flu, courtesy of Tara at Aetiology (she didn’t cause it, she’s just explaining it)
• NHS Blog Doctor takes a hard look at Bird Flu…and Malaria
• An explanation of Ludwig’s Angina from Inside Surgery

Mental Health

• A nice post and video over at Treatment Online dealing with Loss and Grieving
• Dr. Deborah Serani is not sure that T-Shirts for mental disorders are a good idea
• Psychiatry versus Pop Culture at Over My Med Body!

Living with Disabilities

• A heartwrenching tale, and the thoughts that follow by Dream Mom
• TC from Donorcyle talks about her Aunt

Medical Economics

• The Health Business Blog addresses the concept of Guaranteed Issue and how it is actually a boon for entrepreneurs
• Over at Healthy Concerns, Elisa looks at another blogger’s ideas on how to “Fix the System.”
• A lone hospital financial administrator in a convention of nurses? Get the lowdown at Hospital Impact.
• The Medical Blog Network addresses consumers and RHIOs (Regional Health Information Organizations)
• The Canadian Health System and Universal Health Care — not as broken as we’ve been led to believe? From Healthy Policy

Technology

• The effects of electronic medical records on the doctor-patient relationship, from Wandering Visitor
• Why read journals at all? Clinical Cases and Images reports that JAMA is now available via podcast.
• Straight from the Doc reports on the new technology of Terahertz Imaging for breast cancer

Nutrition, Weight Loss, and Dieting

• Disease Proof warns us to beware the high fructose corn syrup
• A fascinating look at supermarket purchases as opposed to self-reporting as a source of diet information, from Fixin’ Healthcare.
• Orac discusses a celebrity nutritionist — respectfully, of course
• Dr. ibear from Doc Around the Clock has decided that It’s Time to Get Healthy
• Medic of One gives some blunt advice on losing weight

International Medical News

• Dr Ng Swee Choon reports that some top California researchers are heading to Singapore
• From Hsien-Hsien Lee, PhD comes the news about the working conditions of healthcare workers in Lesotho.
• Parallel Universes explains why Filipino doctors are choosing to work abroad…as nurses

Next week Aetiology is hosting Grand Rounds. And remember that Unintelligent Design is hosting the second edition of the Pediatric Grand Rounds and needs your submission s by Saturday!

It seems a certain unnamed hosting company neglected to re-register my domain which led to those lovely palm trees you may have seen this morning.

All fixed.

(Don’t worry — I don’t plan on going away for quite a while)

The first part of a two-episode storyline in House. This one features a strangely giddy cop, and an infected Foreman (so far no sex, but let’s wait and see). There are plenty of spoilers below, so beware!

Joe Luria, a police officer, chases a suspect through an abandoned warehouse and into an alley. Joe has a dry cough, but doesn’t seem particularly short of breath. After he finds the suspect hiding in a trash bin, he starts laughing uncontrollably. He makes bizarre jokes and even continues laughing after he has been shot in the head.

At the hospital, it is noted that Joe has patchy infiltrates on his chest x-ray. A drug screen is negative, and it is decided that the bullet fragments are in the wrong part of his brain to cause his symptoms (and he had the symptoms before he was shot). Chase suspects Joe may have carbon monoxide poisoning and a blood gas test does show elevated levels of carbon monoxide.

Meanwhile, as Joe is being placed in a hyperbaric chamber to treat his carbon monoxide poisoning, Foreman is searching Joe’s apartment, which is a pig sty. He collects several samples and discovers that Joe is growing marijuana in a shed on the patio. Back at the hospital, Joe has developed involuntary muscle contractions of the hand.

After a visit to the police station, House determines that Joe is suffering from Legionnaire’s disease (from a dirty air conditioning unit), and this explains his cough and chest x-ray findings. Whether or not it is supposed to explain his carbon monoxide poisoning is never revealed, as that subject is dropped and never mentioned again.

The team discovers that Joe has “Anton’s Syndrome” — a type of blindness where the eyes are working, but the brain is processing the information wrong. It is caused by damage to the occipital lobe of the brain, and could be related to gunshot trauma, though House suspects a stroke. He wants an MRI, but Foreman reminds him that the bullet fragments are magnetic and are not safe in an MRI. House places Joe on the blood thinner Heparin for treatment of the suspected stroke. An angiogram (where dye is injected into the arteries of brain and then x-rayed) is obtained and it does suggests some clotting around the Circle of Willis (a group of arteries which supply blood to the brain).

Down in the morgue, House shoots a corpse at close range with a bullet similar to the one in Joe. When they MRI the corpse, sure enough, the metallic fragments are drawn out of the head and wreck the MRI machine. Luckily the hospital still has their portable MRI machine.

Events start happening at a rapid pace now. An echocardiogram of Joe’s heart is obtained to look for sources of stroke, but is normal. During the test, Joe develops a sudden tachycardia (a rapid heart rate) and is discovered to have bleeding in the brain. A hole is drilled into his skull (trepanation) to relieve the pressure. Meanwhile, Foreman has become giddy and starts laughing uncontrollably. Both he and Joe are placed in isolation. An MRI of Foreman’s brain shows a lesion in the cingulate cortex (an area in the center of the brain). The differential diagnosis now includes West Nile Virus (a disease spread by mosquito bite), Eastern Equine Encephalitis (another viral disease carried by mosquits), and toxins. The MRI also shows some inflammation around the ventricles which Foreman interprets to mean that he has a Staph infection (an infection from a bacteria of the Staphylococci family). He wants an Ommaya reservoir to feed the antibiotic linezolid (also known as Zyvox — a potent and somewhat controversial antibiotic) directly to the brain.

The tests for West Nile, Eastern Equine, and various toxins all come back negative. Foreman tests himself and notes that he has a negative Kernig’s sign, but a somewhat positive Brudzinski sign (Both are classic tests for acute meningitis). In the same room, Joe is having increased contractions of the hands and forearms. House wants a biopsy of Foreman’’s brain, but Foreman wants his Ommaya reservoir and antibiotics. He shows House the thermometer to prove that he is running a fever. In the operating room, House pretends to place an Ommaya, but takes a biopsy instead.

Up in isolation, Joe develops full blindness and starts complaining of intractable pain that is not helped by the morphine (House refers to this as hyperalgesia).

Foreman’s biopsy shows only non-specific signs of inflammation (in other words, the biopsy shows something is going on, but gives no clue as to what that something is) and the Staph tests are all negative. The differential diagnosis is wide open: any bacteria, fungus or toxin that might cause brain damage.

Foreman stabs Cameron with a needle while she is drawing his blood so that she is exposed too and will have to go back to the Joe’s apartment for more samples. Thoughts at this time include listeriosis, SSPE (Subacture Sclerosing Panencephalitis, a rare late complication of measles infection. Despite what the Chase implies, it has never been reliably shown to be related to vaccination), Aureobacidium fungus (one of the alleged “toxic molds”), toxocara (a parasitic worm common in cats and dogs), trichinella (another parasitic worm, this one from undercooked pork), ergot (a nasty mold that grows on rye wheat, and Cryptococcus neoformans (an infectious fungus). The last seems the most likely and both Joe and Foreman are started on Amphotericin B and Flucytosine (both very strong anti-fungal drugs).

Foreman seems to improve initially, with a lowered fever and a drop in white count. But then Joe develops ventricular tachycardia then ventricular fibrillation, then asystole. Foreman tries to revive him, but can’t, and Joe is pronounced dead. At the same time, Cameron reports that there is no evidence of Crytpococcus in the samples so they’re back to square one. (End episode. Cue “To Be Continued” sign).

So far, it’s an involving mystery. It appears to be an infection of some sort, but I wouldn’t be surprised if many of the symptoms ended up being red herrings. House’s reactions are interesting as well; Wilson points out that for once is acting “cautious” and “common.”

The bad?

• I’m surprised Cameron was caught off guard when House wanted to get an echocardiogram of the heart. That’s standard procedure in a stroke situation, as well as obtaining a Doppler of the carotid arteries.
• The idea of checking a sedimentation rate to look for signs of exposure/infection in the rest of the team is ridiculous — it’s an incredibly nonspecific test and will be elevated with any sort of inflammation anywhere in the body.
• Why did Foreman inject the morphine directly into Joe’s carotid artery? He had a perfectly good IV, so why waste the time and risk the complications in a carotid stick.
• Finally, that code at the end was pitiful. Cameron announces that Joe has “multiple system failure” — with little, if any evidence — and the code is called after barely a minute. That’s ridiculous and embarrassing for all involved.

The ethics shown by Foreman and House in this episode were appalling — more than usual. Shooting a corpse in the head was shocking, but served no real purpose (to prove what would have been easier to test by just placing a bullet fragment in a sealed box in the MRI — it worked for Mythbusters.) Performing a brain biopsy without patient consent? There are simply too many risks involved. Stabbing a colleague, even one as Pollyanna as Cameron, was a little too Machiavellian for Foreman. Sure, he may not have been thinking clearly, but that’s still felonious assault.

No grades yet for the episode, not until I get to see the conclusion tomorrow night.

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

Still want more great medical reading? This week’s Grand Rounds are being held right here at Polite Dissent! Of course, I think it’s an especially good Grand Rounds this week. Make sure you take a look.

The second part of a two-episode storyline. This review builds on the last one, so make sure you’ve read it before starting. As always, spoiler warnings apply.

The story picks up where the episode ended last night. Foreman is in isolation, sick with whatever disease or condition killed Joe the police officer. Because of the possibility of an unknown and fatal disease, Cuddy has contacted the CDC (the Federal Center for Disease Control), who have taken charge of the policeman’s autopsy. They’ll get to it in a few days. This doesn’t sit well with House who wants the autopsy performed now! He brings autopsy tools to Foreman in isolation and convinces him to get a sample of the policeman’s brain. Foreman attempts the autopsy and actually thinks he has succeeded, but in reality he has developed Anton’s Syndrome (where the eyes work, but the visual processors in the brain don’t), and is effectively blind — it seems he biopsied the mattress instead of the patient, but never realized it.

At this point, the differential diagnosis includes bacterial meningitis, “toxic mold“, Guillain-Barre Syndrome (a paralyzing disease following a viral infection or vaccination), and arbovirus infections (A large group of viral diseases which are carried by bugs. In fact, that’s where the name arbovirus comes from: arthropod-borne virus. Arboviruses include Yellow Fever, Dengue, and various encephalitis infections, including the Eastern Equine Encephalitis mentioned in the previous episode. Cameron is wrong; arboviruses are found the world over, not just in “Africa.”) There is evidence against all of these diagnoses, so House widens the suspected agents to any bacteria, virus, fungus, parasite, or toxin that might cause brain damage. House starts Foreman on a wide variety of antimicrobials, hoping one will work. Foreman is given levofloxacin (brand name Levaquin, an antibiotic), acyclovir (brand name Zovirax, an antiviral), and fluconazole (brand name Diflucan, an anti-fungal), plus five other unnamed drugs.

The medications seem to be working as Foreman’s symptoms improve and he regains his eyesight, but it is not clear which of the drugs is working. Foreman’s lipase and amylase (two enzymes found made by the pancreas) are significantly elevated, meaning that Foreman has developed pancreatitis (the team assumes it is from the meds, but it seems to me it could have been from the infection as well). House gives Foreman a choice (or at least pretends to): stay on the medications and die of pancreatitis in 4 hours (which seems mighty quick to die of pancreatitis), or stop the medications and die of the mysterious brain disease in 14 hours. Foreman chooses the latter and the medications are stopped.

House has also exposed his pet rat Steve McQueen to all the things Foreman encountered in Joe’s apartment, but Steve never develops the disease.

Foreman’s father arrives and House parades him in front of Cuddy, trying to guilt trip her into letting him perform the autopsy on Joe. Cuddy is no fool and knows what House is up to; she handles herself extremely well.

Since the antimicrobials have been stopped, Foreman has started developing symptoms of the brain disease again. Cameron and House notice that the disease is progressing faster in Foreman than it did in Joe. House reasons that this is because Foreman is too healthy, whereas Joe was infected with Legionella (the bacteria that causes Legionnaire’s Disease). House intentionally exposes Foreman to Legionella, hoping the subsequent infection will slow down the brain disease. It seems to work, though Foreman develops a nasty case of pneumonia,

House now wants Chase and Cameron to help him discover which infection commonly gives false negative test results (in other words, it doesn’t show up on the tests, even though the patient is infected) and infects humans but not rats. The team decides that it must be Listeria (a rare bacterial disease caused by contaminated food), so they start Foreman on ampicillin and gentamicin, two powerful antibiotics (and with serious infections, both are given intravenously, so why is House giving Foreman pills?). The risk is that the antibiotics will kill the protective Legionella too, and this might make the brain disease worse, particularly if House is wrong and it is not Listeria.

Foreman doesn’t believe that Listeria is the cause, and wants House to perform another brain biopsy, this time a deeper one of the white matter. House is reluctant knowing that there is a strong risk of permanent brain damage from such a procedure.

As Foreman’s pain increases to an unbearable level, it is decided to place him in a medically-induced coma. He asks Cameron to be his medical proxy (make important medical decisions in his place) while he is in the coma. Cameron demands the biopsy, but House still refuses. He talks her into waiting an hour, or until Foreman’s oxygen saturation (the level of oxygen in the blood) drops below 90%, for him to inspect Joe’s apartment one last time. House hunts down what appears to be a blind pigeon, then at the last minute discovers that Joe’s marijuana plants had been irrigated with water from a rooftop cistern, a cistern that is infected by the parasitic ameba Naegleria. He phones Cameron with the information, but she has already had the biopsy performed — which shows the same germ. Foreman is started on antiparasitic medications and brought out of the coma. He is recovering from the infection but the question remains whether the biopsy did any brain damage. It looks bad in the end when Foreman tries to move his left toes and arm, but moves his right side instead.

Naegleria is a very rare cause of disease is America. There were only 24 cases of human infection between 1989 and 2000. It is acquired by diving or swimming in a contaminated pool of water and having the ameba enter the nose and then into the brain. I’m not sure inhaling a fine spray of contaminated water runs the same risk. There is no definitive treatment for the ameba. There are some drugs that should work, but the patients usually end up dying anyway.

House’s statements about testing for antibodies instead of the bacteria itself are true — to a point. The most common test for bacterial infection is a bacterial culture — basically waiting for the bacteria to grow in a sample — and that usually takes up to 48 hours. For some rare bacterial diseases (tuberculosis, for example) and fungal diseases, a culture can take much longer — weeks in some cases. Antibody tests tell us only whether a person has ever had an infection with a particular germ, but not necessarily that an infection is going on currently. That usually takes repeat tests over several days.

I’m interested in how House and Cameron both managed to diagnose the ameba at the same time. Did House take a microscope with him to the apartment? He must have.

I am not a lawyer, but the whole medical proxy concept seemed screwed up in this episode. Cameron may have Foreman’s proxy, but that doesn’t mean she can overrule the attending physician like she did. She could refuse a test in Foreman’s name, but not order one. Later, it seems as if she is acting as the lead physician, which is a clear conflict of interest. She can’t be both lead physician and proxy at the same time.

Overall, the mystery was good and earns an A, the final solution was clever and I’ll give it an A-. The medicine as a whole earns a B, because while there were no major mistakes, there were enough smaller ones to knock the grade down. The non-medical aspect gets an A because the Foreman/father, Foreman/Cameron, and House/Cuddy scenes were all excellent.

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

I am in Chicago today through Sunday for a conference (not a fun conference; it’s a four-day “Board Review Boot Camp” to get me ready for my every-seven-year Family Medicine certification renewal, which is due this summer).

I’ve got internet access, I’ve got comics, I’ve got television, so posting will continue. It just may take me a little bit longer than usual to respond to comments and e-mails (and to rescue wayward comments from the spam queue).

In the Villains United Special, Toyman mixes the drugs Velocity-9 and Venom into the food at Blackgate prison and soon the prisoners — and even some of the guards — are rioting.

Velocity-9 is a drug designed by the villain Vandal Savage. It grants its users super speed, much like the Flash. However, as the drug wears off, it causes the user’s metabolism to dramatically increase, leading to dehydration and rapid aging. The only way to stop these effects is by taking another dose of the medication. Velocity-9 is also immediately addictive. Vandal Savage used this fact to his advantage by forcibly addicting rivals to the drug and making them work for him.

Velocity-9 exists in both injectable and oral forms. It first appeared in Flash #12 and has been featured in several Flash storylines. A modified version, Velocity-10, later appeared in The Titans #7 and #8.

Venom is the super steroid that gives Bane his powers. It grants enhanced strength and endurance. Over time, the drug increases aggression in the user. It also becomes addictive with repeated use.

To my knowledge, Venom has always been shown in the past as an injectable drug*; this is the first time it has been used as an oral medication.

The prisoners at Blackgate have super speed, super strength, and enhanced endurance. They may be showing some increased aggression from the Venom, or they could just be hot tempered by nature. They should all addicted be to Velocity-9 now as well, and maybe even Venom.

*In the Batman Beyond TV series (and maybe the comic as well), Venom was used in the transdermal “Slapper” patches, but that can’t really be considered in continuity.

In Checkmate #1, the team is hunting for the source of a recent Cyclosarin attack. Cyclosarin (also known as GF) is a real world nerve agent — or “weapon of mass destruction” if you prefer. As the name suggests, it is based on the nerve agent Sarin. It was discovered by German scientists either during World War II or shortly thereafter (sources vary).

The affects of Cyclosarin are identical to those of Sarin, including runny nose, chest tightness, pinpoint pupils, nausea, drooling, and difficulty breathing. This is followed by uncontrollable muscle twitching, paralysis, loss of consciouness, and ultimately death by respiratory arrest.

Cyclosarin is more stable than Sarin, but it has some drawbacks. Cyclosarin occurs only as a liquid and does not vaporize easily so it cannot be used as a gas. It is less potent than Sarin and much more expensive to produce. Iraq is the only nation known to have used Cyclosarin, and that was back during the Iran-Iraq war in the 1980s.

Generation M #5 (of 5)
Paul Jenkins, writer
Ramon Bachs, penciler

Miinie, the young daughter of reporter Sally Floyd, is in the hospital in critical condition. An alarm suddenly goes off and a team of doctors rushed in.

Doctor: Get the crash cart! Three cc’s of Lithium Dioxide! And call Dr. Randle!

I have no idea what this doctor is thinking. Lithium dioxide has absolutely no use in medicine. Lithium carbonate (and similar lithium salts) are used medically, but only to treat mood disorders such as mania and bipolar. There’s no reason to use it in an emergency situation.

As far as I can tell, Lithium dixoide is used in batteries and as a catalyst in certain chemical reactions. Not in medicine. (And can someone who’s better than me at chemistry explain what difference there is — if any — between lithium dioxide and lithium superoxide. Both have the same chemical formula LiO₂.)

Admittedly. things my be different when running codes on age-regressing critically ill mutants. I must have missed that day at med school.

Time for another look at what strange internet searches have led people to Polite Dissent over the past two months. Here are a selection of some that cuaght my eye (as usual, my comments are in green italics).

Frequent Searches:

• Hawk and Dove
• Wormy by Dave Trampier
• Tanith Belbin
• Scottie from Mythbusters
• “We Make Holes in Teeth”

Medically-related Searches:

• Bleach accidentally injected into bloodstream How exactly does one “accidentally” inject bleach?
• Discharge plan for unconscious patient with head injury Well for starters, I wouldn’t discharge them until they woke up.
• Why does the gallbladder cause pain in the upper right hand corner under the ribcage? Because that’s where it is located: under the liver in the upper right hand quadrant of the abdomen.
• Can a woman fall pregnant if she had a pacemaker inserted and her husband has recovered from a stroke 3 years ago/ If she’s having unprotected sex, yes.
• Are b12 injections good for you? If you have a B12 deficiency. Otherwise, they’re pretty much a placebo.
• Temperature scales for normal human body kelvin Strange question, but the normal human body temerature in Kelvin is 310.
• The subtance in the fluid lining the alveoli that prevents their collapse Surfactant

Comic Book-related:

• Spider-man comic aunt may is sick That narrows it down to about one hundred and fifty different issues.
• How to draw and create my own comic book of heroes and violins This one speaks for itself, musically.
• How to shoot heat vision from your eyes I wasn’t sure if this was medical or comic related.
• Unknown soldier hush See, I’m not the only one who thought so.
• Rudolph the red nosed reindeer with tusky I’d like to see this too.

Television-related Searches:

• We’re leaving mother earth save human race Those would be from the lyrics to the opening theme from the first season of Star Blazers
• cuddy and cameron wedding fanfiction I’m confused — are Cuddy and Cameron marrying each other? Because I find that hard to believe after the way Cameron cut her down to size last episode.
• kim possible and ron stoppable pregnancy and graduation stories fan fiction I just find it interesting that the pregnancy comes before graduation.

“I Have No Idea What On God’s Green Earth They Were Looking For” Searches

• uterus polite
• caveman voodoo convents

“Scary Thoughts” Searches

• homemade defibrillator
• o negative blood groups and alien connections

Dawn e-mailed to ask about an editor’s footnote in the final volume of the manga Marmalade Boy which reads, “In Japan, the normal length of a full-term pregnancy is considered to be 10 months, not 9 months.”

That footnote is correct: Traditionally in Japan, pregnancies are considered ten months long.

Now, it’s not that Japanese women are pregnant a month longer than non-Japanese women, but instead it all comes down to semantics.

According to the Gregorian calendar, where months range from 28-31 days, this means the average pregnancy lasts a little over nine months.

On the other hand, if you’re counting the more traditional lunar months of exactly 28 days (i.e. 4 weeks), then 40 weeks = 10 months. The Japanese belief that a pregnancy lasts ten months refers back to their original calendar that used these shorter months.

So:

(And just to further confuse thing, the classical phrase regarding a pregnancy in Japan is totsuki tooka, which actually refers to a length of ten months plus ten days)

• A piece of Japanese art from 1882 titled “Knowing the blessings of one’s parents.” This is a niece piece from the collection of the University of Kansas Medical Center and shows the ten-months of pregnancy (remember to read form right to left).

A very somber (but sadly, not sober) episode this week. As usual, there are significant spoilers for this week’s episode of House ahead, so don’t come crying to me claiming nobody warned you.

A husband returns home to find his wife Kara have a seizure in the bathtub and their four-week old son Mikey drowning. By the time they reach the hospital, Mikey has resumed breathing and Kara has stopped seizing. Mikey is taken to the neonatal intensive care unit (NICU), where Chase happens to be working. Kara’s case is tackled by House, Cameron, and Foreman. Her calcium is elevated, and the initial concerns are hyperparathyroidism, cancer, and a “calcium-mediated neurotoxicity” — but apparently all those were ruled out in the ER. The next diagnoses considered include polyarteritis nodosa (a rare inflammation of blood vessels), Whipple’s disease (a rare type of bowel infection), a Strep infection, and vasoconstriction (a sudden narrowing of important arteries). The Strep test is negative, and when she is undergoing angiography, Kara suffers some sort of massive muscle contraction/seizure.

Meanwhile, Mikey’s oxygen levels suddenly drop. Chase listens to his lungs and diagnoses a collapsed lung (pneumothorax). He performs a needle thoracostomy and then acquires x-rays. He thinks the x-rays show a chemical pneumonitis (an inflammation of the lungs caused by an inhaled — or swallowed — irritant), but House disagrees and thinks the x-rays look like a bacterial pneumonia. He suggests placing Mikey on antibiotics and ECMO. Chase decides that House must be correct and starts the antibiotics and ECMO (extracorporeal membrane oxygenation — a big machine that oxygenates the blood and removes carbon dioxide).

In terms of Kara, the doctors are now considering a lithium toxicity and a myelogenous meningitis (a rare complication of leukemia where the cancer cells invade the lining of the brain). An MRI shows no brain tumor, but it does show a subarachnoid hemorrhage. It turns out that Kara has a bleeding disorder and her blood is not clotting as well as it should. Foreman’s search of Kara’s apartment turned up no lithium, but it did show a hidden bottle of vodka. When the team discovers that Kara is a former alcoholic, House suspects that she started drinking again and is now suffering from delirium tremens (a dangerous form of alcohol withdrawal). The liver damage from the alcohol would cause her bleeding problem (though they never seemed to run any liver tests). Foreman thinks it may be a conversion disorder, basically her body is having seizures to cope with the severe stress in her life. House overrules him and they place Kara in a phenobarbital coma to essentially sleep off her delirium tremens.

Kara’s feeling better when she awakens from her coma, and she is delighted to see her son (who appears fully recovered) and her husband. A short time later, House discovers her trying to suffocate Mikey. Chase resuscitates the baby and rushes him back to NICU. The team is now concerned that Kara has postpartum psychosis, especially after she admits that she hears voices telling her to kill her son. To ensure there is not some other neurological condition going on as well, they attempt to cause a seizure in her with sleep deprivation and strobe lights. Ultimately they succeed in setting off an atypical seizure that causes them to think that Kara is suffering from some sort of progressivedelirium. The possible diagnoses at this time includes Wernicke’s Encephalopathy (neurological disease caused by a severe thiamine deficiency – common in alcoholics), lithium toxicity, Whipple’s Disease, and pellagra (neurological disease caused by a severe niacin deficiency). Pellagra is the best fit, so they start her on niacin supplementation.

In the NICU, Mikey is not doing well. The lack of oxygen has severely damaged his kidneys and he has developed hyperkalemia (high potassium). Chase tries medication to bring the potassium level back to normal but it doesn’t work, and Mikey suffers a fatal arrhythmia (an abnormal heart rhythm — ventricular fibrillation in this case).

Kara is not improving despite the niacin, and complains of stomach pain shortly before vomiting blood. House has an idea but needs an intestinal biopsy. Because he suspects a disease that has a genetic component (and because Mikey has been breastfeeding and essentially eating the same food as mom), he can test the baby. A post-mortem examination of Mikey’s intestine reveals celiac disease, an autoimmune disease tied to eating food with gluten (wheat protein). This has caused malabsorption of vitamins (niacin, leading to pellagra and vitamin K, leading to a clotting disorder) as well as led to the development of a stomach cancer.

As the episode ends, both Kara and her husband are trying to come to terms with their son’s death — and having a hard time of it. Foreman is struggling to regain the skills he lost, and did I mention that Cuddy is looking for a sperm donor?

Kara’s medical care wasn’t that bad, but the pediatric medicine was sub-par. First, Chase is an adult intensivist, not a neonatologist, and the two are not interchangeable. Second, why did Mikey develop a pneumothorax? Infection (or pneumonitis) are not causes of a collapsed lung. Third, speaking of a collapsed lung, a needle thoracostomy is for treatment of a tension pneumothorax, not a spontaneous pneumothorax. The needle simply converts the tension pneumothorax into an open pneumothorax, which they neglected to treat. Fourth, I know ECMO machines look cool, but pneumonia is not an indication for using one (though bacterial sepsis can be an indication).

In terms of Kara’s treatment, isn’t it ironic that she was found to have a cancer after we were told in the beginning that the ER had categorically ruled out cancers? For Foreman, I’m glad to see he’s recovering, albeit slowly, but why is everyone convinced it was the biopsy alone that caused his problems. Meningitis takes at least a month of convalescence (which does not include going to a stressful job) before a person is anywhere near recovered. Finally, shame on House and Wilson (especially Wilson, as an oncologist he should know better). Tumor markers can be used to follow an established cancer or to check for a recurrence, but have no use in screening for tumors (except maybe the PSA — prostate specific antigen — in men, and even that’s open for debate).

The mystery was interesting and gets a B and the solution logically followed, earning a B+. However, the medicine and in particular the pediatric medicine was bad enough that I can’t give a higher grade than a C-. The soap opera component, particularly the Wilson/Cuddy “date”, had potential and deserves a B+.

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

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

Generally, I ignore Grant Morrison’s more eccentric declarations and ideas. Every once in a while though, there is a statement that I simply cannot ignore and must address. Seven Soldiers: Frankenstein #3 contains such a statement.

It would be understandable if you thought Dr. Emoto was a creation of Morrison’s. His name does have that comic book ring to it. However, Dr. Masuru Emoto is a very real person (or at least Emoto is real, the “doctor” part is the subject of some controversy*).

Emoto claims that when positive or negative thoughts are directed at a sample of water, and that sample is then frozen and thawed, the resulting ice crystals differ on whether the thoughts focused on the water were good or bad. Positive thoughts result in beautiful ice crystals, while negative thoughts result in ugly misshapen ones. Emoto has even gone so far as to claim that positive or negative words taped to the water container can have the same effect.

Sadly, there’s not one iota of science supporting his claims. It’s all sloppy pseudoscience and wishful thinking. His results are nonsense for several reasons, but let me focus on the two main ones.

1. Science is independently reproducible. Given the same equipment and training, anyone should be able to reproduce experiments and gain the same results. In legitimate science, this happens. When it doesn’t, we become very suspicious — to say the least. No other independant researcher has been able to reproduce Emoto’s results.

Before you believe any research touted on the news or internet, wait and see if the results can be legitimately reproduced by other researchers. If they can’t, don’t bother wasting your time on the claims.

(This replies to all science: if it’s not reproducible by others, it’s likely that something fishy is going on. Consider cold fusion that we all heard so much about a few years ago but that has now been relegated to “might-have-beens.” Or more recently the Korean cloning scandal. Neither of these experiments were reproducible and both ultimately were shown to be false in large part).

2. Science experiments are designed to eliminate — or at the very least minimize — bias. Emoto’s experiments don’t avoid bias, instead they welcome it. His studies are not randomized and not blinded. He knows before looking at crystals which sample he is looking at and whether it is positive or negative; he knows what results he wants to find. Consciously or unconsciously this leads to a selection bias.

Personally, I wonder about positive and negative words. It seems to me that the same words can have different connotations depending upon the situation and the observer. For example, what if I taped the name “Osama bin Laden” to a glass of water? To me and most Americans, that would be a strongly negative word. To certain Muslims though, his name is regarded postively. So which crystals would form, beautiful or ugly? Same goes for “Tom Delay,” “Abortion,” or “Reaganomics” — who’s to say which are positive or negative? Even emotions are not so clear cut. What if I taped the word “love” to a glass of water? Certainly love can be a beautiful thing, and it usually is. But what about the love of an alcoholic for his liquor, or the love that causes an abused spouse to return to their abuser, or a misguided love that leads to murder. Love is not always good (nor hate always bad).

More Information:

• The Wikipedia article on Masura Emoto
• Randi on Masura Emoto’s Experiments (second story down).
• Images of the Emoto’s Water Crystals ( warning – this site features very suspect medical advice — but pretty picturesof crystals ).

*Emoto earned his degreee from the Open International University for Alternative Medicine whose doctorate program requires one year, five “papers”, and $350.

Somebody please explain the recent Warlord mini-series to me. I can’t be the only one who thinks it’s a complete mess and a disservice to a character with a respected pedigree.

The original Warlord by Mike Grell was great. It was a fun pastiche of Burroughs, Howard, Kane, and Stoker (but mostly Burroughs) that never failed to enterain, particularly the issues drawn and written by Grell himself. Travis Morgan is the epitome of Grell’s über-masculine characters, later seen in his runs on Green Arrow (still my favorite take on the character) and Jon Sable, Freelance. Morgan’s shown up once or twice since the demise of his series, first in Green Arrow (in a classic storyline where everyone tries to kill him because they think he’s Ollie), a second time in a six issue 1992 mini-series, and then more recently in a storyline in Aquaman (Dan Jurgens’ run towards the end of the 1994 series). (And how could I forget Justice League Unlimited?)

The new Warlord, by Bruce Jones and Bart Sears, is wrong on so many levels. The story is paper thin and even that has already been stretched out for too many issues. Characters who were once complex and interesting are now two-dimensional caricatures (oh how I miss thee, fur-clad Tara). Morgan no longer feels lost in this strange new world, but is smugly confident that he can conquer it from his first appearance. To top it off there’s the addition of that cheapest of fantasy plot devices: the prophecy — and one that Morgan just happens to fulfill. It’s like Strange all over again, only without the nice Brandon Peterson art (I normally like Sears’s unique take on human anatomy, but this series just isn’t working for him. The action is messy and hard to understand, and the art is entirely too sketchy. He needs a bold inker; add him to the list of pencilers who should not ink themselves).

I would welcome Jones and Sears working on a Warlord series that builds upon Grell’s, but why start over when the new version offers no improvement upon the original?

We need a new way of looking at continuity. It seems to be me that there needs to be a standardized score given to comics rating their continuity requirement. That way a new reader (or even an established one) will know before a comic or storyline starts exactly how much backstory they are required to be familiar with to enjoy and “get” the story.

Therefore, I am proposing a standardized unit for scoring comic book continuity. I suggest we call it the Geoff (abbreviated G). The standardized unit will be set as equal to Silver Age Batman. Therefore 1 Geoff (1G) is equal to the amount of continuity required to enjoy Silver Age Batman.

The Geoff score is set on a straightforward scale. A comic with a score of 2G required twice as much knowledge of continuity of a 1G comic. A book with a 0.5G score requires half as much knowledge.

At the basic score of 1G, the reader should be familiar with the main characters and their back-story, as well as familiar with the main villains and a little of their history. Only minimal knowledge of specific past storylines is required.

A story that that has recurrent characters with minimal backstory and no required knowledge of previous issues would be about 0.5G. These would include most children’s comics such as Bugs Bunny and Mickey Mouse, as well as many Golden Age comics.

Stories such as Scott Pilgrim or the initial Ex Machina storyline, which require no previous knowledge, have a continuity score of 0G. Generally, these scores don’t last long as backstory is fairly quickly accumulated, raising the scores for subsequent storylines to 0.5G or even higher.

At the other end of the scale would be the James Robinson’s Starman, Geoff John’s JSA, or pretty much any non-Conan story by Roy Thomas. These comics would all earn continuity score in the 3-4G range, depending the particular storyline. Most of Claremont’s X-Men stories would be in the 5G range, as would a large chunk of Legion of Super-Hero series.

Personally, I think this score should be displayed prominently on the cover (next to the S.C.R.U.B.S. score for Batman storylines, of course).

The Geoff Score is a surprisingly flexible concept:

• There could be negative scores. These would be given to stories that purposefully throw out or ignore previously established continuity. Some readers would view these scores as a good thing, while established readers probably won’t. Strange would be a good example of a comic with a negative G score.
• Just like computer games, dual ratings could be given for certain books. There would be the “Minimum Continuity Requirement” and the “Recommended Continuity Requirement.” For example, take a look at Sandman: The Doll’s House. For basic enjoyment, little knowledge is required other than who Morpheus himself is, so the minimum requirement at 0.5G. However, to fully understand all the intricacies of the storyline, it helps to know who the Silver Age Sandman was, who Hector and Lyta Hall were, and even who Matthew Cable was. This increases the Recommended Continuity Rating to 3G. So Sandman: The Doll’s House would be rated at 0.5G/3G.

Ealier this week, I was talking about the use of prophecies in literature. Almost every fantasy story seems to have one — I suspect there’s a law on the books somewhere requiring their use, much like the castles on the grounds of Illinois state-funded colleges — and they rarely add anything to the story. Below are a list of what I consider good and bad use of prophecies (and I’m being loose in my definitions here, considering almost any sort of foretelling a prophecy). Feel free to add in your thoughts…

Good:

• Oedipus
• Micronauts
• Krull (in this otherwise forgettable movie, the scene where the cyclops knew he was going to die and rides out to meet his death.)
• Lord of the Rings (no man can kill the king of the Nazgûl)

Bad:

• Warlord
• Strange
• The Matrix
• Books by David Eddings
• Conan the Destroyer
• Anything attributed to Nostrodamus or Sylvia Brown

Somehow I never Superman for much of a muscial theater buff — but making a Lerner and Loewe joke while flying in to rescue Lois — that’s impressive.

So, does this make Superman Henry Higgins?

A year after Marvel Comics published the Heroes for Hope comic, DC Comics published a similar comic: Heroes Against Hunger. Organized by the same two people, Jim Starlin and Berni Wrightson, this is another “jam comic” by dozens of famous comic book writers and artists published to raise money for, and awareness of, the famine in Ethiopia.

The plot is delivered over 48 pages, with every artist and writer handling two pages apiece. Superman is delivering tons of topsoil to famine-ravaged Ethopia, but is shocked when his latest shipment is destroyed. Batman is also in the area looking for clues as to who is shooting down several Wayne Foundation cargo planes carrying food. The two heroes discuss the situation and formulate a plan: Superman will look into the destruction of the planes while Batman heads off to talk Lex Luthor, who has developed a super plant growth formula.

Superman discovers an un-imaginitively named villain, the Master, who derives his power from human misery and despair. He’s the one who’s been destroying the planes and ruining Superman’s efforts. Meanwhile, Batman is able to convince Luthor to help them by pointing out that if his formula works, the world will know that he succeeded where Superman failed.

Working together, Batman , Superman and Luthor are able to defeat the Master. They now work to put superpowers and super-science together to halt the famine. Superman lays down more topsoil and Luthor uses his plant growth accelerant, but nothing happens. A local Peace Corps worker chides them for their efforts, pointing out that it took years of bad faming for the famine to develop in Ethiopia, and it will take years to fix thr problem. The comic claims it ends on an up note, but it’s really more of a downer than anything else.

Unlike the Marvel book, there is an actual villain here for the heroes to vanquish. Of course, he’s not the cause of the famine, he’s just along for the ride, so defeating him really doesn’t accomplish much. In the end — just like the X-Men in Heroes for Hope — Superman, Batman and Luthor are defeated by the famine.

The art is classic and the individual pages of storytelling are well done. Despite this, like its Marvel counterpart, the comic just isn’t that good a read. The villain is rather lightweight and the story seems padded out to reach 48 pages. It’s also a depressing subject. That’s not meant as a criticism, just a fact. Even today, twenty years later, the famine in Africa remains a serious problem with no simple answers. This makes it a legitimate cause for concern and action, but not a very good basis for a comic book storyline.

Apparently Superman’s not the only one with a taste for Broadway. Here’s Lex Luthor — in his battlesuit even — letting loose with a little improptu song from Oklahoma!

An underwhelming episode of House this week. There are spoilers below, but not the “big one” (is he or isn’t he?) so you can still watch the episode. (Feel free to mention it in the comments though, as it is an interesting situation.)

I didn’t particularly care for this episode of House. The main plot — House’s old friend and whether or not he was the girl’s father — did little for me. The medicine was uninspired as well. The team just lurched along from diagnosis to diagnosis with little reason, like a drunk stumbling down the street. That’s not to say the episode didn’t have its charming moments. The sperm donor scenes with Cuddy were good and seeing Wilson jealous over the fact that House actually has another friend was quite enjoyable.

Let’s start at the beginning: Crandall, one of House’s old friends, is flying on a plane with Leona, a teenage girl who claims to be his daughter. She was a victim of hurricane Katrina and has basically been living on the streets until recently. On the plane, she suffers a sudden intense hallucination and then collapses.

House and the team are called in to assess Leona. They are told that she has suffered cardiogenic shock (but it’s never explained how this conclusion was reached), but that it was not caused by a heart attack. The ER also managed to rule out toxins, infections, and Wolff-Parkinson White (a heart condition that can lead to a potentially dangerous heart rhythm). The team settles on the diagnosis of an arrhythmia. Leona must have experienced a bad heart rhythm which led to her hallucinations as well as her collapse.

An electrophysiology study (which looks at the electrical conduction within the heart) is performed and they find a spot in Leona’s heart that induces both an arrhythmia and a hallucination. The abnormal area of the heart is frozen to prevent the arrhythmia from recurring and the team believes that they’ve solved her problem. However, we know better as it’s only twenty minutes past the hour.

Despite the treatment, Leona suffers another hallucination. House wonders if it might be an atypical seizure or post-traumatic stress disorder. Then he decides that it must be an autoimmune disease that is causing her to interpret pain as hallucinations. The team straps her into a PET scan machine and House hurts her until she has a hallucination. He is now absolutely convinced that she must have a bad autoimmune disorder. Never mind which one, just know that it’s really bad! And it needs treatment now! Not the normal treatments like steroids or immune suppressants but instead she must have a bone marrow transplant at this instant! Anyway, as she’s undergoing radiation therapy to burn out her bone marrow so she can receive a transplant, House notices a black slime oozing from her mouth. It turns out that this is a combination of feces and partially-digested blood. This means that Leona has some gastrointestinal bleeding as well as a lower intestinal blockage which is causing things to “back up.”

House and team immediately decide that this means Leona has liver failure and she needs an immediate liver biopsy. Just as Chase is ready to perform the biopsy, House tells him to stop. Leona’s grandfather was a great jazz pianist and House has been in his office listening to one of his old jazz sessions. From this recording, House is able to determine that her grandfather had mental problems, hearing damage, and a history of liver disease. Putting this together with Leona’s presentation, House and Cameron deduce that Leona has hemochromatosis, and inherited form of iron overload. She is started on deferoxamine, an intravenous medication that removes excess iron from the body. Strangely, this treatment causes severe lung damage and Leona is placed on a ventilator. The team suspects the iron must be combining with something in her lungs to cause problems; they consider bacterial infections and neurodegenerative diseases, but then settle on fungus. First they suspect Aspergillus, but it doesn’t respond to therapy, so they realize that it must be a different fungus and finally diagnose Zygomycosis. Some IV therapy with Amphotericin B and Leona is ready to start her new life with her “father.”

The criticism: Medically, the arrhythmia diagnosis makes good sense, though the hallucination aspect is reaching. But to jump from that to a super-severe yet vague “autoimmune disorder” makes no sense. (I suspect the writers know this too as they never name the disease and just leave it vague). And then even if it is an autoimmune disorder, why jump to bone marrow transplant, an unproven (though apparently promising) treatment? The risks/benefit ratio is just too high. Now suddenly we’re told that it’s liver failure. Gastrointestinal bleeding and blockage could be due to many other conditions and Leona’s shown no other signs of liver failure. How about at least running some blood tests or an abdominal CT before a biopsy? Now the diagnosis is hemochromatosis. This one is at least logical, and diagnosing it through her dead grandfather is clever. But suddenly the treatment causes lung damage. Notice how the writers tried to pull this off: When deferoxamine is first introduced we’re told (correctly) that it is processed through her kidneys. Later, when the script demands, Chase reminds House that it is processed through “waste” (his vague term) and House then mentions that her waste system is messed up. No, her liver is messed up — her kidneys are still fine, and this bad plot-convention medicine hurts my head.

A few nitpicks too: Why is Chase performing the electrophysiology study? That takes a specially trained cardiologist. Why is Leona wearing EEG leads on her head the entire episode? Phlebotomy (repeat blood draws) is the recommended treatment for hemochromatosis, not deferoxamine. Deferoxamine is only used in very rare instances (when phlebotomy is not feasible or there is severe heart disease). If the team had used Amphotericin B for the Aspergillus — which is the recommended first line treatment — they would’ve covered the Zygomycosis too. And finally, Cuddy needs subcutaneous shots, not intramuscular ones, at this stage in IVF.

This episode gets a C for the mystery (just average) and a B+ for the final solution. The medicine earns a C-, below average and just plain wrong in several places. The soap opera aspect (at least the scenes with Cuddy and Wilson) redeemed the storyline somewhat and earned a strong B+.

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

Still want more great medical reading? This week’s Grand Rounds — the best medical blogging of the past week — are being hosted by Dr. ibear over at Doc Around the Clock. As usual, there’s an incredible amount of fascinating reading. And did I mention the art?

This is the famous scene from the Superman newspaper strip where Clark Kent is denied entry into the army because he is “blind as a bat.” It seems that he got so flustered during the physical exam that he accidentally used his x-ray vision and read the eye chart in the room next door.

A couple of thoughts:

• Superman can fight aliens and super-villains without batting an eye, but gets so preoccupied by a physical exam that he doesn’t realize he’s using his x-ray vision? If that’s the case, it’s probably a good thing he didn’t get in the army because he’s likely to send his men right into the middle of an enemy encampment he missed while accidentally using his x-ray vision.
• Eye charts are fairly standardized, so even if Clark read the wrong one he should still get the letters right. Even if the clinic wasn’t using the now standard E FP TOZ chart, I think it’s safe to assume that they would have purchased all their charts from the same company (the low bidder naturally) and they would have all been the same.
• Look at the first eye chart. Even seen one like that? JKLMNO PQRS. And then the next three lines are the entire alphabet from A – Z. Just get the first couple of letters right, and you can guess the rest of them easily. Makes it way too easy to miss someone with poor vision and have them end up in the infantry (of course, given that this is during WWII, that might be the army’s intention).
  Take home message: eye charts are specifically designed with certain letters, not just a random sampling. Notice how difficult it is to tell F from E or P, or O from C or D in the smaller lines? (The eye charts in our office only use the letters CDEFLOPT and Z)
• Make sure you check out Brian Cronin’s Comic Book Urban Legends Revealed #49 over at Comics Should Be Good. He addresses this very scene.

An easy one today, so no hints. What’s wrong with this picture?

From Doc Samson #4, words by Paul Di Filippo, art by Fabrizio Fiorentino

• Other Picture Quizes

The American Way #3 “Book Three: Let the Word Go Forth”
John Ridley, writer
Georgen Jeanty, penciler

In the middle of the issue, the super hero Secret Agent confronts a murderer at the site of his crime. The killer is holding a young boy hostage, but that doesn’t slow down the Secret Agent: he fires a bullet that ricochets around the room before clipping the murderer in his back.

Narration by Secret Agent: I crease the guy easy. Hit him right in the T7 vertebra. He’ll be a quadriplegic for the rest of his sorry life.

Just one problem there, Secret Agent: a spinal cord injury at T7 leads to paraplegia, not quadriplegia.

The spinal column is made up of 5 sets of vertebrae. The cervical vertebrae (C1-C7) are in the neck, the thoracic vertebrae (T1-T12) are in the upper back, the lumbar vertebrae (L1-L5) are in the lower back, followed by the 5 sacral vertebrae (which in most people are fused together), and finally the coccyx (or tailbone).

The spinal column protects the spinal cord. As the cord moves down from the brain, a pair of spinal nerves split off at the level of each vertebra. These nerves innervate different parts of the body depending on which level they are from. For instance, the C2 – C5 nerves innervate the neck and the back of the head. C5 also supplies some of the nerves to the hand and arm, as do C6, C7, C8, and T1. The thoracic nerves innervate the chest and abdomen. The lumbar nerves innervate the lower back and along with the first two sacral nerves (S1 and S2), supply nerves to the legs.

When a spinal cord injury occurs, it wipes out everything below the injury, but does not affect nerves that split off higher than the injury. A T7 injury would lead to paralysis of the legs and lower trunk and loss of feeling below the rib cage, but it would not cause quadriplegia.

*There are seven cervical vertebrae but eight cervical spinal nerves. Why? Because that’s how they were named. Just one of those wonderful bits of knowledge you learn in medical school.

Let’s look at what we know about Thomas Wayne:

• Wealthy ¹
• Physician ²
• Philanthropist
• Husband of Martha
• Father of Bruce
• Frequent player in Batman storylines

It’s the last item that I’d like to discuss. Thomas Wayne is used in too many storylines; he’s become a crutch of the bat-writers . I suspect they think it makes them clever — and once that might have been true — but now it just makes them cliché.

Their approaches to Thomas Wayne are contradictory too. In the previous Batman: Legends of the Dark Knight storyline, a reporter published a book on the Gotham City Ripper and claimed that it has been Thomas Wayne. Bruce had no doubt that his father was innocent and set out to find the real killer. However, in the current Batman: Legends of the Dark Knight storyline, a hidden room is discovered at Wayne Manor. Bruce’s first thought: “My father was a junkie.”

Make up your mind DC: did Bruce believe in his father or not (I vote yes). Pick one and stick with it.

I’d like to suggest a moratorium on all stories concerning Thomas Wayne. At least until 2010. Let the poor man rest in peace.

(And what about Martha? You never see her except in visions/dreams/nightmares Bruce has of both his parents. The only time she’s played any sort of role in a story was the Batman Family mini-series from three years ago).

²Exactly what sort of doctor was Thomas Wayne? It’s frequently suggested that he was a surgeon, though he’s usually shown acting more as a primary care physician.

This is the a look at the medicine in the fifth chapter of Naoki Urawawa’s Monster. Annotations for chapter one can be found here and here, chapter two here, chapter three here, and chapter four here.

There are three major plot events in this chapter: the police look into the murders of the three senior physicians at Eisler Memorial Hospital, the twin children escape from the hospital, and Dr. Tenma finds himself promoted to Head of the Surgery Department.

Medically, it was fairly uneventful except for these two (unrelated) items:
1. A patient was noted to have suffered a brain contusion¹.
2. The police revealed that the dead physicians had all been poisoned with nitrate².

2. Dr. Tenma identifies nitrate as a muscle relaxant, but that’s not quite true. There are two types* of muscle in our bodies. First, there is skeletal muscle (also known as striated muscle). This is what most of us think about when we hear the word muscle. These are the muscles that we voluntarily control, and they are the muscles that help us move our arms, legs, mouth, etc.

The second type of muscle is smooth muscle. We have no conscious control over these muscles, and that’s why they’re also known as involuntary muscles. Smooth muscles are important for the inner workings of our body. For instance, they surround blood vessels and the gastrointestinal tract. They are controlled by the autonomic nervous system.

The class of drugs known as nitrates relaxes smooth muscles. By relaxing the smooth muscles surrounding the blood vessels, nitrates cause vasodilatation — the drug relaxes the blood vessels and allows them to open wider and carry more blood. This lowers the blood pressure, and in fact nitrates were some of the first effective medications for high blood pressure. In addition, this relaxation of the blood vessels allows more blood to get to the heart muscle itself, and that’s why nitrates are used to treat heart attacks and angina. However, too high a dose of nitrates can drop the blood pressure too low. This can lead to loss of consciousness and even death if the dose is high enough. Common nitrate medications include nitroglycerin, isosorbide mononitrate, isosorbide dinitrate, and nitroprusside.

*technically cardiac muscle is considered a third type of muscle as it shares characteristics of both the smooth and skeletal muscles.

From Airboy #21 (May 1987) comes a PSA celebrating the 200th anniversary of the U.S. Constitution. It does this by playing up a court case that occurred in 1969 (Tinker v. Des Moines Independent School District) and appealing to the sympathy of students (but I wonder how many students actually read Airboy, it always struck me as more of an adult nostalgia title — though a well-written one).

Personally, I’m impressed that the school principal seems to be arguing his case in front of the Supreme Court. Maybe the school district would have won if they’d actually hired a lawyer.

There’s a big nasty spoiler in this week’s review of the season finale of House, so do not read this if you haven’t watched the episode. No really, I’m serious — turn on your VCR or Tivo and watch it before reading any more. And that means you, Jessica.

House and his team are discussing the case of a patient with a swollen tongue and a fever of 103° when a man comes in looking for House. As soon as he finds out which physician House is, he shoots him in the abdomen and then the head.

House wakes up in the intensive care unit. By the growth of his beard, he assumes he has been unconscious for two days. Cameron informs him that the first bullet went through his stomach and bowel before lodging in a rib. The second bullet entered his neck and nicked his jugular vein.

The tests on the patient with the swollen tongue are negative. A tongue biopsy showed no cancer or abnormal cells and all blood tests were negative. The patient’s intracranial pressure is high, which means it is dangerous to perform a lumbar puncture because the brain might herniate. House suggests that the team perform a biopsy of the lymph node under the patient’s jaw.

The man who shot House is placed in the ICU in a bed next to House. It turns out that his wife was a patient of House’s. House cured her problem, but in the course of her treatment, House discovered that her husband had been unfaithful and relayed this information to the patient. She later committed suicide and this man now holds House responsible (or at least partially responsible) for his wife’s death. Anyway, as House is ambling around the hospital, he notices that his leg is feeling better. He begins to wonder if this may be because the surgeon screwed up and somehow injured his peripheral nervous system.

Meanwhile, the patient’s tongue has swollen so much that it makes it difficult for him to breathe and a tracheostomy is performed. Foreman notes that the patient has been on broad spectrum antibiotics but it has made no difference in his symptoms. House tells them to go ahead and perform the lumbar puncture even though the pressure is high. The lumbar puncture results are completely normal and there is no elevated pressure. However, after the procedure is over, when Chase and Foreman flip the patient over, they discover that he is bleeding behind his left eye, and bleeding with enough pressure to enucleate the eyeball (pop it right out).

During the procedure, House has been talking to the patient’s wife, but he has somehow ripped his stitches open and started bleeding again. He collapses onto the floor.

The team’s diagnosis of the patient now includes a bleeding disorder, a sinus mass from Wegener’s Granulomatosis, or something wrong with the blood-brain barrier. The team elects to biopsy the blood-brain barrier and to start the patient on mebendazole (a anti-worm medication), and levofloxacin (brand name Levaquin), and azithromycin (brand name Zithromax) — both fairly broad spectrum antibiotics.

When House realizes that the patient does not have a wife and no one else saw the woman he was talking to, he realizes he has been hallucinating. He obtains his operative report and is puzzled to discover that the surgeon used ketamine on him instead on standard anesthesia (Ketamine causes a dissociative state The patient can still experience pain, but cannot react to it, or really react to much of anything at all; it’s as if the mind and body are separate. Ketamine is commonly used as in veterinary surgery and as a date rape drug). When he confronts Cuddy about this, she tells him that research from Germany has suggested that chronic pain can be treated by inducing a coma and she decided that House was a good candidate for this.

The blood-brain barrier biopsy is negative and the patient continues to run a high fever. The team wonders if the patient may have some sort of foreign object lodged inside his body somewhere. Chase is helping the patient to the bathroom when the patient’s scrotum becomes so full of blood it explodes. The group is now concerned that patient might have testicular cancer.

House continues to have hallucinations, this time involving and argument with Wilson and Cuddy and a fight with Wilson.

The patient does not have testicular cancer. A cystoscopy is also negative. House now considers the diagnoses of bacterial prostatitis or prostate lymphoma. All the prostate tests come back negative. Now House wants to perform another surgical biopsy on the patient, this time using some sort of advanced robot as a surgery aid.

House continues to notice hallucinations and memory lapses. He starts to suspect that everything has been a hallucination, even when he wasn’t hallucinating. He confronts his team as they are performing the surgery and purposefully botches the procedure, killing the patient. This jolts him out of his hallucination and he wakes up as he is being wheeled to the emergency room just after suffering two gunshot wounds.

Notice the green text in the above description. Those were the only parts that were real. All the black text in between was a hallucination. Because it was all a hallucination, it doesn’t matter if the medicine was bad (which much of it was — ridiculously bad) since that was likely the intention of the writers. I would say that most of the individual bits of medicine were fine on their own, but they didn’t come together to make a coherent whole.

I can’t really give the medicine or the soap opera a grade, since it was all a hallucination. I did like the mystery of the swollen tongue, but I would have liked a real answer, not just an imaginary one (and they didn’t find an imaginary one). I applaud the writers for trying something different, but I think last year’s episode Three Stories was a better example outside the box storytelling — and for some reason imaginary stories always make me feel cheated.

Two final thoughts:

1. I don’t think it was mentioned on the show itself (except in the closed captioning) but it was mentioned at various places on the web. The patient who shot House was named Moriarty — another nod to Sherlock Holmes.
2. If this was House’s hallucination and it was showing things that he didn’t want to face consciously, does that mean that he does want to undress Cameron?

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

Still want more great medical reading? This week’s Grand Rounds — the best medical blogging of the past week — are being hosted over at .parallel universes. As usual, there’s a plethora of fascinating reading.

Comic book doctors are rarely written well. Soap opera doctors are even worse.
Ever consider what would happen if you combined the two?

Well, wonder no more. This very scene from Superman Family #210 answers that question (click on the panel to see the full image).

[Programming note: This story was published in the early 80s when Linda Danvers (aka Supergirl) was one of the lead actresses on the WGBS soap opera "Secret Hearts."]

The Punisher #33 “Barracuda, part 3 of 6”
Garth Ennis, writer
Goran Parlov, penciler

Frank Castle (the Punisher) has been captured by a huge thug named Barracuda. Frank manages to escape and ducks into a nearby woodshed only to be followed by Barracuda. He grabs a conveniently located hatchet and lops the four fingers of Barracuda’’s right hand just above the first knuckle.

Given that Barracuda is right handed, this is a pretty devastating injury, especially in light of his chosen career as a professional enforcer. It’’s not going to be a fatal injury though — there-s simply not going to be enough blood loss. At most, Barracuda might get a little light headed and woozy.

The blood vessels supplying the fingers are small and narrow so it would take a very long time to bleed to death from a finger amputation. Long before that would happen, the arteries will have clamped down, clotted off, and stopped bleeding. Any bandages or direct pressure applied to the wound will stop the bleeding even faster. All arteries will clamp down as a result of injury, but the arteries of the fingers and toes are especially sensitive. (This effect is strongest in arteries that have been cut completely through. Arteries that have only been partially cut tend to bleed longer.)

Most of the reactions to finger amputations are due to the psychological shock of the injury, and not to the blood loss. Sure, it looks like a great deal of blood, but because of the narrow blood vessels, it looks worse than it really is. Since Barracuda is one tough hombre, I’ll give him the benefit of the doubt.

Brawling, or any other sort of physical activity, would increase Barracuda’s blood flow, but not significantly enough to matter. On the other hand, the adrenalin released because the fight and the injury would help the blood vessels clamp down faster.

Barracuda has saved the cut off fingers and placed them on ice in hopes that they can be reattached. However, Frank informs him that he should have placed the fingers in a bag first and then on the ice because direct contact with the ice will injure the fingers. He’s right. Score another one for Frank.

In the last few weeks, I’ve been planting a garden in front of our house. I had a very nice butterfly garden at our previous house, but it took a tremendous amount of work to keep the deer away. I was pleased that our new house was in a less deer prone area. Unfortunately, I didn’t count on the depredations of the little rabbit who lives under our neighbor’s woodpile:

I think the rabbit is winning.

It seems that Lex Luthor is not the only fan of Oklahoma! Here’s Chief Plexus Ranger Flagg’s version upon his return from setting the rightful King of England upon his throne. (From American Flagg #38 by J.M DeMatteis and Mark Badger (First Comics, 1986))

Every once in a while I sit back and realize that comic books need to feature more talking animals. I don’t mean Disney books or any “funny animals” comics, but standard comics that feature talking animals. Look at the list below and tell me those characters weren’t one the best parts of their respectiver series:

The Sunday before Memorial Day is one of my favorite days of the year. Friends come over, the barbecue is fire up, and we settle in for 1100 miles of racing good news.

My family’s originally from Indianapolis, so we’ve always watched the Indianapolis 500. I did my Family Practice residency in Indianapolis and lived a little over a half-mile from the track; every May I loved the fact that from my back porch I could here the cars practicing. I was hoping Michael Andretti would finally have his chance to win, and while he was leading with four laps to go, it was mostly due to pit-stop timing and he clearly didn’t have a car that stood a realistic chance of winning. It looked like his son Marco would be able to pull it off, but Sam Hornish was able to pass him in the last few hundred yards. While it would have been nice for an Andretti to win, Hornish has had his own problems in past Indianapolis 500s, so he deserved a win too.

In the evening is the Coca-Cola 600, the longest — and usually one of the best — NASCAR races. Kasey Kahne’s speed is impressive this year, both in qualifying and race day. Tony Stewart looked like he was in a great deal of pain, particularly arm pain, and I would not be surprised to find out he’s got more of an injury than they’re letting on — probably a rotator cuff injury. And Kyle Busch – what a complete ass! He’s worse than his brother ever was.

(I managed to slip in watching some Giro d’Italia between the car races. The Giro is the premier Italian bicycle race. From what I’ve seen so far in the Giro and earlier races, Ivan Basso looks like the man to beat for this year’s Tour de France).

In between the two races, I fire up the grill. This year, I cooked several racks of my special spare ribs, some authentic smoked sausage from the local butcher’s, and some ginger/wasabi chicken for the Polite-Wife. I also cooked up a surprisingly sweet black bean and roasted pepper relish. We topped it all off with a Tortuga rum cake.

All in all, a satisfying, if calorie-laden, day.

To me, reading the autopsy scene in 52 #3 raised more questions than it answered (strictly speaking, it may not be an autopsy scene, but the “the scene with John Irons examining the dead body on the table” seemed a little too wordy.) Some of these points have already been discussed over at Focused Totality and 52 Pickup, but here’s my 2¢ worth from the medical perspective.

I’m not saying these are mistakes, just unanswered questions (and they may well be mistakes, but I’m willing to give the writers the benefit of the doubt at this point.)

• Why is the autopsy taking place at STAR labs? Surely there are more appropriate places in Metropolis to perform an autopsy — and why wasn’t the body autopsied in Gotham City, since that’s it was discovered.
• Is there nobody in Gotham who could identify the body as Luthor’s? Surely there was someone in Metropolis more appropriate than John Irons. (Mercy, perhaps. Or possibly Pete Ross — you know — his Vice President?).
• On a figure as important as Luthor, why did it take over 4 days to perform an autopsy? I’m assuming the autopsy has not already been performed on the w3/d5 day scene as there is no Y incision on the body. Or if the autopsy has already been done, why did they not notice the contacts then?
• Why is John Irons involved in examining the body? He’s an engineer, not a medical examiner or even a doctor. Sure, he was called in to “identify the body”, but this is going a little too far. Mark pointed out that Henry did spend time as a hospital administrator, but trust me, that’s no guarantee that he knows his way around live patients, let alone a dead one.
• Why can Lex Luthor (the live one) and the press just stroll into STAR labs, let alone take photos of the body for publication?

Oops, I accidentally marked two recent posts as “PRIVATE” so they didn’t show up to anyone except me, but since I could see them, I didn’t realize there was a problem. Thanks to David Carter to bringing it to my attention.

Please make sure you check out these previously private posts:

• The Autopsy Scene in 52 #3
• A Medical Review of Punisher #33

One of the enduring concepts in comic books is that of the über-doctor. These are individuals who are beyond brilliant. No matter what their original field of study, they have also mastered every other discipline that’s even vaguely related to science. Unlike Scotty, they can break the laws of physics, and the only limit on their abilities is the imagination of their writers. Über-doctors can be found in many comics, though most seem to gravitate to Marvel. Such über-doctors include Hank Pym, Henry McCoy, Charles Xavier, and Michael Holt.

The über-doc against whom all others are measured is, of course, Reed Richards. Is there anything this man can’t do? This scene has always summed up his über-docness the best:

Here he is, on the Moon, delivering Crystal and Quicksilver’s baby. (Because, apparently, the Inhumans don’t have their own obstetricians or midwives. What do they do when Reed’s not around? Cross their legs?)

This is from Fantastic Four #240, written and drawn by John Byrne, where in a matter of a mere 22 pages, Reed diagnosis a mysterious illness, concocts a temporary antidote, realizes that Earth’s contaminated air is not safe for the Inhumans, directs the conversion of Attilan into a flying city, back-seat-drives while Ben pilots the ship/city, and finally, acts as obstetrician. Now that, ladies and gentleman, is an über-doctor!

Some more thoughts on the concept of the über-doctor. As far as I’m concerned, to be considered an über-doctor, a character must meet three criteria:

1. Hold a doctorate, a medical degree, or the equivalent.
2. Multiple instances of demonstrated expertise outside their stated field of study (or expertise in everything if no specific field of study is mentioned)
3. The ability to build wicked-cool gadgets