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I thought one of the big plot points from the current Justice League of America series was that Vixen had lost her animal powers. Pity somebody forget to tell that to the Countdown team — it could’ve save Jimmy a lot of pain.
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A common scenario in literature, television and movies is the use of a drug to quickly knock a character unconscious so that they can be captured or kidnapped. Usually, these mysterious drugs remain unnamed, but here are two recent (and generally well-done) comic book examples:
Case Study #1: The Programme #2
Max is kidnapped after being sedated by a “standard issue Diazepam-based cocktail.” Diazepam is better known by its brand name Valium, a drug with a wide variety of uses including muscle relaxation, anxiolysis (combating anxiety), and treating vertigo. Its most common side effect is sedation – and sometimes it is prescribed for just that purpose. Of note, Valium and related drugs (such as Klonopin, Xanax, Ativan, Halcion, Librium, and Restoril) can be addictive. These drugs can be given intravenously, intramuscularly, or orally and have a rapid onset of action.
You may recall that this is same drug Dr. Mid-Nite used to combat the dizziness induced by Count Vertigo back in JSA #17. I had concerns about Mid-Nite’s choice of medications due to the risk of sedation. It’s true that Valium is one of the strongest anti-vertigo drugs, but its always used as a second-line agent because of sedation — the same sedation used here to knock out Max (though I’m sure he was given a much higher dose than Dr. Mid-Nite used).
Case Study #2: Black Canary #2 and #3
Merlyn, disguised as Green Arrow, knocks out Sin with a gas. He later reveals that his drug of choice was Halothane.
Halothane is an inhaled anesthetic used for surgery that was developed in the 1950s as a better alternative to ether and chloroform. It was a tremendous improvement and provided rapid general anesthesia. Its use has been supplanted in the last decade by newer, slightly safer drugs — it still has some uses in veterinary medicine.
Two nit-picks here: first, Halothane is colorless, not purple. Second, Halothane is rapidly metabolized by the body and needs to be constantly administered to maintain anesthesia. For Sin to remain sedated, Merlyn would need to keep exposing her to the gas.
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Just in time for Labor Day, here is Superboy: Job Counselor. It’s actually a pretty good PSA, suggesting that people find a career involving what they enjoy. College is mentioned, as are various trades. No sexism either — you’ll notice there’s only one woman shown, but she’s the only character actually going to college.
I do wonder why Superboy is cruising the employment agencies, though.
This PSA comes from the August/September 1950 issues of various DC comics including Action Comics #147, Batman #60, and World’s Finest #47. As always, the PSA was written by Jack Schiff. Art is by frequent PSA collaborator Win Mortimer.
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Amazing Spider-Man #543 “Back in Black, part 5: An Incident on the Fourth Floor”
J. Michael Straczynski, writer
Ron Garney, penciler
Two issues ago, Peter secretly transfused some of his blood into Aunt May. In this issue, the police have finally discovered that there is an old lady with an unexplained gunshot wound in the hospital and are starting to ask questions. One doctor they talk with has a great deal to say:
Doctor: Been tracking her vitals since she got in. And in the last 48 hours there’s been a change in her blood report.
Doctor: In the last 48 hours her blood count changed and we’ve detected traces of radiation in her system that weren’t there when she arrived. And something the lab can only identify as a variant of spider venom.
Two nit-picks to start off with. First, lab reports (or “blood report” as she calls them) it are not vitals. “Vitals” is short hand for vital signs, and as generally understood the four main vital signs are temperature, heart rate, blood pressure, and respiratory rate. Depending on the circumstances, there can be other vital signs (especially in patients in the ICU) including weight, intake/output, and various cardiac numbers. Every once in a while, a special interest group comes out with a report suggesting an additional “fifth vital sign” that we’re all supposed to track. (“Pain” was the most recent of these suggested new vitals.) Regardless, labs are not vitals, they are labs. Second (and I’m being really nit-picky here), as I mentioned above, no physician or nurse would use the phrase blood report. If they were speaking generally, they’d say “lab report” or “labs,” if they were being more specific, they’d say “blood count” or “CBC” (shorthand for Complete Blood Count) — and she got it right the second time.
Aunt May just received a blood transfusion from Peter. We’d expect to see her hemoglobin and hematocrit (“H&H”) significantly elevated compared to her numbers before the transfusion. It’s not uncommon to see a slight day-to-day variation in the blood count, and various conditions can cause a steady or sudden decline in the H&H, but it would be extremely unusual to see the hemoglobin and hematocrit bump up unexpectedly by a several points.
If I were faced with a patient with an unexpectedly elevated blood count, I would first suspect that the patient might be dehydrated. When someone is dehydrated, their blood components are more concentrated and falsely appear to be elevated. Once they are rehydrated, the blood values will return to normal. If the patient is not dehydrated, I would suspect a lab error and repeat the test. If the second blood test showed the same results, then I’d be truly puzzled.
I would never order a radiation test of the blood — mainly because there is no such thing! I can’t imagine how they discovered Aunt May is radioactive unless someone happened to walk by with a Geiger counter (and apparently they do it regularly because they knew she was not radioactive when she was admitted). I also find it hard to believe that any hospital has a test that can identify spider venom (let alone a variant). Even assuming that such a test existed, why would they choose to run it on Aunt May? Is a rising blood count a symptom of spider envenomation? Remember that lab tests are not run haphazardly; they are run for a specific reason, either to rule something in, or rule something out — I can see no good reason to look for radiation or envenomation in May because her symptoms (a rising blood count) are the opposite of what these conditions would cause.
If I were suspicious that the patient had received a surreptitious transfusion — and it seems the doctor has her suspicions — then there are real world tests that can be performed to look for the blood cells of two different individuals in her blood sample. The test works, just ask former professional bicyclists such as Tyler Hamilton and Alexander Vinokourov who were caught blood doping using such tests.
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/>One cannot take a look at memorable transfusions in comic book history without considering John Constantine’s transfusion from Hellblazer #8. Injured after jumping from a speeding train, John wakes up in the intensive care unit of the hospital, gravely injured. The demon Nergal requires John’s assistance to complete his nefarious plans, so he gives Constantine some of his own demon blood, instantly healing him.
Subsequently, when John visits and sleeps with his old lover Zed, the demon-portion of his blood taints her so that she can no longer carry out her destiny, to be the mother of the new Messiah.
Of course, Zed’s not the only one tainted. When the Swamp Thing and Abby wanted to conceive a child, Swamp Thing “borrowed” Constantine’s body to complete the task. He was unaware of John’s corrupted blood and ended up passing on the taint to his own daughter Tefé.
There are a number of infections that can be passed from mother to unborn child (commonly known as the TORCH infections1), but apparently demon blood — though not strictly an infection2 — is the only bloodborne condition that can be passed from father to child3.
Other Comic Book TransfusionsNotes:
1I was taught that TORCH stood for Toxoplasmosis, Other (i.e. Syphilis), Rubella (also known as German measles), Cytomegalovirus, and Herpes, though there are several other versions of the acronym.
2There’s no infectious agent in demon blood (that I’m aware of), so I don’t think it could really be classified as an infection. It’s a long term condition though, so I’m going to classify it as a PABA-N (Persistent Acquired Blood Anomaly – Nefarious) — as opposed to Peter Parker who has a PABA-R (Persistent Acquired Blood Anomaly – Radioactive).
3I wonder how long the taint persists. Could Tefé pass it on the her children?
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Another classic from DC Comics, this PSA advises us to talk our conflicts out instead of fight about them…
…only it’s not really a particularly effective PSA, is it?
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Before turning my attention to Amazing Spider-Man #544, I want to take a last look at some of the more ludicrous aspects of the previous issue. In particular, I want discuss the last portion of the comic where Peter steals an ambulance and moves Aunt May from one hospital to another. It is my contention that Peter’s actions were entirely selfish in nature and actually detrimental to Aunt May’s medical care.
The first hospital has been caring for Aunt May since her injury. They have been closely following her condition, and there is no indication that she received anything other than exemplary care.
Meanwhile, the hospital has reported the case to the police as being suspicious. This should come as no surprise because almost every state legally requires hospitals and physicians to notify the authorities of certain types of injuries, including gunshot wounds.
When the police stop by to investigate, Peter makes things worse by slugging the cop. Bear in mind that he makes things worse for himself, not Aunt May. Peter attacking the police has no bearing Aunt May’s medical care — she will continue to receive the same quality care she has received since admission. Even if Peter is arrested — and even if he is sent to prison in the Negative Zone — Aunt May’s medical care will not suffer. Frankly, the hospital personnel don’t care one whit about him; they care about Aunt May.
Nevertheless, Peter decides that Aunt May needs to be moved to a different hospital. Why? Not for her sake, certainly. She’s getting good care at the first hospital, and the care at the second hospital will not be as good, at least at first. To begin with, the second hospital is not going to have the medical records she’s amassed since her admission. They won’t know what medications she’s on and what procedures have been performed. They won’t know her labs or vitals and how they’ve been changing. At a minimum, there will be a several hour period where Aunt May’s medical care is going to suffer as she is transported and then admitted to the second hospital. Peter is moving her in an effort to save his skin — he’s trying to avoid the police and other authorities. The move is for his sake, not hers.
Aunt May is on a ventilator and multiple IV medications. She would be a tough transport for an experienced ambulance crew, let alone Peter and Mary Jane (plus an experienced crew would know to bring her in through the ambulance bay, not through the ER waiting room. That by itself should have been enough to alert the nurse on duty that something was screwy).
At most, Peter has bought himself a few hours. When the very ill Aunt May is brought to the new hospital, they’re not just going to admit her without questions. First, the paperwork is wrong*. Second, does he think the second hospital is not going to contact the initial hospital and ask them to fax over her medical records ASAP? Of course they are! Plus he was kind enough to steal a transfer form from the first hospital, so there won’t be any question where she came from. Third, Aunt May still has a gunshot wound which is still reportable. I think the authorities will be pretty quick to pick up on the fact that an old lady disappeared from one hospital and a second showed up with an identical wound at a second hospital, even if the last names don’t match. Finally, the second hospital is going to be very suspicious of patient dumping by the first hospital and report Aunt May as a possible EMTALA violation, which will involve an entirely new set of authorities looking closely into the case.
I understand that the underlying theme of this issue is that “Peter is so desperate he is forced to commit felonies” and I further understand that this comic is a prime example of modern Marvel storytelling (get the character from plot point A to plot point B and damn the torpedoes). It just pains me to see common sense and logic (and good medical care) thrown out the window to achieve these goals.
*Not only do you need a transferring doctor (the signature that Peter forged), you need an accepting doctor at the new hospital. This is actually the more important part and you’re not going to be able to transfer a patient without a physician ready to accept care.
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Yesterday, I briefly discussed the Federal statute EMTALA, at least as it applies to patient dumping. Today, a look at a different aspect of the law — a patient arriving at the Emergency Room in active labor.
In this scene from Pulse #12, Jessica Jones — who is 6 months pregnant — has presented to the ER in labor. The doctor is in the process of finishing his evaluation when the chief administrator of the hospital comes down into the ER and kicks her out of the hospital.
Situations like this is where EMTALA (the Emergency Medical Treatment and Active Labor Act) comes in to play. When a patient in labor presents to the ER, and is medically determined to be in active labor, then the hospital is obligated to treat her until the delivery is complete.
There can be circumstances where a patient requires transfer to another facility for appropriate medical care. For instance, a small town ER may not have the capabilities to treat a severe head injury and would need to transfer the patient to a larger hospital. It is entirely possible that Jessica Jones is a patient who will require transfer, but it’s too soon to tell and the hospital still has an obligation to treat her. Under EMTALA, this transfer should wait until the patient is stable or labor is complete. In rare circumstances, an unstable patient (or one in active labor) may be transferred to another hospital, but this has very strict requirements including:
The patient must be stabilized as much as possible by the initial hospital.
The medical benefits of the transfer must outweigh the risks of the transfer1.
A physician2 states — in writing — that this is true.
The receiving facility agrees to accept the patient.
This scene doesn’t meet these criteria. Jessica has presented to the ER in active labor, and preterm labor at that. The hospital administrator — who may or may not have some sort of medical training — has no say in the medical disposition of the patient. You’ll notice that she is over-ruling the doctor3 who is actually providing care to the patient. While she may have some valid points about risk to her facility4, that does not change her obligations to the patient under the law. She does make a perfunctory comment about “call[ing] the Baxter Building or SHIELD,” but she has not arranged any sort of transfer before telling the orderlies to discharge the patient.
Of course, this is assuming that EMTALA or a similar law exists in the Marvel Universe. Even if it doesn’t, you can’t tell me that the hospital wouldn’t have some sort of policy about treating superhuman patients. Hospitals have contingency plans for everything, there’s no way a hospital in Marvel’s NYC would not have some sort of plan for this scenario.
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Scenes are by Katsuhrio Otomo and can be found in Akira #17 (the 1990 version published by Marvel’s Epic Comics imprint )
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To quote from the preview, “In David Hine and Hans Steinbach’s original manga, Poison Candy, a virus infects adolescents giving them telekinetic powers.”
It also seems to give them a need to carry a tissue…
All previous Psychic Nosebleed Zen postsFiled under: Comics, Medicine | 8 Comments »
In the far future universe of the Legion of Super-Heroes, the people of the planet of Winath share a peculiar trait — twins. The vast majority of births on Winath are fraternal twins and singleton births are very rare, and generally pitied.
Medically, fraternal twins occur when a woman releases two eggs in a given cycle instead of the normal one, and both are fertilized and implant. Fraternal twins are also known as dizygotic twins.
No definitive explanation for the increased rate of twins of Winath is ever given. It goes without saying that this is a comic book about the distant future, so there are hundreds — if not thousands — of possible causes ranging from Dominator super-tech to Modru’s magic. There are two possibilities that seem much more likely than the rest, however: genetic mutation and environmental influence.
1. Genetic Mutation
The people of Winath could have a genetic mutation that results in women producing two eggs per cycle instead of one, making fraternal twins much more common. It’s not an unheard of idea — there are certain ethnic groups around the world today that have a higher percentage of twins than normal. If you also consider the Founder Effect, which allows uncommon genetic traits to flourish in small isolated populations (such as an interstellar colony), and realize that having twins would be considered a positive survival trait (more offspring than those without the gene), the genetic mutation explanation make sense.
If the genetic mutation theory were true, then historically you would see a slow increase initially in the number of colonists with twins, followed by a geometric increase once a certain critical mass is reached. Winathian women who moved to a different planet would still bear twins, and non-Winathians who moved to Winath would not bear twins (well, no more than the normal human rate).
2. Environmental Influences
There could be something in the environment on Winath that causes women to release two eggs per cycle instead of one. We know that there are environmental influences on Earth that can have a drastic influence on the fertility of lower forms of animals, so it’s conceivable that somewhere in the Universe there could be an environmental exposure that affects human fertility. Winath could be that place.
If environmental factors were the cause of the twins, then historically,\ we would see a drastic rise in the number of twin births almost immediately after the founding of the colony. If a Winathian woman moved to a different planet she would no longer have twins, and a non-Winathian woman who moved to Winath would have twins.
So which explanation is it?
As much as I like the elegance of the mutation theory, I’m going to have to go with the environmental theory — because of Saturn Girl. Imra Ranzz (nee Ardeen) is a native born Titan, so she would not carry any Winathian twin-mutation — yet after marrying a Winathian she gave birth to twins (twice, if memory serves). Remember, after she and Garth were kicked out the Legion, they spent a significant amount of time ofn Winath, so she would have had the chance to be exposed to whatever environmental fertility influence exists there. Of course this is two continuity reboots ago, so things could have changed.
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It’s time once again for one of my favorite holidays of the year: Talk Like A Pirate Day!
Being the good buccaneer that I am, I looted last year’s post (which was itself plundered from the year before that), and I’m reposting and updating it — and new additions are always welcome!
Comic-book pirates (and pirate comic books) off the top of me head (to be updated as I think of more):
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Stormwatch P.H.D. #11 “Family Matters”
Christos Gage, writer
Andy Smith, penciler
A concussion is a type of mild diffuse brain injury — this means that the injury is spread over a large portion of the brain as opposed to a focal brain injury such as penetrating trauma or a bleed. Concussions are most commonly caused by a direct blow, though acceleration/deceleration injuries can also cause them. Common symptoms include amnesia, headache, confusion, vomiting, visual disturbances, and a loss of consciousness. The amnesia can be retrograde (loss of memory from the period before the injury) or anterograde (loss of memory from the period after the injury).
There have multiple systems devised to classify concussions, but none have been completely satisfactory because they aren’t very good at what we as doctors (and you as patients) are most interested in: predicting outcomes. One of the more common of these systems divides concussions into five grades. Grade I is a concussion where the patient experiences confusion, but no loss of consciousness. Grade II includes anterograde amnesia in addition to the symptoms of a Grade I concussion. Grade III concussion have the symptoms of Grade II concussions, but also include retrograde amnesia and unconsciousness of less than 5 minutes. Grade IV is similar, but has a loss of consciousness of five to ten minutes. Grade V describes a patient with a concussion who remains unconscious more than ten minutes.
Two concerns in patients who suffer concussions are Post-Concussion Syndrome and Second Injury Syndrome.
As the brain is healing after a concussion, neurological symptoms including headache, dizziness, clumsiness, memory problems and light sensitivity can persist. These symptoms are known as Post-concussion Syndrome and can last for days, weeks, or even years (Jackson King is being a little overly optimistic when he tells Gorgeous that it will only last “a couple of days.” But then maybe he can predict the outcome better because of his telepathy — sure would be nice). Post-concussion syndrome can make returning to work, school, or sports a real challenge. For example, Steve Park was once a top tier NASCAR racer who suffered a severe concussion in a crash. He had a protracted post-concussion syndrome and was never able to race successfully at the highest level again. Patients who are experiencing post-concussion symptoms should not return to sports (or crime-fighting) until all the symptoms have resolved. (We generally recommend waiting an extra week after the symptoms have resolved just to be safe). Returning to full activity too early is a bad idea because 1) patients with post-concussion symptoms are apt to injure themselves, or at the very least, embarrass themselves by being very bad at sports (or crime fighting); and 2) the potential for Second Injury Syndrome.
If a person receives a second concussion while they are still recovering from a first concussion, they are at risk if developing a serious condition known as Second Injury Syndrome. Not much is known about this rare condition (less than 50 recorded cases) except that it seems to occur in young patients who sustain two mild head injuries within a fairly short period of time. Second Injury Syndrome is nearly always fatal, and even if the patient survives, they are likely to be severely impaired. There is no effective treatment or cure for Second Injury Syndrome.
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Remember the two-part episode of House late in the second season where Foreman developed meningitis? Meningitis that was ultimately revealed to be caused by the amoeba Naegleria fowleri, an extremely rare disease with only 24 recorded cases in the last 18 years?
Make that 27, because there have been 3 cases reported this summer related to freshwater lakes in Florida — and possibly more unreported cases.
Links:
My reviews of House, Season 2, episode 20 and episode 21
CDC fact sheet on Naegleria infection.
CNN article: “Deadly amoeba lurks in Florida lakes”
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It’s prime ragweed and hay fever season here in the Mid-West. My most common reason for patient visits this week has been allergies.
Allergies are no fun for anyone, but there’s definitely certain characters for whom allergies would be even worse. Here’s the list I came up with:
Tigra
Doctor: “I’m sorry Ms. Grant, but you’re allergic to cats.”
Thor
“Forsooth! Mine sneeze hath leveled that house!”
M.O.D.O.K.
Just imagine all the snot that would come from that giant nose. Come to think of it, I’m actually surprised that no one has written a story where M.O.D.O.K has allergies (or would that be M.O.D.O.S.* or M.O.D.O.R.N.I.E.S.**?).
Dr. Doom
Just try sneezing inside a metal face mask. Would also apply to Iron Man, Crimson Dynamo, War Machine, etc. etc.
All-star Batman
“I’m the godd – ACHOO!! I’m the go – ACHOO!! I’m the – ACHOO!! Eh, forget it.”
Superman
Itchy, watery eyes interfere with x-ray vision. If you want to rob a bank in Metropolis, do it during allergy season.
Madrox
Every time he sneezes, a double is formed.
Wolverine
Hard to track by scent when you’re all stuffed up.
The Human Bomb
Pretty self explanatory.
*Mental Organism Destined Only for Sneezing
**Mental Organism Destined Only for Runny Nose, Itchy Eyes, and Sneezing
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I read Countdown to Mystery and I have to say that I am not excited by the new Dr. Fate. A failed psychiatrist is the new Doctor? Come to think of it, has there ever been a successful good guy psychiatrist in comics?
Doc Samson probably comes the closest. When written by Peter David, he had his brief moments of competence. Other than that, his history is made up of failures and of non-psychiatric-related adventuring and inventing.
Dr Wolper? He didn’t have a great deal of success with either Harvey Dent or the Joker.
Dr. Arkham? Has anyone at Arkham Asylum actually been cured — or even helped?
The bad guys, on the other hand, have their share of successful psychiatrists. Some of them are so successful at being villains because they’re competent psychiatrists (Moonstone, for example). Dr. Psycho, Hugo Strange, Harley Quinn, Maxilla Yale are all good villains and proficient psychiatrist.
This good/evil competent psychiatrist dichotomy just reinforces my belief that comic book writers use “psychiatrist” as shorthand for denoting a character who is shady or sinister, but it would be nice to see an effective heroic psychiatrist every once in a while.
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From The Incredible Hulk’s Book of Strength (DK, 2003):
Strength can mean many different things. Once dictionary says that strength is the “the quality of being strong,” which really doesn’t answer the question, does it? So look under strong: “capable of exerting great power.” That’s more like it!
In Hulk’s case, he can exert, or use, much more power than the rest of is. But when he calls on this great power, he is using pretty much the same method that human beings use when they need strength. Hulk is using muscles.
Your body’s bony skeleton in surrounded by a network of long ropy strands. These muscle strands work together in groups to make your bones move, whether that means walking or running or lifting or even eating.
Together, your bones and muscles are what give you strength.
Hulk has the same major muscle groups as humans…they’re just much bigger and stronger. On this page [reprinted above], we’ve shown on Hulk what some of the most important muscles are and what they’re called.
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The first episode of House’s fourth season begins with — well, not a bang, but not a whimper, either — more of moderately exciting spectacle, like one of those fireworks that trickles down rather than explodes outward. In this episode, bereft of a team, House must solve a case on his own. Mostly.
There are definitely spoiler warnings ahead, especially for the ending, so don’t read if you haven’t seen the episode. Or if you do, don’t whine about it afterwards.
As the episode starts, a young woman named Megan is at work talking on the phone to her boyfriend, Ben. He is trying to persuade her to go to a movie that evening, but she declines, citing fatigue and sneezing. She tells him that she thinks she’s having hallucinations because the building seems to be shaking. There is a sudden roar as her office building collapses in a gas main explosion.
It’s now two days later. Megan is one of the few survivors of the explosion, but she is still very severely injured. She has been through multiple surgeries for fractures and burns. Cuddy consults House because Megan has been running a persistent fever despite being on antipyretics (fever reducing medication like acetaminophen or ibuprofen). She has also been lapsing in and out of consciousness. Cuddy wants to use this case as a goad to get House working with a team again, but he refuses. He cuts her a deal: if he can solve the case by himself that day, she will not bug him for a week.
House ropes a passing janitor into helping him. He describes the case to him in mechanical terms, and asks him what he would do. The two of them come up with several possible diagnoses: brain damage with hypothalamic dysfunction (which House discards because it would have shown up on the brain MRI she already had), infection (possible parasitic or fungal infection, admits House), or Lupus (the janitor’s grandmother had Lupus). House wants to break into Megan’s house, but the janitor refuses (or at least refuses for the amount of money House is offering him). In the end, House shanghais Wilson to help him search the house. They find a diary which reveals that Megan had a history of fatigue and feeling blue. From this, House infers that Megan has depression. He then makes the leap that she was on a certain kind of antidepressant (an MAO Inhibitor — a class of antidepressants used only rarely, if that, because safer more effective drugs are now available), that when combined with Demerol (a narcotic pain killer) she received in the ER, can cause Serotonin Syndrome, of which fever is one symptom (This is true, but there are other symptoms of Serotonin Syndrome which should have shown up as well. Serotonin Syndrome appears rapidly, and should have shown up within a few hours of receiving Demerol, and should have resolved by now, several days since she has had either antidepressants or Demerol.) House decides to place Megan on dialysis to remove the drugs from her system (not a common treatment for Serotonin Syndrome, but it has been used in severe cases). Her boyfriend insists that Megan was not depressed, seeing a psychiatrist, or on antidepressants, but House believes that Megan was just hiding it from him. He gets her mother to sign the consent.
After the dialysis she wakes up and confirms through blinking that she was seeing a psychiatrist and was on an MAO Inhibitor. She then develops ventricular tachycardia and slips into unconsciousness and cardiac arrest. Cuddy has to defibrillate her back into a normal rhythm.
House considers his deal with Cuddy done and himself the winner, but Cuddy disagrees. She wants him to figure out why Megan developed tachycardia. Endocarditis (an infection of the heart) is considered at first, but discarded because blood cultures were negative. Cuddy and House now consider that Megan may have cardiac damage from Crush Syndrome. Crush Syndrome occurs when a patient has been trapped under a heavy object, crushing part of their body and cutting off blood flow. The damage from the crush injury causes an increase in toxic chemicals in the affected parts of the body. When the patient is then released from the heavy object and blood flow resumes, these chemicals circulate throughout their body, causing a variety of serious problems (She’s been in the hospital for 3 days at this point, routine labs should have shown any Crush Syndrome by now; it’s not going to show up suddenly this late). House and Cuddy suspect the high potassium from the crush injury combined with “microvascular occlusion” have caused the heart problem, but luckily, this will show up on an echocardiogram. The echocardiogram is obtained, but it is completely normal. Taking the tachycardia (but normal echocardiogram), sweating, and fever into account, House now decides that Megan is suffering from delirium tremens (alcohol withdrawal). Her boyfriend again objects, saying that he would have noticed if she were an alcoholic. House ignores him and starts her on IV ethanol, which does correct her fever and tachycardia. In real life, IV alcohol is not the recommended treatment for delirium tremens because it doesn’t solve the dependency problem, just prolongs it. Plus, it can lead to electrolyte abnormalities (which Megan already has), gastritis, pancreatitis, and hepatitis. Benzodiazepines (such as Valium, Ativan, or Librium) are the treatment of choice.
When Cuddy visits Megan and her family, she realizes that Megan has been silently screaming in pain for the past 2 hours (but apparently the pain wasn’t enough to raise her blood pressure or heart rate noticeably). Labs show an elevated amylase and lipase, meaning that Megan has developed pancreatitis. The alcohol was the most likely cause for the pancreatitis, but there can be other causes as well. House obtains an MRI which shows a normal pancreas (when it should at least show pancreatitis). The MRI also shows an abnormality around the liver consistent with blood. Sure enough, Megan starts to bleed out both ends and is rushed to surgery with multiple sources of internal bleeding. Watching the surgery, House notices that Megan has an enlarged uterus. He enters the OR and takes a look, realizing that Megan has had a recent abortion. He then hypothesizes that she has been taking birth control pills, which when combined with the Warfarin (a blood thinner) she has been on since hip surgery (which would have been nice to know earlier), led to her bleeding (The effect, if any, oral contraceptives have on Warfarin is not clear. The combination probably does slightly increase the risk of bleeding, so House may be right. Of course, every other medication mentioned in this episode — including MAO inhibitors, ethanol, cephalosporins, tamoxifen, and antipyretics — also increase the chance of bleeding while on Warfarin, only moreso). House puts her on Tamoxifen to block the effects of the birth control pills (this is not a recommended use of Tamoxifen). This revelation that Megan had an abortion is too much for her boyfriend, who leaves the hospital, but he return later to sit by her side.
The bleeding improves, but now Megan develops kidney failure and breathing problems. Her fever returns. House wanders the ER looking for a doctor to bounce ideas off, but discovers that Cuddy has put out a memo prohibiting anyone from talking with him. One young resident decides ignore the memo and talk with him anyway. At first she suggests a fungal infection or haemophilus infection, but House rules these out. She then mentions Crush Syndrome (which House states wouldn’t explain the breathing problems) and ARDS (Adult Respiratory Distress Syndrome — which House complains would only explain the breathing problems). House rethinks the differential diagnoses, and now concludes that the patient is suffering from both Crush Syndrome and ARDS, which is bad news for Megan since these conditions have a poor prognosis. As he is talking with her mother and boyfriend, he notices a large lump in her arm. An MRI shows multiple similar lumps scattered throughout the body which are shown to be Eosinophilic Granulomas, which they say is a sign of an allergic reaction (I don’t know what they are referring to here. Eosinophilic Granuloma is a type of Langerhans Cell Histiocytosis, a rare disease that has nothing to so with allergies. I’m wondering if they are confusing it with feline eosinophilic granuloma, a very different condition.) Apparently Megan is allergic to the antibiotics she was given in the hospital — medications which she has taken before without any problem. Finally, House realizes the solution to this patient’s problems — she isn’t Megan. Both Megan and a similarly appearing girl named Liz survived the explosion. There was a mistaken identification and Megan was identified as Liz and vice versa. Megan died several days ago, and the patient House has been treating is Liz — whose medical records confirm everything House has suspected including the antidepressants, abortion, and use of birth control pills.
For those who may think that the patient mis-identification at the end was a stretch, I know it seems hard to believe that family members wouldn’t recognize their child/significant other, but it has happened more than once. There was a very similar case about a year and a half ago featuring Taylor University students injured in a van crash. I suspect it was the basis for this part of the episode.
A list of all prior House reviews
Filed under: Medicine, TV | 6 Comments »
Episode Title: In Which We Meet Addison, a Nice Girl From Somewhere Else
Since I like a couple of the actors, I thought I’d give ABC’s new show Private Practice a try, even though it’s a spin off of Grey’s Anatomy (which I found too soap opera-y and mopey). Like it’s predecessor, Private Practice favors the dramatic over the medical, but so far has avoided the emo trap. The show seems to be trying a little hard to be both serious and quirky (Cooper, for instance, is more caricature than character), but it has potential.
I don’t plan on doing in-depth reviews like I do for House, but here are the medical issues that caught my eye in this episode, arranged by doctor.
Dr. Addison Montgomery/ Dr. Pete Finch
As anyone who’s joined (or started) a practice can attest, there is an incredible amount of paperwork involved — state forms (license, controlled substance registration) and reams of insurance forms, just to name a few. Unless Naomi was handling all this paperwork herself, someone else in the clinic would have known Addison was joining (Now if Addison already had a California license and the clinic doesn’t take insurance or carry malpractice, then there wouldn’t be nearly as much paperwork).
JVD (Jugular Venous Distention) is a very sensitive sign of congestive heart failure, which this patient seems to have suddenly developed. I get the feeling the writers were shooting for peripartum cardiomyopathy, a rare but serious form of heart disease associated with pregnancy. The sudden onset of her symptoms is unusual for this condition, and would make me concerned about a heart attack or amniotic fluid embolism leading to congestive heart failure. Other causes would include mitral stenosis and aortic stenosis.
They put the patient on oxygen, but it would have been nice for them to give her other medications to relieve her symptoms (diuretic, for instance).
Supposedly the baby was in trouble, but the heart rate (140-150 with normal variability) looked good to me.
If I were undergoing major surgery (and c-sections are major surgery), I would want more than acupuncture for anesthesia, even if it was electrified acupuncture.
About twelve years ago, there was a popular computer game that simulated surgery and allowed you to pretend to be a surgeon. There were only a few surgeries you could perform (appendix, AAA), and you quickly realized that the game had every single patient go into v-fib during surgery. Watching shows like House and Private Practice, I feel like I’m playing this game again when every patient goes into cardiac arrest. Real life isn’t like that. Anyway, it was nice to see they had a crash cart, and their treatment of the code – what little we saw – looked OK, but I wonder about putting her on a Lidocaine drip when we didn’t see them give Lidocaine during the code itself (but again, we only saw part of it).
Dr. Naomi Bennet /Dr. Sam Bennett
For patients who are uncomfortable with providing a specimen in a cup, there are specially made condoms that allow both partners to participate in the collection. The results are better if you do it yourself, but some is better than none.
Why did they provide CPR for 20 minutes without breaking out the crash cart? We know they have one in the clinic – this would have been a good time to use it. And if you’re going to defibrillate the patient, it’s be nice to know the heart rhythm first.
Post-mortem sperm has been collected as long as two or three days after death. It’s still an uncommon procedure — and mostly unsuccessful too, with only 1 successful use in the U.S.. As this episode showed, the ethics are still unclear.
Dr. Violet Turner/Dr. Cooper Freedman
They never explicitly stated the diagnosis, but this patient clearly has obsessive compulsive disorder (OCD). In short, OCD is a type of anxiety disorder – the patient was counting tiles to drive the stressful thoughts of her dead son out of her head. I can see how she would quickly relapse into OCD when she saw the kid in the video, but I can’t see her being talked out of it that easily.
Filed under: Comics | 4 Comments »
From Superman’s Girl Friend Lois Lane #106, here’s a relic of a bygone era: a slide-rule designed for the express purpose of calculating batting averages. And for only a dollar!
It seems to me that any source that listed a player’s at bats and hits would be likely to also list their batting average, but I guess you can always use it for Little League or church softball.
Filed under: Comics, Medicine | No Comments »
Filed under: General | 1 Comment »
It’s not Nick Fury’s psychic nosebleed per se, but one from his eponymous series Nick Fury, Agent of S.H.I.E.L.D. (1989 series). In this scene from issue #16, an evil scientist-wannabe has his mind overloaded when a malfunctioning spy satellite sends all its data directly into his brain.
All previous Psychic Nosebleed Zen posts
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