Polite Dissent

JSA Classified #23 “Nightfall, part 1”
J.T. Krul, writer
Alex Sanchez, artist

It’s a good time to be a Dr. Mid-Nite fan. In addition to his regular appearances in the Justice Society of America and cameos in 52, he has had a starring role in 3 of the past 5 issues of JSA Classified. J.T. Krul, who I’m most familiar with from his work at Aspen, has turned in a strong story in this issue. It returns Dr. Mid-Nite to his roots in Portsmouth, and is more in the vein of a horror and detective story than his last appearance, which (also excellent) was more of a standard super-hero tale. Sanchez’s art is good and fits the noir mood well, except that I’m not a fan of how he draws Dr. Mid-Nite’s costume.

In terms of the medicine, Krul has done his research and it shows. Still, there are a couple of areas I’d like to discuss:

Detective: Big fella. Did he give you much trouble?
Dr. Mid-Nite: Nothing 150mgs of Ketamine couldn’t handle. He should be out for at least the next thirty minutes.

Ketamine is a rapidly acting anesthetic. It is used medicinally in people, but is probably more common nowadays in veterinary use. In lower doses, ketamine has dissociative and hallucinogenic properties and has an extensive history as a street and club drug.

For a generally safe, quick acting anesthetic, Ketamine is a good choice for Dr. Mid-Nite. However, a dose of 150mg is too low for a man of that size. That amount is reasonable (if not a little high) for recreational use (definitely not recommended!) but it wouldn’t be enough to produce the anesthesia shown in the comic. Assuming a 250 pound (114 kg) man, an anesthetic dose would start around 800mg. It should take effect in about 3-5 minutes, and as Dr. Mid-Nite states, lasts for 20-30 minutes. Ketamine is also Schedule III Controlled Substance in the US, so this is yet another example of Dr. Mid-Nite breaking Federal and state drug laws.

Dr. Mid-Nite: You really should consider limiting your blood intake. You could suffer an iron overdose or even develop toxic porphyria.

Porphyria is a condition where there is a breakdown in the synthesis of heme (one of the components of hemoglobin). Toxic levels of precursor chemicals build up and lead to a variety of symptoms including abdominal pain, vomiting, irregular heart rhythms, seizures, hallucinations, and paranoia. Skin rashes are common as well.

Porphyria is usually an inherited disease, but there have been cases where exposures to certain chemicals have caused the condition. This is the “toxic porphyria” Dr. Mid-Nite mentions. The most extensive case occurred in Turkey in the 1950s when grain made into flour was contaminated with hexachlorobenzene. Over a five year period, nearly 5000 people were affected.

I can find no connection between drinking blood and toxic porphyria in the medical literature. Biochemically, it really doesn’t make much sense either unless the blood is somehow contaminated. If ingestion of blood could cause toxic porphyria, then patients with gastrointestinal bleeding would develop the disease, but they don’t. Frankly, the only mentions I can find relating blood and toxic porphyria are on several fringe websites that discuss — and seem to recommend — drinking blood and mention as a side effect “(possibly) toxic porphyria”. It’s not hard to notice that every website has the identical paragraph about the risks of drinking blood so it’s likely they all cribbed it from the same place, and that place was wrong. I think it’s safe to label this one an urban legend.

On the other hand, a good case can be made that drinking blood could lead to iron overload. Most iron overload situations are due to hemochromatosis, a hereditary disease where the body cannot process iron properly. Even without hemochromatosis, it is still possible — though rare — to develop iron overload by taking in too much dietary iron. There is a condition known as “African Iron Overload” that occurs among certain African tribes who brew a drink high in iron. Individuals who imbibe large amounts of this beverage develop iron overload*. I would think that regular ingestion of blood would be a similar situation.

*There is some evidence that there may be a genetic disposition involved as well as drinking high-iron beer.

Tags: comics medicine dr mid-nite ketamine porphyria iron overload

Two psychic bleeds this week courtesy of 52 #43.

First up is Buddy Baker (Animal Man). He’s skipped over the more common nosebleed and gone straight to the ear bleed. Otherwise, it’s a classic psychic bleed as Buddy is pushing his powers to the limit and an anatomically improbable bleed results.

Second is the unfortunate Luribel. Here she is giving birth (or re-birth) to the Lady Styx. While giving birth can certainly raise blood pressure, and even intracranial pressure, so a nose bleed wouldn’t be that out of place — this is no normal birth as Lady Styx is basically cutting her way out; I’m not even sure if Luribel is in labor This may not be a true psychic or super-power related nosebleed, but it’s certainly not normal (and at the very least this scene is being added to my list of comic book pregnancies).

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed 52 animal man pregnancy

There’s been some debate over the earliest appearance of the “psychic nosebleed.” The first reference I’m aware is not from a comic book, but instead from David Cronenberg’s movie Scanners.

Here’s two quick quotes from the film:

I, I must remind you that the, uh, scanning experience is usually a painful one, sometimes resulting in nosebleeds, earaches, stomach cramps, nausea.

and

Cameron: [sees that Kim has had a nosebleed] What happened?
Kim: I was scanned. The woman in the waiting room…
Cameron: She scanned you?
Kim: No, not her. Her child. Her unborn child scanned me.

Scanners is from 1981. Somebody once suggested Stephen King’s Firestarter, published in 1980, but I couldn’t find any occurrences of any sort of psychic bleeding when I read the book. Maybe they meant the movie, which was released in 1984, but I haven’t seen it and Scanners predates it.

For now, I’m going to consider Scanners the earliest psychic nosebleed unless anyone can show me an earlier example.

For comic books, the first example I’m aware of is from the X-Men graphic novel God Loves, Man Kills by Chris Claremont and Brent Anderson, published in 1982, just one year behind Scanners.

For monthly comics, the earliest psychic nosebleed I’ve run across is Adventures of Superman #427 (April 1987) by Wolfman and Ordway, but it wouldn’t surprise me if there are earlier examples.

All previous Psychic Nosebleed Zen posts

Tags: comics medicine psychic nosebleed scanners

I have a short article in this month’s Virtual Mentor, an online journal published by the American Medical Association. The article’s not about comics, but it is about pop culture, and a favorite television show of mine: I take a close look at several diagnoses from House.

This PSA from Ben Casey #3 (Dell Comics, 1962) takes a look at a still-evolving aspect of medicine: organ transplantation.

At the time this comic was published, the Navy Tissue Bank — the first in the United States, if not the world — was fifteen years old. Kidneys had been transplanted successfully for all of 8 years. Neither heart nor liver transplants would be successful for another five years. Lung transplants were still further off.

Click on the image for the full PSA

Currently? In 2004 (the most recent year I have statistics for), there were 27,037 organ transplants in the United States (including 16,004 kidney transplants; 6168 liver transplants; 2016 heart transplants; and 1172 lung transplants).

Its undeniable that organ transplantation has been a dramatic success story, but let’s remember that nearly 90,000 people remain on the transplant waiting list in the U.S. alone. Have you signed your organ donor card?

Statistics from the National Kidney Foundation

Tags: comics medicine psa transplant

I’ve noticed that whenever House features a special guest star, the episode always seems to suffer for it. Tonight’s episode, guest starring Dave Matthews, was no exception. The episode seemed sloppy and was missing that certain “bite” that accompanies the best episodes of House.

I thought Matthews did a good job in his role. Also excellent in an understated role was Kurtwood Smith. With this appearance, he becomes the first person to be featured in two TV shows each featuring an Eric Foreman.

Patrick is a thirty-five year old man who suffered a severe brain injury in a bus accident at the age of twelve. Since then, he has only been functioning at the level of a four year old, except that after the accident he has somehow become a musical genius. The episode starts with Patrick playing some Beethoven for a charity audience when he starts missing notes — something he has never done before. His father rushes over and Patrick tells him that his hand hurts, and then he hold up a hand severely contorted with dystonia (uncontrollable muscle contactions).

Early the next morning after Patrick is admitted to the hospital, the team is discussing his case. Foreman wants to put him on Clonazepam (a muscle relaxant, among other uses) for the dystonia, but Cameron points out that he’s already on it for his seizure disorder. Foreman then suggests Benztropine (a drug usually used to treat Parkinson’s Disease). House arrives orders a blood count, chemistry panel, thyroid tests, and adrenal tests.

Foreman runs some basic neurological tests and reports to House that the Patrick’s motor cortex is good. House is not convinced. He wheels a piano into the exam room and he and Patrick have an impromptu music session (including the opening bars of “I Don’t Like Mondays” by the Boomtown Rats). House orders a functional MRI to evaluate Patrick’s brain function. (A functional MRI works by detecting increases in blood flow within the brain — these are believed to represent area of brain activity.) They first test him while he is simply listening to music and the results are unexciting. They then test him while he is playing music. This time the brain lights up as dramatically, meaning he’s “thinking” quite a bit. Patrick’s heart rate increases and Foreman suggests that it is probably an emotional response. House disagrees. He sees no activity in the limbic system (the area of the brain concerned with emotion), so House deduces that something must be wrong with Patrick’s heart itself.

Next scene, Foreman explains to Cameron that arterial vasoconstriction (a sudden and unexplained constriction of a main artery) in Patrick’s arm led to the dystonia, and the cause for this — for reasons I’m not entirely clear on — lies in the heart. While Foreman is doing some sort of arterial study of the heart, Patrick experiences a rapid increase in his heart rate and ends up in a supraventricular tachycardia (SVT) that Foreman shocks back into rhythm. (Cardioversion is not the usual first-line treatment for SVT, but I won’t say it’s never done).

House now suspects that Patrick is experiencing bouts of sudden unexplained bleeding and these are responsible for his symptoms. A bleed in the heart led to the SVT and a bleed in the brain led to the dystonia. To prove his diagnosis, he wants endoscopy of both the upper and lower gastrointestinal tracts (But why no anesthesia? Intravenous anesthesia is used routinely for ‘scopes). Both are negative, so now he wants a surgical exploration — which does find evidence of a bleed retroperitoneally, behind the kidney. The surgeon also reports that Patrick suffered a severe grand mal seizure while he was closing up. This suggests that Patrick’s underlying seizure disorder is getting worse.

House wants to take Patrick off his seizure medications causing him to have bad seizures so that House can run a PET scan to see which areas of the brain are likely to be causing the seizures. The scan shows several hot spots, with more activity in the left brain than the right. House then performs an MRA and notes a small collection of blood in the white matter. This suggests Patrick’s recent problems may be due to trauma, an aneurysm, cancer, or an autoimmune disease. House wants a brain biopsy, but Foreman talks him into letting him perform an internal EEG to pinpoint the best area for a biopsy. The EEG reveals no abnormalities on the left brain, but a “brain dead” right hemisphere. House convinces Foreman that the right side of the brain is not dead, just severely dysfunctional and the source of all the seizures. Foreman and House understand this to mean that Patrick has an autoimmune disease, in this case Takayasu’s Arteritis.

With treatment for the Takayasu’s and seizure medication, Patrick will be able to return to his previous level of functioning. House is not satisfied however; he recommends a right hemispherectomy — surgically removing the right side of the brain. This would remove the seizure foci and eliminate the need for seizure medication. House also believes it will allow Patrick to be more functional and better able to care for himself. The downside is that he will likely lose all his musical talent in the process. House broaches the subject to Patrick’s father, who in the end agrees to the procedure. After the surgery, Patrick is not talking, but he is able to button up his shirt on his own, something he could not do in the beginning of the show.

There was also a side plot about House having brain cancer, but it never felt “real” to me and I never bought into it. Why would no one suspect House was lying about the cancer? He’s a notorious liar. The supposed terminal cancer led to several intense character scenes, some quite good (Cuddy), some not so good (Cameron). For the record, the tumor was a 6 cm tumor in the dorsal midbrain — though I don’t recall them ever saying exactly what type of tumor it was — only it ended up being a gumma (a soft growth seen in late stage syphilis) instead of a tumor, and it wasn’t House’s chart after all.

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Medically, this episode felt very jumbled. There was no clear indication of why the doctors were doing certain tests, and the usual flow from one diagnosis to the next was missing. Run these blood tests. Why? Just because — don’t worry, they’ll never be mentioned again. Now run a functional MRI. It’s not abnormal enough! It must be vasoconstriction of an artery in the arm, so we’ll check the heart. Must be a bleeding problem in the heart and brain (though we missed that on the scans), so let’s do an upper and lower endoscopy — just in case he’s bleeding there — then we’ll open him up and look surgically, apparently at random, until we find some bleeding. Now the seizures are worse, so let’s run a different brain scan then an angiogram. Now an EEG. Aha, it’s Takayasu’s Arteritis! A diagnosis that fits if yousquint your eyes just right and skip over a bunch of signs, symptoms, and obvious tests.

The final decision, about whether or not to perform the surgery on Patrick, was to some extent a false dilemma. Patrick’s condition was under good control. His Takyasu was managed by medication as were his seizures. There was no reason his father had to decide then and there to have the surgery done, he could have waited and made an informed decision later in less chaotic and emotional surroundings. That’s what I would have suggested.

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Tonight’s medical mystery was only barely interesting, partially because it was ill-defined (where was the whiteboard?). I give it an fully average C. The solution was weak and really didn’t fit all that well: C-. The medicine was sloppy, but rarely wrong per se, so I’ll give it another C-. The character interaction tried to make up for the medicine, but couldn’t quite do it — I give it a B.

The previous House review
A list of all prior House reviews

Tags: television medicine house takayasu’s arteritis seizure dave matthews kurtwood smith

Today, I’m finally going to address a question that I’ve been asked many times: What’s up with Jonah Hex’s mouth?
The first consideration is to determine what type of scar Jonah Hex has. Is it simply a band of scar tissue crossing his mouth — as demonstrated by Britney Hex below? Or is the band of tissue all that remains of the normal edge of his mouth, and what we see on the other side is a permanently gaping wound exposing his back molars and gums (as shown by Nick Hex)?

A strip of scar tissue across the lips would limit Jonah’s ability to yawn and yodel, but otherwise would have little physical effect on him. On the other hand, missing a large chunk of his cheek would cause Jonah problems with chewing and drinking. Food would keep falling out when he tried to eat, and he’d drool constantly.

My interpretation is that Jonah has scar tissue across his mouth, like Britney. This is consistent with how he’s been drawn over the years, and the writers have never mentioned trouble eating or drinking (or any constant drooling), so I think the gaping cheek wound is unlikely. Sorry Nick Hex.

In current continuity, Jonah suffered his injuries when a vengeful Apache with a red-hot tomahawk tortured him. The dramatic scar over his lips was not caused by the injury itself; instead, it was caused by problems during healing. When two areas of very raw and denuded skin are held against each other for long periods of time, they can grow together. This is especially true for mucous membranes like the lips. Jonah suffered second or third-degree burns to the right-side of his lips, probably from a super-heated tomahawk held vertically against them. When these deep burns healed, a portion of skin around the lips had fused together. (In some depictions, particularly cover depictions like Frank Quitely’s cover to Jonah Hex #1 , the right side of the lips are pulled back. This is consistent with burn scars as well. As healing occurred,the vertical scars fused together while the other scars tightened up, retracting the lips.)

There’s no reason the scar couldn’t be removed. Simply cutting it at the top and bottom would be best. This could be done safely and humanely (well, as much as medical care was safe and humane in the Old West), or by a scissor-wielding spaghetti-cooking manga girl. The results would be the same: a small scar above and below the lips, but Jonah would regain the ability to eat a triple cheeseburger. Of course, he’ll never go through with it as the scar is an affectation. It reflects internal scarring — that is, scars on his psyche — and until those are healed it’s unlikely he’ll ever think about getting the mouth scar fixed.

Tags: comics medicine jonah hex scar

Thunderbolts #111
Warren Ellis, writer
Mike Deodato, Jr., artist

Thunderbolts #111 was brutal; a little too brutal for my tastes actually. On the other hand, the medical aspects were correct and well done.

Jack Flag is fleeing from the new Thunderbolts. He acquits himself well and manages to evade the team. At least until he runs into Bullseye. More accurately, Bullseye sneaks up behind him and stabs a sai in his back:

Bullseye: I just jammed the blade through your vertebral canal into the end of your spinal column.

Bullseye: Radio Moonstone, tell her the target’s not going anywhere. I just destroyed his cauda equina. He won’t walk again.

As the spinal cord leaves the brain and travels down the spinal column, a pair of spinal nerves split off at every vertebra. The spinal cord ends around the L2 vertebra (roughly ¾ of the way down the back) and all the remaining spinal nerves fan out from this point to travel the remaining way down to whatever level they exit the spinal column. Because this has the rough appearance of a horse’s tail, it is called the cauda equina which is Latin for — wait for it — horse’s tail.

An injury to the cauda equina can cause paraplegia, loss of sensation to the legs, as well as difficulties with bathroom and sexual functioning.

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The last scene of the comic features Norman Osborne in his office. After a bizarre conversation with his secretary, he fiddles with some pill bottles then finally pops two pills.

Tegretol (generic name carbamazepine) is used primarily to treat seizures. It is also used to for trigeminal neuralgia and to prevent migraines. A common off label use of Tegretol is to treat Bipolar Disorder (old name: manic-depression)

Lithium is also used to treat Bipolar Disorder.

Doses seem a little small though…

Tags: comics medicine thunderbolts warren ellis spinal cord tegretol lithium

This weekend’s moment of psychic nosebleed zen comes from JSA Classified #3 where Kara (Power Girl) is feeling a little under the weather after having Psycho Pirate toy with her mind.

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed power girl jsa

Don’t forget to set your clocks ahead!

In the midst of Hawk’s crime spree, this issue takes a look back at when Dawn first learned Hawk’s secret identity.

Dove swings by Hank’s apartment, but he’s not there. She let’s herself in — he didn’t hide the key well — and sits to wait for him. While she’s waiting, the answering machine picks up a call from Hank’s dead brother Don and she begins to get an idea of what Hawk’s been up to.

Dawn fixes a cup of coffee and remembers when she first heard that Don, the original Dove, was dead. She was in England and had just helped capture some crooks when a police officer mentioned how sorry he was to hear that the other Dove had died. With his comment, Dawn realizes that she is the only Dove and decides that she needs to find Hawk.

She travels to Dove’s memorial service. There, she sees Cyborg, Wally West, and Hank Hall, among others. When Hank makes a comment about his dead brother Don, Dawn realizes that he is Hawk — but she doesn’t know his name. Looking back, she also realizes that Kestrel was there even then, looking for Hawk.

Dawn follows when Hank leaves. She can see that he’s becoming wilder and less restrained in his actions. For instance, when he fights a redneck cyborg named Turbeau (really), he leaves him drowning in the river after the fight.

She tracks Hank down to a hotel and manages to connive his name out of the night clerk. Once again hot on Hank’s trail, she stumbles across Turbeau’s jailbreak. She has to decide whether to follow Hank or stop Turbeau — but it’s not much of a decision. She knows Hank’s name now so she figures she can always find him later. Dawn changes into Dove and with a single penny is able to stop Turbeau in his tracks.

Back at Hank’s apartment, morning has come and still no sign of Hank — except for the morning paper which bears the headline “Wanted: Hawk Hunt Begins!’

Flashback issues are usually disastrous, introducing new characters that the heroes supposedly have always known (like Hush, or that Molten-Man wannabe over in the Amazing Spider-Man). This one actually follows established continuity and manages to fill in a few holes, but still is rather a dull read. The art is good, particularly the design of Turbeau (and speaking of Turbeau, I can’t decide whether his creation was stupidity or genius, but I’m leaning toward the latter — c’mon, he’s a redneck cyborg!). With the several mentions of Kestrel this issue, one gets the idea the writers were setting up his return, but with only two issues (and one annual) left, never got the chance to follow through. (He did re-emerge for two issues of the current Teen Titans series, but it’s yet to be explained how he returned since the last we saw him Barter had his essence in a jar.)

All Previous Hawk and Dove Reviews

Tags: comics hawk dove kestrel

Do you recognize the name Galen?
What about Zacharias Janssen?
Or René Laennec?
How about the brothers Peter and Peter Chamberlen?

If these names don’t sound familiar, I recommend you take a look at today’s PSA “They Were First” from Ben Casey #3 (June 1963). And to quote Bill Cosby, “If you’re not careful, you might learn something before it’s done.”

Tags: comics medicine psa history

A request has been made for me to review New Excalibur #17 which details Talia’s recovery from her stroke. First, however, I’d like to take a look at New Excalibur #16, which features the stroke itself.

New Excalibur #16 “Fallen Friend, part 1”
Chris Claremont, writer
Scot Eaton, penciler

In Excalibur #16, Talia (Nocturne) suddenly suffers an apparent stroke. Visiting Dazzler in the hospital, she suffers a sudden loss of coordination, headache, numbness of both arms and legs, and then unconsciousness.

Generally speaking, there are two types of strokes. The most common (80%) is an ischemic stroke, where blood flow to one of the blood vessels in the brain is blocked by a clot. This prevents blood from getting to part of the brain, and this part will almost immediately stop functioning, and will die if blood flow is not restored quickly. The leading treatment for ischemic strokes are clot-busting drugs (also known as thrombolytics), but they have to be given within 3 hours of the onset of symptoms. Blood thinners may be used to prevent a subsequent stroke,

The second type of stroke is a hemorrhagic stroke, where one of the blood vessels in the brain starts to leak or bleed. This causes damage in several ways. First, the brain tissue beyond the bleed is denied its blood supply and can die, just like in an ischemic stroke. Second, blood is irritating to the brain tissue which causes swelling and inflammation. Third, if enough bleeding occurs, it can raise the intracranial pressure which can restrict blood flow to the entire brain. The treatment of a hemorrhagic stroke should come as no surprise: stop the bleeding. This may require surgery. Additionally, if a large amount of blood has collected, it may need to be surgically drained. Since the treatment for an ischemic stroke, clot-busters and blood thinners, will make a hemorrhagic stroke worse, you need to be sure what type of stroke has occurred before treatment is started.

So far, it’s not clear which type of stroke Talia suffered. Given her headache and loss of consciousness, a hemorrhagic stroke seems more likely as these are symptoms of increased intracranial pressure. However, no mention has been made of any surgery or neurosurgical evaluation. On the other hand, no mention has been made of thrombolytics or blood thinners either, though when Sage explains what a stroke is to Pete Wisdom, she only mentions ischemic strokes. Frankly, I’d be surprised if we ever find out for sure what type of stroke she had.

Doctor: Set up a fell series of x-rays — chest and skull. MRI’s as well — someone find out if we have to worry about her super-powers? And check with her teammates, she’s got different hand and feet structures, blue skin and weird eyes — are there any internal differences we need to know about?

I’m not certain why the x-rays were ordered. Talia was showing neurological symptoms and then she lost consciousness. The differential diagnosis would include stroke, seizure, hemorrhage, drugs, infection, or metabolic disorders — none of which show up on x-ray*. There is only a limited time window to treat a stroke, particularly an ischemic stroke, so there is no need to waste time getting unnecessary x-rays. An MRI makes sense because it has a good study for showing a stoke, either ischemic or hemorrhagic.

It’s nice to see a doctor taking super-powers into account , one would presume both for his sake as well as the patient’s. It’s what I would expect to see in a comic book hospital. Of course, in a comic book universe, we should probably add “telepathic disorder” to the differential — but then again, she doesn’t have a nosebleed, so maybe not.

Tomorrow: The requested review of New Excalibur #17 (plus I believe #18 is available in stores UPDATE: Oops. Not yet)

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*to be fair, “trauma” would also be on the differential – and that would seem a likely possibility in a superhero who had recently been in a fight — and while trauma should show up on x-ray, it would show up on the MRI as well, so there’s no reason to waste time getting an x-ray. (Plus the x-ray wouldn’t give a good view of the brain itself, just the skull. ) Just go straight to the MRI (or CT).

Tags: comics medicine excalibur chris claremont stroke

New Excalibur #17 “Fallen Friend, part 2”
Chris Claremont, writer
Scot Eaton, penciler

As the issue starts, Talia (Nocture) can barely move her right limbs. In addition, she is having trouble remembering her teammate’s names, as well as difficulty speaking and understanding what others are saying.

(I think the listening and speaking difficulties are supposed to be aphasia — damage to language center in the brain– but it wasn’t made entirely clear by the script. She could also be having some dysarthria — trouble controlling the speaking muscles.)

Within the first couple of days after the stroke, Talia’s memory and communication problems have cleared up, but she is still struggling with right hemiparesis (weakness of the muscles of her right side) at the end of the issue.

Medically, this is a good representation. As the issue begins, Talia has two things going wrong within the brain. The first is the damage from the stroke itself. This damage is responsible for the right hemiparesis. With time and aggressive therapy and rehabilitation, these symptoms can sometimes improve. Frankly, complete recovery from a stroke is rare and the majority of patients who suffer strokes will continue to show symptoms for the rest of their life.

Talia also has swelling and inflammation of the brain. This can be seen after some strokes, particularly hemorrhagic strokes (which is what I speculated she suffered). It is this inflammation that is causing her aphasia and memory problems. As the swelling and inflammation resolve — usually in the first couple of days after the stroke — those problems should improve.

What strikes me the most with this storyline is the clear parallel between Talia and the writer, Chris Claremont. Last year he suffered a serious heart problem that required significant rest and rehabilitation. And now in his first story back, the focus is a character who suffers a debilitating cardiovascular disease that also requires extensive rest and rehabilitation. While Claremont’s was a heart problem and Talia suffered a stroke, they are related diseases with similar causes. I don’t think it’s a wish fulfillment or a Mary Sue situation, but just Claremont bringing some of his own recent experiences into the comic. It will be interesting to see how the storyline progresses (and if it is ever explained why Talia suffered the stroke).

Tags: comics medicine excalibur chris claremont stroke aphasia hemiparesis

Julius Caesar, Act I, Scene ii

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

Today’s example of of psychic nosebleed zen comes from JLA #84. In this scene, the Martian Manhunter is trying to access the comatose Lex Luthor’s mind. It starts with the standard bloody nose, but then proceeds rapidly to a full nose-plosion:

Scenes from JLA #84. Words byJ oe Kelly, Art by Doug Mahnke

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed jlamartian manhunter

Busy weekend with family obligations as well as St. Louis’s annual 5-mile St. Patrick’s Day Run.

See everyone Monday!

A cliché that seems to be popping up more and more often in super-hero comics is the unethical drug company — or unscrupulous doctor — testing their drugs on unsuspecting patients. This isn’t the Joker or some other psychopath dumping the latest batch of Smilex in the reservoir, but instead an organized drug trial carried out unethically and illegally.

Like most clichés, it can be effective when used sparingly, but that has not been the case. In the past nine months — in Gotham City alone — this overworked formula has appeared at least three times:

• Legends of the Dark Knight 204-206
• The Creeper
• Tales of the Unexpected

And that’s just one small subset of books from one company. There’s many more examples when you look at superhero comics as a whole.

Now, I’m not trying to defend drug companies (or unscrupulous doctors, for that matter), I’m just trying to call attention to an overused cliché so we can put it to rest (for a few years, at least).

This is the first post of JSA Week — looking back at some of the science and medicine shown in the early issues of JSA.

JSA #6 “Justice, Like Lightning…”
David Goyer and Geoff Johns, writers
Marcos Martin, penciler

Black Adam comes tearing into town and picks a fight with the JSA. Black Canary (back before she regained her sonic scream powers) sneaks up behind Adam and places one of her “Canary Cry” screamers in his ear:

Black Canary: Since we’ve got special ear plugs — let’s see what 300 decibels does to your heightened hearing at close range.

A decibel (dB) is unit of ratio. It uses a logarithmic scale so small numbers can represent a large difference in effect. The most common use of decibels is to describe the intensity of a sound.
(Now remember that a sound wave is actually a compression wave, and that while the eardrums are the most sensitive part of the body to sound, they are not the only part affected by strong sounds — as anyone who’s ever “felt” the bass at a rock concert can attest). So how does Black Canary’s 300 dB Screamer rate?

decibel	event	effect on human body
40	Whisper
60-70	Normal conversation
100	Average car stereo
116		Human body (not just the ear) perceives low frequency sounds
120-130	Front row at rock concert	Tinnitus (ringing in the ears) begins
140		Pain threshold (hearing is painful)
145	Formula 1 race car	Vision becomes blurry
152		Joints are vibrating and painful; difficult to swallow
160	NHRA dragster
163	Minimum glass breaking level
165	Boeing 727 take off	Air begins to heat up due to compression
190-195		Eardrums rupture 50% of time
194	1 atmosphere of pressure. At this level and higher, sound waves begin to act like shock waves
200	Richter 1.0 earthquake	Human death from shock wave
212	Sonic boom from jet
220	Saturn V rocket launch
230	Richter 4.0 earthquake
240	F5 tornado
243	Largest non-nuclear explosion
257	1-megaton nuclear bomb
286	Mount St Helens 1980 explosion
300	CANARY CRY “SCREAMER”
302	Tunguska event (estimated)

Oops. Looks like the screamer’s a little too powerful — stronger than the shock wave from a 1-megaton nuclear bomb.

I think those ear plugs are probably a moot point.

Tags: comics medicine jsa black canary

Continuing JSA Week…

JSA #8 “Darkness Falls – Part 2: Shawdowland”
David Goyer and Geoff Johns, writer
Stephen Sadowski, penciler

Black Canary has been injured escaping from Obsidian and his shadow minions. Luckily she has stumbled across Dr. Mid-Nite who takes a look at her wound with his equipment:

Ultrasonic Scanning — Possible fracture, eighth floating rib. Possible puncture in right common iliac artery

The first part makes no sense. The 11th and 12th pair of ribs, since they are not part of the ribcage, are known as “floating ribs.” There is no eighth floating rib.

The common iliac arteries are a pair of large arteries in the lower abdomen/pelvic area. Damage to one of the common iliac arteries could easily lead to a dangerous loss of blood.

After assessing her wounds, Dr. Mid-Nite moves on to treatment:

Dr. Mid-Nite: This is a fibrin sealant foam made from elastic proteins. It should stop the bleeding, seal off your severed arteries.

I’m going to assume Johns wrote this part because it follows a pattern I’ve noticed when he writes medical scenes. He’ll take a cutting edge medical concept and then extrapolate one or two steps further. In this case, starting in 1998 — a year or so before this comic came out — there was a great deal of press about the Army working on new bandages that incorporated fibrin (one of the proteins our bodies use to form clots). These fibrin bandages were supposed to stop bleeding better than regular bandages. Johns has taken this idea and gone one step further, giving Dr. Mid-Nite a fibrin foam (a 2002 article suggests that the Army had a similar idea, but could never get the foam to work). As far as I know, the Army is still working on their bandages.

Later, Black Canary and Dr. Mid-Nite free the rest of the JSA:

Dr. Mid-Nite: Watch your breathing Hawkgirl. It’s shallow and rapid. Your carbon dioxide levels are dropping. Don’t let the anxiety overwhelm you.

While what Dr. Mid-Nite is saying is entirely correct — it’s just too damn wordy (I’d call it a clear case of Claremont-level wordiness). For Heaven’s sake, just say, “Stop hyperventilating.”

Tags: comics medicine jsa dr. mid-nite black canary

JSA #17 “Injustice Be Done, part 2: Cold Comfort”
David Goyer and Geoff Johns, writers
Stephen Sadowski, pencils

The JSA has been attacked by the Injustice Society and Sentinel takes a severe blow to the chest. Mr. Terrific drags him into a side room and prepares for surgery:

Mr. Terrific: The big gun of the JSA, Sentinel, just got his chest ripped apart. He’s gone into shock and he’s lost a lot of blood. We’re lucky he’s not already dead.
It’s my job to get his oxygen-starved pumper up and running again. Dr. Mid-Nite’s book on TMR is my only option other than cardiac bypass surgery.

Hold on a minute there, Mr. Terrific (a.k.a. “the World’s third-smartest-man”). Both TMR (transmyocardial revascularization) and CABG (coronary artery bypass grafting) are used to treat patients with severe coronary artery disease — people who are not getting enough blood flow to the heart because of narrowed or blocked arteries. That’s not Sentinel’s problem. He had a huge branch shoved through his chest — that’s the problem. He doesn’t need TMR or CABG, he needs the damage caused by that branch repaired. If he has an oxygen-starved heart, it’s only because he’s lost a tremendous amount of blood from the injury. He needs fluids (which, to be honest, Mr. Terrific is providing) and surgical repair of the trauma ASAP, not revascularization surgery.

---

Meanwhile, Dr. Mid-Nite and Black Canary enjoying a dinner date when they are ambushed by Count Vertigo. True to his name, he causes everyone in the restaurant to become dizzy and nauseated. To counteract the count’s attack, Dr. Mid-Nite injects Black Canary with meclizine and diazepam.

That’s the right idea, but probably a little overkill. Meclizine (brand names: Antivert, Bonine) is a drug similar to Dramamine that is good for treating motion sickness and dizziness. It is usually the first-line agent for treating vertigo. If the meclizine doesn’t work, then diazepam (brand name: Valium) is prescribed. Drowsiness is a significant side-effect of both of these drugs, and I suspect it would be hard to avoid with both medications taken at the same time.

Also, Diazepam is a Schedule IV Controlled Substance — which means that this is yet another example of Dr. Mid-Nite giving out controlled substances illegally without a prescription (and without a medical license, state controlled substance registration, or DEA number). “But your honor, I was just giving the Valium to my date.” Yep. That’ll go over real well.

Tags: comics medicine jsa dr. mid-nite black canary

Long before a certain mutant super-heroine songstress, there was another Dazzler gracing the pages of the American comic book. This was Dr. Dan Dazzler, intern extraordinaire, who appeared as a back-up feature in Dell’s Ben Casey comic.

For your weekend reading pleasure, here is Dr. Dan Dazzler in “I Can’t Breathe” from Ben Casey #8 (November-January 1964).

Click on any of the images for the full story

Discussion questions:
1. Just how stupid is Jimmy?
2. Does Dr. Dazzler really think that shaking Jimmy upside down is the best way to remove the coin?
3. Is the zoo-keeper psychic? How does he know Dr. Dazzler wants a knife when he never asks for one?
4. Will Dr. Dazzler get a second date with Nurse Cagle?

Tags: comics dell ben casey dazzler

To the best of my knowledge, this back-up story from Ben Casey #2 (Dell, October 1962) represents the first appearance of that intrepid intern, Dr. Dan Dazzler.

Click on any of the images for the full story

Discussion questions:
1. Melvin’s not too bright either, is he?
2. What are the odds that it’s hereditary?
3. How does Dr. Dazzler keep his scrubs so white, even after climbing through all that dirt?
4. What is a 7-letter word for “stupid”?

Tags: comics dell ben casey dazzler

With spring here, and summer not far behind, it’s time to start thinking about vacation travel plans. In this comic book PSA from Superman’s Pal Jimmy Olsen #24 (October 1957), let Terry the dog tell you how not to have a vacation.

Click on the image for the full PSA ad

I think this PSA also reminds us why not to take a dog on vacation: they always whine and talk about you behind your back. Not to mention that they’re also the worst back seat drivers ever (”You’re going too fast!” “Turn left — no, your other left” “Change the damn radio station” and “You missed that fire hydrant back there”)

Tags: comics psa vacation dog jimmy olsen

The first of nine new House episodes in a row, tonight’s show featured a Iraq veteran suffering from Gulf War Syndrome, though little attention was actually paid to the controversial diagnosis. Medically, an above average episode, though it felt fairly light otherwise.

House is asked by Cuddy to see a patient who just happens to be the nephew of one of the hospital’s benefactors. Strangely, House has just had a dream about the patient, and is sure that he has seen his face somewhere before (he probably recognized him as Riley from Buffy the Vampire Slayer). John is a thirty-four year-old sergeant in the Marine Corps who recently returned from a two-year tour of duty in Iraq. John believes that he has Gulf War Syndrome and complains of chronic fatigue, intermittent rashes, joint pain, and frequent sore throats. While Chase seems predisposed to believe that it might be Gulf War Syndrome, the rest of the team suspect that he must have another diagnosis because there has never been any definitive medical proof of Gulf War Syndrome — in fact, there is medical evidence against it. House orders a blood work-up including tests for HIV, Hepatitis C, Malaria, schistosomiasis (a parasitic infection acquired from contaminated fresh water. Schistosomiasis does not occur naturally in the US, but does in Irag), and Acinetobater baumannii (a bacteria that can cause health-care related infections and has been seen with some frequency in soldiers who have served in the Middle East).

John’s physical exam is normal. He describes a frequent rash of black dots on his palms and soles, but he doesn’t have the rash currently. He also mentions a cough and sore throat, as well as chronic joint pain and tingling in his legs. Nothing shows up on exam. His routine blood work is also normal, except for his potassium which is a little low. Chase suspects John may be suffering from the after-effects of chemical warfare medication, military pre-deployment vaccinations, or toxins encountered in Iraq. He also mentions that John could be suffering from radiation poisoning from depleted uranium (depleted uranium is used in artillery and tank shells because it is extremely dense and has very good penetration). He wants to order a special urine test from England No one else agrees with his suspicions and House orders a polysomnogram (sleep study) figuring that poor sleep may be at the root of John’s problem.

The polysomnogram is normal, but John starts to complain of a foul smell. Foreman discovers that John has a nasty oral infection that is causing the odor. The team describes it as “bacterial vaginosis of the mouth.” (Bacterial vaginosis is an overgrowth of normally occurring vaginal anaerobic bacteria. It is a common cause of vaginal infections and is not usually considered to be sexually transmitted.) John is started on antibiotics for the infection (metronidazole is the most common). His HIV test is negative and there is no evidence of diabetes or other endocrine problems. Cameron suspects an autoimmune disease such as Sjogren’s Syndrome, but Foreman rules that out (but you’ll notice that he doesn’t rule out any other autoimmune diseases). Foreman suspects lymphoma, a cancer of the lymphatic system. House agrees that it is cancer, but suspects it is a parotid tumor (the parotid gland is the large salivary gland on the side of the jaw). He criticizes Chase for not sending John’s urine to England for the uranium test. Wilson performs a parotid biopsy, but the results are inconclusive. He next performs a sialogram (a test to look for blockages or obstructions in the salivary ducts), but it is normal. During the test, John suddenly becomes deaf. Wilson obtains a head CT which shows 6 tumors in the brain.

House is having problems of his own. He has been unable to urinate for three days — a side effect of the Vicodin — and has painful bladder distention. He tries some alfuzosin (brand name: Uroxatral) ( a drug that relaxes the prostatic and bladder muscles), but it doesn’t help. There is a funny scene in the clinic with a patient with diabetes insipidus (a condition where the kidneys are unable to concentrate the urine correctly, and thus the patient is urinating frequently and always thirsty).

A brain biopsy is scheduled, but just as Foreman is about to cut (or drill) into John’s skull, he realizes that the tumors aren’t showing up anymore on the scanner — they’ve disappeared. Looking over the symptoms, the team now considers the diagnoses of infection or infection plus cancer. Chase arrives with the tests from England showing that John does have evidence of depleted uranium in his urine. Since House no longer suspects cancer, he is not interested in the urine results. He tells the team to continue John on the antibiotics and monitor his symptoms. He goes home to catheterize himself and sleep. While House is gone, the Young Guns decide to go ahead and treat John for presumptive uranium poisoning, but the treatment does no good and may actually have worsened the situation. John now complains of paralysis to the abdomen (though the show confuses paralysis and lack of sensation, which are two different conditions).

When House arrives the next morning, he’s cracked the case thanks to another dream about John. He is aware that John is showing a lowered blood pressure and a lower hematocrit (signs of blood loss) and House announces that John has Hereditary Hemorrhagic Telangiectasia (also known as Osler-Weber-Rendu Syndrome). This condition can lead to AVMs (arteriovenous malformations) which cause frequent bleeding. Epistaxis (nosebleeds) are one of the earliest symptoms. House states that an AVM in the spine led to John’s neurological symptoms, and one is his lungs led to the joint pain as well as the mouth and brain infection.

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Overall, the medicine wasn’t too bad this time. Hereditary Hemorrhagic Telangiectasia is a logical diagnosis and fits most of the symptoms. However, I do have some concerns. I don’t understand how an AVM in the lung led to the blood not being “filtered” and this “dirty blood” led to joint pain and mouth and brain infections. First of all, very little filtering occurs in the lungs, (mostly gas exchange exchange) — blood is filtered in the liver, kidney, and spleen (depending on what you are filtering for). Similarly, what exactly is this “dirty blood” and how does it cause joint pain, because I’m sure my patients with long-standing arthritis would love to know. Is House saying that John’s joints are infected? All this still doesn’t explain how a vaginal pathogen managed to end up in John’s mouth, let alone survive there and cause an overwhelming infection.

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I wasn’t too keen on the whole “dreaming about the patient” concept either. For a show which prides itself on being (more or less) realistic and factual, the dreaming aspect seemed out of place.

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I give the medical mystery a B and the ultimate solution a B+. The medicine was above average, but I’m deducting for “bad blood”: C+. The soap opera/non-medical content, despite Cameron and Chase’s best efforts, only struck me as so-so and deserves another C+ .

Last week’s House review
A list of all previous House reviews
A story from medical school involving a urinary catheter

Tags: television medicine house hereditary hemorrhagic telangiectasia gulf war syndrome depleted uranium

In the excitement of having an actual day off work last Friday, I neglected to post the last review of JSA Week.

JSA #18 “Injustice Be Done, part 4: Into the Labyrinth”
Geoff Johns and David Goyer, writers
Stephen Sadowski, penciler

This issue pretty much picks up where issue #17 left off (the intervening issue #18 was a flashback issue). Mr. Terrific decides against performing surgery himself on the wounded Sentinel (thank goodness) and rushed him to the hospital:

Mr. Terrific: Start an I.V. Two liters of Lactated Ringer’s over the next twenty minutes and type and cross for six units of whole blood

Lactated Ringer’s (abbreviation LR) is a commonly used intravenous fluid. It contains sodium, chloride, lactate, potassium, and calcium. Other common intravenous fluids include Normal Saline (abbreviated NS), a 0.9% w/v sodium chloride solution, and Half-Normal Saline (½NS), a 0.45% w/v sodium chloride solution. Different physicians will go to great lengths to tell you which fluid is better for which situation, but I have always found the debate more academic than practical.

As a nitpick, most clinicians would have phrased it “2 liters Lactated Ringer’s wide open.”

When practical, it is always best to transfuse blood that matches the recipient’s blood. To check this, a type and cross is performed. The donor blood is matched to the recipient’s blood type (the “type”) and an antibody screen is checked (the “cross”). Cross-matched blood minimizes the risk of transfusion reactions. A type and cross takes time though, up to forty-five minutes. In emergencies, non-cross-matched type O blood can be given.

Sentinel has been bleeding heavily for quite some time. I think he’d benefit from some type O blood initially, followed by cross-matched blood when it becomes available. Speaking of blood transfusion, whole blood hasn’t been used for years; instead, PRBCs (packed red blood cells) are given.

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Meanwhile, Dr. Mid-Nite has seen the true face of Johnny Sorrow and collapsed. Black Canary cannot find a pulse and begins CPR.

Black Canary: Mid-Nite! Oh Thank God! I thought you were –
Dr. Mid-Nite: Damn Close. Definite myocardial infarction. You give good C.P.R. Canary.

A myocardial infarction is fancy doctor-speak for a heart attack. Dr. Mid-Nite is saying that the sight of Johnny Sorrow’s true face caused him to have a heart attack. And not just a minor heart attack either, but one that actually caused his heart to stop and required CPR from Black Canary.

Heart attacks, even small ones, are serious. Part of the heart has died, and will not grow back. This can lead to all sorts of problems from arrhythmias to heart failure. It is not a good idea for Dr. Mid-Nite to get up and resume fighting crime immediately after the heart attack. Doctors have several names for patient’s like that: a charitable one would be “non-compliant,” a better one would be “idiot.” I’m not saying that patients with heart attacks are doomed to the life of an invalid — far from it — but they need to take it easy immediately after the attack because this is when the risk of complications is the highest.

Other issues: How exactly did Dr. Mid-Nite diagnose his heart attack? Does he have an EKG wired in his suit (OK, he probably does). What about treating the heart attack? I know he carries bottles of controlled substances in his costume, but what about drugs commonly used to treat heart attacks such as clot-busters, blood thinners, or nitroglycerin (the medication, not the explosive)? Don’t tell me he doesn’t at least have an aspirin in there. (Admittedly, Mid-Nite’s heart attack was caused by “fear” — whatever that entails — so clot-busters and blood thinners may not be appropriate. Aspirin and Nitroglycerin would still be a good idea though).

Tags: comics medicine jsa dr. mid-nite mr. terrific transfusion myocardial infarction

Punisher #28 “The Slavers, part 4”
Garth Ennis, writer
Leandro Fernandez, penciler

I’ve had a request to look at the Punisher’s impromptu surgery in Punisher #28 (current series). The images are rather graphic — and since I don’t want to scare any small children or Congressmen — you’ll have to click on the thumbnails at the bottom of the post to see the full pages (or buy the comics or trade).

Now let’s talk about the Punisher’s surgical skills:

1. Is this even anatomically possible?
In the average adult male, the small intestine is 20 feet (6 m) long. That’s certainly long enough to loop around a few branches like in the picture.
On the other hand, the small intestine is not just lying loose in the abdomen. It’s tethered to a membrane known as the mesentery. This is a very important anatomical structure because it carries the blood supply and nerves of the intestine. To get one large loop of bowel like the one shown in the panel, the Punisher would have to cut away nearly all the mesentery. It’s certainly possible, it would just be very messy and time consuming — plus likely fatal to the bowel.

2. What about infection?
There is a very high risk of infection. First, the abdominal cavity is open to the world. In medical parlance, this is called a “bad idea.” It leaves a normally sterile environment wide open for invading germs. Second, as mentioned above, the Punisher cut away the blood supply to the intestine. A dying or dead bowel is very susceptible to infection. Finally, given its “artistic arrangement,” the bowel is likely to get some wood splinters or bark chips embedded in it. Plant matter carries a high rate of infection because of the wide variety of bacteria, fungi, and other organisms that inhabit it.

3. Is this survivable?
Barely, at best. Our victim requires emergency surgery quickly. Without a blood supply, the bowel is dying. In the best case scenario, the patient will lose most of his small intestine, need massive amounts of powerful antibiotics, and require an extended stay in the hospital. A far more likely scenario has him dying long before he reaches the hospital, let alone the operating room.

Final thoughts:
It’s nice to see that the Punisher wore gloves (or at least a glove) when operating, but I’m sure it was more to protect himself from infection rather than reduce his patient’s risk of infection.
I’m not sure what drug was in that small syringe, but it must have been powerful for our victim to endure that surgery without waking up.
That is simply a great Tim Bradstreet cover.

Tags: comics medicine punisher small intestine mesentery infection garth ennis

I’m just back from donating blood, which means it’s time for another blood-themed post.

Kevin Tremain was a rather generic (if blue-skinned) mutant who used to run with Cable and his mercenary team. At one point, he was captured by the Mandarin, who planned to use Tremain’s DNA to clone a bunch of super-powered soldiers. After stopping Mandarin’s operation, the rest of the team high-tails it back to the United States. Cable stays behind to help the badly wounded to Tremain. Initially, he uses his telekinetic powers to keep Tremain’s heart and lungs going. When that’s not enough, Cable decides that a transfusion is needed.

Thoughts:
1. Hopefully Cable and Tremain have compatible blood types. If not, “Well Kevin, I saved your life, but it’s a moot point because soon the transfusion reaction will kill you.”
2. Cable carries transfusion equipment with him?
3. That’s a tiny tube for a transfusion. In any given minute, Tremain’s bleeding out more than that little line could transfuse.
4. Cable raises an excellent point about the techno-organic virus. “Well Kevin, I saved your life, but it’s a moot point because soon you’ll be taken over and absorbed by this techno-virus.”
5. Actually, it was all a moot-point. Tremaine died shortly thereafter — or so Cable thought. He showed up years later, alive, working for Onslaught, and calling himself “Post.”

Other notable comic book transfusions:
♥  Marvel Mystery Comics #19 — the Human Torch and a flame transfusion.
♥  The Savage She-Hulk #1, wherein meek Jennifer Walters becomes the jade giantess.
♥  Our Army at War #160 — the best comic book transfusion (and boxing) story ever.
♥  Transfusion Confusion — my list of notable transfusion stories.

When Cable encounters his other-dimensional counterpart Nate Grey in Cable #30, the younger — and supposedly more powerful telepath — gets the worst of it. The erstwhile “X-Man” ends up with a psychic nosebleed as well as the less common ear bleed.

Scenes from Cable #30. Words by Jeph Loeb, Art by Ian Churchill

We also get treated to this bizarre nosebleed scene which seems to defy the very laws of time (or at least gravity):

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed cable nate grey